Clinical Rehabilitation 2012 (Apr); 26 (4): 351–361 ~ FULL TEXT
Aliaa A Diab and Ibrahim M Moustafa
Basic Science Department,
Faculty of Physical therapy,
Cairo University, Egypt.
OBJECTIVE: To investigate the effect of forward head posture correction on pain and nerve root function in cases of cervical spondylotic radiculopathy.
DESIGN: A randomized controlled study with six months follow-up.
SETTING: University research laboratory.
SUBJECTS: Ninety-six patients with unilateral lower cervical spondylotic radiculopathy (C5-C6 and C6-C7) and craniovertebral angle measured less than or equal to 50° were randomly assigned to an exercise or a control group.
INTERVENTIONS: The control group (n = 48) received ultrasound and infrared radiation, whereas the exercise group (n = 48) received a posture corrective exercise programme in addition to ultrasound and infrared radiation.
MAIN OUTCOME MEASURES: The peak-to-peak amplitude of dermatomal somatosensory evoked potentials, craniovertebral angle, visual analogue scale were measured for all patients at three intervals (before treatment, after 10 weeks of treatment, and at follow-up of six months).
RESULTS: There was a significant difference between groups adjusted to baseline value of outcome at 10 weeks post-treatment for craniovertebral angle, pain, C6 and C7 peak-to-peak amplitude of dermatomal somatosensory evoked potentials P = 0.000, 0.01, 0.000, 0.001 respectively and at follow-up for all previous variables (P = 0.000).
CONCLUSION: Forward head posture correction using a posture corrective exercise programme in addition to ultrasound and infrared radiation decreased pain and craniovertebral angle and increased the peak-to-peak amplitude of dermatomal somatosensory evoked potentials for C6 and C7 in cases of lower cervical spondylotic radiculopathy.
From the Full-Text Article:
Although age appears to be the major risk factor
for degenerative changes, mechanical disturbance
of the cervical spine is considered as one
of the most deteriorative factors for cervical
spondylosis.  In this regard, forward head posture
has been shown to be a common postural
displacement, with a conservative estimate being
66% of the patient population.  It is generally
believed that this abnormal posture is associated
with the development and persistence of many
disorders including cervicogenic and migraine
headaches,  myofacial pain syndrome,  abnormal
scapular movement,  and even temporomandibular
disorders,  which justify the
growing interest with the importance of normal
posture as clinical outcome of health care as
supported by many authors. [7, 8]
The association between forward head posture
and neck pain has been investigated in
many studies. However, the literature does not
give concrete information on this relationship.
Two recent systematic reviews did not find an
association between head posture and neck
pain. [9, 10] Conversely, two other systematic
reviews have shown a significant differences in
the cervical posture of an adult neck pain patient
population when compared to a matched
asymptomatic group. [11, 12]
More important, while the adverse effect that
forward head posture has on the nervous system
was supported by several studies, [13–15] there is a
limited amount of literature and overall lack of
controlled studies evaluating the effect of forward
head posture correction in cervical nerve
Specifically, despite the widespread inclusion
of postural correction in therapeutic interventions,
16 there are limited experimental data to
support its effectiveness. Accordingly, the purpose
of this study was to investigate the effect
of forward head posture correction on nerve
root function and pain in cases of lower cervical
spondylotic radiculopathy. In the current study
we used a combination of strengthening, stretching,
and behavioural/biofeedback training to
correct the abnormal forward head posture as
supported by Harman et al.  The highly reliable
craniovertebral angle was used to assess the
forward head position.  For measuring the
nerve root function, we used dermatomal
somatosensory evoked potential to minimize
the inherent problems associated with mixed
nerve stimulation as in F wave or mixed nerve
somatosensory-evoked potentials. Moreover, it
provides reliable information about segmental
nerve root function that corresponds to clinical
symptoms more closely than did the other electrophysiological
examinations. [19, 20]
A prospective, randomized, controlled study
was conducted in the research laboratory of
our university. All the patients were conveniently
selected from our institution’s outpatient
clinic. They participated in the study after signing
an informed consent form prior to data collection.
