Is Neck Pain Related to Sagittal Head and Neck Posture?: A Systematic Review and Meta-analysis

Background

Neck pain (NP) is common in all age groups and adversely affects the patients' entire lifestyle. There exists inconclusive evidence relating faulty craniocervical posture with pain-related disability. This review aims to determine whether sagittal head and neck posture differs in NP and pain-free subjects, to critically appraise the correlation of posture with NP.

Methods

Of 3796 articles identified at primary search from CINAHL, PubMed, Google Scholar, EMBASE, 26 were included based on eligibility criteria. Mean pooled difference (MPD) and effect size (ES) were calculated to establish relationship among studies, to assess postural correlation with NP measures [Visual Analogue Scale (VAS), Numeric Pain Rating Scale (NPRS), neck disability index (NDI), Northwick Park NP Questionnaire (NPQ)] and for age- and gender-wise variation. Risk of bias was assessed using Newcastle-Ottawa Quality Assessment Scale.

Results

Craniovertebral angle (CVA) had a significant MPD of - 2.93(95% CI - 4.95 to - 0.91). Sagittal head angle (SHA) and forward head posture (FHP) had an insignificant MPD of 1.15 (95% CI - 1.16 to 3.46) and - 0.26 (95% CI - 1.89 to 1.36), respectively. Age- and gender-wise CVA difference was found to be 2.36° and 2.57°, respectively. ES was significant for correlation between CVA and pain intensity [NPRS: - 0.44 (95% CI - 0.61 to - 0.26); VAS: - 0.31 (95% CI - 0.46 to - 0.16)], and between CVA and disability [NDI: - 0.18 (95% CI - 0.31 to - 0.05); NPQ: - 0.47 (95% CI - 0.61 to - 0.320)].

Conclusion

CVA differs for age, gender, and pain vs pain-free subjects, and correlates negatively with NP measures. Other surrogate measures (SHA, cranial and cervical angles, FHP) warrant further research.

PROSPERO Registration

PROSPERO 2021 CRD42021275485.

Effectiveness of posture-correction interventions for mechanical neck pain and posture among people with forward head posture: protocol for a systematic review

INTRODUCTION

Forward head posture (FHP) is the most common postural deviation of the upper back. It is believed to be one of the predisposing factors for the development of mechanical neck pain (MNP). We propose doing a systematic review to find the effectiveness of interventions targeted on FHP with MNP and assess implementation fidelity associated with these interventions.

METHODS AND ANALYSIS

Medline (PubMed), Web of Science (Social Science Citation Index), EMBASE, Scopus, PEDro and CINAHL databases will be searched for studies published in English from their inception. Forward and backward citations of the included studies will be investigated for identifying additional records. We will include randomised controlled trials and non/quasi-experimental studies with two groups assessing the effectiveness of interventions targeted on FHP with MNP. Observational studies, non-randomised studies with single group and reviews will be excluded. We will consider the following outcome measures: postural variables of FHP, neck pain, performance-based functional disability scores of the neck, quality of life, basic activities of daily living and work-related outcomes. The unique citations will be screened by titles/abstracts and full texts, independently. The Cochrane Risk of Bias 2 tool will be used to critically appraise the included studies. The risk of bias and data abstraction of included studies will be undertaken independently. A qualitative synthesis will be conducted and, if sufficient studies with comparable outcome measures are available, we will statistically pool the result.

ETHICS AND DISSEMINATION

We will undertake a systematic review of primary studies, and will not directly recruit participants hence, ethical clearance is not applicable. We will aim to present the findings of the completed systematic review at an international conference and subsequently submit the manuscript in a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42021250310.

Posture and Health: Are the Biomechanical Postural Evaluation and the Postural Evaluation Questionnaire Comparable to and Predictive of the Digitized Biometrics Examination?

