Research Review By Dr. Demetry Assimakopoulos©


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Date Posted:

March 2016

Study Title:

The effect of adding forward head posture corrective exercises in the management of lumbosacral radiculopathy: A randomized controlled trial


Moustafa IM & Diab AA

Author's Affiliations:

Basic Science Department, Faculty of Physical Therapy, Cairo University, Egypt.

Publication Information:

Journal of Manipulative & Physiological Therapeutics 2015; 38(3): 167-78.

Background Information:

Lumbosacral radiculopathy is a common health complaint, often associated with delayed recovery, persistent disability and increased health care utilization (1). In spite of its prevalence, no strong evidence for the effectiveness of conservative management exists. This is because many clinicians and researchers pay attention to the patho-anatomical factors associated with the disorder, while perhaps ignoring the potential role of general spinal dysfunction or posture.

Abnormal posture is thought to be an important etiological factor associated with low back pain. Further, the importance of the cervical spine in sensorimotor integration within the body is the subject of much study currently. Postural reflexes and general cervical somatosensory function are central to this line of investigation. Given the high incidence of forward head posture, especially in older adults, the authors sought to evaluate the immediate and long-term effects of a multimodal spinal rehabilitation program including correction of forward head posture on low back and leg pain, disability, 3-dimensional spinal posture, and S1 nerve function in patients suffering from chronic lumbosacral radiculopathy.

Pertinent Results:

A total of 131 subjects were followed for 2-years – a decent sample size! The experimental group performed a 3-phase Functional Restoration Program (FRP) and cervical spine postural exercises. The standard-care group performed the FRP-only.

Oswestry Disability Index (ODI): The experimental group had a superior short-term improvement on the ODI score. The ODI scores were not statistically different between the two groups at 10-week follow-up. However, the experimental group interestingly performed significantly better than the standard care group at 2-year follow-up.

Secondary outcomes: The experimental group had a superior effect on anterior head translation (AHT), H-reflex amplitude, H-reflex latency, back pain and leg pain at short-term follow-up. There was no statistically significant effect favouring any group for surface rotation, lumbar lordosis posture, thoracic kyphosis, trunk inclination or trunk imbalance at this time. However, at 10-weeks post-treatment, the experimental group showed significant improvement in AHT, trunk inclination, lumbar lordosis, thoracic kyphosis, trunk imbalance, pelvic inclination and surface rotation compared to the FRP-only group. At the 2-year follow-up mark, the analysis revealed a significant difference for all measured variables favouring the experimental group.

Clinical Application & Conclusions:

Adding cervical spine postural exercise to a lumbosacral radiculopathy Functional Restoration Program provided superior improvement in ODI score, AHT, low back pain, leg pain, and S1 neurophysiological parameters in the short-term compared to the FRP-only group. Pain intensity, H-reflex amplitude and latency, AHT and 3-dimensional spinal posture all favoured the experimental group at 10-weeks post-treatment. Interestingly, there were no between group differences in ODI score at 10-weeks post-treatment. However, the experimental group showed statistically superior changes in ODI score compared to the FRP-only group at 2-years post-treatment. The experimental group also showed statistically significant changes in S1 neurophysiological findings, AHT and 3-dimensional parameters at the two-year follow-up mark. These results demonstrate that effort to correct forward head posture positively influences both the short and long-term recovery of lumbosacral radiculopathy.

Study Methods:

This was a prospective, randomized, controlled study conducted on patients suffering from lumbosacral radiculopathy, selected from the lead author’s outpatient clinic. The subjects underwent a 10-week program of care, with a 2-year follow-up. Subjects avoided other exercise programs for the duration of the study.

Inclusion Criteria:
  • Anterior head translation (AHT) greater than 15 mm, measured by lateral cervical spinal radiograph.
  • Confirmed L5-S1 disc prolapse, causing chronic unilateral S1 radiculopathy.
  • Symptoms lasting longer than 3 months.
  • Unilateral leg pain.
  • Oswestry Disability Index (ODI) score demonstrating mild-to-moderate disability.
  • Side-to-side H-reflex latency difference is > 1 millisecond, and a prolonged H-reflex latency of > 30 milliseconds.
  • Hyperlordotic lumbar posture (assessed via general observation).
Exclusion Criteria:
  • Previous history of lumbar spinal surgery.
  • History of metabolic disorder or cancer.
  • Presence of osteoporosis, cardiac problems, peripheral neuropathy, upper motor neuron lesion, spinal stenosis or rheumatoid arthritis.
  • Presence of any lower extremity deformity that might interfere with postural alignment.
Treatment Protocols:
The standard care group underwent a 3-phase Functional Restoration Program (FRP-only). The experimental group performed the FRP, plus forward head posture corrective exercises.

FRP phase 1 consisted of two 90-minute physiotherapy sessions per week for 4 weeks. This block largely consisted of injury education, self-management strategies, patient empowerment, coping strategies and reduction of catastrophization. The subjects also took part in daily relaxation exercises. Phase 1 also included an exercise portion, which consisted of transversus abdominus, lumbar multifidus and pelvic floor muscle retraining. The experimental group also performed the forward head posture corrective exercise program 4-times weekly. The postural correction program consisted of deep neck flexor and shoulder retraction strengthening, and pectoral and neck extensor stretching.

FRP phase 2 consisted of three 90-minute physiotherapy sessions a week for 6 weeks. Participants also performed 2 individual exercise sessions at home. Sessions included the exercise portion of phase 1, in addition to treadmill walking, 15 cm step-ups, bicep curls, resisted shoulder flexion and shoulder abduction. Two sets of each exercise were performed. Both groups were encouraged to maintain an upright cervico-thoracic posture.

FRP phase 3 consisted of 20-30 minute independent low-impact aerobic sessions.

The treating clinician employed various cognitive behavioural therapy (CBT) strategies throughout the FRP, such as challenging counterproductive beliefs, emphasis on active exercise, and positive reinforcement. They were also encouraged to return to social activity.

The ODI, AHT, 3-dimensional spinal posture parameters, numeric pain rating, and S1 neurophysiological findings were measured. Lateral cervical radiographs to measure AHT were taken pre-treatment, 10-weeks post-treatment and at 2 year follow-up. Electromyography/Nerve condition velocity was used to measure H-reflexes at pre-treatment and at 10-weeks post-treatment.

Writer’s note: H-reflexes are defined as a muscular reaction to sensory fibre electrical stimulation. In the case of the S1 nerve root, sensory nerves in the popliteal fossa are stimulated, and the timing of corresponding reactionary muscle contraction is measured. The H-reflex amplitude and latency are compared to the contralateral side, and to age-matched normals.

Study Strengths / Weaknesses:

  1. Patients were recruited from the authors’ private practice. It is possible that the authors knew the subjects and hence applied some personal bias to their selection.
  2. Lack of investigator blinding or a ‘no-treatment’ control group.
  3. Only patients with hyperlordotic lumbar spinal posture were selected. These patients were selected because hyperlordotic posture might be neurophysiologically connected to forward head posture via the pelvi-ocular reflex.
  4. Invasive nature of x-ray assessment.
  1. Two-year follow-up – this is something rarely seen in manual therapy or neurophysiological basic science research.
  2. Standardization of the base Functional Restoration Program for both groups.
  3. Inclusion of Cognitive Behavioral Therapy (CBT) methods.

Additional References:

  1. Tarulli A, Raynor E. Lumbosacral radiculopathy. Neurol Clin 2007; 25: 387-405.