Pain is an uncomfortable sensation that occurs as a result of the body's response to stimuli that damage tissues or potentially cause injury. In muscles, pain is a painful sensation that arises due to tension, injury, or excessive activation of the muscles, resulting in a lack of oxygen and the accumulation of lactic acid (Tournaire & Theau-Yonneau, 2007). Neck pain is one of the most common musculoskeletal complaints and has a high prevalence rate among the adult population, including university students. Based on studies and data from the Global Burden of Disease Study, the prevalence of neck pain globally reaches 27% and is the fourth cause of disability in the world (Safiri et al., 2020). In Indonesia, based on data from the Ministry of Health and previous studies, the incidence of neck pain ranges from 17 to 24% in prevalence, with the majority of the population being of productive age and students (Ladhina & Wahid, 2023). Some of the leading causes of neck pain reported include poor posture while sitting or working, excessive use of devices or computers, psychological stress and strain, and increased activation of the neck muscles (Hogg-Johnson et al., 2008). One posture problem strongly associated with neck pain is Forward Head Posture (FHP).

Forward Head Posture (FHP) is a deviation in cervical posture characterized by head protrusion or head positioning more anterior to the shoulders in the sagittal plane with a craniovertebral angle lower than 50 degrees (Ramalingam et al., 2019). Recent studies have shown that FHP has become a common condition across different age groups and continues to increase in various populations. Based on a study conducted in adults, the average cranio-vertebral angle in the male group aged 22-44 years was 48.8 degrees, while in the female group aged 23-66 years, it was 47.6 degrees (Worlikar & Shah, 2019). Previous studies have also reported a prevalence of FHP of 66% among individuals aged 20-60 years (Ramalingam et al., 2019).

One of the muscles highly affected in FHP-related complaints is the upper trapezius, a superficial muscle located in the posterior part of the neck and upper back, with important functions in scapula movement, shoulder stabilization, and contributing to cervical extension and rotation movements (Ludewig & Braman, 2012). Excessive tension in the upper trapezius muscle can cause active localized pain, trigger points, limitation of motion, and referred pain to the head and upper shoulder area (Ludewig & Braman, 2012). Pain in the trapezius is particularly prevalent among adults with sedentary habits, poor posture, and prolonged use of computers or smartphones (Cagnie et al., 2007; Kim, 2015). A previous study reported that around 54% of office workers experience complaints in the upper trapezius muscle due to work that requires a static sitting position and repetitive shrugging activities (Cagnie et al., 2007). Additionally, the lack of stretching and muscle relaxation habits is also a contributing factor to the onset of these complaints (Kim, 2015). Pain in this muscle not only causes local disturbances but also has the potential to reduce quality of life, interfere with daily activities, and trigger secondary psychological complaints such as stress and chronic fatigue (Kim, 2015).

In physiotherapy, two common approaches to alleviate muscle pain are spinal manipulation and stretching exercises. Spinal manipulation is a manual therapy technique involving high-velocity, low-amplitude thrusts applied to the spinal joints—cervical, thoracic, or lumbar—to restore mobility and reduce pain. A systematic review demonstrated that spinal manipulation provides significant short-term reductions in pain and disability in patients with neck pain, although the long-term effects remain uncertain (Huisman et al., 2013). Previous research involving 457 participants demonstrated that thoracic spine manipulation significantly reduced neck pain and disability, with a reported pain reduction score of 12.46 (Tsegay et al., 2023). Similarly, a randomized controlled trial demonstrated that thoracic spine manipulation, combined with exercise, improved pain and disability more effectively than exercise alone in patients with mechanical neck pain (Masaracchio et al., 2019).

