Musculoskeletal Science and Practice 74 (2024) 103205

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Musculoskeletal Science and Practice

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Original article

More neck pain, less spinal mobility, altered sitting posture: Sagittal spinal
alignment and mobility in women with chronic neck pain
Nur Efsan Unal a , Sevtap Gunay Ucurum b, Muge Kirmizi b,* , Elif Umay Altas c
a
Institute of Health Sciences, Department of Physiotherapy and Rehabilitation, Izmir Katip Celebi University, Izmir, Turkey
b
Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Izmir Katip Celebi University, Izmir, Turkey
c
Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Bakircay University, Izmir, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Increasing evidence suggests that people with chronic neck pain (CNP) may display altered
Neck pain biomechanics beyond the cervical spine. However, whether spinal alignment and mobility are associated with
Spinal curvatures neck pain is not clarified.
Spinal mobility
Objectives: To investigate whether there is a significant association between neck pain intensity and sagittal spinal
Spinal health
alignment and mobility in people with CNP, and to examine whether sagittal spinal alignment and mobility differ
according to pain intensity.
Design: A cross-sectional study.
Method: Forty-four women with CNP were included. The neck pain intensity at rest and during neck movements
was assessed with the visual analogue scale (VAS). A skin-surface measurement device was used to assess sagittal
alignment and mobility while sitting and standing. Linear regression analysis was used to assess associations.
Participants were divided into two groups according to the pain intensity as group with mild pain (VAS≤4.4 cm)
and group with moderate to severe pain (VAS>4.4 cm) and compared using the analysis of covariance.
Results: Greater resting pain was associated with a more forward trunk during sitting (Beta = 0.433, p < 0.05).
Greater pain during neck movements was associated with increased lumbar lordosis during sitting (Beta =
− 0.376, p < 0.05). Classified by pain intensity at rest, trunk mobility while sitting was lower and forward trunk
inclination and sacral kyphosis while sitting were higher in those with moderate/severe pain (η2p = 0.093–0.119,
p < 0.05). By pain intensity during neck movements, women with moderate/severe pain exhibited lower sacral
mobility while sitting (η2p = 0.129, p < 0.05).
Conclusions: Addressing the entire spine in the assessment and management of CNP may help reduce pain.

1. Introduction muscular control of the spine. Moseley (2004) found that patients with
neck pain had impaired trunk muscle control assessed via the abdominal
Neck pain poses a significant health and economic burden in modern drawing-in task, furthermore, reduced trunk muscle function in patients
society with a high prevalence, incidence, and years lived with a with neck pain was associated with an increased risk of developing low
disability (Kazeminasab et al., 2022; Shin et al., 2022). The tendency for back pain (LBP). Moreover, Falla et al. (2017) reported that people with
neck pain to become a chronic issue increases the personal, economic, CNP walked with reduced trunk rotation, suggesting that in the long
and public health burden (Kazeminasab et al., 2022; Kim et al., 2018). term, stiffer spine could lead to the development of LBP. Considering the
There is a growing body of research indicating that people with mentioned studies, we thought that moving to a more comprehensive
chronic neck pain (CNP) exhibit altered mechanical features regarding approach, rather than solely focusing on the cervical region, in the
spinal health beyond the cervical spine. Salahzadeh et al. (2020) found management of neck pain may be promising in improving neck pain
that people with forward head posture (FHP) had lower trunk muscle complaints.
endurance than those without FHP, suggesting that it may lead to poor Studies investigating sagittal alignment in people with CNP are

* Corresponding author. Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Izmir Katip Celebi University, TR-35620, Cigli, Izmir,
Turkey.
E-mail address: [email protected] (M. Kirmizi).

https://doi.org/10.1016/j.msksp.2024.103205
Received 16 March 2024; Received in revised form 19 September 2024; Accepted 13 October 2024
Available online 15 October 2024
2468-7812/© 2024 Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
N.E. Unal et al. Musculoskeletal Science and Practice 74 (2024) 103205

Fig. 1. Left to right, description of measurements performed in the (A) usual, (B) maximal flexion, and (C) maximal extension positions of trunk.

