Introduction
Forward head posture (FHP) is a postural deviation of the upper back, involving abducted scapulae and kyphotic thoracic spine. The condition is associated with increased cervical lordosis and forward head alignment [1]. Additionally, FHP induces changes in the alignment of scapulae in sagittal and frontal planes [1,2].
The scapula serves as a dynamic link between the upper limb and trunk, providing proximal stability during upper limb activities [2]. Prolonged slouching alters scapular alignment [3], which in turn disrupts the length-tension relationship of surrounding muscles, ultimately resulting in various shoulder conditions [4,5].
FHP alters the recruitment pattern of cervicoscapular muscles and scapular kinematics, often presenting subclinically in its early stages. However, if left unaddressed, FHP can lead to the development of symptomatic shoulder and neck-related conditions [6].
The development of FHP involves complex mechanisms and various contributing factors, including prolonged sitting posture, muscular imbalance, compensatory changes secondary to deviations in other body segments, muscular tightness, and poor postural habits [7]. Furthermore, inadequate awareness of correct posture, stemming from inappropriate proprioceptive feedback, can also lead to postural deviations [7].
FHP is considered one of the major predisposing factors for the development of upper-quarter musculoskeletal dysfunctions such as neck pain, increased upper limb neural tissue tension, thoracic outlet syndrome, bicipital tendinitis, trigger points in the upper back, and shoulder impingement syndrome [1,2].
“Mechanical neck pain” or “nonspecific neck pain” is defined as “pain primarily confined to the posterior aspect of the neck, which can be exacerbated by neck movements or by sustained postures” [8]. Mechanical neck pain (MNP) is common among individuals with FHP, with a reported prevalence of 38%–52% [1,2]. Poor posture is a major contributing factor to MNP. The thoracic spine serves as a base of support for the head and neck, influencing cervical spine kinematics [9]. Reduced mobility or altered posture of the thoracic column affects the cervical column by altering mobility or impacting key postural muscles, including the trapezius, levator scapulae, and serratus anterior, which have attachments from the cervical and thoracic spine. Furthermore, poor posture causes altered mechanical loading of the cervical spine, leading to mechanical neck dysfunctions or pain [10,11].
Since FHP is a multifactorial condition, correcting posture and achieving an ideal posture requires a combination of treatments, including stretching, strengthening, joint mobilization, and postural reeducation [12]. This exercise therapy program can improve muscle flexibility, muscle strength, and range of motion (ROM). Moreover, increasing self-awareness of posture is crucial for effective posture correction [13]. Altered scapular alignment can impose sustained stress on the muscle and ligaments of the cervical spine and shoulder joints, potentially impairing proprioceptive function. Therefore, restoration of proprioceptive function should be considered in the management of FHP [14]. Taping is one such treatment option for improving proprioception.
The taping techniques involve the application of rigid or stretchable adhesive tape to the skin for therapeutic purposes. This stimulates cutaneous receptors, providing continuous feedback about posture and thereby increasing postural awareness during daily activities. Research has shown that taping techniques are effective in reducing pain and improving muscle recruitment patterns [15]. Additionally, taping has been found to improve proprioception and motor control function [15,16].
Several treatment techniques, including joint mobilization techniques and deep cervical muscle activation, are effective in providing immediate pain relief, improving ROM, and correcting posture. However, the effect of the application of posture correction taping on scapulothoracic muscle activity, neck pain, and neck ROM in individuals with FHP and MNP has not been investigated. The objective of this study was to examine the immediate effect of posture correction taping on neck pain, neck ROM, and scapulothoracic muscle activity in individuals with FHP and MNP.
Materials and Methods
Ethical considerations
This study was conducted as part of an ongoing randomized controlled trial among individuals with FHP and MNP. The study protocol was approved by the Ethics Committee of the Kasturba Medical College and Kasturba Hospital Manipal (IEC 1070-2019). The study was registered in the “Clinical Trials Registry of India” (CTRI/2020/09/027805). Written informed consent was obtained from all participants prior to enrolment. All procedures were conducted in accordance with the 1964 Helsinki Declaration and its later amendments. The study was conducted at the Department of Physiotherapy of a tertiary care hospital.
Study population
This study included participants with MNP for more than 3 months and FHP with a forward head angle ≥46°. The age range of the participants was 20–45 years. Patients were excluded if they had structural deformities of the upper back, a history of trauma or surgeries on the upper back, pulmonary or chest conditions, or if they used medication or alternative treatments for neck pain. Additionally, individuals with non-MNP or established conditions of shoulder and neck were not included. MNP was defined as pain perceived along the posterior aspect of the neck, from the superior nuchal line to the first thoracic vertebra, in the absence of any neurologic signs or specific pathologies.
