Somatosensory & Motor Research

ISSN: 0899-0220 (Print) 1369-1651 (Online) Journal homepage: http://www.tandfonline.com/loi/ismr20

Forward head posture is associated with pressure

pain threshold and neck pain duration in
university students with subclinical neck pain

Joana Pacheco, João Raimundo, Filipe Santos, Mário Ferreira, Tiago Lopes,
Luis Ramos & Anabela G. Silva

To cite this article: Joana Pacheco, João Raimundo, Filipe Santos, Mário Ferreira, Tiago Lopes,
Luis Ramos & Anabela G. Silva (2018): Forward head posture is associated with pressure pain
threshold and neck pain duration in university students with subclinical neck pain, Somatosensory &
Motor Research, DOI: 10.1080/08990220.2018.1475352

To link to this article: https://doi.org/10.1080/08990220.2018.1475352

Published online: 08 Jun 2018.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ismr20
SOMATOSENSORY & MOTOR RESEARCH
https://doi.org/10.1080/08990220.2018.1475352

ARTICLE

Forward head posture is associated with pressure pain threshold and neck pain
duration in university students with subclinical neck pain
Joana Pachecoa, Jo~ao Raimundoa, Filipe Santosa, Mario Ferreiraa, Tiago Lopesa, Luis Ramosa and
Anabela G. Silvaa,b
a
School of Health Sciences, University of Aveiro, Aveiro, Portugal; bCenter for Health Technology and Services Research (CINTESIS), Porto,
Portugal

ABSTRACT ARTICLE HISTORY

Objective: The aims of this study are to investigate the association between: (i) forward head posture Received 27 February 2018
(FHP) and pressure pain thresholds (PPTs); (ii) FHP and maladaptive cognitive processes; and (iii) FHP Accepted 8 May 2018
and neck pain characteristics in university students with subclinical neck pain.
KEYWORDS
Materials/methods: A total of 140 university students, 90 asymptomatic and 50 with subclinical neck
Forward head posture; neck
pain, entered the study. Demographic data, anthropometric data, FHP, and PPTs were collected for pain; pressure pain
both groups. In addition, pain characteristics, pain catastrophizing, and fear of movement were threshold; university
assessed for participants with neck pain. FHP was characterized by the angle between C7, the tragus students
of the ear, and the horizontal line. Correlation analysis and multivariate regression analysis were
conducted.
Results: Participants with subclinical neck pain showed significantly lower PPTs than participants with-
out neck pain (p < .05), but similar FHP (p > .05). No significant association was found between FHP
and PPTs in the asymptomatic group. In the group of participants with subclinical neck pain, PPTs at
the right trapezius and neck pain duration explained 19% of the variance of FHP (R2 ¼ 0.23; adjusted
R2 ¼ 0.19; p < .05).
Conclusion: This study suggests that FHP is not associated with PPTs in asymptomatic university stu-
dents. In university students with subclinical neck pain, increased FHP was associated with right trapez-
ius hypoalgesia and with neck pain of shorter duration. These findings are in contrast with current
assumptions on the association between neck pain and FHP.

