Effect of integrated neuromuscular inhibition technique on subjects with neck pain and forward head posture: a randomized controlled trial

ABSTRACT

Objective

Forward head posture (FHP) and neck pain are common musculoskeletal complaints. This study aimed to evaluate the effect of the Integrated Neuromuscular Inhibition Technique (INIT) on the range of motion (ROM) and craniovertebral angle (CVA) in individuals with FHP and neck pain.

Methods

A total of 40 physical therapy participants (26 females and 14 males), aged 18 to 23 years (mean age: 20 ± 1.71 years), participated in this study. They were randomized into two groups: Group A received conventional therapy combined with Integrated Neuromuscular Inhibition Technique (INIT) targeting the upper trapezius and suboccipital muscles, while Group B received conventional therapy consisting of strengthening and stretching exercises only. The treatment was administered three times per week for one month.

Photographic sessions were conducted using a mobile phone. A Realme 7 Pro camera and CorelDRAW software were employed to analyze the craniovertebral angle (CVA). A pressure algometer was used to measure the pressure pain threshold (PPT), while a visual analogue scale (VAS) was utilized to assess pain severity. Additionally, a clinometer application on an Android device was used to evaluate cervical range of motion (ROM).

Results

Both groups demonstrated significant improvements in craniovertebral angle (CVA) and visual analogue scale (VAS) scores, with Group A showing a 16.12% improvement in CVA and a 75.61% reduction in VAS, compared to a 7.20% improvement in CVA and a 57.14% reduction in VAS in Group B.

Group A also showed a significantly greater post-treatment increase in CVA (p = 0.01), cervical range of motion (ROM) for flexion (p = 0.002), extension (p = 0.005), right bending (p = 0.001), left bending (p = 0.001), right rotation (p = 0.001), and left rotation (p = 0.001). Additionally, Group A exhibited a significantly greater decrease in VAS (p = 0.003) compared to Group B following treatment.

Conclusion

The Integrated Neuromuscular Inhibition (INI) technique, which combines ischemic compression, strain-counterstrain, and muscle energy techniques, yields superior outcomes compared to conventional therapy alone for individuals with forward head posture (FHP) and neck pain. It is particularly effective in improving craniovertebral angle (CVA), reducing pain levels, and enhancing cervical range of motion (ROM).

Introduction

Chronic neck pain is one of the most prevalent musculoskeletal complaints [1]. It is characterized by durations exceeding three months and limitations in activities that hinder daily functioning [2]. Estimates suggest that 70% to 80% of individuals may experience neck discomfort at some point in their lives, and up to 60% of them may suffer from persistent and recurrent pain [1]. Myofascial pain syndrome, a chronic pain condition caused by trigger points, is associated with autonomic symptoms that impair physical capabilities and musculoskeletal disorders, such as muscle spasms, limited range of motion (ROM), and reduced tissue flexibility [3,4].

Trigger points in the neck affect approximately 85% of patients who visit pain clinics, with women being more frequently affected than men [5]. These tense bands of muscle fibers contain hyperirritable, palpable nodules known as myofascial trigger points (MTrPs) [6]. The neck and shoulder muscles are commonly involved, with the trapezius being the most frequently affected [7]. Clinically, MTrPs are categorized as latent or active [8,9]. Latent trigger points elicit pain when palpated and limit mobility, whereas active trigger points cause continuous pain at rest and are associated with referred pain patterns [8,9].

Forward head posture (FHP) is observed in approximately 60% of individuals with neck pain [10]. Prolonged use of communication devices such as computers and smartphones has been linked to FHP, potentially exacerbating mechanical cervical pain [11]. Prolonged head flexion can lead to a forward shift of the head and neck, restricting cervical ROM and causing postural abnormalities in the sagittal plane. These abnormalities affect head control and balance, increasing mechanical stress and dysfunction [11]. Long periods spent with the neck in a bent-forward position or repetitive neck movements during work can also contribute to postural issues [11].

