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Year : 2020  |  Volume : 2  |  Issue : 1  |  Page : 25-30

Effect of self- care exercises in forward head posture on craniovertebral angle and craniocervical flexion endurance: A pilot study

Departments of Orthopaedic Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission12-Jun-2019
Date of Decision28-Jun-2019
Date of Acceptance17-Feb-2020
Date of Web Publication03-Jul-2020

Correspondence Address:
Dr. Peeyoosha Gurudut
Department of Orthopaedic Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_48_19

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Background: Forward head posture (FHP) is the most frequently attained attitude of the head associated with rounded-shoulder posture (RSP) that leads to muscle imbalances. This needs to be corrected to prevent neck pain. Self-care exercises are home exercises that work positively for the prevention of the secondary effects of RSP.
Aims: The aim of this study is to determine the effects of two self-care exercises, namely Bruegger's postural relief position and quadruped track cervical brace exercise in the management of asymptomatic FHP in terms of craniovertebral angle (CVA) and craniocervical flexion endurance (CCFE).
Settings and Design: A single-group pre–post study design was conducted on physiotherapy volunteer student population of the Health Science University, Belagavi.
Materials and Methods: Fifteen participants with asymptomatic FHP (<44° of CVA) were recruited. They have prescribed the two self-care exercises (Bruegger's postural relief exercise and quadruped track cervical brace exercise), twice a day for 10 consecutive days. The outcome measures were the degree of FHP in terms of CVA and strength of deep cervical flexor muscles by CCFE test that were assessed pre- (day 1) and posttreatment (day 10).
Results: The mean age of the participants was 23.00 years (standard deviation = 1.56). The comparison of pre- and postintervention scores for CVA and CCFE outcomes demonstrated a statistically significant improvement (P < 0.0001).
Conclusions: The two self-care exercises showed an effective reduction of CVA and increased deep cervical flexor strength in FHP. Once learned by the patients, the exercises can be self-administered and can be performed independently by the patients.

Keywords: Forward head posture, Home exercises, Muscle imbalance, Postural correction, Self-help

How to cite this article:
Gurudut P, Welling A, Chodankar A. Effect of self- care exercises in forward head posture on craniovertebral angle and craniocervical flexion endurance: A pilot study. Indian J Phys Ther Res 2020;2:25-30

How to cite this URL:
Gurudut P, Welling A, Chodankar A. Effect of self- care exercises in forward head posture on craniovertebral angle and craniocervical flexion endurance: A pilot study. Indian J Phys Ther Res [serial online] 2020 [cited 2023 Sep 27];2:25-30. Available from: https://www.ijptr.org/text.asp?2020/2/1/25/288863

  Introduction Top

Forward head posture (FHP) is a common postural abnormality that is generally described as relative anterior position of the head in relation to the vertical line of gravity when observed in the sagittal plane. Increasing use of smartphones and computers has led to increase in the occurrence of FHP.[1] Carrying heavy school bags, sitting for a long period of time in front of the computer screen without appropriate use of desk and chair for the physique, and lack of exercise also accounts for FHP.[2]

People having FHP remain asymptomatic for some time which at later stage initiates the symptoms and are predisposed toward pathological conditions such as headache, neck pain, temporomandibular disorders, and scapula/shoulder dyskinesis.[3] FHP is shown to be associated with weak deep cervical flexors and a smaller craniovertebral angle (CVA).[3],[4] FHP leads to lengthening and weakness of the anterior cervical muscles such as deep cervical flexors and shortening of the posterior cervical muscles like trapezius and levator scapule. If this lengthening and weakness or imbalances in musculature is prolonged, it may negatively affect the cervical mobility and decrease the muscular performance which is demonstrated by decreased strength or endurance in deep cervical flexors.[4]

The assessment of FHP has become increasingly crucial in clinical practices to aid in planning treatment for patients with neck pain and its related conditions because of its associated problems.[4] FHP can be diagnosed subjectively by observation method and objectively by measuring CVA either using electronic head posture instrument or using X-rays or photographic method. The photographic method is one of the common objective methods in assessing FHP.[4] The strength or endurance affection of the cervical flexors can be measured by the craniocervical flexion endurance (CCFE) test using the pressure biofeedback unit (PBU).[5],[6]

Symptomatic FHP requires conventional physiotherapy treatment that mainly includes pain-relieving modalities, reduction of muscle spasm, and correction of muscle imbalances. However, when diagnosed at the stage of asymptomatic FHP, simple home exercise programs that may include self-care exercises may be prescribed which may be of great benefit while avoiding further complications.