Introduction our knowledge, the potential relationship between FHP and

Ideal head posture is considered to be when the cranium is
not tilted, retracted, rotated, or extended (Kendall et al.
2005). An increase in the anterior position of the head in
relation to the trunk is often termed forward head posture
(FHP) (Kendall et al. 2005), which has been found to be
increased in individuals with neck pain when compared to
age- and sex-matched asymptomatic individuals (Yip et al.
2008; Lau et al. 2008). Furthermore, studies aiming to correct
FHP in patients with neck pain have reported that a decrease
in FHP is associated with a decrease in neck pain intensity
(Abdulwahab and Sabbahi 2000; Diab and Moustafa 2012).
However, how FHP relates to neck pain is unclear. Increased
FHP is likely to maintain ligaments and/or joint capsules in a
lengthened position, increasing loading on the neck struc-
tures. This could lead to peripheral nociceptive nerve sensi-
tization and consequently to lower pressure pain thresholds
(PPTs). Lower PPTs have already been reported for individuals
with a depressed shoulder when compared to individuals
with a normal shoulder (Azevedo et al. 2008). To the best of
PPTs has not been investigated.
Recently, FHP has been found to be associated with
depression (Richards et al. 2016) and cognition (Cohen et al.
2016). Previous research had already shown that positive
thoughts are easier to generate in upright postures while
negative thoughts are easier to generate in less correct pos-
tures (slumped postures) (Wilson and Peper 2004), support-
ing a close relationship between posture and mind
(Niedenthal 2007). Negative thoughts, such as catastrophizing
and fear of movement, are important factors in individuals
with neck pain (Lee et al. 2015), but to our knowledge, their
association with FHP has not been investigated.
The main aims of this study were to investigate the asso-
ciation between FHP and PPT in university students with and
without subclinical neck pain and between FHP and mal-
adaptive cognitive processes and pain characteristics in uni-
versity students with subclinical neck pain. We chose to use
university students as the university student population is
highly affected by neck pain, with 1-year prevalence reaching
46% (Kanchanomai et al. 2011), and are highly exposed to

CONTACT Anabela G. Silva asilva@ua.pt School of Health Sciences, University of Aveiro, Campus Universitario de Santiago, 3810-193 Aveiro, Portugal
Supplemental data for this article can be accessed here.
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
2 J. PACHECO ET AL.

information and communication technologies, which seem to
be related with increased FHP (Kang et al. 2012).
Furthermore, using participants with subclinical neck pain
may inform on the association between FHP and the main-
tenance of neck pain.
Materials and methods
The study took place at the School of Health, Aveiro
University. Participants provided written informed consent
and the study received ethical approval from the Aveiro
University Ethics Council.
Participants
Students of Aveiro University were invited to participate in
this study. To be included in the subclinical neck pain group,
participants had to: report chronic idiopathic neck pain,
defined as pain with no known cause felt between the super-
ior nuchal line and a horizontal line crossing the spinous pro-
cess of T1, at least once a week in the previous 3 months.
Subclinical neck pain was defined as pain of mild intensity
for which no treatment was received (except occasional pain-
killers). To enter the asymptomatic group, participants had to
report no current or previous neck pain. Both groups were
required to be 18 years old or older and report no current
musculoskeletal, neurological, or cardiorespiratory disorders.
motion and stopping at their usual head posture (Bister et al.
2002). Then C7–tragus–horizontal angle measurements were
taken. This procedure was repeated three times.
Measurements were taken from the left side based on a pre-
vious study that reported no significant differences between
right and left side measurements (Soares et al. 2012). The
C7–tragus–horizontal angle was found to be both reliable
and valid (van Niekerk et al. 2008).
Assessment of PPT
PPTs were measured using a pressure algometer
(CommanderTM Algometer, JTech Medical, Midvale, UT, USA) in
line with the procedures described by de Camargo et al.
(2011). Force was applied perpendicularly to the skin at a rate
of approximately 3 N/s with a ferrule of 0.5 cm2. Measurements
were taken bilaterally at the midpoint of the upper trapezius
and at C5/C6 articular pillars (Figures 1 and 2). The articular pil-
lar of C5/C6 and the upper trapezius muscle were chosen for
PPT measurements as they have been reported to be the most
common sites of neck pain (Ylinen et al. 2005).

Procedures
Participants attended the laboratory where measurements
were taken for one session only. Demographic, anthropomet-
ric, FHP, and PPT data were collected for both groups.
Measurements of FHP were taken before measurements of
PPT. In addition, neck pain characteristics, catastrophizing,
and fear of movement were also assessed in the neck pain
group. Fourth year physiotherapy students collected data
after adequate training and a reliability study with 10 asymp-
tomatic participants not included in the final study sample. Figure 1. Middle point of the upper trapezius muscle defined as the midpoint
between C7 and the posterior angle of the acromion.

