TABLE OF CONTENTS

INTRODUCTION ..........................................................................................................................................2
Rationale: ....................................................................................................................................................4
RESEARCH QUESTION...............................................................................................................................4
OBJECTIVES .................................................................................................................................................4
Primary Objectives .....................................................................................................................................4
Secondary Objective ...................................................................................................................................4
HYPOTHESIS ................................................................................................................................................4
Null Hypothesis ..........................................................................................................................................4
Alternative Hypothesis ...............................................................................................................................5
OPERATIONAL DEFINITION .....................................................................................................................5
Forward Head Posture: ...............................................................................................................................5
Breathing: ...................................................................................................................................................5
MATERIALS AND METHODS ....................................................................................................................5
Study Design ...............................................................................................................................................6
Study Population .........................................................................................................................................6
Study Setting ...............................................................................................................................................6
Study Duration ............................................................................................................................................6
Sampling Technique ...................................................................................................................................6
Sample Size ................................................................................................................................................6
Sampling Procedure ....................................................................................................................................7
Inclusion Criteria ....................................................................................................................................7
Exclusion Criteria ...................................................................................................................................7
Measuring Outcomes Variables ..................................................................................................................7
DATA COLLECTION PROCEDURE...........................................................................................................7
Craniovertebral angle (CVA):.....................................................................................................................8
Self-evaluation breathing questionnaire (SEBQ):.......................................................................................8
Breath-Hold time: .......................................................................................................................................9
DATA ANALYSIS.........................................................................................................................................9
BIBLIOGRAPHY .........................................................................................................................................10

1
INTRODUCTION

Forward head posture (FHP) is a poor habitual neck posture defined by hyperextension of the
(1)
upper cervical vertebrae and forward translation of the cervical vertebrae. Studies have
reported that symptoms, including neck pain, headache, temporomandibular pain, and
musculoskeletal disorders, are related to FHP. FHP greatly influences respiratory function by
weakening the respiratory muscles and results in respiratory dysfunction. The muscles
participating in primary inspiration are the Diaphragm, the external, internal intercostal
muscles, parasternal, internal intercostal muscles, and the scalene group, out of which the
Diaphragm provides 70%-80% of the inhalation force. There is a fascia continuity between the
Diaphragm's apex and the skull's base. Any discontinuity or stress affecting its structure will
directly affect other parts of the structure, compromising the breathing mechanism and
(2)
resulting in dysfunctional Breathing. Risk factors associated with forward head posture
include female gender, older age, being an ex-smoker, high job demands, and low social or
work support. (3) Studies show that computer and smartphone users have a significantly greater
risk of developing forward head posture. (4)

Many studies have been conducted measuring forward head posture in institutions worldwide.
In Pakistan, the prevalence of forward head posture was found to be 63.96%, according to a
study in 2018. (5) A study on Indian students showed that 58.5% of affected students were not
(4)
aware of their forward head posture. A recent study in 2022 measured the prevalence of
breathing dysfunction in individuals with musculoskeletal disorders and found the prevalence
to be 62% in individuals with the back and neck involved and with the knee at 50%. They also
associated prevalence with gender and showed females at 70.16% and males at 67.7% prevalent
for breathing dysfunction. (2)

This study will assess the population's forward head posture (FHP) using goniometry.
Craniovertebral angle (CVA) will be measured with the help of a goniometer. Individuals with
CVA less than 53 degrees will be marked as having a forward head posture and included for
assessment of Breathing. (5) To determine the impact of FHP on Breathing, both subjective and
objective tools will be used. Objective assessment will include measuring Breath-hold time
with an electronic stopwatch. Subjective assessment will be done through Self Evaluation
Breathing Questionnaire(SEBQ). (6)

2
Physiotherapy Management of FHP includes postural alignment and improving joint mobility
and range of motion. (7) Studies suggest that therapeutic exercises may result in large changes
in CVA and moderate improvement in neck pain in participants with FHP. (8) Reducing spasms,
muscle strengthening, endurance training, and maintenance of ergonomics are also considered
(9)
physiotherapy protocols for managing FHP. Limited literature is found on treating
dysfunctional Breathing as it mainly involves the treatment of associated symptoms. A
systemic review aimed to determine whether breathing retraining has beneficial effects or
improves the life quality of children with dysfunctional Breathing. They used electronic and
manual methods to search CENTRAL, MEDLINE, EMBASE, and National Research Register
(NRR) Archive. They screened 224 papers and found no studies that could provide evidence
on whether breathing retraining is effective in managing children with dysfunctional Breathing.
(10)

