The Effects of Forward Head Posture on

Neck Extensor Muscle Thickness: An

Ultrasonographic Study
Fereshte Goodarzi, PT, MSc, a Leila Rahnama, PT, PhD, a Noureddin Karimi, PT, PhD, a
Raziyeh Baghi, PT, MSc, a and Shapour Jaberzadeh, PT, PhD b

ABSTRACT

Objective: This study aimed to compare neck extensor muscle thickness, thickness changes, and strength between
participants with forward head posture (FHP) and controls with normal head posture (NHP).
Methods: Twenty college students with FHP (mean age 21.30 ± 2.36 years) and 20 students with NHP (mean age
21.85 ± 2.78 years) participated in this case-control study. The thickness of neck extensor muscles was measured at
rest and at maximal voluntary isometric contraction (MVIC). In addition, the craniovertebral angle (CVA) was
calculated. To compare thickness changes between the 2 groups and among 5 muscles, a 2-way repeated measures
analysis of variance was applied. In addition, Pearson’s correlation test was performed to investigate the relationship
between neck extensor MVIC and CVA.
Results: The FHP group demonstrated lower MVIC compared with the NHP group (P = .03). Semispinalis capitis
showed the smallest thickness changes during neck extensor MVIC in FHP compared with the controls (P b .001).
However, no significant difference in terms of muscle thickness was observed between the 2 groups at the state of rest
(P = .16-.99). A positive association was also found between the MVIC and CVA (P = .02).
Conclusions: Semispinalis capitis had less thickness changes during MVIC of neck extensors in individuals with
FHP compared with those with NHP. This indirectly implies lower activity of this muscle in FHP condition. This
study finding may help researchers develop therapeutic exercise protocols to manage FHP. (J Manipulative Physiol
Ther 2017;xx:1-8)
Key Indexing Terms: Muscle Contraction; Muscle Strength; Neck Muscles; Posture; Ultrasonography

INTRODUCTION joints, altered neck extensor muscles activity, and length of

cervical muscles. 3-6 Forward head posture is defined as
One of the predisposing factors that cause occupational
leaning the head and the upper cervical spine anterior to
neck pain is irregular head and neck posture. 1 Forward head
the plumb line that passes the lateral malleolus in sagittal
posture (FHP) is one of the most common deviations from
view. 7 It is expected that FHP should be typically
normal cervical posture 2 and may lead to an increase in
accompanied by shortening of neck extensor muscles and
gravitational load and mechanical stress to cervical facet
lengthening of neck ventral muscles. 4 This length alteration
could secondarily decrease neck muscles’ tension during
daily or work-related activities. Each muscle induces the
a
Department of Physiotherapy, University of Social Welfare largest tension in only an optimal resting length. 8 If a
and Rehabilitation Sciences, Tehran, Iran. muscle passes its own optimal length by getting either
b
Department of Physiotherapy, School of Primary Health Care, lengthened or shortened, the tension produced by the
Faculty of Medicine, Nursing and Health Sciences, Monash muscle can be reduced. As such, it is expected that neck
University, Frankston, Australia. extensor muscles produce altered tension in individuals
Corresponding author: Leila Rahnama, PT, PhD, Department of
Physiotherapy, University of Social Welfare and Rehabilitation with FHP compared with individuals with normal head
Sciences, Kodakyar Ave, Daneshjo Blvd, Evin, Tehran, Iran, posture (NHP). Forward head posture is recognized as a risk
1985713834. Tel.: +98 21 22180039. (e-mails: [email protected], factor for neck pain; therefore, studying neck muscle
[email protected]). function and strength in individuals with FHP may reduce
Paper submitted June 16, 2016; in revised form November 2, the incidence of neck pain.
2017; accepted July 28, 2017.
0161-4754 Ultrasonographic studies on neck muscles have revealed
© 2017 by National University of Health Sciences. that there is a correlation between thickness and strength of
https://doi.org/10.1016/j.jmpt.2017.07.012 neck muscles. 9-15 In other words, reduced muscle thickness
2 Goodarzi et al Journal of Manipulative and Physiological Therapeutics
Head Posture and Neck Extensor Thickness Month 2017

probably implies muscle weakness. Although such mor- based on the following formula assuming ∝= 0.05 and β =
phologic and physiologic changes have been reported in 0.2. Based on the pilot study, the mean difference and
patients with neck pain, 10,14,16-18 there are limited studies standard deviation for the muscle thickness changes were
on neck muscles in FHP. Evidence in the literature supports expected to be 0.2 and 0.2, respectively.
that poor postural orientation could predispose people to the


