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This study introduces the Global Sagittal Deviation Index (GSDI-5), a composite measure integrating multiregional sagittal alignment with explicit inclusion of the upper cervical spine.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Standing lateral EOS radiographs from 201 adults referred for evaluation of low back pain were analysed and classified into FHP and non-FHP groups. Standardized sagittal parameters across the cervical, thoracic, lumbar, and global spine were combined into a single score. Initial construct validity was examined through known-groups comparisons and convergent analyses with TPA and PI\u2013LL.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Individuals with FHP demonstrated higher GSDI-5 scores. GSDI-5 showed a large effect size for differentiating FHP from non-FHP (Hedges\u2019 g\u2009=\u20090.85), slightly exceeding that of TPA (g\u2009=\u20090.81) and PI\u2013LL (g\u2009=\u20090.32), with increasing severity associated with progressive changes in global alignment measures.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>By integrating upper cervical alignment into a whole-spine framework, GSDI-5 summarizes cranio-cervical behaviour relevant to FHP and may serve as a complementary exploratory measure for global sagittal deviation in radiographic and postural assessment, alongside existing sagittal alignment metrics.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00586-026-10390-9","type":"journal-article","created":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T02:56:48Z","timestamp":1791341808000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A global sagittal deviation index (GSDI-5) incorporating upper cervical alignment: initial construct validation in forward head posture"],"prefix":"10.1007","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9244-5490","authenticated-orcid":false,"given":"Katterine N.","family":"R\u00edos-Peralta","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathleen M.","family":"Curran","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2959-698X","authenticated-orcid":false,"given":"David B.","family":"MacManus","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0743-8860","authenticated-orcid":false,"given":"Lukas","family":"Sch\u00f6nnagel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthias","family":"Pumberger","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3300-8685","authenticated-orcid":false,"given":"Hendrik","family":"Schmidt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4335-1698","authenticated-orcid":false,"given":"Ali","family":"Firouzabadi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,10,7]]},"reference":[{"issue":"4","key":"10390_CR1","doi-asserted-by":"publisher","first-page":"562","DOI":"10.1007\/s12178-019-09594-y","volume":"12","author":"NF Mahmoud","year":"2019","unstructured":"Mahmoud NF, Hassan KA, Abdelmajeed SF, Moustafa IM, Silva AG (2019) The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis. 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