Effectiveness of an Exercise Program to Improve Forward Head

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

Katherine Harman, PT, PhD
Cheryl L. Hubley-Kozey, PhD
Heather Butler, MSc (Kin), PhD (Candidate)

Abstract: Forward head posture (FHP) is most often described as excessive anterior positioning of the head in relation to a vertical reference line, involving increased cervical spine
lordosis (head forward, middle cervical spine extended, lower cervical spine flexed) and
rounded shoulders with thoracic kyphosis. Although exercise is routinely used to improve
FHP, relatively little data exists on efficacy. The present study was designed to examine the
impact of a 10-week targeted and progressive home exercise program on improving FHP. As
improvement through exercise of postural alignment depends upon participants adhering to
the 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- and
post-exercise postural measurements of FHP were obtained from the sagittal plane using the
BiotonixTM 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 extensor
and pectoralis major stretches and deep neck flexor and shoulder retractor strengthening
exercises for the 10-week period. Two-factor (group, pre-test/post-test) analysis of variance
models 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 significant
differences and interactions (p<0.05) between pre- and post-tests and also between the E
and C groups at post-test for range of motion and one postural measurement. The results
demonstrate that a short, home-based targeted exercise program can improve postural alignment related to FHP. These results provide a foundation for further development of postural
improvement programs that include an exercise component.
Key Words: Forward Head Posture, Home Exercise Program, Randomized Controlled Trial,
Compliance, Postural Exercise

ostural 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 asymptomatic individuals8-10 . Attempts to correct this misalignment 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
Address all correspondence and request for reprints to:
Katherine Harman
School of Physiotherapy
5869 University Ave.
Halifax, Nova Scotia,
B3H 3J5.
k.harman@dal.ca

The Journal of Manual & Manipulative Therapy

Vol. 13 No. 3 (2005), 163 - 176

thoracic musculoskeletal conditions, i.e., physical therapy,

as well as part of wellness programs promoting general
fitness, e.g., yoga, Feldenkrais11. Although improvement
in postural alignment secondary to exercise would be
expected due to improvement in muscle length and/or
strength, the influence of self-awareness of posture must
also be taken into consideration. To some extent, postural
correction is under our conscious control, so a program
that includes postural assessment and exercises explicitly
designed to improve posture could increase the postural
awareness of participants and potentially change their
habitual postures. Interestingly, despite the widespread
inclusion of postural correction in therapeutic interventions, there is limited experimental data to support its
effectiveness 12-14 . A recent study provided evidence to
link short-term lower trapezius strength increases to
thoracic manipulation in asymptomatic individuals15, but
few studies have directly assessed the impact of targeted

Effectiveness of an Exercise Program to Improve Forward Head Posture

in Normal Adults: A Randomized, Controlled 10-Week Trial / 163

postural exercises on FHP14 despite its widespread occurrence in the general population8-10.
Forward head posture (FHP) is a head-on-trunk misalignment 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 kyphosis 16-18 . This posture is associated with
weakness in the deep cervical short flexor muscles and
mid-thoracic scapular retractors (i.e., rhomboids, serratus anterior, middle and lower fibers of the trapezius)
and shortening of the opposing cervical extensors and
pectoralis muscles (known as the upper crossed postural 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 postures), 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 presence 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 discomfort, fatigue, and pain28, symptoms and risk factors
associated with chronic musculoskeletal disorders 24,29.
Watson and Trott25 found that in a group of 60 female
adult participants, FHP was associated with headache
and poor strength and flexibility of the upper cervical
flexors. Clinicians target this head-on-trunk misalignment 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 one
study 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

164 / The Journal of Manual & Manipulative Therapy, 2005

presence of cervical radiculopathy. Although they did not

measure postural alignment in the non-impaired subgroup, 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 program of pectoralis muscle, while Wright, Domenech,
and Fischer 31 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 combined 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 improvement 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 reduction 12,34-36 . 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 that
is 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 supervision 39 . An
additional factor that may influence compliance is the
presence or absence of symptoms40. Maintaining alignment change requires conscious attention, especially in
the presence of a strength/tightness imbalance such as
described for FHP. An exercise program that uses repetitive postural correction across the day serves to improve
postural 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 deviations have a potentially large biomechanical impact.

In studies of head-on-trunk alignment, many measurement 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 a
perpendicular 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 System 48 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 program 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.

Methods

The study design was a randomized, controlled, 10week program. The Dalhousie University Health Sciences
Ethics Review Board approved this study.