mostly limited to head and cervical posture (Jouibari et al., 2019; Li Research Ethics Board (Number: 0617, Date: January 20, 2022). All
et al., 2020; Rani et al., 2023). In a meta-analysis published in 2023, procedures were conducted according to the Declaration of Helsinki.
which compared sagittal thoracic postural parameters, including the Participants read and signed the informed consent before their
thoracic kyphosis angle, between people with and without nontraumatic participation.
neck pain, no significant difference was found between the groups (Rani
and Paul, 2023). Straker et al. (2009) compared sagittal spinal posture
2.1. Participants
during sitting in adolescents with and without prolonged neck/shoulder
pain (NSP) and reported that female adolescents with NSP had more
Forty-four women with chronic non-specific neck pain were
lumbar lordosis during sitting than those without NSP and NSP was
included. The inclusion criteria were as follows: (1) being between 18
weakly associated with a more lordotic lumbopelvic posture. The au­
and 65 years of age, (2) having neck pain lasting longer than three
thors stated that the clinical assumption regarding that NSP is related to
months. The exclusion criteria were as follows: (1) having a history of
cervicothoracic postures was not corroborated after controlling for
spinal pain lasting longer than three months, excluding pain in the
gender. On the other hand, the alignment and mobility of the lumbar
cervical spine, (2) having current spinal pain, excluding pain in the
and sacral regions and trunk inclination have not been investigated in
cervical spine, (3) having a history of trauma or surgery in the spine or
adults with neck pain. Clarifying the association between sagittal
head regions, (4) having been diagnosed with any neurological or
alignment and mobility of spinal regions beyond the cervical region and
vestibular disorders which may affect trunk movements, (5) having
neck pain intensity in adults with CNP may contribute to moving to­
neurological deficits resulting from neck disorders.
wards a more comprehensive approach in managing neck pain.
Given the foregoing information, the study was designed to investi­
gate whether there is a significant relationship between neck pain in­ 2.2. Assessment of pain intensity
tensity and sagittal spinal alignment and mobility in people with CNP, as
well as to examine whether sagittal spinal alignment and mobility differ The intensity of neck pain experienced over the past week at rest
according to pain intensity in this population. (while physically immobile and untouched) and during daily tasks
requiring neck movements (pain experienced in response to neck
2. Methods movements) was assessed (He et al., 2017). The visual analogue scale
(VAS) was used to assess neck pain intensity. Participants were asked to
This study was conducted in the Bakircay University Cigli Regional mark the intensity of their pain on the 100 mm line. The VAS pain ranges
Education Hospital in February and March 2022. Ethical approval was from 0 to 100. A score of 0 represents no pain while a score of 100
obtained from Izmir Katip Celebi University Institutional Non-invasive represents the worst imaginable pain. The intensity of neck pain was
interpreted as follows: 0–4 mm = no pain, 5–44 mm = mild pain, 45–74

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N.E. Unal et al. Musculoskeletal Science and Practice 74 (2024) 103205

Fig. 2. Left to right, description of sagittal spinal alignment measured in the (A) maximal flexion, (B) usual, and (C) maximal extension positions of trunk.

