Comparison of Craniocervical Flexion and Scapular Stabilization Exercises in Forward Head Posture and Neck Pain
Condition: Cervical Pain
MeSH terms: Neck Pain
Study type: Interventional

Summary: 
      The aim of this research is to compare the effects of craniocervical flexion exercises and
      scapular stabilization exercises in reducing neck pain and forward head posture among females
      wearing head scarves. Quasi experimental trials done at Akhtar Saeed Trust hospital, Falah o
      Behbud Associations and Medicare Hospital (Lahore, Pakistan). A sample size of 50 patients
      was taken using non-probability purposive sampling technique. Subjects were randomly divided
      into 2 groups. Subjects in group A were treated with craniocervical flexion exercises and the
      subjects in group B were treated with scapular stabilization exercises with 25 subjects in
      each group. Pretreatment evaluation was done using numeric pain rating scale (NPRS) and neck
      disability index (NDI) as subjective measurement and Goniometry for assisted range of motion
      (AROM) and plumb line method for measuring head posture as objective measurement. The
      baseline values for all dependent variables were recorded on day one and at the end of 4th
      week.
    

Detailed description: 
      Neck pain is very common problem which is characterized by pain and soreness, felt in the
      area that lies between the lower margin of the occiput and 1st thoracic vertebra. Forward
      head posture can take place when head translated anteriorly and lower cervical spine goes
      into flexion or both and it is thought to be related with an increase in upper cervical spine
      extension. Most common abnormality which is associated with neck pain is forward head posture
      also known as chin poking. In which head is protrude out in sagittal plane and placed
      anteriorly to the trunk. It is considered that forward head posture causes an increase in
      compressive forces on the apophyseal joints of cervical spine and also on the posterior
      portion of vertebra. That is why, the length and strength of connective tissue change (due to
      the stretching of anterior structures and shortening of posterior muscles of neck ) following
      the pain. Shoulder blades and thoracic spine may also be affected with forward head posture,
      generally causing the imbalance in musculoskeletal system. Cervical flexor and extensor
      muscle groups strength & endurance performance ratio determined the magnitude of forward head
      posture . During daily activities the prolonged static posture in neck , shoulders and head
      may cause neck pain. Neck pain persistence is often considered to be associated with
      abnormalities in head posture, therefore some clinicians emphasized its importance while
      during examination. Postural effects on health is becoming more apparent and the most
      frequent postural problem is forward neck posture, occurring in between 66-90% of the
      population approximately. However, with increasing age the cervical range of motion decreased
      and it's prevalence increased with longer disease period. Generally, the neck pain is more
      prevalent in women than men. Wearing the headscarf is a part of an essential religious
      practice by females in Islamic cultures. The headscarf is referred to the scarf that wraps up
      over the head and around the neck. According to the Pew Research Center there are
      approximately 1.7 billion Muslims in the world. Estimating the total number of females
      worldwide who wear headscarves is difficult. Several Islamic countries mandate females to
      wear headscarves when out in public, while other countries have banned the use of headscarves
      in public. However, in the majority of the world's countries, wearing headscarves is
      optional. Females in Islamic cultures wear the headscarf when they are in public and usually
      begin wearing it at the onset of puberty. Regular wear of the headscarf might have an
      influence on cervical proprioception and range of motion (ROM). Recent studies have
      identified impaired activation of the deep cervical flexor muscles, the longus colli and
      longus capitis, in people with neck pain. Craniocervical flexion is the principal action of
      deep cervical muscles. Given the role of the deep cervical flexor muscles in postural support
      and the knowledge of impaired activation of these muscles in people with neck pain, it is
      likely that this patient population also would display deficits in the postural endurance of
      these muscles and painful cervical spine disorders. Indeed, evidence suggests that people
      with neck pain drift into a more forward head position when distracted and Craniocervical
      flexion exercises improves forward head posture and reduce neck pain.Moreover, retraining the
      deep cervical flexor muscles, which has been shown to decrease neck symptoms and increase the
      activation of the deep cervical flexor muscles during performance of the clinical test of
      craniocervical flexion, may improve the ability to maintain an upright posture of the
      cervical spine. Furthermore, there is a relationship between cervical ROM and forward head
      posture.Repeated upper cervical retractions (strengthening deep cervical flexors and
      stretching cervical extensors) changed resting neck posture. Scapular stabilization brought
      about improvement in posture through activation of the neck muscles, the lower trapezius, and
      the serratus anterior. Therefore, this intervention has a positive effect on neck alignment
      by reducing the compensatory movements of the muscles involved in forward head posture. There
      is a lack of literature regarding neck pain and forward head posture in females wearing head
      scarves . That is why, in this study,Forward head posture measurements will be obtained. In
      addition, the effect of interventions to improve cervical muscle flexibility in this
      population will be explained. In this study, we considered three factors related to
      headscarves, Onset of the practice, hours worn per day, and the number of years worn.

