422/2012 and the Declaration of Helsinki of 1975. The Research Ethics Committee of Centro Universitário Augusto Motta approved this study protocol (CAAE 091314.5235), designed in accordance with National Health Council Resolution No. Because of the controversy about the association between craniocervical posture and neck pain or disability, 1, 2 ,5, 6, 7, 8, 9, 10 we secondarily examined the correlation of CCA calculated with either palpation method with neck-pain intensity and disability in adults. We hypothesized that measuring the craniocervical angle (CCA) with the flexion-extension method (FEM) and the modified thorax-rib static method (MTRSM)-2 methods with very distinct accuracies-would yield distinct classifications of individuals as with or without FHP. The purpose of this study was to compare craniocervical posture assessed by photogrammetry using 2 distinct palpation methods for locating the spinous process of the seventh cervical vertebra (C7SP). However, it remains undetermined whether a palpation method with higher accuracy yields different assessments of craniocervical posture and FHP classifications. 27, 28 The MTRSM applies a multivariate linear regression model to adjust for body mass and age the location of the C7SP as determined by palpation. 26 Recently, a palpation method for locating the C7SP that outperforms the accuracy of the FEM has been proposed and validated: the MTRSM. 2 ,21, 22, 23 Despite its low accuracy, the FEM 24, 25 has been regarded as the best method for locating this structure. There are several palpation methods for locating the tragus of the ear and the C7SP, which are both required to assess the CCA. Photogrammetry is an accurate and reliable tool for the objective measurement of body angles and alignments, as well as their interrelations, that characterize body posture.12, 13, 14, 15, 16 The distinction between individuals with and without FHP has been examined using photogrammetry by measuring the CCA, defined as the inner angle between the absolute horizontal line and the line drawn from the posterior tip of the C7SP to the midpoint of the tragus (Fig 1) 17, 18 the lower the CCA, the greater the degree of FHP.5, 6, 7, 8, 11 Because photogrammetry assessment-as well as other marker-based assessments in biomechanics 19, 20-is preceded by locating anatomic landmarks, the use of accurate palpation methods is arguably preferred for their location. 11 Altogether, these data suggest that accurate measurement of FHP is required for better assessment of craniocervical posture and management of musculoskeletal complaints. 10 A longitudinal study has shown that a reduction in FHP is associated with a decrease in neck-pain intensity in individuals with cervical spondylotic radiculopathy.
9 Another recent cross-sectional study has verified that posture assessment by photogrammetry or visual inspection cannot detect the presence of neck pain in young adults.
3, 4 Cross-sectional studies have reported an association of FHP with neck pain.5, 6, 7, 8 Another study, though, has reported no association between cervical posture and neck pain in young healthy adults, although no objective assessment of FHP was provided. 1, 2 Many individuals naturally adopt a forward head posture (FHP), characterized by anterior displacement of the head with respect to the trunk. The relationship between craniocervical posture and musculoskeletal complaints is controversial.
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