FHP is associated with the shortening of several muscles, including the upper trapezius, posterior cervical extensors, sternomastoid, and levator scapulae [12]. The craniovertebral angle (CVA) is the angle between a line drawn from the tragus of the ear to a horizontal line through the spinous process of the seventh cervical vertebra (C7) (Figure 1). Angles less than 49° are classified as FHP [13]. Studies have shown a negative correlation between CVA and disability in individuals with neck pain, where a smaller CVA corresponds to increased FHP and higher levels of disability [13].

Figure 1.

Angles of head and shoulder.

A):sagittal head; B): craniovertebral angle; C): shoulder angle (adopted from Yip et.al,2008) [12]

A variety of manual and non-manual techniques are available for deactivating trigger points (TrPs), including ischemic compression [14], instrument-assisted soft tissue mobilization [15], Kinesiotape (KT) [16], and transcutaneous electrical nerve stimulation (TENS) [17]. One manual method for deactivating MTrPs is the Integrated Neuromuscular Inhibition Technique (INIT), introduced by Chaitow. This technique combines ischemic compression (IC), strain-counterstrain (SCS), and muscle energy techniques [18].

This study aimed to evaluate the impact of integrating INIT into conventional therapy. It was hypothesized that individuals with neck pain and FHP would experience greater improvements in cervical ROM, CVA, and pain levels when treated with INIT in addition to conventional therapy compared to conventional therapy alone.

Methods

Study design

The study protocol was approved by the Faculty of Physical Therapy’s Research Ethics Committee (NO: P.T.REC/012/003727) and registered at the Clinical Trial Registry (NCT05439018). The study was conducted from October 2022 to December 2022.

Participants

A total of 60 participants were initially selected from Cairo University’s undergraduate physical therapy students. During eligibility screening, ten participants declined to participate, four were excluded due to receiving treatment within the previous three months, and six did not meet the inclusion criteria. Consequently, 40 participants were included in the study. All participants received both written and verbal explanations of the study procedures and signed an informed consent form approved by the Faculty of Physical Therapy (Figure 2).

Figure 2.

Flow chart of the study.

Randomization

A total of 40 participants were included in this research after providing written informed consent. They were randomly divided into two groups using a computer-generated random number program. To maintain allocation concealment, the random allocations were enclosed in sealed, opaque envelopes. The fifth author supervised the randomization process but was not involved in the assessment or treatment. The second author, blinded to the group allocation and treatment stages, evaluated the participants’ outcomes.

The experimental group (Group A) received Integrated Neuromuscular Inhibition Technique (INIT) targeting the upper trapezius and suboccipital muscles, in addition to conventional therapy comprising stretching and strengthening exercises. Group B received conventional therapy alone.

Participants were aged 18 to 23 years, had a body mass index (BMI) between 18.5 and 25 kg/m², exhibited symptomatic forward head posture (FHP) with a craniovertebral angle (CVA) of 49° or less, presented with a latent trigger point, a jump sign under pressure, and had experienced neck pain for more than three months [2]. Participants were excluded if they had undergone a cervical operation, suffered a whiplash injury, or had any degenerative disease [19].

Sample size

Using CVA data from a pilot study involving five participants per group, the G*POWER statistical software (version 3.1.9.2; Franz Faul, Universitat Kiel, Germany) was employed to calculate the required sample size. The analysis determined that 40 participants were needed for the study, with calculations based on α = 0.05, β = 0.2, and an effect size of 0.91.

Intervention

The INIT targeting the upper trapezius and suboccipital muscles, in addition to conventional therapy, was administered to Group A three times a week for one month.

INIT for the upper trapezius muscles

To alleviate tightness in the upper trapezius, the participant lay supine. The PPT evaluation process was used to locate the trigger point.

