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Effect of Neck Exercise on Sitting Posture in Patients

With Chronic Neck Pain

Deborah Falla, Gwendolen Jull, Trevor Russell, Bill
Vicenzino and Paul Hodges
PHYS THER. 2007; 87:408-417.
Originally published online March 6, 2007
doi: 10.2522/ptj.20060009

The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/87/4/408

Online-Only Material http://ptjournal.apta.org/content/suppl/2007/03/30/ptj.200

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Injuries and Conditions: Neck
Therapeutic Exercise
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Research Report

Effect of Neck Exercise on Sitting

Posture in Patients With Chronic
Neck Pain
Deborah Falla, Gwendolen Jull, Trevor Russell, Bill Vicenzino, Paul Hodges
D Falla, PhD, BPhty(Hons), is
NHMRC Research Fellow, Center
for Sensory-Motor Interaction, De-
Background and Purpose
partment of Health Science and Poor sitting posture has been implicated in the development and perpetuation of
Technology, Aalborg University, neck pain symptoms. This study had 2 purposes: (1) to compare change in cervical
Fredrik Bajers Vej 7D-3, DK-9220, and thoracic posture during a distracting task between subjects with chronic neck
Aalborg, Denmark, and Division of
Physiotherapy, The University of
pain and control subjects and (2) to compare the effects of 2 different neck exercise
Queensland, Brisbane, Queens- regimens on the ability of people with neck pain to maintain an upright cervical and
land, Australia. Address all corre- thoracic posture during this task.
spondence to Dr Falla at: deborahf
@hst.aau.dk. Subjects
G Jull, PhD, MPhty, GradDipAdv Fifty-eight subjects with chronic, nonsevere neck pain and 10 control subjects
ManipTher, is Professor and Head, participated in the study.
Division of Physiotherapy, The
University of Queensland.
T Russell, PhD, BPhty, is Lecturer,
Division of Physiotherapy, The
Change in cervical and thoracic posture from an upright posture was measured every
University of Queensland. 2 minutes during a 10-minute computer task. Following baseline measurements, the
subjects with neck pain were randomized into one of two 6-week exercise interven-
B Vicenzino, PhD, MSc, GradDip-
Phty(Sports), BPhty, is Associate
tion groups: a group that received training of the craniocervical flexor muscles or a
Professor, Division of Physiother- group that received endurance-strength training of the cervical flexor muscles. The
apy, The University of Queensland. primary outcomes following intervention were changes in the angle of cervical and
P Hodges, PhD, BPhty, is Professor
thoracic posture during the computer task.
and NHMRC Senior Research Fel-
low/Professorial Research Fellow, Results
Division of Physiotherapy, The Uni- Subjects with neck pain demonstrated a change in cervical angle across the duration
versity of Queensland.
of the task (mean⫽4.4°; 95% confidence interval [CI]⫽3.3–5.4), consistent with a
[Falla D, Jull G, Russell T, et al. Ef- more forward head posture. No significant difference was observed for the change in
fect of neck exercise on sitting cervical angle across the duration of the task for the control group subjects
posture in patients with chronic
neck pain. Phys Ther. 2007;87:
(mean⫽2.2°; 95% CI⫽1.0 –3.4). Following intervention, the craniocervical flexor
408 – 417.] training group demonstrated a significant reduction in the change of cervical angle
across the duration of the computer task.
© 2007 American Physical Therapy
Discussion and Conclusion
This study showed that people with chronic neck pain demonstrate a reduced ability
to maintain an upright posture when distracted. Following intervention with an
exercise program targeted at training the craniocervical flexor muscles, subjects with
neck pain demonstrated an improved ability to maintain a neutral cervical posture
during prolonged sitting.
For The Bottom Line:

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Neck Exercise and Sitting Posture in Patients With Chronic Neck Pain