Randomization
A total of 42 participants were randomly allocated into two groups: the taping group and the control group. Block randomization was employed using a computer-generated serially numbered opaque envelope method. The randomization process was ensured by opening the sealed envelopes, which revealed the group assignment for each participant.
Outcome variables
Variables measured in the study were forward head angle (FHA), Numeric Pain Rating Scale (NPRS), cervical ROM, and electromyogram (EMG) activity of neck and scapulothoracic muscles. FHA was measured during the initial screening for inclusion. NPRS and cervical ROM were evaluated at baseline and 48 hours after the first treatment session. NPRS and ROM were assessed by an experienced physiotherapist who was blinded to the group identity. EMG activity of selected muscles was recorded to examine the influence of taping on muscle activity with and without taping. EMG activity of muscles was recorded before and immediately after the application of the first treatment session.
Measurement of FHA
FHA was measured using the method described by Thigpen et al. [6]. This method has been shown to have good intra-tester (intraclass correlation coefficient [ICC]=0.92) and inter-tester (ICC=0.78) reliability [6]. FHA was measured in a relaxed standing position. Two-mm reflective markers were placed over the C7 spinous process, tragus of the ear, and posterior-lateral border of the acromion process. A 5-megapixel digital camera was positioned 1 meter above the ground and 3.5 meters away from the subject. Participants were instructed to reach overhead and bend forward three times to achieve a relaxed standing position. A digital image was then obtained and transferred to a desktop computer. FHA was measured as the angle between a vertical line at the C7 spinous process and a line connecting the C7 to the tragus of the ear using MB Ruler software (Markus Bader, Munich, Germany).
Pain intensity
NPRS was used to assess the average level of pain experienced by patients over the last 24 hours. It is an 11-point scale, ranging from 0 (no pain) to 10 (worst possible pain). Participants were instructed to mark their NPRS on a printed NPRS scale after receiving a thorough explanation. They were asked to mark their average level of pain over the last 24 hours at the baseline assessment and again 48 hours post-intervention. Previous studies have reported fair to moderate test-retest reliability of the NPRS in patients with MNP [11].
Cervical range of motion
The cervical range of motion device (CROM) was used to assess the ROM of the cervical spine. The device has demonstrated good inter-tester reliability (0.8–0.87) and intra-tester reliability (0.7–0.9) [17], as well as excellent validity [18]. To perform the CROM measurements, participants were seated with their backs supported, and hips and knees flexed at 90°. The CROM device was securely fixed to the head, with the torso placed against the backrest and hands resting comfortably on the lap. The ROM of flexion, extension, side flexion, and rotation were recorded for active pain-free ROM [19,20].
Measurement of EMG activity
EMG activity of the neck and scapulothoracic muscles was recorded during 180° of shoulder abduction with a 2 kg weight cuff at the wrist using a surface EMG instrument. The muscles examined included serratus anterior (SA), upper trapezius (UT), middle trapezius (MT), lower trapezius (LT), pectoralis major clavicular head (PM CH), and pectoralis major sternal head (PM SH). Surface electrodes (Delsys EMG system; DelSys, Natick, MA, USA) were placed at the mid-point of each muscle belly, parallel to the muscle fibers, following SENIAM (Surface ElectroMyoGraphy for the Non-Invasive Assessment of Muscles) guidelines [21]. The sensors were attached to the skin using Delsys adhesive sensor interface (DelSys). Wireless EMG signals were captured at 0–500 Hz and pre-amplified (0–1.5 mV) using a Delsys, Trigno wireless EMG system (8 channel) (AD Instruments, Colorado Springs, CO, USA). EMG activity was recorded just before and immediately after the treatment session. In the taping group, EMG was recorded before and after the completion of the first treatment session with taping. In the control group, EMG was recorded before and immediately after the first treatment session without taping. EMG amplitudes were normalized to a percentage of EMG amplitude during free shoulder abduction for analysis purposes.
Interventions
Both the taping group and control group received treatment sessions from a physiotherapist specializing in musculoskeletal physiotherapy. The treatment sessions, lasting 40 minutes, consisted of three components: mobilization of the hypomobile joints of the thoracic spine, cervical spine, and joints of the ribcage; stretching of shortened muscles in the upper back and neck; and stabilization exercises for neck and scapular muscles. The experimental group received an additional intervention of taping, where taping was applied to correct FHP. Taping was applied after the aforementioned therapeutic interventions and maintained for 48 hours, until the next treatment session. To apply the tape, the patient was seated erect in a chair with a corrected FHP posture, guided by the therapist. Skin-colored stretch tape (Kinesiotape, Albuquerque, NM, USA) was applied with moderate stretch from the acromion process to medially and inferiorly toward the spine, bilaterally. Two strips of tape were applied parallel to the thoracic spine over the paraspinal muscles. The stretch and application of strips were adjusted to achieve a visually identifiable correction of the FHP posture. If necessary, the stretch and pattern of application were readjusted to ensure observable correction of posture immediately after application.
