2005. Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults

8/9/2019 2005. Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults

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Postural misalignment of head on trunk (e.g., forward

head posture) is associated with complaints of pain in

the neck and shoulder region1-5 and temporomandibular

joint dysfunction6,7, but is also observed in asymptom-

atic individuals8-10. Attempts to correct this misalign-

ment towards an ideal posture using a combination of

strengthening, stretching, and behavioral/biofeedback

training represent a significant component of the physical

intervention provided to clients with painful neck and/or

Effectiveness of an Exercise Program to Improve Forward Head

Posture in Normal Adults: A Randomized, Controlled 10-Week Trial

Address all corre spondence and request for repri nts to:

Katherine Harman

School of Physiotherapy

5869 University Ave.

Halifax, Nova Scotia,

B3H 3J5.

[email protected]

Abstract: Forward head posture (FHP) is most often described as excessive anterior position-ing of the head in relation to a vertical reference line, involving increased cervical spinelordosis (head forward, middle cervical spine extended, lower cervical spine flexed) androunded shoulders with thoracic kyphosis. Although exercise is routinely used to improveFHP, relatively little data exists on efficacy. The present study was designed to examine theimpact of a 10-week targeted and progressive home exercise program on improving FHP. Asimprovement through exercise of postural alignment depends upon participants adhering tothe program, we also looked at issues related to exercise compliance. Seventeen control (C)and 23 exercise (E) participants with a FHP deviation were part of this program. Pre- andpost-exercise postural measurements of FHP were obtained from the sagittal plane using theBiotonixTM Postural Analysis System; in addition neck flexion range of motion was measured.

Participants were randomly assigned to C or E groups. The E group performed neck extensorand pectoralis major stretches and deep neck flexor and shoulder retractor strengtheningexercises for the 10-week period. Two-factor (group, pre-test/post-test) analysis of variancemodels were used to test main effects and interactions. There were no significant differences(p>0.05) between groups on any pre-test measure. For the E group, there were significantdifferences and interactions (p


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164 / The Journal of Manual & Manipulative Therapy, 2005

postural exercises on FHP14 despite its widespread oc-

currence in the general population8-10.

Forward head posture (FHP) is a head-on-trunk mis-

alignment and is described (in sitting or standing) as the

excessive anterior positioning of the head in relation to

a vertical reference line, increased lower cervical spine

lordosis (head forward, middle cervical spine extended,

lower cervical spine flexed), and rounded shoulders with

thoracic kyphosis16-18. This posture is associated with

weakness in the deep cervical short flexor muscles and

mid-thoracic scapular retractors (i.e., rhomboids, ser-

ratus anterior, middle and lower fibers of the trapezius)

and shortening of the opposing cervical extensors and

pectoralis muscles (known as the upper crossed pos-

tural syndrome19)8,9,16-18,20. Although there is consensus

that the prolonged adoption of FHP can result in this

muscle imbalance, which may in turn contribute to its

persistence, it is generally held that FHP results from

habitual postures adopted over time (e.g., working pos-

tures), thus making it amenable to correction through

exercise12,21-24. In addition to muscle imbalance, FHP has

been linked to pain, fatigue, and restricted movement

of the neck as well as symptoms attributed to excessive joint and muscle loading18,21,22.

With FHP alignment, the center of gravity of the

head is anterior to the vertical axis (often measured by

a plumb line9), thereby increasing the load on posterior

neck muscles1,18. This biomechanical strain, in the pres-

ence of reduced strength of the core stabilizing neck

musculature25, in particular if it is repeated or prolonged26,

is the predominant explanation for symptoms associated

with FHP18,27. This joint and muscle load leads to dis-

comfort, fatigue, and pain28, symptoms and risk factors

associated with chronic musculoskeletal disorders24 ,29.

Watson and Trott25 found that in a group of 60 female

adult participants, FHP was associated with headacheand poor strength and flexibility of the upper cervical

flexors. Clinicians target this head-on-trunk misalign-

ment with corrective exercises8,30 ,31.