ⱕ15 indicates mild to moderate neck

n an upright, neutral posture of sitting.11–14 Moreover, retraining the
the cervical spine, passive resis- deep cervical flexor muscles, which pain.18
tance to motion is minimal.1 Sup- has been shown to decrease neck
port of the cervical segments is pro- symptoms15,16 and increase the activa- Subjects in this category were se-
vided by the muscular sleeve formed tion of the deep cervical flexor mus- lected because previous studies in-
by the longus colli muscle anteriorly cles during performance of the clinical vestigating motor control deficits in
and the semispinalis cervicis and test of craniocervical flexion,16 may people with neck pain examined pa-
cervical multifidus muscles poste- improve the ability to maintain an up- tients with similar perceived pain
riorly.2–5 In particular, the longus right posture of the cervical spine. and disability scores. For example,
colli muscle has a major postural reduced activation of the deep cervi-
function in supporting and straight- This study had 2 purposes: (1) to iden- cal muscles has been observed in
ening the cervical lordosis.4 In addi- tify whether people with neck pain people with neck pain with an NDI
tion, the craniocervical region is demonstrate differences in their ability score of ⱕ15.9,19 Moreover, the av-
supported by muscles that attach to to maintain an upright posture when erage NDI score of the patients in-
the cranium and span the upper distracted by a computer task com- cluded in this study is similar to pre-
cervical motion segments, such as pared with a group of control subjects vious exercise trials.20,21 People with
the longus capitis muscle anteriorly and (2) to compare the effects of a more severe pain were excluded be-
and the subocciptal extensor, semi- low-load craniocervical flexion train- cause the endurance exercise regi-
spinalis, and splenius capitis muscles ing regimen against a conventional men may have increased the symp-
posteriorly.6 neck flexor endurance-strength train- toms of this group.
ing program on functional control of
The importance of the deep mus- head and neck posture in people Subjects also had to have palpable cer-
cles for the maintenance of cervical with chronic neck pain. The low-load vical joint tenderness22 and demon-
posture was verified in a computer craniocervical flexion training regi- strate poor performance (unable to
model, which showed regions of lo- men was compared with a conven- achieve 24 mm Hg) on the clinical test
cal segmental instability if only the tional strengthening regimen because of craniocervical flexion as defined
large superficial muscles of the neck it is not known whether such specific by Jull et al.23 Further details of the
were simulated to produce move- training of the deep cervical muscles is test are presented in the “Exercise
ment, particularly in near-upright or required in rehabilitation or if a more Regimens” section. Subjects were ex-
neutral postures.7 Deep cervical general strengthening exercise of the cluded if they had undergone cervical
muscle activity was required in syn- neck flexor muscles would be suffi- spine surgery, reported any neuro-
ergy with superficial muscle activity cient to improve control of the cervi- logical signs, or had participated in a
to stabilize the cervical segments, cal postural position. neck exercise program in the past 12
especially in functional mid-ranges of months.
the cervical spine. This study forms part of a series of
experiments to investigate the mech- The mean score of subjects on the
Recent studies have identified im- anisms of efficacy of cervical muscle NDI was 9.9 (out of a possible 50)
paired activation of the deep cervical retraining. The effect of both exer- (SD⫽3.1), and the average intensity
flexor muscles, the longus colli and cise regimens on measures of pain of neck pain was 4.1⫾2.1 on a 10-cm
longus capitis, in people with neck and disability have been reported in numerical rating scale (NRS) an-
pain.8,9 Given the role of the deep our previous work.16,17 chored with “no pain” and “the
cervical flexor muscles in postural worst possible pain imaginable.” The
support and the knowledge of im- Method subjects with neck pain who par-
paired activation of these muscles in Subjects ticipated in this study also formed
people with neck pain, it is likely Fifty-eight female subjects (mean part of another study.17 The sample
that this patient population also age⫽37.9 years, SD⫽10.2 years) with size (26 per group plus a 10% drop-
would display deficits in the postural a history of chronic, non-severe neck out allowance) was based on the
endurance of these muscles. Indeed, pain of greater than 3 months (X⫽7.9 difference in fatigue of the cervical
evidence is emerging that suggests years, SD⫽6.4 years) participated in muscles between a group of sub-
that people with neck pain drift into this study. Subjects were recruited by jects with neck pain and subjects
a more forward head position when advertisements in the local press. To who were asymptomatic (mean dif-
distracted.10 This has been observed be included, the subjects had to score ference⫽0.65 Hz, SD⫽0.83, power⫽
despite a lack of postural differences ⱕ15 (out of a possible 50) on the Neck 90%).24 Thus, the study had suffi-
in people with neck pain in erect Disability Index (NDI).18 An NDI score cient power to detect a difference in

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Neck Exercise and Sitting Posture in Patients With Chronic Neck Pain

the ability of the exercise interven- tragus of the ear and the spinous
tions to change parameters of mus- processes of the seventh cervical
cle function, but was not designed to and seventh thoracic vertebrae and
compare the efficacy of the ap- were fixed with double-sided medical
proach to reduce pain and disability. tape.

