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Tuesday, June 6, 2023

Incidence of Common Postural Abnormalities in the Cervical, Shoulder, and Thoracic Regions and Their Association with Pain in Two Age Groups of Healthy Subjects

Brent Brookbush

Brent Brookbush


Research Review: Incidence of Common Postural Abnormalities in the Cervical, Shoulder, and Thoracic Regions and Their Association with Pain in Two Age Groups of Healthy Subjects

By Susan Ackerman DPT, PT, PMA-CPT

Edited by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation:

Griegel-Morris, P., Larson, K., Mueller-Klaus, K., & Oatis, C. A. (1992). Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Physical therapy72(6), 425-431. FULL ARTICLE


Additional research has demonstrated a relationship between upper body postural dysfunction and upper body pain (1-5). Common postural abnormalities of the upper body include forward head posture, rounded shoulders, excessive thoracic kyphosis, and shoulder height asymmetry (6). This 1992 study, out of the Philadelphia Institute of Physical Therapy, demonstrated that participants from two age groups with excessive thoracic kyphosis, forward head, and rounded shoulders had increased incidence of headaches, interscapular pain and cervical pain. This implies the postural assessment may be beneficial for developing injury prevention programs, as well as intervention plans for the treatment of upper body dysfunction and pain.

Study Summary

Study DesignObservational Study
Level of Evidence III Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies
Participant CharacteristicsDemographics
  • Total number of participants: 88
    •  41 men and 47 women

  • Younger group (n=58)
    • 25 +/- 6.3 years old 

  • Older group (n=30)
    • 47 +/- 2.6 years old 

Inclusion Criteria:

  • Healthy volunteers
  • 20 to 50 years old

Exclusion Criteria:

  • Physical therapy professionals
  • Physical therapy students
  • History of idiopathic scoliosis
  • Persons with corrected leg-length discrepancy
  • Information was collected from each participant, which included the following:
    • Demographics
    • Handedness
    • History of scoliosis or other skeletal problem
    • Frequency of pain
    • Severity of pain
    • Location of pain

  • Postural assessment was completed standing with a plumb line and 3 examiners objectively measured:
      • Ear lobe
      • Acromial process
      • Thoracic spine
      • Lateral malleolus

    • Posture was graded using the following scale:
      • 0=normal
      • 1=mild
      • 2=mild+
      • 3= moderate
      • 4=moderate+
      • 5=severe

  • For analysis:
    • After participants were graded on a scale of 0-5, they were grouped into 1 of 3 categories:
      • Grade 1 (Normal to mild): Center landmark in line with, or up to 1 cm anterior to the plumb line
      • Grade 2 (Mild+ to Moderate): Posterior border of landmark in line with, or displaced up to 1 cm anterior to plumb line
      • Grade 3 (Moderate+ to Severe): Posterior border of bony landmark displaced > 1 cm beyond plumb line

    • Kyphosis was graded as within normal limits (WNL), moderate, or severe with no specific operational definitions as usually done in clinical settings.

  • Data Collection and Analysis
  • Prior to study initiation, all experimenters were trained to establish procedures and techniques for postural assessment.
  • Intra-rater and inter-rater reliability were established after training and prior to experiment using Cohen's Kappa with coefficients of 0.825 (almost perfect) and 0.611 (substantial) respectively.
  • Incidence of postural abnormalities in the two age groups were determined using frequency counts and percentages.
  • Severity of postural abnormalities (i.e. forward head posture, rounded shoulders, and excessive thoracic kyphosis) and frequency of pain in thoraco-cervical-shoulder region were compared using Spearman's rank-order correlations.
  • Chi-square (Χ2) analyses were used for the following:
    • To determine the relationship between postural abnormality and age
    • To determine the relationship between postural abnormality and pain
    • Frequency counts were used to determine incidence of persons in each category with any degree of pain regardless of frequency or severity.

Outcome Measures
  • Pain frequency
  • Pain intensity
  • Location of pain using body diagram
  • Postural assessment
  • Relationship between posture and age
  • Postural abnormality incidence was recorded as:
    • Forward head posture: 66%
    • Rounded shoulders: right 73% and left 66%
    • Kyphosis: 38%

  • No significant findings regarding age and postural abnormalities
  • No significance between severity of postural abnormalities and frequency/severity of pain according to Spearman rank-order correlation.
  • Relationships were observed between self-reported pain and severity classification of postural abnormalities and areas of pain:
    • Kyphosis and interscapular pain (Χ2=6.99)
    • Forward head and right cervical pain (Χ2=7.05)
    • Forward head and left cervical pain (Χ2=8.21)
    • Forward head and headaches (Χ2=6.45)
    • Forward head and interscapular pain (Χ2=9.79)
    • Left rounded shoulder and interscapular pain (Χ2=7.15)
    • Right rounded shoulder and interscapular pain (Χ2=7.07)

