Background: Forward head posture affects many individuals and can cause pain and dysfunction in the muscles and joints of the head, neck, and shoulders. Objectives: This study aimed to assess muscle activity and onset time of cervical and scapular muscles during 180° shoulder flexion and abduction in individuals with normal head posture (NHP) and in those with forward head posture (FHP), both before and after correction. Design: Cross-sectional study. Methods: Thirty-six individuals were divided into FHP and NHP groups. Muscle activity and muscle contraction onset time of the splenius capitis, sternocleidomastoid, upper middle and lower trapezius, and serratus anterior muscles were measured during shoulder flexion and abduction using wireless surface electromyography. Results: The FHP group exhibited increased muscle activity compared to the NHP group (P<.05), notably in the sternocleidomastoid and middle trapezius muscles, more so during shoulder abduction than flexion (P<.05). Regarding muscle contraction onset time, sternocleidomastoid onset was fastest during shoulder abduction in the FHP group (P<.05), while serratus anterior onset was slowest during both shoulder abduction and flexion (P<.05). Conclusion: These findings highlight distinct muscle activity and muscle contraction onset time patterns based on head posture and shoulder movement. Selective muscle activation strategies may help reduce heightened sternocleidomastoid and trapezius activity and enhance serratus anterior engagement in individuals with FHP.

Background: Pain neuroscience education (PNE) with other therapeutic approaches can reduce pain intensity in patients with Chronic musculoskeletal pain and chronic spine pain by improving quality of life and disability. However, in various clinical trials and reviews, the optimal dose of an intervention combined with PNE is still an area to be studied. Objectives: To investigated the effect of forward head posture (FHP) with chronic neck pain on the PNE combined with cervical and thoracic mobilization. Design: A non-randomized, controlled intervention study. Methods: Thirty-two subjects were allocated to pain neuroscience education combined with cervical and thoracic mobilization group (PCTMG, n=17) and cervical and thoracic mobilization with TENS group (CTMG, n=15). For 6 weeks, the PCTM group applied PNE and cervical and thoracic mobilization and the CTM group applied cervical and thoracic mobilization and TENS. Changes in intervention pre-post pain and kinesiophobia were observed. Results: Results from the study indicated that statistically significant decrease in VAS and TSK-11 in PCTMG. In CTMG, there was a statistically significant decrease in VAS. And in PCTMG, there was a statistically significant decrease in VAS and TSK-11 than in CTMG. Conclusion: Therefore, this study confirmed that PNE combined with cervical thoracic mobilization is an effective intervention compared to ervical thoracic mobilization alone in reducing pain and kinesiophobia in FHP with chronic neck pain.

Background: The craniocervical flexion test (CCFT) was developed for the activation and endurance of deep cervical flexors. However, the muscle thickness and muscle thickness changing ratio of the sternocleidomastoid (SCM) and deep cervical flexor (DCF) muscles in subjects with and without forward head posture (FHP) have not been reported. Objects: To determine the difference in thickness of the SCM and DCF muscles and the difference in the muscle thickness changing ratio between SCM, DCF, and DCF/SCM 20 mmHg and DCF/SCM 30 mmHg between subjects with and without FHP. Methods: Thirty subjects with and without FHP were enrolled. The muscle thickness of the SCM and DCF was measured when maintained at a baseline pressure of 20 mmHg and a maximum pressure of 30 mmHg using a pressure biofeedback unit during the CCFT. Ultrasonography was used to capture images of SCM and DCF muscle thickness during the CCFT, which was calculated using the picture archiving and communication system (PACS). Results: We observed a significant difference within the pressure main effect between SCM and DCF at a baseline pressure of 20 mmHg and a maximum pressure of 30 mmHg (p < 0.05). However, there was no significant difference in the muscle thickness and muscle thickness changing ratio for SCM and DCF during CCFT between subjects with and without FHP. Conclusion: There was no significant difference in the muscle thickness recruitment pattern during CCFT in posture changes between subjects with and without FHP.

