Comparison Between Dynamic Neuromuscular Stabilization Breathing and Manual Therapy on Forward Head Posture in University Students

The Effects of Dynamic Neuromuscular Stabilization Breathing and Manual Therapy on Forward Head Posture in University Students: A Randomized Controlled Trial

Forward Head Posture (FHP) is a common postural dysfunction characterized by the anterior displacement of the head relative to the shoulders, leading to cervical spine misalignment, increased muscle strain, and neck pain. It is highly prevalent in university students (63-66%), largely due to prolonged sedentary behaviors and the use of smartphones, laptops, and tablets in poor ergonomic postures .

This randomized controlled trial aims to evaluate the effectiveness of three intervention strategies for managing FHP in university students:

Dynamic Neuromuscular Stabilization (DNS) Breathing + Conventional Exercises: DNS breathing will emphasize diaphragmatic activation and postural stabilization, combined with stretching, strengthening, and postural education.

Myofascial Release (MFR) + Conventional Exercises: Suboccipital MFR to release fascial tension, combined with the same conventional exercise program.

Conventional Exercises Alone (Control Group): A standard rehabilitation protocol of stretching, strengthening, and postural correction.

All interventions will be delivered three times per week for six weeks, with each session lasting 45 minutes.

Assessments will be conducted at baseline, week 4, and week 6:

Craniovertebral Angle (CVA) and Forward Shoulder Angle (FSA) measured using smartphone photographic analysis.

Wall Test to assess forward head and rounded shoulder posture.

Visual Analog Scale (VAS) to measure subjective pain intensity.

SF-36 Health Survey to evaluate quality of life across eight health domains.

The study will compare the relative effectiveness of DNS breathing and MFR, each combined with conventional therapy, against conventional therapy alone. Findings are expected to contribute to evidence-based postural rehabilitation, particularly for young adults with sedentary lifestyles.

Study Overview

• Status: Recruiting
• Conditions: Forward Head Posture
• Intervention / Treatment: Other: Dynamic neuromuscular stabilisation breathing; Other: Convetional Exercises; Other: Myofascial Release

• Study Type: Interventional
• Enrollment (Estimated): 60
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Prof.Dr. H. Habibe serap INAL, doctor of physical therapy; Phone Number: +905325573354; Email: serap.inal@galata.edu.tr
• Study Contact Backup: Name: PT Rami M.osama Ramdoun, Bachelor of physical therapy; Phone Number: +905344100383; Email: 2333095007@stu.istinye.edu.tr

Study Locations

• Turkey (Türkiye)
  • Zeytinburnu
    • Istanbul, Zeytinburnu, Turkey (Türkiye), 34010
      • Recruiting
      • İstinye University, Fizyoterapi ve Rehabilitasyon Uygulama ve Araştırma Merkezi -İSÜFİZYOTEM
      • Contact: Dr. Öğr. Üyesi Nurgül Dürüstkan Elbaşı, phd of physical therapy; Phone Number: 0850 283 00 00; Email: sbf@istinye.edu.tr

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

University student aged 18 to 28 years

Presence of forward head posture confirmed by photogrammetric assessment

Mild to moderate cervical pain (VAS score between 0 and 6)

Voluntary agreement to participate in the study

Exclusion Criteria:

History of cervical spine surgery

Presence of neurological disorders

Diagnosis of cervical disc herniation

Severe musculoskeletal pain (VAS ≥ 7)

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

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Conventional Therapy	Other: Convetional Exercises; Standardized exercise protocol including head rotation, neck/upper back extension, swimmer exercise, head retraction with resistance band, and upper trapezius/levator scapulae stretches.
Experimental: dynamic neuromuscular stabilisation breathing	Other: Dynamic neuromuscular stabilisation breathing; Diaphragmatic breathing exercises performed in supine, side-lying, and quadruped positions, 3 sets of 1 minute each.; Other: Convetional Exercises; Standardized exercise protocol including head rotation, neck/upper back extension, swimmer exercise, head retraction with resistance band, and upper trapezius/levator scapulae stretches.
Experimental: Myofacial release	Other: Convetional Exercises; Standardized exercise protocol including head rotation, neck/upper back extension, swimmer exercise, head retraction with resistance band, and upper trapezius/levator scapulae stretches.; Other: Myofascial Release; Manual sustained pressure applied to the suboccipital region, upper trapezius, and levator scapulae, 2-3 minutes per site, to reduce myofascial stiffness and improve tissue extensibility