  • Significance was not found between the following:
    • Rounded shoulder and pectoral pain
    • Rounded shoulder and shoulder pain

ConclusionsIncidence of postural abnormalities were high in all groups. A linear relationship between the severity of posture and the intensity of pain was not demonstrated. The incidence of pain and subject reported severity of pain was higher in those with the most severe postural abnormalities, suggesting that a threshold level of postural abnormality may be necessary to increase incidence and intensity of pain.

How this study contributes to the body of research:

This study investigated the relationship between thoraco-cervical-shoulder posture, age, and the incidence and severity of pain. Unique to this study, general signs of postural dysfunction were investigated in two age groups, stratifying posture into 3 levels of dysfunction, demonstrating that the incidence and severity of pain is higher in the group with the largest amount of dysfunction. This study suggests that the relationship between posture and pain is likely dependent on a threshold level of severity and not purely linear.

How the Findings Apply to Practice:

The findings of this study demonstrate a relationship between significant cervico-thoracic-shoulder postural dysfunction and the severity and incidence of pain. This may imply that human movement professionals should assess upper body posture with the intent of reducing the incidence of future pain, as well as identify signs associated with current pain and impairment. Further, human movement professionals should develop a repertoire of techniques that demonstrate effectiveness for improving posture.


  • This study was the first to investigate the relationship between posture and pain, stratified by severity.
  • Participants were divided into two age groups to account for the effect age, and or time exhibiting the dysfunction, may have on the incidence and severity of pain.
  • Multiple variables were investigated, allowing for direct comparison. Specifically, signs and levels of severity could be compared to determine the most reliable indicators of pain and dysfunction.


  • Although stratification likely increased reliability, the assessment used in the study should be investigated for reliability.
  • The number of incidence and intensity of pain were gathered using a questionnaire. Relying on participant memory of the painful experience may reduce accuracy.
  • The majority of the individuals in the study displayed postural dysfunction; finding matched-controls without dysfunction may have resulted in a more accurate representation of the relationship between posture and pain.

How the study relates to Brookbush Institute Content?

The Brookbush Institute (BI) is continuing to develop and refine its content related to Upper Body Dysfunction (UBD) . This study provided additional evidence of a correlation between thoraco-cervical-shoulder abnormality and pain which reinforces the hypothesis that addressing posture may be beneficial for the treatment and prevention of pain. The BI will continue to pursue optimal practice by refining its content, using the aggregated results of all available research related to human movement science.

Brookbush Institute Videos:

Cervical Extensor Release

Combined Deep Cervical Flexor and External Rotator Activation

Serratus anterior activation


  1. Brink, Y., Louw, Q., Grimmer, K., & Jordaan, E. (2015). The relationship between sitting posture and seated-related upper quadrant musculoskeletal pain in computing South African adolescents: A prospective study. Manual therapy, 20(6), 820-826.
  2. Fernández‐de‐las‐Peñas, C., Alonso‐Blanco, C., Cuadrado, M. L., Gerwin, R. D., & Pareja, J. A. (2006). Trigger points in the suboccipital muscles and forward head posture in tension‐type headache. Headache: The Journal of Head and Face Pain, 46(3), 454-460.
  3. Harrison, D. D., Harrison, D. E., Janik, T. J., Cailliet, R., Ferrantelli, J. R., Haas, J. W., & Holland, B. (2004). Modeling of the sagittal cervical spine as a method to discriminate hypolordosis: results of elliptical and circular modeling in 72 asymptomatic subjects, 52 acute neck pain subjects, and 70 chronic neck pain subjects. Spine, 29(22), 2485-2492.
  4. Haughie, L. J., Fiebert, I. M., & Roach, K. E. (1995). Relationship of forward head posture and cervical backward bending to neck pain. Journal of Manual & Manipulative Therapy, 3(3), 91-97.
  5. Fernández-de-Las-Peñas, C., Cuadrado, M. L., & Pareja, J. A. (2006). Myofascial trigger points, neck mobility and forward head posture in unilateral migraine. Cephalalgia, 26(9), 1061-1070.
  6. Kendall FP, McCreary EK. Muscles: Testing and Function. 3rd. Baltimore, Md: Williams & Wilkins; 1983:112-113, 116, 270-315.

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