A study included 197 students from 4 different universities in Pakistan and found the
prevalence of forward head posture to be 69.96%, including both male and female students. (11)
Pushpendra Yaduvanshi et al. conducted a study on the Screening of FHP and its impact on
daily lives. They found a significant prevalence of forward head posture, and this lousy posture
has specific adverse effects on daily activities. (12) Studies indicate that forward head posture
could reduce vital capacity, possibly because of weakness or disharmony of the accessory
respiratory muscles. (13) A study showed that Forward head posture increased the activities of
the sternocleidomastoid muscles and the anterior scalene muscles and decreased the forced
vital capacity. It found a positive correlation between the CVA and the forced vital capacity,
while a negative correlation was observed between the CVA and the sternocleidomastoid
muscle. (14) A study included 83 adults with suspected breathing dysfunction, including 29 with
abnormal spirometry values, and found breath-hold time was significantly shorter in people
(15)
with abnormal spirometry (FEV1 or FVC < 15% below predicted) A research studied
effects of FHP on cranial morphology and concluded that 70% of cases show relation existing
(16)
between head posture, craniofacial morphology, and craniomandibular dysfunction. A
study explored the effect of different head and neck positions on respiratory function. The
participants were instructed to actively adopt forward head and torticollis postures by bending
and rotating the neck. Respiratory functions were assessed in those positions, which showed
that alteration of head and neck postures affected respiratory function. (17)

3
Rationale:
Limited literature was found on the association of FHP with Breathing function, and no such
study was previously conducted in our region. Our study will counter-weigh the limitations of
related studies performed in the past. Most of the previous studies on FHP were associated with
activities of daily life (ADLs) or neck pain; few related it with respiratory function, mainly
including lung capacities and spirometry. Lung functioning is an immense term, so it needs
several aspects to describe it, which cannot be covered in a single study. This study takes a
different angle of describing it, which was not covered in past studies.

This study aims to find the relationship between FHP and Breathing function. As forward head
posture is prevalent in the young generation, this study will provide valuable knowledge to the
whole community about postural care closely related to our regional population.

RESEARCH QUESTION
What is the prevalence of forward head posture and its impact on breathing among students of
Ibadat International University, Islamabad?

OBJECTIVES

Primary Objectives
To find the prevalence of forward head posture in students of Ibadat International University.

Secondary Objective
To find the impact of forward head posture on the Breathing of university students.

HYPOTHESIS

Null Hypothesis
● Forward head posture is not prevalent among students of IIUI.

● Forward head posture has insignificant impact on Breathing.

4
Alternative Hypothesis
● Forward head posture is prevalent among students of IIUI.

● Forward head posture has significant impact on Breathing.

As the study is descriptive, no hypothesis testing is conducted.

OPERATIONAL DEFINITION

Forward Head Posture:

The forward head position is characterized by a dorsal extension of the head together with the
upper cervical spine (Cl-C3), accompanied by a flexion of the lower cervical spine (C4-C7),
whereby the cervical curvature is increased, a condition called hyperlordosis. This abnormal
postural position is most frequently adopted and maintained by patients as a response to a
pathological condition. (16) In this study, individuals with a craniovertebral angle less than 53
degrees will be marked positive for forward head posture.

Modern-day lifestyle has become a significant reason for FHP. A recent study shows that
almost 78% of the population have their neck in a working position within 24 hours, causing
continuous stress on the neck and shoulders, forcing the neck into an anterior or forward head
posture. FHP is a commonly seen disorder among younger adults. (18)

Breathing:
Breathing movements depend on a pump, resistance, and accessory muscles. Pump muscles
include the dome-like, Diaphragm and the external intercostals. During inspiration, the descent
of the Diaphragm and rib elevation by the external intercostals expands the lungs to draw in
air. The oblique abdominals and transverses abdominus, and internal intercostals are expiratory
pump muscles. Airway resistance muscles, which control inspiratory and expiratory airflow,
include skeletal muscles of the tongue (including the genioglossus and the hyoglossus,
styloglossus and stylohyoid muscles), glottis, larynx, and pharynx, as well as smooth muscle
of the bronchi. (19)

The regulation of Breathing relies on feedback from peripheral and central chemosensors.
Carotid bodies, at the branch point of the carotid arteries, monitor the partial pressure of O2

5
(pO2), the partial pressure of CO2 (pCO2), and pH in arterial blood and signal to the brainstem
via the glossopharyngeal nerve (cranial nerve IX). (19)

MATERIALS AND METHODS

Study Design
The study design used will be a Descriptive Cross-Sectional Study

Study Population
The population will be "Students of Ibadat International University, Islamabad."