2  
risk of neck pain. 5,6 One of the most common postural Z 1− α
þ Z 1−β δ ð1:96 þ 0:84 Þ0:2 2
deviations associated with suboccipital trigger points, N¼2 2
¼ ¼ 16
Δμ 0:2
headache, and neck pain is FHP. 19 This signals the need
for a study to investigate neck extensor muscles and their Accordingly, the number of participants in each group
strength in individuals with FHP compared with individuals was estimated to be 16 persons. To boost statistical power,
with NHP. Thus, the present study was carried out to 20 participants were included in each group. Participants
compare the thickness and strength of neck extensor were recruited from among healthy college students who
muscles in individuals with FHP compared with individuals had no history of any neck pain, trauma to the cervical
with NHP. The study also examined the possible relation- spine, inflammatory or infectious diseases of the spine, or
ship between the strength of neck extensor muscles and the congenital spinal deformities. 7,20,21 The participants in both
degree of FHP. As such, the following hypotheses were groups were statistically similar in terms of age, body mass
formulated: (1) Neck extensor muscles could produce less index, and height. All the experimental procedures in this
tension during maximum voluntary isometric contraction study were approved by the local Ethics Committee
(MVIC) in individuals with FHP compared with individuals (IR.USWR.REC.1393.126) and conformed to the Declara-
with NHP; (2) Neck extensor muscles have less thickness in tion of Helsinki (1964).
individuals with FHP compared with individuals with NHP; The aims and objectives of the study were explained to
(3) Neck extensor muscles have altered thickness changes the volunteers verbally prior to obtaining their written
during an isometric neck extension task in individuals with informed consent.
FHP compared with individuals with NHP. Moreover, it
was hypothesized that there is a direct relationship between
the amount of forward head inclination and neck extensor Procedure
muscle strength. Postural Assessment. To find out whether there was FHP,
this study applied 2 different ways to carry out the postural
assessment, including plumb line assessment and cranio-
METHODS vertebral angle (CVA) measurement. First, all participants
Participants were asked to stand normally in their own relaxed position
Twenty college students with FHP (11 females, 9 males; while the plumb line was passed anterior to their lateral
mean age 21.85 ± 2.87 years) and 20 students with NHP (11 malleolus. At this position, FHP was recognized by placing
females, 9 males; mean age 21.30 ± 2.36 years) participated the ear tragus anterior to the plumb line. 7,22,23 To measure
in this case-control study. The experimental setup is the CVA, participants were asked to stand relaxed with
described in Figure 1. The sample size was estimated arms by their sides. The spinous process of C7 was

Fig 1. Experimental setup for assessment of FHP, neck extensor muscle strength, and neck extensor muscle thickness. FHP, forward
head posture; MVIC, maximal voluntary isometric contraction (kgf); NHP, normal head posture.
Journal of Manipulative and Physiological Therapeutics Goodarzi et al 3
Volume xx, Number Head Posture and Neck Extensor Thickness

Fig 2. Participant position during isometric neck extension.