mm = moderate pain, 75–100 mm = severe pain (Jensen et al., 2003; and lumbar spine and trunk (Mannion et al., 2004; Post and Leferink,
Hawker et al., 2011). 2004; Topalidou et al., 2014; Zafereo et al., 2016). Furthermore, in the
validity studies, the correlation coefficients between the skin-surface
2.3. Assessment of sagittal spinal alignment and mobility measurement device and lateral radiographs were reported to be
0.81–0.86 for sagittal alignment and 0.85 for sagittal mobility
Sagittal spinal alignment and mobility were assessed using a skin- (Guermazi et al., 2006; Fadaee et al., 2017).
surface measurement device (Hocoma, Valedo®Shape device, Idiag During the measurement, the skin-surface device was rolled along
GmbH, Fehraltorf, Switzerland), a hand-held, computer-aided, and non- the spine from the spinous process of C7 to the spinous process of S3.
invasive electronic device. The following parameters were obtained in First, spinous processes from C7 to S3 were palped and marked with an
degrees: thoracic kyphosis angle (sum of 11 segmental angles from T1-2 ink pen on the skin by the examiner (NEU) after undressing the upper
to T11-12), lumbar lordosis angle (sum of 6 segmental angles from T12- body. The C7 spinous process was identified using the flexion-extension
L1 to L5-S1), sacral/hip angle (angle formed between a straight line method (Shin et al., 2011). The data were obtained in both standing and
from S1 to S3 and a vertical line, representing the orientation of the sitting positions and participants were asked to take the following trunk
sacrum relative to the vertical axis), and trunk inclination angle (angle positions: the usual posture, maximum flexion, and maximum extension,
between straight line from T1 to S1 and a vertical line). The skin-surface respectively (Fig. 1). For the usual standing posture, participants were
measurement device was reported to be reliable in adults with and asked to stand as usual with their feet shoulder-width apart and their
without spinal musculoskeletal complaints in previous studies (Mannion eyes looking straight ahead. For the usual sitting posture, participants
et al., 2004; Post and Leferink, 2004; Topalidou et al., 2014; Zafereo sat in a chair without a backrest or armrests, with their knees and hips
et al., 2016). The intraclass correlation coefficients (ICCs) were reported flexed at a 90-degree angle and their feet shoulder-width apart on a
to be higher than 0.70 for the global sagittal angle of the thoracic spine footrest angled at 30◦ . They were asked to sit in their usual sitting
and the total sagittal mobility of the sacrum (Mannion et al., 2004; Post posture with their eyes looking straight ahead. The order of whether
and Leferink, 2004; Topalidou et al., 2014). The ICCs were reported to measurements were taken first in the sitting or standing position was
be higher than 0.80 for the global sagittal angle of the lumbar and sacral randomized. All assessments were repeated three times with 1-min in­
spine, trunk inclination angle, and total sagittal mobility of the thoracic tervals between each measurement. The average of the three measures

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N.E. Unal et al. Musculoskeletal Science and Practice 74 (2024) 103205

Table 1
Demographic characteristics and spinal variables of all participants.
Demographic and spinal variables Women with chronic neck
pain (n = 44) Mean (SD)

Age, years 39.4 (16.2)

Body weight, kg 69.6 (14.8)
Height, cm 162.5 (5.6)
Body mass index, kg/m2 26.5 (6.2)
Education level, n (%)
Primary school 10 (%23)
Secondary school 4 (%9)
High school 10 (%23)
Bachelor 20/%45)
Employment status, n (%)
Employed 7 (%16)
Retired 7 (%16)
Unemployment (not retired) 19 (%43)
Student 11 (%25)
Visual Analogue Scale at rest, cm 4.9 (1.8)
Visual Analogue Scale during neck movements, cm 5.6 (2.1)
Upright position (alignment) standing sitting
Thoracic angle, degree 52 (13.4) 43.6 (12.7)
Lumbar angle, degree − 30.7 (10.2) − 16.7 (12.6)
Sacral angle, degree 15.1 (10.1) 11.8 (9.5)
Trunk inclination angle, degree 2 (5.4) 8.1 (5.3)
E-F ROM (mobility) standing sitting
Thoracic angle, degree 20.6 (15.3) 27.2 (18)
Lumbar angle, degree 47.7 (16.6) 39.6 (16.9)
Fig. 3. Trunk inclination angle was defined as the angle between straight line Sacral angle, degree 51.8 (22.2) 34.5 (22.7)
from T1 to S1 and vertical line originating at S1, left to right, measured in the Trunk inclination angle, degree 98.5 (23.5) 74 (26.7)
(A) maximal flexion, (B) usual, and (C) maximal extension positions of trunk. SD: Standard deviation, E-F ROM: Total range from extension to flexion.

