PONE-D-25-29149Exercise therapy for cervical proprioception in individuals with asymptomatic forward head posture: a systematic reviewPLOS ONE

Dear Dr. Alimoradi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Kindly make the below changes suggested by the reviewers

==============================

Please submit your revised manuscript by Aug 16 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Prateek Srivastav

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Unclear Definition of 'Diagnostic Inconsistencies': Mentioning "diagnostic inconsistencies" is appropriate, but without a brief example (e.g., varying CVA thresholds), readers are left in the dark.

The phrase “exercise-based interventions” is repeated excessively.

The paper states that exercise may improve proprioception via “neuromuscular re-education” but does not adequately elaborate.

There is no mention of how the lack of blinding in included RCTs may affect bias in outcome measurements.

While ESs are given per direction (flexion, extension), this becomes hard to digest. A table summarizing overall ESs by intervention type (e.g., stabilization vs. WBV) and direction would help.

Statements like “more research is needed” or “future studies should standardize protocols” are expected and lack depth.

Reviewer #2: Suggested improvements:

I do appreciate the motive behind this review manuscript, which is focused on summarizing the current unknowns, and potential benefits of exercise-based interventions in improving cervical proprioception in individuals with forward head posture. This is a well-flowed review article whose theme is suitable to this journal. The objectives are relevant, and the discussion is well-written and flows with the paper. However, the authors overlooked several key and relevant literature that deems this systematic review incomplete and requires major revisions. Mainly since the reviewers did not include “google scholar” as one of the search engines. By running a search using “google scholar”, I found several key RCT publications that could play a major role on the evidence provided in this systematic review, which are provided bellow. The authors also misused several words which portrays a completely different meaning. The manuscript requires major revisions for vocabulary and grammatic errors. Lastly, the discussion could benefit from a subsection that specifically addresses the exercise prescription (i.e., frequency, intensity, type, and duration); specifically, since the authors stated in the introduction that exercise prescription remains unclear and is a clear limitation within the literature. Once these points, and all the other revisions mentioned in the article, are addressed, I will indicate this systematic review research article for publication.

1. Miçooğulları, M., Yüksel, İ., & Angın, S. (2024). Efficacy of scapulothoracic exercises on proprioception and postural stability in cranio-cervico-mandibular malalignment: A randomized, double-blind, controlled trial. Journal of Back and Musculoskeletal Rehabilitation, 37(4), 883-896.

2. Kang, N. Y., Im, S. C., & Kim, K. (2021). Effects of a combination of scapular stabilization and thoracic extension exercises for office workers with forward head posture on the craniovertebral angle, respiration, pain, and disability: A randomized-controlled trial. Turkish journal of physical medicine and rehabilitation, 67(3), 291–299. https://doi.org/10.5606/tftrd.2021.6397

3. Sarıyıldız, A., Deniz, V., & Başaran, S. (2022). Effectiveness of corrective exercise program on alignment, muscle activation and biomechanical properties in forward head posture: a randomized controlled trial. Cukurova Medical Journal, 49(4), 1082-1092.

4. Igbokwe, E. O., Taube, W., & Beinert, K. (2022). A Comparison of the Effects of Stochastic Resonance Therapy, Whole-Body Vibration, and Balance Training on Pain Perception and Sensorimotor Function in Patients With Chronic Nonspecific Neck Pain: Protocol for a Randomized Controlled Trial. JMIR Research Protocols, 11(6), e34430.

5. Gulati, M., Harikesavan, K., & Venkatesan, P. (2025). Immediate effects of thoracic postural correction taping on sensorimotor and respiratory functions in healthy office workers with forward head posture-A randomized controlled trial. Journal of Bodywork and Movement Therapies.

6. Anwar, S., Zahid, J., Alexe, C. I., Ghazi, A., Mareș, G., Sheraz, Z., ... & Gasibat, Q. (2024). Effects of Myofascial Release Technique along with Cognitive Behavior Therapy in University Students with Chronic Neck Pain and Forward Head Posture: A Randomized Clinical Trial. Behavioral Sciences, 14(3), 205.

7. Sarıyıldız, A., Deniz, V., & Başaran, S. (2022). Effectiveness of corrective exercise program on alignment, muscle activation and biomechanical properties in forward head posture: a randomized controlled trial. Cukurova Medical Journal, 49(4), 1082-1092.