An exercise program for FHP guided by strengthening

and stretching principles that address underlying soft

tissue imbalances would include deep cervical flexor and

shoulder retractor strengthening and cervical extensor and

pectoral muscle stretching. The therapeutic approach of

strengthening weakened postural muscles and stretching

shortened ones to improve postural alignment has been

advocated9,19,32, and is a focus of physiotherapy practice as

well as other bodywork programs12,33

. Although only onestudy of the effectiveness of a combination of exercises for

FHP has been published31, there is evidence to support

the benefits of the individual exercises1,13 ,14,17,24.

Pearson and Walmsley13 found that repeated upper

cervical retractions (strengthening deep cervical flexors

and stretching cervical extensors) changed resting neck

posture. Abdulwahab and Sabbahi30 conducted a controlled

study examining the effect of neck retractions in the

presence of cervical radiculopathy. Although they did not

measure postural alignment in the non-impaired sub-

group, they reported that cervical retraction exercises

had a positive effect on physiologic measurements of

nerve compression (H-reflex amplitude) and psychological

measurements (pain reports) as compared to controls.

Roddey, Olson, and Grant14 demonstrated improvements

in resting scapular position following a stretching pro-

gram of pectoralis muscle, while Wright, Domenech,

and Fischer31 reported on a randomized, controlled

study of a postural correction program for clients with

temporomandibular disorder and pain. Their study used

three distance measurements to capture head-on-trunk

alignment and a four-week postural program that com-

bined strengthening and stretching exercises similar

to the program used in this study but excluding a deep

cervical flexor strengthening exercise. They reported that

the exercise group experienced a significant improve-

ment in symptoms (jaw and neck pain) as compared

to the control group; however, no significant change

in posture was found. This might be explained by the

short duration of the program, the lack of progression

with weights/resistance, and the variable compliance rate(45-100%). The choice of the combined exercises used

in the present study that form part of the Biotonix

system is based on this previous literature.

Postural correction interventions are most frequently

based on anatomic reasoning, and judgments of impact

are usually based on symptom reduction12 ,34-36. If a

short home exercise program can be demonstrated to

improve the postural alignment in individuals with FHP

and thereby reduce the biomechanical load on the neck

and shoulders, then these exercises could contribute to

evidence-based practice and may be useful in treating or

preventing symptoms of FHP. In addition to considering

the anatomic aspects of exercise, the change of habit thatis required for persistent adaptation must be considered

in designing a program to improve posture. Research has

demonstrated that stretching and strengthening must

be repeated over time to achieve the desired effect37,38.

This requires participation motivation and compliance

that is maximized by motivation or supervision39. An

additional factor that may influence compliance is the

presence or absence of symptoms40. Maintaining align-

ment change requires conscious attention, especially in

the presence of a strength/tightness imbalance such as

described for FHP. An exercise program that uses repeti-

tive postural correction across the day serves to improvepostural awareness and reinforce exercise programs. The

Biotonix™ Health Solutions posture exercise program

uses these principles to design exercises to improve

postural deviations.

The measurement of postural alignment is not

without its challenges. There is a need to consider

posture from multiple planes, and relatively small de-

viations have a potentially large biomechanical impact.


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In studies of head-on-trunk alignment, many measure-

ment approaches have been used, such as observation,

observation with checklists, cinematography, radiography,

2-D and 3-D imaging, and goniometry41-46. Observation

without quantification is the most often used approach

and this will limit the determination of the impact of any

intervention. When measured, head-on-trunk alignment

is most often quantified in the sagittal plane using the

external auditory meatus (tragus), the spinous process

of the seventh cervical vertebrae (C7), a structure on the

front of the head such as the glabella or nasion, and the

acromion as landmarks16,47. A neutral posture is defined

as the vertical alignment of the tragus and acromion9.

To capture the multi-segmental alignment of FHP, three

angles are most often reported (similar measures are

used in this present study; see Figures 2 and 3): head

angle (flexion or extension of the head on the neck, as

measured by the angle created by either a horizontal

or vertical line intersecting with the tragus-to-glabella

line), neck angle (angle created by either a horizontal or

vertical line intersecting with the C7-to-tragus line), and

shoulder position (an indicator of a rounded shoulder

posture, measured by an inter-acromion distance or aperpendicular linear distance between one acromion and

C7). Additional distance measurements often examined

include the head-on-trunk alignment of head distance

(horizontal distance from tragus to vertical plumb),

shoulder distance (horizontal distance from acromion to

plumb line), and horizontal distance between acromion

and tragus (HScal)16,31,42 ,47.

