Fathollahnejad et al.

BMC Musculoskeletal Disorders (2019) 20:86

https://doi.org/10.1186/s12891-019-2438-y

RESEARCH ARTICLE Open Access

The effect of manual therapy and stabilizing

exercises on forward head and rounded
shoulder postures: a six-week intervention
with a one-month follow-up study
Kiana Fathollahnejad 1, Amir Letafatkar1,2* and Malihe Hadadnezhad1

Abstract
Background: The purpose of this study is to evaluate the effect of a six-week combined manual therapy (MT) and
stabilizing exercises (SEs), with a one-month follow-up on neck pain and improving function and posture in
patients with forward head and rounded shoulder postures (FHRSP).
Methods: Sixty women with neck pain and FHRSP were randomized into three groups: Group 1 performed SE and
received MT (n = 20), Group 2 performed SE (n = 20) and Group 3 performed home exercises (n = 20) for six weeks.
The follow-up time was one month after the post test. The pain, function, and head and shoulder angles were
measured before and after the six-week interventions, and during a one-month follow-up.
Results: There were significant within-group improvements in pain, function, and head and shoulder posture in
groups 1 and 2. There were significant between-group differences in groups 1 and 2 in head posture, pain, and
function favoring group 1 with effect size 0.432(p = 0.041), 0.533 (P = 0.038), and 0.565(P = 0.018) respectively. There
were significant between-group differences in both intervention groups versus the control group favoring the
intervention groups.
Conclusion: These findings suggest that both interventions were significantly effective in reducing neck pain and
improving function and posture in patients. However, the improvement in function and pain were more effective
in Group 1 as compared to Group 2, suggesting that MT can be used as a supplementary method to the stabilizing
intervention in the treatment of neck pain. More researches are needed to confirm the result of this study.
Trial registration: UMIN000030141 modified on 2018.03.08.
This study is a randomized control trial registered at UMIN-CTR website, the trial was retrospectively registered and
the unique trial number is UMIN000030141.
Keywords: Forward head posture, Function, Manual therapy, Neck pain, Stabilization exercises

Background associated with altered scapula position in terms of kine-

Forward head posture (FHP) is a kind of poor posture matic and muscle activities [2].
associated with increased kyphosis in the thoracic spine In FHP, hyperextension of the upper cervical spine
and anterior shoulder position [1]. Poor posture is also associated with shortening of the upper trapezius, cer-
vical extensor muscles (e.g. Suboccipital, Semispinalis,
and splenius), Sternocleidomastoids and the Levator
* Correspondence: [email protected]
1
scapulae muscles has been observed [2]. On the other
Faculty of Physical Education and Sport sciences, Department of
Biomechanics and Sport injuries, Kharazmi University, Tehran, Islamic
hand, in round shoulder posture (RSP), there is acro-
Republic of Iran mion forward displacement in relation to the 7th cer-
2
Biomechanics and Corrective Exercise Laboratory, Faculty of Physical vical spinous process and can be measured by the
Education and Sport sciences, Kharazmi University, Mirdamad Blvd., Hesari St,
Tehran 00982122258084, Iran
shoulder angle associated with a protracted, anteriorly

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Fathollahnejad et al. BMC Musculoskeletal Disorders (2019) 20:86 Page 2 of 8

