A Comparison of Two Forward Head Posture Corrective Approaches in Elderly with Chronic Non-Specific Neck Pain: A Randomized Controlled Study

Aisha Salim Al Suwaidi, Ibrahim M Moustafa, Meeyoung Kim, Paul A Oakley, Deed E Harrison, Aisha Salim Al Suwaidi, Ibrahim M Moustafa, Meeyoung Kim, Paul A Oakley, Deed E Harrison

Abstract

Forward head posture (FHP) is a common postural displacement that is significantly associated with neck pain, with higher risks of having neck pain in female and older populations. This study investigated the effect of two different forward head posture (FHP) interventions in elderly participants with poor posture and non-specific neck pain. Sixty-six elderly participants with a craniovertebral angle (CVA) < 50° were randomized into either a Chiropractic Biophyics® (CBP®) or a standardized exercise based FHP correction group (Standard Group). Both groups were treated for 18 sessions over a 6-week period. A 3-month post-treatment follow-up was also assessed with no further interventions. The CBP group received a mirror image® exercise and a Denneroll™ cervical traction orthotic (DCTO); the standard group performed a protocol of commonly used stretching and strengthening exercises for the neck. Both groups received 30 min of their respective interventions per session. The primary outcome was the CVA, with secondary outcomes including pain intensity, Berg balance score (BBS), head repositioning accuracy (HRA), and cervical range of motion (CROM). After 18 sessions (6 weeks later), the CBP group had statistically significant improvement in the CVA (p < 0.001), whereas the standard group did not. In contrast, both groups showed improved functional measurements on the BBS and HRA as well as improved pain intensity. However, at the 3-month follow-up (with no further treatment), there were statistically significant differences favoring the CBP group for all outcomes (p < 0.001). The differences in the between group outcomes at the 3-month follow-up indicated that the improved outcomes were maintained in the CBP group, while the standard group experienced regression of the initially improved outcomes at 6 weeks. It is suggested that the improvement in the postural CVA (in the CBP group but not in the standard group) is the driver of superior and maintained pain and functional outcomes.

Keywords: craniovertebral angle; exercise; forward head posture; neck pain; orthotic.

Conflict of interest statement

PAO is a paid consultant for CBP NonProfit, Inc. DEH teaches is the CEO of Chiropractic BioPhysics, owns the registered trademark, teaches rehabilitation methods, and sells products used in this manuscript for patient rehabilitation to physicians in the USA. All the other authors declare that they have no competing interests.

Figures

Figure 1
Figure 1
Cervical Denneroll™ traction.
Figure 2
Figure 2
A simple bike chain analogy of the sequence of movements for the CBP group’s mirror image exercise and its proposed effect on the sagittal cervical spine alignment. (A) depicts neutral alignment with an altered curve; (B) depicts forward head posture (+TzH); (C) depicts upper neck/head extension (-RxH); and (D) depicts the effects of posterior head translation (-TzH) with slight inferior compression (-TyH). Images courtesy of Curtis Fedorchuk, reprinted with permission [28,29].
Figure 3
Figure 3
A patient’s lateral cervical x-rays are shown in neutral and after the mirror image exercise sequence (+TzH, −RxH, −TzH, −TyH) demonstrating the change in alignment from neutral with this sequence of movements: forward head posture (+TzH), upper neck/head extension (−RxH), followed by posterior head translation (−TzH) with an inferior compression component (−TyH). Images courtesy of Curtis Fedorchuk, reprinted with permission [28,29].
Figure 4
Figure 4
The chin tuck exercise: (A) starting position; (B) chin tucks performed while lying supine with the posterior aspect of the skull in contact with the floor; (C) the head is then lifted off the floor in a tucked posture.
Figure 5
Figure 5
The chin drop exercise: (A) the starting position; (B) the end stretching position; (C) a modification of the chin tuck that further emphasizes strengthening of the deep neck flexor muscles.
Figure 6
Figure 6
Scapular retractors strengthening exercise: (A) pulling the shoulders back using a theraband for resistance while standing to strengthen the shoulder retractors; (B) the initial progression step was to use weights to do shoulder retraction from a prone posture.
Figure 7
Figure 7
In (A) a unilateral pectoralis stretch is shown. In (B) a bilateral pectoralis stretch position is shown.
Figure 8
Figure 8
CVA at three intervals: (1) baseline, (2) one day following the completion of 18 visits after 6 weeks of treatment, and (3) three months after the participants’ 18-session re-evaluation.
Figure 9
Figure 9
Flow chart of study participants.

