Clinical measurement of head and shoulder posture variables

Characteristics of head and neck alignment and function of deep cervical flexor muscles in patients with nonspecific neck pain

OBJECTIVES

The objectives were to compare forward head posture (FHP) in natural and corrected head postures between patients with nonspecific neck pain (NSNP) and controls and to clarify the relationship between natural and corrected head posture angle differences and deep cervical flexor function. This study aimed to provide useful evidence for postural assessment and treatment in patients with NSNP.

METHODS

In this cross-sectional study, 19 patients with NSNP reporting a pain score of 3-7 for at least 3 months and 19 participants with no neck pain within the previous 12 months were recruited. To evaluate FHP, the cranial rotation and vertical angles were measured using lateral head and neck photographs. The craniocervical flexion test was used to evaluate deep cervical flexor activation and endurance. We evaluated the head and neck alignment in natural and corrected head postures and the relationship between the degree of change and deep cervical flexor function.

RESULTS

FHP in the natural head posture did not differ between groups. In the corrected head posture, FHP was significantly smaller in the NSNP group than in the control group. In the NSNP group, the cranial rotation and vertical angles were significantly different between the natural and corrected head postures, and the angle difference correlated significantly with deep cervical flexor function.

CONCLUSIONS

Patients with NSNP show hypercorrection in the corrected head posture, which may be correlated with deep cervical flexor dysfunction. Further investigation into the causal relationship between hypercorrection, deep neck flexor dysfunction, and neck pain is required.

Systematic review and meta-analysis on efficacy of various exercise programs to improve postural parameters, pain and disability in neck

Forward head posture is a common abnormal posture characterised by weakness of muscle around neck and shoulder. Persistent forward head posture can impair respiratory functions and cervical proprioception. The aim of this systematic review and meta-analysis is to determine the effectiveness of exercises to improve the forward head posture. The online literature search performed on various databases, i.e. PubMed, Cochrane, PEDro, Science Direct and Scopus databases resulted in 601 articles, but only 11 articles were found relevant to perform meta-analysis. The primary outcome measure was craniovertebral angle and other outcome measures were neck pain, cranial angle, cranial rotation angle and Neck Disability Index (NDI). Methodological quality of studies was assessed by PEDro scoring and risk of bias assessment was performed using Cochrane collaboration tool of risk of bias. Results of meta-analysis revealed that craniovertebral angle (CVA), cranial rotation angle (CRA), visual analogue scale and NDI improved significantly (P<0.00001) in forward head posture participants who followed any type of exercise regime compared to the participants who did not follow any exercise program. However, cranial angle was not found significantly (P=0.73) improved in exercise groups. Exercises are effective in improving postural parameters, such as CVA, CRA and pain and neck disability in subjects with forward head posture.

Systematic analysis registry at PROSPERO: CRD42020175372

Is Neck Pain Related to Sagittal Head and Neck Posture?: A Systematic Review and Meta-analysis

Background

Neck pain (NP) is common in all age groups and adversely affects the patients' entire lifestyle. There exists inconclusive evidence relating faulty craniocervical posture with pain-related disability. This review aims to determine whether sagittal head and neck posture differs in NP and pain-free subjects, to critically appraise the correlation of posture with NP.

Methods

Of 3796 articles identified at primary search from CINAHL, PubMed, Google Scholar, EMBASE, 26 were included based on eligibility criteria. Mean pooled difference (MPD) and effect size (ES) were calculated to establish relationship among studies, to assess postural correlation with NP measures [Visual Analogue Scale (VAS), Numeric Pain Rating Scale (NPRS), neck disability index (NDI), Northwick Park NP Questionnaire (NPQ)] and for age- and gender-wise variation. Risk of bias was assessed using Newcastle-Ottawa Quality Assessment Scale.

Results

Craniovertebral angle (CVA) had a significant MPD of - 2.93(95% CI - 4.95 to - 0.91). Sagittal head angle (SHA) and forward head posture (FHP) had an insignificant MPD of 1.15 (95% CI - 1.16 to 3.46) and - 0.26 (95% CI - 1.89 to 1.36), respectively. Age- and gender-wise CVA difference was found to be 2.36° and 2.57°, respectively. ES was significant for correlation between CVA and pain intensity [NPRS: - 0.44 (95% CI - 0.61 to - 0.26); VAS: - 0.31 (95% CI - 0.46 to - 0.16)], and between CVA and disability [NDI: - 0.18 (95% CI - 0.31 to - 0.05); NPQ: - 0.47 (95% CI - 0.61 to - 0.320)].

Conclusion

CVA differs for age, gender, and pain vs pain-free subjects, and correlates negatively with NP measures. Other surrogate measures (SHA, cranial and cervical angles, FHP) warrant further research.

PROSPERO Registration

PROSPERO 2021 CRD42021275485.

Correlation between the Photographic Cranial Angles and Radiographic Cervical Spine Alignment

The cranial vertical angle (CVA) and cranial rotation angle (CRA) are used in clinical settings because they can be measured on lateral photographs of the head and neck. We aimed to clarify the relationship between CVA and CRA photographic measurements and radiographic cervical spine alignment. Twenty-six healthy volunteers were recruited for this study. Lateral photographs and cervical spine radiographs were obtained in the sitting position. The CVA and CRA were measured using lateral photographs of the head and neck. The C2-7 sagittal vertical axis (SVA), cervical lordosis (C2-7), and occipito-C2 lordosis (O-C2) were measured using radiographic imaging as a standard method of evaluating cervical spine alignment. Correlations between the CVA and CRA on photographs and cervical spine alignment on radiographs were analyzed. The CVA and SVA were significantly negatively correlated (ρ = −0.51; p < 0.05). Significant positive correlations were found between CVA and C2-7 (ρ = 0.59; p < 0.01) and between CRA and O-C2 (ρ = 0.65; p < 0.01). Evaluating the CVA and CRA on photographs may be useful for ascertaining head and neck alignment in the mid-lower and upper parts of the sagittal plane.

