Effects of a Resistance and Stretching

Training Program on Forward Head

and Protracted Shoulder Posture
in Adolescents
Rodrigo Miguel Ruivo, PhD, a Pedro Pezarat-Correia, PhD, a and Ana Isabel Carita, PhD b

ABSTRACT

Objective: The purpose of this study was to evaluate the effects of a 16-week resistance and stretching training
program applied in physical education (PE) classes on forward head posture and protracted shoulder posture in
Portuguese adolescents.
Methods: This prospective, randomized, controlled study was conducted in 2 secondary schools. One hundred and
thirty adolescents (aged 15-17 years) with forward head and protracted shoulder posture were randomly assigned to a
control or experimental group. Sagittal head, cervical, and shoulder angles were measured with photogrammetry and
Postural Assessment Software. The American Shoulder and Elbow Surgeons Shoulder Assessment was used to assess
shoulder pain, and neck pain during the last month was self-reported with a single question. These variables were
assessed before and after a 16-week intervention period. The control group (n = 46) attended the PE classes, whereas
the exercise group (n = 84) received a posture corrective exercise program in addition to PE classes.
Results: A significant increase in cervical and shoulder angles was observed in the intervention group from pretest to
posttest (P b .05). For the shoulder pain scores in both groups, there were no significant changes after the 16 weeks.
Conclusions: A 16-week resistance and stretching training program decreased forward head and protracted shoulder
postures in adolescents. (J Manipulative Physiol Ther 2017;40:1-10)
Key Indexing Terms: Neck; Exercise; Posture; Rehabilitation

