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Objective: To determine exercise management for pain and forward head posture in patients with cervical spondylosis. Study Design: Randomized Control Trial (IRCT20230124057196N2). Place and Duration of Study: Physical therapy department of Water and Power Development Authority (WAPDA) Teaching Hospital, Lahore, Pakistan, from Jun to Dec 2023. Methodology: Sixty-eight diagnosed cervical spondylosis patients aged 40-60 years of age were included, randomly allocated into experimental and control groups, 34 in each group. The experimental group received cervical, postural, and shoulder dynamic exercises, while the control group received cervical and postural exercises for the 6th week. Measurement of clinical outcomes, pain via visual analog scale, and forward head posture via craniovertebral angle was taken at baseline and 6th week. Results: Analysis of 61 patients was conducted with 31 in experimental group and 30 in the control group. Mean age for the experimental and control groups was 52.26±5.98, 52.40±5.69 years respectively. Results showed that there was a statistically and clinically significant difference between the groups from baseline to 6th week in pain p≤0.001 and forward head posture p≤0.001, more reduction in pain and forward head posture were observed in the experimental group. Conclusion: Cervical isometric, postural corrective exercises with shoulder dynamic exercises (experimental group) have a positive effect on patients with cervical spondylosis on clinical outcomes, that was pain and forward head posture.

Purpose Head postural assessment is part of the orthopaedic physical examination process and could help to identify faulty head postures. One of the most common faulty postures of the craniocervical region is the forward head posture (FHP). There are several methods to evaluate FHP but it is not clear which method is more precise. The aim of this study was to compare the craniovertebral angle (CVA) between a FHP and a healthy group in sitting and standing positions. Methods Twenty-five subjects with FHP (22.9 ± 2 years) and 25 normal subjects (21.9 ± 5 years) participated in this case–control study. Photography of the sagittal view was done in standing and relaxed sitting postures to determine the amount of the FHP. Results The results of independent t test showed a significant difference in the CVA between the FHP and healthy groups ( P  < 0.001). The result of paired t test showed a significant difference between CVA in standing and sitting postures for both groups ( P  < 0.001). Furthermore, the BMI had a significant negative correlation with CVA in standing position ( P  < 0.01). Conclusions Our results indicated that the CVA was increased in the sitting posture compared to the standing posture and introduced the standing posture as a more sensitive posture to evaluate the FHP.

IntroductionForward head posture (FHP) is a condition where the head shifts anteriorly in the cervical spine's sagittal plane, which affects the activation of the muscles encompassing the shoulder complex as well as scapular mechanics, leading to changes in force couples, tissue overuse, pain, weakness in the deep cervical flexors, and uncontrolled movement of the cervical and shoulder muscles.Material and methodsForty-two participants with symptomatic FHP, aged 18-40 years, were randomly distributed into two equal groups; in the control group (A), 21 participants received conventional physical therapy; in the experimental group (B), 21 participants underwent the same treatment as the control group plus kinetic control exercises (KC). Treatments were conducted three times weekly for four weeks. Craniovertebral angle (CVA) by Photographic Posture Analysis Method, pain severity by Numeric Pain Rating Scale (NPRS), neck function by Neck Disability Index (NDI), and Deep Cervical Flexor Endurance (DCFE) by Craniocervical Flexion Test (CCFT) were evaluated pre- and post-study program.ResultsPost-intervention, comparisons between groups demonstrated a further significant improvement in NDI and DCFE in group B compared to group A (p < 0.05) across both groups.ConclusionsKC is more effective in improving DCFE (motor control) and functional disability than conventional therapy. Both KC and conventional therapy demonstrated equal effectiveness in enhancing CVA and NPRS.

