The Role of Exercise in the Management of Forwarding Head Posture A.K.A. Upper Crossed Syndrome. A Critically Appraised Topic

Focused Clinical Question

The focused clinical question that is being posed for this paper is “What is the role of exercise in the management of forwarding head posture aka. Upper crossed syndrome”.

Search Strategy

The search strategy for this paper began with a pub med review consisting of the terms anterior head, an exercise which returned few relevant papers within the allotted time bracket of 0-5 years. This prompted a second, more detailed search using the terms “craniocervical flexion and exercise”. This search criterion resulted in 20 papers within the last

5 years. Further analysis for appropriate titles brought this number to 3 relevant papers (Figure 1).

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Evidence Quality

Evidence quality was assessed using the PEDro assessment for the remaining three studies (Table 1). With an average PEDro score of 8.67/10 the quality of evidence brought to answer this clinical question is high. The PEDro assessment was selected as the quality evaluation method as the three papers obtained were randomized clinical trials.

Results of Search

The results of the search brought back 20 papers with only 3 meeting the inclusion criteria for answering the focused clinical question of this critically appraised topic in comparing cranio-cervical flexion to exercise. The other 17 were either irrelevant or compared other modalities to the effects of exercise and cranio-cervical angles. Evidence quality was assessed using the PEDro assessment for the remaining three studies See (Table 1).

Results of Evidence Quality Assessed

Examined sixty-five teachers (age, 25-45 years) with more than 5 years of teaching experience [3]. The inclusion criteria included a chronic numerical pain score of more than 5 on the numeric pain rating scale (NPRS), mild-to-moderate disability on The Neck Disability Index (NDI), and poor results on the cranio-cervical flexion test (CCFT). The exclusion criteria included the presence of any neurological signs or symptoms, history of spinal surgery, and any ongoing treatment for the pain. Pain intensity was measured using NPRS. The subjects rated their pain on the 0-10 rating scale, where 0 implied no pain and 10 implied the worst possible pain. Endurance of the deep cervical neck flexor muscles was measured by the CCFT using a pressure biofeedback instrument (Stabilizer TM, Chattanooga Group, Inc., Chattanooga, TN). Functional disability was assessed using the NDI questionnaire. On day 0, there were no significant differences in age, pain, muscle endurance, and disability levels between the groups. After initiating the intervention, although there were improvements in both groups, there was a statistically significant improvement in muscle endurance, pain, and disability in subjects who received additional training with pressure biofeedback. Due to the design and caliber of this study, it was awarded a SORT B, 2b, and a PEDro Score: 9/10 [4]. Investigated A total of 72 subjects aged ≥45 years with chronic neck pain. Inclusion criteria: aged 45 years or older, experienced intermittent or continued neck pain for >3 months in the past year, measured ≥30 mm on the Visual Analogue Scale, were able to express themselves coherently and had the patience to fill out the questionnaire [4]. Excluded (N.=14) for not meeting inclusion criteria. (N.=6) - declined to participate, (N.=4) were excluded for working factors, and for (N.=4) the primary test was the cranio-cervical flexion test. The secondary test was the Superficial Cervical Muscle Strength Test (consisting of superficial neck flexor and extensor muscle strength). Outcomes measures were assessed before and after the intervention.

Clinical Bottom Line

There is statistically significant data to demonstrate that corrective exercise can improve cervical muscle endurance, pain, and disability [3]. Improvement in superficial neck flexor strength and overall cervical muscle function was able to be obtained in as little as a 6-week intervention [4]. The use of corrective exercise improved alignments of the head, shoulder, and thoracic spine in people with upper crossed syndrome even after 4 weeks of detraining [2].

Strength of Recommendation

With an average PEDro score of 8.87 (Table 1), there is high-quality evidence to support the notion that exercise is an effective intervention for increased cranio-cervical angle, upper crossed syndrome, and forward head posture.

Implications for Practice, Education, and Future Research

Of the three studies that passed the inclusion criteria for answering the focused clinical question, an average of 8.67 on the PEDro assessment was achieved. Such a score is directly indicative of high-quality evidence in favor of the use of exercise for the treatment of forwarding head posture aka upper crossed syndrome. Each study viewed a cohort of different ages and gender. One study demonstrated improvement in muscle endurance, pain, and disability while another suggested cervical muscle strength improvement. The final study demonstrated improvements in the movement pattern such as scapular dyskinesis along with the alignment of the head, shoulder, and thoracic spine in people with upper crossed syndrome.

Overall clinicians should feel confident in prescribing corrective exercise for those suffering from upper crossed syndrome as the exercises are both cost and time effective.

The selection of exercise can range from simplistic chin tucks and cranio-cervical flexion exercises to band-based resistance training for both the upper back and neck. Doing so supports the development of the deep cervical flexor, longus colli and longus capitus [3], while simultaneously strengthening the various upper back and neck muscles. Positive outcomes consist of reduced forward head posture, cervical spine pain and abnormal postures of the head, neck, and thorax.

Future research should be done to capitalize on the differences between exercises and outcomes along with the volume of exercise and outcomes. Follow-up research of this type can help establish if these results would be reached in a shorter time with higher loads, or does more time under tension matter, therefore, meaning higher reps and lighter loads? Such research would aid caregivers in overall program design and prescription.

Despite outcomes, both medical and non-medical providers should proceed with caution when dealing with cervical spine pain. Being diligent in ruling out red flags is crucial when evaluating spinal pain due to the rate at which the viscera can refer pain to this region. Various red flags can present as cervical spine pain therefore the ability to recognize and act quickly is essential. Nausea, vomiting, dizziness, and anxiety can all be signs of serious or life- threatening conditions associated with cervical spine pain. Practitioners should have an emergency response plan in place in case any of these symptoms present before, after, and during any neck exercise program.