Participants
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 FHP. All patients were informed of the objectives of the research and subsequently provided written consent for voluntary participation in the measurements. The study adhered to the CONSORT guidelines and was approved by the Institutional Review Board of the Physical Therapy Department at the University of Patras. For mixed ANOVA, by using G-power software [13] and based on the study design (number of groups = 2, number of measurements = 5, correlation among repeated measures = 0.5, nonsphericity correction epsilon = 1, error type I = 0.05, effect size=0.27, partial η2 = 0.07, power = 0.8), the minimum sample size was estimated to be 18. The inclusion criteria included female patients with a diagnosis of mechanical neck pain syndrome (cervical soft tissue pathologies, cervical strain/sprain or myofascial pain)from a medical orthopaedic doctor and pain symptoms lasting over three months accompanied by FHP based on a cranioverterbral angle (CVA) of <50°. The selection of a CVA <50° as the reference angle for the presence of FHP was based on the study of Yip et al. [14], which reported 55.02° ± 2.86° as the normal range. The evaluation of only female patients was based on the prevalence of the disease, which is higher in women than men [1], to ensure the homogeneity of the sample. The exclusion criteria consisted of patients with little or no anterior head projection (CVA <50°); patients with minor neck injuries, intervertebral disc hernias, spondylolisthesis, accompanying neurological, musculoskeletal and mental problems; and patients using medication.
The patients were randomly divided by a third party 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 by a classical massage (Group B-control, N=10).The variables evaluated in this study were FHP, cervical ROM and strength, and pain and disability [15]. The evaluation of FHP was based on measuring the CVA according to the procedure proposed by Ruivo et al [16] and Van Niekerk et al [17]. Based on these approaches, reflective markers were placed on the tragus of the ear and the spinous process of the seventh cervical vertebra (C7), and two photos were taken before and after the interventions in both upright and sitting positions. The CVA was then calculated by processing the pictures with the IMAGE J computational program (LOCI, University of Wisconsin, USA). This procedure can provide valid and reliable postural indicators in both sitting and standing evaluation [17,18].
Cervical ROM and strength were assessed with an inclinometer (baseline inclinometer ® bubble inclinometer) and a MicroFET2 dynamometer (Hoggan Scientific LLC, Salt Lake City, USA) , respectively. Cervical flexion and extension and lateral flexion ROM were assessed in a sitting position, while cervical rotation ROM was assessed in the supine position according to the procedures proposed by Norkin & White [19]. Three measurements per movement were performed, and the mean was used in the analysis. Cervical strength evaluation was performed in the supine position according to the procedure proposed by Tierney et al., 2005. The measurements had to cause no pain, and the research protocol included 3 isometric contractions for 3 seconds with a 30 second rest between contractions. After familiarization with the measurement, the mean value from the 3 maximal contractions was used in the analysis.
The Visual Analogue scale (VAS) was used for subjective pain assessment, and the neck disability index (NDI) questionnaire was used to record patients’ 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 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. The study outcomes and possible adverse effects from the therapeutic interventions' application were evaluated by experienced physical therapists who were blind both to the study scope and treatment allocation.
Therapeutic Interventions
Participants in Group A received soft tissue techniques in the form of the ERGON IASTM technique [20] in targeted cervical and thoracic spine areas with the aim of myofascial release of shortened structures. Participants in Group B, for the same purpose, received a classical massage in the same areas. The anatomical areas that received the treatment and detailed data (strokes, treatment direction, speed and duration) of applying the two therapeutic interventions are presented in Table 1. Subsequently, participants in both groups underwent specialized neuromuscular exercises to correct 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 IASTM application for another 10 min, while in Group B, the massage lasted 20 minutes. Thus, the overall soft tissue interventions for both groups lasted 20 min.
Immediately after the application of the soft tissue techniques, four selected neuromuscular exercises were applied to both groups (Table 2). The first exercise included strengthening of the deep neck flexors with a combination of a neck curl with a chin tuck position in the supine position using the Chattanooga Stabilizer Pressure biofeedback device (Figure 1)[9].The second and third exercises included cervical rotation and lateral flexion strengthening through contraction of the deep neck flexors at the same time as the rotating or lateral flexor muscles in a sitting position (figures 2 and 3). Finally, the fourth exercise was aimed at correcting the forward position of the shoulder blades by activating the trapezius and rhomboid muscles from the prone position through horizontal abduction of the shoulder blades (Figure 4). The exercises were performed with 10 repetitions and 3 sets, while instructions were given to the patients to perform all the exercises on the other days of the week for the entire eight weeks of the intervention [21].
Statistical analysis
To compare the effectiveness of the intervention programs, as well as to investigate their effects over time, the mixed ANOVA method was used with univariate analysis. 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 the statistical tests was set at 5%.