tilted, internally rotated scapula and the pectoralis Thus, the authors of this study tried to compare the
minor muscles shortness [3]. effects of a six-week intervention and one-month
Forward head and round-shoulder postures (FHRSP) follow-up of a combined treatment consisting of SEs and
can result in shoulder pain and dysfunction because of MT, with SE alone, on neck pain, function, and cranio-
altered scapular kinematics and muscle activity and cervical and rounded shoulder angles in patients with
consequently, placing increased stress on the shoulder neck pain and FHRSP.
[4]. Therefore, FHRSP has to be modified to decrease
stress on the shoulder [4]. Methods
Changes have been shown in head, shoulder and thor- Participants and procedure
acic posture in people with neck pain compared to asymp- This study is a randomized controlled trial registered at
tomatic ones [5]. Nejati et al. (2014) stated that FHP and UMIN_RCT website, and the unique trial number is
thoracic kyphosis are associated with neck pain although UMIN000030141.
they did not find any relationship between RSP and neck
pain in Iranian office workers [5]. Similarly, Silva et al. Ethics and consent statements
(2008) indicated that those with chronic non-traumatic The patients were informed about the details of the
neck pain have more FHP in standing position than pain- study and the volunteer subject provided written con-
free participants. The difference was considered statisti- sent to participate before study enrollment. Informed
cally not clinically meaningful [6]. consent was obtained from all the participants, and
Despite the fact that neck disorders are common in the procedures were conducted according to the Declar-
population, little evidence supporting effective interven- ation of Helsinki.
tions has been identified [7]. Meanwhile, one of the sug- Using a G-power software, with a power of 0.92 and a
gested interventions for improving musculoskeletal 3-group design tested at an alpha level of 0.01, 20 sub-
disorders is exercise therapy that includes a large variety jects per group are required to detect a posture data of
of methods such as mobilizing, stretching, isometric/static 0.8 points (Power and Precision™ 2.0).
or dynamic strengthening, endurance training, direction- This study was conducted for six weeks in the clinic
movement control and proprioceptive exercises [7]. Due of the university, with a one-month follow-up on mar-
to the contradictory results from different studies, treat- ried women aged 32–42 years with neck pain and
ment of neck pain has been considered challenging in FHRSP. Participants were recruited through physicians,
clinical healthcare’s [8]. orthopedic surgeons and physical therapists working in
It has been indicated that stabilization exercises private centers.
(SEs) for the scapula by improving and normalizing An experienced physiotherapist assessed the subjects
muscular activities can improve pain and posture in based on clinical history, posture and symptom responses
patients with neck pain and FHP and consequently, to active movements. For all the assessments, the assessor
the quality of life [9]. was blinded to the group allocation. The data analyst was
On the other hand, manual therapy (MT) is another form only blinded to the treatment allocation.
of conservative treatment provided by physical therapists, Initially, a total of 80 volunteers were evaluated with
chiropractors, osteopaths and sometimes other healthcare photogrammetry. The subjects were screened by meas-
providers. MT can be used as an effective modulation in re- uring the cervical angle (CA > 46°) and shoulder angle
lieving soft tissue, a range of motion (ROM), and pain, and (SA > 52°) with photogrammetry [15]. Given the inclu-
altering muscle function in musculoskeletal disorders [10]. sion and exclusion criteria, a total of 60 participants
There is also limited evidence that a multimodal were recruited.
intervention consisting of spinal and neuro-dynamic The inclusion criteria were non-specific neck pain
mobilizations and specific exercises is effective on pain reproduced by neck movement or provocation tests in
in patients with neck pain [10]. the location of the neck [16], neck pain between 3 and
There are studies that have reported considerable ef- 8 cm on a visual analog scale, and at least within the
fects on improving pain, shoulder and neck ROM, last three months as chronic pain [15, 17–19]. Subjects
function [11, 12] and posture [9, 13, 14] in patients were excluded when they had a history of cervical spine
with FHRSP using exercises, but most of them have no injury or surgery, neck pain secondary to other condi-
control or comparison groups. To our knowledge, there tions (e.g. neoplasm, neurological diseases or vascular
is no study which compared the effectiveness of a com- diseases), a neurological deficit, infection or inflamma-
bined MT and SE intervention and stabilizing interven- tory arthritis in the cervical spine, received physiother-
tion alone on posture, function, and pain in patients apy within the last 6 months, smoking habits, and poor
with chronic neck pain. Also, there is no one-month general health status that would interfere with the exer-
follow-up to support the effect of SE on FHRSP. cises [15–18].
Fathollahnejad et al. BMC Musculoskeletal Disorders (2019) 20:86 Page 3 of 8