INTRODUCTION
Epidemiological studies have reported a high prevalence of
spinal postural deviations in children and adolescents, 1,2 with a
high prevalence of self-reported upper quadrant musculoskel-
etal pain among adolescents. 3 Forward head posture (FHP)
and protracted shoulders (PSs) are 2 of the most common
postural deviations in people of all ages, including children and
a the vertebra and to changes in connective tissue length and
Laboratory of Motor Behavior, Faculdade de Motricidade
Humana, Universidade de Lisboa, CIPER, Lisbon, Portugal.
b
Secção Autónoma de Métodos Matemáticos, Faculdade de
Motricidade Humana, Universidade de Lisboa, CIPER, Lisbon,
Portugal.
Corresponding author: Rodrigo Miguel Arsénio dos Santos
Ruivo, PhD, Avenida Fernando Pessoa, lote 3.20.01, Bloco B, 4
A, 1990-102 Lisbon, Portugal. Tel.: +351 919996559; fax: +351
217507001. (e-mail: rodrigo.ruivo@netcabo.pt).
Paper submitted May 14, 2014; in revised form September 18,
2016; accepted September 27, 2016.
0161-4754
Copyright © 2016 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2016.10.005
adolescents of school age, 4 with the shoulder and neck regions
being cited in many references as the areas of greatest
discomfort in adults 5,6 and adolescents. 3,7
Forward head posture is characterized by hyperextension
of the upper cervical spine (C1–C3) and flexion of the
lower cervical spine (C4–C7), 8 and it is associated with
shortening of the upper trapezius, posterior cervical
extensor muscles (suboccipital, semispinalis, and splenii),
sternocleidomastoideus, and levator scapulae muscles. 9 It is
suggested that FHP leads to an increase in the compressive
forces on the cervical apophyseal joints and posterior part of
strength resulting in pain. 10
A PS is a forward displacement of the acromion with
reference to the seventh cervical spinous process and can be
measured by the shoulder angle. It is frequently associated with
a protracted, anteriorly tilted, and internally rotated scapula and
with a tightness of the pectoralis minor muscle, 11 shoulder
modifications that can be associated with pain. 12
To correct FHP, stretching of the shortened upper
trapezius, sternocleidomastoid, and levator scapulae and
strengthening of the deep cervical flexor muscles have been
found to be effective, 9 whereas PS treatment most often is
2 Ruivo et al
Postural Correction Training
based on strengthening of the scapular stabilizers and rotator
cuff muscles and stretching of the anterior musculature,
namely, the pectoralis minor. 9,13,14 Interventions based on
these premises have already produced good results. 9,15 To
our knowledge, no study has attempted to correct posture
through a training protocol involving flexibility and strength
exercises with adolescents in a school context.
The purpose of this study was to evaluate the effects of
a 16-week resistance and stretching training program
applied in physical education (PE) classes on Portuguese
adolescents (15-17 years old) with FHP and PSs. Effects
on neck and shoulder pain were also assessed. We
hypothesized that measures of FHP and PSs, neck pain
(NP), and shoulder pain and function would improve after
the intervention.
METHODS
Ethics
The Research Ethics Committee of the Faculty of
Human Kinetics of the Technical University of Lisbon
approved the study, and all procedures were performed
according to the Declaration of Helsinki. The clinical trial is
recorded in the ClinicalTrials.gov Identifier with the
following registration code: NCT02190331. The participa-
tion of all students was voluntary, and written informed
consent was obtained from all participants and their parents
or legal guardians prior to commencement of the study.
Participants
A prospective, randomized, and controlled study was
conducted over a 4-month period, starting in October 2012,
with adolescents of two public secondary schools located in
Lisbon, Portugal. At the beginning, a total of 275 adolescent
students aged 15 to 17 years were evaluated with photogram-
metry. We chose this age group to avoid the effects of a
pubertal jump. The cervical and shoulder angles were
measured using photogrammetry. If the cervical and shoulder
angles were b50° and b52°, respectively, the adolescent was
considered to have FHP and PSs and was referred to the study.
Participants were excluded if their cervical and shoulder
angles were ≥50° and ≥52°, respectively; if they had visual
deficits, diagnosed balance disorders, or musculoskeletal
pathologies (such as a history of shoulder surgery, or cervical
or thoracic fractures); if they were nonambulatory; if they
exhibited functional or structural scoliosis; or if they had
excessive thoracic kyphosis.
Thoracic kyphosis was calculated by an experienced
investigator who has worked in musculoskeletal therapy for
more than 10 years, using the Bioprint software and a
validated and optimized estimation technique. 16
Given these criteria, 130 adolescents from 17 different
classes (9 from the 10th grade, 7 from the 11th grade, and 1
from the 12th grade) met the inclusion criteria and were
Journal of Manipulative and Physiological Therapeutics
January 2017
recruited for the study. They were randomly assigned to two