The Biotonix™ Postural Assessment System48 was

used in the present study to quantify FHP, using a set of

angular and distance measurements, and to assess the

change in FHP, if any, after a 10-week targeted exercise

program. Reliability and validity of the Biotonix™ System

has been demonstrated49 ,50.The purpose of the study was to determine if a

10-week, targeted and progressive home exercise pro-

gram could improve FHP in asymptomatic adults. Our

working hypothesis was that a short, home exercise

program with periodic supervision would improve the

misalignment associated with FHP as measured by the

Biotonix™ system. We also assessed the impact of the

FHP targeted exercises on cervical range of motion as

measured by the CROM.

MethodsThe study design was a randomized, controlled, 10- week program. The Dalhousie University Health Sciences

Ethics Review Board approved this study.

ParticipantsRecruitment for participants involved physiothera-

pists and exercise consultants as well as posters and

electronic notice boards. Potential participants were

screened prior to inclusion by measuring the horizontal

distance between the tragus and posterior angle of the

acromion in standing using a customized graduated

setsquare. If the tragus was >5 cm anterior, then a

participant was referred to the study. Participants were

included if they were pain-free, healthy, between 20

and 50 years old; and had not sought medical/health

care for neck, shoulder, or low back pain over the past

year. No additional screening was performed in terms of

physical fitness, weight, etc. All referrals were telephone

interviewed, given the full description of the study and

if still interested, were invited to the laboratory for an

initial assessment. At that time, full informed consent

(including the possibility of using their photographs)

was given in accordance with the Dalhousie University

Health Sciences Ethics Board.

Initial AssessmentScreening for forward head posture was assessed as

described above, followed by screening for exercise risk

(Par-Q1); as a result of these two measurements, no par-

ticipants were excluded. The initial assessment included

a postural assessment and range of motion testing.

Postural assessment Age, height, and body mass were recorded. To best

display anatomical landmarks and their posture, participants

wore tight shorts and sleeveless T-shirts. Six reflective

adhesive markers were placed over anatomical landmarks

[acromion, anterior superior iliac spine (ASIS), posterior

superior iliac spine (PSIS), glabella, tragus, and C7] in

accordance with the BiotonixTM postural assessment pro-

tocol. A tripod-mounted digital camera was set 33 inches

from the ground and 104 inches from a wall-mounted

grid, and participants stood 9 inches from the wall. Three

pictures in standing were taken: right sagittal, anterior,and posterior views (see Figure 1).

To capture the participant’s natural head-on-trunk

alignment, each person was asked to look straight ahead

and to march on the spot 5 times before each picture

was taken52. Each picture was taken within 5 seconds of

the marching sequence. The location of the anatomical

landmarks were determined by the Biotonix™ system50

and sent via the Internet to a central server for detailed

calculations of body postures including FHP. The postural

measurements were calculated from the anatomical land-

marks and are indicated in Figures 2 and 3. A report of

the postural assessment was generated for each participantand was reviewed by the investigators for the presence of

FHP based on the tragus-to-acromion distance (HScal >

2.5 cm.) [one participant was excluded due to an anterior

horizontal deviation less than 2.5 cm (tragus-to-acromion)].

Note that this value differs from the screening value of

5 cm since the latter was estimated from the posterior

aspect of the acromion then aligning the set square to

the tragus. The deviation from the photographs was a

Effectiveness of an Exercise Program to Improve Forward Head Posturein Normal Adults: A Randomized, Controlled 10-Week Trial / 165


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more accurate measure of the horizontal distance from

the center of the acromion to the center of the tragus.

The screening was simply to identify those with potential

FHP and the photographs were used to confirm this.

Participants were then randomly assigned to control (C)

or exercise (E) groups. A second set of photographs was

taken using the same protocol after the 10-week exercise

or control period. The computer operators were blind to

the group assignment of the participants.