Ten volunteers (mean age⫽35.0 The digital technique used to quan-

years, SD⫽4.6) formed the control tify angular displacement in this study
group. The control group subjects has been previously described.25,26
were recruited via local advertise- The technique has been shown to
ments and were free of neck pain, produce reliable angular measure-
had no past history of orthopedic ments (intraclass correlation coeffi-
disorders affecting the neck, and had cient [ICC](2,2)⬎.93) and the crite-
no history of neurological disorders. rion validity of the technique has
been established when compared to
Experimental Procedure the universal goniometer by a non-
Phase I. Subjects were positioned significant (F⫽0.02; df⫽1,5; P⫽.887)
in front of the computer in sitting mean absolute difference (0.26°) be-
with their knees in 90 degrees of tween the 2 measurement tech-
flexion and their feet flat on the niques.25 Using this technique, mea- Figure 1.
ground. A plumb line was positioned sures of angular displacement in the Cervical and thoracic postural parameters.
in the background. The starting po- shoulder, elbow, wrist, and knee joints Subjects were positioned in an upright
sition was standardized by placing have demonstrated standard error of neutral posture. Anatomical markers were
the subject in an upright posture, measurement values of 0.83, 0.38, positioned on the tragus of the ear, spi-
which was defined as a vertical pel- 0.37 and 0.50 degree and a minimal nous process of the seventh cervical ver-
tebra, and the spinous process of the
vic position (no anterior or posterior detectable change at the 90% confi- seventh thoracic vertebra. The angle of
tilt) with the assumption of a lumbar dence interval (CI)27 of 0.34, 0.23, forward head posture (A) was measured
lordosis and thoracic kyphosis.23 Sub- 0.17 and 0.23 degree, respectively from a line drawn from the tragus of the
jects were asked to maintain the posi- (Russell et al, unpublished data).25 ear to the seventh cervical vertebra sub-
tion while they were distracted by tended to the horizontal. Thoracic posture
was calculated as the angle between the
playing the game of Solitaire on the The angle of forward head posture horizontal line and the line drawn from
computer for 10 minutes. Subjects was measured from a line drawn the seventh cervical spinous process to
used the mouse with their domi- from the tragus of the ear to the the seventh thoracic spinous process (B).
nant hand and the other hand seventh cervical vertebra subtended
rested motionless on the desk in to the horizontal (Fig. 1, angle A).28
front of them. The software produced a horizontal 2 exercise groups: a training regimen
line perpendicular to the vertical of the craniocervical flexor muscles
Postural analysis. Cervical and plumb line captured in the back- or an endurance-strength training
thoracic posture was measured ground of the image. Thoracic pos- regimen for the cervical flexor mus-
throughout the 10-minute computer ture was calculated as the angle be- cles. The allocation sequence was
task from a lateral photograph taken tween the horizontal line and a line generated by an independent body
with a digital camera (Canon Digital drawn between the seventh cervical and an independent investigator as-
IXUS, 1600 ⫻ 1200 pixels)* posi- spinous process and the seventh tho- signed participants to their group.
tioned on a tripod at a distance of racic spinous process (Fig. 1, angle Figure 2 illustrates the progression of
0.8 m. The axis of the lens of the B). Changes in angles from an erect subjects through the exercise trial.
camera was placed orthogonal to starting posture (time 0) to the an- Postural analysis during the com-
the sagittal plane of the patient at a gles measured at 2-minute intervals puter task was performed at baseline
height that corresponded with the throughout the 10-minute task were and in the week immediately after
seventh cervical vertebra. Anatomi- calculated and expressed relative to the 6-week intervention period
cal markers were positioned on the the angle at time 0. (week 7) for the patient group. The
researcher taking the measurements
Phase II. Following baseline mea- was blinded to subject group for the
* Cannon Australia Pty Ltd, 1 Thomas Holt Dr,
North Ryde, New South Wales, Australia, surements, the subjects with chronic outcome assessments and statistical
2113. neck pain were randomized into 1 of analyses.