Quality and usability of clinical assessments of static standing and sitting posture: A systematic review

BACKGROUND

A validated method to assess sitting and standing posture in a clinical setting is needed to guide diagnosis, treatment and evaluation of these postures. At present, no systematic overview of assessment methods, their clinimetric properties, and usability is available.

OBJECTIVE

The objective of this study was to provide such an overview and to interpret the results for clinical practice.

METHODS

A systematic literature review was performed according to international guidelines. Two independent reviewers assessed risk of bias, clinimetric values of the assessment methods, and their usability. Quality of evidence and strength of recommendations were determined according to the Grading of Recommendations Assessment, Development and Evaluation working group (GRADE).

RESULTS

Out of 27,680 records, 41 eligible studies were included. Thirty-two assessment instruments were identified, clustered into five categories. The methodological quality of 27 (66%) of the articles was moderate to good. Reliability was most frequently studied. Little information was found about validity and none about responsiveness.

CONCLUSIONS

Based on a moderate level of evidence, a tentative recommendation can be made to use a direct visual observation method with global posture recorded by a trained observer applying a rating scale.

The association between forward head posture and non-specific neck pain: A cross-sectional study

BACKGROUND

Poor posture is traditionally associated with various musculoskeletal disorders. Consequently, educators in the musculoskeletal field have been teaching postural observation as part of the physical assessment. Forward head posture (FHP) is hypothesized to be associated with neck pain; however, evidence in this topic remains inconclusive.

PURPOSE

To investigate the association between FHP and neck pain intensity, disability, and cervical kinematics in individuals with neck pain compared to asymptomatic individuals. A secondary aim of this study was to explore the possible effect of a head-mounted display (HMD) used in a virtual reality (VR) assessment on FHP.

METHODS

The study was conducted with 43 volunteers (20 asymptomatic individuals, 23 individuals with neck pain) aged 19 to 62. FHP was assessed by measuring craniovertebral angle on profile photographs. Secondary outcome measures included pain intensity, the neck disability index (NDI) questionnaire, and neck kinematics using specialized VR software.

RESULTS

There were no significant differences between individuals with neck pain and asymptomatic individuals in FHP (craniovertebral angle = 48.24°±7.29; 48.90°±5.89, respectively, p > .05). The neck pain group demonstrated a restricted range of motion and slower neck movements (p < .05). We found no significant correlation between FHP and visual analog scale, NDI, and most neck kinematic measures.

CONCLUSIONS

Our findings cannot support a clinically applicable association between FHP and neck pain. Additionally, individuals with neck pain had a lower range of motion and slower neck movements.

Augmented Reality Approach for Marker-based Posture Measurement on Smartphones

Marker tracking for postural and range of motion (ROM) measurements transcends multiple disciplines (e.g., healthcare, ergonomics, engineering). A viable real-time mobile application is currently lacking for measuring limb angles and body posture. To address this need, a novel Android smartphone augmented-reality-based application was developed using the AprilTag2 fiducial marker system. To evaluate the app, two markers were printed on paper and attached to a wall. A Samsung S6 mobile phone was fixed on a tripod, parallel to the wall. The smartphone app tracked and recorded marker orientation and 2D position data in the camera frame, from front and rear cameras, for different smartphone placements. The average error between mobile phone and measured angles was less than 1 degree for all test settings (back camera=0.29°, front camera=0.33°, yaw rotation=0.75°, tilt rotation=0.22°). The average error between mobile phone and measured distance was less than 4 mm for all test settings (back camera=1.8 mm, front camera=2.5 mm, yaw rotation=3 mm, tilt rotation=3.8 mm). Overall, the app obtained valid and reliable angle and distance measurements with smartphone positions and cameras that would be expected in practice. Thus, this app is viable for clinical ROM and posture assessments.

The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

Forward head posture (FHP) is the most common cervical postural fault in the sagittal plane that is found with different severity levels in almost all populations. Despite claims that FHP may be related to neck pain, this relation seems to be controversial. Thus, our purpose is to determine whether FHP differs between asymptomatic subjects and those with neck pain and to investigate if there is a relationship between head posture and neck pain.

RECENT FINDINGS

A total of 15 cross-sectional studies were eligible for inclusion for this systematic review and meta-analysis. Ten studies compared FHP between a group of asymptomatic participants and a group of participants with neck pain and an overall mean difference (MD) of 4.84 (95% CI = 0.14, 9.54), indicating a significant between-group difference, contrary to adolescent (MD = - 1.05; 95% CI = - 4.23, 2.12). Eight studies showed significant negative correlations between FHP and neck pain intensity (r = - 0.55; 95% CI = - 0.69, - 0.36) as well as disability (r = - 0.42; 95% CI = - 0.54, - 0.28) in adults and older adults, while in adolescents, only lifetime prevalence and doctor visits due to neck pain were significant predictors for FHP. This systematic review found that age played an important role as a confounding factor in the relation between FHP and neck pain. Also, the results showed that adults with neck pain show increased FHP when compared to asymptomatic adults and that FHP is significantly correlated with neck pain measures in adults and older adults. No association was found between FHP and most of neck pain measures in adolescents.

A systematic review with meta-analysis on functional changes associated with neck pain in adolescents

BACKGROUND

Neck pain (NP) is highly prevalent in young people, but there has been no systematic review synthetizing the functional changes associated with this in adolescents. The aim of the present study was to identify and assess critically the evidence on the functional changes associated with NP in adolescents, specifically for: (a) posture; (b) postural control; (c) range of motion; (d) proprioception; (e) muscle function; and (f) sensory threshold.