groups, a control group and an exercise group. The
randomization was generated using an arbitrary number
table, and allocation to one of the two groups was concealed
using sequentially numbered opaque envelopes held at a
central location. The investigator responsible for the outcome
assessments was blinded to group allocation. Participants were
blinded to which intervention was considered therapeutic.
After randomization, the intervention group, composed of 84
participants (50 female and 34 male; 15.5 ± 1.1 years), began a
16-week stretching and strengthening program that was
performed in the last part of the PE classes. The control
group, composed of 46 adolescents (32 female and 14 male;
15.9 ± 1.1 years), participated only in the PE classes. It must be
emphasized that the numeric discrepancy between the control
and intervention groups was justified because the intervention
group would be split into two subgroups for future study
purposes after the 4-month program. Figure 1 is a diagram of
retention and randomization of patients throughout the study.
One hundred thirty students fulfilled the inclusion criteria
and were assessed at the beginning. After the 4-month period,
15 participants who were selected (7 from the control group
and 8 from the experimental group) did not return for the
second assessment because they were transferred from school
or class, or were excluded because they missed practice for 2
consecutive weeks because they missed classes.
Testing Procedure: Posture Alignment Assessment
Posture alignment assessment in both groups was per-
formed at the beginning and after the 4-month training period.
Standing cervical and shoulder posture was measured with a
highly reliable photogrammetric method, 17-19 which allows
quantitative assessment of postural alterations, 20 and Postural
Assessment Software (PAS). This software had already proven
to be valid and reliable. 21,22
Three angles were measured: sagittal head, cervical, and
shoulder angles. We chose these angles because they had been
used in previous studies and were found to be reliable, 23
enabling the comparison of results. The intrarater reliability of
the researcher with computerized photogrammetry using the
PAS for the angles studied was also confirmed by a separate
preparatory study. 21
The angles in the sagittal view (Fig 2) were obtained as follows:
Sagittal head angle: The angle formed at the intersection of
a horizontal line through the tragus of the ear and a line
joining the tragus of the ear and the lateral canthus of the eye.
Cervical angle: The angle formed at the intersection of a
horizontal line through the spinous process of C7 and a
line to the tragus of the ear. If the cervical angle was less
than 50°, the participant was considered to have FHP.
Selection of 50° as a reference angle was guided by the
studies of Diab and Moustafa 24 and Yip et al, 25 with the
latter reporting 55.02° ± 2.86° as a normal range. As is well
Journal of Manipulative and Physiological Therapeutics
Volume 40, Number 1
Fig 1. Flow of study participants. PE, physical education.
Fig 2. Adhesive marker placement and postural angles: A,
sagittal head; B, cervical angle; C, shoulder angle.
known, participants with FHP have a significantly smaller
cervical angle compared with normal participants. 15
Shoulder angle: The angle formed at the intersection of
the line between the midpoint of the humerus and the
spinous process of C7 and the horizontal line through the
midpoint of the humerus.
Ruivo et al 3
Postural Correction Training
Based on the premise that participants with PSs have a
significantly smaller shoulder angle when compared with
normal participants 26 (Lewis et al 27 reported, for asymptom-
atic participants, a mean shoulder angle value of 61.9° ±
10.4°; Thigpen et al 28 reported, for 310 participants evaluated
in a standing position, a normal range of 52.6° ± 15.3°; and
Raine and Twomey 23 reported, for 160 participants evaluated
in a standing position, a normal range of 53.7° ± 11.5°), we
considered 52° as the reference angle. We considered an
individual to have PSs if the angle was b52°.
The same researcher who was experienced in the
assessment of postural alignment and blinded to the group
assignment of each student performed all measurements.
Photography took place in the gymnasiums of the two
secondary schools, with the areas arranged identically.
Landmarks were placed on the floor to ensure the same
positioning of all participants in front of the camera and to
ensure that the participant was aligned perpendicular to the
camera. A landmark was placed in front of a white wall to
ensure a contrast of the participants against the background.
One Canon Power Shot A4000 IS was supported on a
Manfrotto tripod, Model 055 CLB, 3 m from the line marking
the position of the participant. The height of the tripod was
adjusted so that the middle of the objective lens was 130 cm
above the ground. A calibration board was placed in the white
wall in the field of view and aligned with the participant to
4 Ruivo et al Journal of Manipulative and Physiological Therapeutics
Postural Correction Training January 2017