The dimension of the sample was calculated to be at (no pain at all) to 10 (unbearable pain), which were dis-
least equal to 60 patients (20 per group) based on a 0.95 played along a horizontal line, 10 cm in length. Each
confidence level, a 0.8 statistical power, and a 0.6 score subjectively reported by a participant was
Cohen’s d effect size coefficient. regarded as her level of pain based on a range of scores
from 0 to 10 [17].
Randomization
Randomization was included in 2 sections. Firstly, a
list of numbers with each being randomly assigned to Functional endurance
a type of treatment (SE or SE plus MT), was provided. Progressive Iso-inertial Lifting Evaluation (PILE) has
Then, the SE or SE plus MT intervention was allo- been developed and modified over several years and is
cated to each of the participants based on their known as a standardized protocol and a functional test
recruiting order. Secondly, randomization followed a for measuring muscle endurance with ICC ≥ 0.85 [20,
fixed-size design with a concealed allocation ratio of 21]. In addition, the quantification of lifting capacity is
1:1. Thus, 20 participants were assigned to the SE plus an important measure of functional evaluation in this
MT intervention, and 20 participants were assigned to test [21].
the SE program. Women began with an eight-pound load divided into
Demographic data (age, sex and body mass index five-pound iron bar plus container weight. The weight
(BMI)) and information on smoking habits, physical ac- was increased every 20 s at an equal rate to the initial
tivities, marital status and referred pain were obtained at free weight [7, 12, 15, 20]. The subjects performed four
baseline. All outcome measures were captured at base- lifting movements for 20 s. The PILE protocol (score)
line (time 1), 6 weeks’ post- intervention (time 2), and included the lifting of weights in a box, in a test for the
during one-month follow up (time 3) by an assessor capability of cervical lifting from waist to shoulder
blinded to the group allocation. height (30–54 in.). Also, the endpoint was also estab-
In order to reduce bias in data analyses, participants lished when fatigue or aerobic incapability in perform-
were blinded to which group considered (study flowchart). ing the test were felt [11, 20, 21]. An assessor evaluated
After randomization, Groups 1 (SE plus MT, n = 20) and 2 the PILE test. To be experienced in the evaluation of
(SE, n = 20) performed the interventions, 30 min/day, the test, the assessor had three days training according
three days/week for six weeks. The subjects in the control to the PILE test protocol.
group (n = 20) performed only a total of 3 times home ex-
ercise program weekly described as a postural correction
on daily activities but met more irregularly for lectures Measurement of forward head and protracted shoulder
and were given information on activities promoting gen- angles
eral health. The exercise interventions were performed Posture was assessed using the BioPrint postural analysis
under the supervision of the physiotherapist and two cor- system (Biotonix Inc., Montreal, CA). Markers were
rective exercise trainers. The subjects were asked not to placed over the right tragus of ear, acromion process and
receive any extra intervention for neck-shoulder pain. All C7 spinous process.
the subjects could take medications to reduce pain if Then, the subjects were asked to stand at 40 cm dis-
needed and prescribed by their physicians. However, the tance in front of a backdrop, bent forward three times,
participant did not report the use of any pill. reached overhead three times, and then stood to look
Subjects were also excluded if they missed practice for straight ahead in their natural resting position. A
three consecutive sessions or more. Pain, function and digital camera (Canon Power shot 95 USA) was placed
forward head and round-shoulder angles were measured on a tripod 1 m high and 3.5 m from the wall. Forward
three times in each group at baseline, after a six-week head angle (FHA) and forward shoulder angle (FSA)
intervention, and during a one-month follow-up after were measured using an image processing software
the intervention. (i.e. Adobe Photoshop) by the respective angles be-
tween the centers of the markers. FHA was measured
Instrumentation from the vertical anterior to a line connecting the tra-
Pain intensity gus and the C7 marker. FSA was measured from the
To evaluate pain intensity, as one of the primary out- vertical posterior to a line connecting the C7 marker
comes, visual analog scale (VAS) was used. This scale is and the acromial marker. FHA and FSA were mea-
widely used in clinical settings and is known as a valu- sured three times, and the average was used for subse-
able tool for assessing pain [18, 19] with ICC = 0.81 quent photos [15].
[18]. After an explanation, the participants indicated Normative value for FSA was an angle greater than 52°
their current pain level by choosing a number from 0 and FHP was an angle greater than 46° [1].
Fathollahnejad et al. BMC Musculoskeletal Disorders (2019) 20:86 Page 4 of 8