Background: Postural tone alterations are expressions of myofascial and, therefore, of structural, visceral, and emotional disorders. To prevent these disorders, this study proposes a quantitative investigation method which administers a postural evaluation questionnaire and a postural biomechanical evaluation to 100 healthy subjects. Methods: The reliability of the method is studied by comparing both assessments with digitized biometrics. In addition, 50 subjects undergo the biomechanical evaluation form twice, by four different operators, to study the intraoperative repeatability. Results: The results show a satisfactory overlap between the results obtained with the postural evaluation questionnaire and the postural biomechanical evaluation compared to computerized biometrics. Furthermore, intraoperative repeatability in the use of the biomechanical evaluation form is demonstrated thanks to a minimal margin of error. Conclusions: This experience suggests the importance of undertaking this path in both the curative and the preventive sphere on a large scale and on different types of people who easily, and even unknowingly, may face dysfunctional syndromes, not only structural and myofascial but also consequently of the entire body’s homeostasis.

Is Neck Posture Subgroup in Late Adolescence a Risk Factor for Persistent Neck Pain in Young Adults? A Prospective Study

OBJECTIVE

The purpose of this study was to determine whether sagittal neck sitting posture subgroup membership in late adolescence was a risk factor for persistent neck pain (PNP) in young adults.

METHODS

There were 686 participants enrolled in the Raine Study at the 17- and 22-year follow-ups. At 17 years of age, posture was measured by photographs, and 4 subgroups of sitting neck posture were determined by cluster analysis. Height and weight were measured, and exercise frequency, depression, and PNP were assessed by questionnaire. At 22 years of age, participants answered questions about neck pain and occupation type. Logistic regression examined if neck posture subgroups at 17 years of age were a risk factor for PNP at 22 years of age, taking into account other factors.

RESULTS

Female sex (odds ratio [OR] = 1.75, 95% CI = 1.16-2.65) and PNP at 17 years of age (OR = 3.78, 95% CI = 2.57-5.57) were associated with PNP at 22 years of age. In females, neck posture subgroup at 17 years of age was a risk factor for PNP at 22 years of age. Compared with the upright subgroup, both the slumped thorax/forward head subgroup groups and the intermediate subgroup had decreased odds for PNP at 22 years of age (OR = 0.24, 95% CI = 0.08-0.76; OR = 0.38, 95% CI = 0.15-0.99, respectively). No association was found in males.

CONCLUSION

After taking into account PNP at 17 years, sitting neck posture at 17 was not a risk factor for PNP at 22 years of age in males, whereas in females, more relaxed postures (slumped thorax/forward head and Intermediate postures) were protective of neck pain compared with upright posture.

IMPACT

Females in late adolescence who sat in slumped thorax/forward head or intermediate posture rather than upright sitting posture had a lower risk of PNP as a young adult. The practice of generic public health messages to sit up straight to prevent neck pain needs rethinking.

Craniocervical Posture Assessed With Photogrammetry and the Accuracy of Palpation Methods for Locating the Seventh Cervical Spinous Process: A Cross-sectional Study

OBJECTIVE

The purpose of this study was to compare craniocervical posture assessed by photogrammetry using 2 distinct palpation methods for locating the spinous process of the seventh cervical vertebra (C7SP).

METHODS

This cross-sectional study was conducted in 2 phases. In phase I (n = 42), the assessor's accuracy in locating the C7SP using the flexion-extension and the modified thorax-rib static methods was compared to radiography. In phase II (n = 68), the craniocervical posture was analyzed with photogrammetry after palpation using the 2 methods. Neck pain intensity and disability were also determined.

RESULTS

The accuracy in locating the C7SP was higher using the modified thorax-rib static method (67%, 95% confidence interval [CI], 55-79) compared to the flexion-extension method (38%, 95% CI, 26-50, P = .016). Lower values of the craniocervical angle were obtained with the flexion-extension method than the modified thorax-rib static method (mean difference = -1.1°, 95% CI, -1.6 to -0.6, P < .001). However, both palpation methods resulted in similar classifications of participants as with or without forward head posture (P = .096). Weak correlations were observed between the craniocervical angle and neck pain intensity (ρ = -0.088 and -0.099, respectively) and disability (ρ = -0.231 and -0.249, respectively).

