Comparative Effects of Suboccipital Muscle Inhibition vs Instrument Assisted Soft Tissue Mobilization in Forward Head Posture

Forward Head Posture (FHP) is a prevalent postural dysfunction characterized by anterior displacement of the head relative to the shoulder line. It is often linked to musculoskeletal pain, restricted cervical mobility, and altered muscle activation patterns. The condition manifests with shortening of the upper trapezius, suboccipital muscles, semispinalis, splenius capitis, Sternocleidomastoid (SCM), and levator scapulae. Concurrently, there is weakness or inhibition in the deep cervical flexors, resulting in an imbalance between the cervical flexor and extensor muscle groups. These muscular imbalances contribute to dysfunctional cervical movement patterns, altered proprioception, and increased joint loading, particularly at the atlanto-occipital and cervico-thoracic junctions. The objective of this randomized controlled trial is to compare the effectiveness of Sub-Occipital Muscle Inhibition (SMI) and Instrument Assisted Soft Tissue Mobilization (IASTM) in improving postural alignment, reducing pain, and enhancing cervical range of motion in individuals with Forward Head Posture. It will address a common postural and musculoskeletal problem that affects a large portion of the population which will contribute to a more effective management approach for Forward Head Posture and will guide clinicians in selecting targeted, evidence-based therapies for their patients with FHP. As there is a lack of comparative studies assessing their relative effectiveness specifically for FHP, it will contribute novel data to the field of physiotherapy and rehabilitation science. A total of 38 participants with FHP will be randomly assigned into two equal groups (n=19). Group A will receive conventional physiotherapy along with Sub-Occipital Muscle Inhibition, while Group B will receive conventional physiotherapy combined with Instrument Assisted Soft Tissue Mobilization. Both groups will undergo 18 treatment sessions over six weeks, administered on alternate days. Both interventions are expected to show positive outcomes in improving FHP; however, the study aims to determine which technique is more effective. The results will help clinicians understand which manual therapy methods work best. This can make it easier for them to choose the right treatment for Forward Head Posture. Using proven techniques can improve patient comfort and recovery. In the end, it will help to provide advance approach and more personalised care for the patients.

Study Overview

• Status: Recruiting
• Conditions: Forward Head Posture; Occipital Muscle Inhibition Technique
• Intervention / Treatment: Procedure: suboccipital muscle inhibition; Procedure: Instrument assisted soft tissue mobilization

Detailed Description

Participants in this study will be randomly divided into two groups: Group A, which will undergo conventional physical therapy (hot pack, stretching, and strengthening), combined with suboccipital muscle inhibition (SMI), and Group B, which will receive conventional physical therapy (hot pack, stretching, and strengthening), along with instrument-assisted soft tissue mobilization (IASTM). Both groups will receive a total of 18 treatment sessions over a duration of 6 weeks, scheduled on alternate days (three sessions per week).

Each session will begin with application of a hot pack to the posterior cervical area (upper cervical spine) for 10 minutes while the patient lies in a relaxed prone position.

Following thermotherapy, Group A will undergo sub occipital muscle inhibition. The subjects will be placed in the supine position, with their eyes closed; the evaluator will sit at the head of an adjustable table and placed both palms under the subjects' head, contacting the evaluator's index, middle, and ring fingertips of both hands with the metacarpophalangeal joints in 90◦ flexion between the spinous process of the second cervical vertebra and the occipital condyles. Thereafter, painless and constant pressure will be exerted upward and toward the evaluator the pressure will be maintained for 2 minutes until tissue relaxation of the suboccipital region has been achieved. During the SMI technique, the subjects will be asked to keep their eyes closed to avoid eye movements that might change the suboccipital muscle tone Group B will undergo IASTM. Firstly explain the procedure, Position the patient comfortably to expose the target area. Apply emollient (e.g., massage cream or lubricant) to reduce friction. The technique will be delivered in unidirectional for 3- 5 minutes per muscle group, with controlled pressure and specific strokes (e.g., sweeping, fanning, strumming) adjusted according to patient tolerance (3 sessions/week). A cold pack may be applied to the treated area afterward to manage any potential soreness, minor inflammation, or bruising.

Then a structured stretching protocol will be implemented to address tight musculature commonly associated with Forward Head Posture (FHP). The targeted muscles include the pectoralis major, levator scapulae, sternocleidomastoid, and upper trapezius.