Stabilizing exercises the subject was asked to stay in the same supine pos-
Neck SEs were performed under the supervision of the ition as an extension. The C5–6 joints motion was
physiotherapist and two corrective exercise trainers checked to assess the flexion ROM. Then, the manipu-
three times a week for groups 1 and 2. The authors lation was performed by checking mobility [22]. To in-
provided cards and written illustrations to inform the crease the side bending motions of the cervical joints,
subjects how to properly perform the exercises. The the same method was used to analyze the ROM restric-
neutral posture during daily activities and the exer- tion and manual application was done for side bending
cises was educated using mirrors putting in the side motions [22]. It should be noted that during manual
and the front of the subjects. The subjects were asked therapy for all extension, flexion and side bending
to have the neutral position on the stable and unstable ROMs, movements of the other surrounding joints
surfaces during the exercises. The warm up was con- were prevented (to find full detailed information con-
sisted of 5–6-min walking. Descriptions of the exer- cerning the applied manual intervention, please check
cises are shown in Tables 1 and 2. Strengthening the study of Gong (2015)).
exercises targeted the periscapular muscles (Y to W, L
to W, scapular protraction). Stabilization of the scap- Statistical analysis
ula was emphasized during instruction. Strengthening The statistical analyses of the data were performed by a
exercises were progressively performed for three sets, biostatistician using SPSS version 19.0 software (SPSS
with 10 to 15 repetitions. The stretching part of the Inc., Chicago, IL) with the values of p < 0.05. Shapiro-
exercises was done with the purpose of increasing the Wilk and Levene tests were used to respectively to as-
flexibility of the pectoralis and the cervical neck ex- sess the distribution and homogeneity of variance before
tensors muscles (pectoralis stretch, chin tuck). Exer- performing analysis of covariance (ANOVA). One-way
cises have been approved to be effective on the ANOVA was used to identify differences in the VAS,
lengthening of the pectoralis minor, activation of the function, and neck and shoulder angles before the inter-
lower trapezius/middle trapezius, serratus anterior, ventions among the three groups. Two-way ANOVA
and improvement of the posture [1]. was used to evaluate the effects of experimental groups
and pre-and post-tests as well as follow-up times on the
Manual interventions outcomes. Between-groups effect sizes were calculated
Manual therapy interventions were performed by a and interpreted according to Cohen’s d. Effect sizes were
skilled manual therapist in neck pain based on the classified as small (d = 0.20), medium (d = 0.50), or large
study conducted by Gong (2015). Group 1 received ma- (d = 0.80).
nipulation for 10 min, three times a week, for six weeks.
The aim of manipulation in the experimental group Results
was to increase flexion, extension, and side bending The results of the Shapiro-Wilk test indicated normal
ROMs by checking the passive motion in cervical facet data distribution.
joints. To assess the passive motions, firstly, the subject A total of 60 female subjects who had a history of neck
was asked to lay supine on the bed while the 7th cer- pain with forward head and rounded shoulder postures
vical vertebra was placed on the edge of the bed and participated in this study (Additional file 1). Table 3 pre-
others above the 7th vertebra were placed off the bed. sents the demographic data of all groups.
Thereafter, a manual therapist held the occipital region There were no differences in the demographic data of
and C6 spinous process with both hands and checked all groups. All the subjects completed 6 weeks of exer-
the mobility of the C5 and C6 joints. This method was cise intervention with no dropouts.
used to check the extension ROM restriction of the There were no differences in the characteristics of sub-
joint in the cervical spine by holding the C5, C4, and jects using VAS, function scores, as well as neck and
C2 SPs. Then, the therapist applied the manual inter- shoulder angles before the exercise interventions among
vention for extension ROM. To increase flexion ROM, the three groups (P > 0.05) (Table 4).