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Craniovertebral Angle (CVA)	The craniovertebral angle (CVA) will be measured using digital photogrammetry to assess the degree of forward head posture. A marker will be placed on the tragus of the ear and the spinous process of C7, and the angle formed between a horizontal line through C7 and the line connecting C7 to the tragus will be calculated. Smaller angles indicate a greater degree of forward head posture.	4 weeks, and 8 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Visual Analogue Scale (VAS)	Pain intensity will be assessed using a 10 cm Visual Analogue Scale (VAS), where 0 indicates no pain and 10 indicates worst imaginable pain. Participants will mark their perceived pain level at rest and during activity.	Baseline, 4 weeks, and 8 weeks

Collaborators and Investigators

• Sponsor: Istinye University
• Investigators: Principal Investigator: Prof.Dr. Habibe. Serap İnal, doctor of physical therapy, istinye university, faculty of health sciences , Department of physical therapy and rehabilitation

Publications and helpful links

General Publications

• Ajimsha MS, Al-Mudahka NR, Al-Madzhar JA. Effectiveness of myofascial release: systematic review of randomized controlled trials. J Bodyw Mov Ther. 2015 Jan;19(1):102-12. doi: 10.1016/j.jbmt.2014.06.001. Epub 2014 Jun 13.
• Karimian R, Rahnama N, Ghasemi G, Lenjannejadian S. Photogrammetric Analysis of Upper Cross Syndrome among Teachers and the Effects of National Academy of Sports Medicine Exercises with Ergonomic Intervention on the Syndrome. J Res Health Sci. 2019 Jul 3;19(3):e00450.
• Fathollahnejad K, Letafatkar A, Hadadnezhad M. The effect of manual therapy and stabilizing exercises on forward head and rounded shoulder postures: a six-week intervention with a one-month follow-up study. BMC Musculoskelet Disord. 2019 Feb 18;20(1):86. doi: 10.1186/s12891-019-2438-y.
• Salahzadeh Z, Maroufi N, Ahmadi A, Behtash H, Razmjoo A, Gohari M, Parnianpour M. Assessment of forward head posture in females: observational and photogrammetry methods. J Back Musculoskelet Rehabil. 2014;27(2):131-9. doi: 10.3233/BMR-130426.
• Okuro RT, Morcillo AM, Ribeiro MA, Sakano E, Conti PB, Ribeiro JD. Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children. J Bras Pneumol. 2011 Jul-Aug;37(4):471-9. doi: 10.1590/s1806-37132011000400009. English, Portuguese.
• Briem K, Huijbregts P, Thorsteinsdottir M. Immediate effects of inhibitive distraction on active range of cervical flexion in patients with neck pain: a pilot study. J Man Manip Ther. 2007;15(2):82-92. doi: 10.1179/106698107790819882.
• Gulrandhe P, Kovela RK, Samal S. Effect of the Dynamic Neuromuscular Stabilization Technique on Functional Capacity in Overweight and Obese Individuals: A Randomized Controlled Trial. Cureus. 2023 Jul 18;15(7):e42076. doi: 10.7759/cureus.42076. eCollection 2023 Jul.
• Aggarwal, A., Nair, A., Palekar, T. J., & Bhamare, D. (2022). Effect of suboccipital release technique in forward head posture: A comparative study. Medical Journal of Dr. DY Patil University, 15(4), 534-537.
• Alshahrani, A., Aly, S. M., Abdrabo, M. S., & Asiri, F. Y. (2018). Impact of smartphone usage on cervical proprioception and balance in healthy adults. Biomed res, 29(12), 2547-2552.
• Naz, A., Bashir, M. S., & Noor, R. (2018). Prevalance of forward head posture among university students. Rawal Med J, 43(2), 260-2.

Study record dates

Study Major Dates

• Study Start (Actual): May 16, 2025
• Primary Completion (Estimated): July 15, 2026
• Study Completion (Estimated): July 15, 2026

Study Registration Dates

• First Submitted: December 29, 2025
• First Submitted That Met QC Criteria: July 20, 2026
• First Posted (Actual): July 23, 2026

Study Record Updates

• Last Update Posted (Actual): July 23, 2026
• Last Update Submitted That Met QC Criteria: July 20, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: Forward Head Posture, Dynamic Neuromuscular Stabilization, Myofascial Release, Conventional Therapy, Neck Pain, Cervical Spine
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Neck Pain; Therapeutics; Complementary Therapies; Physical Therapy Modalities; Rehabilitation; Therapy, Soft Tissue; Musculoskeletal Manipulations; Massage; Myofascial Release Therapy
• Other Study ID Numbers: 25 - 26 - 2025

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

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