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Table of Contents
Year : 2020  |  Volume : 52  |  Issue : 3  |  Page : 85-89

Effect of upper back brace with auditory feedback for forward head rounded shoulder posture among office workers with chronic neck pain – A pre-post single group study

1 Department of Occupational Therapy, Lokmanya Tilak Municipal Medical College and GH, Mumbai, Maharashtra, India
2 Department of Occupational Therapy, D.Y. Patil University, Navi Mumbai, Maharashtra, India

Date of Submission24-Jul-2020
Date of Acceptance26-Sep-2020
Date of Web Publication23-Oct-2020

Correspondence Address:
Rashmi Sudhakar Yeradkar
Lokmanya Tilak Municipal Medical College and GH, Sion, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijoth.ijoth_26_20

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Background: Forward head and rounded shoulder posture (FHRSP) is a poor habitual neck posture among office workers. The posture results in muscle tension and pain around the neck and shoulders and nerve root symptoms in the upper extremities. Objectives: The aim of this study was to investigate the effect of upper back brace with auditory feedback on posture among office workers with neck pain and forward head posture. Study Design: The study design involves prospective, experimental, pre–post single group. Methods: The office workers (males and females aged 25–60 years) were screened on shoulder girdle flexibility test (fingertips > 2 inches [5 cm] apart). Ten subjects (out of 50 screened subjects) meeting the eligibility criteria were selected for the study. The subjects wore the upper back brace with auditory feedback for 6 h in a day (minimum 30 min in continuation) for 2 weeks. Pre- and post-assessments of the neck disability index (NDI), visual analog scale (VAS), craniovertebral angle (CVA), and scapular index (SI) were carried out at the baseline and after 2 weeks, respectively. Results: Postintervention, significant reduction was found in NDI score (P < 0.05, 95% confidence interval (CI) of mean difference (CI): 2.33–8.72 and VAS score (P < 0.05, 95% CI: 0.70–2.89) and significant improvement was found in CVA score (P < 0.05, 95% CI: 0.60–6.59) and SI score (P < 0.05, 95% CI: 0.70–10.01). Conclusion: The results indicate that the upper back brace with auditory feedback improves the FHRSP and reduces neck pain and related disability among office workers.

Keywords: Auditory Feedback, Cranio-Vertebral Angle, Forward Head, Neck Disability Index, Rounded Shoulder, Scapular Index, Upper Back Brace

How to cite this article:
Bankhele JR, Yeradkar RS, Mulye MM. Effect of upper back brace with auditory feedback for forward head rounded shoulder posture among office workers with chronic neck pain – A pre-post single group study. Indian J Occup Ther 2020;52:85-9

How to cite this URL:
Bankhele JR, Yeradkar RS, Mulye MM. Effect of upper back brace with auditory feedback for forward head rounded shoulder posture among office workers with chronic neck pain – A pre-post single group study. Indian J Occup Ther [serial online] 2020 [cited 2023 Feb 6];52:85-9. Available from: http://www.ijotonweb.org/text.asp?2020/52/3/85/298982

  Introduction Top

Forward head posture (FHP) is defined as excessive anterior positioning of the head in relation to a vertical reference line. Rounded shoulder posture (RSP) refers to acromion and shoulder protraction, downward rotation, and anterior tilt. Long-term use of computer leads to slouched posture as compared to other occupations.[1],[2] Risk indicators for computer users includes prolonged sitting, inappropriate monitor height, uncomfortable back support, and nonadjustable chair.[2]

The scapular brace may help in restoring the normal shoulder posture and maintain proximal shoulder girdle stability.[3] In this study, the upper back brace with auditory feedback was designed for office workers with Forward Head RSP (FHRSP) and neck pain. The rationale of auditory feedback, based on a closed-loop notion of motor control, was to provide additional sensory information to correct the posture.[4] Thus, the purpose of the study was to determine the effect of the novel brace on disability, pain, and posture among the office workers.

  Methods Top

Study Design and Setting

The study was a prospective, pre–post single group investigation carried out on the in the occupational therapy department of a medical hospital over a period of 6 months (June–November 2019).

Sample Size

Being a pilot study, only ten subjects were planned to be recruited to investigate the effectiveness of the novel brace.

Inclusion and Exclusion Criteria

Inclusion criteria were: subjects in the age group of 20–60 years working as office workers of the Municipal Corporation of Greater Mumbai (MCGM), those having chronic neck pain for >6 months and subjects with poor shoulder girdle flexibility test (distance between fingertips >2 inches [5 cm] apart).