Measurement of FHP
FHP was characterized by the angle between the seventh
cervical vertebra (C7), the horizontal line, and the tragus of
the ear (C7–tragus–horizontal angle). Lower values indicate
more FHP (De-la-Llave-Rinco n et al. 2009). A goniometer (EZ
Read JamarV Goniometer, Nottinghamshire) was used to
R

measure the C7–tragus–horizontal angle with an air bubble

level attached to the horizontal arm to inform the true hori-
zontal. Measurements were taken while participants were
standing in their stocking feet. Participants were instructed
to assume their usual head posture, keep a symmetrical dis-
tribution of their weight, with their feet shoulder width apart
and arms close to the body. The spinous process of C7 was
identified by palpation as described by Bister et al. (2002)
and marked with tape. To help participants assume their
usual head posture, they were asked to move their head
backwards and forwards, progressively reducing range of Figure 2. Identification of C5/C6 articular pillars.

Participants were in a prone lying position for the meas-
urement of the PPTs at the articular pillar of C5/C6 and in a
sitting position for measurements taken at the trapezius.
They were instructed to report ‘pain’ as soon as the feeling
of pressure changed to pain. The investigator would immedi-
ately remove the pressure algometer, which recorded the
maximum pressure applied. For familiarization with the pro-
cedure, the first trial was performed in the hypothenar region
of the hand. The maximum pressure of 60 N was not
exceeded to avoid tissue damage and a 30-s interval was
used between measurements. Three measurements were
taken for each point and the mean of the three measure-
ments used for data analysis. The investigator measuring PPT
was blind to FHP measurements.
C5/C6 articular pillars were identified as follows: first C7
was identified as previously described, then we palpated C6
and C5 and marked a point 1 cm laterally to the midpoint
between C6 and C5 spinous processes (Javanshir et al. 2010).
The midpoint of the trapezius was defined as the midpoint
of a line between the anterior angle of the acromion and C7.
The identification of these anatomical points was performed
with the participant seated and then confirmed in supine
position as PPTs for C5/C6 articular pillars were taken in this
position. PPT measurements have been shown to have good
intra- (ICC ¼ 0.86) and interrater reliability (ICC ¼ 0.76)
(Azevedo et al. 2008; Javanshir et al. 2010).
Neck pain characteristics
Neck pain intensity, location, and duration were assessed.
Intensity now was measured using a 10 cm visual analogue
scale (VAS) anchored with ‘no pain’ and ‘worst pain imagi-
nable.’ It has been shown to be reliable among literate
patients (r ¼ 0.94) (Ferraz et al. 1990). Location was assessed
using a body chart and pain was posteriorly categorized into
upper and/or lower neck pain by dividing the neck into two
equal halves. Pain duration was given in months or years
(months/years).
Catastrophizing and fear of movement
Pain catastrophizing was assessed using the pain catastroph-
izing scale (PCS), which has 13 statements grouped into three
subscales: rumination (4 items), magnification (3 items), and
helplessness (6 items). Total score ranges from 0 to 52 and
higher scores are indicative of higher catastrophic thinking
(Sullivan et al. 1995).
Fear of movement was assessed using the Tampa Scale of
Kinesiophobia (TSK), and integrates 13 items, which are rep-
resentative statements of each individual’s perception of fear
to perform a movement due to their pain. Scores range from
13 to 52, with higher scores representing a higher degree of
kinesiophobia (Cordeiro et al. 2013).
The Portuguese versions of the PCS and the TSK were
found to be reliable in individuals with neck pain (ICC  0.73)
(Martins et al. 2017).
SOMATOSENSORY & MOTOR RESEARCH 3
Statistical analysis
All statistical analyses were performed using SPSS Statistics
(IBM, New York, USA), version 24. Descriptive statistics were
used to characterize the sample: mean and standard devi-
ation for continuous variables and frequency for ordinal and
nominal variables. An ICC (two-way random, absolute agree-
ment) was used to assess within-session intrarater reliability
for FHP and PPT in a sample of participants not included in
the final study. To investigate the association between FHP
and demographics, PPT, pain characteristics, fear of move-
ment, and catastrophizing, a Spearman correlation coefficient
was used. The strength of the correlation was interpreted as
low (<0.3), moderate (0.3–0.5), and strong (>0.5) (Cohen
1998). For between-group comparisons a chi-square (nominal
variables) or an independent t-test (continuous variables)
was used.
Independent multiple linear regression models, using the
stepwise method, were used to predict FHP in both groups.
In the subclinical neck pain group, independent variables
were: weight, PPTs, helplessness, and neck pain duration. In
the asymptomatic group, independent variables were: weight
and PPTs. These independent variables were chosen as their
correlation with FHP was higher than 0. No multicollinearity
was present as assessed by a matrix of correlations and by
tolerance values <0.2 and variation inflation factor >10.
Results were considered statistically significant at p < .05.
Results
Within-session reliability
Measurements of FHP and PPTs showed high reliability. ICC
was: 0.93 (95% CI ¼ 0.90–0.95) for C7–tragus–horizontal angle
measurements, 0.90 (95% CI ¼ 0.86–0.93) for both left and
right trapezius PPT measurements, 0.81 (95% CI ¼ 0.72–0.87)
for the left articular pillar PPT measurements and 0.85
(95% CI ¼ 0.79–0.89) for the right articular pillar PPT
measurements.
Participants’ characteristics and between-group
comparisons
A total of 140 participants entered the study (90 asymptom-
atic and 50 with subclinical neck pain). Data on participants’
demographics, PPT, and FHP are presented in Table 1.
Participants with subclinical neck pain were older and shorter
than the asymptomatic group and showed lower PPTs for all
the four measurement sites. No significant between-group
difference was found for FHP.
Mean (± standard deviation) neck pain intensity at the
moment of data collection was 2.10 ± 1.80 and all but one
participant reported pain in the lower part of the neck. Of
the 49 participants with lower neck pain, 38 reported pain at
both the right and left sides, 3 on the right side only and 8
on the left side only. Table 1 also presents a detailed charac-
terization of neck pain, disability, fear of movement, and
catastrophizing.
4 J. PACHECO ET AL.