Table 1. Description of Strengthening and Stretching Exercises Used During the Training Program
Exercise Principal Muscle Description
Side-lying external rotation Teres minor Side lying with arm fully adducted to side and internally rotated
infraspinatus with elbow flexed to 90°. Patients then externally rotate the
shoulder with the hand moving in an arc away from the body.

Prone horizontal abduction Middle trapezius In a prone horizontal abduction position, the patient horizontally
with external rotation Lower trapezius abducts the arm with the elbow extended and with external humeral
Rhomboids rotation. The participant lifts the hand toward the ceiling keeping
Infraspinatus head/neck neutral and squeezing both shoulder blades together.
Teres minor

Y-to-I exercise Middle trapezius The patient retracts the scapulae with the arms abducted to 90°.
Lower trapezius As the patient advances, the shoulders are externally rotated with
Serratus anterior the elbows flexed to 90°, forming a Y. Then the patient moves into
a position of full bilateral elevation with the elbow extension forming an I.

Chin tuck Longus colli This exercise targets the deep flexor muscles of the upper cervical region,
Longus capitis the longus capitis and longus colli muscles. This is a low-load exercise51
that involves performing and holding inner range positions of craniocervical
flexion that specifically activate and train the deep cervical flexor,
rather than the superficial flexors muscles. This exercise is done in
a supine lying position with the head in contact with the floor.

