Forward Head Posture (FHP) is a prevalent postural dysfunction characterized by anterior displacement of the head relative to the shoulder line. It is often linked to musculoskeletal pain, restricted cervical mobility, and altered muscle activation patterns. The condition manifests with shortening of the upper trapezius, suboccipital muscles, semispinalis, splenius capitis, Sternocleidomastoid (SCM), and levator scapulae. Concurrently, there is weakness or inhibition in the deep cervical flexors, resulting in an imbalance between the cervical flexor and extensor muscle groups. These muscular imbalances contribute to dysfunctional cervical movement patterns, altered proprioception, and increased joint loading, particularly at the atlanto-occipital and cervico-thoracic junctions. The objective of this randomized controlled trial is to compare the effectiveness of Sub-Occipital Muscle Inhibition (SMI) and Instrument Assisted Soft Tissue Mobilization (IASTM) in improving postural alignment, reducing pain, and enhancing cervical range of motion in individuals with Forward Head Posture. It will address a common postural and musculoskeletal problem that affects a large portion of the population which will contribute to a more effective management approach for Forward Head Posture and will guide clinicians in selecting targeted, evidence-based therapies for their patients with FHP. As there is a lack of comparative studies assessing their relative effectiveness specifically for FHP, it will contribute novel data to the field of physiotherapy and rehabilitation science. A total of 38 participants with FHP will be randomly assigned into two equal groups (n=19). Group A will receive conventional physiotherapy along with Sub-Occipital Muscle Inhibition, while Group B will receive conventional physiotherapy combined with Instrument Assisted Soft Tissue Mobilization. Both groups will undergo 18 treatment sessions over six weeks, administered on alternate days. Both interventions are expected to show positive outcomes in improving FHP; however, the study aims to determine which technique is more effective. The results will help clinicians understand which manual therapy methods work best. This can make it easier for them to choose the right treatment for Forward Head Posture. Using proven techniques can improve patient comfort and recovery. In the end, it will help to provide advance approach and more personalised care for the patients.
Both genders
Age: 18-40 years
Increased upper thoracic spine kyphosis
Craniovertebral angle CVA of < 52°
Cervical radiculopathy
Neurological deficit
Previous surgery of cervical or thoracic spine
Spondylolisthesis
Parallel
suboccipital muscle inhibition
Procedure/SurgeryGroup A will receive total 18 sessions in 6 weeks (3 sessions per week on alternate days). Each session will begin with application of a hot pack to the posterior cervical area (upper cervical spine) for 10 minutes while the patient lies in a relaxed prone position.Following thermotherapy, Group A will undergo sub occipital muscle inhibition. The subjects will be placed in the supine position, with their eyes closed; the evaluator will sit at the head of an adjustable table and placed both palms under the subjects' head, contacting the evaluator's index, middle, and ring fingertips of both hands with the metacarpophalangeal joints in 90◦ flexion between the spinous process of the second cervical vertebra and the occipital condyles. Thereafter, painless and constant pressure will be exerted upward and toward the evaluator the pressure will be maintained for 2 minutes until tissue relaxation of the suboccipital region has been achieved.
Instrument assisted soft tissue mobilization
Procedure/SurgeryGroup B will receive total 18 sessions in 6 weeks (3 sessions per week on alternate days). Each session will begin with application of a hot pack to the posterior cervical area (upper cervical spine) for 10 minutes while the patient lies in a relaxed prone position. Following thermotherapy, Group B will undergo IASTM. Firstly explain the procedure, Position the patient comfortably to expose the target area. Apply emollient (e.g., massage cream or lubricant) to reduce friction. The technique will be delivered in unidirectional for 3- 5 minutes per muscle group, with controlled pressure and specific strokes (e.g., sweeping, fanning, strumming) adjusted according to patient tolerance (3 sessions/week).Then a structured stretching protocol will be implemented to address tight musculature in Forward Head Posture (FHP). The targeted muscles include the pectoralis major, levator scapulae, sternocleidomastoid, and upper trapezius.
Pain Intensity
It will be measured by numeric pain rating scale in which patients rate their pain from 0 (no pain) to 10 (worst pain imaginable).
Neck Disability Index (NDI)
The Neck Disability Index (NDI) is a ten-item questionnaire based on the Owestry Low Back Pain Index that assesses disability associated with neck pain and whiplash. Participant will select from one of six potential responses for each item ranging from no disability (0) to total disability (5). The ten items are summed to gain the total score thus ranging from 0 (no disability) to 50 (maximum disability).
DEEP NECK FLEXORS ENDURANCE TEST
The test is performed in the supine and crook lying position with the chin maximally tucked and maintained isometrically, the subject lifted the head and neck until the head will be approximately 2.5 cm off the plinth while maintaining the chin retracted to the chest. During the test verbal commands such as "tuck your chin in" or "hold your head up" will be given whenever there is a loss of chin tuck. The test will be stopped if the subject's head touched the investigator's hand for more than one second, if the skin folds began to separate due to a loss of chin tuck for the same amount of time, or if the subject wanted to stop because of fatigue or pain. The test will also be stopped if the subject lost more than 5° for over two seconds and in the end time will be measured in seconds by the therapist.
CRANIOVERTEBRAL ANGLE
Goniometer is used to measure craniovertebral angle (CVA) and subsequently forward head posture (FHP). The CVA will be assessed in a relaxed sitting position on a high back chair with both feet on the floor and a position with the hips and knees maintained at 90◦. The subjects' hands should be relaxed on the thighs, with the eyes looking forward in a horizontal eye level. The CVA can be defined as the angle made by a horizontal line passing through C7 vertebra the line connecting the tragus of the ear. Greater measure of CVA is indicative of an ideal alignment whereas a smaller value indicates forward head posture. For this study we will place the immovable arm of the goniometer at the C7 spinous process and the movable arm at the tragus of the ear making an angle between the two lines, normal of which is 52◦ and angle less than that is considered as abnormal.
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