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Neck Exercise and Sitting Posture in Patients With Chronic Neck Pain

cervical flexors, rather than the neck

Assessed for eligibility flexors as a whole, which occurs in a
head lift exercise. The exercise used an
air-filled pressure sensor (Stablizer),†
which was placed sub-occipitally to
Excluded (n=89)
NDI >15 (n=78) monitor the subtle flattening of the
Other reasons (n=11) cervical lordosis that occurs with
the contraction of the longus colli
(n=58) The subject was guided by the feed-
back from the pressure sensor to se-
quentially reach 5 pressure targets in
2–mm Hg increments from a base-
Randomization line of 20 mm Hg to the final level of
(n=58) 30 mm Hg. Subjects were instructed
to “gently nod their head as though
they were saying ‘yes’.” The physical
therapist identified the target level
that the subject could hold steadily
for 10 seconds without resorting to
Allocated to CCF Allocated to retraction, without dominant use of
training endurance- the superficial neck flexor muscles,
strength training
(n=29) and without a quick, jerky cranio-
(n=29) cervical flexion movement.23 Contri-
bution from the superficial muscles
was monitored by the physical ther-
apist in all stages of the test using
Followed up at week 7 Followed up at week 7 observation or palpation.
(n=29) (n=29)
Training was commenced at the tar-
Figure 2. get level that the subject could achieve
Progression of participants through the exercise trial. NDI⫽Neck Disability Index, with a correct movement of cranio-
CCF⫽craniocervical flexor.
cervical flexion and without dominant
use or substitution by the superficial
muscles (sternocleidomastoid, hyoid,
Exercise Regimens occupied a period of no longer than and anterior scalene muscles). The sub-
The exercise regimens were con- 10 to 20 minutes per day. The exer- jects were taught to perform a slow
ducted over a 6-week period and cises were performed without any and controlled craniocervical flexion
subjects in each group received per- provocation of neck pain. action. They then trained to be able to
sonal instruction and supervision by sustain progressively increasing ranges
an experienced physical therapist Craniocervical flexor training in- of craniocervical flexion using feed-
once per week for the duration of tervention. Training of the cranio- back from the pressure sensor, which
the trial. None of the exercise ses- cervical flexor muscles followed the was placed behind the neck. For each
sions were longer than 30 minutes. protocol described by Jull et al.23 The target level, the contraction duration
Subjects were asked not to receive exercise targets the deep flexor mus- was increased to 10 seconds, and the
any other specific intervention for cles of the upper cervical region, the subject trained to perform 10 repeti-
their neck pain; however, any medi- longus capitis and longus colli mus- tions. At this stage, the exercise was
cation that a subject was currently cles, rather than the superficial flexor progressed to train at the next target
taking was not withheld. All subjects muscles, the sternocleidomastoid and level.
were supplied with an exercise diary anterior scalene, which flex the neck
and requested to practice their re- but not the head.19,29 In addition, the
spective regimen twice per day for exercise is a low-load exercise in na- †
Chattanooga Group Inc, 4717 Adams Rd,
the duration of the trial. The exercise ture to more specifically train the deep Hixson, TN 37343.

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Neck Exercise and Sitting Posture in Patients With Chronic Neck Pain

