The Effects of Postural Education or Corrective Exercise Intervention on the Craniovertebral Angle in Young Adults With Forward Head Posture: A Randomized Controlled Trial
Phase: NA
Conditions: Postural; Defect
Sponsor: Liberty University

The Effects of Postural Education or Corrective Exercise Intervention on the 
Craniovertebral Angle in Young Adults with Forward Head Posture: A Randomized 
Controlled Trial 
David A. Titcomba,e, Bridget F. Meltonb, Theresa Miyashitac, Helen W. Blandd, Andrew D. 
Fieldse, Charis M.L. Browne, Cassie M. Brookse, Courtney T. Greene, Theodore T. Hue, Noah C. 
Owense, Tara B. Wadforde 
a) DPT, Department of Allied Health Professions, Liberty University, 1971 University 
Blvd., Lynchburg, VA, 24551, USA. Concordia University Chicago, 7400 Augusta St., 
River Forest, IL 60305, USA. 
b) EdD, Department of Health Sciences and Kinesiology, Georgia Southern University, 
Statesboro, GA 30460, USA 
c) PhD, ATC, Division of Health Sciences and Human Performance, Concordia University 
Chicago, 7400 Augusta St., River Forest, IL 60305, USA. 
d) PhD, Department of Health Policy and Community Health, Georgia Southern University, 
Statesboro, GA 30460, USA 
e) Department of Allied Health Professions, Liberty University, 1971 University Blvd., 
Lynchburg, VA, 24551, USA. 
 
Corresponding author: David A. Titcomb, DPT. Department of Allied Health Professions, 
Liberty University, 1971 University Blvd., Lynchburg, VA, 24551. dtitcomb@liberty.edu 
 
Declarations of interest: The current study was part of the requirements for completion of a 
Ph.D. dissertation (Concordia University Chicago) written by Dr. David Titcomb. Conflicts of 
interest: none. 
 
Funding: This work was supported by the National Academy of Sports Medicine and Liberty 
University Center for Research & Scholarship [grant number UR2201]. Funding sponsors had no 
involvement in study design; in the collection, analysis and interpretation of data; in the writing 
of the report; or in the decision to submit the article for publication. 
 
Document date: 03/17/2022 
 
 
 
 

Study Protocol, Statistical Analysis, and Results 
Study Protocol 
Participants who responded to invitations to voluntarily participate completed the 
Physical Activity Readiness Questionnaire (PAR-Q+) (Warburton et al. 2011), followed by a 
questionnaire to rate their current stage of change (SOC) from the Transtheoretical Model 
adapted to assess exercise/postural modification behavior change. On this questionnaire, 
participants also responded to a yes/no question regarding if they have had a recent injury to their 
head, shoulders, or spine; or have ever been diagnosed with a pathology related to their 
cervical/thoracic spine or extremities, as part of exclusion criteria for the study. Participants then 
underwent a head posture screening with the use of photogrammetry. Screening was performed 
by the primary investigator who is a licensed physical therapist in the Liberty University 
Biomechanics & Motion Analysis Laboratory.  
Participants were asked to arrive at the lab wearing either a tank top or t-shirt, as well as 
to have their hair tied back if necessary. Height and weight were measured using a digital scale 
(Health-o-meter Professional, model 500KL, McCook, IL). Participants were instructed to sit 
comfortably on a stool with hands resting approximately two-thirds down their thighs with palms 
supinated and feet flat on the ground with hips and knees at 90 degrees (Richards et al. 2016); 
and to look straight ahead at an opposite wall in the laboratory (Kim et al. 2016). A digital 
camera (Canon Powershot, model SX540, Tokyo, Japan) was mounted and leveled on a tripod 
(Manfrotto, model 055, Cassola, IT) and placed three meters away from the subject (Ruivo et al. 
2014). Two photographs were taken of participant’s posture (Kim et al. 2016). Immediately after 
data capture, image files were uploaded into Kinovea video analysis software (version 8.15) for 
CVA assessment. On each image file, the PI assessed participant CVA by measuring the angle 

