International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Original Research Article

Effect of McKenzie Self-Therapy Protocol on

Forward Head Posture and Respiratory Functions
of School Going Adolescent Girls
Shreya Joshi1, Megha Sheth2
1
Intern, SBB College of Physiotherapy, Ahmedabad, Gujarat
2
Lecturer, SBB college of Physiotherapy, Ahmedabad, Gujarat
Corresponding Author: Shreya Joshi

ABSTRACT

Background: The McKenzie exercise is a self-therapy exercise done through repetitive motions.
Objective of this study was to find effect of McKenzie self-therapy protocol on Forward Head Posture
and respiratory functions of adolescent girls.
Materials and Methods: An experimental study was conducted on 60 school going girls randomly
allocated into two groups. Group A was given McKenzie self-therapy for 12 weeks and group B was
control. Forward head angle was measured by measuring craniovertebral angle (CVA). Peak
expiratory flow rate (PEFR) was measured by peak expiratory flow meter.
Results: Difference in CVA-group A(t=-3.77,p=0.001) and PEFR(Z=-3.97,p<0.01). For group B
difference in CVA (t=-0.289,p=0.77) for PEFR(Z=-3.886,p,0.01). Between group for CVA
(t=2.06,p=0.04) and for PEFR(Z=-0.052,p=0.962) was seen.
Conclusion: Significant difference was seen in forward head posture and respiratory function with
McKenzie self-therapy. Significant difference was seen in respiratory function in control group.
Difference in CVA was more in exercise group and respiratory function was not significantly
different between the groups.

Keywords: Forward head posture, Cranio-vertebral angle, Peak expiratory flow rate, McKenzie self-
therapy

INTRODUCTION examination no significant impairments in

Postural orientation is defined as flexibility and strength are found. But if the
control of the relative positions of body faulty posture continues it tends to result in
parts by skeletal muscles with respect to postural dysfunction. Postural dysfunction is
each other and gravity during activity of defined as the weakness and adaptive
daily living. Good postural habits in the shortening of soft tissues. Mechanical stress,
adult are necessary to avoid postural pain impaired postural support (stretch weakness
syndromes and postural dysfunctions. A or tight weakness because of shift in length-
postural fault is a posture that deviates from tension curve) and impaired muscle
normal alignment but has no structural endurance are the major factors playing role
impairments. Postural pain syndrome refers in pain syndromes related to impaired
to the pain that result from the mechanical posture. (1)(2)
stress when a person maintains faulty Forward head posture (FHP) is
posture for a prolonged period of time. Pain defined as excessive anterior positioning of
is usually relieved with activity and on the head in relation to a vertical reference

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Shreya Joshi et.al. Effect of McKenzie Self-Therapy Protocol on Forward Head Posture and Respiratory
Functions of School Going Adolescent Girls