PurposeIn this article, we summarize our work on understanding the influence of cervical sagittal malalignment on the mechanics of the cervical spine.MethodsBiomechanical studies were performed using an ex vivo laboratory model to study the kinematic and kinetic response of human cervical spine specimens in the setting of cervical sagittal imbalance. The model allowed controlled variations of C2–C7 Sagittal Vertical Alignment (C2–C7 SVA) and T1-Slope so that clinically relevant sagittally malaligned profiles could be prescribed, while maintaining horizontal gaze, and their biomechanical consequences studied.ResultsOur results demonstrated that increasing C2–C7 SVA caused flexion of lower cervical (C2–C7) segments and hyperextension of suboccipital (C0–C1–C2) segments to maintain horizontal gaze. An increase in C2–C7 SVA increased the lower cervical neural foraminal areas. Conversely, increasing T1-slope predominantly influenced subaxial cervical lordosis and, as a result, decreased cervical neural foraminal areas. Therefore, we believe patients with increased upper thoracic kyphosis and radicular symptoms may respond with increased forward head posture (FHP) as a compensatory mechanism to increase their lower cervical neural foraminal area and alleviate nerve root compression as well as reduce the burden on posterior muscles and soft and bony structures of the cervical spine. Increasing FHP (i.e., increased C2–C7 SVA) was associated with shortening of the cervical flexors and occipital extensors and lengthening of the cervical extensors and occipital flexors, which corresponds to C2–C7 flexion and C0–C2 extension. The greatest shortening occurred in the suboccipital muscles, suggesting considerable load bearing of these muscles during chronic FHP. Regardless, there was no evidence of nerve compression within the suboccipital triangle. Finally, cervical sagittal imbalance may play a role in exacerbating adjacent segment pathomechanics after multilevel cervical fusion and should be considered during surgical planning.ConclusionsThe results of our biomechanical studies have improved our understanding of the impact of cervical sagittal malalignment on pathomechanics of the cervical spine. We believe this improved understanding will assist in clinical decision-making.

Forward head posture (FHP) induces forward shifts in the center of gravity (COG), affecting postural control and gait ability. Uphill and downhill walking require different postural control and gait strategies than overground walking due to the altered gravitational effect. The biomechanical characteristics of uphill and downhill walking in healthy adults have been demonstrated; however, those in individuals with FHP remain unclear. This study aimed to investigate COG, spatiotemporal, and kinematic parameters during uphill and downhill walking in individuals with FHP. This study included 10 individuals with FHP (FHP group) and 10 healthy adults (control group). All participants performed three experimental sessions: uphill, downhill, and overground walking. Spatiotemporal and kinematic parameters were measured using a motion analysis system. Results showed significant differences in COG parameters between groups in all sessions (p < 0.05), while no significant differences were found in spatiotemporal parameters (p > 0.05). In the uphill walking session, the mean and peak of head and knee joints during the stance phase in the FHP group were significantly greater than in the control group (p < 0.05). The FHP group showed a significantly greater mean of the knee joint during the stance phase than the control group in downhill and overground walking sessions (p < 0.05). Our results indicate that individuals with FHP have different gait mechanisms during uphill, downhill, and overground walking due to forward-shifted head COG relative to the body. These findings provide the biomechanical mechanisms related to uphill and downhill walking in individuals with FHP.

Background The purpose of this study is to evaluate the effect of a six-week combined manual therapy (MT) and stabilizing exercises (SEs), with a one-month follow-up on neck pain and improving function and posture in patients with forward head and rounded shoulder postures (FHRSP). Methods Sixty women with neck pain and FHRSP were randomized into three groups: Group 1 performed SE and received MT ( n  = 20), Group 2 performed SE (n = 20) and Group 3 performed home exercises (n = 20) for six weeks. The follow-up time was one month after the post test. The pain, function, and head and shoulder angles were measured before and after the six-week interventions, and during a one-month follow-up. Results There were significant within-group improvements in pain, function, and head and shoulder posture in groups 1 and 2. There were significant between-group differences in groups 1 and 2 in head posture, pain, and function favoring group 1 with effect size 0.432( p  = 0.041), 0.533 ( P  = 0.038), and 0.565( P  = 0.018) respectively. There were significant between-group differences in both intervention groups versus the control group favoring the intervention groups. Conclusion These findings suggest that both interventions were significantly effective in reducing neck pain and improving function and posture in patients. However, the improvement in function and pain were more effective in Group 1 as compared to Group 2, suggesting that MT can be used as a supplementary method to the stabilizing intervention in the treatment of neck pain. More researches are needed to confirm the result of this study. Trial registration UMIN000030141 modified on 2018.03.08. This study is a randomized control trial registered at UMIN-CTR website, the trial was retrospectively registered and the unique trial number is UMIN000030141 .