Background: Forward head posture leads to resulting in posture instability and changes in spine alignment. To treat this condition, numerous studies have shown the effectiveness of joint mobilization. However, only a few studies have reported on the intervention location of joint mobilization or its effects on heart rate variability. Objectives: To investigated the effects of joint mobilization intervention at the lower cervical spine on pain, head posture, and heart rate variability (HRV) in patients with a forward head posture. Design: A randomized controlled trial. Methods: Twenty patients with forward head postures who met the study inclusion criteria were recruited. A randomization program was used to divide the subjects into experimental and control groups. Each group consisted of ten subjects. The intervention was performed for four weeks, three sessions per week, 15 min per day, and non-simultaneously throughout the 12-week study period. Results: A significant decrease in neck pain was shown in both the experimental and control groups. In contrast, significant changes in craniovertebral angle (CVA), cranial rotation angle (CRA), and HRV were found only in the experimental group. Conclusion: The mobilization of the cervical spine is an effective intervention for improving pain, head posture, and HRV.

Background: Forward head posture (FHP) causes various posture imbalances associated with the head and neck. Myofascial release is an effective treatment method used for relaxing muscles and reducing muscle hyperactivity, but no studies have been conducted on suboccipital and neck muscles related to FHP. Objects: The purpose of this study was to investigate the immediate effect of roller massages on the cranio-cervical flexion (CCF) range of motion (ROM) and CCF strength applied to suboccipital and neck muscles in subject with forward head posture. Methods: Twenty-four FHP subjects (male: 13, female: 11) were recruited for this study. All subjects were recruited with a craniovertebral angle (CVA) of 53 degrees or less and a head tilt angle (HTA) of 20.66 degrees or higher. CCF strength was measured using Pressure biofeedback unit (PBU) in the supine posture and CCF ROM was measured using smartphone-based inclinometer. Roller massage (RM) was applied to suboccipital and neck muscles for 2 minutes and CCF ROM and strength were remeasured. Results: These results of this study showed that CCF ROM was a significant difference in CCF ROM before and after RM (p < 0.05). CCF strength also showed a significant difference before and after RM (p < 0.05). Conclusion: RM method might be recommended to increase the immediate ROM and strength of CCF in subjects with forward head posture.

Background: Forward head posture (FHP) is common postural malalignment. FHP is described relatively extension to upper cervical and lower cervical is relatively flexion. Although several researchers mentioned the lower cervical flexion posture in FHP, most of the studies related to FHP is focused on the deep cervical flexor function. Objects: The purposes of present study is to compare the cervical strength (upper cervical extension [UCE], lower cervical extension [LCE], upper cervical flexion [UCF], lower cervical flexion [LCF]) between individuals with and without FHP. Methods: Fifty-one participants are recruited. Participants who have the craniovertebral angle (CVA) less than 48 degree were classified to the FHP group (n = 24) and the others were included in without FHP group (n = 27). The cervical strength (UCE, LCE, UCF, LCF) were measured using Smart KEMA strength sensor and the strength data was normalized by body weight. All strength measurement conducted at head and neck neutral position in sitting. Independent t-test was used to compare the cervical strength between individuals with and without FHP. Results: The mean value of CVA was greater in without FHP group than with FHP group (p < 0.000). The strength value of UCF (p < 0.002) and LCE (p < 0.001) was significant less in FHP group than without FHP group. But no significant differences were seen in the LCF and UCE strength between two groups. Conclusion: UCF and LCE weakness in FHP group should be considered to evaluate and manage the individuals with FHP.

Background: Adults with forward head posture (FHP) often suffer from thoracic hyperkyphosis and thoracic dysfunction, and including reduction of the craniovertebral angle (CV angle) and tightening of the superficial neck muscles. In order to treat thoracic dysfunction, interventions aimed at improving thoracic mobility are necessary. Objectives: To examine the effects of maitland manual mobilization therapy on the thoracic spine in adults with FHP. Design: Single-blind randomized controlled trial. Methods: Thirty adults with FHP who met the selection criteria were randomized to the thoracic multiple joint mobilization (TMJM; n=15) group and the thoracic general joint mobilization (TGJM; n=15) group. Joint mobilizations were performed for 23 minutes a day for 4 weeks continuously, two times per week. Outcome measures were ImageJ, BTS FREE EMG 1000, neck disability Index (NDI). Results: Although changes in the left sternocleidomastoid muscle activity and NDI scores over time between the two groups differed, other variables were noted only changes observed over time. Muscle activity in the right sternocleidomastoid increased again in the TGJM group post-intervention and 2 weeks after the end of the experiment, but changes in other variables were retained or improved, confirming the lasting effects of thoracic joint mobilization. Conclusion: Thoracic multiple joint mobilization may be recommended as a more effective intervention for adults with FHP.