that is plumb line (Line of Gravity) in respiratory system functioning which can be
sagittal plane. (3) A forward head involves done easily by patient using peak flow
increased flexion of the lower cervical and meter. (8)
upper thoracic regions, increased extension McKenzie self-therapy exercises are
of the upper cervical vertebrae and a set of exercises which focus on flexibility
extension of the occiput on C1. The cranio- of muscle groups around the cervical spine
vertebral angle (CVA) is defined as the which helps to maintain normal spinal
angle of the horizontal line running through alignment and includes mobilization and
the C7 spinous process and the line manipulation. Its main focus is on stretch
connecting the C7 spinous process to the exercises. This self-therapy also showed
tragus of the ear. (4) FHP in school going effective results in reducing pain. (3) Studies
adolescents can be because of sitting at a on effects of McKenzie self-therapy
desk for a long time, use of desks and chairs exercises on FHP and PEFR are less so the
not appropriate for the physique, a bed not aim of the study is to find the effect of
conducive to good posture, lack of exercise, McKenzie self-therapy on forward head
excessive learning activities, and heavy posture and respiratory function of school
school bags. (4) Increasing use of electronic going girls.
screens, such as smart phones and personal
computers, to an average of about 8 hours MATERIALS AND METHODS
per day, has led to an increasing number of This study was done in Vadodara,
people with forward head posture. (4) Verma Gujarat, India (Adarsh Nivasi School).
et al. identified the prevalence of FHP Permission from the principal was taken to
among 12–16-year-old school going perform this study. The study was explained
students in Gujarat, India to be 63%. (5) to all students. This study was done on 60
Forward Head Posture can cause muscle school going adolescent girls. Participants
ischemia and spasm, pain, fatigue, who were 13-16 years old with CVA less
decreased range of motion of cervical spine than 55° and who enrolled themselves
as well as shoulder, early disc degeneration willingly for participation were included.
and osteophyte formation, possible According to the school medical records,
protrusion of nucleus pulposus and nerve students who had neuromuscular,
compression, tension headache, increased respiratory, musculoskeletal or
thoracic kyphosis, decreased vital capacity cardiovascular impairments, psychological
and Temporo-Mandibular joint pain and co morbidities and congenital disorders
inflammation. were excluded from this study. Participants
Peak Expiratory Flow Rate (PEFR) were explained whole procedure
can be determined by volume of the lungs, thoroughly. Assent to participate was taken
elastic properties of the lung and the power from the participants. Participants were
and co-ordination of expiratory muscles in randomly assigned to two different groups
healthy people. Movements of thoracic rib of 30 participants by random table. Group A
cage are interdependent with spinal was given intervention and group B was
movements and other surrounding joints. kept in waiting period. Group A girls were
Forward head posture can aggravate given McKenzie self-therapy on daily
thoracic kyphosis which may hamper follow up basis. Outcomes were forward
thoracic mobility especially thoracic head angle and peak expiratory flow rate.
extension. Because of flexed thoracic spine Forward head posture was measured
individual may have neck pain, depression by craniovertebral angle by
of ribs and therefore excursion will be photogrammetry. (9) A digital photograph of
limited and respiratory functioning will sagittal view was taken in standing by
have a negative effect. (6)(7) PEFR is simple Nikon S3100, placed at a distance of 1.5
outcome measure used to determine meter on a fixed base without rotation or tilt.

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Vol.9; Issue: 12; December 2019
Shreya Joshi et.al. Effect of McKenzie Self-Therapy Protocol on Forward Head Posture and Respiratory
Functions of School Going Adolescent Girls

The height of the camera was adjusted to the

level of the subject’s shoulder. Participants
were asked to have a natural head position
and then instructed to assume normal resting
standing position on barefoot. Neck region
was sufficiently exposed, jewelries were
removed and hair was tied. Colored tape
was used to mark tragus of the ear and C7
spinous process. Taken image was
digitalized and CVA was measured using
adobe photoshop CS6 software. Which is
shown in Figure 1.
Figure 2: PEFR measurement

Group of six exercises (McKenzie self-

therapy exercises) were given to group A.
1) chin tucks
2) neck flexion extension side bending and
rotation(until it has reached the full
stretched point)
3) scapular protraction retraction (until it
has reached the full stretched point)
Figure 1: photogrammetry method for CVA measurement
4) move the head in backward direction, and
turn it until it has reached the fully stretched
Respiratory function was measured
point
by peak expiratory flow meter in sitting
5) Lower the head, and turn it until it has
position. (10) Participants were asked to sit
reached the maximal point
with back supported straight in the chair and
Intervention was given for 12weeks.
feet flat on the floor. Participants were
Participants of group A were asked to do
asked to remove any food or gum from the
exercises on six days per week. Each motion
mouth. At the beginning, it was made sure
had to be maintained for 10 sec followed by
that scale on the meter pointed at zero.
5 sec rest. Each subject performed 10 sets.
Participants were asked to hold peak flow
All exercises took 30 minutes to perform.
meter exact horizontally and at 90 degree
Correct method of exercises was shown to
angle. Mouth piece was placed in correct
the participants and material was provided
manner to avoid acceleration of air with the
to show how to carry out correct way of
tongue. Participants were asked to inhale
deeply and slowly and asked to place exercise. Weekly follow ups were done to
see whether protocol is going correctly or
mouthpiece on tongue (they were asked not
to put tongue in the hole) and close the lips not. Group B participants were allowed to
participate in daily sports activities in
around it to form a tight seal. The
participants were asked to blow out as fast school.
and hard as possible. They were instructed
not to blow slowly. Three trials were given Statistical Analysis:
Pre-intervention data and post-intervention
to each student and the maximum value was
considered. Figure 2 shows how to blow air data were collected. Dependent and
Independent t-tests were used for CVA and
in peak flow meter.
Wilcoxon and Mann-Whitney tests for
PEFR to compare data between both the
groups. The data were analyzed at 5% level
of significance using SPSS version 16.