Stretching exercise, on the other hand, is a safe, non-invasive intervention aimed at lengthening muscles and connective tissue to improve flexibility and Range of Motion. Based on previous literature, stretching exercise has several benefits, such as reducing pain, increasing flexibility and ROM, improving blood circulation, and reducing muscle tension (Zvetkova et al., 2023). When compared to other interventions, stretching exercise is considered safer as it has lower side effects, is flexible, and improves flexibility and ROM. A systematic review also confirmed that stretching and strengthening exercise programs effectively reduce pain intensity and improve function in patients with neck pain (Louw et al., 2017). While the effects of stretching are not immediately apparent because they require a more extended period, they can be sustained in the long term (Albazee et al., 2024).

Although both spinal manipulation and stretching exercises are widely used in clinical practice, there is limited randomized controlled evidence in young adult populations directly comparing their superiority, immediate effects, and clinical significance for trapezius muscle pain. This gap creates uncertainty for physiotherapists in selecting the most effective intervention to address posture-related musculoskeletal complaints in university students (Albazee et al., 2024; Langevin et al., 2016). The null hypothesis (H0) states that there is no significant difference in pain reduction between spinal manipulation and stretching exercise. The alternative hypothesis (H1) states that there is a significant difference in pain reduction between the two interventions. Therefore, the objective of this study is to compare the immediate effects of spinal manipulation and stretching exercise on upper trapezius muscle pain in university students, thereby providing evidence to guide physiotherapy clinical decision-making.

In terms of gender distribution, treatment group I consisted of 4 male subjects (20%) and 16 female subjects (80%), while treatment group II included three male subjects (15%) and 17 female subjects (85%). Regarding the average duration of digital device usage, treatment group I comprised five subjects (25%) who used devices for less than 5 hours, five subjects (25%) with usage between 5 and 6.5 hours, and 10 subjects (50%) with usage exceeding 6.5 hours per day. In treatment group II, four subjects (20%) reported using less than 5 hours, five subjects (25%) used between 5 and 6.5 hours, and 11 subjects (55%) used more than 6.5 hours. Based on Body Mass Index (BMI), treatment group I included three underweight subjects (15%), 11 with normal weight (55%), two overweight (10%), and 4 with obesity (20%). Treatment group II consisted of 11 subjects (55%) with a normal BMI, 5 (25%) who were overweight, and 4 (20%) classified as obese. For craniovertebral angle (CVA), the mean pre-test value in treatment group I was 55.20°, increasing slightly to 55.40° post-test. In contrast, treatment group II exhibited a decrease in CVA from 52.40° pre-test to 51.55° post-test. Regarding pain intensity measured by the Numeric Rating Scale (NRS), treatment group I showed a reduction from a pre-test median of 4.5 to a post-test median of 2.5. In contrast, treatment group II experienced a reduction from 4.25 to 1.

In summary, the results of the statistical analyses indicate that although both interventions produced a significant and clinically meaningful reduction in pain intensity within each group, there was no significant difference in the magnitude of improvement between the two treatments. These findings suggest that both intervention methods were equally effective in alleviating pain among participants. Therefore, the subsequent discussion will focus on interpreting these outcomes in relation to previous research, possible physiological mechanisms underlying the observed effects, and the clinical implications of comparable treatment efficacy.

This study investigated the effects of spinal manipulation and stretching exercises on pain intensity and craniovertebral angle (CVA) among physiotherapy students with Forward Head Posture (FHP), while also exploring contributing factors such as age, gender, body mass index (BMI), and duration of device use. The main findings revealed that both interventions led to a decrease in pain intensity—spinal manipulation from 2.52 to 1.32 and stretching from 2.95 to 1.42 on the NRS scale—and an improvement in CVA from 45.5° to 47.5°, indicating postural enhancement. However, no statistically significant difference was found between the two groups (p > 0.05), suggesting comparable short-term effectiveness. Although the results did not reach statistical significance, both interventions achieved clinically meaningful improvements in pain reduction and posture correction.