METHODS

We searched PubMed, ScienceDirect, Web of Science, PEdro, Scielo, Scopus and Academic Search Premier databases for relevant studies. Two reviewers screened studies for inclusion and assessed the quality of the included studies. One reviewer extracted relevant data from the included studies. A meta-analysis was performed for studies that measured forward head posture (FHP).

RESULTS

Ten studies were included and a total of 15 comparisons for different variables were made. When compared with adolescents without NP, those with NP showed no differences in cervicothoracic posture or FHP. However, statistically significant differences were found for range of motion: weighted mean difference (WMD) from -14.0° (-21.1° to -1.1°) to 9.4° (2.8° to 16.0°); flexor muscle endurance: WMD -11.4 (-21.8 to -0.9) s; extensor muscle endurance: WMD -42.0 (-77.8 to -6.3) s; joint repositioning error for right and left rotation: WMD 1.9° (0.8° to 2.9°) and 2.4° (1.3° to 3.5°), respectively; and pressure pain threshold: WMD from -15.6 (-18.5 to -12.8) to -9.3 (-11.3 to 7.2) N/ cm².

CONCLUSION

There is very limited to limited evidence that there is no difference in posture between adolescents with and without NP, and that there is a difference for range of motion, muscle function, proprioception and pressure pain threshold.

Correlations among visual analogue scale, neck disability index, shoulder joint range of motion, and muscle strength in young women with forward head posture

This study investigated the correlation between the neck disability index (NDI) and visual analogue scale (VAS), which are indicators of neck pain, shoulder joint range of motion (ROM), and muscle strength in women with a slight forward head posture. This study was carried out on 42 female college students attending Uiduk University in Gyeongju, Korea. The neck pain and disability index for each subject was measured using VAS and NDI, respectively. Two physiotherapists measured the shoulder joint ROM and muscle strengths of the subjects using a goniometer and a dynamometer, respectively. External rotation, internal rotation, and abduction of the shoulder joint were measured for each subject. A significant negative correlation between neck pain and shoulder joint ROM in external rotation and the muscle strength of the shoulder joint in abduction was found in the subjects. In addition, a significant positive correlation was observed between ROM in external rotation and muscle strength in abduction. This study showed a significant negative correlation between neck pain and ROM in external rotation as well as between neck pain and the muscle strength in abduction.

Reliability of forward head posture evaluation while sitting, standing, walking and running

Forward head posture has been evaluated mostly by visual observation or simple non-invasive measurements without a standardized evaluation method or protocol. In this experimental study, the reliability of existing forward head-posture measurement methods was evaluated by computing the intra-class correlation coefficients of three different head-position variables (two horizontal gap variables and one head-orientation variable) in seven different posture conditions from 20 asymptomatic participants. The position variables of the head were measured three times using a three-dimensional motion capture system while sitting comfortably, sitting with the back straight, standing comfortably, standing with the back straight, walking at 4 and 6km/h on a treadmill, and running at 8km/h on a treadmill. Intra-class correlation coefficients between repetitive measures ranged from 0.81 to 0.96, and high correlation coefficient values (>0.9) were produced when the head-position variables were measured during straight sitting, straight standing, and walking at 6km/h. Among the three head-position variables, a horizontal gap between the tragus and the 7th cervical vertebra was recorded more consistently than other variables. Results of this study highlight the importance of a standardized evaluation protocol for more reliable assessment of the forward head posture.

Correlation between forward head posture, respiratory functions, and respiratory accessory muscles in young adults

BACKGROUND

Forward head posture (FHP) causes changes in the strengths and rigidities of cervical muscles.

OBJECTIVE

The aim of this study was to investigate correlations between FHP and respiratory functions and the muscle activities of respiratory accessory muscles in young adults in their 20s.

METHODS

A volunteer sample of 33 healthy young adults participated in this study. Craniovertebral angle (CVA), cranial rotational angle (CRA), vital capacity (VC), forced vital capacity (FVC), forced expiratory volume at 1 second (FEV1), peak expiratory flow (PEF), maximal voluntary ventilation (MVV), and sternocleidomastoid (SCM) and upper trapezius activity ratios were measured.

RESULTS

Significant positive correlations were found between CVA and VC, FVC, FEV1, PEF, and MVV, and a significant negative correlation was found between CVA and SCM activity ratio. Significant negative correlations existed between CRA and VC and FVC, and significant positive correlations between CRA and SCM and upper trapezius activity ratios.

CONCLUSION

FHP may act to lower respiratory functions, and thus, the maintenance of correct head posture is required to prevent such functional reductions.

Photogrammetric Assessment of Upper Body Posture Using Postural Angles: A Literature Review

OBJECTIVE

The purpose of this paper was to review the literature regarding the measurement properties of various angles used for postural assessment of the head, neck, shoulder, and thorax and to discuss the utility of these measures.

METHODS

The inclusion criteria for this literature review were use of postural angles to assess posture, measurement of upper body posture, and research studies conducted in last 3 decades that had free full-text available online entirely in the English language. The exclusion criteria were review articles; studies involving subjects having obesity, visual problems, any history of surgery, respiratory, cardiovascular, neurologic, or congenital pathology or disease; and research studies in which postural angles were measured with respect to vertical only. The following databases were searched: PubMed Central, PubMed, ResearchGate, Springer Link, ScienceDirect, Google Scholar and Scielo through February 20, 2016.

RESULTS

A total of 21 studies that were found to be best suited to explain the craniovertebral (CV) angle, sagittal head tilt, sagittal shoulder-C7 angle, coronal head tilt, coronal shoulder angle, and thoracic kyphosis angle were included in this review. Craniovertebral angle, sagittal head tilt, sagittal shoulder-C7 angle, coronal head tilt, and coronal shoulder angle possess moderate to high intrarater reliability. Craniovertebral angle, sagittal head tilt, sagittal shoulder-C7 angle and thoracic kyphosis angle possess high interrater reliability (except for sagittal head tilt when measured using the goniometer). Craniovertebral angle, sagittal head tilt, and sagittal shoulder-C7 angle have been proved to be valid measures of posture when compared with similar angles measured on radiographs. None of the studies reported intrarater reliability of thoracic kyphosis angle, interrater reliability of coronal head tilt and coronal shoulder angle, and validity of coronal angles and thoracic kyphosis angle.