identified through palpation and marked with a conical adhesive the trials to prevent muscle fatigue. 27 The trial with
marker. In the next step, participants were instructed to perform maximum amount of force was chosen as participant’s
head flexion and extension 3 to 4 times so that their self- maximal neck extensor muscle strength. 9-11 Once partici-
balanced head position could be obtained. 24 A digital camera pants’ MVICs were identified, they were given 5 minutes of
(Canon model IXUS, Canon, Tokyo, Japan) was placed at a rest to prepare for the main procedure. 28 In the next step,
distance of 1.5 m from each participant’s shoulder. Digital participants were asked to perform the MVIC of neck
lateral view images from each participant’s head, neck, and extensor muscles and reach their force to the target MVIC.
shoulder were captured for further measurement. The angle At the same time, the ultrasonic imaging of their neck
between the lines connecting the spinous process of C7 to the extensor muscles was taken. Once they had kept their neck
ear tragus and the horizontal line passing C7 was considered the extensor MVIC for 4 seconds, the examiner froze the
CVA. 4,7 A CVA less than 49 degrees was considered the FHP. ultrasound image for further measurements.
24
The measurements were carried out using Autocad Software Ultrasonography. Ultrasonographic imaging of neck
Version 12 (Autodesk, San Rafael, California). 25 extensor muscles was carried out using Ultrasonix ES 500
Neck Extensor Muscle Strength. A Multi-Analyzer (Ultrasonix Medical Corporation, Vancouver, BC, Canada)
Myometer (MIE Medical Research Ltd., Leeds, United with a linear 4.5-cm and 12 MHz transducer. The fourth
Kingdom) was utilized to assess the MVIC of the neck cervical (C4) spinous process was identified through
extensor muscles. 12 Participants were instructed to sit palpation. 26 This level was chosen as the level of
relaxed on a chair while putting their hands on their legs and ultrasound imaging because the muscle cross-sectional
keeping their heads and necks in neutral position. Two belts area is larger than C3 level and is very similar to the level of
were used to fasten the participant’s trunk to the chair—1 at C5. 29 Thus, the transducer transversely was positioned at
the level of scapular spine and the other at the level of iliac the level of C4 spinous process, sliding it slowly to the
crest (Fig 2). A strap wrapped around the head was right, upward, and downward until the echogenic vertebral
connected to the tensiometer located in front of participant’s lamina could be identified clearly. The thickness of the neck
forehead 12 (Fig 2). Participants were asked to perform 2 to extensor muscles comprising the trapezius, splenius capitis,
3 submaximal contractions of the neck extensor muscles as semispinalis capitis, semispinalis cervicis, and multifidus
a warm-up exercise. Then, the participants performed 3 muscles were measured at the same level at the state of rest
trials of MVIC of neck extensor muscles. 21,26 They were and MVIC (Fig 3). The thickness of each muscle was
instructed to avoid upward or downward movements of measured by determining the maximal distance between the
their chins to prevent craniocervical extension. Each trial muscle’s facial borders. 27,29 The measured muscle thick-
took 4 seconds. There was a 2-minute rest period between ness was divided by the participant’s weight to normalize
4 Goodarzi et al Journal of Manipulative and Physiological Therapeutics
Head Posture and Neck Extensor Thickness Month 2017

Fig 3. Ultrasonic image of neck extensor muscles. The vertical lines indicate the thicknesses of different muscles.

muscle thickness for both sexes. 30 The difference of each 0.04, which was negligible and indicated equal variances
muscle normalized thickness at the level of MVIC minus its for all variables across groups. To determine the relative
normalized thickness at rest was calculated and used in the and absolute reliability of the muscle thickness measure-
data analysis. 26 ment and the neck muscle strength, intraclass correlation
Reliability Study. The intrarater reliability was deter- coefficient (ICC) and standard error of mean (SEM) were
mined on 8 NHP participants and 8 FHP participants to computed, respectively. Pearson’s correlation test was
estimate the reliability of muscle thickness measurements at performed to evaluate the strength of the relationship
rest and 100% of MVIC and of the muscle strength test. The between the amount of forward head inclination and neck
required data were collected from 2 separate sessions within extensor muscle strength. Statistical significance was
a period of 3 to 7 days. identified at the level of P b .05.
Data Management and Statistical Analysis. SPSS software for
Windows, version 20.0 (IBM, Armonk, New York) was
applied to analyze the data. To test the normality, the
Shapiro-Wilk test was performed. Additionally, indepen-
RESULTS
dent t test was conducted to compare the demographic data, Participants’ Demographic Data
muscle thickness at rest, and target force between the 2 The Shapiro-Wilk test revealed normal distribution of all
groups. For the estimation of the main and interaction data. Therefore, parametric statistical tests were carried out to
effects of variables, 2-way repeated measures analysis of analyze the data. Participant demographic data, including age,
variance were performed with muscle (5 neck extensor weight, height, and body mass index, are presented in Table 1.
muscles) as the within factor and group (FHP and NHP) as
the between factor. Post hoc pairwise comparison was
carried out using Bonferroni correction. Furthermore, to Reliability Study
evaluate the homogeneity of variances for repeated The evaluated ICC and SEM varied from 0.82 to 0.94
measures analysis of variance, Leven’s test was used. The and 0.11 to 0.69 for muscle thickness measurements. The
homogeneity of variances was not violated for all variables ICC and SEM for neck extensor muscle strength were 0.94
except for multifidus muscle thickness changes with ∝ = and 0.19, respectively.
Journal of Manipulative and Physiological Therapeutics Goodarzi et al 5
Volume xx, Number Head Posture and Neck Extensor Thickness