One-sided unilateral self-stretch exercise Pectorals minor The participant’s forearm is stabilized by a vertical plane
before the trunk is rotated in the opposite direction. Therefore,
the arm on the involved side is externally rotated and abducted to 90°.

One-sided unilateral self-stretch exercise Pectorals minor The participant’s forearm is stabilized by a vertical plane before the
trunk is rotated in the opposite direction. Therefore, the arm on the
involved side is externally rotated and abducted to 90°.

Static sternocleidomastoid stretch
Sternocleidomastoid Start in optimal posture and place right arm behind body, depressing
the shoulder. Draw abs in. Tuck chin and slowly draw left ear to the
left shoulder. Continue by rotating the neck upward toward the ceiling
until a slight stretch is felt on the right side. We can use the left hand to
apply slight pressure and assist in lateral flexion and rotation.
Switch sides and repeat.

Static levator scapulae stretch
Levator scapulae Start in optimal posture and place right arm behind body, depressing
the shoulder. Draw abs in. Tuck chin and slowly draw left ear to the
left shoulder. Continue by rotating the neck downward toward the ceiling
until a slight stretch is felt on the right side. We can use the left hand to
apply slight pressure and assist in lateral flexion and rotation.
Switch sides and repeat.

allow referencing of horizontal and vertical axes from the
photographs. The calibration board also displayed each
participant’s identification number. For positioning, the
adolescent was instructed to stand comfortably in a normal
standing position and to look straight ahead.
Before photographing the student, the researcher
placed reflective markers, polystyrene foam balls 20 mm
in diameter, on the following anatomical points on the side
of the participant’s body: tragus of the ear, lateral canthus
of the eye, spinous process of C7, and midpoint of the
humerus. With these markers, we were able to calculate
the sagittal head, cervical, and shoulder angles. To enable
precise positioning of the markers, we instructed partic-
ipants to wear sleeveless T-shirts, with elastic for the hair
when needed. The same researcher performed all proce-
dures. To capture the participant’s natural head-on-trunk
and shoulder alignment, each person was asked to look
straight ahead and to march on the spot five times before
each picture was taken. 29 Each picture was taken 5
seconds after the marching sequence in a lateral view, with
the right side of the participant photographed for right
hand–dominant individuals and the left side for left hand–
dominants. The dominant arm was defined as the one most
used in daily activities. The photographic analysis was
performed using PAS, which determined coordinates of
the anatomical points on the photographs. The zoom was
standardized at 200% to improve the accuracy of the
analysis, and the angles were measured in degrees. One
researcher undertook all scanning and digitizing to
eliminate interexaminer error. Data were submitted to
descriptive statistical analysis, and quantitative values for
head and upper member angles were obtained.
Journal of Manipulative and Physiological Therapeutics
Volume 40, Number 1
Self-Assessment of Shoulder Pain and Function and NP
The self-report section of the American Shoulder and Elbow
Surgeons Standardized Shoulder Assessment Form (ASES) has
already been validated and culturally adapted to the Portuguese
language. 30,31 This Portuguese version was used to record the
presence of shoulder pain and function in the participants. The
questionnaire addressed self-evaluation of pain using a visual
analogue scale and activities of daily living questionnaire. The
maximum score is 100. A high total score indicates low
perceived pain and low dysfunction in activities of daily living.
After postural assessment and completion of the ASES
questionnaire, students were asked about their 1-month
experience of NP. The question was: Has your neck been
painful in the last month? (“yes” or “no”). Straker et al used the
same question in a previous study. 32 These procedures were
repeated in the beginning and after the 4-month period.
Intervention Protocol
After the testing protocol, adolescents in the intervention
group began a 16-week stretching and strengthening
program. Exercises were performed twice a week, in the
last 15-20 minutes of each PE class, with the supervision and
help of the PE teacher and the aid of an illustrated handout.
Physical education classes for the control group did not include
this specific protocol. Each PE teacher was responsible for
approximately 20 students from the same class.
The training protocol comprised four strengthening
exercises and three stretching exercises (Table 1) and was
designed based on the assumption that the use of
therapeutic exercise is effective in the correction of specific
neck and shoulder postures. 9,24,33-35 Strengthening exer-
cises (Fig 3) are targeted to elicit activation of the rotator cuff,
Fig 3. Strengthening exercises.
Ruivo et al 5
Postural Correction Training
namely, teres minor and infraspinatus, the scapula stabilizers
such as the trapezius (mainly the medium trapezius and lower
trapezius), the rhomboids, and the deep cervical flexor muscles.
Stretching exercises (Fig 4) are directed to the pectoralis minor
and the neck muscles, such as sternocleiomastoid and levator
scapulae.
Based on the training principles and considering the
school calendar, we developed a long-term plan with an
appropriate selection of training intensity, volume, rest
interval between sets, velocity, and frequency. As the
plan was to be performed in PE classes, the prescribed
exercises were to be strictly followed in 2 nonconsecutive
training days a week. For resistance training, we started
with light loads and 2 sets of 15 repetitions for a general
adaptation, and then we applied changes throughout 16
weeks, with periods with gradual and smooth increase in
intensity and sets and/or repetitions, and other periods,
after the Christmas holidays, with a lower intensity or
volume. Briefly, the students performed 2 sets of 15
repetitions in October; in November they added 1 more
set; and in December they maintained 3 sets, but now
with 12 repetitions and N1 kg in the dumbbell exercises.
In January, they did 3 sets of 10 and 12 repetitions,
respectively, with a 0.5-kg increase from December to
January. The rest interval between sets was 30 seconds.
With these planned changes in program variables, we
expected to maintain training-induced gains and prevent
training plateaus, which are common in the first 8-12 weeks
of resistance training. 36
In the three stretching exercises, we used the static
stretching with a 30-second hold for 2 sets. 37 The
all-interventional program took an average of 15 minutes
to perform, and the order of the exercises was random.
6 Ruivo et al Journal of Manipulative and Physiological Therapeutics
Postural Correction Training January 2017