CONCLUSIONS

We found several reliable methods to measure the postures of the head, neck, shoulder, and thoracic regions by measuring the CV angle, sagittal head tilt, sagittal shoulder-C7 angle, and thoracic kyphosis angle, respectively. Standardization of methods for angular measurement is recommended so that there is uniformity among studies regarding camera height, participant-camera distance, and type of software to generate normative data for postural angles.

Does Deep Cervical Flexor Muscle Training Affect Pain Pressure Thresholds of Myofascial Trigger Points in Patients with Chronic Neck Pain? A Prospective Randomized Controlled Trial

Background. We need to understand more about how DNF performs in different contexts and whether it affects the pain threshold over myofascial trigger points (MTrPs). Purpose. The objectives were to investigate the effect of neck muscles training on disability and pain and on pain threshold over MTrPs in people with chronic neck pain. Methods. Patients with chronic neck pain were eligible for participation with a Neck Disability Index (NDI) score of over 5/50 and having at least one MTrP on either levator scapulae, upper trapezoid, or splenius capitis muscle. Patients were randomly assigned into either DNF training, superficial neck muscle exercise, or advice group. Generalized linear model (GLM) was used to detect differences in treatment groups over time. Results. Out of 67 participants, 60 (47 females, mean age: 39.45 ± 12.67) completed the study. Neck disability and neck pain were improved over time between and within groups (p < 0.05). However, no differences were found within and between the therapeutic groups (p < 0.05) in the tested muscles' PPTs and in cervicothoracic angle over a 7-week period. Conclusion. All three groups improved over time. This infers that the pain pathways involved in the neck pain relief are not those involved in pain threshold.

Does a Novel-Developed Product of Wheelchair Incorporating Pelvic Support Prevent Forward Head Posture during Prolonged Sitting?

Disabled elderly individuals with kyphosis or loss of muscle strength often display forward head posture (FHP). This study aimed to determine the utility of a wheelchair incorporating pelvic support in preventing FHP in disabled elderly individuals. In this study, 14 disabled elderly individuals (87.1 ± 8.1 years) were selected. A wheelchair incorporating pelvic support (RX_ABS Lo) and a basic wheelchair (RX-1) were used. Each individual sat on both wheelchairs for 30 minutes. RX_ABS Lo has two belts to support the pelvic and thorax. Postures were recorded in the sagittal plane using a video camera. Cervical and trunk angles from horizontal were measured every 5 minutes. Simultaneously, contact areas and total pressures applied to the wheelchair seats and back supports were measured every 5 minutes. Comparisons of area under the curve values between the wheelchairs were performed using the paired t-test. Comparisons of time-dependent parameters for each wheelchair were performed using repeated one-way ANOVA. Cervical angles were greater when using RX_ABS Lo than RX-1. Although cervical angles were unchanged during 30 minutes when using RX_ABS Lo, the angles were significantly decreased after 30 minutes of using RX-1. Back support pressures and contact areas were greater for RX_ABS Lo than for RX-1. No significant difference in back support pressure distributions was observed during 30 minutes in the wheelchairs. The RX_ABS Lo may have utility in improving FHP by increasing cervical angles and improving stability with a back support to the upper thorax, lower thorax, and pelvis during prolonged sitting.

Baropodometric analyses of patients before and after bariatric surgery

OBJECTIVE

The aim of this study was to evaluate the vertical component of the ground reaction force, plantar pressure, contact area of the feet and double-support time using static and dynamic (gait) baropodometry before and after bariatric surgery.

METHODS

Sixteen individuals with a body mass index of between 35 and 55 were evaluated before and after bariatric surgery. Thirteen patients (81.3%) were female and three (18.8%) male and their average age was 46±10 (21-60) years. An FSCAN system (version 3848) was used for baropodometric analyses (1 km/h and 3 km/h). The peak plantar pressure and ground reaction force were measured for the rear foot and forefoot. The double-support time and foot contact area were measured during gait.

RESULTS

There were reductions in the ground reaction force in the forefoot and rear foot and in the foot contact area in all evaluations and of the double-support time at 3 km/h, as well as a significant reduction in the body mass index at six months post-surgery. The peak pressure did not vary at 1 km/h and at 3 km/h, reductions in peak pressure were observed in the left and right rear feet and left forefoot.

CONCLUSIONS

Weight loss after bariatric surgery resulted in decreases in the ground reaction force and contact area of the foot. Plantar pressure was decreased at 3 km/h, especially in the forefoot. There was an increase in rhythm because of a reduction in the double-support time at 3 km/h.

Reliability and validity of cervical position measurements in individuals with and without chronic neck pain

OBJECTIVES

The cervical range of motion device (CROM) has been shown to provide reliable forward head position (FHP) measurement when the upper cervical angle (UCA) is controlled. However, measurement without UCA standardization is reflective of habitual patterns. Criterion validity has not been reported. The purposes of this study were to establish: (1) criterion validity of CROM FHP and UCA compared to Optotrak data, (2) relative reliability and minimal detectable change (MDC95) in patients with and without cervical pain, and (3) to compare UCA and FHP in patients with and without pain in habitual postures.

METHODS

(1) Within-subjects single session concurrent criterion validity design. Simultaneous CROM and OP measurement was conducted in habitual sitting posture in 16 healthy young adults. (2) Reliability and MDC95 of UCA and FHP were calculated from three trials. (3) Values for adults over 35 years with cervical pain and age-matched healthy controls were compared.