Study Setting
The study setup will be at Ibadat International University, Islamabad.

Study Duration
The study will be completed in 6 months post the approval of the synopsis

Sampling Technique
Non-probability Convenient sampling technique will be considered to collect the sample.

Sample Size
Data about the university population was requested from the HR department of Ibadat
International University, Islamabad, which is:

● Currently enrolled students = 3000

● Currently active students = 2138

According to Slovin's Formula:

𝑁 3000
n= = = 352.94 = 353 (rounded off to nearest unit)
1+𝑁𝑒2 1+3000 (0.05)2

Where,

● n = no. of samples collected from the setting

● N = Total population of the study setting

6
 ● e = Margin of error (0.05)

Sampling Procedure
Inclusion Criteria
● Age 18-25

● Students of Ibadat International University, Islamabad

● Forward Head Posture (CVA<53)

● Both male and female genders

Exclusion Criteria
● Smoker/ Addict

● Lung diseases (any active or former)

● Cardiovascular diseases

● Traumatic injury to chest or cervical region in previous six months

Measuring Outcomes Variables

● Craniovertebral Angle (degrees)
• Goniometer

● SEBQ score (0 - 75)

● Breath-hold time (seconds)

▪ Stopwatch

● Body-Mass Index
▪ Weight machine

DATA COLLECTION PROCEDURE

Permission will be taken from the head of the department of physical therapy (Dr. Ishaq
Ahmed; PT), the Institutional Review Committee (IRC), and the Ethical Review Board (ERB)

7
of the Ibadat International University, Islamabad. The participants willing to participate in the
study will be asked to sign a consent form. A semi-structured questionnaire will be given to
the participants, including questions about the prevalence of FHP and its impact on Breathing.

The study will measure forward head posture by measuring craniovertebral angles with a
goniometer; individuals with an angle less than 53 degrees will be further tested for breathing
dysfunction.

Craniovertebral angle (CVA):

It is the acute angle formed between a straight line connecting the spinous process of C7 to the
tragus of the ear and the horizontal line passing through the spinous process of the C7.
Participants will be asked to stand still with their hands and neck relaxed in a comfortable
position while looking forward at the level of their eyes. The resting arm of the goniometer
will be placed in a horizontal line with C7 prominence, while the moveable arm will be brought
right above the tragus of the ear. The angle will be recorded rounded to the nearest unit.

A study tested this device on 23 young male subjects, including two independent testers, and
found it accurate. They measured its Inter-rater reliability using Cronbach's alpha value of
(20)
0.893. The device is simple, cost-effective, and reliable for clinical physiotherapy for
objectively assessing the forward head posture. It is a reliable method for objectively assessing
forward head posture in daily clinical physiotherapy practice as a reliable alternative to high-
end equipment that may not always be available. (20)

Self-evaluation breathing questionnaire (SEBQ):

The 25-item Self Evaluation of Breathing Questionnaire (SEBQ) has been developed to
measure breathing-related symptoms. Participants with FHP will be asked to respond to 25
questions by marking from 0 to 3 where (0) is /not true at all; (1) is occasionally/a bit true; (2)
is frequently-mostly true, and (3) is very frequently/very true. Data will later be analyzed, and
scores greater than 11 will be marked as significant.

A study included 180 participants and showed high internal consistency with Cronbach's α
value of 0.93. The SEBQ has high test-retest reproducibility and thus may be a useful clinical
screening tool for dysfunctional Breathing. (21)

8
Breath-Hold time:
Breath-holding ability is an aspect of breathing functionality commonly less in individuals with
dysfunctional Breathing. Individuals will be asked to sit on comfortable chairs in a quiet room.
They will be instructed to take two deep breaths, and just after they expire their second breath,
they will pinch their nose with their hand; and hold until any involuntary movement to breathe
in. The time during hold will be measured using an electronic stopwatch with an accuracy of
0.01 seconds, then rounded off to 0.1 seconds. Two measurements for each individual will be
taken with a rest of at least one minute in between. The mean value will be calculated for later
analysis.

A study included 84 self-referred or practitioner-referred individuals and assessed their

Breathing using breath hold time as a screening tool to identify dysfunctional Breathing. They
employed the Buteyko Method technique of the Control pause and marked individuals showing
breath hold time of fewer than 20 seconds with dysfunctional Breathing. (15)

DATA ANALYSIS
Data will be analyzed by software named IBM SPSS (Statistical Package for the Social
Sciences) Statistics v26 2019

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