Participants

Recruitment for participants involved physiotherapists 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 Assessment

Screening 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 participants 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 protocol. 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 participants 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 landmarks and are indicated in Figures 2 and 3. A report of
the postural assessment was generated for each participant
and 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 Posture

in Normal Adults: A Randomized, Controlled 10-Week Trial / 165

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 superior
iliac spine (ASIS), posterior superior iliac spine (PSIS), glabella, tragus and C7.
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 Biotonix 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 Motion

Pre-and post-study neck flexion range of motion

(ROM) was measured to the nearest degree using the

166 / The Journal of Manual & Manipulative Therapy, 2005

CROM instrument10,54. Five measurements were taken,

with the last three used in the data analysis. The same
individual performed all measurements.

Exercise (E) program

Participants were given a list and description (with

illustrations) of each exercise and were required to
demonstrate their ability to perform each exercise correctly. 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 als approach9. The exercises 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 bilateral
pectoralis 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 program 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

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 progression

The 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) program

Controls did not participate in the exercise program

but were asked to carry on with their regular activities

Fig. 2: Description of the postural angles derived from

the photographs. Angles measured: a) head angle (the angle
between 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 positive shoulder angle is indicated on
the diagram.

and were telephoned at the end of each week to monitor their activity.

Other outcome measurements

All participants (Control and Exercise) were asked

to complete an activity log each day. Participants completed 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.

Statistics

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

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).

Effectiveness of an Exercise Program to Improve Forward Head Posture

in Normal Adults: A Randomized, Controlled 10-Week Trial / 167

Table 1: Brief description of exercises and progression

Exercise

Progression 1

Progression 2

Progression 3

Progression 4

Progression 5

Strengthen
Deep Cervical
Flexors

Lying chin tuck

Lying chin
tuck with head
lift*

Stretch
Cervical
Extensors

Chin drop

Chin drop with

hand assistance

Chin drop

Chin drop
with hand
assistance

Chin drop with

hand assistance

Strengthen
Shoulder
Retractors

Standing
shoulder
pull back
with elastic
resistance

Shoulder pull
back with weight
L and R

Shoulder pull
back with elastic
resistance
and weight
L and R

Stretch
Pectoralis
Muscle

Pectoral stretch
L and R

Bilateral Pectoral
stretch

Pectoral stretch
L and R

Bilateral Pectoral
stretch

Bilateral
Pectoral
stretch

The progressions for each strengthening exercise are indicated from left to right. Participants performed each level for two weeks.
At the consultation, if they could complete 3 sets of 12 repetitions correctly for the strengthening (except *), they were progressed to
the next exercise. For the stretching exercises, the participants alternated back and forth between the two exercises throughout the
10-week period.
* The chin tuck with head lift was progressed by holding the head lift for longer periods of time. Initially, this was to progress by 2second holds starting at 2 seconds i.e., 2, 4, 6, and 8 seconds. (Note that in some cases, participants were unable to progress by 2
seconds, but rather by 1 second)
R= right side
L=left side

ferences between the groups in age, body mass, or height.

The main dependent measurements (neck flexion ROM
and the 6 posture variables) were examined for homogeneity of variance and normality. A 3-factor mixed model
analysis of variance (ANOVA) was used to test between
trial, between group, between pre-test/post-test, and all
two and three-way interactions for neck flexion range
of motion. A 2-factor mixed-model ANOVA was used to
test between group, and between pre-test/post-test, and a
group by time interaction for the posture measurements
( = 0.05). Scores on the physical activity questionnaires
were compared between groups for pre- and post-study
differences, using a 2-factor ANOVA. Appropriate post
hoc tests were conducted on significant main effects or
interactions using the Bonferroni method56. Statistical
analyses were performed using MinitabTM version 13.

Results

Seventeen Controls [4 participants did not finish (DNF)]

and 23 Exercise Group (11 DNF) participants completed the
10-week study. DNF participants were excluded because

168 / The Journal of Manual & Manipulative Therapy, 2005

they did not attend the final testing session. Two subjects
in the exercise group did not attend consultation sessions
and did not comply with the exercise program; therefore
the final number in the Exercise Group was 21.
The average age, mass and height of the final groups
are found in Table 2. There were no statistically significant
differences (df=36, p>0.05) between the groups for any of
these measurements. The lack of significant differences
in age, mass, height, and the percentage of males and
females in the C and E groups demonstrated an effective
randomization procedure and equivalence of groups at
the pre-test data collection phase.
The physical activity scores are found in Table 3, indicating the activity level of the 2 groups prior to the pre-test
and during the 10-week period. There were no significant
(df=1,36, p> 0.05) interactions, or main effects. Since no
differences in activity scores between groups on pre-test
and post-test measurements and no changes between
pre-test and post-test were found for either group, we
demonstrated that participants did not alter their activity
patterns during the study; therefore, changes in activity
patterns were not a covariate in the analyses.