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Vol.9; Issue: 12; December 2019
Shreya Joshi et.al. Effect of McKenzie Self-Therapy Protocol on Forward Head Posture and Respiratory
Functions of School Going Adolescent Girls

RESULTS Table 1: Demographic details of participants

Demographics Group A Group B t p
Table 1 shows demographic details of value value
participants from both groups. As shown Age (years) 14.13±0.68 14.33±0.86 -4.79 0.07
Weight (kg) 43.98±6.36 44.18±7.58 -0.108 0.91
there is no difference between the groups. Height (cm) 152.37±5.15 152.78±5.33 -0.385 0.70

Table 2 shows the mean and SD of outcome measures of group A and group B.
Table 2: Mean and SD of outcome measures of groups A and B
Outcome measures Group A Group B
Pre Post Pre Post
CVA 46.54°±4.26° 49.56°±5.16° 48.83°±7.18° 49.14°±6.69°
PEFR (L/min) 225±80.08 278±70.16 265 ±84.03 320±81.56

Difference in outcomes using paired t-test weight can also affect PEFR values. (11)
for group A was significant for CVA and Difference in age, height and weight among
using Wilcoxon was significant for PEFR. participants of both groups was not found to
For group B difference was significant for be statistically significant.
PEFR but using paired t-test was not- Difference in mean for CVA of
significant for CVA. Table 3 shows group A was (t=-3.77,p=0.001). In present
differences in outcome measures within the study, physical therapy protocol was
groups. focused mainly on range of motion and
Independent t-test for mean flexibility of muscles and postural
difference data of CVA between both the alignment. However this protocol had not
groups was significant and difference using only shown improvement in
Mann-Whitney for PEFR was not musculoskeletal dysfunctions but also
significant.Table 4 shows difference in improved respiratory function. Lee et al.
outcome measures between the groups. applied three kinds of exercises to different
groups i.e. McKenzie group, Kendall group,
Table 3: Difference in outcome measures within the groups self-stretch therapy group for 8 weeks. (3)
OUTCOME MEASURES t/Z Value p value
Group A CVA t=-3.77, p=0.001 The findings of this study were consistent
Group B CVA t= -0.289, p=0.77 with the present study in which FHP
Group A PEFR Z=-3.97, p<0.01
Group B PEFR Z=-0.052, p=0.01 reduced through McKenzie therapy. Ruivo
et al. concluded in their study that FHP and
Table 4: Difference in outcome measures between the groups rounded shoulder postural malalignment is
OUTCOME MEASURES t/ z value p value
CVA t=2.06 p=0.04
more seen in adolescent age group.
PEFR z=-0.052 p=0.962 Adolescent girls are more prone to have
forward head posture and related pain
DISCUSSION compared to same age group of boys.
The present study found statistically Females had reported increased degrees of
significant difference in both CVA and neck flexion (approximately 2°-3°) with
PEFR by intervening McKenzie self therapy decreased CVA (46.5°-48.4°). Moreover
in group A. In group B there was no with this, risk of neck pain in girls also
significant difference found in CVA but for tends to increase. (9) However pain was not
PEFR difference was statistically assessed in the present study.
significant. Mean difference for CVA in Difference in mean PEFR was (Z=-
group A is significant while for group B it is 3.97,p<0.01)in the present study. Park et al.
not significant. So, McKenzie self-therapy reported that individuals with forward head
protocol was beneficent for increasing posture had decrease in their FVC and FEV1
craniovertebral angle and decreasing values compared to the normal individuals.
forward head postures. Mishra et al. They have also reported diminished
concluded in her study that height and muscular activation of Sternocleidomastoid,
Upper trapezius and Pectorals. This can be
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Vol.9; Issue: 12; December 2019
Shreya Joshi et.al. Effect of McKenzie Self-Therapy Protocol on Forward Head Posture and Respiratory
Functions of School Going Adolescent Girls

