Comparative Effects of ACBT and MET for Chronic Neck Pain and Associated Postural Dysfunctions

 

 

Neck pain is one of the most prevalent musculoskeletal (MSK) disorders and is considered a complex, multifactorial condition affecting quality of life and functional ability (Kazeminasab et al., 2022). It is particularly common among students and office workers due to prolonged sitting and poor posture (Chan et al., 2020). Globally, approximately 203 million people experienced neck pain in 2020, with a higher prevalence among females, and its burden is expected to increase substantially by 2050 (Al-Shalalfeh et al., 2026).

Prolonged smartphone use and poor posture are important contributing factors to neck pain. Forward head posture (FHP), characterized by the head positioned anteriorly relative to the shoulders, increases mechanical stress on the cervical spine and alters muscle balance (Nejati et al., 2014; Çobanoğlu et al., 2024; Raoofi et al., 2019). Neck pain and FHP are also associated with altered breathing patterns and increased reliance on accessory respiratory muscles, such as the sternocleidomastoid and scalene muscles, which may further increase cervical muscle tension and disability (Nair et al., 2022).

 

Breathing-pattern retraining, particularly diaphragmatic breathing, may improve postural stability, reduce accessory muscle overactivity, and alleviate neck pain (Heo & Shin, 2025). Although conventional physiotherapy and manual therapy are commonly used for chronic neck pain, evidence regarding the role of breathing retraining remains limited.

 

This study therefore compares Active Cycle of Breathing Techniques (ACBT) combined with stretching and Muscle Energy Techniques (METs) combined with stretching in individuals with chronic neck pain, altered breathing patterns, and postural dysfunction. While previous research has examined diaphragmatic breathing and manual therapy separately, limited evidence directly compares these two active approaches. This study aims to address this gap by evaluating their relative effects on neck pain, posture, and functional disability.

 

Objectives:                    

The objectives of this study are to determine the effectiveness of breathing pattern retraining on chronic neck pain, to evaluate changes in posture following breathing retraining and to assess the improvement in functional difficulty in patients with CNP.

 

Hypotheses

Alternative hypothesis (H₁): There is a significant difference between the effects of Active Cycle of Breathing Techniques (ACBT) combined with stretching and Muscle Energy Techniques (METs) combined with stretching on pain, functional disability, breathing pattern, and forward head posture in individuals with chronic neck pain.

 

Null hypothesis (H₀): There is no significant difference between the effects of ACBT combined with stretching and METs combined with stretching on pain, functional disability, breathing pattern, and forward head posture in individuals with chronic neck pain.

 

 

48 participants were selected based on the inclusion and exclusion criteria. Out of 48 subjects 42 subjects were selected and distributed into two groups ( Group 1:ACBT + Stretching & Group 2: METs + Stretching) based on convenient sampling technique.Both groups socio-demographic information was similar at baseline.Participants in ACBT group were presented with mean age of 29.48±7.587 Years and in METs group with 32.29±8.198 years.

 

Normality of both groups was checked through Shapiro Wilk test.Both the groups appeared normal. Independent t test was performed for between group comparison of SEBQ,NDI,VAS and CVA individually.

 

Table 1 showing between group comparison of SEBQ scores.

 

 

After treatment p value is <0.05 which tells us that significant improvement was seen after treatment in SEBQ score in both the groups.However group 2 (METS + stretching) slightly more improvement.

 

Figure 1 showing between group comparison of SEBQ

 

Between group comparison of NDI scores was also done by independent t test and the results were as following:

 

Table 2 showing between groups comparison of NDI score.

 

As the after treatment values of p are <0.05 it means significant reduction in neck disability was seen post treatment.However METs group showed slightly better results than ACBT group.

 

Figure 2 showing between group comparison of NDI scores.

 

 

Between group comparison of group 1 and group 2 VAS scores was done by independent t test.After treatment the values of p were seen to be < 0.05 which suggests that significant reduction was seen in pain in both groups. However, group 2 showed slight better improvement than group 1.

 

Table 3 showing between group comparison of VAS score.

 

 

 

Figure 3 showing between group comparison of VAS scores.

Between group comparison of CVA scores was also done by independent t test that showd before and after treatment p values to help us determine the effectiveness of both groups.

 

Table 4 showing between group comparison of CVA scores.