between the intersection of two lines: the first line drawn from the tragus of the ear to the spinous 
process of C7 vertebrae and the second line drawn horizontally through C7 spinous process (Kim 
et al. 2016). A second researcher directly observed the PI perform each CVA assessment, as well 
as provided verbal agreement with the accuracy of angle measurement. For each participant, the 
CVA was derived by taking the mean of two CVA measurements that were assessed on the 
captured photographs (Kim et al. 2016).  
Inclusion criteria included completion of informed consent, craniovertebral angle ≤ 53 
degrees (Lee et al. 2017) and self-rating of Transtheoretical Model stage of change stage ≥ 3/5 
on a questionnaire to indicate their readiness to comply with an assigned exercise prescription or 
postural guidelines (Kuroda et al. 2012). Exclusion criteria consisted of any musculoskeletal 
injury to the head, shoulders, or spine within the last six months; diagnosis of pathology related 
to the cervical spine, thoracic spine, or upper extremities; or non-clearance for physical activity 
based on results of the PAR-Q+ questionnaire. A total of 79 participants met inclusion criteria 
and were included in the study. 
Randomization of participant group assignments was completed by the PI using a block 
randomization generator on a website (http://www.randomization.com). Utilizing a sequence 
created by the block randomizer, the PI placed participants who met inclusion criteria into one of 
four groups: (PE; n = 20), self-myofascial release + stretching (SMRS; n = 20), self-myofascial 
release + stretching + strengthening (SMRSS; n = 19), and control group (CG; n = 20). A hard-
copy of the sequence generator report was kept concealed in a manila folder and was only 
opened by the PI during group delegation. Participants and researchers were not blinded to group 
assignment. 
Intervention Groups 
 

Postural Education (PE) Group. Immediately after baseline posture assessment, PE 
group members received a one-time 20-minute in-person one-on-one standardized educational 
session by a research team member in the laboratory. Topics included health risks associated 
with forward head posture (Bayattork et al. 2019; Cuellar & Lanman 2017; Kalichman et al. 
2016; Hansraj 2014; Lau et al. 2010); postural guidelines for using mobile electronic devices 
(Abdelhameed & Abdel-aziem 2016; Gustaffson 2012; Syamala et al. 2018), desktop computers 
(NIH 2021), laptop computers (NIH 2021; Sahu et al. 2021), and rest break guidelines (Kim & 
Koo 2016; Neupane et al. 2017; Vate-U-Lan 2015; Kar & Hedge 2020; Carter et al. 2018; 
Engelmann et al. 2011). At the conclusion of the educational session, each PE group participant 
was emailed a copy of the presented educational information and guidelines. A weekly email 
was sent to group members during the 4-week intervention period to provide reminders and 
encouragement to adhere to postural guidelines. Participants were asked not to begin any new 
exercise program or alter their current physical activity level over the next four weeks. 
Self-Myofascial Release + Stretching (SMRS) Group. Immediately after baseline 
posture assessment, SMRS group members received a 15-minute in-person one-on-one 
standardized instructional/training session for the SMRS intervention provided by a research 
team member in the laboratory. A 12 x 6 x 6 inch high-density myofascial roller (NASM Tool, 
Cygnet Systems, Dallas, TX) and a 23-inch soft-tissue mobilization tool (STMT) (Therapist’s 
Choice® Pressure Point Hook Cane, Tampa, FL) was provided at no cost to group members to 
enable implementation of a 4-week home program. Implemented protocols followed the National 
Academy of Sports Medicine (NASM) recommendations for inhibitory and lengthening 
techniques (Fahmy 2022). Participants were instructed to apply self-myofascial release (SMR) to 
the thoracic spine (TS) using the myofascial roller by holding pressure over the central region of 

the TS for 30 seconds, followed by six repetitions of active rolling up and down the length of the 
TS (up + down equaling 1 repetition) over a 90 second time period to promote mobilization of 
restricted myofascial tissues and restoration of upright posture (Fahmy 2022). Participants were 
asked to apply SMR to the center of the muscle belly in bilateral sternocleidomastoid (SCM) and 
upper cervical extensor (UCE) muscles using self-applied pressure with fingertips, while the 
STMT was utilized to administer SMR to center of the muscle belly in bilateral upper trapezius 
(UT) muscle and pectoralis minor (PM) muscle for 30 seconds (Fahmy 2022). For the first two 
weeks of the study, participants performed SMR three times per week on non-consecutive days. 
During weeks three and four, participants were instructed to progress SMR protocol frequency to 
five days per week. They were also instructed to perform static stretching to bilateral SCM, UT, 
PM, and UCE muscles after SMR on three non-consecutive days per week. During the first two 
weeks of the study, subjects performed two repetitions of stretches held for 20 seconds, and 
progressed to three repetitions of 30 seconds, five days per week during weeks three and four. At 
the conclusion of the training session, each group participant was emailed a copy of instructions 
for the assigned intervention. A weekly reminder email was sent to group members during the 4-
week intervention period to encourage corrective exercise program (CEP) adherence. 
Participants were asked not to begin a new exercise program other than their assigned CEP or 
alter their current physical activity level during the 4-week intervention period.  
Self-Myofascial Release + Stretching + Strengthening (SMRSS) Group. Immediately 
after baseline posture assessment, SMRSS group members received a 20-minute in-person one-
on-one standardized instructional/training session provided by a research team member in the 
laboratory that included the same SMR + stretching protocol as the SMRS group, as well as 
incorporated strengthening exercises following NASM recommendations for activation and 