The common home exercise programs that are administered or prescribed for the participants with FHP include multi-planar isometric neck exercises. The operational definition of self-care exercises in the present study was those exercises that can be performed by the participants at home without the supervision of a therapist once learnt. Self-care exercises help the participants in reducing the health-care visits and reversing the bad posture or hunching, thereby making the subject feel confident. Two self-care exercises such as Bruegger's postural relief position[7] and quadruped track cervical brace have been suggested in the improvement of cervical posture.[8]

Although these exercises have been widely suggested or advised clinically by the physiotherapists, there is a lack of research-based evidence/data which proves regarding its effect in the correction of FHP. Hence, it was hypothesized that the two self-care exercises, namely Bruegger's postural relief position along with quadruped track cervical brace exercise will show favorable results in the correction of asymptomatic FHP on CVA and CCFE.

  Materials and Methods Top

Study design and settings

The present pilot study was a single-group pre–post study design. The trial was conducted on the volunteer students of the Physiotherapy Institute from Health Science University, Belagavi, Karnataka, India, for which permission was obtained from the institutional head for the conduct of study. The study was approved by the Institutional Ethical Committee (Ref No: KIPT/90/16-10-17). All participants gave written consent to participate in the study and to publish their photographs and case details with hidden identity. The trial is registered under Clinical Trial Registry-India with trial number CTRI/2018/04/013061.


Since the study was a pilot study, the sample size was kept open ended with the sample of convenience. Three hundred and fifty students were screened for the presence of FHP in standing posture by observation method in the sagittal plane, of which 38 students were shown to have FHP. Out of the 38 eligible participants, 9 were excluded because of the presence of symptoms such as neck pain or upper back pain. The remaining 29 were further assessed objectively by measuring CVA using the photography method. Those with the CVA angle <44° were eligible to participate. Of 29 participants, 14 had CVA of more than 44°. Hence, the remaining 15 participants volunteered to participate and were recruited in the study. The participants included in this study were volunteers who were aged between 18 and 26 years with asymptomatic FHP with CVA of 44° or lesser as measured by the photographic method.[9] Participants were excluded if they had undergone recent neck or shoulder surgeries or had injuries and those who were already undergoing treatment for FHP. All participants completed the entire intervention program with no loss to follow-ups.

Outcome measures

All the study participants underwent a pretreatment (day 1) and posttreatment (day 10) assessments for CVA using the photographic method and CCFE test using PBU.

Craniovertebral angle

The angle was measured using the photographic method. A digital camera was mounted 1.5 m away from the participant. The participant was in standing position, and a lateral view picture was taken. All the photographs were taken from participant's right-hand side. The angle was measured at the juncture of a line drawn from spinous process of C7 to the tragus of the ear and a horizontal line that passes through C7.[10],[11] According to a previous study, the intra-rater reliability of this method has shown to be high (intraclass correlation coefficient [ICC] = 0.98)[11] [Figure 1].
Figure 1: Craniovertebral angle using the photographic method

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Craniocervical flexion endurance test

The position of the participant was supine with cervical spine in the neutral position. The PBU was placed between the plinth and the posterior neck just below the occiput. The cuff was then inflated to a baseline of 20 mmHg. Single practice session was given to each participant to understand the testing procedure. The participant was then asked to avoid head lift during CCFE test, thereby reducing the recruitment of superficial flexors. Each participant was then asked to perform the neck flexion movement at five different pressure levels (22, 24, 26, 28, and 30 mmHg) with 10 s hold at each level and 30 s rest between each level. The test was terminated if the subject was not able to hold the position of the neck for 10 s at a specific pressure level or if the maximum level of 30 mmHg was achieved[6] [Figure 2]. A previous study has shown high inter-rater reliability (ICC) for the CCFE test (95% confidence interval [CI], 0.83–0.96).[12]
Figure 2: Craniocervical flexion endurance using the pressure biofeedback unit

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All the participants were taught to perform Bruegger's postural relief exercise using an elastic resistance band and quadruped track cervical brace exercise.