CONCLUSION

Craniocervical angles obtained using palpation methods with different accuracies were different, although the magnitude of the difference was insufficient to lead to different classifications of a forward head posture in adults with mild neck pain and disability. Craniocervical posture was weakly correlated with neck-pain intensity and disability.

Effects of Deep Cervical Flexor Training on Forward Head Posture, Neck Pain, and Functional Status in Adolescents Using Computer Regularly

In contemporary societies, computer use by children is a necessity and thus highly prevalent. Using computers for long hours is related to a higher risk of computer-related muscular disorders like forward head posture (FHP) and neck pain (NP). Deep cervical flexor (DCF) muscles are important head-on-neck posture stabilizers; thus, their training may lead to an improvement in FHP and NP. The aim of this study was to determine if 4 weeks of DCF training is effective in alleviating NP, improving FHP, and functional status in adolescent children using computers regularly, a pretest-posttest experimental group design was used. Subjects were randomly assigned into the experimental group (receiving DCF training and postural education) and the control group (receiving postural education only). 30 subjects with a mean age of 15.7 ± 1.725 years with NP and FHP using computers regularly participated in the study. Dependent variables were measured on day 1 (at baseline) and after 4 weeks of training. Photographic analysis was used for measuring FHP, visual analog scale for NP intensity, and neck disability index for functional status. Data analysis showed that in both groups, no significant improvement occurred in FHP. In both groups, there was a significant improvement in functional status and NP. There was no significant difference between both groups for FHP and NP. There was a significant improvement in functional status in the experimental group in comparison to the control group. Four weeks of DCF training does not cause a significant improvement in FHP in 13 to 18 years old adolescent children using computers regularly.

A 10-week exercise intervention can improve work posture but not neck/shoulder symptoms in dental health students: A pilot cohort study

BACKGROUND

Dental workers including dental health students experience a high incidence of neck/shoulder symptoms. However, research into interventions has been scarce and largely focused on tools and technological modifications.

OBJECTIVE

This study investigates the feasibility and benefits of a neck/shoulder exercise intervention on work posture and local symptoms in dental health students.

METHODS

Twenty-three students participated in a 10-week resistance exercise program for 2 minutes daily, 5 days per week. Work posture (evaluated with the Rapid Upper Limb Assessment tool, RULA), muscle strength measures, self-rated symptom severity and function were collected. Feasibility of the intervention was determined with six items scored on a 5-point Likert scale.

RESULTS

The exercise intervention improved: work posture score by 1.88 (95% CI 1.05-2.70, p < 0.01) points on the RULA; isometric maximal strength of neck flexor and extensor muscles by 17.2% (95% CI 6.9-27.6%, p < 0.01) and 23.2% (95% CI 10.2-36.3%, p < 0.01) respectively; and clinical performance (77%). Isometric strength of the shoulder muscles, and symptom severity at the neck/shoulder showed no improvement. Adherence to training was 77%.

CONCLUSION

Ten weeks of exercise was feasible for dental health students, and likely beneficial with improvements in work posture and neck muscle strength.

The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

Forward head posture (FHP) is the most common cervical postural fault in the sagittal plane that is found with different severity levels in almost all populations. Despite claims that FHP may be related to neck pain, this relation seems to be controversial. Thus, our purpose is to determine whether FHP differs between asymptomatic subjects and those with neck pain and to investigate if there is a relationship between head posture and neck pain.

RECENT FINDINGS

A total of 15 cross-sectional studies were eligible for inclusion for this systematic review and meta-analysis. Ten studies compared FHP between a group of asymptomatic participants and a group of participants with neck pain and an overall mean difference (MD) of 4.84 (95% CI = 0.14, 9.54), indicating a significant between-group difference, contrary to adolescent (MD = - 1.05; 95% CI = - 4.23, 2.12). Eight studies showed significant negative correlations between FHP and neck pain intensity (r = - 0.55; 95% CI = - 0.69, - 0.36) as well as disability (r = - 0.42; 95% CI = - 0.54, - 0.28) in adults and older adults, while in adolescents, only lifetime prevalence and doctor visits due to neck pain were significant predictors for FHP. This systematic review found that age played an important role as a confounding factor in the relation between FHP and neck pain. Also, the results showed that adults with neck pain show increased FHP when compared to asymptomatic adults and that FHP is significantly correlated with neck pain measures in adults and older adults. No association was found between FHP and most of neck pain measures in adolescents.