Shoulder girdle flexibility test

The left shoulder was tested by standing with the right arm straight up and then bending the elbow, so the hand hangs behind the head. Keeping the upper arm stationary, the palm was rested between the shoulder blades. Then, the subject was asked to reach around behind with his left arm so the palm is facing out and then try to touch the fingers of both hands together. The procedure was repeated with the opposite shoulder. The scoring was based on the minimum distance between hands (good, fingertips are touching together; fair, fingertips are not touching but are <2 inches apart; poor, fingertips are >2 inches apart) [Figure 1].[5]
Figure 1: Shoulder girdle flexibility test (Distance between fingertips >2 inches [5 cm] apart were included)

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Subjects with cervical and shoulder trauma or surgical intervention, congenital abnormalities, neurological disorders, psychiatric illness, and pregnancy were excluded from the study.


MCGM office workers with chronic neck pain were included with convenient sampling and screening of fifty office workers for FHRSP was done using shoulder girdle flexibility test. Ten office workers were selected after the screening, meeting the inclusion criteria.

Subjects were enrolled in the study after signing the consent form. The study was approved by the Institutional Ethics Committee of Human Research, Lokmanya Tilak Municipal Medical College (LTMMC). Recruited subjects wore the upper back brace with auditory feedback. Pre- and post-assessments were done by the researchers at the baseline and after 2 weeks, respectively.


The upper back brace with auditory feedback was designed in a pattern of figure of eight which was made up of cloth, adjustable straps with pressure sensors (2 Flexiforce sensors of 100 lbs and 4 flex sensor of 4.5 lbs) incorporated in the padding under axilla that detected the abnormal posture and electrical circuit box which was attached to the pouch attached at the backside of the brace. It had start button, which was to be pressed after wearing of the brace.

As it had adjustable straps, the same brace was used for all the recruited subjects. The brace was designed and constructed by the researchers with technical assistance from a biomedical engineer. The cost of brace was rupees 2000, which was borne by the researchers. This brace was worn on the upper back on normal clothing [Figure 4]. Training for donning and doffing of the brace was given to each subject. The subjects were advised to wear the brace for 6 hours per day in continuation for 30 min during office hours for 2 weeks. Rest breaks were not mandatory, but the subjects were informed to remove the brace while performing the activities that involved standing and walking. The brace had adjustable straps and adequate padding for the comfort of the subject.

Mechanism of the brace: when the subject slouched while working in sitting position, it activated pressure sensors and triggered the electrical circuit, thus provided the subject with auditory feedback to correct the habitual posture. The rationale for using augmented auditory feedback was based on a closed-loop notion of motor control and it provided patients with additional sources of sensory information about the occurrence, duration, and location of force production so that errors in motor performance between intended action and outcome were readily detected and used to correct subsequent performances during maintaining the posture.

The subjects were also given demonstration of the scapular exercises that included T to Y to W exercises to be performed as home program for 2 weeks.[8] The patient was positioned in prone with arms abducted to 90° (the letter T); then was told to do flexion at the elbows to 90°, retracting his scapulas and externally rotating his arms while keeping his arm in 90° abduction. Then maintaining retraction of the scapula, the patient was told to raise his arms above the head and extend the elbow while keeping arm in flexion and abduction to 120° (the letter Y). After that, maintaining the retraction of the scapula, he was shown to flex his elbows and extend his shoulders to form the letter W. The intervention was provided by the investigators.

Outcome Measures

Neck disability index

The neck disability index (NDI) is a ten-item questionnaire that assesses disability associated with neck pain. There are four items that relate to subjective symptomatology (pain intensity, headache, concentration, and sleeping) and six items that relate to activities of daily living (lifting, work, driving, recreation, personal care, reading). The questionnaire requires only 5–10 min to complete and score, and requires no special training to administer. Responses for each item ranging from no disability (0) to total disability. The ten items are summed to gain the total score thus ranging from 0 (no disability) to 50 (maximum disability). A score of <4 indicates no disability, 5–14 mild disability, 15–24 moderate disability, 25–34 severe disability, and scores >35 complete disability. Reliability and validity of NDI has been found to be high (Pearson's r = 0.95 and 0.94, respectively) in a cohort of chronic neck pain participants.[6]

Visual analog scale

A Visual Analog Scale (VAS) is a unidimensional measure of pain intensity. It is a 10-cm line that represents a continuum between the two ends of the scale–”no pain” on the left end (0 cm) of the scale and the “worst pain” on the right end of the scale (10 cm) The patients' marks are recorded in centimeters and are interpreted as their pain. Test–retest reliability has been shown to be good, but higher among literate (r = 0.94, P = 0.001) than illiterate patients (r = 0.71, P = 0.001).[7]