Bruegger's postural relief position

Participant was in a high sitting position. An elastic resistance band was wrapped on each hand of the participant leaving the palm open and was told to do abduction and extension of thumb along with fingers, followed by wrist extension and forearm supination. Then, the participant was instructed to perform scapular retraction with shoulder external rotation, elbow extension, shoulder abduction, and extension.

Bruegger's exercise was started with 10 s hold on day 1 and progressed to 30 s hold by the end of the 10th session with 5 s of increment every 2 days. The rest time was 30 s which was constant throughout. The exercise was repeated fifteen times per se ssion[8],[13] [Figure 3]a and [Figure 3]b.
Figure 3: (a) Starting (b) ending position of Bruegger's postural relief position exercise

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Quadruped track cervical brace

The participant was asked to assume a position on all four limbs and was asked to push the inter-scapular region superiorly toward the ceiling. Then, the participant was told to tuck the chin and retract the head and lower cervical spine until the tension is felt along the posterior cervical musculature. The participant was instructed to prevent any exaggerated cervical spine extension or flexion and to maintain lumbar spine stability without allowing the stomach to sag. This position was to be held for 30 s with a rest time of 30 s. The exercise was repeated three times each session[8] [Figure 4]a and b].
Figure 4: (a) Starting (b) ending position of quadruped track cervical brace exercise

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Both exercises were performed twice a day for 10 consecutive days. Out of the two sessions per day, one session was performed under the supervision of the therapist, whereas the second session was performed at home. For this, a logbook was provided to the participant to mark to understand the compliance to the exercises. The home exercise session for Bruegger's exercise was performed without the elastic resistance band.

Statistical analysis

The statistical calculations were performed using the SPSS software version 21.0 (IBM, Armonk, NY, USA) with 95% CI. Normality testing of variables was checked by the Kolmogorov–Smirnov test which showed that it follows a normal distribution; therefore, a parametric paired t-test was applied. The comparison between pre- and postvalues was carried out using a paired t-test. P <0.05 was considered statistically significant.

  Results Top

The mean ± standard deviation (SD) for the age of the study participants was 23.00 ± 1.56 years, and the average body mass index was 22.23 ± SD = 4.98 kg/m2. The mean ± SD scores of CVA (degrees) at preintervention were 40.07 ± 3.97 and postintervention was 46.67 ± 5.55 with the percentage difference of 16.47%. The mean ± SD values of CCFE test (mmHg) at preintervention was 22.93 ± 1.28 and at postintervention was 26.67 ± 1.80 with percentage difference of 16.28%. The comparison of pre- and posttest for CVA (P < 0.0001) and CCFE test (P < 0.0001) scores as analyzed by the paired t-test demonstrated a statistically significant difference [Table 1] and [Figure 5]. Thus, the results indicated the improvement in strength of deep cervical flexors and increased CVA.
Table 1: Comparisons of pre- and posttest craniovertebral angle and craniocervical flexion endurance scores#

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Figure 5: Comparisons of pre- and posttest craniovertebral angle and craniocervical flexion endurance scores

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  Discussion Top

The present study was conducted to determine the effect of Bruegger's postural relief position and quadruped track cervical brace in FHP. The exercises showed significant correction in FHP in terms of CVA and improvement in CCFE scores.

In FHP, there is the shortening of the neck extensors posteriorly, tightening of anterior neck and shoulder muscles and also has kinematic effects on the scapular position. To correct this muscle imbalance, strengthening and stretching are strongly indicated in the literature.[4],[14]

These self-care exercises are easy to perform as they may be performed with or without the supervision of therapist.[15] The two prescribed exercises help the participants in reversing the bad posture, reducing the tension, and making the participants feel confident. A study conducted on acute nonspecific low back pain where self-care exercises were advised, including mind-body exercises such as progressive muscle relaxation concluded that health-care providers should shift their importance to educating patients to care for back pain on their own and said that this could be accomplished by improving communication with patients and encouraging them to perform simple self-care exercises.[16] Another study was conducted on 125 patients with a frozen shoulder where the home exercise program was compared with manipulation with home exercise and concluded that both the exercise programs were equally effective, and condition of the patient improved more quickly than expected.[17] A similar study was conducted on osteoarthritis of the hip where participants were told to do home exercises and the other group received hydrotherapy. This study concluded that home exercises were beneficial in treating OA of the hip over hydrotherapy.[18]