Recruitment began after approval was
obtained from the local institutional review
board. Patients were recruited from September
2009 to July 2010 with six months of follow-up.
They were screened prior to inclusion by measuring
the craniovertebral angle, if the angle was
less than 50°, then a participant was referred to
the study (selection of 50° as a reference angle
was guided by the study of Yib et al.  who
reported 55:02±2:86 as a normal range and,
as it well known, subjects with forward head
had a significant smaller craniovertebral angle
when compared with normal subjects [21, 22]).
Patients were included if they had unilateral
radiculopathy due to spondylotic changes of
the lower cervical spine (C5–C6 and C6–C7),
side-to-side amplitude differences of 50% or
more in dermatomal somatosensory-evoked
potentials measurement, duration of symptoms
was more than three months to avoid acute stage
of inflammation. Exclusion criteria included
spinal canal stenosis, rheumatoid arthritis and
Patients were randomly assigned into two
groups of equal number using the roll of a
dice, an exercise group (odd number) and a control
group (even number). Random permuted
size 4 blocks were employed to achieve a balance
of the sample sizes between the two groups.
A resident who was blinded to the research
protocol and was not otherwise involved in the
trial, operated the random assignment. A diagram
of patients’ retention and randomization
throughout the study is shown in Figure 1. The
figure shows that 140 patients were initially
screened, after the screening process 98 were
eligible to participate in, and 96 completed, the
Patients in both the experimental (n = 48) and
the control group (n = 48) received superficial
heat in the form of infrared radiation on the
neck for 10 minutes followed by continuous
ultrasound application on upper trapezius,
for 10 minutes with 1.5 w/cm2 intensity. This
conventional treatment was to be repeated
three times per week for 10 weeks.  Those
in the control group received this conventional
treatment only. The exercise group additionally
received a posture corrective exercise programme
in the form of two strengthening
(deep cervical flexors and shoulder retractors)
and two stretching (cervical extensors and
pectoral muscles) exercises. The exercise programme
was done according to Harman et al.’s
protocol  and based on Kendall et al.’s
approach.  It involved:
Strengthening deep cervical flexors through
chin tucks in supine lying with the head
in contact with the floor, the progression of
this exercise was to lift the head off the floor
in a tucked position and hold it for varying
lengths of time (this was to progress by twosecond
holds starting at two seconds i.e. 2, 4,
6, and 8 seconds).
Stretching cervical extensors through a chin
drop while sitting (the progression of this
exercise was to drop the chin with hand
Strengthen shoulder retractors first while
standing using a theraband by pulling the
shoulder back. The patient was asked to
pinch scapulae together without elevation
or extension in the shoulder holding this
position for at least six seconds then relaxing.
The first progression was by conducting
the shoulder retraction from a prone position
by using weights. The second progression
was through using elastics resistance
and weights. Participants performed each
progression for two weeks. At the consultation,
if they could complete three sets of
12 repetitions correctly for the strengthening,
they were progressed to the second
Unilateral and bilateral pectoralis stretches
alternating each two-week period. For bilateral
pectoralis stretching, the patient was
seated comfortably with their hand behind
their head, from this position, the patient’s
elbow was moved up and out to the end
of the available range. For unilateral stretching,
the arm on the involved site was moved
into abduction and external rotation. To
stretch the costal division, the ram should
be elevated to approximately 135 degrees.
For sternal division, the arm abducted to
90 degrees. For clavicular division, the arm
was rested at the side.
Participants were instructed to complete three
sets of 12 repetitions of the strengthening exercises
and three stretching exercises held for 30
seconds each. This exercise programme was to
be repeated four times per week for 10 weeks.
Patients in both groups were instructed to avoid
any other exercise programmes that could interfere
with the results. The therapist telephoned
the patients weekly to supervise and guide them.