Endurance-strength training inter- as a change from the starting angle at minute computer task (F⫽19.3;
vention. The endurance-strength each time interval throughout the 10- df⫽1,56; P⬍.001; Fig. 3A). In con-
training regimen consisted of a pro- minute computer task. A repeated- trast, for the control subjects, there
gressive resistance exercise program measures general linear model was was no evidence for a change in cer-
for the neck flexors. The exercise was used to identify whether change in vical angle over the 10-minute com-
performed in supine position, with cervical and thoracic angles across puter task (F⫽1.95; df⫽1,56; P⫽.17;
the head supported in a comfortable the duration of the task were differ- Fig. 3A). Compared with the starting
resting position. Subjects were in- ent between the 2 subject groups. position, the mean change in cervi-
structed to lift up their head so that The independent variable was the cal angle at 10 minutes was 4.4 de-
cervical flexion occurred while main- subject group (between-subjects fac- grees (SD⫽4.1°, 95% CI⫽3.3–5.4)
taining a neutral upper cervical spine tor), and the within-subject factor for the neck pain group and 2.2 de-
position. The subjects slowly moved was the time interval of the task (5 grees (SD⫽1.6°, 95% CI⫽1.0 –3.4)
the head and neck through as full a measurements). for the control group.
range of motion as possible without
causing discomfort or reproducing Change in posture before and af- The subjects with neck pain also dem-
their symptoms. ter intervention for the exercise onstrated a significant, progressive in-
groups. Paired sample t tests were crease in change of thoracic angle
This exercise regimen was a 2-stage conducted to determine if NDI and from baseline across time (F⫽45.3;
program. The first stage was of 2 NRS measurements were significantly df⫽1,56; P⬍.001; Fig. 3B). Although
weeks’ duration and the second was different before and after the interven- less than the subjects with neck pain,
of 4 weeks’ duration as recommend- tion for both exercise groups, and the control subjects also demonstrated
ed30 for initiating a weight program independent sample t tests were con- an increase for the change of thoracic
in previously untrained individuals. ducted to compare for group differ- angle (F⫽11.4; df⫽1,9; P⬍.01;
In stage 1, the subjects performed ences. A repeated-measures general Fig. 3B). Compared with the starting
12 to 15 repetitions with a weight linear model was used to compare position, the mean change in thoracic
that they could lift 12 times (12- baseline cervical and thoracic angles angle at 10 minutes was 8.2 degrees
repetition maximum [RM]) on the between the 2 intervention groups (SD⫽4.8°, 95% CI⫽6.9 –9.5) for the
first training session and progressed with factors of group (craniocervical subjects with neck pain and 4.8 de-
to 15 repetitions and maintained this flexor training and endurance-strength grees (SD⫽3.3°, 95% CI⫽2.4 –7.1) for
level for the remainder of the 2-week training) and time (5 measurements). the control subjects.
For the preintervention to postinter- Changes in Cervical and
In stage 2, the subjects performed 3 vention analysis, a repeated-measures Thoracic Angle After Exercise
sets of 15 repetitions of the initial general linear model was applied. The Intervention
12-RM load once per day. One- independent variables were the 2 in- Of the 58 participants with neck
minute rest intervals were provided tervention groups (between-subjects pain who participated in the exer-
between sets. If repetitions were factor) and the within-subject factor cise interventions, none were lost to
easily achieved, weighted sandbags was the time interval of the task (5 follow up assessment. Subject de-
were applied to the patient’s fore- measurements). A polynomial or lin- scriptive data are presented in the
head in 0.5-kg increments. If the sub- ear trend was fitted to the time factor Table. Baseline characteristics of
ject was unable to perform repeti- to explain the relative change in cer- pain (NRS) and disability (NDI) were
tions of the head lift maneuver then vical and thoracic angle across the du- not different between the 2 interven-
the load on the neck flexors was re- ration of the task. A value of P⬍.05 tion groups (P⬎.05). In addition,
duced by allowing the subject to per- was used as an indicator of statistical preintervention cervical (F1⫽0.28,
form the task with the upper body significance. P⬎.05) and thoracic (F1⫽2.13, P⬎.05)
(trunk and neck) inclined up from angles were not significantly different
the horizontal so that the subject Results between the 2 intervention groups.
could perform the required repeti- Comparison of Postural Position All participants in the endurance-
tions of the movement. Between Subjects With Neck Pain strength training group and cranio-
and Control Subjects cervical flexor training group received
Data Analysis Subjects with neck pain demon- the full 6 treatments. According to the
Comparison between subjects strated a significant, progressive in- patient diaries, adherence to exercise
with neck pain and control sub- crease in change of cervical angle was 91.0% (SD⫽0.12%) for the
jects. Angle data were expressed from baseline throughout the 10- endurance-strength training group

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Neck Exercise and Sitting Posture in Patients With Chronic Neck Pain

Figure 3.
Group comparisons for change in cervical and thoracic posture. Data (mean and standard deviation) are presented for change in
cervical posture (left) and change in thoracic posture (right) for patients with neck pain and for control subjects. Change in angle
from an erect starting posture (time 0 [T0]) are expressed relative to the angle measured at 2-minute intervals (T2, T4, T6, T8, T10)
throughout the 10-minute task.

and 94.8% (SD⫽0.06%) for the cranio- duction in the change of cervical angle the ability to maintain an upright
cervical flexor training group. No (F⫽7.44; df⫽1,1,1; P⬍.01; Fig. 4) cervical posture during this task.
patients reported any adverse events. across the duration of the task when
compared with the endurance-strength Comparison Between
Both intervention groups demon- training group. In addition, both groups Subjects With Neck Pain and
strated a reduction in average intensity improved their ability to maintain an Control Subjects
of pain (craniocervical flexor training: upright posture of the thoracic spine; In support of previous findings,10
⫺0.9⫾2.3, endurance-strength train- however, there was no significant dif- subjects with neck pain demon-
ing: ⫺1.1⫾2.8), and NDI score (cranio- ference between the 2 intervention groups strated a reduced ability to main-
cervical flexion training: ⫺3.5⫾4.8, (F⫽2.55; df⫽1,1,1; P⬎.05; Fig. 5). tain an upright posture during a
endurance-strength training: ⫺2.8⫾ computer task. There was a subtle
4.0). However, there was no differ- Discussion forward drift of the head of a mag-
ence between groups for change in The results of this study demonstrated nitude of 4.4⫾4.1 degrees in asso-
pain (NRS) or disability (NDI) that subjects with chronic non-severe ciation with a subtle increase in
(P⬎.05). neck pain had a reduced ability to main- the thoracic flexion curve of
tain an upright neutral posture when 8.2⫾4.8 degrees in subjects with
Following 6-weeks of intervention, distracted by a computer task. More- neck pain. This may reflect im-
the craniocervical flexor training over, exercise targeted at training the paired endurance of the muscles
group demonstrated a significant re- craniocervical flexor muscles improved that would be required to control