Cranio-vertebral angle

The craniovertebral angle (CVA) was assessed using a digital, lateral-view photograph of the subjects in their usual standing posture. An imaginary horizontal line was drawn that passes through the C7 spinous process. A second imaginary line was drawn from the C7 spinous process up to the tragus, a pointed part in front of the earhole. The CVA is formed at the point where these two lines join together at the C7 vertebra. A cranio vertebral angle of <50° in the standing position is considered as FHP [Figure 2].[1]
Figure 2: Measurement of craniovertebral angle using pointers at the C7 spinousprocess (b) and tragus of Ear (a)

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Scapular index

Subjects were asked to stand with hands hanging beside the body. The coracoid process (CP), the sternal notch (SN), the posterolateral angle of acromion (PLA), and the adjacent thoracic vertebral spine (TS) were palpated and marked. Distance between the coracoid process and SN, and that between the posterior edge of the acromion process and adjacent TS was measured with a measuring tape. Scapular index[1] (SI) was estimated by using the following formula, CP to SN/PLA to TS ×100 [Figure 3].
Figure 3: Measurement of scapular index: (1) (a) Sternal Notch to (b) Corocoid process distance. (2) (c) Posterolateral angle of scapula to (d) thoracic spine distance

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Figure 4: Subject wearing upper back brace with auditory feedback in sitting position

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Data Analysis

The data were analyzed using windows-based SPSS, Version 16.0, released 2007, Chicago, SPSS Inc. Paired t-test was used as statistical tests of significance. P value was set at 0.05 level of significance, and 95% confidence interval (CI) value were computed.

  Results Top

The study population included 10 subjects (5 men and 5 women) with the mean age of 39.0 ± 11.75 (SD) years. The average working hours and working years for the study participants were 7.5 ± 0.52 (SD) hours and 15.1 ± 10.27 (SD) years, respectively.

The subjects reported that donning and doffing of brace was effortless. Further, they did not feel any discomfort and adverse effects in wearing the brace during the study duration. They also followed the T to Y to W exercises as home program without any breaks. They reported that there was a decrease in the neck pain post-intervention and could voluntarily maintain the correct posture while working using the upper back brace with auditory feedback for a period of 2 weeks.

The mean value of difference in NDI, VAS, CVA and SI Scores were 5.53, 1.8, 3.6, and 5.36, respectively. Post intervention there was significant reduction in NDI score (P < 0.05, 95% CI of mean difference [CI]: 2.33–8.72 and VAS score (P < 0.05, 95% CI: 0.70–2.89). Significant increase was also found in CVA score (P < 0.05, 95% CI: 0.60–6.59) and SI score after the intervention (P < 0.05, 95% CI: 0.70–10.01) [Table 1].
Table 1: Comparison Between Pre- and Post-score of NDI, VAS, CVA, and SI among Subject Using Upper Back Bracem with Auditory Feedback (n=10)

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  Discussion Top

In this study, it was observed that MCGM office workers had neck pain, FHP, and rounded shoulders. Static neck posture with repetitive and prolonged exposure to stress in sitting position is frequently assumed by office workers, and it must be possible factors in work-related neck and upper limb disorders.

The static neck posture and prolonged sitting must have caused cumulative microtrauma to tissue in the cervical region, which leads to neck pain.[9] Nejati et al. also revealed that office employees had defective posture while working and developed neck pain.[10] Eltayeb et al. found that among office workers the neck and shoulder complaints were more often than the other complaints of upper extremity region, associated with poor head and body posture and work demands.[11]

The scapula is important for uniform and harmonious movement of the shoulder girdle. Thus alterations in the normal position of the scapula and functions of its stabilizing muscles can be important factor in the development of abnormal biomechanics of shoulder girdle that leads to RSP. Thus the novel brace was introduced to maintain the scapula in normal position and improve the posture.

In this study, it was found that with the use of novel brace there was significant increase in the CVA and SI scores, which may have led to decrease in the forward head and RSP, respectively. Lee, et al. also stated that as the CVA increased the FHP decreased and as SI increased the RSP decreased.[1]

The proprioceptive padding of the brace may have helped to improve the scapular kinematics with the strapping system and sensors cues the mechanoreceptors to keep the scapula in normal position. Thus, the compressive aspects of brace may have improved posture and decrease neck pain.

