Attentional focus strategies alter muscle activation during combined chin tuck and prone T exercise in individuals with forward head posture: a cross-over pilot study

Aims: This pilot study aims to assess the feasibility and preliminary effects of external versus internal attentional focus cues on cervical muscle activation during combined chin tuck and prone T exercises. Methods: This cross-over, prospective, and pilot study included 15 individuals with forward head posture (FHP). Photographic analysis using Kinovea software was performed to identify individuals with FHP. Surface EMG system (Noraxon, USA, Inc., Scottsdale, AZ) was used to assess the activation of the sternocleidomastoid (SCM), upper trapezius (UT), middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) during a combined chin tuck and prone T exercise. Exercises were performed under three attentional focus conditions: unguided, internal, and external. Friedman and Wilcoxon signed-rank tests with Bonferroni correction were used to analyze differences. Results: Friedman analysis revealed significant differences in SCM (p=0.008), UT (p=0.012), MT (p=0.013), and LT (p=0.017) activation across focus conditions, but not for SA (p>0.05). Pairwise comparisons showed that internal and external focus both increased SCM activation compared to unguided (p=0.004 and p=0.008), while internal focus significantly increased UT and MT activation (p=0.013 and p=0.002). LT activation showed an upward trend under internal focus but did not reach Bonferroni-corrected significance (p=0.02). No significant changes were observed in UT/MT and UT/LT ratios, although a decreasing (favorable) trend was noted under guided conditions (p>0.05). Conclusion: This pilot study provides preliminary evidence that internal attentional focus cues may selectively enhance cervical and scapular muscle activation, particularly for the SCM, UT, and MT, with a similar trend noted for the LT during combined chin tuck and prone T exercises. These findings could support the potential role of attentional cueing in postural rehabilitation and guide the development of more targeted exercise protocols.