• Pectoralis major: Stand in open type doorway or a wall corner. Raise each arm to the sideways bent to 900, palm forward Rest the palm on wall. By slowly stepping forward using one foot, feel for stretch in chest and shoulder. Hold the position and step back and then relax. (27)

• Levator Scapulae: It is begun by sitting upright in chair, while rotating head to opposite side of that of anchored arm, chin tuck is to be performed toward the chest. With one hand grasping the back of head, gently pull downward until stretch is felt and hold.

• Sternocleidomastoid Patients will sit or stand tall with relaxed shoulders, gently tilt the head toward the opposite side (e.g., right ear to right shoulder), then slightly turn the chin upward and to the left, hold the position before repeating on the opposite side.
• Upper trapezius It involves sitting with the ipsilateral hand behind the back to stabilize the scapula, while the therapist applies a combination of cervical flexion, rotation to the tight side, and side-bending away from the tight side.

After stretching, a series of strengthening exercises will be conducted for muscles commonly weak in individuals with FHP, including the deep neck flexors, rhomboids, and serratus anterior.

• Deep neck flexors (chin tucks) Patients will perform chin tucks while standing with their back against a wall and feet slightly in front, nodding the head to slide the base of the skull toward the wall. Each repetition will be held for 5 seconds, repeated 10 times.
• Rhomboids (prone lateral raises) It will be done when the patient lies flat on the stomach, holding weights with arms extended and palms facing inward. The arms are lifted to the sides until parallel to the floor while squeezing the shoulder blades together, then slowly lowered.
• Serratus anterior (wall slide push-ups) The patient will stand with forearms against a wall and slides the arms upward while pushing the shoulder blades forward, simulating a push-up against the wall.

• Study Type: Interventional
• Enrollment (Estimated): 38
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Iqra Shafiq, DPT; Phone Number: 03115055398; Email: iqrashafiq944@gmail.com
• Study Contact Backup: Name: Hafiz Ali Bin Asim, MS-SPT; Phone Number: 03135088144; Email: pt.ali.asim@gmail.com

Study Locations

• Pakistan
  • Punjab Province
    • Islamabad, Punjab Province, Pakistan, 44000
      • Recruiting
      • Foundation University College of Physical Therapy
      • Contact: Iqra Shafiq, DPT; Phone Number: 03115055398; Email: iqrashafiq944@gmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Both genders
• Age: 18-40 years
• Increased upper thoracic spine kyphosis
• Craniovertebral angle CVA of < 52°

Exclusion Criteria:

• Cervical radiculopathy
• Neurological deficit
• Previous surgery of cervical or thoracic spine
• Spondylolisthesis
• Spinal stenosis
• Rheumatoid arthritis
• Vertebrobasilar artery insufficiency
• Congenital deformities like kyphosis, scoliosis.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Group A: suboccipital muscle inhibition; Group A will receive total 18 sessions in 6 weeks (3 sessions per week on alternate days). Each session will begin with application of a hot pack to the posterior cervical area (upper cervical spine) for 10 minutes while the patient lies in a relaxed prone position.Following thermotherapy, Group A will undergo sub occipital muscle inhibition. The subjects will be placed in the supine position, with their eyes closed; the evaluator will sit at the head of an adjustable table and placed both palms under the subjects' head, contacting the evaluator's index, middle, and ring fingertips of both hands with the metacarpophalangeal joints in 90◦ flexion between the spinous process of the second cervical vertebra and the occipital condyles. Thereafter, painless and constant pressure will be exerted upward and toward the evaluator the pressure will be maintained for 2 minutes until tissue relaxation of the suboccipital region has been achieved.	Procedure: suboccipital muscle inhibition; Group A will receive total 18 sessions in 6 weeks (3 sessions per week on alternate days). Each session will begin with application of a hot pack to the posterior cervical area (upper cervical spine) for 10 minutes while the patient lies in a relaxed prone position.Following thermotherapy, Group A will undergo sub occipital muscle inhibition. The subjects will be placed in the supine position, with their eyes closed; the evaluator will sit at the head of an adjustable table and placed both palms under the subjects' head, contacting the evaluator's index, middle, and ring fingertips of both hands with the metacarpophalangeal joints in 90◦ flexion between the spinous process of the second cervical vertebra and the occipital condyles. Thereafter, painless and constant pressure will be exerted upward and toward the evaluator the pressure will be maintained for 2 minutes until tissue relaxation of the suboccipital region has been achieved.
Experimental: Group B: Instrument assisted soft tissue mobilization; Group B will receive total 18 sessions in 6 weeks (3 sessions per week on alternate days). Each session will begin with application of a hot pack to the posterior cervical area (upper cervical spine) for 10 minutes while the patient lies in a relaxed prone position. Following thermotherapy, Group B will undergo IASTM. Firstly explain the procedure, Position the patient comfortably to expose the target area. Apply emollient (e.g., massage cream or lubricant) to reduce friction. The technique will be delivered in unidirectional for 3- 5 minutes per muscle group, with controlled pressure and specific strokes (e.g., sweeping, fanning, strumming) adjusted according to patient tolerance (3 sessions/week).Then a structured stretching protocol will be implemented to address tight musculature in Forward Head Posture (FHP). The targeted muscles include the pectoralis major, levator scapulae, sternocleidomastoid, and upper trapezius.	Procedure: Instrument assisted soft tissue mobilization; Group B will receive total 18 sessions in 6 weeks (3 sessions per week on alternate days). Each session will begin with application of a hot pack to the posterior cervical area (upper cervical spine) for 10 minutes while the patient lies in a relaxed prone position. Following thermotherapy, Group B will undergo IASTM. Firstly explain the procedure, Position the patient comfortably to expose the target area. Apply emollient (e.g., massage cream or lubricant) to reduce friction. The technique will be delivered in unidirectional for 3- 5 minutes per muscle group, with controlled pressure and specific strokes (e.g., sweeping, fanning, strumming) adjusted according to patient tolerance (3 sessions/week).Then a structured stretching protocol will be implemented to address tight musculature in Forward Head Posture (FHP). The targeted muscles include the pectoralis major, levator scapulae, sternocleidomastoid, and upper trapezius.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain Intensity	It will be measured by numeric pain rating scale in which patients rate their pain from 0 (no pain) to 10 (worst pain imaginable).	baseline and post-intervention (week 6)
Neck Disability Index (NDI)	The Neck Disability Index (NDI) is a ten-item questionnaire based on the Owestry Low Back Pain Index that assesses disability associated with neck pain and whiplash. Participant will select from one of six potential responses for each item ranging from no disability (0) to total disability (5). The ten items are summed to gain the total score thus ranging from 0 (no disability) to 50 (maximum disability).	baseline and post-intervention (week 6)
DEEP NECK FLEXORS ENDURANCE TEST	The test is performed in the supine and crook lying position with the chin maximally tucked and maintained isometrically, the subject lifted the head and neck until the head will be approximately 2.5 cm off the plinth while maintaining the chin retracted to the chest. During the test verbal commands such as "tuck your chin in" or "hold your head up" will be given whenever there is a loss of chin tuck. The test will be stopped if the subject's head touched the investigator's hand for more than one second, if the skin folds began to separate due to a loss of chin tuck for the same amount of time, or if the subject wanted to stop because of fatigue or pain. The test will also be stopped if the subject lost more than 5° for over two seconds and in the end time will be measured in seconds by the therapist.	baseline and post-intervention (week 6)
CRANIOVERTEBRAL ANGLE	Goniometer is used to measure craniovertebral angle (CVA) and subsequently forward head posture (FHP). The CVA will be assessed in a relaxed sitting position on a high back chair with both feet on the floor and a position with the hips and knees maintained at 90◦. The subjects' hands should be relaxed on the thighs, with the eyes looking forward in a horizontal eye level. The CVA can be defined as the angle made by a horizontal line passing through C7 vertebra the line connecting the tragus of the ear. Greater measure of CVA is indicative of an ideal alignment whereas a smaller value indicates forward head posture. For this study we will place the immovable arm of the goniometer at the C7 spinous process and the movable arm at the tragus of the ear making an angle between the two lines, normal of which is 52◦ and angle less than that is considered as abnormal.	baseline and post-intervention (week 6)
Cervical Range of Motion	Goniometer is used to measure cervical range of motion that is available across a joint.	baseline, and post-intervention (week 6)

Collaborators and Investigators

• Sponsor: Foundation University Islamabad
• Investigators: Principal Investigator: Iqra Shafiq, DPT, Foundation University Islamabad

Study record dates

Study Major Dates

• Study Start (Estimated): May 13, 2026
• Primary Completion (Estimated): July 1, 2026
• Study Completion (Estimated): July 15, 2026

Study Registration Dates

• First Submitted: May 12, 2026
• First Submitted That Met QC Criteria: May 12, 2026
• First Posted (Actual): May 18, 2026

Study Record Updates

• Last Update Posted (Actual): May 18, 2026
• Last Update Submitted That Met QC Criteria: May 12, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Other Study ID Numbers: FUI/FUCP/CTR/09.26/Iqra Shafiq

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No