      LITERATURE REVIEW

      In 2017 determined the effects of wearing the headscarf on cervical spine ROM and joint
      position error. To analyze the influence of age at onset of wearing the headscarf and
      duration of hours per day wearing the headscarf on cervical range of motion and joint
      position error. The headscarf group reported a significant limitation in cervical range of
      motion in all six directions. Joint position error test revealed no significant difference
      between groups. Moreover, females in the headscarf group who wore the headscarf for more than
      6 hours per day had significantly less left rotation compared to those who wear it for less
      than or equal to 6 hours, Wearing of the headscarf may result in cervical range of motion
      limitation. The duration of wearing the headscarf daily is a key factor to limited cervical
      range of motion an increase in cervical Joint position error.

      In 2017 determined the effect of forward head posture-improving exercises on rounded shoulder
      posture when employing the self-stretch exercise, the McKenzie exercise, and the Kendall
      exercise as intervention methods based on previous studies that reported negative effects of
      unbalanced posture and musculoskeletal problems on forward head posture and rounded shoulder
      posture. Their study results showed that all interventions increased the craniovertebral
      angle and the scapular index, which revealed that the applied exercises had a positive effect
      on forward head posture and rounded shoulder posture.

      In 2018, designed the basic data for developing exercise program that helps correcting
      posture by knowing the effect of strengthening and elongation exercises of upper extremity
      muscle to forward head posture correction. After 4 weeks of neck and chest extensor muscle
      exercise, the group who exercised both showed increase in range of neck joint motion and neck
      flexion of the forward head posture. However, this study provides the fact that the group who
      exercised both neck and chest muscle had more effect than the control group.

      In 2017 evaluated 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.. Study concluded that A 16-week resistance and stretching training
      program decreased forward head and protracted shoulder postures in adolescents.

      In 2017 , evaluated the effect of modified cervical exercise and determine whether such
      exercise improves the range of motion of the cervical movement in smartphone users with
      forward head posture.According to the results of this study,A significantly increased range
      of motion was seen in all three groups that performed the modified cervical exercises,
      although the modified cervical exercises were performed for only a relatively short duration
      (four weeks), the exercises brought about an improvement in the forward head posture that was
      induced by using a smartphone.

      In 2018 investigated the effects of scapular stabilization exercise on neck posture, muscle
      activity, pain, and quality of life in individuals with neck pain and forward head posture.
      Training the scapular stabilization group showed significant improvement on the
      craniovertebral angle, upper trapezius muscle activity, serratus anterior muscle. Study
      concluded that Scapular stabilization exercise can help improve the head posture and pain in
      the patients with neck pain and forward head posture. Controlling the muscular activities
      through scapular stabilization exercise also improves the patients' quality of life.

      In 2018 investigated the effects of scapula movement on neck alignment and the muscles in
      patients with forward head posture, who has the structural changes around the neck caused
      from the forward head posture, when scapular stabilization exercise is applied. Scapular
      stabilization brought about improvement in posture through activation of the neck muscles,
      the lower trapezius, and the serratus anterior. Therefore, the intervention has a positive
      effect on neck alignment by reducing the compensatory movements of the muscles involved in
      forward head posture.
    

Intervention name(s): Craniocervical flexion exercises; Scapular stabilization exercises
Intervention type(s): Other; Other
Intervention description(s): Command the subject to be in crook lying position. Lock their finger to place their finger below the skull and retract the lower jaw and retract chin as far as possible. Subject has to slightly raise his/he skull a few centimeters. Fingers should be touching the cranium but not supporting it. Subject had to respire and hold the position. Subject has the move out the chin. Stop exercise and restart again. Perform this exercise for 10 times by holding this position for 20 sec at the start of the exercise, increasing it by 10 seconds every session commonly underwent pectoralis minor stretching before every session of exercise of 4 sets with 30 second's hold; The scapular stabilization exercises were made up of four stages: (1) In supine position, the patient was commanded to deep respire for the sake of relaxation by maintain the cervical and shoulder in relaxing position to take a deep breath to relax the body while holding her shoulders and neck in relaxing position. (2) The patient then flex her knees and placed her feet flat on the plinth, and maintain the pose without any cervical movement. Then the patient asked to raise her dominant arm to 90° shoulder flexion with full elbow extension and scapular protraction. This position was sustained for 10 seconds before going to initial position. Three laps of 10 repetitions with one-minute interval in between were performed. (3) In quadruped position, the patient raise her arms alternatively with shoulder abduction and 120 ° flexion. That posture was held for 10 seconds before returning to the starting position. (4) In sitting position
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Forward head posture, Craniocervical flexion exercises