Effect of Postural Corrective Exercises in Forward Head Posture: A Systematic Review

BackgroundNeck pain is a common condition across various populations, with a substantial impact on daily life and quality of life. Forward head posture is frequently observed in individuals with neck pain and is closely associated with lifestyle factors. This study aimed to examine the relationship between lifestyle factors and forward head posture in young adults with neck pain and determine the optimal cutoff value for assessing the risk of forward head posture.MethodsIn total, 200 men and women aged 35–44 years with persistent or recurrent neck pain with a numeric rating scale score of ≥ 3 in the previous week were included in the study. The participants’ sex, age, medical history, anthropometric parameters, posture- and activity-related lifestyle, pain, radiographs, and the craniovertebral angle were obtained. The associations between lifestyle factors and forward head posture were analyzed using logistic regression. The cutoff values for risk prediction were analyzed using receiver operating characteristic curves. The impact of lifestyle factors on changes in craniovertebral angle at the 6-month follow-up was analyzed using multiple linear regression and analysis of covariance.ResultsAfter adjusting for covariates, there were significant differences in lying time (odds ratio = 3.342, 95% confidence interval = 1.607–6.952) and physical activity level index (odds ratio = 0.404, 95% confidence interval = 0.210–0.775) between the forward and non-forward head posture groups. The cutoff values for detecting forward head posture were 6.50 h of lying time and a physical activity level score of 2.88. At the 6-month follow-up, the craniovertebral angle was closer to the diagnosis of forward head posture, with increasing lying time and lower physical activity level score; however, the association was not statistically significant.ConclusionsThe findings indicate that lying time and physical activity level scores are important lifestyle-related predictors of forward head posture. Thus, lying time and physical activity level should be addressed to predict and prevent forward head posture.

BackgroundNeck pain is a common musculoskeletal disorder, often linked to forward head posture (FHP). Studies have shown that exercise interventions can improve pain, craniovertebral angle (CVA), range of motion, and function in individuals with FHP. While telerehabilitation exercise has proven effective for other musculoskeletal conditions, its effectiveness in addressing neck pain and FHP is still being investigated.ObjectiveThis study aimed to evaluate and compare the effectiveness of an internet-based telerehabilitation therapeutic exercise program with an in-person supervised program in improving clinical outcomes among young adult females with chronic nonspecific neck pain and FHP. The study hypothesized that there would be no significant differences in outcomes between the 2 groups.MethodsA randomized controlled trial was conducted with 50 participants experiencing chronic neck pain and FHP, recruited through public announcement and voluntary sign-up. Participants were randomly assigned to either a telerehabilitation group or an in-person supervision group. Both groups completed the same 6-week, physiotherapist-supervised therapeutic exercise program, delivered via Zoom (Zoom Video Communications) or in the physiotherapy department laboratory, respectively. Outcome assessments were conducted face-to-face by blinded assessors at baseline, after 4 and 6 weeks of intervention, and at a 2-week follow-up. Outcome measures included pain intensity (assessed using the Visual Analog Scale [VAS]), CVA, neck disability (assessed using the Neck Disability Index [NDI]), and cervical range of motion (CROM). Adherence was monitored using attendance logs.ResultsOf the 50 participants, 48 completed the intervention with 1 dropout from each group. Adherence among completers was 100 percent in both groups. All 50 participants were included in the analysis using the intention-to-treat principle. No differences in effectiveness were found between the telerehabilitation and in-person groups, as no significant interaction effect between group and time was observed across all outcome measures including VAS, CVA, NDI, and CROM (P values ranged .07-.61). However, improvements were observed in all outcomes across time, including a 2.2‐ to 4.1-cm reduction in VAS, 5°-8.8° increase in CVA, 3.3‐ to 7.1-point reduction in NDI (P<.001 for all), and 3.5°-22.7° increase in CROM (P<.001 to P=.04).ConclusionsBoth telerehabilitation and in-person supervision were similarly effective in improving pain, posture, neck disability, and CROM in young adult females with chronic neck pain and FHP. These findings suggest that telerehabilitation may be a feasible and accessible alternative to conventional in-person therapeutic exercise programs for managing chronic neck pain with FHP.