Baseline Characteristics for Patients With Chronic Neck Pain Randomized Into a Craniocervical Flexor Exercise Intervention or an
Endurance-Strength Exercise Intervention

Craniocervical Flexor Exercise Endurance-Strength Exercise

Intervention (nⴝ29) Intervention (nⴝ29)

MeanⴞSD Median Range MeanⴞSD Median Range

Age 37.7⫾9.9 38.0 22.0–55.0 38.1⫾10.7 38.0 22.0–55.0
Length of neck pain history (y) 7.5⫾5.9 7.0 0.5–21.0 8.3⫾7.0 5.5 1.0–30.0
Neck pain intensity (0–10 cm) 3.6⫾2.0 3.4 0.7–7.1 4.7⫾2.0 4.5 1.8–9.0
Neck Disability Index (0–50) 9.8⫾3.3 10.0 2.0–14.0 10.4⫾3.4 10.0 3.0–15.0

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Neck Exercise and Sitting Posture in Patients With Chronic Neck Pain

Figure 4.
Group data for change in cervical posture following intervention in patients with neck pain. Preintervention and postintervention data
(mean and standard deviation) are presented for change in cervical posture throughout the 10-minute computer task for the
craniocervical flexor (CCF) training group and endurance-strength training group. Change in angle from an erect starting posture
(time 0 [T0]) are expressed relative to the angle measured at 2-minute intervals (T2, T4, T6, T8, T10) throughout the 10-minute task.

the postural position of the spine dur- position awareness also may explain and people with neck pain follow-
ing sitting. In agreement with previous the differences observed for the ing a whiplash injury.32–34
research, decreased endurance of the group with neck pain compared
craniocervical flexor muscles has been with the control group. Evidence A reduced ability to maintain an up-
observed in patients with neck pain at of reduced cervical kinesthetic right posture of the cervical spine
20% of their maximal voluntary contrac- sense has been identified in both when distracted during sitting might
tion.31 Other factors such as reduced people with idiopathic neck pain be considered a measure of impair-
proprioception resulting in poor head ment in the postural supporting mus-

Figure 5.
Group data for change in thoracic posture following intervention in patients with neck pain. Preintervention and postintervention
data (mean and standard deviation) are presented for change in thoracic posture throughout the 10-minute computer task for the
craniocervical flexor (CCF) training group and the endurance-strength training group. Change in angle from an erect starting posture
(time 0 [T0]) are expressed relative to the angle measured at 2-minute intervals (T2, T4, T6, T8, T10) throughout the 10-minute task.

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Neck Exercise and Sitting Posture in Patients With Chronic Neck Pain