Table 1. Participants’ demographic characteristics.

Neck pain (n ¼ 50) Asymptomatic (n ¼ 90) p
Sex 8 males 26 males .109
42 females 67 females
Age (years) 20.80 ± 2.37 19.89 ± 1.15 .009
Weight (kg) 59.18 ± 10.34 61.80 ± 10.91 .170
Height (m) 164.44 ± 8.57 169.54 ± 9.17 .001
FHP ( ) 49.02 ± 4.66 47.89 ± 3.78 .090
PPT right trapezius (kgf) 15.49 ± 5.25 18.84 ± 8.27 .001
PPT left trapezius (kgf) 15.69 ± 6.02 18.26 ± 7.68 <.001
PPT C5–C6 right pillar (kgf) 13.44 ± 3.93 20.99 ± 7.59 .040
PPT C5–C6 left pillar (kgf) 13.53 ± 3.99 20.39 ± 6.80 .010
Neck pain intensity (VAS: 0–10) 2.10 ± 1.80
Catastrophizing (PCS) 16.08 ± 11.08
Fear of movement (TSK) 24.96 ± 5.02
Duration of neck pain (months) 35.98 ± 31.01
FHP: forward head posture; PPT: pressure pain threshold; VAS: visual analogue scale; PCS: pain catastrophiz-
ing scale; TSK: Tampa Scale of Kinesiophobia.