Table 1 Description of strengthening exercises used during 8-week intervention program

Exercise Description
Y to W Arms flexed and abducted to 120°, thumbs pointed up, arms 4–5 in. raisied while keeping the retraction of scapula.
Then elbows flexed and shoulders moved into a position of extension
L to Y Arms abducted to 90° and elbows flexed to 90° with retracted scapula and arms externally rotated. Arms raised above
the head and fully extended the elbows so that formed the letter Y.
Scapular Prone hip bridge, shoulder retracted with forearms and toes supporting the body on the floor or table. Then 1–2 cm
protraction pushed up while protracting the scapula, and preventing the scapula winging.
Fathollahnejad et al. BMC Musculoskeletal Disorders (2019) 20:86 Page 5 of 8

Table 2 Description of the flexibility exercises used in the 8- Head posture

week intervention program The ANOVA analysis showed that there was significant
Exercise Description difference in head posture between the groups (F =
Pectoralis Supine on a foam roller with their spine, contracting 4.312, P = 0.016).
flexibility transverses abdominous and flattening the lumbar curve There was within group changes (pretest to posttest) in
against the foam roller. Arms together with shoulders and
elbows flexed to 90°, touching forearms and palms.
the head posture of Groups 1 (pretest: 47.50 ± 6.00, post-
Then shoulders horizontally abducted and scapula retracted, test: 42.25 ± 4.05, and differences: − 5.31 ± 0.41, p = 0.001,
wrists and elbows aligned in the plane of the body. Holded ES: 0.721) and Groups 2 (pretest: 47.41 ± 1.16, posttest:
for 5 s and repeated 10 times.
42.75 ± 5.24, and differences: − 5.21 ± 0.18, P = 0.003,
Chin tucks The chin pushed into the table in an entirely posterior P:0.714). There was no significant within group changes in
motion. It was not an exercise of tucking the chin to chest
through neck flexion Groups 3 (pretest: 48.75 ± 0.86, posttest: 48.16 ± 7.02, and
differences: 1.08 ± 0.75, P = 0.62) (Tables 4 and 5).
There was a significant difference in head posture
Pain degree between pre- and post-tests in Groups 1 and 2
The ANOVA analysis showed a significant difference in (p = 0.041).
VAS between groups (F = 5.514, P = 0.012). There was no significant difference in head posture
There was within group changes (pretest to posttest) in from a one-month follow-up to post-intervention in all
the VAS score of Groups 1 (2.14 ± 0.1, P = 0.008, ES:0.629), the groups (P = 0.148) (Table 5).
and also between Groups 2 (0.70 ± 0.28, P = 0.015, ES:
611), but no difference in the control group (P = 0.18) Shoulder posture
(Tables 4 and 5). The ANOVA analysis showed that there were signifi-
There was a significant difference in VAS in the pre- cant differences in shoulder posture between the
and post-tests in Groups 1 and 2 (p = 0.038). groups (F = 4.318, P = 0.018).
There was a significant difference in VAS from a There was within group changes (pretest to posttest) in
1-month follow-up to post-intervention (decrease, − 1.34 the head posture of Groups 1 (pretest: 53.66 ± 1.07, post-
± 0.22 score change) only in the exercise plus MT group test: 49.95 ± 6.28, and differences: − 5.33 ± 1.08, P = 0.006,
(P = 0.016) (Table 5). ES: 0.597) and Groups 2 (pretest: 54.00 ± 1.12, posttest:
49.66 ± 4.72, and differences: − 5.48 ± 1.33, P = 0.004,