A. Ischemic Compression of the Upper Trapezius: The therapist pinched the trigger point in the middle of the upper trapezius’ horizontal portion using the thumb and index finger (Figure. 3a) [18].

Figure 3.

Integrated neuromuscular inhibition for left upper trapezius.

A) ischemic compression for Left upper trapezius

B) strain counterstrain for Left upper trapezius

C) Muscle Energy technique for Left upper trapezius

B. Strain Counterstrain for the Upper Trapezius: The therapist applied pressure to the trigger point while grasping the participant’s forearm and passively moving the shoulder on the painful side to approximately 90° of abduction, tracking the trigger point pain with the other hand (Figure. 3b) [18].

C. Muscle Energy Technique for the Upper Trapezius: The therapist applied METs by stabilizing the affected shoulder with one hand and placing the other hand on the temporal region of the head on the same side (Figure. 3c). The participant was instructed to move the stabilized shoulder and ear toward one another with 20% of their maximal voluntary contraction, maintaining the contraction for seven seconds. Afterward, the upper trapezius was stretched for 30 seconds [18].

INIT for suboccipitals

A. Ischemic Compression of Suboccipital Muscles: The therapist pinched the trigger point of the suboccipital muscles (Figure. 4(a)) [18].

Figure 4.

Integrated neuromuscular inhibition for suboccipitals.

A) ischemic compression for suboccipitals

B) strain counterstrain for suboccipitals

C) Muscle Energy technique for suboccipitals

B. Strain Counterstrain for Suboccipital Muscles: The therapist placed the head in an extended position, which shortens the suboccipital muscles, while pinching the trigger points in this position (Figure. 4(b)) [18].

C. Muscle Energy Technique for Suboccipital Muscles: The therapist grasped the occiput with one hand and the chin with the other. An isometric contraction of the suboccipital muscles was applied by instructing the participant to press their head against the therapist’s left hand without moving the head, holding the contraction isometrically against resistance for several seconds. The participant was then asked to relax, and the therapist applied pressure with the right hand to stretch the suboccipital muscles for 30 seconds (Figure. 4(c)) [18].

The conventional therapy, comprising stretching and strengthening exercises, was administered to both Group A and Group B three times a week for one month.

• Stretching Exercises: Targeted the scalene, upper trapezius, sternomastoid, levator scapulae, and pectoralis major muscles. Each muscle was stretched for 30 seconds, followed by a 30-second rest, with 3–5 repetitions per session, three times weekly for four weeks.

• Strengthening Exercises: Focused on the scapular retractors and deep cervical flexor muscles. Participants performed three sets of twelve repetitions, holding each repetition for six seconds with a 1–2-minute rest between sets, three times weekly for four weeks.

Outcome measures

Pre-and post-treatment, all outcome variables were evaluated.

Primary outcome measure

The primary outcome measure was the craniovertebral angle (CVA). Photographic Posture Analysis was used to calculate CVA, which has been reported to have high reliability, with intra-class correlation coefficients (ICCs) ranging from 0.892 to 0.999 [20]. To ensure consistent positioning, landmarks were placed on the floor to maintain the participants’ location and distance from the camera. A Realme 7 Pro mobile camera mounted on a tripod was used to capture side-view images of participants with forward head posture (FHP) [21].

Participants stood upright during imaging [22], and a tape measure was used to ensure a distance of 1.5 meters between the participants’ feet and the tripod’s center [23]. The camera height was adjusted to align with the dominant shoulder’s center. Adhesive markers were placed on the tragus of the ear and the spinous process of C7. The images were analyzed using CorelDraw graphic suite X7 software [23].

Secondary outcome measures

1. Visual Analogue Scale (VAS): The VAS was used to assess pain severity. This self-reported pain scale typically consists of a 10 cm horizontal or vertical line, with ‘no pain’ and ‘worst pain’ labeled at the extremes Each participant marked a point on the line that represented their pain level [24].

