Clin Rehabil. 2012 (Apr); 26 (4): 351–361 ~ FULL TEXT
Diab AA, Moustafa IM.
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 root function.
Specifically, despite the widespread inclusion of postural correction in therapeutic interventions,  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 ]
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 radiculopathy.
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 only.
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 adolescents.
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 sample.
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 spine. 
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 long-lasting effect.
Posture corrective exercise programme in the form of stretching
and strengthening exercises is beneficial in correcting the
forward head posture in cervical sondylotic patients.
Correction of forward head posture is essential in the management
of cervical spondylotic radiculopathy.
All of the improvements were still present six months after
termination of treatment.
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