The purpose of this study was to identify the effect of upper thoracic mobilization on cervical alignment in stroke patients with forward head posture. The subject's of this study were two stroke patients with forward head posture and a cervical curve angle (four-line Cobb's method; FLCM) less than 40°. The intervention, central posterior-anterior (PA) mobilization, was applied to the T1-T4 vertebrae (upper thoracic spine) following the Maitland concept. This mobilization was applied three times per week for four weeks. In the results, the cervical curve angle (FLCM) increased for both subject 1 and 2. However, Jochumsen method score was decreased in subject 1, while it was increased in subject 2. These results demonstrate that upper thoracic mobilization had the positive effect on the cervical curve angle but not on Jochumsen method score. These findings suggest that PA mobilization on the upper thoracic spine could correct cervical curve angle measured by FLMC in stroke patients with FHP.

The purpose of this study was to identify the effects of cervical alignment, pain, and physique to apply proprioceptive neuromuscular facilitation( PNF) techniques in patients with forward head posture (FHP). The subjects of this study were 24 patients diagnosed with FHP. They were randomly divided into two groups: a PNF group(n=12) and a control group(n=12). The intervention was performed a total of 24 times, 30 min a day, six times a week for four weeks. Data on cervical alignment(forward head displacement, FHD), pain(visual analog scale, VAS), and physique(height, weight, and body mass index) were obtained pre- and post-intervention. Two-way repeated measures ANOVA was used to compare the groups and time. For FHD, the VAS, and physique(height and BMI), there was an interaction effect for the groups and time(p<.001, BMI: p<.05) and main effects for time(p<.001, BMI: p<.05). For weight, there were main effects of time(p<.01). For FHD(p<.01) and the VAS(p<.05), there were main effects for the groups. In the PNF group, there were significant improvements in FHD, VAS, and physique. In the control group, there was a significant increase in FHD. The results of this study indicated that PNF intervention using scapular and upper extremity patterns effective in FHP positively. The use of a therapeutic intervention on physique changes may also be effective in improving poor posture and help to better patients’ quality of life.

The purpose of this study was to investigate the effects of occipital bone stimulation by cervical stabilizing exercise on the muscle tone, stiffness, ROM, and cervical lordosis in patient with forward head posture( FHP). This study was a case study of a single patient with forward head posture. This study used a ABA' design, A and A' were the baseline phases and B was the intervention phase. The intervention was occipital bone stimulation by cervical stabilization exercise. It was administered once daily for 7 days. The therapist kept hands together, and placed the two index fingers under the subject's occipital bone. The subject performed the chin-in exercise with a maximum isometric contraction for 20 sec.The exercise was implemented by performing the movements 10 times as a set and repeating the set three times. The muscle tone was not significantly changed after intervention. However, the stiffness was decreased and lasted the effect lasted without intervention. The cervical flexion angle was increased, but the cervical extension angle was not significantly changed after the intervention. The left and right lateral flexion angles were increased and the effect lasted without any intervention. However, the left and right rotation angles were significantly changed after the intervention. Cervical lordosis increased not from 37° to 41° after the intervention. These results suggest that occipital bone stimulation by cervical stabilizing exercise had a positive effect on cervical stiffness, flexion and lateral flexion ROM, and lordosis in a patient with forward head posture.

