A Review of Forward Head Posture
Neck pain, much like low back pain, is a condition that most people will have to deal with at some point in their lives. One systematic review found that neck pain affects as much as two thirds of the general population at some point in their lives (1). Head position is often blamed for persistent neck pain and is often part of the clinical analysis (2). A forward head posture has often taken the blame as the culprit for neck pain. Forward head posture is defined as “the protrusion of the head in the sagittal plane so that the head is placed anterior to the trunk” (2).
This forward head posture has been anecdotally “linked to musculoskeletal dysfunction and pain including craniofacial pain, headache, neckache, and shoulder pain” (3). Forward head posture has also been linked and related to “an extended cervical spine, or to protracted shoulder girdles and a kyphotic thoracic spine” (3). This essentially describes Janda’s proposed Upper Cross Syndrome which through specific muscle tightness and weakness of the upper body is thought to cause protraction of the head amongst other things (4).
In order for the assumption that neck position is the cause of pain to be valid a few key points have to be met.
- Control subjects without pain should have less of a forward head posture when compared to subjects in pain. If control subjects have ‘normal posture’ then we can work with this theory. Just because subjects in pain have a different posture does not mean that we can view that as causation. We know that pain changes movement and posture (5) so causation is difficult to prove but it can keep the theory alive.
- If there are differences in forward head posture amongst different sexes it should be reflective of pain being greater in those with greater forward head when comparing gender and at least when comparing within the same sex.
- If there are age related increases in forward head posture that should be reflective of greater prevalence of pain in an older population.
- Improvements in posture should be correlated with reduction of pain when compared to any other exercise intervention.
Control subjects without pain should have less of a forward head posture when compared to subjects in pain.
Normal posture as defined by Kendall and McCreary would be described as “a vertical line passing through the lobe of the ear, the seventh cervical vertebra, the acromial process, the greater trochanter, just anterior to the midline of the knee and slightly anterior to the lateral malleolus.” According to the postural-structural-biomechanical model this ideal posture requires little amounts of muscular activity to maintain which in turn produces minimal stress and strain on the body (6). If this model is correct than an excessive forward head posture would put stress on the neck making it the cause of pain.
In one study comparing patients with neck pain to patients without neck pain the experimenters matched the subjects for age and for sex. The study included 40 patients with chronic neck pain (nontraumatic origin) and 40 patients without neck pain. There were more women in this study than men (6 men, 34 women for each group) which makes sense since many studies show that women report more neck pain than men (1). The results of their study showed that patients with neck pain typically have more forward head posture in standing (45.4 degrees +/- 6.8 pain free versus 48.6+/- 7.1). However, the ability of a clinician to detect the 3.2 degree difference was questionable (2).
The clinicians also found that for, “participants over 50 years of age there was no association between head posture and neck pain.” (2). It was the opposite for younger patients with neck pain being more associated with forward head posture. This calls into question whether or not pain caused the forward head posture. Perhaps increased forward head is simply a natural result of the aging process since patients and controls showed equal measures of forward head. Perhaps pain changes posture which leads to more forward head. More research is needed to determine causation.
In another study that looked at postural deviations in the thoraco-cervical- shoulder region (forward head being one of the abnormalities) the authors found that pain increased for subjects with severe postural abnormalities but found people with normal posture also experienced pain” (6). This contradicts our first point that if controls have normal posture they should have less pain than subjects with postural deviations. For the most part this is true but it is certainly not law. The authors also state that pain may be the cause of poor functional alignment.
This calls into question the necessity to correct postural problems. Maybe these deviations from the ‘norm’ are the body’s response to pain so it can still function. Correcting the postural problem, if possible, may not reduce pain (7).
Moving on to the next point;
If there are differences in forward head posture amongst different sexes it should be reflective of pain being greater in those with greater forward head when comparing gender and at least when comparing within the same sex.
We have already identified that women experience more neck pain than men (1). One would expect that if forward head posture is the cause of pain then asymptomatic women would have a greater forward head posture than men. Using an asymptomatic population is better than using a population in pain because if we determine women without pain show more of a forward head we may be able to humor causation since women have more incidences of pain.
In a study with 160 asymptomatic men and women the clinicians measured sagittal head tilt; “ a line was drawn between the inferior aspect of the fold of skin below the left eye, and the midpoint of the tragus of the left ear, and the angle of the line to the horizontal was calculated in degrees” (3). This study found no significant difference which implies that women and men hold their heads in relatively the same position (3). There have been reports that men have greater forward head postures (8) and there have been reports that women have greater forward head postures (9).
It should be noted that one study recommended against comparing head and neck posture between women and men. They argued that the larger head size of men might account for some of the differences in posture. They state that, “Head/neck posture is different for men and women and should not be judged by the same standard” (11).