8. Dareh-Deh, H. R., Hadadnezhad, M., Letafatkar, A., & Peolsson, A. (2022). Therapeutic routine with respiratory exercises improves posture, muscle activity, and respiratory pattern of patients with neck pain: A randomized controlled trial. Scientific reports, 12(1), 4149.

Specific Recommendations:

See manuscript draft.

Reviewer #3: 1. Summary of the research and my overall impression

Forward head posture (FHP) has various adverse effects, thereby leading to an increasing social demand for its improvement. However, there is no established interventional method, specifically for managing cervical proprioceptive deficits, which is a feature of FHP. As a result, various interventional approaches have been developed. By systematically reviewing existing evidence, this study aimed to clarify the effect of exercise-based interventions on cervical proprioception. This review revealed limitations in this field, such as the lack of established diagnostic criteria and studies with reliable protocols. The authors concluded that although various interventions may be effective in improving cervical proprioception, no definitive conclusions can be drawn due to the low certainty of evidence.

The main strength of this paper is a clear and socially valuable research question. In addition, this systematic review has transparency because this study describes the limitations of each included study in detail. Some of the weaknesses are unclear logical links between the results and the conclusion, especially regarding the comparison among various intervention methods. Therefore, there is a concern that the collected data may not support a part of the conclusion.

Overall, the manuscript is certainly readable and attractive. Especially in the discussion, the possible mechanisms for why interventions improve cervical movements are well-structured. Since this systematic review provides an important contribution to help initiate future reliable studies, I recommend it for publication after some revisions and answers to my questions.

2. Evidence and examples

Major Issues

1. My main concern is related to the claim about the comparison of effectiveness among intervention methods. I will mention three parts: Figure, Discussion, and Conclusion (and Abstract).

• (Figure) As the authors mentioned in the introduction, one of the purposes of this study was to clarify which interventions are most effective among different methods. Therefore, I recommend adding a new figure that summarizes the effect sizes of each intervention method. This visualization would help the readers to interpret the authors’ claims.

• (Discussion) Regarding alternative interventions in the discussion, where it states, “While these alternative modalities …, their relative efficacy compared to conventional stabilization exercises remains unclear (line 342-344 of page 9)”. Indeed, this claim is important to reveal the challenges for the alternative interventions, but the rationale behind this claim is unclear. Please clarify the reason why the effectiveness of alternative intervention methods is unknown compared to traditional interventions for the readers.

• (Conclusion) As pointed out above, the present discussion regarding the comparison of intervention methods seems vague. Therefore, it is unclear which results support a part of the conclusion (“… particularly cervical stabilization exercises, can improve …“, lines 387-388 of page 10). Specifically, a question is: if this conclusion that cervical stabilization exercises were most effective is based on effect size, should the authors consider the fact that the cervical retraction method also had equivalent effect sizes?

(Abstract-result) Regarding the abstract, there is a concern regarding the claim: “Cervical stabilization exercises demonstrated the most consistent benefits, particularly in rotation and flexion tasks” (lines 62-63 of page 2). There are two questions: Firstly, what is this “most” compared with (directions of motion or intervention methods)? Second, if the comparison is regarding intervention methods, what is the logic of this claim? If the claim is based on the number of studies (i.e., the fact that 3/9 are stabilization exercises), it could be misunderstood that alternative intervention methods lacked consistency. To ensure rigor, it is helpful to clarify that consistency regarding alternative interventions could not be evaluated due to the number of studies.

Together, regarding both the conclusion and abstract, the authors might want to consider clarifying the reasons for their claim that stabilization exercises were most or consistently effective. I recommend giving the evidence explicitly in the Discussion. If there is no valid basis, I would recommend that the authors exclude the claim on which interventions are most effective from the conclusions and the result of abstract.

2. Regarding data synthesis and narrative review in the results, the authors grouped the studies that used standard outcome measures as JPE and otherwise as JPS. If this understanding is correct, there is a question about whether it is necessary to separate the included studies into two groups. If the authors interpret that both outcome measures are used to measure joint position sense (i.e., proprioception acuity), the authors could analyze all studies in a unified way without grouping. What are the criteria and rationale for separating JPE and JPS in this analysis?