Table 2: Demographics: Mean (Standard Deviation) of

age, mass, and height

Exercise
Female 14/
Male 10

Control
Female 12/
Male 5

Age (yrs)

38.4 (11.3)

36.9 (9.5)

Mass (kg)

70.3 (7.6)

73.8 (17.5)

Height (cm)

169.8 (7.1)

170.3 (7.2)

interaction plot is in Figure 4. Post hoc results revealed

no significant differences between C and E on the pretest 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 (p<0.0001), and
between the C and E group on the post-test (p=0.03).
The neck flexion ROM increased on average by 3.7 for
the E group.

Postural alignment measurements

The means and standard deviations for the 6 pos-

Table 3: Physical Activity Scores: Mean (Standard Deviation) and Median (Range) of pre-test and post-test scores

Mean (SD)

Median (range)

Pre-Test

7.7 (3.1)

8 (3-11)

Post-Test

7.3 (3.1)

8 (0-11)

Pre-Test

8.2 (3.3)

9 (3-11)

Post-Test

8.0 (3.2)

9 (1-11)

Control

Exercise

Compliance to the program

Participants returned for consultations to correct exercise execution and recommend progression. The average
attendance number was 4.4, out of a possible 5. Participants
recorded in their logs that they completed all exercises
attempted. The average reported number of times that
participants exercised per week was 4.4, which exceeded
the required 4, giving a compliance rate of greater than
100%. If we include the 2 participants who did not do the
exercises, the compliance rate is still 91% (21/23). As evidenced by these attendance and participation scores, once
the participant became engaged in the exercise program,
there was a commitment to perform the exercises over the
10-week period and to periodically return for consultation.
Participants were progressed at a rate appropriate to the
individual and these rates are documented for the chin
tuck (deep flexor strengthening) and shoulder retraction
exercises in Tables 4 and 5 respectively. Three participants
did not progress for the chin tuck with the majority only
holding for one second. All participants progressed for the
shoulder retraction exercises with over half reaching the
5-pound weight resistance.

Neck range of motion (ROM)

There were no statistically significant (df=2,180,

p>0.05) trial effects or trial interactions for neck flexion ROM. There was a statistically significant group by
pre-test/post-test interaction (df=1,180, p<0.05). The

tural measurements are found in Table 6. There were no

significant interactions (df=36,p>0.05) or main effects
for head angle. There was a statistically significant interaction (df=1,36, p<0.05) for shoulder-to-pelvis angle
and the interaction plot is found in Figure 5. Post hoc
results illustrate no difference between groups on pretest. The E group angle became more negative whereas
the C group became more positive when pre-test scores
were compared to post-test scores. The only statistically
significant difference however was the 1.4 o between C
group and E group post-test (df=1,36, p=0.003).
There were statistically significant (df=1,36, p<0.05)
differences between pre-test and post-test measurements
(but no between group differences) for neck angle, shoulder distance, head distance and HScal distance. Figures
6-9 illustrate that the shoulder distance decreased, the
head distance decreased, the neck angle increased, and
the acromion-tragus distance decreased between pre-test
to post-test for both groups. Of these 4 figures, Figure 9
is the only one that clearly illustrates that the two lines
were completely parallel for the HScal, indicative of no
interaction but simply a pre-test/post-test difference,
whereas the other 3 measurements showed slight deviations. We observed rather large standard deviations in
all of these postural measurements. Despite this and
relatively small changes in degrees or distance, statistical
significance was found between groups or across time,
suggesting a strong directional effect.

Effectiveness of an Exercise Program to Improve Forward Head Posture

in Normal Adults: A Randomized, Controlled 10-Week Trial / 169

Table 4: The results of progression for neck strengthening exercise (n=21)

Progressions

# Participants
attaining this level

Table 5: Participant progression for shoulder retraction

exercise (n=21)

# Participants
attaining this level

Progressions
TherabandTM

2 lbs. Resistance

5*

3 lb. + TherabandTM

5 lb.