RESULTS

(1) Forward head position distances were moderately correlated and UCA angles were highly correlated. The mean (standard deviation) differences can be expected to vary between 1·48 cm (1·74) for FHP and -1·7 (2·46)° for UCA. (2) Reliability for CROM FHP measurements were good to excellent (no pain) and moderate (pain). Cervical range of motion FHP MDC95 was moderately low (no pain), and moderate (pain). Reliability for CROM UCA measurements was excellent and MDC95 low for both groups. There was no difference in FHP distances between the pain and no pain groups, UCA was significantly more extended in the pain group (P<0·05).

DISCUSSION

Cervical range of motion FHP measurements were only moderately correlated with Optotrak data, and limits of agreement (LOA) and MDC95 were relatively large. There was also no difference in CROM FHP distance between older symptomatic and asymptomatic individuals. Cervical range of motion FHP measurement is therefore not recommended as a clinical outcome measure. Cervical range of motion UCA measurements showed good criterion validity, excellent test-retest reliability, and achievable MDC95 in asymptomatic and symptomatic participants. Differences of more than 6° are required to exceed error. Cervical range of motion UCA shows promise as a useful reliable and valid measurement, particularly as patients with cervical pain exhibited significantly more extended angles.

Photographic measurement of head and cervical posture when viewing mobile phone: a pilot study

PURPOSE

With the dramatic growth of mobile phone usage, concerns have been raised with regard to the adverse health effects of mobile phone on spinal posture. The aim of this study was to determine the head and cervical postures by photogrammetry when viewing the mobile phone screen, compared with those in neutral standing posture.

METHODS

A total of 186 subjects (81 females and 105 males) aged from 17 to 31 years old participated in this study. Subjects were instructed to stand neutrally and using mobile phone as in daily life. Using a photographic method, the sagittal head and cervical postures were assessed by head tilt angle, neck tilt angle, forward head shift and gaze angle.

RESULTS

The photographic method showed a high intra-rater and inter-rater reliability in measuring the sagittal posture of cervical spine and gaze angle (ICCs ranged from 0.80 to 0.99). When looking at mobile phone, the head tilt angle significantly increased (from 74.55° to 95.22°, p = 0.000) and the neck angle decreased (from 54.68° to 38.77°, p = 0.000). The forward head posture was also confirmed by the significantly increased head shift (from 10.90 to 13.85 cm, p = 0.000). The posture assumed in mobile phone use was significantly correlated with neutral posture (p < 0.05). Males displayed a more forward head posture than females (p < 0.05). The head tilt angle was positively correlated with the gaze angle (r = 0.616, p = 0.000), while the neck tilt angle was negatively correlated with the gaze angle (r = -0.628, p = 0.000).

CONCLUSIONS

Photogrammetry is a reliable, quantitative method to evaluate the head and cervical posture during mobile phone use. Compared to neutral standing, subjects display a more forward head posture when viewing the mobile phone screen, which is correlated with neutral posture, gaze angle and gender. Future studies will be needed to investigate a dose-response relationship between mobile phone use and assumed posture.

Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders

[Purpose] This study investigated upper-extremity muscle activities in natural, ideal, and corrected head positions. [Subjects and Methods] Forty subjects with a forward head posture and rounded shoulder were recruited and randomly assigned to the natural head position group (n = 13), ideal head position group (n = 14), or corrected head position group (n = 13). Muscle activities were measured using a four-channel surface electromyography system at the sternocleidomastoideus, upper and lower trapezius, and serratus anterior muscles on the right side during an overhead reaching task. [Results] The muscle activities of the upper trapezius and serratus anterior differed significantly among head positions. Post hoc tests revealed significant differences between natural and ideal head positions, and natural and ideal head positions for both the upper trapezius and serratus anterior. [Conclusion] Recovery of normal upper trapezius and serratus anterior muscle functions plays an important role in correcting forward head posture and rounded shoulders.

Characteristics of upper quadrant posture of young women with temporomandibular disorders

[Purpose] This study aimed to investigate the characteristics of upper quadrant posture of young women with temporomandibular disorders. [Subjects] The participants were 19 female patients with temporomandibular disorders (patient group: mean age, 30.1 years) and 14 controls (control group: mean age, 24.6 years). [Methods] Outcome measures were the neck inclination angle (formed by a line connecting C7 and the ear tragus with a horizontal line), the angle of the shoulder (formed by a line connecting C7 and the acromial angle with a horizontal line), the cranial rotation angle (formed by a line connecting the ear tragus and the corner of the eye with a horizontal line), and the neck-length/shoulder-width ratio [the ratio of the neck length (from C7 to the tragus) to the width of the shoulder between the acromial angle]. The maximum range of mouth opening was measured using a scale. [Results] The neck inclination angle and maximum range of mouth opening were significantly smaller in the patient group than in the control group. No significant differences were observed in the other outcome measures between the two groups. [Conclusion] Temporomandibular disorders with limited mouth opening in young females are associated with the head position relative to the trunk.

Methods of postural assessment used for sports persons

Occurrence of postural defects has become very common now-a-days not only in general population but also in sports persons. There are various methods which can be used to assess these postural defects. These methods have evolved over a period of many years. This paper is first of its kind to summarize the methods of postural assessment which have been used and which can be used for evaluation of postural abnormalities in sports persons such as the visual observation, plumbline, goniometry, photographic, radiographic, photogrammetric, flexiruler, electromagnetic tracking device etc. We recommend more and more postural evaluation studies to be done in future based on the photogrammetric method.

Anatomical landmark position--can we trust what we see? Results from an online reliability and validity study of osteopaths

BACKGROUND

Practitioners traditionally use observation to classify the position of patients' anatomical landmarks. This information may contribute to diagnosis and patient management.