3. Regarding the conclusion, where it states, "… exercise-based interventions ...can improve cervical proprioception in individuals with forward head posture" (lines 387-389 of page 10). Indeed, the results of this review support the improvement of sensorimotor control using cervical spine movements (i.e., the improvement of “Joint Position Error Test”). However, it appears difficult to identify the mechanism of improvement, as the authors mention it in the Key findings and mechanisms of improvement, too. Therefore, to avoid misleading, the authors might want to consider avoiding a definitive claim that "can improve cervical proprioception."

Minor Issues

1. Page 2 Abstract and Page 4 Search strategy: The authors state “A systematic search of PubMed, Scopus, and Web of Science was conducted up to March 28, 2025” in Abstract-Methods (line 54 of page 2). However, the authors also state, “The search included the electronic databases Web of Science, PubMed, and Scopus, from inception to April 20, 2025…” in Search strategy (lines 132-133 of page 4). Does each statement indicate something different? In addition, did the authors have any restrictions on the publication year of studies they searched?

2. Page 5, lines 163-164 Quality assessment: At the domain of the randomization process, were baseline differences between groups evaluated (if available)?

3. Page 5, Data synthesis: How did the authors treat the results of conditions for comparison (e.g., a result of the SE-VF group in Goo et al. (2024))? Were the results in those conditions excluded because more than one intervention was compared at the same time?

4. Page 5, Data synthesis: For better interpretation for the readers, could the authors fill in item 1 Grouping studies for synthesis, item 3 Describe the synthesis methods, item 7 Data presentation methods, following the SWiM reporting guideline.

5. Page 5, lines 187-189 Data synthesis: Were Kappa statistics conducted between two reviewers at any stage?

6. Page 6, lines 206-207 Study identification and Figure 1: There is a discrepancy between the numbers reported in the text and those reported in Figure 1. Does each indicate something different?

7. Page 6, lines 220-221 Descriptive characteristics of the included studies: Regarding the study referenced as number 30, which did not mention the sex of the participants, which sex group were that participants finally included into?

8. Page 8, line 277 Certainty of the evidence / Page 10, line 380 Limitations and future directions / Table 4: There is a discrepancy between the certainty reported in the text (moderate) and those reported in Table 4 (Low) about JPS. Please correct the discrepancy.

9. Page 8, line 301 Key findings and mechanisms of improvement: This may be a typo: “ES= 1.12=3.66”.

10. Pages 9-10, Limitations and future directions: I suppose that any assessment tools used by the included studies have a limitation that the current measurement tasks (i.e., Joint Position Error Test) cannot evaluate cervical proprioceptive acuity directly. Specifically, there is a possibility that the component of body sway may lead to measurement error, or the fact that it is difficult to isolate the influence of the vestibular system or motor control dysfunction. Are these inherent limitations of assessment tests not mentioned in the section on Limitations and future directions?

11. Figure 2: The black square and black triangle probably represent the mean or median.　Please specify what each symbol indicates and what the error bars demonstrate.

12. References: The cited studies are sometimes misnumbered. Please check the reference list and corresponding numbers throughout the whole text.

Reviewer #4: The manuscript is well structured , evidenced based , methodology aligns well with augment. I therefore endorse the manuscript for publication being very comprehensive structured to provide readers with a clear insight.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes:  Ebenezer Ad Adams

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: PONE-D-25-29149_reviewer_AO.pdf

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

PONE-D-25-29149R1

Dear Dr. Alimoradi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support .

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Prateek Srivastav

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The authors carefully reviewed and addressed all comments and concerns. I know indicate it for publication.

Reviewer #3: The authors have addressed several questions raised in my previous review. The revised manuscript is well structured, and the data support the revised conclusions. No major concerns remain. However, I encourage the authors to consider the following minor points to improve clarity for readers.

Minor Points

1. Page 6, lines 216, Study identification and Figure 1:

There is a discrepancy in the number of studies reported. The text refers to n = 547, while Figure 1 states n = 574. Clarifying this inconsistency would improve the accuracy of reporting.

2. Page 22, Figure 2:

The black circles appear to indicate the studies with the smallest and largest effect sizes. I recommend revising the figure caption to state this explicitly, which would assist readers in interpreting the figure.

Overall, I recommend this systematic review research article for publication.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #2: No

Reviewer #3: No

**********