Introduction: One of the most common poor postures in the head and neck region is the forward head posture (FHP). It seems that improper posture for a long period of time causes abnormal physiological load on the neck. Thus, the result can be neck pain (NP). The aim of this study was to compare the relationship between intensity of FHP and a history as well as intensity of NP plus disability in the cervical region. Material and Methods: A total of 32 female students with FHP and history of mild NP participated in this study. The craniovertebral angle (CVA) was measured by taking photos via a digital camera in standing and sitting positions. Intensity of pain was investigated using the Visual Analog Scale (VAS) and the severity of disability was tested with Neck Disability Index (NDI). Results: The Pearson's correlation coefficient was used to investigate the association between the CVA, VAS, NDI, and duration of neck pain. There was a significant positive relationship between the CVA in standing and sitting positions along with a negative correlation between CVA in both standing and sitting positions and the intensity as well as history of NP and severity of disability. Conclusion: Proper postural habits can contribute to prevention of NP. Also, postural correction training in subjects with FHP and NP, in addition to pain decrement methods, can help to reduce pain and disability in these subjects.Keywords: Forward Head, Head Posture, Neck Pain, Neck Disability Index

Background Poor posture is traditionally associated with various musculoskeletal disorders. Consequently, educators in the musculoskeletal field have been teaching postural observation as part of the physical assessment. Forward head posture (FHP) is hypothesized to be associated with neck pain; however, evidence in this topic remains inconclusive. Purpose To investigate the association between FHP and neck pain intensity, disability, and cervical kinematics in individuals with neck pain compared to asymptomatic individuals. A secondary aim of this study was to explore the possible effect of a head-mounted display (HMD) used in a virtual reality (VR) assessment on FHP. Methods The study was conducted with 43 volunteers (20 asymptomatic individuals, 23 individuals with neck pain) aged 19 to 62. FHP was assessed by measuring craniovertebral angle on profile photographs. Secondary outcome measures included pain intensity, the neck disability index (NDI) questionnaire, and neck kinematics using specialized VR software. Results There were no significant differences between individuals with neck pain and asymptomatic individuals in FHP (craniovertebral angle = 48.24°±7.29; 48.90°±5.89, respectively, p > .05). The neck pain group demonstrated a restricted range of motion and slower neck movements (p < .05). We found no significant correlation between FHP and visual analog scale, NDI, and most neck kinematic measures. Conclusions Our findings cannot support a clinically applicable association between FHP and neck pain. Additionally, individuals with neck pain had a lower range of motion and slower neck movements.

Background: Although previous researches have developed interventions for neck problems, headache, and temporomandibular disorder in patients with forward head posture (FHP), changes in masticatory muscle tone or stiffness as FHP worsening have not been investigated. Objective: To examine changes in masticatory muscle tone and stiffness through craniovertebral angle (CVA). Design: Cross sectional study Methods: The subjects were 21 healthy males with normal head posture. Three CVA were established for posture measurement in which the bilateral anterior temporal and masseter muscles were measured during the subjects maintained a series of postures. Results: The Right masseter muscle significantly increased in stiffness with advancing FHP (p < 0.05). No significant changes were observed in the muscle tone or stiffness of any other masticatory muscles, and no significant differences were found in bilateral masticatory muscle tone or stiffness in each measurement posture. Conclusions: This study suggests that the increased stiffness of the right masseter muscle as the FHP worsened requires consideration in physical therapy assessment and intervention.