Background: A forward head posture (FHP) is one of the most common types of poor head posture in patients with neck disorder. A prolonged FHP might increase pressure on the posterior cranio-cervical structure and exhibit reduced performance on a cranio-cervical flexion test (CCFT). CCFT is included to activate deep cervical flexor muscles and inhibit excessive activation of superficial cervical flexor muscles. Therefore, the selective activation of deep cervical flexors is needed for effective exercise for FHP. Objects: The purpose of this study was to compare muscle thickness between longus colli (Lco) and sternocleidomastoid (SCM) using ultrasonography in subjects with FHP depending on head support. Methods: This was a cross-sectional, case-control research design study. The ultrasonographic images of Lco and SCM were taken in 17 subjects with FHP during the 5 phases of the CCFT with and without a head support. Towel was used for supporting head to make the neutral head position in supine. Changes in muscle thickness during the test were calculated to infer muscle activation. Data were analyzed using repeated measures of two-way analysis of variance with the significance level of .05. Results: When subjects performed the CCFT with head support, there was a significant difference in muscle thickness of Lco and SCM (p<.05). According to a post hoc paired t-test, change of thickness of Lco was greater at all phases, and change of thickness of SCM muscle was less at phase 4 and 5 in condition with head support (p<.01) compared to condition without head support (p<.01). Conclusion: The result of this study suggest that applying head support for neutral head position during CCFT could be a useful method for activating Lco muscle without excessive activation of SCM muscle.

Background: For the treatment of forward head posture (FHP) and forward shoulder posture, methods for strengthening scapular retractors and deep cervical flexors and stretching pectoralis and upper cervical extensors are generally used. No study has yet assessed whether suboccipital release (SR) followed by cranio-cervical flexion exercise (CCFE) (SR-CCFE) will result in a positive change in the shoulders and neck, showing a “downstream” effect. Objects: The purpose of this study was to investigate the immediate effects of SR-CCFE on craniovertebral angle (CVA), shoulder abduction range of motion (ROM), shoulder pain, and muscle activities of upper trapezius (UT), lower trapezius (LT), and serratus anterior (SA) and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction in subjects with FHP. Methods: In total, 19 subjects (7 males, 12 females) with FHP were recruited. The subject performed the fifth phase of CCFE immediately after receiving SR. CVA, shoulder abduction ROM, shoulder pain, muscle activities of UT, LT, and SA, and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction were measured immediately after SR-CCFE. A paired t-test and Wilcoxon signed-rank test were used to determine the significance of differences in scores between pre- and post-intervention in the same group. Results: The CVA (p<.001) and shoulder abduction ROM (p<.001) were increased significantly postversus pre-intervention. Shoulder pain was decreased significantly (p<.001), and LT (p<.05) and SA (p<.05) muscle activities were increased significantly post- versus pre-intervention. The LT/UT muscle activity ratio was increased significantly post- versus pre-intervention (p<.05). However, there was no significant change in UT muscle activity and SA/UT muscle activity ratio between pre- and post-intervention (p˃.05). Conclusion: SR-CCFE was an effective intervention to improve FHP and induce downstream effect from the neck to the trunk and shoulders in subjects with FHP.

The purpose of this study is to investigate effects of Maitland orthopedic manipulative physiotherapy and stretching on pain, cervical range of motion, and muscle tone of adults with forward neck posture. A total 40 subjects were divided into a Maitland OMPT group(n=20) and a stretching group(n=20), performing joint mobilization exercise and stretching three times per week for six weeks. As for changes in pain, statistically significant decrease were found before and after the exercise within group comparison( p<.01), while no statistically significant difference was observed between-group comparison. In changes in cervical range of motion before and after the exercise, the Maitland OMPT group showed statistically significant increase(p<.01) in flexion, (left lateral flexion(p<.05), extension, left rotation, right rotation, and right lateral flexion, while the stretching group showed statistically significant increase(p<.05) in extension(p<.01), left rotation, left lateral flexion, right rotation, and right lateral flexion. However, no significant differences in between group comparison in flexion, extension, right rotation, left rotation, right lateral flexion and left lateral flexion. The results of measuring muscle tone changes showed that the Maitland OMPT group and the stretching group did not show significance in within and between group comparison(p<.05). In conclusion, the Maitland OMPT and stretching were effective on improving pain and range of motion.

This study compared the effects of the initial head position (i.e., a HHP versus a relaxed head position) of subjects with and without a FHP on the thickness of the deep and superficial neck flexor muscles during CCF. The study recruited 6 subjects with a FHP and 10 subjects without a FHP. The subjects performed CCF in two different head positions: a HHP, with the head aligned so that the forehead and chin formed a horizontal line, and a relaxed head position (RHP), with the head aligned in a self-selected comfortable position. During the CCF exercise, the thickness of the longus colli (LCo) and the thickness of the sternocleidomastoid (SCM) were recorded using ultrasonography. The thickness of each muscle was measured by Image J software. The statistical analysis was performed with a two-way mixed-model analysis of variance. The thickness of the SCM differed significantly (p<.05) between the subjects with and without FHP. According to a post hoc independent t-test, the change in thickness of the SCM increased significantly during CCF in the subjects with FHP while adopting a HHP compared to that in the subjects without FHP. The change in thickness of the SCM was not significantly different between the two positions in subjects without FHP, and there was no significant change in thickness of the LCo muscle during the CCF exercise according to the initial position in both subjects with and without FHP. The results suggest that CCF should be performed in RHP to minimize contraction of the SCM in subjects with a FHP.

This case report describes the effectiveness of cervical corrective exercises in a patient with cervical radiculopathy (CR) who experienced radicular pain, upper limb paresis, and limited functional activity. A 39-year-old male with cervical radiculopathy performed the cervical corrective exercises for reducing pain. Pain intensity, cervical posture, and active range of motion of cervical intersegmental spine motion were measured baseline, after 4 weeks, and after 8 weeks with self-reported questionnaire and radiographs. After 8 weeks of intervention, the patient demonstrated alleviated radicular symptoms, improved neck posture and active range of flexion and extension of the cervical intersegmental spine. Especially in the angle between the cervical vertebra 6 and 7, the angle was changed from -4.69° to 3.30° during resting position after intervention. The present case indicates that the cervical corrective exercises might be a possible treatment to effectively reduce radicular symptoms, improve neck posture, and active cervical intersegmental motion for patient with CR.

This study aims to reveal the impact of continuous antagonist strengthening( CAS) and Evjenth-Hamberg stretching(EHS) on the cervical mobility in the university students with abnormal transformation of forward head posture( FHP). Our experiment was conducted 3 times a week for 6 weeks in a total of 20 individuals : continuous antagonist strengthening(CAS) group(n=10) & Evjenth-Hamberg stretching(EHS) group(n=10). In a pre and post comparison, both CAS group and EHS group appeared significantly in mSBI and SBA(p<.05) and the two-group comparison showed a significant difference(p<.05) : CAS group showed better effects. Thus, it is considered that the combined use with continuous antagonist strengthening(CAS) had better effects for cervical mobility than Evjenth-Hamberg stretching(EHS) alone.

경추관절의 부정렬로 인한 두부전방자세를 가진 대상자에게 관절가동술을 적용 후 경추관절의 자세변화와 기능에 영향을 미치는지 알아보고자 한다. 대상자들은 경상북도 G대학 학생 39명 중 경부관절가동술그룹 20명, 가동술을 적용하지 않은 그룹 19명을 나누어서 실시하였으며, 대상자들은 방사선 사진 촬영을 한 후 그 중 경추전만각(cervical lordosis angle)이 21°이하이고, 머리의 전방무게부하(anterior weight bearing, AWB)가 15㎜이상이며, 경추 신전 관절가동범위(extension ROM)가 70°이하인 대학생을 선별하여 자발적 동의를 구하였다, Mulligan 기법(1995) 중 SNAGS로 경추 신전과 굴곡 운동을 주당 3회, 4주간 통증이 있는 관절을 치료사가 지속적인 종속활주운동(sustained accessory glide)을 적용하는 동안 환자가 능동적으로 관절운동을 각 회마다 천천히 8회 정도 적용하였다. 측정 방법은 방사선 검사와 경부장애지수를 통해 실시하였다. 실험 결과 두부전방자세 대상자에게 경부관절가동술 적용 후 경부관절가동술군에서 경부의 AWB와 ARA, 굴곡신전범위 변화, NDI에 대한 변화가 있음을 알 수 있었다. 대조군에서는 거의 변화가 없었다. 결론적으로 관절가동술 적용이 경부관절의 자세개선을 향상시키는데 영향을 미친 것으로 나타났고, 또한 두경부의 기능개선에서도 도움이 된 것으로 나타났다.