References

    1. Harman K., Hubley-Kozey C.L., Butler H. Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults: A Randomized, Controlled 10-Week Trial. J. Man. Manip. Ther. 2005;13:163–176. doi: 10.1179/106698105790824888.
    1. Kendall F.P., McCreary E.K., Provance P.G., Rodgers M.M.I., Romani W.A. Muscles: Testing and Function, with Posture and Pain. LWW; Baltimore, MD, USA: 2014.
    1. Griegel-Morris P., Larson K., Mueller-Klaus K., Oatis C.A. Incidence of Common Postural Abnormalities in the Cervical, Shoulder, and Thoracic Regions and Their Association with Pain in Two Age Groups of Healthy Subjects. Phys. Ther. 1992;72:425–431. doi: 10.1093/ptj/72.6.425.
    1. Mahmoud N.F., Hassan K.A., Abdelmajeed S.F., Moustafa I.M., Silva A.G. The Relationship Between Forward Head Posture and Neck Pain: A Systematic Review and Meta-Analysis. Curr. Rev. Musculoskelet. Med. 2019;12:562–577. doi: 10.1007/s12178-019-09594-y.
    1. Quek J., Pua Y.H., Clark R.A., Bryant A.L. Effects of Thoracic Kyphosis and Forward Head Posture on Cervical Range of Motion in Older Adults. Man. Ther. 2013;18:65–71. doi: 10.1016/j.math.2012.07.005.
    1. Lee J.H. Effects of Forward Head Posture on Static and Dynamic Balance Control. J. Phys. Ther. Sci. 2016;28:274–277. doi: 10.1589/jpts.28.274.
    1. Koseki T., Kakizaki F., Hayashi S., Nishida N., Itoh M. Effect of Forward Head Posture on Thoracic Shape and Respiratory Function. J. Phys. Ther. Sci. 2019;31:63–68. doi: 10.1589/jpts.31.63.
    1. Diab A.A., Moustafa I.M. The Efficacy of Forward Head Correction on Nerve Root Function and Pain in Cervical Spondylotic Radiculopathy: A Randomized Trial. Clin. Rehabil. 2012;26:351–361. doi: 10.1177/0269215511419536.
    1. Ling F.P., Chevillotte T., Leglise A., Thompson W., Bouthors C., Le Huec J.C. Which parameters are relevant in sagittal balance analysis of the cervical spine? A literature review. Eur. Spine J. 2018;27((Suppl. S1)):8–15. doi: 10.1007/s00586-018-5462-y.
    1. Ruivo R.M., Pezarat-Correia P., Carita A.I. Effects of a Resistance and Stretching Training Program on Forward Head and Protracted Shoulder Posture in Adolescents. J. Manip. Physiol. Ther. 2017;40:1–10. doi: 10.1016/j.jmpt.2016.10.005.
    1. Oakley P.A., Moustafa I.M., Harrison D.E. Spinal Deformities in Adolescents, Adults and Older Adults. IntechOpen; London, UK: 2021. Restoration of Cervical and Lumbar Lordosis: CBP® Methods Overview.
    1. Harrison D.D., Janik T.J., Harrison G.R., Troyanovich S., Harrison D.E., Harrison S.O. Chiropractic biophysics technique: A linear algebra approach to posture in chiropractic. J. Manip. Physiol. Ther. 1996;19:525–535.
    1. Oakley P.A., Harrison D.D., Harrison D.E., Haas J.W. Evidence-Based Protocol for Structural Rehabilitation of the Spine and Posture: Review of Clinical Biomechanics of Posture (CBP) Publications. J. Can. Chiropr. Assoc. 2005;49:270–296.
    1. Oakley P.A., Ehsani N.N., Moustafa I.M., Harrison D.E. Restoring Cervical Lordosis by Cervical Extension Traction Methods in the Treatment of Cervical Spine Disorders: A Systematic Review of Controlled Trials. J. Phys. Ther. Sci. 2021;33:784–794. doi: 10.1589/jpts.33.784.
    1. Moustafa I.M., Diab A.A., Harrison D.E. The Efficacy of Cervical Lordosis Rehabilitation for Nerve Root Function and Pain in Cervical Spondylotic Radiculopathy: A Randomized Trial with 2-Year Follow-Up. J. Clin. Med. 2022;11:6515. doi: 10.3390/jcm11216515.
    1. Moustafa I.M., Diab A.A.M., Harrison D.E. Does Improvement towards a Normal Cervical Sagittal Configuration Aid in the Management of Lumbosacral Radiculopathy: A Randomized Controlled Trial. J. Clin. Med. 2022;11:5768. doi: 10.3390/jcm11195768.