was used in data analysis. The positions were first described and separately for both groups to transform the trunk inclination angle while
demonstrated by the examiner, and participants practiced each position sitting to the normal distribution. Analysis of covariance (ANCOVA) was
once before the three sets of measurements were taken. Participants performed using spinal alignment and mobility variables as the depen­
were instructed to move at their chosen speed and to hold the end po­ dent variable, having mild pain or moderate/severe pain as the inde­
sition for a few seconds while the measurement was made. None of the pendent variable, and age and body mass index (BMI) as covariates.
participants experienced pain during the testing. Also, effect sizes for ANCOVA, partial eta squared (η2p), were interpreted
The angles obtained in the usual posture were recorded as sagittal as follows: An η2p value less than 0.01 represents small effect, 0.06 me­
spinal alignment (Figs. 2 and 3). Positive values indicate kyphosis dium effect, and 0.14 large effect (Fritz et al., 2012). The level of sig­
(anterior concavity); negative values indicate lordosis (posterior con­ nificance was set at p < 0.05.
cativiy). Also, a greater trunk inclination angle indicates a forward
stooped posture. Furthermore, the software calculated the flexion- 3. Results
extension range of motions by subtracting the angles measured in the
maximum extension position from those measured in the maximum Demographic characteristics, VAS scores, and sagittal spinal align­
flexion position (flexed angle minus extended angle) and recorded this ment and E-F ROM values were presented in Table 1. Also, demographic
as sagittal spinal mobility. All participants were assessed by same characteristics of groups were presented in Table 2. There was no sig­
examiner (NEU). nificant difference between groups regarding demographic characteris­
tics (p > 0.05).
The results of the linear regression analysis, as presented in the co­
2.4. Statistical analyses efficients table, were shown in Table 3. Higher pain intensity at rest was
associated with a more forward-leaning trunk while sitting (Beta =
The statistical analysis was performed on the 44 participants using 0.433, p < 0.05). Additionally, higher pain intensity during neck
the SPSS 25. The Shapiro-Wilk test and descriptive statistics showed that movements was associated with greater lumbar lordosis while sitting
all data had a normal distribution, except for the trunk inclination angle (Beta = − 0.376, p < 0.05).
while sitting. The log10 transformation was applied to transform the Age and BMI-adjusted spinal alignment and mobility variables were
trunk inclination angle while sitting to the normal distribution. Linear presented in Table 4. Women with moderate to severe neck pain at rest
regression analysis was used to determine the association of pain in­ had a greater degree of forward trunk inclination and greater sacral
tensity with spinal variables, and the coefficients tables were examined kyphosis while sitting, with moderate effect sizes for these differences
and interpreted to assess the individual contributions of pain intensity at (η2p = 0.093 and 0.097, p < 0.05). Trunk mobility while sitting was lower
rest and pain intensity during neck movements. Furthermore, partici­ in women with moderate to severe neck pain at rest compared to those
pants were divided into two groups according to the pain intensity at with mild pain at rest and the effect size was also moderate for the
rest and during neck movements: group with mild pain (VAS score≤4.4 difference (η2p = 0.119, p < 0.05). Furthermore, when classified ac­
cm) and group with moderate to severe pain (VAS score>4.4 cm) cording to pain intensity during neck movements, women with moder­
(Jensen et al., 2003; Hawker et al., 2011). Classified by pain intensity at ate to severe neck pain exhibited less sacral mobility compared to those
rest, 18 participants were in the mild pain group and 26 in the moderate with mild pain and the effect size was moderate (η2p = 0.129, p < 0.05).
to severe pain group. By pain intensity during neck movements, 12 were
in the mild pain group and 32 in the moderate to severe pain group.
Descriptive statistics and the normality test were performed for both
groups separately and then the log10 transformation was applied

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N.E. Unal et al. Musculoskeletal Science and Practice 74 (2024) 103205

Table 2
Demographic characteristics of the groups.
Demographic variables Grouping by pain at rest Grouping by pain during neck movements

Mild pain (n = 18) Mean Moderate/Severe pain (n = 26) p Mild pain (n = 12) Mean Moderate/Severe pain (n = 32) p
(SD) Mean (SD) (SD) Mean (SD)