2. Pressure Pain Thresholds (PPTs):

   PPTs were measured using a Commander Algometer (JTECH Medical, Midvale, Utah, USA), a portable device that applies manual pressure to elicit pain [25]. The algometer has been widely validated and demonstrated high reliability, with ICCs ranging from 0.9 to 0.95 [26,27]. The algometer’s tip was placed on the trigger point, and pressure was applied at a rate of 1 kg per second. The pressure reading in kg/cm² was recorded when the participant reported discomfort. This process was repeated three times at 60-second intervals, and the average of the three readings was calculated [26].

3. Cervical Range of Motion (CROM):

   Cervical ROM was assessed using a smartphone application called Clinometer, which has been validated as a reliable tool for measuring active cervical ROM, with ICCs ranging from 0.89 to 0.94 [28,29].

Participants performed the following movements: cervical flexion, extension, side bending, and rotation. For flexion and extension, participants were seated with their arms at their sides, torso upright against the chair, feet flat on the ground, and eyes gazing straight ahead. The head was aligned with the external auditory meatus, and a smartphone was placed on the left side of the participant’s head to record measurements [30].

Lateral flexion (side bending) was measured by positioning the smartphone on the opposite side of the head, with the display level aligned with the participant’s eyes [30]. After seated motions were completed, participants lay supine on a treatment plinth to measure cervical rotation. The smartphone was positioned so the display arrow pointed in the direction of the participant’s nose [30].

Each measurement was repeated three times, and the average value was recorded for statistical analysis.

Statistical analysis

An unpaired t-test was conducted to compare subject characteristics between groups. The Shapiro-Wilk test was used to assess the normal distribution of the data, and Levene’s test for homogeneity of variances was applied to evaluate the equality of variances between groups.

A mixed multivariate analysis of variance (MANOVA) was performed to examine the effects of treatment on craniovertebral angle (CVA), Visual Analogue Scale (VAS), Pressure Pain Thresholds (PPT), and cervical range of motion (CROM). Post-hoc analyses with Bonferroni correction were conducted for multiple comparisons.

The level of significance for all statistical tests was set at p <0.05. All statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 25 for Windows (IBM SPSS, Chicago, IL, USA).

Results

Subject characteristics

Table 1 presents the characteristics of subjects in Groups A and B. No significant differences were observed between the groups in terms of age, weight, height, BMI, and chronicity (p > 0.05).

Table 1.

Comparison of subject characteristics between group A and B.

	Group A	Group B
	Mean ± SD	Mean ± SD	MD	t- value	p-value
Age (years)	19.70 ± 1.34	20.30 ± 2.00	−0.6	−1.11	0.27
Weight (kg)	59.35 ± 12.21	60.90 ± 10.05	−1.55	−0.43	0.66
Height (cm)	161.55 ± 4.59	160.40 ± 6.44	1.15	0.65	0.52
BMI (kg/m2)	22.71 ± 4.30	23.63 ± 3.41	−0.92	−0.75	0.45
Chronicity(months)	5.65 ± 1.76	5.7 ± 1.75	−0.05	0.09	0.93

SD, Standard deviation; MD, mean difference; p value, Probability value.

Effect of treatment on CVA, VAS, PPT, and cervical ROM

Mixed MANOVA revealed a significant interaction effect between treatment and time (F = 8.92, p = 0.001, partial eta squared = 0.80). There was also a significant main effect of treatment (F = 2.14, p = 0.04, partial eta squared = 0.48) and a significant main effect of time (F = 175.79, p = 0.001, partial eta squared = 0.98).

Within-group comparison

Both groups demonstrated a significant increase in CVA and PPT of the right and left upper trapezius and right and left suboccipital muscles post-treatment compared to pre-treatment (p < 0.001). A significant reduction in VAS scores was also observed in both groups post-treatment compared to pre-treatment (p < 0.001) (Table 2).

Table 2.

Mean CVA, VAS and PPT pre and post treatment of group A and B.

