The research sample consisted of 20 female adult patients, aged 43–65 years, weighing 51–73 kg with a height of 1.56–1.75 m, with a diagnosis of mechanical neck pain syndrome and accompanying pathological adjustments of the body, such as the FHP. All patients were informed of the objectives of the research, the days of measurements and therapies, and subsequently signed written consent of voluntary participation in the measurements.The study adhered to CONSORT guidelines and was approved by the Institutional Review Board approval of the Physical Therapy department at the University of Patras.Based on the desired power level of 0.80 for both bivariate comparisons and repeated measure ANOVA, and by using the G-power software , the sample size was estimated to be 18. The inclusion criteria included patients with a diagnosis of mechanical neck syndrome from a medical orthopedic doctorand pain symptoms lasting over three months (including headaches) accompanied by the FHP at an angle of <50o. The exclusion criteria consisted of patients with little or no anterior head projection (<50o) and patients with minor neck injuries, intervertebral disc hernias, spondylolisthesis, accompanying neurological, musculoskeletal and mental problems, and patients under medication.
The patients were randomly divided into two groups using an online random generator(https://www.randomizer.org/), receiving either targeted IASTM Techniques and neuromuscular exercises (Group A, N=10), or the same exercise prescription accompanied with classical massage (Group B-control, N=10).Randomization and evaluation of the interventions were done by experienced physical therapists (members of the Laboratory of Human Evaluation and Rehabilitation of the University of Patras) who were blind to the study scope.The variables evaluated in this study were the FHP, cervical ROM and strength, and pain and disability . A photographic lens of the mobile iPhone X was used for the photographic evaluation of the FHP, and the IMAGE J computational program was used for the assessment of the cervical vertebral angle (CVA). Cervical ROM and strength were assessed with an inclinometer (Baseline inclinometer ® bubble inclinometer), and the MicroFET2 dynamometer, respectively. TheVAS scale was used for subjective pain assessment, and the neck disability index (NDI) questionnaire was used to record patient’s functional status.A total of eight treatment sessions were performed on all patients, two each week. FHP, ROM, and cervical strength were evaluated before and after each session, while the functionality of the cervical spine through the NDI questionnaire was evaluated five times (before the 1st, 4th, and the 8th treatment sessions and at two and four weeks post-treatment).The therapeutic sessions and evaluations of the participants were carried out in the Laboratory of Human Evaluation and Rehabilitation of the University of Patras.
Participants in Group A received soft tissue techniques in the form of the ERGON IASTM technique  in targeted cervical and thoracic spine areas with the aim of the myofascial release of shortened structures. Participants in Group B, for the same purpose, received a classical massage in the same area. Subsequently, participants in both groups underwent specialized neuromuscular exercises to correct the FHP. The duration of each treatment session was 50 min for both research groups. At the beginning of the procedure, the therapist performed a warm-up massage for both groups. In Group A, the massage lasted 10 min and was followed by the IASTM application for another 10 min, while in Group B, the massage lasted20 minutes. Thus, the overall soft tissue interventions for both groups lasted 20 min.
The IASTM techniques were performed for 10 min on the anatomical structures of the cervical area, the thorax (back and front) and the shoulder girdle. Particular attention was paid to the treatment of local adhesions and myofascial restrictions. The massage techniques were applied in the same treatment areas as those in Group A and Group B.
Immediately after the application of the soft tissue techniques, four selected neuromuscular retraining exercises were applied to both groups.The first exercise included the strengthening of the deep neck flexors with a combination of neck curl with a chin tuck position in the supine position using the Chattanooga Stabilizer Pressure biofeedback (figure 1). The second exercise included cervical rotation strengthening through the contraction of the deep flexors at the same time as the rotating muscles (figure 2).The third exercise was aimed at strengthening the cervical lateral flexion and rotation and was performed from a sitting position (figure 3). For this exercise, the participants first performed a chin tuck and head pushing against the palm with their chin tucked (in all directions), and then the neck lateral flexion on the diagonal with chin tuck (left and right). Finally, the fourth exercise was aimed at correcting the forward position of the shoulder blades ; thus assisting the correct biomechanical posture of the chest by activating the trapezius and rhomboid muscles from the prone position through horizontal abduction of the shoulder blades (figure 4).All exercises were performed for 10 repetitions and 3 sets while the instructions were given for performing the exercises on the other days of the week for the entire eight weeks that the intervention lasted .
To compare the effectiveness of intervention programs, as well as to investigate their effects over time, the Repeated Measures ANOVA method (RM-ANOVA) was used with the one-variable approach. For statistical analysis of the data, the statistical software SPSS-25 was used. The minimum value of the statistical significance level, the p-value, in all statistical tests was set at 5%.