    1. Ruivo R.M., Carita A.I., Pezarat-Correia P. The Effects of Training and Detraining after an 8 Month Resistance and Stretching Training Program on Forward Head and Protracted Shoulder Postures in Adolescents: Randomised Controlled Study. Man. Ther. 2016;21:76–82. doi: 10.1016/j.math.2015.05.001.
    1. Diab A.A. The Role of Forward Head Correction in Management of Adolescent Idiopathic Scoliotic Patients: A Randomized Controlled Trial. Clin. Rehabil. 2012;26:1123–1132. doi: 10.1177/0269215512447085.
    1. Mulet M., Decker K.L., Look J.O., Lenton P.A., Schiffman E.L. A Randomized Clinical Trial Assessing the Efficacy of Adding 6 x 6 Exercises to Self-Care for the Treatment of Masticatory Myofascial Pain. J. Orofac. Pain. 2007;21:318–328.
    1. Im B., Kim Y., Chung Y., Hwang S. Effects of Scapular Stabilization Exercise on Neck Posture and Muscle Activation in Individuals with Neck Pain and Forward Head Posture. J. Physical. Ther. Sci. 2015;28:951–955. doi: 10.1589/jpts.28.951.
    1. Jang H.J., Kim M.J., Kim S.Y. Effect of Thorax Correction Exercises on Flexed Posture and Chest Function in Older Women with Age-Related Hyperkyphosis. J. Phys. Ther. Sci. 2015;27:1161–1164. doi: 10.1589/jpts.27.1161.
    1. Kang D.Y. Deep Cervical Flexor Training with a Pressure Biofeedback Unit Is an Effective Method for Maintaining Neck Mobility and Muscular Endurance in College Students with Forward Head Posture. J. Phys. Ther. Sci. 2015;27:3207–3210. doi: 10.1589/jpts.27.3207.
    1. Kang J.-I., Jeong D.-K., Choi H. The Effect of Feedback Respiratory Exercise on Muscle Activity, Craniovertebral Angle, and Neck Disability Index of the Neck Flexors of Patients with Forward Head Posture. J. Phys. Ther. Sci. 2016;28:2477–2481. doi: 10.1589/jpts.28.2477.
    1. Lee S.M., Lee C.H., O’Sullivan D., Jung J.H., Park J.J. Clinical Effectiveness of a Pilates Treatment for Forward Head Posture. J. Phys. Ther. Sci. 2016;28:2009–2013. doi: 10.1589/jpts.28.2009.
    1. Seidi F., Rajabi R., Ebrahimi I., Alizadeh M.H., Minoonejad H. The Efficiency of Corrective Exercise Interventions on Thoracic Hyper-Kyphosis Angle. J. Back Musculoskelet. Rehabil. 2014;27:7–16. doi: 10.3233/BMR-130411.
    1. Ikegami S., Uehara M., Tokida R., Nishimura H., Sakai N., Horiuchi H., Kato H., Takahashi J. Cervical Spinal Alignment Change Accompanying Spondylosis Exposes Harmonization Failure with Total Spinal Balance: A Japanese Cohort Survey Randomly Sampled from a Basic Resident Registry. J. Clin. Med. 2021;10:5737. doi: 10.3390/jcm10245737.
    1. Yip C.H.T., Chiu T.T.W., Poon A.T.K. The relationship between head posture and severity and disability of patients with neck pain. Man. Ther. 2008;13:148–154. doi: 10.1016/j.math.2006.11.002.
    1. Fedorchuk C. Cervical Coupling Patterns following head retraction with compression to neutral: A Prospective Study; Proceedings of the 39th CBP Annual Convention; Scottsdale, AZ, USA. 13–15 October 2017.
    1. Fedorchuk C., Lightstone D., Comer R. Radiographic stress analysis to determine the proper coupling patterns of the cervical spine prior to intervention; Proceedings of the 2nd International Conference on Medical Imaging and Case Reports (MICR) 2019; Newton, Boston, MA, USA. 20–22 November 2019.
    1. SolakoÄa&lu Ö., Yalçin P., Dinçer G. The Effects of Forward Head Posture on Expiratory Muscle Strength in Chronic Neck Pain Patients: A Cross-Sectional Study. Turk. J. Phys. Med. Rehabil. 2020;66:161–168. doi: 10.5606/TFTRD.2020.3153.