Fig 4. Stretching exercises.

Table 2. Postural Angles and ASES Scores for Control and Intervention Participants, Pretest and Posttest
Within Group
Measure
Control (n = 39) Experimental (n = 76)
Between-Group
Paired t Test Paired t Test Independent t Test
Pretest Posttest Pretest Posttest
Mean ± Mean ± Mean Mean ± Mean ± Mean Mean Score
SD SD Difference t P SD SD Difference t P Change t P
a
Sagittal head 15.9 ± 7.1 13.4 ± 5.7 2.5 2.41 .021 18.6 ± 6.5 17.5 ± 5.7 1.2 1.72 .09 1.34 1.12 .265
tilt angle
Cervical 45.7 ± 3.0 46.2 ± 3.5 –0.5 –0.93 .357 44.4 ± 3.5 46.8 ± 3.9 –2.5 –5.84 b.001 a 1.95 2.78 .006 b
angle
Shoulder 45.5 ± 5.1 47.5 ± 5.2 –2.0 –3.06 .004 a 45.9 ± 4.9 49.8 ± 6.5 –3.9 –5.54 b.001 a 1.93 2.02 .046 b
angle
ASES score
Right 95.3 ± 6.3 95.5 ± 5.1 –0.2 –0.80 .845 93.2 ± 9.1 94.2 ± 6.6 –1.0 –0.95 .347 0.80 0.45 .651
Left 93.2 ± 7.2 94.0 ± 6.3 –0.8 –0.60 .553 91.6 ± 9.4 92.8 ± 7.2 –1.1 –1.03 .307 0.34 0.19 .852
ASES, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; SD, standard deviation.
a
Statistically significant difference with Bonferroni correction (P b .025).
b
Statistically significant difference (P b .05).