The improvement in CVA observed in this study aligns with previous findings, which demonstrate that postural correction through spinal manipulation, stabilization, and stretching exercises can enhance cervical alignment and reduce muscle tension (Acet et al., 2025; Lee et al., 2015). Similarly, activation of the deep neck flexor muscles has been shown to improve neck stability and postural control (Apriliani, Yusrin, & Pristianto, 2021). Other studies also reported that integrative interventions, such as neuromuscular reeducation or ultrasound-assisted therapy, significantly improved CVA (Saraswati et al., 2024). Despite these findings, Wibisono et al. (2022) reported that changes in CVA were not always associated with pain reduction, highlighting the influence of habitual postures and prolonged smartphone use on FHP independent of treatment (Wibisono et al., 2022).

Regarding pain reduction, this study supports evidence that both spinal manipulation and stretching exercises are practical for managing musculoskeletal discomfort. Spinal manipulation may reduce pain through neuromodulation and improved local circulation (Chihwan & Donggeon, 2020). Previous research has shown a marked decrease in pain intensity after chiropractic intervention in cases of low back pain (Fagundes Loss et al., 2020; Wulandari, 2020). Stretching exercises similarly reduce pain by improving muscle flexibility, elasticity, and blood flow, thus alleviating tension in the neck and shoulder region (Arooj et al., 2022; Mardiyana et al., 2022). The comparable pain reduction between both interventions in this study suggests that either can be utilized as a short-term management strategy for FHP-related neck discomfort.

The analysis of contributing factors revealed that most subjects were aged 19–20 years, a population prone to FHP due to sedentary lifestyles and prolonged device use (Arooj et al., 2022; Naz et al., 2018; Singh et al., 2020). Although age may contribute to FHP prevalence, it is not the dominant determinant compared to postural habits and ergonomics (Savitri & Faidlullah, 2022). Female students were more frequently affected, consistent with reports linking lower cervical strength and greater neck mobility to higher FHP risk (Karthik et al., 2022; Mahmoud et al., 2019; Sarraf & Varmazyar, 2022). Device use exceeding 5 hours daily also showed strong associations with FHP, corroborating previous findings that prolonged head flexion (>15°) induces mechanical strain on the cervical spine (Lee et al., 2015; Maharani & Dewi, 2019; Shah & Sheth, 2018). In contrast, BMI exhibited inconsistent relationships with FHP, where higher BMI may contribute to postural imbalance (Kocur et al., 2019; Mahmoud et al., 2019; Noviati, 2022), though other studies found ergonomic factors to be more influential (Pangestu et al., 2021; Karthik et al., 2022).

From a critical perspective, several factors could explain the absence of statistically significant differences between the two interventions. First, the limited sample size (n = 8) may have reduced the statistical power to detect minor effect differences. Second, the single-session intervention design may not have been sufficient to produce lasting neuromuscular adaptations. Third, non-specific treatment effects, such as the placebo effect, therapist influence, or participants' expectations, might have contributed to the perceived improvements. Moreover, sample characteristics—predominantly female physiotherapy students—limit generalizability to other populations. The use of subjective measures (NRS, CVA via photographic analysis) may also introduce measurement bias compared to objective assessments, such as pressure pain threshold or range of motion.

In this randomized pilot study involving physiotherapy students (n = 40), both single-session thoracic spinal manipulation and passive stretching exercises demonstrated immediate reductions in pain intensity and improvements in the craniovertebral angle (CVA). However, no statistically significant difference was found between the two interventions, suggesting comparable short-term efficacy. Given the small sample size, single-session design, and short-term outcome assessment, these findings should be interpreted with caution. Future studies with larger sample sizes, multiple treatment sessions, extended follow-up periods, and objective assessment tools are recommended to validate the clinical relevance and long-term effectiveness of these interventions.

The author extends sincere gratitude to the supervisor and to the Physiotherapy Study Programme, Faculty of Health Sciences, Universitas Muhammadiyah Surakarta, for their valuable support, as well as to all respondents whose participation contributed significantly to the completion of this study.

All data supporting the findings of this study are included in the article and its supplementary materials. Additional datasets are available from the corresponding author upon a reasonable request.

This research was conducted independently, without receiving funding from any institution, including government, private sector, or non-profit organizations.

The author hereby declares that this research is free from conflicts of interest with any party.