    1. Subbarayalu A.V. Measurement of Craniovertebral Angle by the Modified Head Posture Spinal Curvature Instrument: A Reliability and Validity Study. Physiother. Theory Pract. 2016;32:144–152. doi: 10.3109/09593985.2015.1099172.
    1. Pickenbrock H.M., Diel A., Zapf A. A Comparison between the Static Balance Test and the Berg Balance Scale: Validity, Reliability, and Comparative Resource Use. Clin. Rehabil. 2016;30:288–293. doi: 10.1177/0269215515578297.
    1. Young I.A., Dunning J., Butts R., Mourad F., Cleland J.A. Reliability, Construct Validity, and Responsiveness of the Neck Disability Index and Numeric Pain Rating Scale in Patients with Mechanical Neck Pain without Upper Extremity Symptoms. Physiother. Theory Pract. 2019;35:1328–1335. doi: 10.1080/09593985.2018.1471763.
    1. Rix G.D., Bagust J. Cervicocephalic Kinesthetic Sensibility in Patients with Chronic, Nontraumatic Cervical Spine Pain. Arch. Phys. Med. Rehabil. 2001;82:911–919. doi: 10.1053/apmr.2001.23300.
    1. Lee H.Y., Teng C.C., Chai H.M., Wang S.F. Test-Retest Reliability of Cervicocephalic Kinesthetic Sensibility in Three Cardinal Planes. Man. Ther. 2006;11:61–68. doi: 10.1016/j.math.2005.03.008.
    1. Reddy R.S.Y., Maiya A.G., Rao S.K. Effect of age on cervicocephalic kinesthetic sensibiity. Int. J. Curr. Res. Rev. 2011;3:42–48.
    1. Moustafa I.M., Diab A.A., Hegazy F., Harrison D.E. Does Improvement towards a Normal Cervical Sagittal Configuration Aid in the Management of Cervical Myofascial Pain Syndrome: A 1- Year Randomized Controlled Trial. BMC Musculoskelet. Disord. 2018;19:396. doi: 10.1186/s12891-018-2317-y.
    1. Moustafa I.M., Diab A.A., Harrison D.E. The Effect of Normalizing the Sagittal Cervical Configuration on Dizziness, Neck Pain, and Cervicocephalic Kinesthetic Sensibility: A 1-Year Randomized Controlled Study. Eur. J. Phys. Rehabil. Med. 2017;53:57–71. doi: 10.23736/S1973-9087.16.04179-4.
    1. Moustafa I.M., Diab A.A., Taha S., Harrison D.E. Addition of a Sagittal Cervical Posture Corrective Orthotic Device to a Multimodal Rehabilitation Program Improves Short- and Long-Term Outcomes in Patients With Discogenic Cervical Radiculopathy. Arch. Phys. Med. Rehabil. 2016;97:2034–2044. doi: 10.1016/j.apmr.2016.07.022.
    1. Harrison D.E., Harrison D.D., Betz J.J., Janik T.J., Holland B., Colloca C.J., Haas J.W. Increasing the Cervical Lordosis with Chiropractic Biophysics Seated Combined Extension-Compression and Transverse Load Cervical Traction with Cervical Manipulation: Nonrandomized Clinical Control Trial. J. Manip. Physiol. Ther. 2003;26:139–151. doi: 10.1016/j.jmpt.2005.02.001. Erratum in J. Manip. Physiol. Ther. 2005, 28, 214.
    1. Harrison D.E., Cailliet R., Harrison D.D., Janik T.J., Holland B. A New 3-Point Bending Traction Method for Restoring Cervical Lordosis and Cervical Manipulation: A Nonrandomized Clinical Controlled Trial. Arch. Phys. Med. Rehabil. 2002;83:447–453. doi: 10.1053/apmr.2002.30916.
    1. Oliver M.J., Twomey L.T. Extension creep in the lumbar spine. Clin. Biomech. 1995;10:363–368. doi: 10.1016/0268-0033(95)00001-2.
    1. Jackson A., Gu W. Transport Properties of Cartilaginous Tissues. Curr. Rheumatol. Rev. 2009;5:40–50. doi: 10.2174/157339709787315320.
    1. Zioupos P., Currey J.D., Hamer A.J. The Role of Collagen in the Declining Mechanical Properties of Aging Human Cortical Bone. J. Biomed. Mater. Res. 1999;45:108–116. doi: 10.1002/(SICI)1097-4636(199905)45:2<108::AID-JBM5>;2-A.
    1. Wallmann H.W. Stretching and Flexibility in the Aging Adult. Home Health Care Manag. Pract. 2009;21:355–357. doi: 10.1177/1084822309334073.