	Pre treatment	Post treatment
	Mean ± SD	Mean ± SD	MD	% of change	p value
CVA (degrees)
Group A	42.86 ± 5.41	49.77 ± 3.18	−6.91	16.12	0.001
Group B	43.78 ± 4.65	46.93 ± 3.76	−3.15	7.20	0.001
MD	−0.92	2.84
	p = 0.56	p = 0.01
EF		0.82
VAS
Group A	6.15 ± 1.56	1.5 ± 0.82	4.65	75.61	0.001
Group B	5.60 ± 1.23	2.4 ± 0.94	3.2	57.14	0.001
MD	0.55	−0.9
	p = 0.22	p = 0.003
EF		1.02
PPT (kg)
Right upper trapezius
Group A	3.45 ± 0.87	6.34 ± 0.65	−2.89	83.77	0.001
Group B	3.56 ± 0.85	5.52 ± 0.96	−1.96	55.06	0.001
MD	−0.11	0.82
	p = 0.69	p = 0.003
EF		1.01
Left upper trapezius
Group A	3.15 ± 0.83	6.11 ± 0.64	−2.96	93.97	0.001
Group B	3.18 ± 0.97	5.17 ± 0.72	−1.99	62.58	0.001
MD	−0.03	0.94
	p = 0.91	p = 0.001
EF		1.38
Right suboccipital
Group A	2.62 ± 0.88	5.52 ± 1.07	−2.9	110.69	0.001
Group B	2.84 ± 0.91	4.63 ± 0.89	−1.79	63.03	0.001
MD	-0.22	0.89
	p = 0.42	p = 0.007
EF		0.90
Left suboccipital
Group A	2.41 ± 0.72	5.52 ± 0.88	−3.11	129.05	0.001
Group B	2.70 ± 0.68	4.78 ± 0.83	−2.08	77.04	0.001
MD	−0.29	0.74
	p = 0.19	p = 0.009
EF		0.87

SD, Standard deviation; MD, Mean difference; p value, Probability value.

Additionally, both groups showed a significant improvement in cervical ROM, including flexion, extension, right and left bending, and right and left rotation, post-treatment compared to pre-treatment measurements (p < 0.001) (Table 3).

Table 3.

Mean cervical ROM pre and post treatment of group A and B.

ROM (degrees)	Pre treatment	Post treatment
	Mean ±SD	Mean ±SD	MD	% of change	p value
Flexion
Group A	58.12 ± 10.56	75.43 ± 6.21	−17.31	29.78	0.001
Group B	57.07 ± 9.21	68.25 ± 7.13	−11.18	19.59	0.001
MD	1.05	7.18
	p = 0.73	p = 0.002
EF		1.07
Extension
Group A	50.96 ± 12.61	68.32 ± 8.61	−17.36	34.07	0.001
Group B	49.90 ± 10.88	59.70 ± 9.53	−9.8	19.64	0.001
MD	1.06	8.62
	p = 0.77	p = 0.005
EF		0.95
Right bending
Group A	30.31 ± 4.61	40.39 ± 4.39	−10.08	33.26	0.001
Group B	31.45 ± 4.88	35.35 ± 4.39	−3.9	12.40	0.001
MD	−1.14	5.04
	p = 0.45	p = 0.001
EF		1.15
Left bending
Group A	31.75 ± 3.97	39.03 ± 3.77	−7.28	22.93	0.001
Group B	30.25 ± 3.49	34.85 ± 3.84	−4.6	15.21	0.001
MD	1.5	4.18
	p = 0.21	p = 0.001
EF		1.1
Right rotation
Group A	62.55 ± 5.56	79.25 ± 5.49	−16.7	26.70	0.001
Group B	60.20 ± 6.22	72 ± 6.08	−11.8	19.60	0.001
MD	2.35	7.25
	p = 0.21	p = 0.001
EF		1.25
Left rotation
Group A	61.36 ± 6.85	78.60 ± 4.22	−17.24	28.10	0.001
Group B	62.40 ± 7.41	72.60 ± 5.78	−10.2	16.35	0.001
MD	−1.04	6
EF		1.19
	p = 0.65	p = 0.001

SD, Standard deviation; MD, Mean difference; p value, Probability value.