Forward head posture (FHP), commonly described as “text neck,” is an increasingly prevalent postural deviation linked to extended digital device use. It leads to muscular imbalance, cervical discomfort, and impaired daily function. Corrective exercise interventions, such as scapular retraction and McKenzie techniques, are widely utilized to address FHP, yet comparative evidence of their relative effectiveness remains limited. This study aimed to compare the effectiveness of scapular retraction exercises versus the McKenzie method in improving craniovertebral angle (CVA), reducing neck pain, and minimizing neck disability among university students exhibiting forward head posture. A quasi-experimental comparative design with pre- and post-intervention assessments was employed. The research was conducted at the Faculty of Nursing, Mansoura National University. A total of 116 university students with FHP were randomly allocated into two equal groups (n = 58 each). Group A performed scapular retraction exercises, while Group B practiced McKenzie method exercises. Both interventions were administered for 20 min, three times weekly over 8 weeks. Data were collected using four tools: (1) a structured interview sheet, (2) craniovertebral angle measurement via goniometer, (3) Neck Disability Index (NDI), and (4) Numeric Pain Scale (NPS). Both groups exhibited statistically significant improvements post-intervention in CVA, neck pain, and NDI scores ( p  < 0.05). The effect sizes were large in both groups (Cohen’s d = 0.79–1.69). However, intergroup comparison revealed no significant differences in post-intervention outcomes ( p  > 0.05), indicating comparable efficacy of both exercise approaches in enhancing posture and reducing neck-related disability. Both scapular retraction and McKenzie method exercises effectively improved craniovertebral alignment, alleviated pain, and decreased neck disability among students with forward head posture. Neither technique showed superior outcomes over the other. Trial registration : The study registered at Clinicaltrials.gov (identifier (NCT07317999) on December, 19 2025.

Forward Head Posture (FHP) is a prevalent musculoskeletal disorder strongly associated with neck pain and functional disability. Although therapeutic exercise is commonly recommended in clinical practice, there remains a lack of consensus regarding the most effective exercise modalities and optimal intervention duration. This systematic review evaluated the efficacy of therapeutic exercise on posture, pain, and functional outcomes in individuals with FHP, and to identify key factors that may influence treatment effectiveness. Literature searches were conducted following the PRISMA guidelines to identify randomized controlled trials (RCTs) on therapeutic exercises for FHP. Dates were extracted and pooled using a random-effects model. Prespecified subgroup analyses were performed to examine the influence of exercise modality (single vs combined) and intervention duration (<8 weeks vs ≥8 weeks). Ten RCTs, involving 550 participants were included in the analysis. Compared with control groups, therapeutic exercise significantly improved the craniovertebral angle (MD = 3.38°, 95% CI: 2.10° to 4.65°, p < 0.001; SMD = 0.95, 95% CI: 0.61 to 1.28), reduced pain intensity (MD = -1.42, 95% CI: -2.11 to -0.73, p < 0.001; SMD = -1.72, 95% CI: -2.69 to -0.71), and enhanced neck functional capacity (MD = -5.44, 95% CI: -8.56 to -2.32, p < 0.001; SMD = -1.08, 95% CI: -1.66 to -0.50). Exploratory subgroup analyses suggested potential trends: interventions employing combined exercise modalities and those lasting ≥8 weeks appeared to be associated with greater clinical benefits, although these findings should be interpreted with caution due to limited statistical power and high between-study heterogeneity. Therapeutic exercise may be associated with improved craniovertebral angle, reduced pain intensity, and better neck function in individuals with FHP and neck pain. Exploratory analyses suggested that combined exercise approaches and interventions lasting at least 8 weeks may yield larger improvements, although the overall certainty of evidence remains low to moderate.