ABSTRACTBackground and AimsUsing ultrasonography to systematically review all published studies that investigated the association between craniovertebral angle (CVA) and neck muscle size.MethodsThis systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Searches were performed in PubMed, Science Direct, OVID, MEDLINE, and Google Scholar databases from January 2000 to October 2024. The keywords used were: “Forward head posture,” “Cranial vertebral angle,” “size,” “thickness,” “weakness,” “enlargement,” “hypertrophy,” “ultrasonography*,” “Diagnostic ultrasound,” “ultrasonic imaging,” “imaging,” “medical sonography,” and “ultrasonic diagnostic”.ResultsOf the 329 articles retrieved from the databases, 10 studies fulfilled the inclusion criteria. Four studies investigated the size of neck flexor muscles, four articles investigated the size of neck extensor muscles, and two articles focused on the size of both neck flexor and extensor muscles. Six studies compared participants with and without forward head posture (FHP). Two studies were conducted among asymptomatic subjects, while the other two studies were conducted among participants with and without neck pain. Consistent evidence supported that a significant correlation between the CVA and the thickness of deep neck flexor muscles (n = 1), a significant correlation between FHP and the thickness of the splenius capitis muscle (n = 1), an increase in sternocleidomastoid (SCM) muscle thickness (n = 2) and a decrease in semispinalis capitis (SSC) muscle thickness (n = 1) in subjects with FHP compared to those without, and a decrease in semispinalis capitis muscle thickness in individuals with FHP accompanied by neck pain compared to those with FHP without neck pain (n = 1).ConclusionThe reviewed studies demonstrated that changes in the CVA are associated with alterations in neck muscle size, particularly affecting the SCM and SSC muscles. Additional research is necessary to investigate the functional implications of alterations in muscle characteristics.

Assessment of forward head posture in individuals with and without chronic neck pain: A cross-sectional study.

BackgroundPrevious studies have addressed the effects of different exercises and modalities on forward head posture (FHP), but the minimal clinically important difference (MCID) of the effect of exercises on FHP remains unclear. Therefore, this study aimed to investigate the effects of selective corrective exercises (SCEs) on the craniovertebral angle (CVA) and shoulder angle (SA) in students with FHP and to establish MCID for these angles.MethodsIn this randomized clinical trial study, a total of 103 second-grade male students with FHP were enrolled. Participants were randomly assigned to experimental and control groups. CVA and SA of participants were measured before and after the 8-week selective corrective exercise program (including strengthening and stretching exercises). The photogrammetric method was used to measure CVA and SA. MCID value was calculated for CVA and SA using the distribution method.ResultsThe results showed that there was a significant difference between the experimental and control groups in terms of CVA (F = 89.04, P = 0.005, Effect size = 0.47) and SA (F = 18.83, P = 0.005, Effect size = 0.16). After eight weeks of selective corrective exercises, the MCID values of CVA and SA were 1.40° and 1.34°, respectively.ConclusionThis study revealed that the selective corrective exercises might lead to postural correction of students having FHP problem. Results further indicated that a corrective exercise program would be considered beneficial if it increased CVA and SA values at least 1.40 and 1.34 degrees, respectively.

Background: The importance of postural stabilization and cervical mobilization in subjects with pain from the anterior head posture is drawing more attention. However, studies on head and neck stabilizing intervention after mobilization are lacking. Objective: To examine the effects of Kinesiotaping and posture setting exercise on forward head posture (FHP). Design: Crossover Study Design Methods: The subjects were 17 male and female college students in their 20s with FHP. They were randomized into the Kinesiology taping group (KTG) with 9 subjects and posture stabilizing exercise group (PSEG) with 8 subjects. The intervention was conducted for 4 weeks, and changes in pain, craniovertebral angle (CVA), and proprioception were observed before and after intervention. Results: Pain was significantly reduced in the KTG and PSEG both before and after intervention. CVA and proprioception were significantly increased only in the PSEG. The differences in CVA and proprioception between the two groups were significant. Conclusions: These findings suggest that the application of posture setting exercise could decrease pain, proprioceptive error and increase CVA on FHP

Forward head posture is common among office workers who sit for long periods of time and is one of the main causes of neck pain. This study aimed to assess the effects of utilizing a standing desk on the craniovertebral angle, muscle fatigue, work performance, and discomfort in individuals with forward head posture. Twenty-four participants meeting the inclusion criteria were randomly assigned to either a traditional desk group (n = 12) or a standing desk group (n = 12). Each group engaged in 30 min of computer typing. To evaluate the impact of posture change using a standing desk, pre- and post-experiment discomfort surveys were conducted, and the craniovertebral angle and muscle fatigue were measured throughout the experiment. Work performance was assessed post-experiment based on the work completed by the participants. Intra-group analysis of the craniovertebral angle showed a significant decrease in the traditional desk group (p < 0.05) and a significant increase in the standing desk group (p < 0.05). When comparing the craniovertebral angle between the two groups, a significant difference was observed (p < 0.05). Additionally, significant differences in muscle fatigue, particularly in the levator scapulae muscles, were observed between the two groups (p < 0.05). The traditional desk group reported increased discomfort in the neck and shoulders (p < 0.05). These findings suggest that utilizing a standing desk can positively impact posture, reduce muscle fatigue, and alleviate discomfort in individuals with forward head posture, potentially serving as an intervention to prevent musculoskeletal disorders.

The study aimed to determine the effect of the proprioceptive neuromuscular facilitation (PNF) cervical stabilization exercise on pain, cranio vertebral angle (CVA), and neck disability index (NDI) in chronic neck pain patients with forward head posture. Following baseline measurements, 26 subjects (n=26) with chronic neck pain were randomized into two groups: the experimental group (n=13), which received PNF cervical stabilization exercise, and the control group (n=13), which received traditional physical therapy. Each group participated in the intervention for three times per week, for six weeks. The visual analogue scales (VAS) for pain, CVA, and NDI Korean version (KNDI) of both groups were recorded at both pre- and post-intervention. Paired t-tests were used to determine significant changes in the post-intervention period compared with pre-intervention, and independent t-tests were used to analyze differences in the dependent variables between the two groups. After the six-week intervention, both groups experienced significantly decreased VAS and KNDI (p<.05) and significantly increased CVA (p<.05). The experimental group that received the PNF cervical stabilization exercise showed greater improvements in pain, CVA, and KNDI than those of the control group (p<.05). These results suggest that the PNF cervical stabilization exercise reduces neck pain and functional disability and enhances CVA in chronic neck pain patients with forward head posture.

Background: The alignment of the neck and shoulder is important in people with forward head posture. However, previous studies have mainly conducted fragmentary studies on the neck and shoulders, and studies on the combined movement of the neck and shoulders are incomplete. Objective: To investigate the effects of 6 week dynamic exercise program using Thera-band on craniovertebral angle (CVA) in adults with forward head posture. Design: Quasi-experimental study. Methods: The study was conducted on 24 adults with forward head posture and experimented with neck and shoulder exercises and divided them into groups of neck exercises, shoulder exercises, and neck and shoulder exercises to measure CVA values before and after the experiment. The neck exercise program included flexion and extension muscles of the neck and shoulder exercises included dynamic exercise of the upper extremities such as the trapezius muscles and serratus anterior muscle. The CVA results were measured using PA200. Results: Following the interventions, neck exercise group showed significant improvement in CVA (P .05). However, both groups showed some positive results. Significant differences were seen in the comparisons between the three groups (P<.05), and the results of the posthoc test showed significant differences in neck exercise group and shoulder exercise, neck exercise and combine exercise group. Conclusion: This study suggested that the Thera-band neck exercise is beneficial for foward head posture patients and is expected to be used in clinical trials.