Function ES:0.619). There was no significant within group changes
The ANOVA analysis showed a significant difference in in Groups 3 (pretest: 53.25 ± 1.13, posttest: 52.25 ± 6.28,
function between the groups (F = 5.213, P = 0.009). and differences: − 1.25 ± 0.43, P = 0.19) (Tables 4 and 5).
There was within group changes (pretest to posttest) in There were no differences among the shoulder posture
the head posture of Group 1 (pretest: 0.33 ± 0.49, posttest: degree of Groups 1 and 2 (P = 0.54).
1.50 ± 0.36, and differences: 1.25 ± 0.21, p = 0.002, ES:0.638) There was no significant difference in shoulder posture
and Group 2 (pretest: 0.25 ± 0.45, posttest: 1.08 ± 0.19, and from a one-month follow-up to post-intervention in all
differences: 0.95 ± 0.32, P = 0.005, ES:0.608). There was no the groups (P = 0.213) (Table 5).
significant within group changes in Group 3 (pretest:
0.08 ± 0.28, posttest: 0.16 ± 0.38, and difference: 0.07 ± Discussion
0.12, p: 0.23) (Tables 4 and 5). This study aimed to investigate if SEs plus MT is more ef-
There was a significant between group post-test differ- fective than SEs alone in the management of neck pain.
ence in function in Groups 1 and 2 (p = 0.018). The results showed that pain and function signifi-
There was no significant difference in function from a cantly improved in the treatment groups after the
1-month follow-up to post-intervention in all the groups six-week exercises; this improvement was also main-
(P = 0.128) (Table 5). tained after one-month follow-up. Moreover, when
compared with Group 2, function and pain improve-
ment in Group 1 were more effective.
Table 3 Participant characteristicsa
Altered scapula-humeral rhythm and decreased up-
Exercise plus manual Exercise Control P-value
therapy group group group ward rotation of the scapula have been seen in individ-
Age, y 37 ± 3.10 36.4 ± 7.41 36.7 ± 4.38 0.659
uals with FHRSP, fatigue, and disability in shoulder
muscle, impingement or instability of the glenohumeral
Height, cm 165 ± 7.14 170.3 ± 9.09 168.3 ± 9.17 0.431
joint [23].
Mass, kg 63.4 ± 4.32 67 ± 6.13 66.8 ± 5.69 0.385 The trapezius and serratus anterior muscles as the
BMI, kg/m2 23.12 ± 1.07 22.32 ± 1.52 22.65 ± 1.44 0.359 upward rotators of the scapula are essential for normal
a
Values are mean ± SD. All groups, n = 20 shoulder function [24]. In this condition, the middle
Fathollahnejad et al. BMC Musculoskeletal Disorders (2019) 20:86 Page 6 of 8

Table 4 Pre-intervention, post-intervention and 1-month follow up valuesa

Pre-intervention Post-intervention 1 month follow-up
Exercise plus manual therapy group
Head posture, degree 47.50 ± 6.00 42.25 ± 4.05 42.58 ± 5.90
Shoulder posture, degree 53.66 ± 1.07 49.95 ± 6.28 49.58 ± 7.08
Function (score) 0.33 ± 0.49 1.50 ± 0.36 1.41 ± 0.41
Pain (0–10) 4.83 ± 0.83 2.16 ± 0.93 1.50 ± 1.08
Exercise group
Head posture, degree 47.41 ± 1.16 42.75 ± 5.24 42.87 ± 1.15
Shoulder posture, degree 54.00 ± 1.12 49.66 ± 4.72 49.97 ± 5.67
Function (score) 0.25 ± 0.45 1.08 ± 0.19 0.91 ± 0.28
Pain (0–10) 4.91 ± 0.66 3.08 ± 0.79 2.75 ± 0.75
Control group
Head posture, degree 48.75 ± 0.86 48.16 ± 7.02 47.33 ± 6.88
Shoulder posture, degree 53.25 ± 1.13 52.25 ± 6.28 52.67 ± 6.97
Function (scores) 0.08 ± 0.28 0.16 ± 0.38 0.16 ± 0.39
Pain (0–10) 5.08 ± 0.90 5.11 ± 0.65 5.25 ± 1.21
a
Values are mean ± SD. All groups, n = 20