Data analysis
Data analyses were performed using SPSS ver. 16.0 (SPSS Inc., Chicago, IL, USA). The Kolmogorov-Smirnov test was employed to assess the normality of the distribution of variables. Post-intervention outcomes between the two groups were compared using a one-way analysis of covariance (ANCOVA), with the group as a between-subject factor and baseline score as a covariate. This approach allowed for the comparison of post-intervention outcomes while accounting for potential baseline differences between the two groups. A paired t-test was used to examine the changes in variables within each group.
Results
A total of 56 patients with neck pain were screened for eligibility. Of these, 42 participants met the inclusion criteria and were randomly assigned to either the taping group (n=22) or the control group (n=20) (Fig. 1). The demographic characteristics of the study population are summarized in Table 1.
The baseline and post-treatment session scores, as well as the adjusted mean differences for pain and ROM between groups (95% confidence interval [CI]), are presented in Table 2. A paired t-test revealed statistically significant improvements in NPRS within both the taping group (mean difference, 1.36; 95% CI, 1.01–1.71; p<0.001) and the control group (mean difference, 0.45; 95% CI, 0.09–0.80; p=0.01). Post-intervention baseline adjusted mean NPRS score comparison using ANCOVA showed statistically significant differences between the groups (adjusted mean difference, −0.92; 95% CI, −1.40 to −0.44; p<0.001).
Comparison of cervical extension ROM within the groups revealed statistically significant improvement in the taping group (mean difference, 2.13; 95% CI, −3.30 to −0.96; p=0.001). In contrast, no significant improvement was observed in the control group (mean difference, 0.60; 95% CI, −1.28 to 0.08; p=0.08). However, between-group comparison for cervical extension ROM did not show any significant difference (adjusted mean difference, 0.96; 95% CI, −0.09 to 2.01; p=0.07). Additionally, no significant differences were found in cervical flexion, cervical side flexion, and cervical rotation for both within-group and between-group comparisons.
The results of the comparison of muscle activity (normalized sEMG amplitude) between the taping group and control group during shoulder abduction with a 2 kg weight cuff at the wrist level are shown in Table 3. Between-group comparisons of EMG amplitude revealed a statistically significant decrease in EMG amplitude in the UT muscle with taping compared to the control group (adjusted mean difference, −13.71; 95% CI, −17.34 to −10.06; p<0.001). Conversely, a statistically significant increase in EMG amplitude was found in the SA muscle during shoulder abduction with taping compared to the control group (adjusted mean difference, 6.41; 95% CI, 4.7 to 8.0; p<0.001). The EMG amplitude of the MT also increased after taping compared to baseline (mean difference, −4.99; 95% CI, −8.33 to −1.65; p=0.005); however, there was no significant between-group difference in this respect. No significant differences in EMG amplitude were observed between the taping group and the control group for the LT, PM CH, or PM SH.
Discussion
The objective of this study was to evaluate the immediate effects of neck and upper back posture correction taping on neck pain, neck ROM, and scapulothoracic muscle activity in individuals with FHP and MNP. Both groups in the present study received a common comprehensive treatment, which included mobilization of hypomobile joints in the thoracic spine, cervical spine, and ribcage joints, as well as stretching of shortened muscles in the upper back and neck, and stabilization exercises for neck and scapular muscles. The experimental group additionally received posture correction taping applied over the upper back, aiming to correct FHP.
The key result of the study was the significant reduction in neck pain intensity after the first treatment session in both groups. The taping group showed a significantly greater reduction in resting pain compared to the control group. Several studies have demonstrated immediate reductions in pain after mobilization or neck stabilization exercises [22–24]. The immediate pain reduction after a single treatment session may be attributed to a combination of neurophysiological, biomechanical, and psychological effects. The greater reduction in pain in the taping group may be further attributed to posture correction, with altered neck loading and reduced myogenic pain. Additionally, taping stimulates the skin mechanoreceptors and provides continuous postural awareness during day-to-day activities, which may contribute to further pain reduction.