Chin tuck, release

Chin tuck plus

one-second hold

2-second hold

5 lb. + TherabandTM

3-second hold

8 lb.

4-second hold

6-second hold

8-second hold

No data

Qualitative data

Table 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

10 lb.

2*

10 lb. + Theraband

TM

No data

1
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.

schedules was a challenge.

In summary this set of findings is consistent with
a change over time of postural alignment in the direction 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.

Discussion

This study was designed as a randomized, controlled,

Fig. 4: Mean scores (SD) for neck flexion ROM in

degrees for each group measured prior to the 10-week
exercise 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 significant group by pre-test/post-test
interaction (df =1,180, p<0.05). *Indicates statistically
significant difference between the E post-test and all three
measurements based on post hoc analysis.

170 / The Journal of Manual & Manipulative Therapy, 2005

Fig. 5: Mean scores (SD) for shoulder-to-pelvis angle

in degrees for each group measured prior to the 10-week
exercise program (pre-test) and afterwards (post-test). There
was a statistically significant group by pre-test/post-test
interaction (df=1,36, p<0.05). * Indicates statistically significant difference between the C post- test and E post-test
and all three measurements based on post hoc analysis

Table 6: Means and standard deviations for all variables pre- and post-10-week program
Measure
Neck angle ()
Shoulder to Pelvis ()
Head angle ()
Head distance (cm.)
Shoulder distance (cm.)
H-Scal (cm.)

Time

Control

Exercise

Mean (SD)

Mean (SD)

pre

24.1 (6.4)

25.7 (5.8)

post*

21.8 (7.3)

24.5 (6.6)

pre

-3.8 (2.5)

-4.2 (2.2)

post

-3.3 (2.7)

-4.7 (1.8)

pre

38.1 (6.0)

36.4 (6.3)

post

38.0 (7.4)

36.8 (5.8)

pre

6.1 (3.0)

5.6 (2.9)

post*

5.2 (3.0)

4.1 (2.7)

pre

0.5 (3.0)

-0.7 (2.7)

post*

0.0 (2.4)

-1.8 (2.2)

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

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 by
the 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 10week exercise program.
Maintaining any exercise program is difficult and
King et al57 classified success as at least 66% of participation. Our compliance rate (100%) was higher than a
study 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.

Panjabis 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 intent 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 flexion
of 47o (SD=10) 61, which is about 10o lower than the pretest 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

Effectiveness of an Exercise Program to Improve Forward Head Posture

in Normal Adults: A Randomized, Controlled 10-Week Trial / 171

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 significant decrease in the distance between scapulae in the
stretching group as compared to controls reflects a positive 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 misalignments
involved 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 and
head 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 concomitant increase in cervical ROM. One of the strengths
of the Biotonix system is visual feedback; images are
provided to the participants highlighting postural measurements 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 statistically significant pre-test/post-test main (df=1,36,
p<0.05).

Fig. 7: Mean scores (SD) head distance in cm. for each

group measured prior to the 10-week exercise program
(pre-test) and afterwards (post-test). There was a statistically significant pre-test/post-test main effect (df=1,36,
p<0.05).

172 / The Journal of Manual & Manipulative Therapy, 2005

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 benet of advice and direction.

The most difcult part of

the study was(n=25)

24% nothing was difcult.

48% reported difculty completing the exercise schedule.
20% said that keeping track of their exercises was the most difcult.

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 difculty nding a location to anchor the Theraband for
shoulder retraction work.
28% no comment.

When asked whether they

thought that their posture
had changed over the
period of the study.

Exercise Group (n=15)

47% Yes, they believed that their posture had changed. Also 40%
specically 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 and
consciously 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 statistically significant pre-test/post-test main effect
(df=1,36, p<0.05).

Fig. 9: Mean scores (SD) for HScal (horizontal distance

between acromion and tragus) in cm. for each group measured prior to the 10-week exercise program (pre-test) and
afterwards (post-test). There was a statistically significant
pre-test to post-test main effect (df=1,36, p<0.05).

Effectiveness of an Exercise Program to Improve Forward Head Posture

in Normal Adults: A Randomized, Controlled 10-Week Trial / 173

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 alignment. 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 program, as working at a lower percentage would minimize
fatigue in those muscles. Although we addressed some
of 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 control group, the addition of postural awareness reminders
would likely enhance the impact of exercise.

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