Between-group comparison

There was a significant improvement in CVA (p = 0.01) and PPT of the right upper trapezius (p = 0.003), left upper trapezius (p = 0.001), right suboccipital (p = 0.007), and left suboccipital (p = 0.009) in Group A compared to Group B post-treatment. Additionally, Group A showed a significantly greater reduction in VAS scores compared to Group B post-treatment (p = 0.003) (Table 2).

Cervical ROM improvements in Group A were significantly greater than in Group B for flexion (p = 0.002), extension (p = 0.005), right bending (p = 0.001), left bending (p = 0.001), right rotation (p = 0.001), and left rotation (p = 0.001) post-treatment (Table 3).

Discussion

The goal of this study was to investigate the effectiveness of adding Integrated Neuromuscular Inhibition Technique (INIT) to conventional therapy in improving craniovertebral angle (CVA), pain, and range of motion (ROM) in participants with forward head posture (FHP) and neck pain lasting more than three months.

The analysis of the current study’s data revealed significant improvements in both groups for CVA (16.12% in Group A and 7.20% in Group B) and Visual Analogue Scale (VAS) scores (75.61% in Group A and 57.14% in Group B). There was a significant increase in CVA (p = 0.01) and cervical ROM, including flexion (p = 0.002), extension (p = 0.005), right bending (p = 0.001), left bending (p = 0.001), right rotation (p = 0.001), and left rotation (p = 0.001). Additionally, a significant decrease in VAS scores (p = 0.003) was observed in Group A compared with Group B post-treatment.

The findings of the present study showed improvements across all assessed variables in both groups, with INIT demonstrating superior results. The improvement in CVA can be attributed to a reduction in the moment arm, leading to decreased torque generated by the muscles. This, in turn, reduces pain, improves ROM, and enhances craniocervical biomechanical alignment [31]. CVA is a critical indicator of pain in individuals with FHP, as a lower CVA causes cervical vertebrae to flex forward, increasing the load on neck extensors and adjacent connective tissues by increasing the external moment arm. Prolonged external moment arm loading generates higher torque in the muscles, causing pain and restricting ROM [31].

This study found significant differences in CVA in both groups; however, the improvement was greater in Group A due to the combined effects of INIT components: ischemic compression (IC), strain-counterstrain (SCS), and muscle energy techniques (MET). These techniques contributed to decreased pain, increased blood supply to the muscles, improved muscular extensibility through reflex relaxation, and viscoelastic and stretch changes [30,32,33]. The minimal clinically important difference (MCID) for CVA is 1.40 [34], indicating that the differences observed between the groups were both statistically and clinically significant.

Pain intensity and pressure pain thresholds

Pain intensity, measured by VAS, showed statistically significant differences between the groups. The MCID for VAS is 1.37 [35], indicating that these differences were clinically meaningful. Additionally, there were statistically and clinically significant differences in pressure pain thresholds (PPTs), with the MCID for PPT ranging from 17–33% [35].

The improvements in pain and ROM in Group A can be attributed to the positive effects of INIT’s three manual therapy techniques. First, intermittent IC reduces pain by stimulating A-beta fibers, which modulate the pain gate during compression and improve circulation upon release of pressure [15,32,33]. Second, SCS promotes ROM, function improvement, and pain reduction by positioning the muscle in a passively contracted state. This resets muscle spindle activity and enhances blood supply [36–38]. Finally, METs target autogenic inhibition of muscles by applying isometric contractions. This activates the Golgi tendon organ, leading to muscle relaxation and improved extensibility through reflex relaxation and viscoelastic changes, ultimately enhancing ROM [33,38].