OBJECTIVES

To calculate a) Inter-rater reliability of categorising the sagittal plane position of four anatomical landmarks (lateral femoral epicondyle, greater trochanter, mastoid process and acromion) on side-view photographs (with landmarks highlighted and not-highlighted) of anonymised subjects; b) Intra-rater reliability; c) Individual landmark inter-rater reliability; d) Validity against a 'gold standard' photograph.

DESIGN

Online inter- and intra-rater reliability study.

SUBJECTS

Photographed subjects: convenience sample of asymptomatic students; raters: randomly selected UK registered osteopaths.

METHODS

40 photographs of 30 subjects were used, a priori clinically acceptable reliability was ≥0.4. Inter-rater arm: 20 photographs without landmark highlights plus 10 with highlights; Intra-rater arm: 10 duplicate photographs (non-highlighted landmarks). Validity arm: highlighted landmark scores versus 'gold standard' photographs with vertical line. Research ethics approval obtained.

RATERS

Osteopaths (n = 48) categorised landmark position relative to imagined vertical-line; Gwet's Agreement Coefficient 1 (AC1) calculated and chance-corrected coefficient benchmarked against Landis and Koch's scale; Validity calculation used Kendall's tau-B.

RESULTS

Inter-rater reliability was 'fair' (AC1 = 0.342; 95% confidence interval (CI) = 0.279-0.404) for non-highlighted landmarks and 'moderate' (AC1 = 0.700; 95% CI = 0.596-0.805) for highlighted landmarks. Intra-rater reliability was 'fair' (AC1 = 0.522); range was 'poor' (AC1 = 0.160) to 'substantial' (AC1 = 0.896). No differences were found between individual landmarks. Validity was 'low' (TB = 0.327; p = 0.104).

CONCLUSION

Both inter- and intra-rater reliability was 'fair' but below clinically acceptable levels, validity was 'low'. Together these results challenge the clinical practice of using observation to categorise anterio-posterior landmark position.

Reliability of Upper Quadrant Posture Analysis Using an Ultrasound-based Three-dimensional Motion Analyzer

[Purpose] The aim of this study was to evaluate the reliability of upper quadrant posture analysis using an ultrasound-based three-dimensional motion analyzer. [Subjects] Subjects were 72 healthy young adults. [Methods] Neck inclination angle formed by a line connecting C7 and the tragus with a horizontal line, angle of the shoulder formed by a line connecting C7 and the acromial angle with a horizontal line, and cranial rotation angle formed by a line connecting the tragus and corner of the eye with a horizontal line were measured using an ultrasound-based three-dimensional motion analyzer. Intra- and inter-rater reliabilities of two testers, standard error of measurements, minimal detectable change at the 95% confidence level, and systematic bias were evaluated. [Results] Intra-class correlation coefficients (1,1) were 0.65 to 0.82. Intra-class correlation coefficients (2,1) were 0.76 to 0.82. High measurement error was found in the cranial rotation angle. Fixed bias was found for the angle of the shoulder in the inter-rater reliability. [Conclusion] Posture analysis using an ultrasound-based three-dimensional motion analyzer appears useful for assessing neck inclination angle and the angle of the shoulder in individuals, and cranial rotation angle in patient groups.

The intra- and inter-rater reliability of the tragus wall distance (TWD) measurement in non-pathological participants ages 18-34

OBJECTIVES

To assess intra-rater and inter-rater reliability of the tragus wall distance (TWD) measurement in non-pathologic individuals aged 18-34.

BACKGROUND

Physical therapists evaluate posture as a component of health status. A literature review suggests need for reliable clinical tools to assess head position.

METHODS

The TWD measurement is the horizontal distance between the tragus, the auricular cartilaginous flap anterior to the external auditory meatus, and a wall. Sixty-three adults aged 18-34 years were consecutively assigned to three raters for double-blinded repeated measures of TWD distance. Statistical analyses included descriptive statistics of the sample, interclass correlation coefficient (ICC), analysis of variance (ANOVA), t-tests (p < 0.05), and Pearson correlation coefficients to quantify correlations between raters and repeated measures.

RESULTS

ANOVA results for intra-rater reliability indicated consistency among individual raters. All raters demonstrated significant correlations across repeated measures, ICC = 0.92-0.94. ANOVA and t-test results did not support inter-rater reliability. However, ICC = 0.90, standard error of measurement = 0.22, and Pearson R = 0.84 supported inter-rater reliability. The evidence suggests that although the absolute TWD measurement values may not be reliable among raters, relative change between TWD measures demonstrates high inter-rater reliability.

CONCLUSIONS

TWD measurement has high intra-rater reliability. TWD measurement of a single patient by multiple raters is not supported.

The effect of the forward head posture on postural balance in long time computer based worker

Objective

To estimate the effects of a relatively protruded head and neck posture on postural balance, in computer based worker.

Method

Thirty participants, who work with computers for over 6 hrs per day (Group I), and thirty participants, who rarely work with computers (Group II), were enrolled. The head and neck posture was measured by estimating angles A and B. A being the angle between the tragus of the ear, the lateral canthus of the eye, and horizontal line and B the angle between the C7 spinous process, the tragus of the ear, and the horizontal line. The severity of head protrusion with neck extension was assessed by the subtraction of angle A from angle B. We also measured the center of gravity (COG) and postural balance by using computerized dynamic posturography to determine the effect of computer-based work on postural balance.

Results

Results indicated that group I had a relatively more protruded head with extensive neck posture (angle B-A of group I and group II, 28.2±8.3, 32.9±6.0; p<.05). The COG of group I tended more toward the anterior than that of group II. Postural imbalance and impaired ability to regulate movement in forward and backward direction were also found.

Conclusion

The results of this study suggest that forward head postures during computer-based work may contribute to some disturbance in the balance of healthy adults. These results could be applied to education programs regarding correct postures when working at a computer for extended periods of time.