Bruegger's postural relief position is one such self-care exercise that works in order to reverse FHP by strengthening the scapular retractors meanwhile stretching the protractors. By retracting the shoulders and maintaining an isometric contraction of the neck in the chin tuck position, the deep cervical neck flexors also get strengthened. With frequent repetitions and increased hold time, the participants get adapted to maintain the Bruegger's posture and there is reversing in the FHP. At the same time, the strength of the deep cervical flexors is also gained. Bruegger's postural relief position along with an elastic resistance band further helps in correcting this posture by using the antagonistic muscles by strengthening the scapular muscles, maintaining chin tuck and stretching the pectoral muscle. Another such self-care exercises included in the present study was quadruped track cervical brace. This exercise helps in aligning the spine in correct position through isometric co-contraction of scapular muscles, thereby improving scapular stabilization. The exercise helped in strengthening the weak deep cervical flexor muscles since it includes isometric contraction of neck muscles through chin tuck.

Clinical evidence exists in the form of suggestions or advice of Bruegger's exercise for the symptomatic patients with FHP as a home exercise program. To the best of the author's knowledge and literature search, there is no research-based evidence in form of clinical trials or case reports where these two self-care exercises have been evaluated for their efficacy. However, a few textbooks suggest that Bruegger's postural relief position and quadruped track cervical brace are the best cervical and scapular stabilization strengthening exercises which help in strengthening the weak muscles while reciprocally inhibiting and relaxing the shortened ones. It also states that they improve cervical, thoracic, and scapular posture.[8] Further, one clinical trial was done to study the effect of Bruegger's exercise on chronic low back pain along with lower cross syndrome, in which the authors had prescribed Bruegger's exercise along with low back pain exercises alone in population with low back pain for the correction of posture and it was found to be effective.[7] To the best of the literature search conducted till date by the author, there are no hardly any studies conducted on quadruped track cervical brace exercise, the correction of FHP by this exercise can be attributed to the fact that the position of the upper limbs and neck attained in this exercise causes co-contraction of the scapular girdle muscles and the neck muscles. This indicates that Bruegger's postural relief position and quadruped track cervical brace have been prescribed by the physiotherapists for neck posture correction and the treatment of neck pain. Hence, the present study proposes the benefits of two self-care exercises, i.e., Bruegger's postural relief position and quadruped track cervical brace in correcting the FHP.

Hence, self-care exercises are beneficial due to the fact that people can perform by themselves and maintain their emotional and physical health and prevent themselves from minor or chronic illnesses or conditions. Self-care exercises include helping individuals explore the barriers to self-care that aid in people to monitor their symptoms and receive peer support from other service users.[15] The advantages of these exercises are that it reduces the health-care visits and reduces the costs associated with the treatment of various conditions.

The study had a few limitations. Since it was a preliminary study, the authors only investigated young asymptomatic individuals with FHP and they were not compared with symptomatic individuals. There was no follow-up done to assess for the carryover effect on the correction of FHP. In future, it would be meaningful to add control groups for generalization of study findings along with a longer duration of exercises with a long-term follow-up and added assessment of carryover effect. The analysis may be carried out to evaluate the muscle activity using electromyography during the self-care exercises.

  Conclusions Top

The two self-care exercises, Bruegger's exercise and quadruped cervical brace showed the significant correction of FHP. The results of the study showed promising outcomes with prescription of self-care exercises. These exercises may be advised by the physiotherapists to the patients with FHP as a home exercise program. These exercises are beneficial for the prevention of future postural problems.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


We are grateful to the head of the institution for granting us permission to conduct the study and use the research related infrastructure. We are thankful to the statistician for helping us with the data analysis. We also thank all the volunteer students for participating in the study.

Financial support and sponsorship


Conflicts of interest

There are no conflict of interest.

  References Top

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Kang DY. Deep cervical flexor training with a pressure biofeedback unit is an effective method for maintaining neck mobility and muscular endurance in college students with forward head posture. J Phys Ther Sci 2015;27:3207-10.  Back to cited text no. 4
Nezamuddin M, Anwer S, Khan SA, Equebal A. Efficacy of pressure-biofeedback guided deep cervical flexor training on neck pain and muscle performance in visual display terminal operators. J Musculoskelet Res 2013;16:1350011-5.  Back to cited text no. 5
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1]

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