Table 2. Correlation between FHP and demographic variables, PPT, pain char- Table 3. Results for the regression analysis for the group with subclinical neck
acteristics, disability, catastrophizing, and fear of movement. pain and FHP as the independent variable (FHP: R2 ¼ 0.23; adjusted R2 ¼ 0.19).
Neck pain Asymptomatic Variable Coefficient 95% CI p
(n ¼ 50) (n ¼ 90) Constant 52.85 49.05; 56.65
Age (years) 0.03 0.03 PPT right trapezius 0.37 0.60; 0.13 .003
Weight (kg) 0.16 0.13 NP duration 0.05 0.01; 0.09 .012
Height (m) 0.09 0.04
PPT right trapezius (kgf) 0.34 0.08
PPT left trapezius (kgf) 0.17 0.14 with larger C7–tragus–horizontal angles (i.e., less FHP)
PPT C5–C6 right pillar (kgf) 0.23 0.05 (Table 3).
PPT C5–C6 left pillar (kgf) 0.22 0.08
Neck pain frequency 0.04
Neck pain intensity (VAS) 0.05
Neck pain duration 0.25 Discussion
Magnification 0.03
Rumination 0.02 We hypothesized that increased FHP would be associated
Helplessness 0.19 with decreased PPTs due to lengthening/stretching of soft
Catastrophizing (PCS—total score) 0.12
Fear of movement (TSK) 0.04 tissues and compression of joint surfaces. Results did not
FHP: forward head posture; PPT: pressure pain threshold; VAS: visual analogue support this hypothesis. In the asymptomatic group, no sig-
scale; PCS: pain catastrophizing scale; TSK: Tampa Scale of Kinesiophobia. nificant association was found between PPTs and FHP, sug-
p < .05.
gesting that the degree of FHP does not affect tissue
sensitivity in the lower neck and upper trapezius. In the sub-
Correlation analysis clinical neck pain group, only the PPT at the right trapezius
and the duration of pain remained significant in the multi-
In the asymptomatic group there was a weak and negative
variate model, explaining 19% of FHP variance. Nevertheless,
correlation between FHP and weight (r ¼ 0.13) and between
the direction of this association was opposite to what was
FHP and the PPTs at the left trapezius (r ¼ 0.14).
initially hypothesized as less FHP was associated with lower
In the group with neck pain, there was a moderate and
PPTs and neck pain of longer duration was associated with
negative correlation between FHP and PPTs measured at the
less FHP.
right trapezius (r ¼ 0.34, p < .05), a weak and negative cor-
Several aspects might explain the lack of association
relation between FHP and the PPTs at the remaining sites (r between FHP and PPTs in the asymptomatic group. There is
between 0.17 and 0.22) and between FHP and body no consensus on what constitutes normal FHP, which seems
weight (r ¼ 0.16). In addition, there was a weak and positive to show a wide variation (Silva et al. 2009a). Therefore, it
correlation between FHP and neck pain duration. Correlation may be that habitual mid-range FHPs do not increase tissue
analyses are presented in Table 2. No between-group differ- strain and that only end of range FHPs impose added strain
ence was found for FHP (p < .05). to neck structures. Previous studies reporting a decrease in
range of motion with an increase in FHP used end of range
Multivariate associations FHPs (i.e., asked participants to increase their habitual degree
of FHP) (Walmsley et al. 1996; Edmondston et al. 2005). A
In the asymptomatic group, no variable remained in the study investigating the association between habitual FHP
model. In contrast, in the neck pain group, PPT at the right and range of motion found no correlation between these
trapezius and neck pain duration were significantly associ- variables (Shaghayegh Fard et al. 2016). In addition, neck
ated with FHP and explained 19% of its variance (PPTs alone pain is associated with a variety of factors including physical
explained 10%). Increased PPTs seemed to be associated and psychological factors (Hogg-Johnson et al. 2009) and
with smaller C7–tragus–horizontal angles (i.e., more FHP) FHP has also been associated with factors other than pain,
while neck pain of longer duration seems to be associated such as mental concentration and psychosocial stress