The three angles and three distances, commonly

used to assess FHP, that were calculated by the Bioto-

nix™ automated biomechanical assessment tool included

shoulder-to-pelvis angle (the angle between vertical and

the line joining acromion to mid-point between ASIS and

PSIS indicating trunk inclination), head angle (the angle

between horizontal and the glabella-to-tragus line), neck

angle (the angle between horizontal and the tragus-to-C7

line); and head distance (horizontal distance from tragus

to vertical plumb aligned with base of fifth metatarsal);shoulder distance (horizontal distance from acromion

to plumb line) and HScal (horizontal distance between

acromion and tragus). All angles were measured in degrees

and distances were measured in cm (Figures 2 and 3).

Range of MotionPre-and post-study neck flexion range of motion

(ROM) was measured to the nearest degree using the

CROM™ instrument10,54. Five measurements were taken,

with the last three used in the data analysis. The same

individual performed all measurements.

Exercise (E) programParticipants were given a list and description (with

illustrations) of each exercise and were required to

demonstrate their ability to perform each exercise cor-

rectly. The program consisted of two strengthening

(deep cervical flexors and shoulder retractors) and two

stretching (cervical extensors and pectoral muscles)

exercises based on Kendall et al’s approach9. The exer-

cises involved (a) chin tucks in supine lying with the

head in contact with the floor (the progression of this

exercise was to lift head off floor in tucked position and

hold it for varying lengths of time), (b) a chin drop in

sitting (c) shoulder retraction first in standing using

Theraband™ and then progressed to shoulder retraction

in prone using weights, and (d) unilateral and bilateralpectoralis stretches alternating each 2-week period (see

Table 1 for descriptions and progressions).

Participants were instructed to complete 3 sets

of 12 repetitions of the strengthening exercises and 3

stretching exercises held for 30 seconds each. This pro-

gram was to be repeated 4 times per week. In addition,

participants recorded an exercise log documenting the

number of exercises and sessions they completed in a

Fig. 1: Examples of the photographs taken using the Biotonix™ Health Solutions protocol. Anterior, sagittal plane,

and posterior views. The 6 reflective markers from the sagittal plane used in the analysis are: acromion, anterior superioriliac spine (ASIS), posterior superior iliac spine (PSIS), glabella, tragus and C

7.

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2-week period. They also returned for a consultation

every 2 weeks to be checked for exercise technique and

progression, if appropriate. Progress to the next exercise

level was indicated if the participant could complete 12

repetitions, 3 times easily with correct form38. The same

individual performed all instruction and consultation.

Attendance, exercise compliance, and progressionThe attendance scores for the 5 scheduled consultation

visits were counted. The compliance rate was calculated

from the exercise logs. Progression was determined by

the level of difficulty achieved for each exercise at the

end of the 10 weeks.

Control (C) programControls did not participate in the exercise program

but were asked to carry on with their regular activities

and were telephoned at the end of each week to moni-

tor their activity.

Other outcome measurements All participants (Control and Exercise) were asked

to complete an activity log each day. Participants com-

pleted a physical activity questionnaire55 prior to and at

the end of the study that included questions about the

number of times they had exercised in the past week and

the intensity of the exercise. A one-page questionnaire

was given to all participants upon completion of the

study asking questions with respect to whether they felt

their posture improved and what they liked and disliked

about the study.

StatisticsT-tests were used to determine if there were any dif-

Fig. 2: Description of the postural angles derived from

the photographs. Angles measured: a) head angle (the anglebetween horizontal and the glabella-to-tragus line); b) neck

angle (the angle between horizontal and the tragus-to-C7

line) and c) shoulder-to-pelvis angle (the angle between

vertical and the line joining acromion to mid-point between ASIS and PSIS) . A posit ive shoulder angle is indicated on

the diagram.

Fig. 3: Description of the postural distances derived from the photographs. Distances measured: a) head distance

(horizontal distance from tragus to vertical plumb from

base of fifth metatarsal), b) HScal (horizontal distance

between acromion and tragus) and c) shoulder distance(horizontal distance from acromion to vertical plumb from

base of fifth metatarsal).