If there are age related increases in forward head posture that should be reflective of greater prevalence of pain in an older population.
In the introduction to “Head Posture and Neck Pain of Chronic Nontraumatic Origin: A Comparison Between Patients and Pain-Free Persons,” the authors review three papers and state that the degree of forward head posture in pain free individuals over the age of 55 was greater than the posture of neck pain subjects with a mean age of 38. It should be noted that there was a wide variability in the way neck angles were measured in the reviewed studies including “a personal analysis digitizing system, a goniometer, and the use of photographs” (2).
If these results are reliable, however, it would make one question cervical posture as a cause for pain since older individuals had a greater degree of forward head but with no pain. Of course this is comparing individuals in pain to individuals without pain and at different ages so only assumptions can be made. However, it is not unreasonable to conclude that forward head posture may not play a role in pain.
Improvements in posture should be correlated with reduction of pain when compared to any other exercise intervention
One study on patients with chronic neck pain had two different 6-week exercise intervention protocols to determine if ideal posture could be held longer in a ten minute distracting activity. In the pre test the clinicians put subjects in front of a computer in an “upright posture which was defined as a vertical pelvic position” (10). Subjects played Solitaire for 10 minutes while posture was observed. The neck pain group had greater changes in cervical neck angle. After the test, subjects were then lumped into two different exercise groups, a craniocervical flexor training group which had exercises that “targeted the deep flexor muscles of the upper cervical region” (10) and an endurance-strength training intervention group for the neck flexors.
Post intervention it was discovered that the craniocervical flexor training group demonstrated a significant reduction in the change of cervical angle compared to the endurance-strength training group to the point where they resembled the initial control group. However, both groups demonstrated a reduction in the average intensity of their pain. So we have two groups, both groups with reduced pain and only one group with improved posture.
A few things should be noted with this study, (1) “This study was not designed to “compare the efficacy of the approach to reduce pain and disability” (10) even though reduction in pain intensity occurred. This could possibly be due to expectations from the participants or even from general exercise (although the intervention could hardly be considered rigorous). (2) Subjects in pain were placed in an ‘ideal’ posture. These subjects more than likely adopted a new posture because of pain so discovering that they had a harder time holding an unnatural posture when compared to controls is not surprising. (3) Finally, I find it hard to believe that lasting postural changes occurred because of a six week intervention; rather better postural control in an ‘unnatural’ position was what probably occurred.
Either way with the reduction in pain without a change in posture one would have to doubt that the posture was causing the pain.
It is difficult to determine causation when talking about posture and pain. I’ve said it before but structure may play a part in certain groups of people, my conclusion however, is that it’s difficult to say that structure is the sole cause when there are certainly plenty of other factors.
(1) Fejer R, Kyvik KO, Hartvigsen H. The prevalence of neck pain in the world population: a systematic critical review of the literature. Eur Spine J. 2004;15:834–848.
(2) Silva A. G., Punt T. D., Sharples P., Vilas-Boas J. P., Johnson M. I. Head posture and neck pain of chronic nontraumatic origin: A comparision betweeen patients and pain- free persons. Phys Med Rehabil. 2009; 90: 669-674
(3) Raine S., Twomey L. T. Head and shoulder posture variations in 160 asymptomatic women and men. Phys Med Rehabil. 1997; 78: 1215-1223.
(4) Moore M. K. Upper crossed syndrome and its relationaship to cervicogenic headache. Journal of Manipulative and Physiological Therapeutics. 2004; 27: 414-420
(5) Hodges P., Moseley L., Gavrielsson A., Gandevia S. Experimental muscle pain changes feedforward postural response of the trunk muscles. Exp Brain Res. 151: 262-271, 2003
(6) Griegel-Morris P., Larson K., Mueller-Klaus K., Oatis C. A. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their associations with pain in two age groups of healthy subjects. Journal of the American Physical Therapy Association. 1992; 425-431
(7) Lewis J., Wright C., Green A. Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. Journal of Orthopaedic & Sports Physical Therapy. 2005; 35: 72-87
(8) Braun B. L. Postural differences between asymptomatic men and women and craniofascial pain patients. Arch Phys Med Rehabil. 1991; 72:653-656
(9) Hanten W. P., Lucio R.M., Russell J. L., Brunt D. Assessment of total head excursion and resting head posture. Arch Phys Med Rehabil. 1991; 72: 887-880
(10)Falla D., Jull G., Russell T., Vicenzino B., Hodges P. Effect of neck exercise of sitting posture in patients with chronic neck pain. Journal of the American Physical Therapy Association.2007; 87: 408-417.
(11) Hanten W. P., Olson S. L., Russell J. L., Lucio R. M., Campbell A. H. Total head excursion and resting head posture: Normal and patient comparisons. Arch Phys Med Rehabil. 2000; 81: 62-66