Comparative Effects of Visual and Pressure Biofeedback on Pain and Range of Motion in Symptomatic Forward Head Posture

Abstract

Background: Forward head posture (FHP) is a prevalent sagittal plane postural deviation associated with neck pain, reduced cervical range of motion (ROM), and neuromuscular imbalance, particularly involving deep cervical flexor dysfunction. Biofeedback-guided rehabilitation has been proposed to enhance motor control and optimize therapeutic outcomes, yet direct comparative evidence between pressure and visual biofeedback modalities remains limited. Objective: To compare the effects of pressure biofeedback–guided versus visual biofeedback–guided stabilization exercises on cervical ROM and pain in individuals with symptomatic FHP. Methods: In this assessor-blinded randomized controlled trial, 32 participants aged 20–35 years with FHP (craniovertebral angle <49°; Numeric Pain Rating Scale [NPRS] >3) were allocated equally to pressure biofeedback (n=16) or visual biofeedback (n=16), both combined with standardized stabilization exercises for 4 weeks (3 sessions/week). Cervical flexion, extension, bilateral rotation (goniometry), and pain (NPRS) were assessed at baseline and post-intervention. Within- and between-group analyses were performed using paired and independent t-tests with effect sizes and 95% confidence intervals. Results: Both groups demonstrated significant improvements in ROM and pain (p<0.001). Between-group comparisons favored pressure biofeedback for flexion (mean difference 4.62°, p=0.009), right rotation (5.95°, p=0.02), and left rotation (5.54°, p=0.02), with moderate-to-large effect sizes (d=0.82–0.99). No significant differences were observed for extension (p=0.56) or pain reduction (p=0.10). Conclusion: Both biofeedback modalities effectively improved cervical ROM and pain; however, pressure biofeedback produced superior gains in flexion and rotation, suggesting enhanced neuromuscular specificity in movement restoration.