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interaction plot is in Figure 4. Post hoc results revealed

no significant differences between C and E on the pre-

test measure, or for the C group between the pre-test

and post-test measurements. Significant differences were

found between the pre-test C and post-test E (p=0.005),

pre-test and the post-test for the E group (p0.05) or main effects

for head angle. There was a statistically significant in-

teraction (df=1,36, p


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Qualitative dataTable 7 provides the answers from 26 (15-E group;

11-C group) completed questionnaires. Note: not all

questions were answered on each questionnaire. As the

exit questionnaire data reveals, the majority enjoyed

the exercises and felt that they were important but that

keeping track of the exercises and fitting them into their

schedules was a challenge.

In summary this set of findings is consistent with

a change over time of postural alignment in the direc-

tion of a more neutral posture (away from the FHP) in

both groups, with an increase in neck flexion ROM and

an improved shoulder to pelvis angle unique to the E

group only. The combination of measurements provides

a comprehensive assessment of the postural changes

compared to just one measure.

DiscussionThis study was designed as a randomized, controlled,

Table 4: The results of progression for neck strength-ening exercise (n=21)

Progressions# Participants

attaining this level

Chin tuck, release 3

Chin tuck plus

one-second hold7

2-second hold 5

3-second hold 1

4-second hold 2

6-second hold 1

8-second hold 1

No data 1

Table 5: Participant progression for shoulder retraction

exercise (n=21)

Progressions# Participants

attaining this level

TherabandTM 0

2 lbs. Resistance 5*

3 lb. + TherabandTM 3

5 lb. 7


8 lb. 1

10 lb. 2*


No data 0

Each participant progressed at least one step past baseline.

This is an indirect measurement of improved strength. *Weights

were reduced due to discomfort or poor technique.

Fig . 4: Mean scores (SD) for neck flexion ROM indegrees for each group measured prior to the 10-week

exerci se program (pre-test ) and afterwards (post-test).

The Control group is represented by diamonds and the

Exercise group by squares in all subsequent figures. There was a statistically signi ficant group by pre-test/post-test

interaction (df =1,180, p


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home exercise program with periodic supervision. This

study is unique in that we have addressed a posture

that is the result of a combination of active, passive,

and control system factors with an exercise program

and measurement approach that captures the multiple

aspects of the misalignment. Recruitment and screening

results revealed that the group of asymptomatic adults

with a FHP was motivated to participate in a postural

improvement exercise program. The screening method

designed for this study was effective, with only one

participant excluded due to a lack of confirmation bythe Biotonix™ analyses. We had equivalent groups of

asymptomatic adults with FHP who did not change their

general physical activity over the 10-week period and who

fully participated in the prescribed exercise program. A

bi-weekly consultation with a researcher experienced in

exercise prescription was included to enhance compliance

and assure safe exercise progression. We demonstrated

improvements in postural measurements with this 10-

week exercise program.

Maintaining any exercise program is difficult and

King et al57 classified success as at least 66% of partici-

pation. Our compliance rate (100%) was higher than astudy that included home exercise sessions with physical

therapist supervision (85%)58, and another, similar home

exercise program that was 4 weeks long, and reported a

75% compliance rate31. Our success may be due to the

simplicity of the exercise program, the requirement

to return for consultation or the motivation of the

participants, elements identified as significant factors

influencing compliance57-59.

Panjabi’s conceptual model60 explaining stabilization

of the spine acknowledges three systems that interact to

influence skeletal alignment: passive (structural), active

(contractile), and control (neurologic) systems. The in-

tent of the program for the Exercise group was to affect

the active and passive systems (by strengthening weak

muscles and stretching tight structures) as compared

to the Control group, who did not receive any targeted

exercises. As long as the passive and active systems have

the capacity, to a certain extent, posture is under our

conscious control. In this study, we measured a habitual

standing posture adopted after walking in place and then

looking straight-ahead52.

Our measurements of posture variables revealed

that performance of both the active and passive systems

changed over the 10-week program. For cervical ROM,

the E group had a significant increase (3.7°) in flexion,

as compared to the C group at the end of the study.

Two exercises targeted this movement, and our findings

suggest that the combination of stretching (chin drop)

and strengthening (chin tuck) effected this change. A

previous study of asymptomatic controls of similar ages

using the CROM, (n=41) reported mean cervical flexionof 47o (SD=10) 61, which is about 10o lower than the pre-

test measurements for both of our groups. Perhaps the

higher level of flexibility of our participants restricted

the amount of improvement possible.