Age, years 37.9 (17) 40.5 (15.2) 0.619a 45.4 (17.5) 37.2 (15.4) 0.136a
Body weight, kg 67.8 (13.2) 70.8 (16) 0.524a 69.4 (16.4) 69.6 (14.5) 0.967a
Height, cm 164.2 (5.3) 161.2 (5.6) 0.083a 161.3 (6.5) 162.9 (5.3) 0.426a
Body mass index, kg/ 25.2 (5.2) 27.4 (6.7) 0.259a 26.9 (7.3) 26.3 (5.8) 0.781a
m2
Education level, n (%)
Primary school 3 (%16.7) 7 (%26.9) ​ 3 (%25) 7 (%21.9) ​
Secondary school 1 (%5.6) 3 (%11.5) 0.232b 1 (%8.3) 3 (9.4) 0.678b
High school 4 (%22.2) 6 (%23.1) ​ 3 (%25) 7 (%21.9) ​
Bachelor 10 (%55.6) 10 (%38.5) ​ 5 (%41.7) 15 (%46.9) ​
Employment status, n (%)
Employed 2 (%11.1) 5 (%19.2) ​ 2 (%16.7) 5 (%15.6) ​
Retired 4 (%22.2) 3 (%11.5) 0.638b 3 (%25) 4 (%12.5) 0.453b
Unemployment 8 (%44.4) 11 (%42.3) ​ 5 (%41.7) 14 (%43.8) ​
Student 4 (%22.2) 7 (%26.9) ​ 2 (%16.7) 9 (%28.1) ​
a
Independent samples t-test.
b
Chi-squared test, SD: Standard deviation.

Table 3
Association of pain intensity with spinal variables: Individual contributions.
Dependent variables Independent variables

Pain intensity at rest Pain intensity during neck movements Age Body mass index

Coefficients Coefficients Coefficients Coefficients

Beta pa Beta pa Beta pa Beta pa

Standing Thoracic angle 0.081 0.582 0.000 0.999 0.346 0.019 0.423 0.005
Lumbar angle 0.128 0.491 − 0.219 0.245 − 0,015 0.936 − 0.255 0.174
Sacral angle − 0.127 0.504 0.122 0.526 − 0.132 0.492 0.195 0.309
Trunk inclination angle 0.032 0.866 0.003 0.988 0.099 0.602 0.150 0.429
Thoracic spine E-F ROM − 0.209 0.270 − 0.024 0.899 − 0.028 0.882 0.000 0.999
Lumbar spine E-F ROM 0.024 0.857 − 0.088 0.519 − 0.390 0.006 − 0.440 0.002
Sacral spine E-F ROM − 0.106 0.572 0.027 0.886 0.235 0.221 − 0.132 0.486
Trunk inclination E-F ROM − 0.128 0.471 − 0.025 0.889 − 0.043 0.809 − 0.335 0.066

Sitting Thoracic angle − 0.062 0.677 0.089 0.556 0.467 0.003 0.262 0.087
Lumbar angle 0.046 0.796 − 0.376 0.042 − 0.127 0.480 − 0.150 0.402
Sacral angle 0.129 0.467 0.228 0.210 − 0.022 0.904 0.252 0.163
Trunk inclination angle 0.433 0.008 − 0.185 0.245 0.255 0.110 0.222 0.160
Thoracic spine E-F ROM − 0.224 0.225 0.172 0.357 − 0.214 0.253 0.320 0.088
Lumbar spine E-F ROM − 0.172 0.265 0.083 0.591 − 0.371 0.021 − 0.281 0.073
Sacral spine E-F ROM − 0.042 0.815 − 0.241 0.190 − 0.005 0.980 − 0.265 0.148
Trunk inclination E-F ROM − 0.198 0.220 − 0.114 0.480 − 0.248 0.130 − 0.324 0.049
a
Linear regression, Beta: Standardized coefficients beta, E-F ROM: Total range from extension to flexion.