Changes in head and neck posture using an office chair with and without lumbar roll support

STUDY DESIGN

A repeated measures observational study.

OBJECTIVE

To investigate change in sagittal alignment of head and neck posture in response to adjustments of an office chair with and without a lumbar roll in situ.

SUMMARY OF BACKGROUND DATA

Forward head posture has been identified as a risk factor for neck pain, and there is evidence to show that ergonomic correction in sitting may reduce the incidence of pain. The effect placement of a lumbar roll has on cervical spine posture has not been previously investigated experimentally but rather, is assumed to have a positive influence on head and neck posture.

METHODS

Thirty healthy male participants (18-30 years) were photographed while registered in the natural head resting position in each of 4 sitting positions with and without a lumbar roll in situ. Two positions incorporated adjustments to the back rest and 1 to the seat pan of the office chair. The craniovertebral (CV) angle, as a determinant of head and neck posture was measured from the set of digitized photographs obtained for each participant. Comparisons between the CV angle in all postural registrations were made using a mixed model analysis adjusted for multiple comparisons.

RESULTS

Of the positions examined, significant differences in the mean CV angles were found with the backrest of the chair at 100 degrees and at 110 degrees (P < 0.001). With the lumbar roll in situ and the backrest position at 110 degrees , there was a significant increase in the mean CV compared with the angle without the lumbar roll in situ (2.32 degrees , 95% confidence interval: 1.31-3.33; P < 0.001).

CONCLUSION

The degree of angulation of the backrest support of an office chair plus the addition of lumbar roll support are the 2 most important factors to be taken into account when considering seating factors likely to favorably change head and neck postural alignment, at least in asymptomatic subjects.

Variability of the forward head posture in healthy community-dwelling older women

PURPOSE

The purpose of this research was to describe the variability of forward head posture in healthy older women, and to investigate the influence of age on variability.

METHODS

This cross-sectional descriptive study included 187 healthy community-dwelling women volunteers ranging in age from 65-96 years. The forward head posture (FHP) measurement was derived from a sagittal photograph. The subjects were asked to perform a series of standing activities, and the photograph was taken while the subjects were performing these activities. Data analysis included descriptive analysis, FHP measurement analysis for normalcy, one-factor ANOVA with FHP by age group, post-hoc Tukey analysis, and trend analysis for the age-FHP relationship.

RESULTS

Three age-group normative FHP means were identified: 48.84 degrees (SE 0.97) for the 65-74 year old group, 41.20 degrees (SE 0.78) for the 75-84 year old group, and 35.60 degrees (SE 1.76) for the 85+ year group. Significant differences were found in the FHP between these age groups. A subsequent trend analysis demonstrated a linear relationship between age and the FHP, with older women demonstrating a more severe FHP.

CONCLUSIONS

Age-associated variability in the FHP of healthy elderly women has been identified. The FHP values determined by this research may serve as normative guidelines for clinicians when conducting postural assessments, and in clinical decision-making regarding possible interventions.

Spinal postural alignment variance according to sex and age in 7- and 8-year-old children

PURPOSE

Children's postural alignment undergoes many adjustments due to the changes in body proportions during the stages of growth. The objective of this study was to quantitatively characterize and analyze spinal postural standards in 7- and 8-year-old children to verify which of the differences found were correlated to age and sex.

METHODS

Two hundred thirty public school students (Amparo, São Paulo, Brazil) aged 7 to 8 years were divided into groups according to postural alignment, which were further subdivided by sex and age, for comparison. Digital photos of upright subjects were analyzed to evaluate posture. Lumbar and thoracic curvature, pelvic inclination, head posture, and lateral spine deviation were measured using CorelDraw (Ottawa, Canada) software guidelines and bone landmarks. Descriptive statistics and analysis of variance data analysis were utilized to verify differences among the groups. This was a cross-sectional, descriptive study.

RESULTS

Mean values for the variables analyzed were calculated. For lumbar lordosis, 7-year-old boys showed 38.49 degrees +/- 15.32 degrees in comparison to all other groups (42.29 degrees +/- 7.13 degrees ). For thoracic kyphosis, the 7-year-old children presented 28.07 degrees +/- 7.73 degrees , and the 8-year-olds 30.32 degrees +/- 7.73 degrees . Pelvic inclination presented a mean value of 15.82 degrees +/- 5.46 degrees and single lateral spine deviation mean value of 3.48 degrees +/- 2.12 degrees .

CONCLUSION

For the sample studied, differences based on sex and age were found for some of the body segments analyzed. The values found in this study may contribute to improved physiotherapeutic treatment when associated with other aspects of the clinical assessment and symptomatology.

Head posture and neck pain of chronic nontraumatic origin: a comparison between patients and pain-free persons

OBJECTIVE

To compare standing head posture measurements between patients with nontraumatic neck pain (NP) and pain-free individuals.

DESIGN

Single-blind (assessor) cross-sectional study.

SETTING

Hospital and general community.

PARTICIPANTS

Consecutive patients (n=40) with chronic nontraumatic NP and age- and sex-matched pain-free participants (n=40).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Three angular measurements: the angle between C7, the tragus of the ear, and the horizontal; the angle between the tragus of the ear, the eye, and the horizontal; and the angle between the inferior margins of the right and the left ear and the horizontal were calculated through the digitization of video images.