(Shahidi et al. 2013). Furthermore, the absence of an associ-
ation between FHP and PPTs in asymptomatic individuals
and the direction of the association in participants with sub-
clinical neck pain suggest that increased FHP may be a com-
pensatory strategy to alleviate tissue sensitization, particularly
in the trapezius area and for subclinical neck pain. This
hypothesis contrasts with existing assumptions that FHP pre-
disposes to neck pain. Further research is needed before firm
conclusions can be made.
In line with the current study findings, previous studies
have found that patients with neck pain have significantly
lower PPTs than asymptomatic individuals (H€agg and Åstro €m
1997; La Touche et al. 2010; Fernandez-Perez et al. 2012),
and add to previous studies by showing increased sensitiza-
tion of nociceptors in young adults with subclinical and low
intensity neck pain. In contrast to previous studies was the
lack of a significant difference between groups for FHP (Lau
et al. 2008; Silva et al. 2009b). The different age range and
neck pain characteristics may contribute to explain the con-
trasting results. Nevertheless, the asymptomatic group
showed a lower mean for the C7–tragus–horizontal angle
(47.9 ± 3.8 ), indicative of more FHP, than was previously
reported for asymptomatic and older participants in previous
studies, which were 51.8 ± 5.9 , 50.6 ± 2.1 , and 55.0 ± 2.9
in the studies of Silva et al. (2009b), Lau et al. (2008), and Yip
et al. (2008), respectively. This suggests that the particular-
ities of the university students’ life, such as the time spent
using computers and on activities that require concentration,
may be associated with more FHP.
Interestingly, neither fear of movement nor catastrophiz-
ing were associated with FHP. Nevertheless, the mean values
of the TSK and the range of values of the PCS were not far
from those reported in previous studies for patients treated
for neck pain as their chief complaint (Pillastrini et al. 2016;
Park et al. 2016).
Study limitations and future work
In this study, we used a very specific sample, university stu-
dents, and therefore results may not apply to other samples
on asymptomatic or neck pain participants. We did not con-
trol for depression and anxiety, which could have an impact
on both PPTs and FHP, and we suggest that these should be
considered in future studies. Additionally, the body sites
tested (trapezius and C5/C6 articular pillar) do not cover the
whole neck area and other body sites, particularly in the
upper neck, should also be considered in future studies.
The exact changes in the vertebral alignment of the neck
and in muscle length that occur with an increase in FHP
have not been adequately characterized. Therefore, increases
in tissue strain may occur at body sites not assessed in the
present study.
In conclusion, this study suggests that FHP is not associ-
ated with PPTs in asymptomatic university students. In uni-
versity students with subclinical neck pain, increased FHP
was associated with right trapezius hypoalgesia and neck
pain of shorter duration. These findings are in contrast with
SOMATOSENSORY & MOTOR RESEARCH 5
current assumptions on the association between neck pain
and FHP and need to be further investigated.
Ethical issues
Participants provided written informed consent before entering the
study. The study received ethical approval from the Aveiro University
Ethics Council. The study protocol was not registered.
Disclosure statement
No potential conflict of interest was reported by the authors.
References
Abdulwahab SS, Sabbahi M. 2000. Neck retractions, cervical root decom-