part of the trapezius muscle helps just to control the Gong (2015) demonstrated high levels of EMG activ-
amount of abduction of the scapula during upward ro- ity in the serratus anterior muscle during EMG studies
tation and does not play any role in the upward rota- at 90° flexion with scapular protraction (Y to W). The
tion of the scapula [25]. ‘L to W″ and “L to Y” exercises, with the shoulder hori-
In this study, L to Y exercise was selected because it can zontally abducted with external rotation and with the arm
externally rotate the shoulder to end range at 90° of ab- raised overhead in line with the lower trapezius muscle fi-
duction and cause maximum scapular depression, leading bers, with the subject in the prone position, generated the
to increased activity in the lower trapezius muscle [1, 11]. highest level of mean EMG activity in the middle part of
But there is low evidence of high activation of the upper the trapezius muscle [22]. Therefore, by performing the
trapezius muscle during L to Y exercise without resistance two exercises in this study, it can be speculated that im-
to the head and neck [22]. provement in pain and function may be caused by a

Table 5 Change scores (post-intervention-pre-intervention; 1 month follow up-post-intervention) *

Differences from Post-intervention to pre-intervention
Exercise plus manipulation group Exercise group Control group
Head posture, degree −5.31 ± 0.41¤ −5.21 ± 0.18¤ −1.08 ± 0.75
Shoulder posture, degree −5.33 ± 1.08¤ −5.48 ± 1.33¤ −1.25 ± 0.43
Function (scores) 1.25 ± 0.21*¤ 0.95 ± 0.32¤ 0.07 ± 0.12
Pain (0–10) −2.55 ± 0.41*¤ −1.89 ± 0.13¤ 0.41 ± 0.21
Differences from 1 month follow up
to post-intervention
Head posture, degree 0.65 ± 0.22 0.54 ± 0.31 −1.23 ± 1.02
Shoulder posture, degree −1.16 ± 0.42 0.67 ± 0.11 0.48 ± 0.32
Function (scores) −0.32 ± 0.13 − 0.47 ± 0.18 0.18 ± 0.14
Pain (0–10) −1.34 ± 0.22¥ −0.75 ± 0.21 0.25 ± 0.22
A positive change score indicates an increase in values
A negative change score indicates a decrease in values
¤Statistically significant difference from the control group (P < .05)
¥Statistically significant difference from 1-month follow-up to post-intervention (P < 0.05)
*Statistically significant difference from exercise group (P < 0.05)
*Values are mean ± SD
Fathollahnejad et al. BMC Musculoskeletal Disorders (2019) 20:86 Page 7 of 8