RESULTS

NP patients were found to have a significantly smaller angle between C7, the tragus, and the horizontal, resulting in a more forward head posture than pain-free participants (NP, mean +/- SD, 45.4 degrees +/-6.8 degrees ; pain-free, mean +/- SD, 48.6 degrees +/-7.1 degrees ; P<.05; confidence interval [CI] for the difference between groups, 0.9 degrees -6.3 degrees ). Dividing the population according to age into younger (</=50y) and older (>50y) revealed an interaction, with a statistically significant difference in head posture for younger participants with NP compared with younger pain-free participants (NP, mean +/- SD, 46.1 degrees +/-6.7 degrees ; pain-free, mean +/- SD, 51.8 degrees +/-5.9 degrees ; P<.01; CI for the difference between groups, 1.8 degrees -9.7 degrees ) but no difference for the older group (NP, mean +/- SD, 44.8 degrees +/-7.1 degrees ; pain-free, mean +/- SD, 45.1 degrees +/-6.7 degrees ; P>.05; CI for the difference between groups, -4.9 degrees -4.2 degrees ). No other differences were found between patients and pain-free participants.

CONCLUSIONS

Younger patients with chronic nontraumatic NP were shown to have a more forward head posture in standing than matched pain-free participants. However, the difference, although statistically significant, was perhaps too small to be clinically meaningful.

Use of the Occivator for the correction of forward head posture, and the implications for temporomandibular disorders: a pilot study

Numerous studies suggest that temporomandibular disorders may be associated with forward head posture. The current study presents a need for an intervention that will effectively facilitate an ideal postural alignment of the head. The Occivator (Posteocentric Systems, Mastic Beach, NY) is an intervention speculated to improve forward head posture (FHP). However there has not been a randomized study to correlate use of the Occivator with improvement of FHP. The purpose of this study was to evaluate the effectiveness of the Occivator as a therapeutic intervention for the correction of FHP. Using a plumb line, twenty-nine (29) subjects were selected on the basis of having FHP. The CROM (cervical range of motion) device was used to determine measurement of forward head position for each group, pre and post an eight week period. The experimental group followed a specific protocol of 20 minutes of stretches and exercises on the Occivator, two times a week for eight weeks. The control group did not receive any intervention. The experimental group as compared to the control group, demonstrated significant improvement for forward head posture (p = .02). Further research is needed to evaluate the effectiveness of the Occivator.

Validity of a computer postural analysis to estimate 3-dimensional rotations and translations of the head from three 2-dimensional digital images

OBJECTIVE

The purpose of this study is to describe and evaluate the validity/accuracy of the computerized system PosturePrint for measuring head posture.

METHODS

Computer analysis was compared with 125 measured positions of a mannequin head in 5 degrees of freedom. For each mannequin position, 3 digital photographs were obtained (left lateral, anteroposterior, and right lateral) and were processed through the PosturePrint computer system. For the head analysis, a headgear with 3 reflective markers was placed on a subject; and there were additional click-on markers at the ear tragus, upper lip, acromioclavicular joints, and episternal notch. Head postures were calculated as lateral translation (T(x)), lateral flexion (R(z)), axial rotation (R(y)), flexion-extension (R(x)), and anterior-posterior translation (T(z)). For an error analysis, PosturePrint algorithm calculations were compared with the true mannequin head positions. Furthermore, average head posture was determined in student volunteers (n = 40).

RESULTS

Mean computational errors were R(x) = 1.3 degrees (SD 0.6 degrees) and T(z) = 1.1 mm (SD 0.5 mm) for sagittal displacements and R(y) = 1.1 degrees (SD 0.7 degrees), R(z) = 0.6 degrees (SD 0.4 degrees), and T(x) = 1.1 mm (SD 0.5 mm) for frontal view displacements. For the normal group, mean head displacements were 1.1 degrees or less for all rotations and 1 mm or less for lateral translations (T(x)); and forward head posture (T(z)) averaged 3 cm.

CONCLUSION

From the mannequin positions, small mean errors indicate that the PosturePrint system is accurate. In the future, statistical research determining the correlation between head displacements, neck pain, function, and health status should be performed.

Effects of backpacks on students: measurement of cervical and shoulder posture

The aims of this pilot study were to determine whether the weight of a backpack, its position on the spine or time carried affected adolescents cervical and shoulder posture. Standing posture measured from the sagittal and frontal planes of 13 students was recorded photographically under several load carrying conditions. Cervical and shoulder position angles were calculated and compared. Results revealed that both backpack weight and time carried influenced cervical and shoulder posture. Forward head posture increased when carrying a backpack, especially one with a heavy load. Carrying a backpack weighing 15% of body weight appeared to be too heavy to maintain standing posture for adolescents. These findings have implications for future load carrying studies in adolescents.

Usefulness of posture training for patients with temporomandibular disorders

BACKGROUND

Many practitioners have found that posture training has a positive impact on temporomandibular, or TMD, symptoms. The authors conducted a study to evaluate its effectiveness.

METHODS

Sixty patients with TMD and a primary muscle disorder were randomized into two groups: one group received posture training and TMD self-management instructions while the control group received TMD self-management instructions only. Four weeks after the study began, the authors reexamined the subjects for changes in symptoms, pain-free opening and pressure algometer pain thresholds. In addition, pretreatment and posttreatment posture measurements were recorded for subjects in the treatment group.

RESULTS

Statistically significant improvement was demonstrated by the modified symptom severity index, maximum pain-free opening and pressure algometer threshold measurements, as well as by the subjects' perceived TMD and neck symptoms. Subjects in the treatment group reported having experienced a mean reduction in TMD and neck symptoms of 41.9 and 38.2 percent, respectively, while subjects in the control group reported a mean reduction in these symptoms of 8.1 and 9.3 percent. Within the treatment group, the authors found significant correlations between improvements in TMD symptoms and improvements in neck symptoms (P < .005) as well as between TMD symptom improvement and the difference between head and shoulder posture measurements at the outset of treatment (P < .05).

CONCLUSIONS

Posture training and TMD self-management instructions are significantly more effective than TMD self-management instructions alone for patients with TMD who have a primary muscle disorder.

PRACTICE IMPLICATIONS

Patients with TMD who hold their heads farther forward relative to the shoulders have a high probability of experiencing symptom improvement as a result of posture training and being provided with selfmanagement instructions.