pression, and radicular pain. J Orthop Sports Phys Ther. 30:4–9.
Azevedo DC, de Lima Pires T, de Souza Andrade F, McDonnell MK. 2008.
Influence of scapular position on the pressure pain threshold of the
upper trapezius muscle region. Eur J Pain. 12:226–232.
Bister D, Edler RJ, Tom BD, Prevost AT. 2002. Natural head posture-con-
siderations of reproducibility. Eur J Orthod. 24:457–470.
Cohen J. 1998. Statistical power analysis for the behavioral sciences. 2nd
ed. Hillsdale: Lawrence Erlbaum.
Cohen RG, Vasavada AN, Wiest MM, Schmitter-Edgecombe M. 2016.
Mobility and upright posture are associated with different aspects of
cognition in older adults. Front Aging Neurosci. 8;8:257.
Cordeiro N, Pezarat-Correia P, Gil J, Cabri J. 2013. Portuguese
language version of the tampa scale for kinesiophobia. J.
Musculoskelet Pain. 21:58–63.
de Camargo VM, Alburquerque-Sendın F, Berzin F, Stefanelli VC, de
Souza DP, Fernandez-de-las-Pen ~as C. 2011. Immediate effects on elec-
tromyographic activity and pressure pain thresholds after a cervical
manipulation in mechanical neck pain: a randomized controlled trial.
JMPT. 34:211–220.
De-la-Llave-Rinco n AI, Fernandez-de-las-Pen
~as C, Palacios-Cen
~a D, Cleland
JA. 2009. Increased forward head posture and restricted cervical range
of motion in patients with carpal tunnel syndrome. J Orthop Sports
Phys Ther. 39:658–664.
Diab AA, Moustafa IM. 2012. The efficacy of forward head correction on
nerve root function and pain in cervical spondylotic radiculopathy: a
randomized trial. Clin Rehab. 26:351–361.
Edmondston SJ, Henne S-E, Loh W, Østvold E. 2005. Influence of cranio-
cervical posture on three-dimensional motion of the cervical spine.
Man Ther. 10:44–51.
Fernandez-Perez AM, Villaverde-Gutierrez C, Mora-Sanchez A, Alonso-
Blanco C, Sterling M, Fernandez-de-Las-Pen ~as C. 2012. Muscle trigger
points, pressure pain threshold, and cervical range of motion in
patients with high level of disability related to acute whiplash injury.
J Orthop Sports Phys Ther. 42:634–641.
Ferraz MB, Quaresma MR, Aquino LR, Atra E, Tugwell P, Goldsmith
CH. 1990. Reliability of pain scales in the assessment of literate
and illiterate patients with rheumatoid arthritis. J Rheumatol.
17:1022–1024.
H€agg GM, Åstro €m A. 1997. Load pattern and pressure pain threshold in
the upper trapezius muscle and psychosocial factors in medical secre-
taries with and without shoulder/neck disorders. Int Arch Occup
Environ Health. 69:423–432.
Hogg-Johnson S, van der Velde G, Carroll LJ, Holm LW, Cassidy JD,
Guzman J, Co ^te P, Haldeman S, Ammendolia C, Carragee E, et al.
2009. The Burden and determinants of neck pain in the general popu-
lation: results of the bone and joint decade 2000-2010 task force on
neck pain and its associated disorders. J Manipulative Physiol Ther.
32:S46–S60.
Javanshir K, Ortega-Santiago R, Mohseni-Bandpei MA, Miangolarra-Page
JC, Fernandez-de-Las-Pen ~as C. 2010. Exploration of somatosensory
6 J. PACHECO ET AL.
impairments in subjects with mechanical idiopathic neck pain: a pre-
liminary study. J Manipulative Physiol Ther. 33:493–499.
Kanchanomai S, Janwantanakul P, Pensri P, Jiamjarasrangsi W. 2011. Risk
Factors for the onset and persistence of neck pain in undergraduate
students: 1-year prospective cohort study. BMC Public Health. 11:566
Kang JH1, Park RY, Lee SJ, Kim JY, Yoon SR, Jung KI. 2012. The effect of
the forward head posture on postural balance in long time computer
based worker. Ann Rehabil Med. 36:98–104.
Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. 2005.
Muscles Testing and function, with posture and pain. Philadelphia:
Lippincott Williams & Wilkins.
La Touche R, Fernandez-de-Las-Pen ~as C, Fernandez-Carnero J, Dıaz-
Parren~o S, Paris-Alemany A, Arendt-Nielsen L. 2010. Bilateral mechan-
ical-pain sensitivity over the trigeminal region in patients with chronic
mechanical neck pain. J Pain. 11:256–263.
Lau H, Chiu T, Lam T. 2008. Clinical measurement of craniovertebral
angle by electronic head posture instrument: a test of reliability and
validity. Man Therapy. 14:363–368.
Lee H, H€ ubscher M, Moseley GL, Kamper SJ, Traeger AC, Mansell G,
McAuley JH. 2015. How does pain lead to disability? a systematic
review and meta-analysis of mediation studies in people with back
and neck pain. Pain. 156:988–997.
Martins F, Bento A, Silva AG. 2017. Within-session and between-session
reliability, construct validity, and comparison between individuals with
and without neck pain of four neck muscle tests. PM R. 10:183–193.
Niedenthal PM. 2007. Embodying emotion. Science. 316:1002–1005.
Park SJ, Lee R, Yoon DM, Yoon KB, Kim K, Kim SH. 2016. Factors associ-
ated with increased risk for pain catastrophizing in patients with
chronic neck pain: a retrospective cross-sectional study. Medicine
(Baltimore). 95:e4698
Pillastrini P, de Lima E Sa Resende F, Banchelli F, Burioli A, Di Ciaccio E,
Guccione AA, Villafan ~e JH, Vanti C. 2016. Effectiveness of global pos-
tural re-education in patients with chronic nonspecific neck pain:
randomized controlled trial. Phys Ther. 96:1408–1416.
Richards KV, Beales DJ, Smith AJ, O'Sullivan PB, Straker LM. 2016. Neck
Posture Clusters and Their Association With Biopsychosocial Factors
and Neck Pain in Australian Adolescents. Phys Ther. 96:1576–1588.
Shaghayegh Fard B, Ahmadi A, Maroufi N, Sarrafzadeh J. 2016.
Evaluation of forward head posture in sitting and standing positions.
Eur Spine J. 3577–3582.
Shahidi B, Haight A, Maluf K. 2013. Differential effects of mental concen-
tration and acute psychosocial stress on cervical muscle activity and
posture. J Electromyogr Kinesiol. 23:1082–1089.
Silva AG, Punt TD, Sharples P, Vilas-Boas JP, Johnson MI. 2009a.
Head posture assessment for patients with neck pain: is it use-
ful? Int J Ther Rehab. 16:43–53.
Silva AG, Punt TD, Sharples P, Vilas-Boas JP, Johnson MI. 2009b. Head
posture and neck pain of chronic nontraumatic origin: a comparison
between patients and pain-free persons. Arch Phys Med Rehabil.
90:669–674.
Soares JC, Weber P, Trevisan ME, Trevisan CM, Rossi AG. 2012.
Correlation between head posture, pain and disability index
neck in women with complaints of neck pain. Fisioterapia Pesq.
19:68–72.
Sullivan MJL, Bishop S, Pivik J. 1995. The pain catastrophizing scale:
development and validation. Psychol Assess. 7:524–532.
van Niekerk S, Louw Q, Vaughan C, Grimmer-Somers K, Schreve K. 2008.
Photographic measurement of upper-body sitting posture of high
school students: a reliability and validity study. BMC Musculoskelet
Disord. 9:113.
Walmsley RP, Kimber P, Culham E. 1996. The effect of initial head
position on active cervical axial rotation range of motion in two age
populations. Spine. 21:2435–2442.
Wilson VE, Peper E. 2004. The effects of upright and slumped postures
on the recall of positive and negative thoughts. Appl Psychophysiol
Biofeedback. 29:189–195.
Yip CH, Chiu TT, Poon AT. 2008. The relationship between head posture
and severity and disability of patients with neck pain. Man Ther.
13:148–154.
Ylinen J, Takala EP, Kautiainen H, Nyk€anen M, H€akkinen A, Pohjolainen T,
Karppi SL, Airaksinen O. 2005. Effect of long-term neck muscle train-
ing on pressure pain threshold: a randomized controlled trial. Eur J
Pain. 9:673–681.