influenced in accordance of motor strategies group B participants. While, there was no

to minimize the activities of muscles that significant difference found for PEFR in
are sensing pain and to adapt compensation between the group comparison as there was
for this. Park et al. also reported significant significant difference found for PEFR in
decrease in respiratory functioning in both the groups individually. McKenzie self
individuals with FHP without having pain in therapy has significant effects on both
neck. (12) Thus in the present study decrease outcomes i.e. CVA and PEFR. Many studies
in FHP & changing biomechanics could have been done to see effects of different
lead to increase in PEFR.N. Yozbatiran et kinds of protocol on alleviating problems
al. reported in their study that physiotherapy related to FHP. McKenzie self therapy
protocol applied on neck or back pain would be more effective in this age group
patients had positive effect on increasing which provides home exercise protocol and
PEFR and chest expansion. (7) He also added minimum supervision of therapist with
that weakness of erector spinae of upper proper instructions of how to perform.
back and trapezius muscles influence the There are few limitations in present
postural malalignment and minimize the study.CVA values were taken at rest, hence
respiratory capacity.FHP is known to have findings cannot be generalized to the
an influence on respiratory function by activities of daily living in functional
weakening the respiratory muscles, thereby positions, CVA angle was measured of
decreasing their function. dominant side of the each subject, again for
Similar to the present study, Kim et al. accurate findings both sides dominant and
stated that McKenzie exercise, Kinesio non-dominant should be taken into the
taping, and myofascial release were account. Neck pain of individual
effective in improving the CV angle participants was not evaluated.
contributing to the forward head posture. (13) Implications of the study include
Kim et. al. also reported that McKenzie self using McKenzie home program for school
therapy causes increase in CVA and going adolescents on daily basis to improve
relaxation in forward head posture, (13) FHP and prevent consequences related to
which can influence the proper extension of poor neck posture and improvement of
thoracic spine and increase in respiratory respiratory function. In future studies,
compliance. protocol can be focused on the entire spine
For group B difference in mean for compensation attributed to the FHP. Effect
CVA was (t=-0.289,p=0.77) and for PEFR it of exercises on pain can be assessed and the
was(Z=-3.886, p=0.01).In present study it exercises can be studied in older population.
was found that routine sports activities
(kabbadi, kho-kho, cricket, badminton) can CONCLUSION
improve PEFR in school going adolescents, Significant difference was seen in
which was continued in all the girls, but forward head posture and respiratory
does not have beneficiary effect on the neck function with McKenzie self-therapy.
related (musculoskeletal)pain. Cheng et al. Significant difference was seen in
has also reported that any type of physical respiratory function in control group.
activity can affect respiratory function Difference in CVA was more in exercise
which is similar to findings from the present group and respiratory function was not
study. (14) significantly different between the groups.
For between the groups, CVA
(t=2.06, p=0.04) mean difference was ACKNOWLEDGEMENT
significant and PEFR (Z=-0.052, p=0.962) Authors would like to thank school principal of
mean difference was not significant. Adarsh Nivasi School and also all participants
for giving warm response and supporting us
McKenzie self-therapy had increased CVA
throughout the study.
and improved FHP in Group A compared to

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Shreya Joshi et.al. Effect of McKenzie Self-Therapy Protocol on Forward Head Posture and Respiratory
Functions of School Going Adolescent Girls

REFERENCES 8. Gerald L. B., & Mangan, J. M.