The shoulder-to-pelvis angle was not different between

groups at pre-test, but at post-test, E was significantly

different from C, with the E angle becoming more negative

after the exercise program. This indicates a change in

Table 6: Means and standard deviations for all variables pre- and post-10-week program

Measure Time Control Exercise

Mean (SD) Mean (SD)

Neck angle (°) pre 24.1 (6.4) 25.7 (5.8)

post* 21.8 (7.3) 24.5 (6.6)

Shoulder to Pelvis (°) pre -3.8 (2.5) -4.2 (2.2)

post -3.3 (2.7) -4.7 (1.8)Head angle (°) pre 38.1 (6.0) 36.4 (6.3)

post 38.0 (7.4) 36.8 (5.8)

Head distance (cm.) pre 6.1 (3.0) 5.6 (2.9)

post* 5.2 (3.0) 4.1 (2.7)

Shoulder distance (cm.) pre 0.5 (3.0) -0.7 (2.7)

post* 0.0 (2.4) -1.8 (2.2)

H-Scal (cm.) pre 5.7 (1.7) 6.3 (1.6)

post* 5.1 (2.0) 5.9(1.7)

* Statistically significant pre-test/post-test main effects



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standing trunk alignment consistent with ‘straightening

up’, or pulling the shoulders back, bringing the acromion

marker posterior to a vertical plumb line. Although

there has been a question regarding the relation between

scapular muscle force and scapular abduction position

in standing62, perhaps the explanation of our findings

lies in the fact that the pectoralis stretching exercises

were performed in conjunction with shoulder retraction

exercises which progressed across the 10-week study

period. A study that only examined the effectiveness

of pectoralis muscle stretching on scapular position

in standing reported similar results14. That study had

participants perform the stretch daily for 14 days. The

outcome of scapular position was selected to correlate

with the rounded shoulders of FHP. The result of a sig-

nificant decrease in the distance between scapulae in the

stretching group as compared to controls reflects a posi-

tive change in posture, but when done in isolation from

other measurements, it is unknown from their study14

if the stretch would affect FHP. These results help us to

understand the effectiveness of individual interventions

on aspects of the FHP, for asymptomatic participants,

but do not address the combination of misalignmentsinvolved in this postural deviation.

There were no group differences on the other four

postural measurements we examined (neck angle, head,

shoulder and acromion-tragus distances). However, each

of these measurements for both groups changed from

pre-test to post-test in the same direction, towards a more

vertical head-on-trunk alignment. Wright31 conducted a

study on postural exercises as a treatment intervention

for clients with temporomandibular disorders and found

that although there was improvement in symptoms, there

were no significant changes in posture measurements

(same as our distance measurements) after a 4-week

exercise program. Figures 6 and 7 for the shoulder andhead distances illustrate a trend towards a separation on

post-test with the Exercise group moving towards our

expected findings of a more vertical alignment. These

differences were not significant, perhaps reflecting that

a longer duration program (>10-weeks) is needed. These

postural measurements had large standard deviations,

and finding significant differences despite this suggests a

consistent effect on the dependent variables, encouraging

us to conclude there was an effect of the exercise. Why,

if our exercise program was effective, would some of the

Control participants’ scores also change?

Postural awareness of the Control participants was

likely enhanced by the knowledge that this was a study

about posture and by having had their standing alignment

photographed. In fact, 54% of the Controls indicated

in the exit surveys that they either believed that their

posture improved or that awareness of their posture

was heightened. Perhaps this awareness was affecting

the control system in that it influenced their habitual

carriage, and repeated correction over time resulted in

changes in most measurements of postural alignment

measurements at the end of the study, without a con-

comitant increase in cervical ROM. One of the strengths

of the Biotonix™ system is visual feedback; images areprovided to the participants highlighting postural mea-

surements that encourage them to become more aware

of their postural alignment. Ours is a positive finding

with respect to the education and awareness component

of postural programs and should inform all exercise

programs that the control system should be engaged in

any postural re-education program.

