The Effect of Focus Approaches on Neck Region Muscle Activation

Investigation of the Effect of Externally Vs. Internally Focused Techniques on Neck Region Muscle Activation During Postural Correction Exercises in Individuals with Forward Head Posture: Prospective Randomized Crossover Study

Forward Head Posture (FHP) causes muscle imbalances in the neck and shoulder regions. Various exercises are suggested to correct FHP. During these exercises, internal and external focus techniques are used to enhance motor learning and improve muscle balance. However, there are no studies examining how these approaches affect neck muscle activation in individuals with FHP. Therefore, the purpose of this study is to investigate the effects of external and internal focus techniques, aimed at improving cervical alignment during postural correction exercises, on cervical muscle activation in individuals with FHP.

Various corrective exercises are suggested in the literature to address Forward Head Posture (FHP). For individuals without musculoskeletal issues, chin-tuck and scapular retraction exercises in a supine position have strong evidence for effectiveness. Scapular stabilization exercises help reduce negative mechanical loads caused by abnormal scapular and cervical spine positions. Additionally, focusing attention on the exercise or target area is used to enhance motor learning and muscle balance, with external focus shown to improve performance in various tasks compared to internal focus.

In clinical practice, it is essential to maintain cervical alignment during scapular retraction exercises for individuals with FHP. To optimize muscle balance during these exercises, instructions often emphasize keeping the chin-tuck position to avoid cervical protraction. Internal and external focus approaches during scapular retraction exercises may help balance the muscle imbalances in individuals with FHP. However, no studies have yet examined the effects of internal and external focus approaches on neck muscle activation in individuals with FHP.

Thirty participants with FHP, defined as having a craniovertebral angle less than 50 degrees, will be included in the study. Participants will perform scapular retraction exercises (bilateral row) with a theraband and T-exercises in a prone position. The exercises will be carried out under three conditions: without guidance (control - no corrective cues for the cervical region), external focus, and internal focus. A laser headband will be used for the external focus condition. Muscle activation of the Upper Trapezius, Middle Trapezius, Lower Trapezius, Serratus Anterior, and Sternocleidomastoid muscles will be measured using the Noraxon MiniDTS system (Noraxon, USA, Inc, Scottsdale, AZ). Muscle activation will be calculated as a percentage of Maximum Voluntary Isometric Contraction (MVIC), and the % MVIC values will be used for analysis. The order of exercises will be randomized.

Inclusion Criteria:

• Aged between 18-35 years,
• Craniovertebral angle (CVA) less than 50 degrees,
• Willing to not participate in any treatment/evaluation during the study,
• Voluntary participation.

Exclusion Criteria:

• Experiencing pain in the neck, spine, upper or lower extremities for the past 3 months,
• Body mass index (BMI) greater than 25 kg/m²,
• History of neck injuries or surgeries such as intervertebral disc herniation, spondylosis, radiculopathy, chronic headaches, or whiplash,
• Any visual, auditory, or sensory impairments,
• Temporomandibular joint issues,
• Neurological (e.g., epilepsy), rheumatological, or orthopedic symptoms,
• Any conditions affecting balance and muscle control,
• Cardiopulmonary or systemic diseases that prevent exercise.