Statistical Analysis RESULTS

All statistical analyses were performed using appropriate
software (SPSS Version 22, IBM, Armonk, NY), and the
statistical significance level was defined as P b .05. In both
groups, data were analyzed using descriptive statistics such
as mean, standard deviation, and percentage. The Shapiro–
Wilk test was used to assess normality.
Paired sample t tests were conducted to determine
whether postural angles and ASES scores were significantly
different before and after the 16 weeks for both groups, and
independent sample t tests were conducted to compare for
group differences between mean score difference and to
compare postural angles and ASES scores in all participants
with and without NP in the pretest. For within-subgroup
comparisons, a Bonferroni adjustment for the correction of
type 1 errors was performed.
With respect to the preintervention comparison between
groups, no significant difference was reported between
genders or between those with and without NP.
Postural Angles and ASES scores
Mean and SD values for the postural variables and ASES
scores are listed in Table 2.
Significant differences were observed in two postural
angles in the intervention group from pretest to posttest, with
an increase in the cervical angle (44.4° ± 3.5° vs 46.8° ± 3.9°)
and shoulder angle (45.9° ± 4.9° vs 49.8° ± 6.5°) after the
intervention. In the control group, the cervical angle (45.7° ±
3.0° vs 46.2° ± 3.5°) did not differ significantly from pretest
Journal of Manipulative and Physiological Therapeutics
Volume 40, Number 1
Table 3. Postural Angles and ASES Scores for All Participants With and Without Neck Pain in the Pretest
Overall (n = 115)
Preintervention
No NP a NP a
(n = 66) (n = 49) Mean Score Change
Cervical angle 45.8 ± 3.0 43.5 ± 3.5 –2.3
Shoulder angle 45.4 ± 4.9 46.4 ± 4.8 1.0
ASES score
Right 95.0 ± 7.8 92.4 ± 8.8 –2.5
Left 93.3 ± 8.5 90.7 ± 8.9 –2.6
ASES, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; CI, confidence interval; NP, neck pain.
a
Mean ± SD.
b
Statistically significant difference (P b .05).
to posttest, whereas we observed a significant decrease (15.9°
± 7.1° vs 13.4° ± 5.7°) in the sagittal head angle and a
significant increase (45.5° ± 5.1° vs 47.5° ± 5.2°) in the
shoulder angle.
Considering the comparison between groups, we reported
statistically significant results for the cervical and shoulder
angles, with a P value b 0.05. There were no significant
changes in ASES pain and function scores in both groups
after the 16 weeks.
Postural Angles and NP
In this study, we also compared the postural angles and
ASES scores between the participants with and without NP,
in the overall, in the preintervention (Table 3). For the
postural angles, before the 16-week protocol intervention,
the group with NP had statistically lower cervical angles
compared with group without NP (43.5° ± 3.5° vs 45.8° ±
3.0°). In both groups, fewer participants reported NP after
the 16 weeks (22 vs 12 in the control group and 34 vs 14 in
the experimental group, representing 48% vs 31% and 41%
vs 18%, respectively).
DISCUSSION
This study indicates that a targeted exercise program,
performed twice a week and integrated into PE classes over a
16-week period, can result in posture improvement, with
increases in cervical and shoulder angles. To our knowledge,
this is the first study examining the outcome of a physical
program for postural correction, in a large sample, in a school.
The fact that the program may be conducted in the school,
which is a privileged place to apply changes to lifestyles,
habits, and imbalances 38,39 and a place where children and
adolescents spend much of their time, may favor the systematic
realization of the training protocol. This factor may explain the
relatively small number of study dropouts (15 of 130
adolescents with FHP and PS) in the 16-week period.
The realization of this program in the school also has another
benefit in that there is a PE teacher who can supervise technique.
Ruivo et al 7
Postural Correction Training
T P 95% CI d
–3.78 b.001 b –3.5, –1.1 0.71
1.12 .266 –0.7, 2.9 0.21
–1.63 .106 –5.6, 0.5 0.31
–1.57 .119 –5.8, 0.7 0.30
In this study, the PE teachers were trained to correct postural
alignment during the exercises, and there was a systematic
concern to give useful corrective feedbacks to the students.
Postural Angles and ASES Scores
After the 4-month period, there was a significant increase in
cervical and shoulder angles in the intervention group, whereas
in the control group, there were no significant differences in the
cervical angle, suggesting that the targeted exercises contrib-
uted to improvement of posture.
To correct FHP and PSs, this protocol was intended to
restore the normal muscle balance between opposing
muscle groups (agonists and antagonists) and work the
elongation capacity of muscle groups that restrict the range
of joint movements to which they are opposed. This
concept has been supported by other studies. 9,40
To achieve the desired goal of PS and FHP correction,
we aimed to actively stretch the sternocleidomastoid,
levator scapulae, and pectoralis muscle group and to
strengthen the rhomboids, lower and medium trapezius,
and rotator cuff muscles. 24,41
Previous studies, performed in other contexts and
populations, support our results of decreased FHP and
PSs after an intervention training protocol. For example,
Lynch et al. reported decreased PSs in elite swimmers after
an 8-week intervention including stretching of the anterior
musculature and strengthening of the scapula stabilizers. 9
With respect to FHP correction, Harman et al. reported that
a 10-week home-based targeted exercise program improved
postural alignment. 29 This program included the strength-
ening of deep cervical flexors and shoulder retractors and
the stretching of cervical extensors and pectoralis muscles.
As in the previously mentioned studies, the intervention
protocol was designed on the basis of scientific evidence. We
selected the exercises that have been reported to be the most
effective in achieving the desired goal, based on electromy-
ography research. For strengthening of the deep cervical flexor
muscles, we selected the chin tuck exercise. 41 For rotator cuff
muscles, which are crucial dynamic stabilizers of the
8 Ruivo et al Journal of Manipulative and Physiological Therapeutics
Postural Correction Training January 2017