Table 1. Means and Standard Deviations for Participant Table 3. Means and Standard Deviations for Normalized Muscle
Demographic Data Thickness (Muscle Thickness/Participant’s Weight) at Rest
NHP FHP P Value Muscle NHP FHP
Age, y 21.85 ± 2.78 21.30 ± 2.36 .51 Multifidus 0.1597 ± 0.02067 0.1577 ± 0.01724
Weight, kg 61.65 ± 8.18 61.12 ± 9.76 .85 Semispinalis cervicis 0.0889 ± 0.01987 0.0888 ± 0.02155
Height, cm 170.35 ± 7.70 171.15 ± 7.08 .71 Semispinalis capitis 0.0905 ± 0.02018 0.0807 ± 0.02322
BMI, kg/m2 21.19 ± 1.63 20.77 ± 2.38 .51 Splenius capitis 0.0657 ± 0.01314 0.0705 ± 0.01544
Upper trapezius 0.0209 ± 0.00798 0.0214 ± 0.00775
BMI, body mass index; FHP, forward head posture; NHP, normal head
posture. FHP, forward head posture; NHP, normal head posture.

DISCUSSION
Muscle Strength
Participants with FHP showed statistically lower neck Neck Extensor Muscle Strength
extensor muscle strength (MVIC) compared with individ- The results of the present study indicate that participants
uals with NHP (Table 2). with FHP demonstrated a significant reduction in neck
extensor MVIC compared with those with NHP. Given that
the length tension relationship of neck extensor muscles
changes in FHP, it could produce a lower amount of
Neck Extensor Muscle Thickness
extensor force compared with NHP. This finding is in line
The independent t test revealed no significant differences
with the findings of a study by Lee et al in which less
between the 2 groups in terms of muscles’ normalized
electromyographic activity of some neck extensor muscles
thickness at the state of rest (P = .16-.99) (Table 3).
was reported in individuals with FHP compared with those
with NHP. 31 Another study also reported reduction in neck
extensor strength during intended neck flexion and
Neck Extensor Muscle Thickness Changes During the Extension Task extension resembling FHP, supporting the findings of the
A significant 2-way interaction of group by muscle was current study. 12
observed for neck extensor muscle thickness changes with
P = .03. This could indirectly demonstrate different patterns
of muscle activity in 2 groups while performing the Neck Extensor Muscle Thickness
extension task. Bonferroni’s correction indicated that the We hypothesized that the neck extensor muscles have
semispinalis capitis muscle had significantly less thickness less thickness in individuals with FHP compared with
changes in individuals with FHP in comparison with those individuals with NHP, but this was not supported by the
with NHP (P b .001). No other differences for any other findings in this study. No significant differences on neck
muscle were observed between the 2 groups. However, extensor muscle thickness were found between 2 groups
multifidus showed the biggest thickness changes, whereas at the state of rest. According to Rezasoltani et al, who
the trapezius muscle demonstrated the smallest changes evaluated the size of the semispinalis capitis muscle in 3
among other muscles during the extension task in both different head orientations, including extension, normal,
groups (Fig 4). and flexion, the size of the semispinalis capitis muscle is not
a good indicator of muscle strength. 12 This could have been
the reason for the lack of differences in neck extensor
muscle thicknesses between the 2 groups at rest despite
CVA and Neck Extensor Muscle Strength
their different strengths. In contrast, Peolsson et al
Participants with FHP showed statistically lower CVA demonstrated a bigger deformation of neck extensor
compared with individuals with NHP (Table 2). muscles at the state of rest in an intentional FHP compared
A significant positive correlation between the neck with NHP. 21 Methodologic differences between these 2
extensor muscle strength and the CVA was revealed (P = studies may explain the conflicting results. In the current
.02; r = 0.37). This indicates that the bigger the CVA is, the study, muscle thickness was measured, whereas Peolsson
stronger the neck extensor muscles are (Fig 5). et al calculated the muscle deformation rate, which seems to
be a more sensitive index for muscle activity.
Table 2. Comparison of Neck Extensor Muscle MVIC
Contraction and CVA Between the 2 Study Groups
NHP FHP t P Value Neck Extensor Muscle Thickness Changes
MVIC, kgf 3.54 ± 0.92 2.96 ± 0.62 2.313 .03 The results of the present study revealed an altered
CVA, degree 55.90 ± 2.25 43.43 ± 2.58 16.250 .0001 pattern of neck extensor muscle thickness changes during
Values are mean ± standard deviation. an isometric neck extension task in individuals with FHP.
CVA, craniovertebral angle; FHP, forward head posture; MVIC, maximal The semispinalis capitis muscle showed less thickness
voluntary isometric contraction; NHP, normal head posture. change in participants with FHP compared with those with
6 Goodarzi et al Journal of Manipulative and Physiological Therapeutics
Head Posture and Neck Extensor Thickness Month 2017

