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Vol. 23. Issue 4.
Pages 346-354 (01 July 2019)
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Vol. 23. Issue 4.
Pages 346-354 (01 July 2019)
Original Research
DOI: 10.1016/j.bjpt.2018.08.007
Is forward head posture relevant to cervical muscles performance and neck pain? A case–control study
Leila Ghamkhar, Amir Hossein Kahlaee
Corresponding author

Corresponding author.
Department of Physical Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

  • Forward head posture is not associated with muscular performance in either groups.

  • Forward head posture does not explain pain and disability in CNP patients.

  • The muscle size–endurance relationship is affected in CNP.

  • Deep cervical muscles are selectively affected in the presence of CNP.

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Figures (2)
Tables (3)
Table 1. Comparison of the demographic variables between the two groups.
Table 2. Between groups comparison of the dependent variables including FHP, US imaging measures and endurance test results.
Table 3. Correlational analysis of the head posture, cervical endurance and muscle size in the CNP and asymptomatic groups.
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Forward head posture (FHP) and muscular dysfunction are likely contributing factors to chronic neck pain (CNP) but there are inconsistent findings on the relevance of these factors to clinical CNP characteristics.


To compare FHP, cervical muscles size and endurance between CNP and asymptomatic participants and to investigate their association with pain and disability and relative involvement of deep/superficial and flexor/extensor muscles.


Thirty-two patients with CNP and 35 asymptomatic participants were included in this case–control study. FHP in standing, extensor and flexor muscles endurance and dimensions were assessed using digital photography, clinical tests and ultrasonographic imaging, respectively. The visual analog scale and neck disability index were also used to evaluate CNP patients’ clinical characteristics.


Deep flexor (mean difference=0.06, 95% CI=0.02–0.11) and extensor muscles size (mean difference=0.07, 95% CI=0.01–0.12) were found to be significantly smaller in CNP patients. CNP patients also demonstrated lower levels of flexor (mean difference=14.68, 95% CI=3.65–25.72) and global extensor endurance capacity. FHP was neither different between the groups nor correlated with any of the dependent variables. Neither FHP nor endurance was correlated with pain/disability. Extensor endurance in both groups and flexor endurance in the asymptomatic group showed significant correlations with muscles size.


FHP was found neither different between groups nor correlated with muscle performance or CNP clinical characteristics. While cervical endurance was found lower in CNP patients, it did not show any association with pain/disability. The muscular size–endurance relationship seems to become more complex in the presence of NP. While deep muscles seem to be differentially affected in the presence of CNP, the alterations do not seem to be uniform in the flexor and extensor groups.

Chronic neck pain
Head posture
Extensor muscles
Flexor muscles
Muscle endurance


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