Scapular stabilizing brace trigger the body to correct improper posture by re-educating and re-engineering the musculoskeletal system surrounding the shoulders and spine as well as signaling the neuroreceptors in the skin to engage in proper posture.[3] Further, the posture compression garment causes the scapula to be in neutral position and maintain posterior tilt which helps in improving posture.[12]

It was found that there was decrease in the NDI and VAS scores with the use of the novel brace. It might have been possible as the posture was improved and scapula and neck alignment was achieved with the use of brace. Also, scapular exercises, which were given as home program might have helped in improving the scapula and neck alignment thus reducing the neck pain. Im et al. also observed that the scapular stabilization exercises reduced the VAS score while enhanced the NDI score among subjects with neck pain and forward head posture.[13]

The auditory feedback with the use of brace may have helped the subjects to do self-correction of posture. Augmented sensory feedback in form of an external device increases awareness of sensory events associated with the performance.[4]

The limitations of the study were that the study was conducted for a limited duration, so the long-term effect of the brace could not be studied, the brace was only worn in sitting position and the generalization of the results was not possible owing to a small sample size. Further, the effect of the brace and scapular exercises could not be differentiated. Further recommendation is to conduct a longitudinal study, considering factors such as age-group and occupation. Future studies in the form of randomized controlled trials are also needed to validate the findings of the present study.

  Conclusion Top

The upper back brace with auditory feedback improves the FHRSP and reduces neck pain and related disability among office workers. Thus, the novel brace may be utilized in conjunction with the standard rehabilitation program for correcting poor habitual neck posture among office workers.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


Dr. Mohan Joshi, Dean LTMMC and GH, for granting permission to conduct this study. Office workers of MCGM for their participation in the study.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.

  References Top

Lee DY, Nam CW, Sung YB, Kim K, Lee HY. Changes in rounded shoulder posture and forward head posture according to exercise methods. J Phys Ther Sci 2017;29:1824-1827.  Back to cited text no. 1
Dave VR, Khanpara HJ, Shukla RP, Sonaliya KN, Tolani J, Patel R. Risk factors of occupation related back pain and neck pain among patients attending tertiary care hospital, Ahmedabad, India. J Prev Med Hyg 2019;60:E419-E427.  Back to cited text no. 2
Cole AK, McGrath ML, Harrington SE, Padua DA, Rucinski TJ, Prentice WE. Scapular bracing and alteration of posture and muscle activity in overhead athletes with poor posture. J Athl Train 2013;48:12-24.  Back to cited text no. 3
Batavia M, Gianutsos JG, Kambouris M. An augmented auditory feedback device. Arch Phys Med Rehabil 1997;78:1389-1392.  Back to cited text no. 4
Wood RJ. Complete Guide to Fitness Testing. Topendsports.com; 2010. Available from: https://www.topendsports.com/testing/. [Last retrieved on 2016 Mar 07; Last accessed on 2017 Jan 07].  Back to cited text no. 5
Sterling M, Rebbeck T. The neck disability index (NDI). Aust J Physiother 2005;51:271.  Back to cited text no. 6
Delgado DA, Lambert BS, Boutris N, McCulloch PC, Robbins AB, Moreno MR, et al. Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. J Am Acad Orthop Surg Glob Res Rev 2018;2:e088.  Back to cited text no. 7
Moezy A, Sepehrifar S, Solaymani Dodaran M. The effects of scapular stabilization based exercise therapy on pain, posture, flexibility and shoulder mobility in patients with shoulder impingement syndrome: A controlled randomized clinical trial. Med J Islam Repub Iran 2014;28:87.  Back to cited text no. 8
Cagnie B, Danneels L, Van Tiggelen D, De Loose V, Cambier D. Individual and work related risk factors for neck pain among office workers: A cross sectional study. Eur Spine J 2007;16:679-686.  Back to cited text no. 9
Nejati P, Lotfian S, Moezy A, Moezy A, Nejati M. The relationship of forward head posture and rounded shoulders with neck pain in Iranian office workers. Med J Islam Repub Iran 2014;28:26.  Back to cited text no. 10
Eltayeb S, Staal JB, Hassan A, de Bie RA. Work related risk factors for neck, shoulder and arms complaints: a cohort study among Dutch computer office workers. J Occup Rehabil 2009;19:315-322.  Back to cited text no. 11
Gascon SS, Gilmer GG, Hanks MM, Washington JK, Oliver GD. Biomechanical influences of a postural compression garment on scapular positioning. Int J Sports Phys Ther 2018;13:700-706.  Back to cited text no. 12
Im B, Kim Y, Chung Y, Hwang S. Effects of scapular stabilization exercise on neck posture and muscle activation in individuals with neck pain and forward head posture. J Phys Ther Sci 2016;28:951-955.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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