4. Discussion where pain was experienced. The study revealed that people with
moderate to severe neck pain may have a lower spinal AROM in the
The aim of the study was to investigate whether there is a significant sagittal plane compared to people with mild neck pain. We assessed the
association between neck pain intensity and sagittal spinal alignment sagittal alignment and AROM of the spine while participants were
and mobility in people with CNP, as well as to examine whether sagittal standing and sitting. Thus, the results may not reflect whether spinal
spinal alignment and mobility differ according to pain intensity in this alignment and mobility during functional tasks differ according to neck
population. The results showed that higher pain intensity at rest was pain intensity. On the other hand, Falla et al. (2017) reported that
associated with a more forward-leaning trunk while sitting, whereas people with CNP walked with reduced trunk rotation compared to
higher pain intensity during neck movements was associated with asymptomatic controls, so we can say the neck pain population may
greater lumbar lordosis while sitting. Women with moderate to severe have reduced motion of the trunk during also functional tasks. The
neck pain at rest had less trunk mobility, a more forward trunk posture, current results have indicated that neck pain may result in a decrease in
and greater sacral kyphosis while sitting. Additionally, women with spinal mobility that is not limited to the cervical region, but it needs to
moderate to severe pain during neck movements exhibited less sacral be further supported.
mobility while sitting. Similar to ongoing studies exploring spinal mobility in spinal pain
The ongoing studies have suggested that, compared to asymptomatic conditions, research on sagittal alignment in individuals with CNP has
controls, people with neck pain and people with LBP have decreased predominantly centred on the head and cervical spine (Jouibari et al.,
active range of motion (AROM), especially in the sagittal plane, in the 2019; Li et al., 2020; Rani et al., 2023). On the other hand, a recent
cervical and lumbar spine, respectively (Rudolfsson et al., 2012; Sten­ meta-analysis reported that thoracic kyphosis did not differ between
neberg et al., 2017; Corkery et al., 2014; Errabity et al., 2023). The people with and without nontraumatic neck pain (Rani and Paul, 2023).
existing literature has mostly focused on the AROM in the spinal region Straker et al. (2009) investigated sagittal spinal posture while sitting in

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N.E. Unal et al. Musculoskeletal Science and Practice 74 (2024) 103205