The main outcome measurement used to
assess the forward head posture was the craniovertebral
angle which was considered to be a
valid and reliable assessment tool.  All the measurement
procedures were done following Falla
et al.’s protocol.  The craniovertebral angle
was measured by taking a lateral photograph.
The patients were asked to sit on a chair as
usual and a lateral photograph was taken.
A digital camera was positioned on a tripod at
a distance of 0.8 m from the subject. The axis of
the lens of the camera was placed orthogonal to
the sagittal plane of the patient at a height that
corresponded with the seventh cervical vertebra.
Adhesive markers were fixed on the tragus of
the ear and the spinous processes of the seventh
cervical vertebra. The head forward angle was
measured as an angle between a line drawn
from the tragus of the ear to the seventh cervical
vertebra and horizontal line (Figure 2).
The main outcome measurement used to
assess the nerve root function was the peakto-
peak amplitude of dermatomal somatosensory
evoked potentials. An electromyogram
device (Tonneis neuroscren plus version 1.59,
Germany) was used to measure this variable
for all patients before starting the treatment,
at the end of 10 weeks, and at follow-up
period of six months. All testing procedures
were done following Liguori et al.’s protocol. 
The patient was lying supine on a softly padded
table with a pillow under the head and the knees.
After the skin was abraded and cleaned with
alcohol, the stimulating electrodes were placed
overlying dermatomes of C6 about 7 cm above
the styloid process of the radius and C7 between
the second and the third metacarpal bones.
A bipolar electrode was used for stimulation
with an interelectrode distance of 2.5 cm with
the stimulation cathode placed proximally.
The sensory threshold for the electrical
stimulation was determined by increasing the
intensity of electrical current until the patient
reported its sensation. Tolerable and painless
stimulus intensity was usually set at 2.5 times
above this level. Stimulation was accomplished
with a constant current square wave pulse,
0.2 ms duration, delivered at 3.1 Hz, 200
sweeps preadjusted. Recoding was made with
9-mm diameter tin/lead electrodes affixed with
electrolyte paste to abraded skin. The recording
electrodes were placed at C3' and C4' (between
C3 and P3 and C4 and P4 of the international
electroencephalogram 10–20 system), while the
reference electrode was placed at Fz and the
ground electrode at Fpz. The cortical responses
were amplified, average and displayed using an
analysis time of 50 ms. A filters setting of 2 Hz
to 1KHz was used. After the stimulation was
performed and traces were superimposed
to ensure reproducibility, negative near field
potentials were detected to measure the peakto-
peak amplitude. A representative example of
dermatomal somatosensory evoked potentials at
three intervals of measurement is given graphically
in Figure 3.
Measurement of pain was performed by using
a visual analogue scale (VAS). It is a responsive
pain scale that yields reliable and valid data. 
The patients were asked about the perception of
pain using a 10-cm line with 0 (no pain) on one
end and 10 (worst pain) on the other. Patients
were asked to place a mark along the line to
denote their level of pain. The outcome assessor,
who also applied the treatment intervention programmes,
was not masked during the study.
Sample size determination
To determine the required number of samples
in this study, estimates of mean difference and
standard deviation for craniovertebral angle
were collected from a pilot study consisting of
10 patients who received the same programme
between 1 January 2009 and 30 June 2009. The
mean difference value and standard deviation
were estimated as 4.1 and 4.3, respectively,
a two-tailed test, an alpha level of 0.05, and
a desired power of 90%. These assumptions generated
a sample size of 29 patients per each
group. To account for high drop-out rates, the
sample size was increased by 40%.
Both the mean and standard deviation were calculated
for each variable. The differences in the
baseline data between the exercise and control
group were analysed using t-test for the continuous
variables and Chi-square test for the categorical
variables. To compare the exercise group
and the control group, analysis of covariance
(ANCOVA) at two follow-up points (after
10 weeks of treatment and at follow-up of six
months) was performed for craniovertebral
angle, pain, peak-to-peak amplitude of dermatomal
somatosensory-evoked potentials. The
outcome variables were continuous and all settings/
circumstances were normally distributed.
The baseline value of the outcome as covariates
was used to assess between group differences.
(Baseline outcome in the model = baseline
value – overall mean baseline value). For all statistical
tests the level of significance was set
at P<0.05. SPSS (version 10) was used in
Baseline and demographic data
The clinical and demographic features of the
patients at inception are presented in Table 1.
The exercise and control groups were similar
with regard to age, height, weight, gender,
smoking, history of neck pain, and past use of
physiotherapy. The study specific measurements
(C6 and C7 amplitude of dermatomal somatosensory-
evoked potentials, pain and craniovertebral
angle) were also well balanced between
the groups at baseline (P = 0.85, P = 0.9,
P = 0.87 and P = 0.37, respectively).
Between groups analysis
Results are summarized and presented as mean
(SD) in Table 2. After 10 weeks of treatment, the
analysis of covariance (ANCOVA) revealed a
significant difference between the exercise and
control groups adjusted to baseline value of
outcome for all measured variables; craniovertebral
angle, pain, C6 and C7 peak-to-peak
amplitude of dermatomal somatosensoryevoked
potentials where the (F = 47.5,
P = 0.000), (F = 6.5, P = 0.01), (F = 39.2,
P = 0.000), (F = 13.6, P = 0.001) for all previous
variables respectively. At six-month follow-up,
the analysis showed that there were still significant
differences between the study and control
groups where (F = 23.1, P = 0.000), (F = 22.4,
P = 0.000), (F = 71.5, P = 0.000), (F = 48.8,
P = 0.000) for all the variables respectively.
This study demonstrates that 10 weeks of a posture
corrective exercise programme in addition
to ultrasound and infrared radiation decrease
the pain intensity and increase the craniovertebral
angle and peak-to-peak amplitude of dermatomal
somatosensory-evoked potentials for C6
and C7 levels in patients with cervical spondylotic
radiculopathy. The changes in the study
group were significantly greater than any
changes in the control group which received
infrared radiation and therapeutic ultrasound
only. Furthermore, after six months, these significant
changes were maintained.
However, our analysis has some potential
limitations, each of which points toward directions
of future study. The primary limitation
was the lack of investigator blinding. In addition,
the sample was a convenient sample
rather than a random sample of the whole population.
Furthermore, we did not use functional
outcome measures since we were primarily interested
in assessing the subjective pain experience
alone. Despite the limitations, the present randomized,
controlled study indicates that correction
of biomechanical dysfunction, especially
in terms of forward head posture, is essential
in management of cervical spondylotic
The improvement in the forward head posture
recorded by the exercise group is similar
to those reported in other studies which
showed the effectiveness of the exercise programme
in reducing this abnormal posture. [17, 26]
Correction of forward head posture in the current
study may be achieved by restoring the
normal muscle balance through strengthening
the week muscles and stretching the tight muscles.
This concept was further supported by
many studies which reported the muscle imbalance
represented in weakness in the deep cervical
short flexor muscles and mid-thoracic scapular
retractors (i.e. rhomboids, serratus anterior,
middle and lower fibres of the trapezius) and
shortening of the opposing cervical extensors
and pectoralis muscles as etiological factor for
this abnormal posture. [27, 28]
It may be that improving forward head posture
attributed to pain relief by the traditional
treatment in the form of ultrasound and infrared
radiation. However, we found no statistically
significant differences in the control group
which was subjected to traditional treatment
The second outcome assessment that has been
studied in the present study was the pain.
Overall, our findings are consistent with many
studies which investigated the association
between forward head posture and neck pain,
concluded that individuals experiencing pain
demonstrated a more severe forward head posture
than those who did not experience
pain. [11, 12, 29] In contrast, the findings of the present
study stand in contrast to other studies. In
particular, Willford et al.  found that there was
no significant difference in the forward head
posture between groups of subjects with different
levels of neck pain. In addition, Hanten
et al.  found that the resting head posture was
not significantly different between patients and
the normal population. These findings were further
supported by a systematic review conducted
by Silva et al.  who found that eight out of the
11 studies demonstrated a lack of association
between forward head posture and pain.