cles during a functional task, an out- Craniocervical flexor training involves theless, it can be questioned whether
come that can be easily replicated performing and holding inner range the subtle maintenance of postural
clinically. positions of craniocervical flexion, the angles is clinically meaningful. This
anatomical action of the deep cervical question cannot be answered directly
A sustained forward flexion posture flexor muscles. This training has been in this study. However, the magnitude
of the spine has been associated shown to increase the activation of of change in cervical posture follow-
with increased cervical compressive these muscles.16 The improved ability ing craniocervical flexion training is
loading and a creep response in the to maintain an upright position of the similar to the magnitude of difference
connective tissue.35,36 It would not cervical spine, which was observed observed between the subjects with
be unreasonable to consider that a for the craniocervical flexor training neck pain and the control subjects in
sustained forward head posture asso- group, may reflect an improved en- the first phase of this study. Further-
ciated with prolonged sitting could durance of the deep cervical flexor more, such subtlety in head drift
aggravate, if not initiate, neck pain. muscles, which was identified dur- was also observed by Szeto et al43 in
There is some evidence that has ing the functional task of sitting. This their comparison of computer work-
linked prolonged static posture with improvement occurred even though ers with and without neck pain. The
increased muscle loading and subse- there was no exercise instruction outcomes of both studies suggest that,
quent risk for the development of on postural correction in sitting. This in sitting working postures, subtle
symptoms in the upper body.37,38 finding supports our previous sug- changes in posture over time, possibly
gestion that inadequate control of reflective of poor muscle control as
Although both the subjects with the head in prolonged sitting may be proposed in this study, might be very
neck pain and the control subjects a functional correlate of deep cervi- relevant to the function of office
demonstrated progressive change in cal muscle impairment. workers with neck pain. The possible
thoracic posture throughout the 10- associations between functional work-
minute computer task, this change Moreover, craniocervical flexion di- ing postures and neck pain justifies
was greater for the subjects with rectly activates the deep cervical further research towards meeting the
neck pain. The observation that tho- flexor musculature,19,39 which have challenge of prevention of neck pain
racic angle increased progressively a relatively high density of muscle in office workers, which is recognized
in the control subjects throughout spindles.2 Improved cervical kines- as a significant contemporary problem
the task in the absence of a change in thetic sense following craniocervical in the workforce.44
cervical posture was somewhat sur- flexor training40 also may explain the
prising, but could indicate earlier fa- improved ability to maintain an up- Change in Pain and
tigue in the trunk extensors than in right position of the cervical spine. Perceived Disability
the neck muscles. Further investiga- Following 6 weeks of exercise, a
tion of this finding is necessary. It is notable that the endurance- significant reduction in average in-
strength regimen did not influence tensity of pain (NRS) and perceived
Effect of Exercise on Control of postural parameters of the cervical disability (NDI score) was identified
Posture During Sitting in spine. Although there is some evi- for both training groups. Although
Subjects With Neck Pain dence to suggest that an endurance- only the craniocervical flexor training
Following a 6-week intervention with strength regimen for the neck flexor group showed a significant improve-
either craniocervical flexor training or muscles reduces neck pain,17,41,42 ment in their ability to maintain an
neck flexor endurance-strength train- improves strength,17,42 and reduces upright position of the cervical spine,
ing, the participants with neck pain fatigue of the sternocleidomastoid this was not associated with a greater
improved their ability to maintain an and anterior scalene muscles,17 it reduction in pain or perceived disabil-
upright posture of the thoracic spine does not appear to improve the ity compared with the endurance-
during the 10-minute computer task. ability to maintain an upright strength regimen group. However,
This improvement could be attributed posture of the cervical spine in a because a sustained forward flexion
to factors such as task familiarity or sitting task. posture of the spine has been associ-
increased postural awareness; how- ated with compressive loading of the
ever, only the group that received the The maintenance of cervical postural cervical tissues,35,36 improved cervical
specific craniocervical flexor training angle with the craniocervical flexor posture during sitting may have an ad-
improved their ability to maintain an training during the 10-minute dis- ditional long-term benefit of reducing
upright position of the cervical spine. traction task reached statistical sig- recurrent episodes of neck pain. This
nificance when compared with the is of particular relevance given the high
endurance-strength regimen. Never- recurrence rate of neck pain.45 Further

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Neck Exercise and Sitting Posture in Patients With Chronic Neck Pain