Consultation sessions provided feedback bi-weekly,

improving the effectiveness of the exercises. Proper

technique was a criterion for progression, and early

in the 10-week program, we observed a high incidence

of poorly executed exercises that were corrected. A

few incidents of pain and discomfort occurred which were also addressed. There is a need to challenge the

Fig. 6: Mean scores (SD) for shoulder distance in cm. for each group measured prior to the 10-week exercise

program (pre-test) and afterwards (post-test). There was

a statistical ly s ignif icant pre-test/post-test main (df=1,36,

p


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Table 7: Responses to Questionnaire

Questions Responses

The best part of the

experience was… (n=25)

• 76% wrote positive comments regarding being aware of and doing

exercises to improve posture.

• 40% indicated that they enjoyed the exercise requirement of the study.

• 36% wrote positive comments about learning about posture, the

involvement in research, and the personal benefit of advice and direction.

The most difficult part of

the study was…(n=25)

• 24% nothing was difficult.

• 48% reported difficulty completing the exercise schedule.

• 20% said that keeping track of their exercises was the most difficult.

Regarding procedures,

photography sessions

and exercise prescription

(n=16)

• 36% of responses were positive, reporting clear instructions, and no

problems.

• One person felt that the chin tuck exercise was a bit of a strain, and

another reported difficulty finding a location to anchor the Theraband for

shoulder retraction work.

• 28% no comment.

When asked whether they

thought that their posturehad changed over the

period of the study.

Exercise Group (n=15)

• 47% Yes, they believed that their posture had changed. Also 40%

specifically indicated that their awareness was increased.

• 40% Unsure/maybe, with one additional person saying that it was not

their posture that changed, but the neck muscle strength.

Controls (n=10)

• 20% Yes, one in this group indicated the conscious attention to try to

improve.

• 40% No

• 30% Neither “yes” nor “no” - they were more aware of their posture andconsciously tried to improve it.

Fig. 8: Mean scores (SD) for neck angle in degrees

for each group measured prior to the 10-week exercise

program (pre-test) and afterwards (post-test). There was a sta tis tical ly signif icant pre -test/post-test main effect

(df=1,36, p


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muscle/joint repeatedly over time to achieve strength or

flexibility change38. These challenges, if excessive, may

put patients at risk for discomfort and potential injury.

If not challenging enough however, there may not be

sufficient impact on targeted tissue to improve align-

ment. It is possible that larger effects of the exercise

program were not achieved because some participants did

not progress further into the resistance for a particular

exercise. These issues point to the need for supervision

to ensure proper technique and appropriate progression

to maximize exercise effectiveness.

Future investigations of the effectiveness of exercise

on standing posture likely need to address additional

aspects of our results. Given that with “good” posture a

minimum amount of muscle work is required63 ,64, then

improvements in muscle strength and muscle length

should result in a lower muscular effort to hold the new

aligned posture. This could be further explored through

use of electromyography. Decreasing the percentage of

maximal activity required to maintain an ideal posture

would be a positive outcome of a postural exercise pro-

gram, as working at a lower percentage would minimize

fatigue in those muscles. Although we addressed someof the known structures associated with FHP, we did not

consider the influences from the temporomandibular

joint which have been found to relate to head-on-trunk

alignment8,23,27. Also, given the improvement in the con-

trol group, the addition of postural awareness reminders

would likely enhance the impact of exercise.

The exercises provided by the Biotonix™ system are

designed to be performed within the context of ongoing

medical treatment by medical or allied health personnel,

and it is likely that greater improvements could occur

if they were combined with other therapeutic modali-

ties. However, it remains to be determined if similar

changes would occur with symptomatic individuals, how

long the effects would remain, and what actually is the

mechanism of the postural change.

In conclusion we found that a simple, targeted ex-

ercise program can result in significant improvements

in asymptomatic participants of cervical ROM and 5 out

of 6 measurements of postural misalignment, whereas

postural awareness alone in our control group resulted

in improvements on 4 of 6 measurements of postural

misalignment. These results provide a foundation for

further development of postural improvement programs

that include an exercise component.

AcknowledgementThis study was funded by Biotonix Health Solu-

tions™. The authors wish to acknowledge AlexandraBérubé-Poliquin and Scott Grandy for their assistance

in the project. Also, thanks to all the participants.

1 Par-Q, Canadian Society for Exercise Physiology,

1994.

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2005. Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults

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