Forward head posture (FHP) is a common postural problem experienced by most people. However, its effect on brain activity is still unknown. Accordingly, we aimed to observe changes in brain waves at rest to determine the effect of FHP on the nervous systems. A total of 33 computer users (Male = 17; Female = 16; age = 22.18 ± 1.88) were examined in both FHP and neutral posture. For each session, brain waves were measured for 5 min, and then muscle mechanical properties and cranio-vertebral angle (CVA) were measured. Changes in brain waves between the neutral posture and FHP were prominent in gamma waves. A notable increase was confirmed in the frontal and parietal lobes. That is, eight channels in the frontal lobe and all channels in the parietal lobe showed a significant increase in FHP compared to neutral posture. Additionally, FHP changes were associated with a decrease in CVA (p < 0.001), an increase in levator scapulae tone (Right, p = 0.014; Left, p = 0.001), and an increase in right sternocleidomastoid stiffness (p = 0.002), and a decrease in platysma elasticity (Right, p = 0.039; Left, p = 0.017). The change in CVA was found to have a negative correlation with the gamma activity (P7, p = 0.044; P8, p = 0.004). Therefore, increased gamma wave activity in FHP appears to be related to CVA decrease due to external force that was applied to the nervous system and cervical spine.

Background: Forward head posture is considered a deviation because the position of the head varies from that reference line. Frequent use of computers and mobile phones promote rounded shoulders and humped upper back and therefore resulting in forward head posture and neck pain. Objective: To assess the association between forward head posture and neck pain in office workers. Methods: This is a cross-sectional study in which about 88 office workers with age between 20 to 50 years, having neck pain and those who were actively working in their offices in front of personal computers and laptops were included in this study. Participants who has any neurological conditions and those who had neck pain or faulty posture due to any recent accident, trauma or injury were excluded from this study. A mixture of standardized and self-modified structured questionnaires was given to office workers with neck pain. They were inquired about the intensity of their neck pain, and their work concentration levels and were assessed whether they adopted a forward head posture to do their daily visual tasks at work. The posture was evaluated using the postural assessment checklist form and REEDCO postural assessment form. For qualitative variables percentages and frequency were calculated whereas for descriptive analysis, means and standard deviations were calculated for quantitative variables. Results: Out of 88 office workers with neck pain 46(52.27%) office workers had a severely forward head posture, 35(39.77%) had a moderately forward head posture and only 7 (7.95%) had a normal forward head posture. The results of this study suggest that neck pain might be a cause and risk factor of abnormal forward head posture among office workers or faulty forward head posture might be a cause or risk factor for the pain in the neck. Conclusion: It concludes that neck pain among office workers and forward head posture is associated with each other. Neck pain among office workers might be a cause and risk factor of forward head posture in office workers or adopting forward head posture might be a risk factor leading to neck pain.

INTRODUCTION: Tension headaches can be induced by forward head posture, and there is a wealth of evidence available for managing chronic headaches. The data supports the use of manual therapy approaches to manage tension type headaches. Because of the forward head posture, the suboccipital muscle region becomes short, resulting in an increase in lordosis and neck pain. Patients with an even more forward head posture have a smaller cranio-vertebral angle, which in turn causes tension type headache. OBJECTIVE: The aim of this study is to compare the effects of Myofascial release therapy(MFR) and Muscle energy technique(MET) with general neck exercises on the cranio-vertebral angle and headache in tension type headache patients. METHODS: In total, 75 subjects with tension type headache and suboccipital muscle tenderness were recruited and randomized blindly into three groups: the MFR group, the MET group, and the control group (25 subjects in each group). A pre-craniovertebral angle was taken by photographic method, and a pre-headache disability index questionnaire was filled in. The MFR group receives cranio-basal release in the suboccipital region with neck exercises, the MET group receives post–isometric relaxation in the suboccipital region with exercises, and the control group receives only exercises for 2 weeks. After two weeks, the postcranial angle and the headache questionnaire were taken and measured. RESULTS: Craniovertebral angle and headache index showed significant improvement in both the MET and MFR groups. There was no significant difference when MET and MFR groups were compared. When compared with the control group, both MET and MFR showed a significant increase in craniovertebral angle. There was significant improvement in the headache index following MET, MFR, or routine neck exercise. CONCLUSION: Compared to the control group, MFR shows better results than MET on craniovertebral angle and headache.