Response to the Letter to the Editor: Effect of core stabilization exercises on cervical sagittal balance parameters in patients with forward head posture: a randomized controlled trial in Egypt

Comment 1: Sample size and power calculation

Reply: As outlined in our study’s flowchart, 40 participants were initially allocated (20 per group). However, four participants withdrew: one from the experimental group and three from the control group, resulting in a final sample size of 36. This minor difference did not affect statistical power. While we employed a per-protocol analysis, future studies will consider an intention-to-treat approach to account for missing data.

Comment 2: Study design and randomization

Reply: Randomization was conducted using a computer-generated sequence by an independent researcher who was not involved in data collection or analysis. Blinding was not feasible due to the supervised nature of the intervention, which required therapist monitoring. However, the use of objective X-ray-based cervical sagittal balance measures helped minimize bias. Future studies may explore single-blind designs where feasible.

Comment 3: Long-term follow-up

Reply: Our study aimed to evaluate the short-term effects of core stabilization exercises over 6 weeks. While long-term follow-up was beyond the study’s scope, we recognize its importance in assessing the durability of improvements. Future research will incorporate extended follow-up periods (e.g., 3 to 6 months) to evaluate the sustainability of intervention effects.

Comment 4: Control group issues

Reply: In alignment with ethical considerations, we selected an active control group performing postural correction exercises—an intervention with clinically proven benefits—rather than a sham or no-treatment control. This ensured participants were not deprived of effective care. Additionally, the control group underwent supervised sessions, ensuring adherence was monitored in every session. Future studies could consider a three-arm design, incorporating a no-treatment group for further comparison.

Comment 5: Measurement issues

Reply: Our X-ray analysis was conducted using ImageJ (National Institutes of Health, Bethesda, MD, USA), which has demonstrated high test–retest reliability for radiographic measurements. While Kinovea (https://www.kinovea.org/) was used for craniovertebral angle assessments, we acknowledge that it is not the gold standard. However, it has been validated in previous research for angular and distance measurements. Future studies will include intra- and inter-rater reliability testing to further strengthen measurement accuracy.

Comment 6: Statistical analysis concerns

Reply: Post-hoc pairwise comparisons were explicitly conducted and reported following significant multivariate analysis of variance results. These were included in our manuscript, although they were not specifically requested by the journal. Additionally, effect sizes were provided for key variables to ensure meaningful interpretation. Future studies will ensure further clarity in statistical reporting if required.

Comment 7: Generalizability issues

Reply: Our inclusion criteria ensured a homogeneous sample, focusing on young adults commonly affected by forward head posture (FHP) due to modern lifestyle habits. While we acknowledge the need for broader representation, this limitation was already discussed in our study. Future research will aim to include adolescents and older adults to enhance external validity.

Comment 8: Interpretation of findings

Reply: Our study primarily focused on lumbopelvic control as a key factor in FHP rehabilitation. However, we acknowledge that ergonomic habits, screen time, and muscular imbalances may also play significant roles. These factors will be explored in our ongoing research to provide a more comprehensive understanding of FHP etiology and management.

We greatly appreciate the constructive feedback, which contributes to refining research methodologies and advancing postural rehabilitation strategies. Addressing these considerations in future studies will further strengthen the evidence base for interventions targeting cervical sagittal balance.

We sincerely appreciate the opportunity provided by the journal and look forward to contributing to ongoing scientific collaboration.