Background The increasing use of smartphones and other digital devices has contributed to a rise in forward head posture (FHP) among younger populations due to prolonged poor neck positioning. The aim of this study was to evaluate the effect of cervical stabilization exercises (CSE) and cervical proprioception training (CPT) on FHP. Methods In this single-blinded randomized controlled trial, where only the outcome assessors were blinded, 99 participants (aged 18–24) with FHP were randomly allocated into three groups: Group-I ( n  = 32), which received no exercises; Group-II ( n  = 34), which received CSE; and Group-III ( n  = 33), which received both CSE and CPT. Groups II and III performed the exercises three times per week for six weeks. The joint position error (JPE) test was used to assess proprioception, the craniovertebral angle (CVA) was used to evaluate posture, and the Stork and Y Balance tests were used to assess balance at baseline and after six weeks. Results: The study included 99 participants (mean age: 18.1–19.6 years; BMI: 21.4–23.1 kg/m²). Technology usage analysis revealed that 19.2% of participants reported > 7 h/day of phone use, while the majority (80.8%) used computers for ≤ 1 h/day. Significant group × time interactions were found for JPE (flexion/extension/rotation, p  < 0.001), with Group III showing superior gains versus Group II and controls ( p  ≤ 0.001). Dynamic balance improved in intervention groups ( p  ≤ 0.04), and CVA increased significantly in Group II/III ( p  ≤ 0.03). Static balance improved over time ( p  < 0.001) but without intergroup differences. No sex-based effects were observed ( p  > 0.05) Conclusions The addition of CPT to CSE was found to be more effective than CSE alone in restoring proper proprioception and balance and in reducing poor posture in individuals with FHP. Trial registration This study is registered with ClinicalTrials.gov website with registration no: NCT06932965, date: 10/04/2025. Retrospectively registered.

Objectives The traditional understanding of craniocervical alignment emphasizes specific anatomical landmarks. However, recent research has challenged the reliance on forward head posture as the primary diagnostic criterion for neck pain. An advanced relationship exists between neck pain and craniocervical alignment, which requires a deeper exploration of diverse postures and movement patterns using advanced techniques, such as clustering analysis. We aimed to explore the complex relationship between craniocervical alignment, and neck pain and to categorize alignment patterns in individuals with nonspecific neck pain using the K-means algorithm. Methods This study included 229 office workers with nonspecific neck pain who applied unsupervised machine learning techniques. The craniocervical angles (CCA) during rest, protraction, and retraction were measured using two-dimensional video analysis, and neck pain severity was assessed using the Northwick Park Neck Pain Questionnaire (NPQ). CCA during sitting upright in a comfortable position was assessed to evaluate the resting CCA. The average of midpoints between repeated protraction and retraction measures was considered as the midpoint CCA. The K-means algorithm helped categorize participants into alignment clusters based on age, sex and CCA data. Results We found no significant correlation between NPQ scores and CCA data, challenging the traditional understanding of neck pain and alignment. We observed a significant difference in age (F = 140.14, p  < 0.001), NPQ total score (F = 115.83, p  < 0.001), resting CCA (F = 79.22, p  < 0.001), CCA during protraction (F = 33.98, p  < 0.001), CCA during retraction (F = 40.40, p  < 0.001), and midpoint CCA (F = 66.92, p  < 0.001) among the three clusters and healthy controls. Cluster 1 was characterized by the lowest resting and midpoint CCA, and CCA during pro- and -retraction, indicating a significant forward head posture and a pattern of retraction restriction. Cluster 2, the oldest group, showed CCA measurements similar to healthy controls, yet reported the highest NPQ scores. Cluster 3 exhibited the highest CCA during protraction and retraction, suggesting a limitation in protraction movement. Discussion Analyzing 229 office workers, three distinct alignment patterns were identified, each with unique postural characteristics; therefore, treatments addressing posture should be individualized and not generalized across the population.