The Effect of Ergonomic Latex Pillow on Head and Neck Posture and Muscle Endurance in Patients With Cervical Spondylosis: A Randomized Controlled Trial

OBJECTIVES

Cervical pillows have frequently been reported to attenuate the symptoms of pain and disability. Although the main role of pillows is to optimize head and neck posture and relax the neck muscles, limited studies have examined the effectiveness of pillows from aspects beyond subjective outcome measures, especially their effect on head and neck posture and muscle performance. This study examines the effect of ergonomic latex pillow on the craniovertebral (CV) angle and cervical flexor and extensor muscle endurance in patients with cervical spondylosis.

METHODS

This parallel-group, randomized, controlled trial was conducted from January to June 2017. The patients with cervical spondylosis were randomly allocated to the experimental and control groups, who both received identical standard physiotherapy 3 × a week for 4 weeks. The experimental group received an ergonomic latex pillow, but the control group was asked to continue sleeping on their usual pillow. The CV angle and flexor and extensor muscle endurance were measured before and after the intervention. The independent-sample t test was used to compare changes in the CV angle, whereas the Mann-Whitney test was used to compare changes in flexor and extensor muscle endurance between the groups, respectively.

RESULTS

The experimental group showed significant changes in the CV angle and extensor muscle endurance. A significant increase was observed in extensor muscle endurance in the experimental group compared with the control group.

CONCLUSION

The ergonomic latex pillow may affect neck extensor muscle endurance and CV angle in patients with cervical spondylosis, although further studies are needed before any recommendations.

A systematic review with meta-analysis on functional changes associated with neck pain in adolescents

BACKGROUND

Neck pain (NP) is highly prevalent in young people, but there has been no systematic review synthetizing the functional changes associated with this in adolescents. The aim of the present study was to identify and assess critically the evidence on the functional changes associated with NP in adolescents, specifically for: (a) posture; (b) postural control; (c) range of motion; (d) proprioception; (e) muscle function; and (f) sensory threshold.

METHODS

We searched PubMed, ScienceDirect, Web of Science, PEdro, Scielo, Scopus and Academic Search Premier databases for relevant studies. Two reviewers screened studies for inclusion and assessed the quality of the included studies. One reviewer extracted relevant data from the included studies. A meta-analysis was performed for studies that measured forward head posture (FHP).

RESULTS

Ten studies were included and a total of 15 comparisons for different variables were made. When compared with adolescents without NP, those with NP showed no differences in cervicothoracic posture or FHP. However, statistically significant differences were found for range of motion: weighted mean difference (WMD) from -14.0° (-21.1° to -1.1°) to 9.4° (2.8° to 16.0°); flexor muscle endurance: WMD -11.4 (-21.8 to -0.9) s; extensor muscle endurance: WMD -42.0 (-77.8 to -6.3) s; joint repositioning error for right and left rotation: WMD 1.9° (0.8° to 2.9°) and 2.4° (1.3° to 3.5°), respectively; and pressure pain threshold: WMD from -15.6 (-18.5 to -12.8) to -9.3 (-11.3 to 7.2) N/ cm².

CONCLUSION

There is very limited to limited evidence that there is no difference in posture between adolescents with and without NP, and that there is a difference for range of motion, muscle function, proprioception and pressure pain threshold.

Posture, muscle endurance and ROM in individuals with and without neck pain

Abstract Introduction: Factors such as postural changes, reduced neck muscle endurance and reduced range of motion (ROM) are common characteristics attributed to people with neck pain. Objective: (a) Identify differences in postural, muscular endurance and ROM characteristics between individuals with and without neck pain and (b) relate the presence and intensity of neck pain with the characteristics of static posture, muscular endurance and cervical ROM. Method: A cross-sectional study with 60 subjects equally divided into two groups with respect to the presence of neck pain carrying out the following evaluations: (1) static postural evaluation by digital photogrammetry; (2) the neck flexor endurance test; and (3) evaluation of cervical ROM using a fleximeter. The data were analyzed with independent t-tests, the Mann-Whitney U test, and the Spearman and Tau of Kendall correlation tests (α < 0.05). Results: There were no statistical differences between individuals with and without neck pain regarding the postural, muscle endurance and cervical ROM characteristics. No statistically significant correlations were found between pain and posture, muscle endurance and cervical ROM. Conclusion: Individuals with neck pain do not appear to present differences in their postural, neck flexor muscle endurance or cervical ROM characteristics when compared to individuals without neck pain, and neck pain appears to be unrelated to these variables.

Is forward head posture relevant to cervical muscles performance and neck pain? A case-control study

BACKGROUND

Forward head posture (FHP) and muscular dysfunction are likely contributing factors to chronic neck pain (CNP) but there are inconsistent findings on the relevance of these factors to clinical CNP characteristics.

OBJECTIVE

To compare FHP, cervical muscles size and endurance between CNP and asymptomatic participants and to investigate their association with pain and disability and relative involvement of deep/superficial and flexor/extensor muscles.

METHODS

Thirty-two patients with CNP and 35 asymptomatic participants were included in this case-control study. FHP in standing, extensor and flexor muscles endurance and dimensions were assessed using digital photography, clinical tests and ultrasonographic imaging, respectively. The visual analog scale and neck disability index were also used to evaluate CNP patients' clinical characteristics.

RESULTS

Deep flexor (mean difference=0.06, 95% CI=0.02-0.11) and extensor muscles size (mean difference=0.07, 95% CI=0.01-0.12) were found to be significantly smaller in CNP patients. CNP patients also demonstrated lower levels of flexor (mean difference=14.68, 95% CI=3.65-25.72) and global extensor endurance capacity. FHP was neither different between the groups nor correlated with any of the dependent variables. Neither FHP nor endurance was correlated with pain/disability. Extensor endurance in both groups and flexor endurance in the asymptomatic group showed significant correlations with muscles size.

CONCLUSIONS

FHP was found neither different between groups nor correlated with muscle performance or CNP clinical characteristics. While cervical endurance was found lower in CNP patients, it did not show any association with pain/disability. The muscular size-endurance relationship seems to become more complex in the presence of NP. While deep muscles seem to be differentially affected in the presence of CNP, the alterations do not seem to be uniform in the flexor and extensor groups.

Repositioning error, pressure pain threshold, catastrophizing and anxiety in adolescents with chronic idiopathic neck pain

BACKGROUND

Impaired proprioception, increased pain sensitivity, higher levels of anxiety and catastrophizing are present in adults with chronic idiopathic neck pain. Despite the high prevalence of neck pain, studies in adolescents are scarce.

OBJECTIVES

The main aim was to compare pressure pain thresholds (PPTs) and joint repositioning error (JRE) between adolescents with chronic idiopathic neck pain and adolescents without neck pain. Secondary aims were to compare these groups for catastrophizing and anxiety and to investigate the association between PPTs, JRE and psychosocial variables and pain characteristics.

METHODS

80 adolescents (40 with and 40 without chronic neck pain) were assessed for: neck repositioning error, neck, upper trapezius and tibialis anterior PPTs, anxiety and catastrophizing. Neck pain was characterized in terms of intensity, frequency, duration and associated disability. MANCOVA was used for between group comparisons and Pearson and Spearman coefficients for correlational analysis.

RESULTS

Adolescents with neck pain showed higher levels of catastrophizing (p < 0.001) and anxiety (trait: p < 0.001; state: p = 0.028), lower PPTs (p < 0.001) and higher JRE (p < 0.001) than asymptomatic controls. Pain intensity, frequency and duration were moderately correlated with anxiety, and disability was moderately correlated with anxiety (r between 0.43 and 0.50, p < 0.05) and catastrophizing (r = 0.40, p < 0.05).

CONCLUSIONS

This study suggests that functional changes and maladaptive cognitive processes are present in adolescents with neck pain aged 16-18 years old. These findings need to be replicated in future studies.

Cervical Spine Muscle-Tendon Unit Length Differences Between Neutral and Forward Head Postures: Biomechanical Study Using Human Cadaveric Specimens

BACKGROUND

Forward head posture (FHP) may be associated with neck pain and poor health-related quality of life. Literature describes only qualitative muscle length changes associated with FHP.

OBJECTIVE

The purpose of this study was to quantify how muscle-tendon unit lengths are altered when human cadaveric specimens are placed in alignments representing different severities of FHP.

DESIGN

This biomechanical study used 13 fresh-frozen cadaveric cervical spine specimens (Occiput-T1, 54±15 y).

METHODS

Specimens' postural changes simulating increasing FHP severity while maintaining horizontal gaze were assessed. Specimen-specific anatomic models derived from computed tomography-based anatomic data were combined with postural data and specimen-specific anatomy of muscle attachment points to estimate the muscle length changes associated with FHP.

RESULTS

Forward head posture was associated with flexion of the mid-lower cervical spine and extension of the upper cervical (sub-occipital) spine. Muscles that insert on the cervical spine and function as flexors (termed "cervical flexors") as well as muscles that insert on the cranium and function as extensors ("occipital extensors") shortened in FHP when compared to neutral posture. In contrast, muscles that insert on the cervical spine and function as extensors ("cervical extensors") as well as muscles that insert on the cranium and function as flexors ("occipital flexors") lengthened. The greatest shortening was seen in the major and minor rectus capitis posterior muscles. These muscles cross the Occiput-C2 segments, which exhibited extension to maintain horizontal gaze. The greatest lengthening was seen in posterior muscles crossing the C4-C6 segments, which exhibited the most flexion.

LIMITATIONS

This cadaver study did not incorporate the biomechanical influence of active musculature.

CONCLUSIONS

This study offers a novel way to quantify postural alignment and muscle length changes associated with FHP. Model predictions are consistent with qualitative descriptions in the literature.

Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents

BACKGROUND

There is conflicting evidence on the association between sagittal neck posture and neck pain.

OBJECTIVE

The purposes of this study were: (1) to determine the existence of clusters of neck posture in a cohort of 17-year-olds and (2) to establish whether identified subgroups were associated with biopsychosocial factors and neck pain.

DESIGN

This was a cross-sectional study.

METHODS

The adolescents (N=1,108) underwent 2-dimensional photographic postural assessment in a sitting position. One distance and 4 angular measurements of the head, neck, and thorax were calculated from photo-reflective markers placed on bony landmarks. Subgroups of sagittal sitting neck posture were determined by cluster analysis. Height and weight were measured, and lifestyle and psychological factors, neck pain, and headache were assessed by questionnaire. The associations among posture subgroups, neck pain, and other factors were evaluated using logistic regression.

RESULTS

Four distinct clusters of sitting neck posture were identified: upright, intermediate, slumped thorax/forward head, and erect thorax/forward head. Significant associations between cluster and sex, weight, and height were found. Participants classified as having slumped thorax/forward head posture were at higher odds of mild, moderate, or severe depression. Participants classified as having upright posture exercised more frequently. There was no significant difference in the odds of neck pain or headache across the clusters.

LIMITATIONS

The results are specific to 17-year-olds and may not be applicable to adults.

CONCLUSION

Meaningful sagittal sitting neck posture clusters were identified in 17-year-olds who demonstrated some differences with biopsychosocial profiling. The finding of no association between cluster membership and neck pain and headaches challenges widely held beliefs about the role of posture in adolescent neck pain.

Anatomical landmark position--can we trust what we see? Results from an online reliability and validity study of osteopaths

BACKGROUND

Practitioners traditionally use observation to classify the position of patients' anatomical landmarks. This information may contribute to diagnosis and patient management.

OBJECTIVES

To calculate a) Inter-rater reliability of categorising the sagittal plane position of four anatomical landmarks (lateral femoral epicondyle, greater trochanter, mastoid process and acromion) on side-view photographs (with landmarks highlighted and not-highlighted) of anonymised subjects; b) Intra-rater reliability; c) Individual landmark inter-rater reliability; d) Validity against a 'gold standard' photograph.

DESIGN

Online inter- and intra-rater reliability study.

SUBJECTS

Photographed subjects: convenience sample of asymptomatic students; raters: randomly selected UK registered osteopaths.

METHODS

40 photographs of 30 subjects were used, a priori clinically acceptable reliability was ≥0.4. Inter-rater arm: 20 photographs without landmark highlights plus 10 with highlights; Intra-rater arm: 10 duplicate photographs (non-highlighted landmarks). Validity arm: highlighted landmark scores versus 'gold standard' photographs with vertical line. Research ethics approval obtained.

RATERS

Osteopaths (n = 48) categorised landmark position relative to imagined vertical-line; Gwet's Agreement Coefficient 1 (AC1) calculated and chance-corrected coefficient benchmarked against Landis and Koch's scale; Validity calculation used Kendall's tau-B.

RESULTS

Inter-rater reliability was 'fair' (AC1 = 0.342; 95% confidence interval (CI) = 0.279-0.404) for non-highlighted landmarks and 'moderate' (AC1 = 0.700; 95% CI = 0.596-0.805) for highlighted landmarks. Intra-rater reliability was 'fair' (AC1 = 0.522); range was 'poor' (AC1 = 0.160) to 'substantial' (AC1 = 0.896). No differences were found between individual landmarks. Validity was 'low' (TB = 0.327; p = 0.104).

CONCLUSION

Both inter- and intra-rater reliability was 'fair' but below clinically acceptable levels, validity was 'low'. Together these results challenge the clinical practice of using observation to categorise anterio-posterior landmark position.

Does forward head posture affect postural control in human healthy volunteers?

Proprioceptive afferent input from neck muscles plays an important role in postural control. Forward head posture has the potential to impair proprioceptive information from neck muscles and contribute to postural control deficits in patients with neck pain. This study investigated whether induced forward head posture affects postural control in healthy participants when compared to natural head posture. Centre of pressure sway area, distance covered and mean velocity were measured during 30s of static standing using a force platform with 25 healthy individuals (mean age ± SD = 20.76 ± 2.19 years) in 8 different conditions. Base of support, eyes open or closed and natural or forward head posture varied within these testing conditions. The majority of comparisons between natural and forward head posture were not statistically significant (p>0.05). This suggests that induced forward head posture in young healthy adults does not challenge them enough to impair postural control. Future studies should evaluate whether forward head posture affects postural control of individuals with chronic neck pain.

The efficacy of forward head correction on nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial

Objective: To investigate the effect of forward head posture correction on pain and nerve root function in cases of cervical spondylotic radiculopathy.

Design: A randomized controlled study with six months follow-up.

Setting: University research laboratory.

Subjects: Ninety-six patients with unilateral lower cervical spondylotic radiculopathy (C5–C6 and C6–C7) and craniovertebral angle measured less than or equal to 50° were randomly assigned to an exercise or a control group.

Interventions: The control group ( n = 48) received ultrasound and infrared radiation, whereas the exercise group ( n = 48) received a posture corrective exercise programme in addition to ultrasound and infrared radiation.

Main outcome measures: The peak-to-peak amplitude of dermatomal somatosensory evoked potentials, craniovertebral angle, visual analogue scale were measured for all patients at three intervals (before treatment, after 10 weeks of treatment, and at follow-up of six months).

Results: There was a significant difference between groups adjusted to baseline value of outcome at 10 weeks post-treatment for craniovertebral angle, pain, C6 and C7 peak-to-peak amplitude of dermatomal somatosensory evoked potentials P = 0.000, 0.01, 0.000, 0.001 respectively and at follow-up for all previous variables ( P = 0.000).

Conclusion: Forward head posture correction using a posture corrective exercise programme in addition to ultrasound and infrared radiation decreased pain and craniovertebral angle and increased the peak-to-peak amplitude of dermatomal somatosensory evoked potentials for C6 and C7 in cases of lower cervical spondylotic radiculopathy.