integration techniques (Fahmy 2022). Group participants received a 12 x 6 x 6 inch high-density 
myofascial roller (NASM Tool, Cygnet Systems, Dallas, TX), a 23-inch soft-tissue mobilization 
tool (Therapist’s Choice® Pressure Point Hook Cane, Tampa, FL), a 36 inch medium resistance 
(resistance = 20 lb.) exercise tube with handles (Stroops, model: Slastix Toner, Clearfield, UT), 
and a 36-inch medium resistance (resistance = 3.7-5.5 lbs.) exercise band (Theraband, Akron, 
OH) at no cost to enable implementation of the prescribed 4-week home program. Strengthening 
exercises included the supine chin tuck (SCT), upper thoracic-lower cervical extension 
(UTLCE), and a single-arm row with trunk rotation (SARTR). The SCT was performed 
progressed in three phases: Week 1: chin tuck held 2 seconds, 4 second return to start position, 
repeated five times. Week 2: same as week 1, but incorporated a towel roll placed behind head to 
enable increased range of motion during the exercise. Week 3 and 4: chin tuck with head lift 1 
inch above the towel roll was held for 2 seconds, 4 second return to start position, repeated five 
times. The UTLCE exercise was performed by placing the resistive exercise band around the 
back of the head with neck flexed 15-20 degrees. Participants were instructed to extend their 
neck to a neutral position against the resistance of the band and hold for 2 seconds, followed by a 
4 second return to start position. The SARTR exercise was performed by placing one foot 
forward; completing a single arm row with exercise tubing using the contralateral arm compared 
to the lead leg; rotating the trunk 90 degrees toward the side of the body performing the row; 
followed by reversing these movements to return back to start position in a controlled manner. 
This exercise was performed on both the right and left sides. The UTLCE and SARTR exercises 
were performed with 1 set of 10 repetitions for weeks 1-2 and progressed to 2 sets of 10 
repetitions in weeks 3-4 (Fahmy 2022). Participants were asked to perform all muscle 
strengthening exercises three times per week on non-consecutive days throughout the 4-week 

intervention period. At the conclusion of the training session, each group participant was emailed 
a copy of instructions for the assigned intervention. A weekly reminder email was sent to group 
members during the 4-week intervention period to encourage corrective exercise program (CEP) 
adherence. Participants were asked not to begin a new exercise program other than their assigned 
CEP or alter their current physical activity level during the 4-week intervention period. 
Control Group (CG). Immediately after baseline CVA assessment, participants 
randomly assigned to the CG were informed they would not be receiving an intervention and 
were asked not to begin any new exercise program or alter their current physical activity level 
over the next four weeks. 
Questionnaires and Follow-up Posture Assessment 
Two weeks into the study, participants assigned to intervention groups completed a mid-
study questionnaire to assess intervention compliance. After the completion of 4-week 
intervention period, participants in the intervention groups completed a post-study questionnaire 
to assess intervention compliance and participants in all groups were asked to return to the 
Biomechanics laboratory to undergo a follow-up posture assessment. 
Statistical Analysis  
Data were analyzed using IBM SPSS version 28 for Windows (SPSS Inc., Chicago, IL, 
USA) and reported with mean and standard deviation. Descriptive participant characteristics by 
group were analyzed with a one-way ANOVA. Paired samples t-tests were used to assess within-
group differences in means between pre- and post-intervention CVA measures. Between-group 
comparisons of post-intervention mean CVA change were analyzed with a one-way ANOVA. 
Levene’s test was utilized to assess equality of error variance. Gabriel’s test was selected for 
post-hoc comparisons. The significance level was set at p < 0.05. 
Results 

 
The trial was completed by 72 participants (51 females, 21 males) with a mean age: 20.17 
(SD: ± 2.25 years); mean height: 167.34 (SD: ± 8.25 cm); and mean weight: 70.31 (SD: ± 14.61 
kg). All participants reported SOC self-rating ≥ 3/5. Pre-intervention analysis revealed no 
significant difference (p > 0.05) in participant age or anthropometric characteristics between 
groups. No significant between-group differences (p > 0.05) in baseline CVA were present. 
Within-group comparisons of pre- vs post-intervention CVA outcomes revealed a significantly 
(p < 0.05) greater post-intervention CVA in the PE, SMRS, SMRSS, and CG. Post-hoc 
comparisons indicated post-intervention mean CVA change in the SMRS group: 3.8 (SD: ± 3.3 
deg.); and the SMRSS group: 4.4 (SD: ± 3.1 deg.); was significantly greater (p < 0.01) than the 
CG: 0.8 (SD: ± 1.7 deg.). All participants in the SMRS and SMRSS groups reported intervention 
adherence as moderately consistent (50-75% sessions performed) or higher on both the mid- and 
post-study questionnaire. 91% of the PE group reported intervention adherence as moderately 
consistent (50-75% adherence to guidelines) or higher on the mid-study questionnaire. 96% of 
the PE group reported intervention adherence as moderately consistent or higher on the post-
study questionnaire. 
 
 
 
 
 
 
 
 

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