glenohumeral joint in multiple shoulder positions contributing to functional limitations at the beginning of the training
its health, 42 we chose side-lying external rotation and prone program may explain why the ASES score differences
horizontal abduction with external rotation. 43,44 Because the before and after the 4-month intervention prior were not
humerus, clavicle, and scapula move together in coordination significant.
during arm movements, 44 referred as scapulohumeral rhythm,
we also prescribed two exercises for the scapula stabilizer
muscles, the prone horizontal abduction with external rotation 43
Postural Angles and NP
and the Y-to-I exercise (described in Table 1). Both exercises
We reported, mainly at the beginning of the intervention,
highly activate the lower trapezius and middle trapezius with low
a high prevalence of self-reported upper quadrant muscu-
activation of the upper trapezius. 44 In addition to the strength
loskeletal pain among adolescents. The same findings
training exercises, we prescribed two stretching exercises for the
have been reported in other studies. 3 This can be attributed
sternocleidomastoid and levator scapulae 45 and one for the
to several factors including psychosocial factors, 47
pectoralis minor, with the one-sided unilateral self-stretch
ergonomics, 48 strength imbalances, and neck and shoulder
exercise proving to be the most effective. 11
posture. 49 Results indicated that the group without NP had
To optimize training results, we started with 2 sets of 15
higher cervical angles with a between-group (NP vs no NP)
repetitions with a relatively light or moderate load and
difference of 2.3°. These results are in accordance with
moderate and controlled velocity and then, respecting
previous studies in which participants with NP had a
individual abilities, we progressed to include an additional
significant smaller cervical angle when compared with
set, with heavier loads over time. For stretching exercises,
normal participants. 15,17 It is believed that a sustained FHP,
we used static stretching with a 30-second hold for 2 sets.
with a tightness of the sternocleidomastoid and the levator
This has been recommended 37,41 and used successfully in
scapulae, may increase the loading on the noncontractile
other studies with the achievement of good results in the PS
structures and place abnormal stress on the posterior
correction with the static stretching of pectoralis minor. 11,24
cervical structures, leading to myofascial pain. 17
For postural angle analysis, we also reported a
In terms of the clinical significance of the small
significant increase in the shoulder angle in the control
differences between groups highlighted above (≤2.3°),
group after 16 weeks. We hypothesized that this may be
the literature is still not consensual. For example, in
related to the fact, that by the second evaluation, students
accordance with our results, Silva et al. also reported that
had experienced 4 months of physical activity in PE classes;
NP patients were found to have a significantly smaller angle
this was not true of the first evaluation, which was
between C7, the tragus, and the horizontal, and the mean
performed after a long vacation period. This increase in
difference between the NP group and the pain-free group
exercise practice may have accounted for the increase in
was not greater than 3.2° (mean ± SD; NP, 45.4° ± 6.8°;
muscular strength of the scapular muscles and, therefore, in
pain-free, 48.6° ± 7.1°; P b .05). 10 On the other hand, Falla
the better shoulder posture also seen in the control group.
et al. reported that a change of 2.1° in the angle between C7,
However, it must be pointed out that although the mean
the tragus, and the horizontal in adults with NP did not
shoulder angles in the control group before and after the
result in greater pain improvement when compared with no
4-month period differ significantly (45.5° ± 5.1° vs 47.5° ±
change in FHP. 15
5.2°), the difference in the mean values of the intervention
With respect to these opposite results and the possibility
group is clearly higher (45.9° ± 4.9° vs 49.8° ± 6.5°).
that a single angle is not adequate to capture the postural
We hypothesized that participants in the intervention
changes that might occur in adolescents with NP, 50 further
group would report higher ASES scores after the interven-
studies are needed to ascertain whether FHP differs between
tion, indicating a decrease in shoulder pain and an increase
adolescents with and without NP.
in function after the 16-week intervention. However, our
Another relevant issue in our study is the fact that in the
results indicated no difference in ASES scores, in both
experimental group, the cervical angle improved, and in
groups, possibly because of the high initial score, relatively
both groups, fewer participants reported NP after the 16
large minimal detectable change (9.7 points), and minimal-
weeks. This may be due to the increased levels of physical
ly clinically important difference (6.4 points). 46 Only 5 of
activity and better condition of the adolescents as a
the overall 115 participants experienced a clinically
consequence of the PE classes, or the postural correction
important difference in ASES scores.
protocol in the intervention group, or it may be derived
It must be added that ASES is an evaluative and
from a different pain threshold in the two assessments.
discriminative instrument for patients with shoulder
dysfunction and is characterized by its ability to distinguish
between those patients who have improved and those who
have not by identifying an external criterion indicative of Limitations
clinically meaningfully change. 46 The presence of a huge Future investigations of the effectiveness of the protocol
majority of participants with no shoulder dysfunction or intervention should contemplate the use of a more detailed
Journal of Manipulative and Physiological Therapeutics
Volume 40, Number 1
and reliable NP and disability questionnaire instead of a
simple self-designed question.
Another limitation of this study is that it describes only
the alignment of the spine and the shoulder girdle at rest;
therefore, the findings cannot be generalized to alignment
during functional tasks, especially when the upper limb is
moving or loaded. This is also the case when activities are
prolonged over time.
Finally, it must be mentioned that, although we
encouraged adolescents not to engage in any new activity
or exercise program during the study period, we cannot
guarantee that this did not occur.
CONCLUSION
We found that a simple, targeted exercise program
systematically incorporated into PE classes twice a week
over a 16-week period can result in a posture improvement,
with increases in the cervical and shoulder angles. Shoulder
function and pain, measured with the ASES, did not
change. In both groups, results indicated that participants
with NP had a smaller cervical angle.
FUNDING SOURCES AND CONFLICTS OF INTEREST
This study was supported by the Portuguese Foundation
for Science and Technology (Grant SFRH/BD/77633/
2011). No conflicts of interest were reported for this study.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
R.R., P.P.
Design (planned the methods to generate the results): R.R.
Practical Applications
• A targeted exercise program incorporated into
PE classes resulted in posture improvement.
• Participants with NP had a smaller cervical
angle after the intervention.
Supervision (provided oversight, responsible for orga-
nization and implementation, writing of the manuscript):
R.R., P.P.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data): R.R.
Analysis/interpretation (responsible for statistical analysis,
evaluation, and presentation of the results): R.R., A.I.
Ruivo et al 9
Postural Correction Training
Literature search (performed the literature search): R.R.
Writing (responsible for writing a substantive part of the
manuscript): R.R.
Critical review (revised manuscript for intellectual
content, this does not relate to spelling and grammar
checking): R.R., P.P., A.I.
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