	Group 1 or 2	N	Mean±Std.Deviation	p
CVA score before treatment	Stretching + ACBT	21	43.54±2.623	.530
	STRETCHING + METs	21	44.02±2.285	.530
CVA score after treatment	Stretching + ACBT	21	47.26±2.025	<.001
	STRETCHING + METs	21	51.59±2.117	<.001

 

Figure 4 showing between group comparison of CVA scores

 Hence from the above findings we can say that both ACBT + Stretching and METs + Stretching were effective in improving neck pain, posture, and functional disability. METs + Stretching demonstrated greater improvement across the outcome measures than ACBT + Stretching. Breathing pattern can be considered a valuable adjunct to conventional physiotherapy for managing chronic neck pain.

The present quasi-experimental study compared the effects of neck muscle stretching combined with Active Cycle of Breathing Techniques (ACBT) and stretching combined with Muscle Energy Techniques (METs) in patients with chronic neck pain and forward head posture (FHP). Pain, functional disability, breathing dysfunction, and postural alignment were assessed using the VAS, NDI, SEBQ, and craniovertebral angle (CVA), respectively. Both groups demonstrated significant improvements following 10–12 treatment sessions over 3–4 weeks. However, the METs + stretching group showed significantly greater improvements in breathing dysfunction (SEBQ, p < 0.001), pain (VAS, p = 0.004), functional disability (NDI, p = 0.030), and forward head posture (CVA, p = 0.008). These findings suggest that although both interventions were effective, METs combined with stretching may provide greater short-term benefits in patients with chronic neck pain and postural dysfunction.

The findings are consistent with previous research supporting exercise, breathing re-education, and manual therapy for chronic neck pain. Heo and Shin (2025) reported improvements in pain, disability, and cervical function following breathing and neck exercise interventions, although no significant between-group differences were observed. Similarly, Jeong and Lee (2024) reported beneficial effects of breathing re-education and shoulder stabilization exercises in individuals with upper crossed syndrome, supporting the relationship between respiratory function and postural dysfunction. In contrast, Dareh-Deh et al. (2022) found that adding respiratory exercises to routine therapy improved respiratory parameters but did not provide significant additional benefits for pain or FHP. Differences between these findings and the present study may be related to differences in intervention protocols and study designs, as the current study directly compared two active treatment approaches rather than comparing respiratory exercise with routine therapy alone.

 

The greater improvement observed in the METs + stretching group may be explained by the direct effects of METs on muscular tightness and cervical biomechanics. METs involve controlled isometric contractions followed by relaxation and stretching, which may improve muscle extensibility, reduce muscle hypertonicity, and enhance joint mobility. These effects may be particularly relevant in FHP, where altered muscle length and increased activity of cervical and shoulder musculature can contribute to abnormal cervical loading and pain. When combined with stretching, METs may further improve flexibility and postural alignment, thereby reducing mechanical stress and functional limitations.

 

The improvements observed in the ACBT group may be related to improved breathing control and reduced reliance on accessory respiratory muscles. Individuals with chronic neck pain and FHP may demonstrate altered breathing patterns and increased activity of muscles such as the sternocleidomastoid and scalene. Breathing retraining may help improve respiratory coordination and reduce unnecessary cervical muscle activity. However, the greater response to METs in the present study suggests that directly addressing muscular restrictions may have a stronger short-term influence on pain, disability, and postural alignment in this population.

 

From a clinical perspective, both interventions may be incorporated into physiotherapy management according to the patient's presentation. However, METs combined with stretching may be particularly useful for patients with prominent muscle tightness, postural dysfunction, pain, and functional limitation. The findings also indicate that clinically meaningful improvements may occur within a relatively short treatment period of 3–4 weeks. Nevertheless, these results should be interpreted as evidence of short-term effects, as the study did not include long-term follow-up.

 

The study has several strengths, including the use of multiple outcome measures addressing pain, disability, breathing dysfunction, and posture, as well as the comparison of two active physiotherapy interventions. However, the small sample size, convenient sampling, quasi-experimental design, and short intervention period limit the generalizability of the findings and reduce the ability to establish definitive causal relationships. The absence of long-term follow-up also prevents conclusions regarding the sustainability of treatment effects. Future research should employ larger randomized controlled trials with longer follow-up periods and include additional objective measures such as cervical range of motion, respiratory parameters, muscle activity, and quality of life.

 

Overall, both ACBT + stretching and METs + stretching were effective in improving clinical outcomes in patients with chronic neck pain and FHP. However, METs + stretching produced significantly greater improvements in pain, functional disability, breathing dysfunction, and forward head posture. These findings suggest that METs combined with stretching may be a more effective short-term approach for patients with chronic neck pain accompanied by muscular and postural dysfunction, while ACBT may remain a useful adjunct when altered breathing patterns are a prominent clinical feature.

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