Exercise therapy to improve cervical proprioception in individuals with asymptomatic forward head posture: A systematic review of randomized controlled trials

Abstract

Background Forward head posture (FHP) is a common musculoskeletal condition associated with impaired cervical proprioception, which compromises postural control and neuromuscular function. Exercise-based interventions have been proposed to address proprioceptive deficits in FHP, but their effectiveness remains unclear. This systematic review aimed to evaluate the impact of exercise programs on cervical proprioception in individuals with FHP. Methods A systematic search of PubMed, Scopus, and Web of Science was conducted up to April 20, 2025. Randomized controlled trials (RCTs) assessing exercise interventions on cervical proprioception in FHP were included. Risk of bias was assessed using the RoB-2 tool. Due to heterogeneity in outcome measures, a narrative synthesis was conducted, supported by effect size (ES) calculations. Results Nine RCTs involving 367 participants were included. Interventions ranged from cervical stabilization exercises (most common) to whole-body vibration, backward walking, and muscle energy techniques. ESs varied from trivial to nearly perfect, with trivial-to-very-large improvements observed in joint position sense and joint position error. While cervical stabilization exercises demonstrated positive outcomes in rotation and flexion tasks across some studies, the limited number and heterogeneity of studies on alternative interventions precluded a definitive comparison of consistency or effectiveness. Risk of bias was generally rated as “some concerns” due to lack of blinding and variability in outcome measures. Conclusion Current evidence suggests cervical stabilization exercises, the most studied intervention for FHP, may improve cervical proprioception. However, methodological heterogeneity and diagnostic inconsistencies, such as variations in craniovertebral angle thresholds used to define FHP, limit the ability to draw definitive conclusions. Future studies should standardize diagnostic criteria, outcome assessments, and investigate long-term effects across diverse populations.