Consistency with previous research

The results of this study align with previous research. Lytras et al. (2020) demonstrated the effectiveness of INIT combined with therapeutic exercise (TE) in managing mechanical chronic neck pain. Their study, involving 40 participants divided into two groups, found that individuals receiving INIT and TE showed significant improvements in PPT, Neck Disability Index (NDI), and VAS scores compared to those receiving TE alone [39].

Similarly, Abd El-Azeim et al. (2018) compared INIT and kinesiotape (KT) on VAS, NDI, and ROM, reporting the superiority of INIT across all variables [40]. Jyothirmai et al. (2015) also examined INIT’s effect on upper trapezius trigger points and observed improvements in VAS, cervical ROM (CROM), and NDI in groups treated with INIT alone or in combination with strengthening exercises [41].

The findings of this study are consistent with Sadat et al. (2018), who investigated INIT’s effect on pain thresholds and intensity in patients with upper trapezius trigger points. Their results showed a reduction in pain intensity, though no significant change in PPT was observed [42]. Similarly, Utrera et al. (2020) compared manual therapy and TE in nonspecific chronic neck pain. They found that manual therapy reduced pain faster, while TE provided quicker reductions in disability [43].

Role of conventional therapy

Conventional therapy may also contribute to improvements in CVA by enhancing the extensibility of muscles that limit ROM and reestablishing muscular balance between agonists and antagonists [44].

Limitations

This study was limited by its small sample size and the absence of a follow-up phase.

Conclusion

This research demonstrates that adding Integrated Neuromuscular Inhibition Technique (INIT) to conventional therapy effectively improves craniovertebral angle (CVA), pain, and range of motion (ROM) in individuals with neck pain and forward head posture (FHP).

Biographies

Dr .Rania Reffat Ali PhD, PT Assistant Professor of Physical Therapy ,Department of Basic Science, Faculty of Physical Therapy , Cairo University. Her Research interests focus on manual therapy, musculoskeletal rehabilitation, and in the clinical effectiveness of manual therapy techniques and their impact on pain management and functional recovery.

Somaya Nady Mohamed Elsayed PT Assistant lecturer of Physical Therapy, Department of Basic Science, Faculty of Physical Therapy, Cairo University. My Research interests focus on Musculoskeletal physical therapy Assessment and Management by using different therapeutic exercises and manual therapy techniques.

Dr.Ragia Mohamed Kamel PhD, PT Professor of Physical Therapy, Department of Basic Science, Faculty of Physical Therapy , Cairo University .Her Research interests include the role of musculoskeletal biomechanics, neuromuscular control, and pain science in physical therapy interventions ,manual therapy and therapeutic exercises.

Dr. Ebtisam Mohamed Fahmy PhD, Professor of Neurology, Faculty of Medicine ,Cairo university. Her Research interest include Neurological Assessment of Musculoskeletal Disorders.

Dr.Hend Ahmed hamdy PhD, PT lecturer of Physical Therapy ,Department of Basic Science, Faculty of Physical Therapy , Cairo University. Her Research interests include manual therapy and management of spine musculoskeletal disorder.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethical approval

This research was approved by Cairo University’s Faculty of Physical Therapy Research Ethics Committee and registered in the Clinical Trial Registry (NCT05439018).

Consent form

Before the study commenced, all participants received a detailed explanation of the procedures and signed informed consent forms.

Author contribution statement

• Rania Reffat Ali: Supervision, software validation.

• Somaya Nady: Data curation, methodology, writing, original draft preparation.

• Ragia Mohamed: Supervision, software validation.

• Ebtisam Mohamed: Supervision, software validation.

• Hend Hamdy: Writing, reviewing, supervision, software validation.

Recommendations

We recommend replicating this study with the inclusion of neck stabilization exercises for further evaluation.