temporal bone. 32 Therefore, these fibers are less likely to be

affected by FHP compared with the semispinalis capitis
muscle. Even these fibers might be more activated to
compensate for the decreased participation of semispinalis
capitis. No significant differences were observed in splenius
capitis thickness changes during a neck extension task
between the 2 groups in this study. Semispinalis cervicis
and multifidus are deep neck extensor muscles that are
responsible for stabilizing the neck during neck and head
movements. 9,10,17,26,29 These muscles are known as local
muscles because their attachments are very close to the
cervical spine. The anatomical view shows that these
muscles do not reach the occiput. As a result, altered
Fig 4. Neck extensor muscle normalized thickness changes during orientation of the head, similar to what is seen in FHP,
isometric neck extension: NHP versus FHP. Normalized thickness
changes = (muscle thickness at MVIC/body weight) – (muscle
could hardly affect their thickness during activities.
thickness at rest/body weight). FHP, forward head posture; MF, Besides, these 2 muscles are located very close to the
multifidus; NHP, normal head posture; Sca, splenius capitis; spine, and consequently deviation of the spine has a little
SSCa, semispinalis capitis; SSCe, semispinalis cervicis; Trapz, impact on their length.
trapezius. Superficial muscles, such as splenius capitis and
semispinalis capitis, pass the upper cervical region.
NHP while performing an isometric neck extension task. Therefore, craniocervical extension, observed in FHP, is
This could indirectly indicate less activity of the semi- more likely to influence them. In contrast, deep neck
spinalis capitis muscle during a neck extension task in extensor muscles, such as semispinalis cervicis and multi-
individuals with FHP compared with those with NHP. fidus, which do not have any anatomical attachments above
Semispinalis capitis is considered the main extensor of the the C2 level, may not be affected by FHP.
neck. 11,12 It is worth noting that this muscle originates from Trapezius muscles showed almost no significant thick-
the tips of the transverse processes of the upper 6 or 7 ness changes in both FHP and NHP. This might be
thoracic vertebrae and the seventh cervical vertebra, in explained by the fact that at the level of C4, trapezius is very
addition to the articular processes of C6 to C4. These fibers thin compared with the bulky part on the shoulder. 33,34 As
then move upward and form a wide tendon connecting to such, small thickness changes are to be expected at this
the space between the superior and inferior occiput nuchal level.
line. 32 Because of this fiber direction, semispinalis capitis The findings of the present study are not in line with the
plays a major role in neck extension. It is also very likely to results obtained by Elliot et al, who showed an increased
be negatively affected in terms of altered muscle length by activation of semispinalis capitis in a craniocervical
changing the head posture in FHP. Splenius capitis is extension task. 28 The underlying reason for such discrep-
positioned more medially. It ascends from the spinous ancy could be the intentionally craniocervical hyperexten-
processes of 3 or 4 thoracic vertebrae and the seventh sion position taken by the participants in the mentioned
cervical vertebra. It moves upward and in a laterally oblique study. However, the participants of the present study had
direction and is attached to the mastoid process of the had FHP for a long time. Thus, we believe that the long
period of altered head posture could cause muscles to
behave in a different way in terms of muscle activity. The
current study findings are in accordance with the results of a
study by Peolsson et al indicating a lower deformation of
neck extensor muscles while performing a lifting task in
intentional FHP compared with NHP. 33