    1. Harrison D.E., Colloca C.J., Harrison D.D., Janik T.J., Haas J.W., Keller T.S. Anterior Thoracic Posture Increases Thoracolumbar Disc Loading. Eur. Spine J. 2005;14:234–242. doi: 10.1007/s00586-004-0734-0.
    1. Keller T.S., Colloca C.J., Harrison D.E., Harrison D.D., Janik T.J. Influence of Spine Morphology on Intervertebral Disc Loads and Stresses in Asymptomatic Adults: Implications for the Ideal Spine. Spine J. 2005;5:297–309. doi: 10.1016/j.spinee.2004.10.050.
    1. Protopsaltis T.S., Scheer J.K., Terran J.S., Smith J.S., Hamilton D.K., Kim H.J., Mundis G.M., Hart R.A., McCarthy I.M., Klineberg E., et al. How the Neck Affects the Back: Changes in Regional Cervical Sagittal Alignment Correlate to HRQOL Improvement in Adult Thoracolumbar Deformity Patients at 2-Year Follow-Up. J. Neurosurg. Spine. 2015;23:153–158. doi: 10.3171/2014.11.SPINE1441.
    1. Scheer J.K., Passias P.G., Sorocean A.M., Boniello A.J., Mundis G.M., Klineberg E., Kim H.J., Protopsaltis T.S., Gupta M., Bess S., et al. Association between Preoperative Cervical Sagittal Deformity and Inferior Outcomes at 2-Year Follow-up in Patients with Adult Thoracolumbar Deformity: Analysis of 182 Patients. J. Neurosurg. Spine. 2016;24:108–115. doi: 10.3171/2015.3.SPINE141098.
    1. Glassman S.D., Bridwell K., Dimar J.R., Horton W., Berven S., Schwab F. The Impact of Positive Sagittal Balance in Adult Spinal Deformity. Spine. 2005;30:2024–2029. doi: 10.1097/01.brs.0000179086.30449.96.
    1. Harrison D.E., Cailliet R., Harrison D.D., Troyanovich S.J., Harrison S.O. A Review of Biomechanics of the Central Nervous System—Part II: Spinal Cord Strains from Postural Loads. J. Manip. Physiol. Ther. 1999;22:322–332. doi: 10.1016/S0161-4754(99)70065-5.
    1. Breig A., Marions O. Biomechanics of the Lumbosacral Nerve Roots. Acta Radiol. 1963;1:1141–1160. doi: 10.1177/028418516300100603.
    1. Berland R., Marques-Sule E., Marín-Mateo J.L., Moreno-Segura N., López-Ridaura A., Sentandreu-Mañó T. Effects of the Feldenkrais Method as a Physiotherapy Tool: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Int. J. Environ. Res. Public Health. 2022;19:13734. doi: 10.3390/ijerph192113734.
    1. Harrison D.D., Harrison D.E., Janik T.J., Cailliet R., Ferrantelli J.R., Haas J.W., Holland B. Modeling of the Sagittal Cervical Spine as a Method to Discriminate Hypolordosis: Results of Elliptical and Circular Modeling in 72 Asymptomatic Subjects, 52 Acute Neck Pain Subjects, and 70 Chronic Neck Pain Subjects. Spine. 2004;29:2485–2492. doi: 10.1097/01.brs.0000144449.90741.7c.
    1. McAviney J., Schulz D., Bock R., Harrison D.E., Holland B. Determining the Relationship between Cervical Lordosis and Neck Complaints. J. Manip. Physiol. Ther. 2005;28:187–193. doi: 10.1016/j.jmpt.2005.02.015.
    1. Moustafa I.M., Youssef A., Ahbouch A., Tamim M., Harrison D.E. Is Forward Head Posture Relevant to Autonomic Nervous System Function and Cervical Sensorimotor Control? Cross Sectional Study. Gait Posture. 2020;77:29–35. doi: 10.1016/j.gaitpost.2020.01.004.
    1. Darnell M.W. A Proposed Chronology of Events for Forward Head Posture. J. Craniomandib. Pract. 1983;1:49–54. doi: 10.1080/07345410.1983.11677844.
    1. White M., Panjabi A.A. Clinical Biomechanics of the Spine. 2nd ed. Vol. 2 Lippincott Williams and Wilkins; Philadelphia, PA, USA: 1990.
    1. Miyazaki M., Hymanson H.J., Morishita Y., He W., Zhang H., Wu G., Kong M.H., Tsumura H., Wang J.C. Kinematic Analysis of the Relationship between Sagittal Alignment and Disc Degeneration in the Cervical Spine. Spine. 2008;33:E870–E876. doi: 10.1097/BRS.0b013e3181839733.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe