Clin Rehabil. 2012 (Dec); 26 (12): 1123–1132 ~ FULL TEXT
Aliaa A Diab
Basic Science Department,
OBJECTIVE: To investigate the effectiveness of forward head correction on three-dimensional posture parameters and functional level in adolescent idiopathic scoliotic patients.
DESIGN: A randomized controlled study with three-month follow-up.
SETTING: University research laboratory.
SUBJECTS: Seventy-six adolescent idiopathic scoliotic patients with Cobb angle ranged from 10° to 30° and craniovertebral angle less than 50° were randomly assigned to a study or a control group.
INTERVENTIONS: All the patients (n = 76) received traditional treatment in the form of stretching and strengthening exercises. In addition, patients in the study group (n = 38) received a forward head posture corrective exercise programme.
OUTCOME MEASURES: Craniovertebral angle, Functional Rating Index and posture parameters, including: lumbar lordosis, thoracic kyphosis, trunk inclination, trunk imbalance, lateral deviation, surface rotation and pelvis torsion were measured before treatment, after 10 weeks, and at three-month follow-up.
RESULTS: There was a significant difference between the study and control groups adjusted to baseline values at 10 weeks post treatment with respect to the following parameters: craniovertebral angle (P = 0.006), trunk inclination (P = 0.005), lordosis (P = 0.01), kyphosis (P = 0.001), trunk imbalance (P = 0.001), lateral deviation (P = 0.001), pelvic torsion (P = 0.004) and surface rotation (P = 0.013). At three-month follow-up, there were still significant differences in all the previous variables (P < 0.005). In contrast, while there was no significant difference with respect to Functional Rating Index at 10 weeks (P = 0.8), the three-month follow-up showed a significant difference (P = 0.001).
CONCLUSION: A forward head corrective exercise programme combined with conventional rehabilitation improved three-dimensional scoliotic posture and functional status in patients with adolescent idiopathic scoliosis.
Keywords Exercise, posture, scoliosis, randomized controlled trial
From the Full-Text Article:
Adolescent idiopathic scoliosis is a life-long condition,
probably systemic, of unknown cause. Although
it is common to speak of scoliosis in terms of spinal
curvature in the coronal plane, it is actually a threedimensional
problem comprising torsion, angulation
and translation occurring simultaneously in the
transverse, coronal and sagittal planes.  A recent
review by Everett and Patel found that management
of scoliosis is closely dependent on the ability to
promote symmetry of the global spine, thus removing
asymmetrical gravitational loading. 
Through the years, many studies have supported
that many of our postural reflexes, such as the
vestibulocollic reflex,  cervicocollic reflex,  pelvoocular
reflex,  vestibulo-ocular reflex,  cervico-ocular
reflex and cervical somatosensory input, [7–9] are
housed, or occur, within the head and neck region. A
correction of altered head posture therefore, could be
imperative to achieve optimal full spine postural
correction, where the rest of the spine orients itself in
a top-down fashion. 
Although the forward head posture is one of the
most prevalent conditions in western society, 
occurring more frequently in patients with scoliosis
than in a normal population, [12–14] one component
that is universally lacking in nearly all forms of
scoliosis treatment today is the effect of the head
posture in determining overall spinal posture.
To date, no randomized controlled trials have
been published to address the issue of correction
of forward head posture and its impact on overall
spinal posture. Only a few correlational studies
have been conducted. [15–17] Despite the importance
of these studies, they were limited to certain body
regions. Moreover, the results of these studies
mostly only elucidated an open linear chain linking
the head to the pelvis in the sagittal plane
Accordingly, the main purpose of this study was
to investigate the effect of forward head posture
correction on spinal posture parameters occurring in
the transverse, coronal and sagittal planes in adolescent
idiopathic scoliosis as well as on functional
status which considered a more accurate reflection
of patient clinical state and progress than many
objective clinical or physiological indexes measures
upon which we have traditionally relied. 
A prospective, randomized, controlled study was
conducted in the research laboratory of my university.
All the patients were conveniently selected
from my 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 local institutional
review board. Patients were recruited from
April 2010 to February 2011 with three-month
Participants were screened prior to inclusion by
measuring craniovertebral angle. If the angle was
less than 50°, then a participant was referred to the
study. All the patients underwent careful clinical
and radiologic examinations to confirm a diagnosis
of adolescent idiopathic scoliosis. Patients were
included if they had mild to moderate scoliotic
curve (Cobb angle 10–30°,  Risser grade 0, 1 or 2
to ensure skeletally immaturity). They also were
included if they were under the category of ‘1A–’
according to the new classification method of Lenks
et al.,  which emphasizes consideration of sagittal
and coronal alignment. In this classification, type 1
identified patients with main thoracic curves, modifier
A is used when the centre sacral vertical line
runs between the lumbar pedicles to the level of the
stable vertebra, and the minus (–) sign identifies a
sagittal thoracic curve of less than +10°. Exclusion
criteria included true leg length discrepancy, previous
spinal surgery and associated pathologies of
lower limbs that may interfere with global spinal
posture, such as foot, knee and hip deformities.
Patients were randomly assigned into two groups
by an independent person who picked one of the
sealed envelopes, which contained numbers chosen
by random number generator. Randomization was
restricted to permuted blocks of different size to
ensure that equal numbers were allocated to each
group. Each random permuted block was transferred
to a sequence of consecutively numbered,
sealed, opaque envelopes and these were stored in a
locked drawer until required. As each participant
formally entered the trial, the researcher opened the
next envelope in the sequence in the presence of the
Patients in both the study (n = 38) and the control
group (n = 38) received the same traditional
treatment. This included stretching the tight structures
on the concave side of the spine, erector
spine muscles and tight hamstring muscle. These
exercises would be conducted in conjunction with
strengthening the trunk muscles necessary for postural
control and trunk stability; abdominal, thoracic
and lumbar extensors and trunk musculatures
on the convex side of the curve. This conventional
treatment was to be repeated 3 times a week for 10
weeks. Those in the control group received this
conventional treatment only.
The exercise group also received a corrective
exercise programme for forward head posture in the
form of two strengthening (deep cervical flexors
and shoulder retractors) and two stretching (cervical
extensors and pectoral muscles). The exercise programme
was carried out according to the protocol
devised by Harman et al.: 
Strengthening deep cervical flexors:
supine lying position the patient was instructed
to tuck his or her chin in and keep the head
straight, without turning to either side. The
progression of this exercise was to lift the head
off the floor in tucked position and hold it for
varying lengths of time (2–second holds starting
at 2 seconds, i.e. 2, 4, 6 and 8 seconds).
Stretching cervical extensors through a chin
drop in sitting:
The progression of this exercise
was to drop the chin with hand assistance.
Strengthen shoulder retractors:
was first performed from standing position
using a theraband pulling the shoulders back.
The patient was asked to pinch the scapulae
together without elevation or extension in the
shoulders and to hold this position for at least
6 seconds then relax. The first progression
was to conduct the shoulder retraction from
prone using weights. The second progression
was through using elastic resistance and weights.
Participants performed each progression for
two weeks. At consultation, if they could
complete three sets of 12 repetitions correctly
for the strengthening, they were progressed to
the second progression.
Unilateral and bilateral pectoralis stretches
alternating each two-week period:
pectoralis stretching, the patient was seated on a
treatment table or mat with the hands behind the
head. The therapist kneeled behind the patient,
grasping the patient’s elbows and gently pushing
them back. No forceful stretch is needed against
the elbows, because the ribcage is elongating the
proximal attachment of the pectoralis major
muscles bilaterally. 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°. For sternal division, the arm is
abducted to 90°. For clavicular division, the arm
is rested at the side. Participants completed 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 4 times per week for 10 weeks.
Patients in both groups were instructed to avoid
any other exercise programmes that may interfere
with the results.
The main outcome measurement used to assess
the forward head posture was the craniovertebral
angle, which is considered to be a valid and reliable
assessment tool.  All the measurement procedures
were done following the protocol of Falla
et al.  The craniovertebral angle was measured by
taking a lateral photograph. The patients were
asked to sit on a chair as usual as they were and
a lateral photograph was taken. A digital camera
was positioned on a tripod at a distance of 0.8 m
from the subject at shoulder height. 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 horizontal line passing through C7 and
a line extending from the tragus of the ear to C7.
Other outcome measures used to compare
effectiveness of the treatment between the study
and control groups included three-dimensional
posture parameters using the Formetric II device
and Functional Rating Index. Rasterstereography
(Formetric II, Diers International GmbH,
Schlangenbad, Germany) was used to examine
posture and back shape characters. All testing
procedures were carried out following Lippold’s
protocol.  The patient was positioned in front of
a black background screen 2 m from the measurement
system. The column height was aligned
to move the relevant parts of the patient’s back
into the centre of the control monitor by using
the column up/down button of the control unit.
To ensure the best lateral and longitudinal position
of the patient a permanent mark on the floor
was used. The patient’s back (including upper
buttocks) was completely bare in order to avoid
disturbing image structures. The hair was tied
back so that the neck (in particular the vertebral
prominence) was uncovered.
When the patient and the system were correctly
positioned, the system was ready for image recording.
The projector lamp was automatically switched
on under programme control and the exposure control
was started. The best moment for releasing
image capture was the (slightly) breathed out state.
The patient was first asked to breathe normally.
The moment of breathing out was observed on the
control monitor. The patient was then asked to stop
breathing for a few seconds while the image capture
was released. The print-out of the Formetric
system itself gives a lot of data: sagittal plane
parameters (lumbar angle, thoracic angle and
trunk inclination), frontal plane parameters (trunk
imbalance and lateral deviation) and transversal
plane parameters (vertebral surface rotation and
pelvis torsion) were selected to cover the posture
profile in three planes. A representative example of
a Formetric system print-out is shown in Figures
A1 and A2 (on-line).
The Functional Rating Index  was selected as it
is considered to be a responsive outcome measure
of spinal pain and function. It is a self-reporting
instrument consisting of 10 items, each item is
scored with a 5–point scale ranging from 0 (no pain
or full ability to function) to 4 (worst possible pain
or unable to perform a specific function at all). The
10 items fall within four constructs – pain, sleep,
work, and daily activity – that fit within the three
domains of WHO-ICF: (1) activity limitations daily
activity with six items – personal care, travel, recreation,
lifting, walking and standing; (2) impairment
with three items and two constructs of pain and
sleep – pain frequency, pain intensity and sleep;
and (3) participation restriction with one construct
and item – work. The final score ranges from 0
(representing absence of disability) to 100% (representing
The outcome assessor, who also applied the
treatment intervention programmes, was not masked
during the study. To determine the number of samples
in this study, estimates of mean difference and
standard deviation for the primary outcome craniovertebral
angle were collected from a pilot study
consisting of eight patients who received the same
programme between September 2009 and March
2010. The mean difference value and standard
deviation were estimated as 3.07 and 3.6 respectively,
a two-tailed test, an alpha level of 0.05 and
desired power of 90%. These assumptions generated
a sample size of 30 patients per each group.
To account for some drop-out rates, the sample
size was increased by 20%.
Both the mean and standard deviation were
calculated for each variable. The differences in
the baseline data between the study 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, statistical analysis was based
on the intention-to-treat principle and P-values
less than 0.05 were considered significant. We used
multiple imputations to handle missing data. To
impute the missing data we constructed multiple
regression models including variables potentially
related to the fact that the data were missing and
also variables correlated with that outcome. We
used Stata (Stata Corp, College Station, Texas,
USA). Analysis of covariance (ANCOVA) at two
follow-up points (after 10 weeks of treatment and at
follow-up of three months) was performed for all
variables, the baseline value of the outcome as
covariates was used to assess between-group differences
(baseline outcome in the mode = baseline
value – overall mean baseline value).
A diagram of patient retention and randomization
throughout the study is shown in Figure 1. The figure
shows that 96 were initially screened, after the
screening process 76 patients were eligible to participate
in the study and 76 completed the first
follow-up, and 68 of them completed the study.
Demographics of the participants are described in
Table 1. The study and control groups were similar
with regard to age, height, weight, gender and past
use of physiotherapy. Specific measurements of the
study (craniovertebral angle, functional index scale,
and all the posture parameters) were also well balanced
between the groups at baseline (P > 0.05 for
Results are summarized and presented as mean
(SD) in Table 2. After 10 weeks of treatment, the
ANCOVA revealed a significant difference between
the study and control groups adjusted to baseline
value of outcome for all measured variables; craniovertebral
angle (F = 10.08, P = 0.006), trunk inclination
(F = 10.6, P = 0.005), lordosis (F = 8.5, P =
0.01), kyphosis (F = 17.6 P = 0.001), trunk imbalance
(F = 17.3, P = 0.001), lateral deviation (F =
14.2, P = 0.001), pelvic torsion (F = 11.1, P = 0.004
), surface rotation (F = 7.3, P = 0.013). The only
exception was Functional Rating Index where the
F-value was 0.06 with associated probability of 0.8.
At three-month follow-up, the analysis showed that
there were still significant differences between the
study and control groups for all the measured variables
without any exception; craniovertebral angle
(F = 14.9, P = 0.002), Functional Rating Index
(F = 14.3, P = 0.001), trunk inclination (F = 6.6,
P = 0.02), lordosis (F = 7.01, P = 0.017), kyphosis
(F = 10.9, P = 0.004), trunk imbalance (F = 31.4,
P = 0.000), lateral deviation (F = 13.007, P = 0.002),
pelvic torsion (F = 39.7, P = 0.00), surface rotation
(F = 16.6, P = 0.001).
Changes in posture
parameters, craniovertebral angle,
and Functional Rating Index after
the 10–week treatment period and
after three-month follow-up
This study demonstrates that the group receiving a
forward head correction exercise programme in
addition to traditional treatment in the form of
stretching exercises for tight muscles and strengthening
exercises for weak muscles showed more
improvement than the control group in forward
head angle, three-dimensional postural parameters
based on the decrease in trunk inclination, lateral
deviation, trunk imbalance, thoracic kyphosis, surface
rotation, and pelvic torsion and increase in craniovertebral
angle and lumbar lordosis. Furthermore,
after three months, these significant changes were
Functionally, it is interesting that traditional
treatment alone and traditional treatment in conjunction
with an intervention programme for forward
head correction seem roughly equally
successful in improving functional status after 10
weeks of treatment. However, the three-month
follow-up revealed a significant decline in functional
index for the control group. It seems logical
and is generally admitted that exercise-based therapies
are a logical approach to improve and maintain
flexibility and function in adolescent idiopathic scoliosis
patients,  while the transient improvement in
the control group may be attributed to the continuous
asymmetrical loading from biomechanical dysfunction
represented in forward head posture,
sagittal and coronal abnormal spinal posture that
results in continuous pathological and histological
changes of spinal soft tissues.
The association between normal spinal configuration
and long-term health of the spine in scoliosis
management was confirmed by Rhee and colleagues
who noted that correction of the sagittal curves
might be related to the long-term health of the spine
in scoliosis management.  The improvement in the
forward head posture recorded by the study group is
similar to those reported in other studies that showed
the effectiveness of exercise programmes in reducing
this abnormal posture. [21, 28] This improvement
may be attributed to the fact that muscle imbalance
is considered to be an aetiological factor for this
abnormal posture. 
In the current study we found that the study
group which received the intervention programme
for forward head correction experienced significant
changes in posture parameters in the sagittal, transverse
and coronal planes. These significant changes
may suggest the important role of forward head
correction on global spinal posture. These results
are in agreement with a neurophysiological basis
reported in many studies which implies that neurological
regulation of static upright human posture is
largely dependent on head posture. [3–9] It is apparent
from the literature we searched that posture is
largely maintained by reflexive, involuntary control.
The reflexive components for postural control
are housed, or occur, within the head and neck
region primarily. Because this involuntary control
is largely dependent upon cervical joint mechanoreceptors
and afferent input from ligament and
musculotendinous sources,  correcting the postural
distortions responsible for the dysafferentation
process may be beneficial in correcting scoliotic
posture, where postural control is significantly
Forward head posture as a direct cause for dysafferentation
was supported by another study which
reported that the resultant lack of blood flow in
response to increased strain placed upon various
spinal muscles, such as the splenius capitis, trapezius,
sternocleidomastoid and levator scapula, forces the
muscle to rely on anaerobic metabolism.  As anaerobic
metabolism progresses, metabolites such as
substance P, bradykinin and histamine build up and
excite chemosensitive pain receptors, causing a
barrage of nociceptive afferent input,  resulting in
The role of the cervical spine and position of the
head in postural adaptation due to undisturbed proprioception
by cervical vertebra facets was confirmed
by a number of authors. [35, 36] Therefore, regardless of
the cause of the cervical vertebral imbalance and
changes of head position (whiplash injury, cervical
syndrome or adolescent idiopathic scoliosis), it will
result in an inadequate postural adaptation and a
problem of proprioception. Coppieters et al.  emphasized
a correct perception of the surroundings and the
role of head and eye position in order to maintain
normal postural adaptation. Looking into the matter
further, while there were no previous published
studies that had identified an association between
forward head posture correction and sagittal profile
of the spine, the current results are in agreement with
the findings of another study which reported that
changes in sagittal profile of the spine may be attributed
to a strong association between forward head
and pelvo-ocular reflex, which causes an anterior
pelvic translation to balance the head’s centre of
gravity.  As reported in the literature, modifications
of sagittal spinal curvature have been connected with
changes in pelvic orientation.  Similarly, these
results are in agreement with the concept of Levangie
and Norkin,  who stated that relocation of a body
segment causes a shift in the centre of mass, and thus
the line of gravity shifts in relation to the base of
Concerning the significant changes of posture
parameters in transverse and coronal planes, while
there were no studies have investigated the role of
forward head correction on spinal posture in transverse
and coronal planes, the explanation behind
these findings may be attributed to the resultant
changes in the sagittal contour of the whole spine.
This explanation concurred with several authors
who have confirmed the association between the
sagittal and coronal spinal contour. [41–43] Similarly,
Kadoury et al.  have even been able to predict the
thoracic kyphosis by evaluating the coronal thoracic
curvature, the lumbar lordosis and the slope of the
first lumbar vertebra. New research has discovered
that a kyphotic cervical curvature (sagittal deformity)
occurs more frequently in patients with severe
scoliosis (coronal deformity) than in a normal
population.  In addition, the resultant changes in
sagittal contour of the whole spine may be attributed
to the significant changes in transverse plane
as confirmed by Veldhuizen et al.  who reported
the positive correlation between sagittal configuration
of the spine and axial rotation.
Another study which highlighted the role of the
head in correction of axial rotation deformity was
conducted by Parry,  who reported that human
walking, unique among animals, involves axial
pelvi-spinal rotations and axial spinal counter
rotation. Body axial rotations start at the feet and
are eliminated by the upper cervical spine. As the
forward head posture is considered a direct cause
for dysafferentation,  postural control – especially
for spinal rotation and counter rotation – is
It may be that improving the posture parameters
are attributed to stretching and strengthening exercises.
However, we found no statistically significant
differences in the control group which was
subjected to traditional treatment only. It is interesting
to note that there are no objective data to
indicate that exercise will lead to postural deviations.
Given the available evidence, it is questionable
as to whether resistance training alone or in
combination with stretching exercises will produce
an adaptive shortening of a muscle and hence
elicit postural changes. 
The unique contribution of the current study is
that it evaluated the independent effect of structural
rehabilitation in the form of forward head correction
on long-term global spinal posture in the transverse,
coronal and sagittal planes, which, to my
knowledge, has not been previously reported. In
conclusion, the effectiveness of forward head
correction in improving three-dimensional spinal
posture introduces the possibility of new guidelines
in the treatment of adolescent idiopathic scoliosis.
As effective prevention strategies for spinal disorders
demand a detailed understanding of the interrelationship
among different body segments, as
supported by many studies, we hypothesized that
the results of the current study could be particularly
helpful in the evaluation and treatment planning of
patients with idiopathic adolescent scoliosis.
The analysis has some potential limitations,
however, 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,
short-term follow-up after only three months may
be considered a major limitation. Despite the limitations,
the present randomized controlled study
indicates that correction of biomechanical dysfunction,
especially in terms of forward head posture,
is essential in the management of adolescent
The strengths of this study were
(1) the randomized control design with the control group,
(2) analysis using the intention-to-treat principle,
(3) participants in both intervention groups received the same number of interventions,
(4) the high follow-up rate (greater than 90%).
In the current study we assessed
trunk surface symmetry because the cosmetic
improvement of the trunk after any treatment is of
paramount importance to the patient under treatment
and his or her family. Trunk surface symmetry
is also an important element in improving quality of
life, an issue vital for any human being. 
Forward head correction leads to a significant and permanent improvement
in functional status.
Stretching and strengthening exercises temporally improve functional status.
Forward head correction was effective in improving scoliotic posture in
the transverse, coronal and sagittal planes.
I express my sincere gratitude to all the patients who
kindly participated in the study. I am grateful to the Faculty
of Physical Therapy, Cairo University for facilities and
Conflict of interest
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit
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