Correlation Between CVA and Neck Extensor Muscle Strength

A significantly positive weak to moderate relationship
between CVA and extensor muscle strength was observed.
Indeed, the lower neck extensor muscle strength coincides
with a smaller CVA. This could be explained by the
Fig 5. The relationship between CVA and neck extensor muscles physiologic aspects of the muscle function. If FHP causes
MVIC. CVA, craniovertebral angle (degree); MVIC, maximal elongation or shortening of neck extensor muscles, this
voluntary isometric contraction (kgf). length alteration can lead to decreasing extensor force
Journal of Manipulative and Physiological Therapeutics Goodarzi et al 7
Volume xx, Number Head Posture and Neck Extensor Thickness

produced by these muscles. Based on length-tension CONTRIBUTORSHIP INFORMATION

relationship, more deviation from the optimal position
Concept development (provided idea for the research):
results in more reduction in muscle tension. 8
L.R., N.K.
Design (planned the methods to generate the results):
L.R., N.K.
Study Limitations and Suggestions for Future Research
Supervision (provided oversight, responsible for orga-
The findings in this study should be interpreted taking
nization and implementation, writing of the manuscript):
the following limitations into consideration. We only
L.R., N.K., S.J.
evaluated neck extensor muscles at the level of C4 without
examining extensor muscle function in other cervical levels. Data collection/processing (responsible for experiments,
Additionally, participants in this study were young (mean patient management, organization, or reporting data):
age approximately 22 years). Hence, the findings could not F.G., R.B.
be generalized to older people. Given the limitations of the Analysis/interpretation (responsible for statistical analy-
present study, further research is required to assess the neck sis, evaluation, and presentation of the results): L.R.,
extensor muscles at different levels of cervical spine to shed F.G., N.K.
more light on the biomechanical and physiologic changes Literature search (performed the literature search): F.G.,
happening in the presence of FHP. Investigating the R.B.
function of neck muscles in different age groups may also Writing (responsible for writing a substantive part of the
help researchers to understand the long-term effects of FHP manuscript): L.R., F.G.
on neck muscle function compared with NHP. Furthermore,
patients with neck pain were excluded from the present Critical review (revised manuscript for intellectual
study. Therefore, we did not evaluate the neck extensor content, this does not relate to spelling and grammar
muscles in patients experiencing chronic neck pain and checking): L.R., N.K., S.J., F.G., R.B.
FHP simultaneously. Future research on such individuals
may reveal the effects of pain in the presence of FHP on the
neck extensor muscles.

Practical Applications
Clinical Implications
• The present study showed that neck extensor
In the present study, individuals with FHP demonstrated
muscle strength is significantly lower in FHP
lower neck extensor muscle strength compared with
versus NHP.
individuals with NHP. This finding may be of importance
to clinicians attempting to strengthen these muscles during • During isometric head extension, the semi-
management of FHP. Future studies should evaluate spinalis capitis muscle showed smaller thick-
ness changes in individuals with FHP.
patients experiencing both neck pain and FHP to determine
• A significant negative direct relationship was
the impact of FHP on neck pain.
observed between the severity of FHP and
neck extensor muscle strength.