1. Carolyn Kisner, Lynn Allen Colby, The (2008). Evaluating Individual and Program
spine structure function & posture, Outcomes. In Clinical Asthma (pp. 483-
Therapeutic exercises foundations and 494). Elsevier.
techniques, sixth edition chapter 14, page 9. Ruivo RM, Pezarat-Correia P, Carita AI.
no. 409 -438 Cervical and shoulder postural assessment
2. Thomas j Schmitz, Susan b O'sullivan, of adolescents between 15 and 17 years old
Examination of coordination & balance, and association with upper quadrant pain.
Physical rehabilitation, sixth edition, chapter Braz J PhysTher. 2014 July-Aug; 18(4):364-
6, page no 206 -246 371.
3. DoYoun Lee, Chan Woo Nam, Youn Bum 10. Peter Adams, Khatija AS Mangera, Ian R
Sung, Kyoung Kim, Hae Yong Lee, Hambleton, Euclid H Morris and Joanne L
Changes in rounded shoulder posture and Paul-Charles,does peak expiratory flow
forward head posture according to exercise measured sitting differ from that measured
methods, J. Phys. Ther. Sci. 29: 1824–1827, in standing?a cross over study in primary
2017 care in Barbados, BJGP Open 2018; 2 (2)
4. Sun-Myung Lee, Chang-hyung Lee, 11. Jayanti Mishra, Soumya Mishra,
DaviDO’SuLLivan, JOO-ha Jung, Jung-Jun SudeepSatpathy, Magna Manjareeka,
Park,Clinical effectiveness of a Pilates Prakash Kumar Nayak, PrabhabatiMohanty,
treatment for forward head posture,J. Phys. Variations in PEFR among Males and
Ther. Sci. 28: 2009–2013, 2016 Females With Respect To Anthropometric
5. ShivaniLalitkumarVerma, JilaniShaikh, Parameters, .Volume 5, Issue 1 (Mar - Apr
Ranveer Kumar Mahato, 2013), PP 47-50
MeghaSandeepSheth, Prevalence of forward 12. Jintae Han, SooJin Park, YoungJukim,
head posture among 12–16-year-old school YeonSungCHoi, HYeonnamLYu,Effects of
going students—A cross-sectional study, forward head posture on forced vital
Applied Medical Research, 2018 Vol 4, No. capacity and respiratory muscles activity, J.
2, Page 18–21 Phys. Ther. Sci. 28: 128–131, 2016
6. Se-Yoon Kim, Nan-Soo Kim, Laurentius 13. Jiyoung Kim, SungjoongKim,Jemyung
JongsoonKim ,Effects of cervical sustained Shim, Hyebin Kim, Seoungjun Moon,
natural apophyseal glide on forward head Nahyeon Lee, Mingyeong Lee, Eunju Jin,
posture and respiratory function , J. Phys. EunjiChoi, Effects of McKenzie exercise,
Ther. Sci. 27: 1851–1854, 2015 Kinesio taping, and myofascial release on
7. NurayYozbatiran, NihalGelecek and the forward head posture, J. Phys. Ther. Sci.
DidemKaradibak, Influence of 30: 1103–1107, 2018
physiotherapy programme on peak 14. Y J Cheng, C A Macera, C L Addy, F S Sy,
expiratory flow rate (PEFR) and chest D Wieland, S N Blair. Effects of physical
expansion in patients with neck and low activity on exercise tests and respiratory
back pain, Journal of Back and function, Br J Sports Med 2003;37:521–
Musculoskeletal Rehabilitation 19 (2006) 528.
35–40

How to cite this article: Joshi S, Sheth M. Effect of McKenzie self-therapy protocol on forward
head posture and respiratory functions of school going adolescent girls. Int J Health Sci Res.
2019; 9(12):293-298.

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