Table 4 incidence angle meaning increased anterior pelvic tilt (McKay et al.,
Comparison of age- and BMI-adjusted spinal variables between groups by pain 2018). Therefore, it can be said that our result is consistent with the
intensity. result reported in the study conducted by Straker et al. although females
Spinal Grouping by pain at rest from different age groups were included. They also reported that NSP
variables
Mild pain (n = 18) Moderate/Severe pa, η2p
was weakly associated with more lordotic lumbopelvic posture while
Mean (SE) pain (n = 26) Mean sitting (Straker et al., 2009) and we also found that neck pain intensity
(SE) during neck movements was significantly associated with greater lum­
Upright standing sitting standing sitting standing sitting bar lordosis while sitting. The results have indicated that neck pain may
position be associated with sagittal lumbopelvic posture, which should be further
Thoracic 51.7 44.2 52.2 (2) 43.1 0.857 0.748 validated by additional studies. However, the results concerning sagittal
angle, (2.4) (2.4) (2) spinal alignment in the sitting position in our study should be inter­
deg
Lumbar − 30.4 − 13.5 − 30.9 − 18.9 0.869 0.175
preted with caution, as the participants’ usual posture while using an
angle, (2.5) (3) (2) (2.5) inclined footrest may not accurately reflect usual sitting posture with
deg their feet flat on the floor. Using an inclined footrest could have altered
Sacral 14.4 8.4 15.5 (2) 14.1 0.750 0.049, pelvic alignment, which was not investigated in the study. On the other
angle, (2.5) (2.2) (1.8) 0.093
hand, we used a standardized footrest for all participants, which might
deg
Trunk inc. 1.1 (1.3) 0.7 2.6 (1.1) 0.9 0.374 0.045, have ensured that the significant differences observed between groups
angle, (0.1)b (0.1)b 0.097 were independent of the footrest.
deg The study was planned with the thought that it could serve as a
E-F ROM standing sitting standing sitting standing sitting reference for future research investigating the effectiveness of ap­
Thoracic 23.4 29 18.6 25.9 0.339 0.585
angle, (3.7) (4.3) (3.1) (3.55)
proaches that focus on the entire spine rather than on regional assess­
deg ment in the management of neck pain. To maintain overall sagittal
Lumbar 50.4 43.5 45.9 36.9 0.227 0.126 balance, regional changes in the spine may lead to compensatory
angle, (2.8) (3.3) (2.3) (2.7) changes in other regions and, ultimately, the entire spine (Le Huec et al.,
deg
2019). Although sagittal cervical alignment was not assessed in the
Sacral 55.5 39.8 49.3 30.8 0.374 0.205
angle, (5.3) (5.3) (4.4) (4.4) study, a meta-analysis published in 2023 has suggested that there is
deg strong evidence that neck pain intensity is related to greater forward
Trunk inc. 105.4 83.7 93.8 67.3 0.096 0.026, head posture (Rani et al., 2023). The forward-leaning trunk posture may
angle, (5.2) (5.4) (4.3) (4.47) 0.119 be a consequence of the anterior shift of the gravity line caused by the
deg
forward head posture. Furthermore, increased anterior pelvic tilt may be
Spinal Grouping by pain during neck movements a compensatory strategy to shift the trunk backward to some degree
variables
Mild pain (n = 12) Moderate/Severe pa, η2p (Murta et al., 2020). However, in this study, since data were collected
Mean (SE) pain (n = 32) Mean only at the time of assessment, it is not possible to make a definitive
(SE) conclusion about the cause-and-effect relationship of regional angles.
Upright standing sitting standing sitting standing sitting On the other hand, the prevalence of chronic LBP was reported to be
position three times higher in people with CNP than in the general population
Thoracic 48.6 39.7 53.3 45 0.182 0.131
(Guez et al., 2006). The existing studies reporting altered mechanical
angle, (2.9) (2.9) (1.8) (1.8)
deg features of the trunk in the neck pain population have highlighted the
Lumbar − 29.3 − 10.9 − 31.2 − 18.8 0.604 0.073 possible development of LBP in the long term (Moseley, 2004; Falla
angle, (3) (3.7) (1.8) (2.2) et al., 2017). In the study, women with moderate to severe neck pain at
deg
rest exhibited a greater degree of forward trunk inclination, which was
Sacral 16.2 (3) 9.1 14.6 12.7 0.654 0.264
angle, (2.8) (1.8) (1.7)
previously reported to be associated with the occurrence of low back
deg pain (Hira et al., 2021). Therefore, altered spinal posture may be
Trunk inc. 2.2 (1.6) 0.8 1.96 (1) 0.81 0.908 0.986 addressed to prevent possible LBP in the neck pain population.
angle, (0.1)b (0.1)b There are several limitations that need to be addressed. As a major
deg
limitation, the participants’ usual sitting posture while using an inclined
E-F ROM standing sitting standing sitting standing sitting
Thoracic 22.8 24.8 19.7 28.1 0.582 0.602 footrest may not accurately reflect their usual sitting posture when their
angle, (4.7) (5.3) (2.8) (3.2) feet are flat on the floor. Therefore, measurements taken while sitting
deg should be interpreted with consideration of the use of the inclined
Lumbar 48.4 37.6 47.5 40.3 0.824 0.581 footrest. The other major limitation is that the study did not include a
angle, (3.6) (4.2) (2.2) (2.5)
deg
control group composed of people without neck pain. Future studies are
Sacral 60.3 47.6 48.7 29.6 0.139 0.02, needed to clarify whether there is a clinically significant difference in
angle, (6.5) (6.3) (3.9) (3.8) 0.129 sagittal spinal alignment and mobility between people with and without
deg neck pain. Thirdly, our sample consisted only of female participants;
Trunk inc. 107.7 85.4 95.1 69.7 0.106 0.06
thus, the results cannot be generalized to all gender groups with CNP.
angle, (6.5) (6.8) (3.9) (4.1)
deg Fourthly, we did not determine the required sample size before the study
a
because we could not find a suitable similar study. However, the effect
ANCOVA, SE: Standard error, η2p: partial eta squared values for significant
sizes, the partial eta squared values, ranged between 0.93 and 0.129 for
results, E-F ROM: Total range from extension to flexion, inc: inclination.
b the statistically significant differences, supporting the meaningfulness of
Log transformed data.
the results. Also, cervical angles were not measured due to the limita­
tions of the skin-surface measurement device, which is only capable of
adolescents with and without NSP and reported that female adolescents
measuring the spine from C7 and below. Furthermore, since pain may
with NSP had increased lumbar lordosis and anterior pelvic tilt. We
contribute to general kinesiophobia, future studies could investigate
found that women with moderate to severe neck pain had greater sacral
effect of kinesiophobia on spinal mobility in the neck pain population.
kyphosis while sitting than those with mild neck pain. Sacral kyphosis
was reported to be strongly and positively correlated with pelvic

6
N.E. Unal et al. Musculoskeletal Science and Practice 74 (2024) 103205

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