Similarly, Straker et al.  found no difference
between the neck posture of adolescents with
prolonged neck pain and symptom-free
The discrepancy and conflict found in the
results obtained by the previous studies cannot
be directly compared with the current study. All
of these studies, for example, were correlational
studies and not true experimental studies
which look for a degree of association between
variables without the ability to ascribe cause and
effect. The previous studies which investigated
the relationship between head posture and pain
have also identified subjects with neck pain
retrospectively, or have included heterogeneous
In the control group, while there was a significant
decrease in post-treatment VAS scores, the
follow-up measures revealed a significant
increase in the VAS scores towards initial baseline
values. The temporal reduction of pain came
in agreement with many studies which reported
the beneficial effects of infrared radiation
and therapeutic ultrasound in management of
pain. [32, 33] However, the sustained postural
imbalance represented in forward head posture
may be directly or indirectly responsible for
recurrence of cervical pain.  This highlights
the importance of our current results, which
indicate that the structural rehabilitation is
mandatory if we seek long-lasting effects.
Concerning the peak-to-peak amplitude of
dermatomal somatosensory-evoked potentials,
to the best of our knowledge, this is the first
study to explicitly examine the relationship
between forward head posture and nerve
root function in detail. Forward head posture
is most often described as excessive anterior
positioning of the head, involving extension of
upper cervical and flexion of lower cervical
Mechanically, it seems logical and is generally
admitted that ventroflexion, especially for lower
cervical spine, is more beneficial in improving
the nerve root function. This opinion is further
supported by many studies which reported that
flexion of lower cervical spine will improve
the nerve root function through increasing the
foraminal volume and area at the foraminal isthmus. [36, 37] In contrast to the previous mechanical
principles, the present study revealed remarkable
improvement in dermatomal somatosensory-
evoked potentials following forward head
correction and consequently decreased the flexion
posture of lower cervical spine.
Restoring the normal mechanics for the nervous
system is the likely explanation for significant
improvement in amplitude of dermatomal
somatosensory-evoked potentials. This concept
is supported largely by Harrison et al.  who
reported that flexion of any part of the spinal
column will induce abnormal stresses in the
entire cord and nervous system while the extension
position will minimize these stresses.
This explanation make sense and agrees with
Schnebel et al.  who investigated the role of
spinal flexion and extension in changing nerve
root compression and showed that the amount
of compressive force and tension in the nerve
root increased with flexion of the spine and
decreased with extension of the spine.
Additionally, The relevance of lower cervical
flexion posture to nerve root function has been
questioned by Albert et al.  and Brian et al. 
who reported a non-significant association
between foraminal height and foraminal area
and relief of clinical symptoms in cases of cervical
radiculopathy, which support the role of
nervous system biomechanics in cervical rehabilitation
as reported by Brieg. 
The unique contribution of our study is that
it evaluated the independent effect of structural
rehabilitation in the form of forward head
correction on long-term neural function,
which, to our knowledge, has not been previously
reported. In conclusion, the effectiveness
of forward head correction in reducing pain and
improving the nerve root function in cases of
cervical spondylotic radiculopathy introduces
yet another treatment option to a list that
already includes physical agent modalities
and manual therapies such as massage and
myofascial stretch. Its unique appeal lies in its
Posture corrective exercise programme in
the form of stretching and strengthening
exercises is beneficial in correcting the forward
head posture in cervical sondylotic
Correction of forward head posture is
essential in the management of cervical
All of the improvements were still present
six months after termination of treatment.
The authors express their sincere gratitude to all the
patients who kindly participated in the study.
They are grateful to the management and staff of
El-Farouk Hospital, Cairo, Egypt, for supporting
This research received no specific grant from
any funding agency in the public, commercial, or
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