change in motor recruitment, or strengthening of the tra- Limitations

pezius and serratus anterior muscles. Due to the small sample size, the data analysis of this
Studies supported the present results considering study can not be considered powerful enough to deter-
pain reduction and function improvement through MT mine the real differences between groups. Randomized
[10, 26, 27]. Hakkinen et al. (2007,) which showed that controlled clinical trials with large sample size are
both MT and stretching were effective for short-term needed to confirm the efficacy of the combination of SEs
treatments to reduce both spontaneous and strain- and MT in patients with FHP and RSP.
evoked pain in patients with chronic neck pain [26].
Howe et al. (1983) considered medication and manipu- Conclusion
lation intervention for their subjects separated into two In this study, it was found that a combined treatment
groups. The group that received manipulation had an consisting of MT and SEs, performed three times a week
immediate improvement in ROM and relief from pain over a 6-week period by women aged 32–42 years with
after treatment [28]. neck pain, and FHRSP, resulted in pain reduction, and
Therefore, in the current study, it can be inferred that posture and function improvements, with a reduction in
the statistical advantages of Group 1 as compared to cervical and shoulder angles. The findings showed that
Group 2 in function improvement and pain reduction improvement in function was statistically more effective
over the six-week intervention and the one-month in Group 1 than Group 2. The results of the study also
follow-up, can be due to improved tissue extensibility demonstrated that from posttest to one-month
and ROM; relaxation; altered muscle function, and re- follow-up period outcomes maintained specially in
duction of soft tissue swelling and inflammation using Group 1. However, further studies on large populations
MT [10, 26, 27]. Also, it is possible that the decrease in are required to establish the ultimate effectiveness of SEs
pain reduced inhibition of the motor system and in part plus MT.
improved function [28]. Since disability is usually accompanied by a substantial
The results of this study indicated that cervical and effect on daily life and results in an extensive use of
shoulder angles significantly decreased, suggesting that healthcare resources [27], it is suggested to investigate
both interventions showed statistically significant ef- the effect of MT plus SEs on disability of patients with
fects on cervical and shoulder angles. Interestingly, the chronic neck pain. Also, to better understand how upper
differences were maintained after a one-month follow- limb function is modified after the MT plus stabilizing
up. The control group did not demonstrate such im- exercises, further studies are needed to provide sufficient
provement of posture. However, there were no differ- or reliable information on the recruitment of all the
ences between experimental groups in improvement of muscles involved in functional movement using
posture following the interventions. Exercise interven- electromyography.
tions aimed at strengthening weak muscles and stretch-
ing tight ones. It is thought to improve FHP and RSP Additional file
[1]. Im et al. (2016) reported that stabilization training
can improve the control of the serratus anterior and Additional file 1: Study flowchart. Flow Diagram. Participants and study
upper trapezius muscles, and bring the scapular and design in allocation, enrollment, pre-test, post-test, and follow-up
provided in consort flowchart. (DOCX 44 kb)
thoracoscapular closer to normal positions from FHP
[9]. Lynch et al. (2010) reported that the exercise inter-
Abbreviations
vention (stretching of the anterior shoulder muscles BMI: Body mass index; FHA: Forward head angle; FHP: Forward head posture;
and strengthening of the posterior shoulder muscles) FHRSP: Forward head and rounded shoulder postures; FSA: Forward shoulder
considerably improved FHRSP in elite swimmers [1]. angle; MT: Manual therapy; PILE: Progressive Iso-inertial Lifting Evaluation;
ROM: Range of motion; RSP: Round shoulder posture; SEs: Stabilizing
Also, Ruivoet al. (2016) successfully improved FHP and exercises
protracted shoulder posture following a 32-week resist-
ance and stretching training. The authors suggested Acknowledgements
None.
that the training used in this study seems to strengthen
the scapular stabilizers and stretch the pectoralis minor, Funding
resulting in decreased cervical and shoulder angles to None.
improve RSP [14].
Availability of data and materials
The results indicated that a combined treatment The datasets analysed during the current study are available from the
consisting of MT and SE is more effective than SE corresponding author on reasonable request.
alone in the management of chronic neck pain: it re-
Authors’ contributions
duces chronic pain and improves posture, and upper KF and AL developed the review protocol. MH conducted search process
limb function. and data extraction. All authors did quality appraisal of included studies and
Fathollahnejad et al. BMC Musculoskeletal Disorders (2019) 20:86 Page 8 of 8

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Springer Nature remains neutral with regard to jurisdictional claims in ROM in university students with abnormal posture of the cervical spine.
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