research is now warranted to examine maintain an upright neutral posture 4 Mayoux-Benhamou MA, Revel M, Vallee C,
et al. Longus colli has a postural function
whether an improved ability to main- when distracted by a computer task. on cervical curvature. Surg Radiol Anat.
tain an upright position of the cervical Following intervention with an exer- 1994;16:367–371.
spine following specific exercise inter- cise program targeted at retraining 5 Vasavada AN, Li S, Delp SL. Influence of
muscle morphometry and moment arms
vention is maintained in the long term the craniocervical flexor muscles, on the moment-generating capacity of
and the effect that this may have on subjects with chronic neck pain human neck muscles. Spine. 1998;23:
412– 422.
the recurrence rate of neck pain. demonstrated improved ability to
6 Kettler A, Hartwig E, Schultheiss M, et al.
maintain a neutral cervical posture Mechanically simulated muscle forces
Methodological Considerations during prolonged sitting. This most strongly stabilize intact and injured upper
cervical spine specimens. J Biomech.
This study used photographic analy- likely reflects an improvement in the 2002;35:339 –346.
sis to describe change in cervical and endurance of the muscles that con- 7 Winters JM, Peles JD. Neck muscle activity
thoracic posture using anatomical trol the postural position of the neck and 3D head kinematics during quasistatic
and dynamic tracking movements. In:
markers. Although photographic during function. Winters JM, Woo SLY, eds. Multiple Mus-
analysis has shown to be a reliable cle Systems: Biomechanics and Move-
ment Organization. New York, NY:
tool for quantifying change in cervi- Springer-Verlag; 1990:461– 480.
Dr Falla, Dr Jull, Dr Vincenzino, and Dr
cal angle,46 precise conclusions Hodges provided concept/idea/research de- 8 Falla DL, Jull GA, Hodges PW. Patients
about the anatomical alignment of sign and fund procurement. Dr Falla, Dr Jull, with neck pain demonstrate reduced elec-
tromyographic activity of the deep cervi-
the spine as identified on radio- Mr Russell, and Dr Hodges provided writing. cal flexor muscles during performance of
graphs cannot be inferred from vari- Dr Falla provided data collection, and Dr the craniocervical flexion test. Spine.
Falla, Mr Russell, and Dr Hodges provided 2004;29:2108 –2114.
ation in surface measurement.47 De- data analysis. Dr Falla and Dr Jull provided 9 Falla D, Jull G, Hodges PW. Feedforward
spite this limitation, this study project management. Dr Jull and Dr Hodges activity of the cervical flexor muscles dur-
demonstrates that postural analysis provided facilities/equipment. Mr Russell ing voluntary arm movements is delayed in
chronic neck pain. Exp Brain Res. 2004;
during a common functional activity provided consultation (including review of 157:43– 48.
in sitting may provide a useful mea- manuscript prior to submission). The authors
10 Szeto GP, Straker LM, O’Sullivan PB. A
thank Amy Fagan from The University of
sure to quantify postural changes Queensland, Australia for assistance with
comparison of symptomatic and asymp-
tomatic office workers performing monot-
during tasks and to monitor the ef- data collection. onous keyboard work, 2: neck and
fects of rehabilitation. shoulder kinematics. Man Ther. 2005;10:
Dr Falla is supported by the National Health 281–291.
and Medical Research Council of Australia 11 Grimmer K. The relationship between cer-
Only posture of the cervical and tho- (ID 351678). This study was funded by a vical resting posture and neck pain. Phys-
racic spine were analyzed in this grant (ID 252771) received from the Na- iotherapy. 1996;82:45–51.
study. In future studies, electromyo- tional Health and Medical Research Council 12 Hanten WP, Olson SL, Russell JL, et al. To-
of Australia. tal head excursion and resting head pos-
graphy could be used concurrently ture: normal and patient comparisons.
to provide additional information on Ethical approval for the study was granted by Arch Phys Med Rehabil. 2000;81:62– 66.
muscle activation associated with the Institutional Medical Research Ethics 13 Haughie LJ, Fiebert IM, Roach KE. Rela-
Committee of The University of Queensland, tionship of forward head posture and cer-
the observed postural changes. vical backward bending to neck pain.
and all procedures were conducted accord- Journal of Manual and Manipulative
ing to the Declaration of Helsinki. Therapy. 1995;3:91–97.
Additional methodological aspects
This article was submitted January 9, 2006, 14 Treleaven J, Jull G, Atkinson L. Cervical
may include the duration of the com- musculoskeletal dysfunction in post-
and was accepted December 19, 2006.
puter task used in this study (10 min- concussional headache. Cephalalgia.
utes). However, the duration of the DOI: 10.2522/ptj.20060009
15 Jull G, Trott P, Potter H, et al. A random-
task was sufficient to demonstrate ized controlled trial of exercise and
differences between subjects with manipulative therapy for cervicogenic
headache. Spine. 2002;27:1835–1843.
neck pain and control subjects.
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demonstrated a reduced ability to

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Neck Exercise and Sitting Posture in Patients With Chronic Neck Pain

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April 2007 Volume 87 Number 4 Physical Therapy f 417

Downloaded from http://ptjournal.apta.org/ by Chris Benson on October 17, 2014
Effect of Neck Exercise on Sitting Posture in Patients
With Chronic Neck Pain
Deborah Falla, Gwendolen Jull, Trevor Russell, Bill
Vicenzino and Paul Hodges
PHYS THER. 2007; 87:408-417.
Originally published online March 6, 2007
doi: 10.2522/ptj.20060009

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