The present study also investigated the effect of posture correction taping on scapulothoracic muscle activity in individuals with MNP and FHP. The intervention aimed to correct upper back and scapular posture, and muscle activity was assessed in the UT, MT, LT, SA, PM CH, and PM SH muscles. The results showed a significant reduction in the EMG amplitude of UT and a significant increase in the EMG amplitude of SA during shoulder abduction with a 2 kg weight cuff at the wrist in the taping group. To the best of our knowledge, this is the first study to assess the effect of posture correction taping on scapulothoracic muscle activity in patients with MNP and FHP.
Previous studies have investigated the effect of taping on muscle activity but with different populations and conditions. For instance, Cools et al. [25] studied the effect of taping on the EMG activity of the trapezius and SA muscles in asymptomatic individuals, finding no significant effect of taping. In contrast, Al-Gawad et al. [26] studied patients with subacromial impingement of the shoulder and reported increased activity of the LT and SA muscles after posture correction taping of the scapula. However, the results of the present study cannot be directly compared with the above studies, as the population and conditions differed.
The present study evaluated the EMG activity of MT, a key scapular retractor. The results showed an increase in MT EMG activity after taping in the taping group compared to pre-taping values. Although this increase was not statistically significant in the between-group comparison, it suggests a potential facilitatory effect of taping on MT activity. This finding is consistent with a study by Huang et al. [27], which demonstrated increased EMG activity of the MT muscle with taping in participants with scapular dyskinesis [27]. The application of tape to maintain the scapula in a retracted position may have contributed to the increased MT activity, indicating a potential therapeutic benefit of taping in enhancing scapular stability.
In the current study, we also evaluated the EMG activity of the PM CH and PM SH, as the activity of these muscles may contribute to FHP. However, the study found no significant effect of taping on the activity of PM CH and PM SH muscles. Notably, no previous studies have evaluated the effect of posture correction taping on the pectoralis major group of muscles.
Yoo [15] investigated the effect of neck retraction taping on FHP and UT muscle activity during computer work. The results showed that neck retraction taping significantly reduced FHP and UT activity. Although the methodology differed, the current study similarly found reduced UT activity during weighted arm elevation with posture correction taping, which also resulted in visible reductions in FHP. The application of postural correction tape to the upper back skin may stimulate cutaneous receptors, providing postural feedback that helps maintain proper postural alignment. Correction of postural alignment may also facilitate weakened muscles, such as SA, due to altered posture. Furthermore, stimulation of cutaneous receptors may also play a role in reducing the activity of the overactive UT muscle, suggesting an inhibitory effect of taping.
The present study also investigated the effect of posture correction taping on cervical ROM. The results showed no significant changes in cervical flexion, rotation, or side flexion after a single treatment session in both groups. However, cervical extension did improve in the experimental group after a single treatment session, although the between-group difference in this respect was not statistically significant. A possible explanation for the lack of improvement in cervical ROM is that the baseline restriction in cervical ROM was minimal in both groups, leaving limited room for significant improvement.
Limitations
Some limitations of this study should be acknowledged. First, this study was conducted as part of an ongoing study, and the results presented here only reflect the immediate effects of posture correction taping on neck pain, ROM, and scapulothoracic muscle activity. Another limitation is that neck ROM was not included as an inclusion criterion for participant selection. As a result, the baseline neck ROM may have influenced the study’s outcome.
Clinical implications
The study’s findings may have implications for planning posture correction interventions for MNP with FHP. The immediate reduction in pain and changes in scapulothoracic muscle activity should be taken into account when planning such interventions. While the study’s results are promising, it is imperative to assess the long-term benefits of posture correction taping in individuals with FHP and MNP. The potential benefits of reducing UT muscle overactivity and facilitating SA muscle activity through posture correction taping may play a crucial role in managing FHP with MNP, offering a valuable adjunct to existing treatment approaches.
Conclusions
This study is the first to investigate the effect of posture correction taping on pain, cervical ROM, and scapulothoracic muscle activity in individuals with FHP and MNP. The results showed that posture correction taping alongside other exercise therapy interventions led to an immediate reduction in pain. Additionally, the study found increased EMG activity of the serratus anterior and reduced activity of the upper trapezius during weighted shoulder abduction. While these findings require further evaluation for their long-term benefits, they suggest that posture correction taping may be a valuable adjunct intervention in managing MNP with FHP.
Key Points
This study examines the effectiveness of posture correction interventions for individuals with forward head posture and mechanical neck pain.
Treatment outcomes were compared between two intervention groups within 48 hours of application of interventions to determine the immediate effects.
Objective outcome measures, including the cervical range of motion device and electromyogram, were used to minimize bias.
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