CONCLUSIONS
The findings of this study indicate that FHP weakens the
neck extensor muscles. Within these muscles, semispinalis
capitis has less participation in an isometric neck extension
REFERENCES
task in FHP compared with NHP. Moreover, the strength of
the neck extensor muscles is associated with the severity of
FHP. However, no morphometric changes in terms of 1. Eltayeb S, Staal JB, Hassan A, de Bie RA. Work related risk
thickness were observed in any of the neck extensor factors for neck, shoulder and arms complaints: a cohort study
among Dutch computer office workers. J Occup Rehabil.
muscles in participants with FHP at the state of rest. 2009;19(4):315-322.
2. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA.
Incidence of common postural abnormalities in the cervical,
shoulder, and thoracic regions and their association with pain
FUNDING SOURCES AND CONFLICTS OF INTEREST in two age groups of healthy subjects. Phys Ther. 1992;72(6):
425-431.
No funding sources or conflicts of interest were reported 3. Lau KT, Cheung KY, Chan KB, Chan MH, Lo KY, Chiu
for this study. TTW. Relationships between sagittal postures of thoracic and
8 Goodarzi et al Journal of Manipulative and Physiological Therapeutics
Head Posture and Neck Extensor Thickness Month 2017

cervical spine, presence of neck pain, neck pain severity and chronic neck pain and healthy controls. Man Ther. 2016;22:
disability. Man Ther. 2010;15(5):457-462. 174-178.
4. De-la-Llave-Rincón AI, Fernández-de-las-Peñas C, Palacios- 19. Fernandez-de-las-Peñas C, Pérez-de-Heredia M, Molero-
Ceña D, Cleland JA. Increased forward head posture and Sánchez A, Miangolarra-Page JC. Performance of the
restricted cervical range of motion in patients with carpal tunnel craniocervical flexion test, forward head posture, and
syndrome. J Orthop Sports Phys Ther. 2009;39(9):658-664. headache clinical parameters in patients with chronic
5. Silva AG, Punt TD, Sharples P, Vilas-Boas JP, Johnson MI. tension-type headache: a pilot study. J Orthop Sports Phys
Head posture and neck pain of chronic nontraumatic origin: a Ther. 2007;37(2):33-39.
comparison between patients and pain-free persons. Arch 20. Nam SH, Son SM, Kwon JW, Lee NK. The intra-and inter-
Phys Med Rehabil. 2009;90(4):669-674. rater reliabilities of the forward head posture assessment of
6. Agnihotri S, Warikoo D, Kashyap V. Comparison of Forward normal healthy subjects. J Phys Ther Sci. 2013;25(6):
Head Posture in Subjects With and Without Neck Pain. 737-739.
RRJoHP. 2015;4(3):13-16. 21. Peolsson A, Brodin LÅ, Peolsson M. A tissue velocity
7. Salahzadeh Z, Maroufi N, Ahmadi A, et al. Assessment of ultrasound imaging investigation of the dorsal neck muscles
forward head posture in females: observational and photo- during resisted isometric extension. Man Ther. 2010;15(6):
grammetry methods. J Back Musculoskelet Rehabil. 2014; 567-573.
27(2):131-139. 22. Kendall FP, McCreary EK, Provance PG, Rodgers MM,
8. Levangie PK, Norkin CC. Joint Structure and Function: A Romani WA. Muscles: Testing and Function with Posture
Comprehensive Analysis. 4th ed. Philadelphia, PA: F. A. and Pain. Philadelphia, PA: Lippincott Williams & Wilkins;
Davis; 2005. 2005.
9. Rahnama L, Rezasoltani A, Khalkhali Zavieh M, Noori Kochi 23. Gadotti IC, Biasotto-Gonzalez DA. Sensitivity of clinical
F, Akbarzadeh Baghban A. The effects of isometric assessments of sagittal head posture. J Eval Clin Pract. 2010;
contraction of shoulder muscles on cervical multifidus muscle 16(1):141-144.
dimensions in healthy office workers. J Bodyw Mov Ther. 24. Ahmadi A, Maroufi N, Sarrafzadeh J. Evaluation of forward
2014;18(3):383-389. head posture in sitting and standing positions. Eur Spine J.
10. Rahnama L, Rezasoltani A, Zavieh MK, NooriKochi F, 2016;25(11):3577-3582.
Baghban AA. Differences in Cervical Multifidus Muscle 25. Saeid B, Hassan D, Noureddin K. The relationship between
Thickness During Isometric Contraction of Shoulder Muscles: alignment of upper limb and postural control in adolescents
A Comparison Between Patients With Chronic Neck Pain and with Down Syndrome. Medicina Sportiva. 2014;10(2):2322.
Healthy Controls. J Manip Physiol Ther. 2015;38(3):210-217. 26. Lee JP, Wang CL, Shau YW, Wang SF. Measurement of
11. Rezasoltani A, Ali-Reza A, Khosro KK, Abbass R. Prelim- cervical multifidus contraction pattern with ultrasound
inary study of neck muscle size and strength measurements in imaging. J Electromyogr Kinesiol. 2009;19(3):391-397.
females with chronic non-specific neck pain and healthy 27. Lin YJ, Chai HM, Wang SF. Reliability of thickness
control subjects. Man Ther. 2010;15(4):400-403. measurements of the dorsal muscles of the upper cervical
12. Rezasoltani A, Nasiri R, Faizei AM, Zaafari G, Mirshahvelayati spine: an ultrasonographic study. J Orthop Sports Phys Ther.
AS, Bakhshidarabad L. The variation of the strength of neck 2009;39(12):850-857.
extensor muscles and semispinalis capitis muscle size with head 28. Elliott JM, O’Leary SP, Cagnie B, Durbridge G, Danneels L,
and neck position. J Bodyw Mov Ther. 2013;17(2):200-203. Jull G. Craniocervical orientation affects muscle activation
13. Rezasoltani A, Ylinen J, Vihko V. Isometric cervical when exercising the cervical extensors in healthy subjects.
extension force and dimensions of semispinalis capitis Arch Phys Med Rehabil. 2010;91(9):1418-1422.
muscle. J Rehabil Res Dev. 2002;39(3):423-428. 29. Lee JP, Tseng WY, Shau YW, Wang CL, Wang HK, Wang
14. Fernández-de-las-Peñas C, Albert-Sanchís JC, Buil M, SF. Measurement of segmental cervical multifidus contraction
Benitez JC, Alburquerque-Sendín F. Cross-sectional area of by ultrasonography in asymptomatic adults. Man Ther. 2007;
cervical multifidus muscle in females with chronic bilateral 12(3):286-294.
neck pain compared to controls. J Orthop Sports Phys Ther. 30. Rankin G, Stokes M, Newham DJ. Size and shape of the
2008;38(4):175-180. posterior neck muscles measured by ultrasound imaging:
15. Lieber RL. Skeletal Muscle Structure, Function, and Plasticity. normal values in males and females of different ages. Man
Hagerstown, MD: Wolters Kluwer Health; 2002. Ther. 2005;10(2):108-115.
16. Cagnie B, Cools A, De Loose V, Cambier D, Danneels L. 31. Lee KJ, Han HY, Cheon SH, Park SH, Yong MS. The effect of
Differences in isometric neck muscle strength between forward head posture on muscle activity during neck protraction
healthy controls and women with chronic neck pain: the use and retraction. J Phys Ther Sci. 2015;27(3):977-979.
of a reliable measurement. Arch Phys Med Rehabil. 2007; 32. Gray H. Gray’s Anatomy: With Original Illustrations by
88(11):1441-1445. Henry Carter. London, England: Arcturus Publishing; 2009.
17. Kristjansson E. Reliability of ultrasonography for the cervical 33. Peolsson A, Marstein E, McNamara T, et al. Does posture of
multifidus muscle in asymptomatic and symptomatic subjects. the cervical spine influence dorsal neck muscle activity when
Man Ther. 2004;9(2):83-88. lifting? Man Ther. 2014;19(1):32-36.
18. Karimi N, Rezasoltani A, Rahnama L, Noori-Kochi F, 34. Peolsson AL, Peolsson MN, Jull GA. Cervical Muscle
Jaberzadeh S. Ultrasonographic analysis of dorsal neck Activity During Loaded Arm Lifts in Patients 10 Years
muscles thickness changes induced by isometric contraction Postsurgery for Cervical Disc Disease. J Manip Physiol Ther.
of shoulder muscles: a comparison between patients with 2013;36(5):292-299.