studies on head forward posture

CHRONIC NECK PAIN: THREE DECADES OF RESEARCH STUDIES ON FORWARD HEAD POSTURE (FHP)

Forward Head Posture (FHP)

“Neck pain accounts for 15% of all soft tissue problems seen in general practice.” From the October 2013 issue of the Journal of Clinical and Diagnostic Research.

“Most attempts to correct posture are directed toward the spine, shoulders and pelvis. All are important, but, head position takes precedence over all others. The body follows the head. Therefore, the entire body is best aligned by first restoring proper functional alignment to the head.”  Dr. Rene Cailliet from 1987’s Rejuvenation Strategy

“Despite considerable evidence that posture affects physiology and function, the significant influence of posture on health is not addressed by most physicians. In fact, neither comprehensive postural nor structural evaluation is a routine part of training in physical diagnosis, and most osteopathic physicians do not describe postural/spinal mechanics in their usual patient evaluations.

Observation of the striking influence of postural mechanics on function and symptomatology have led to our hypothesis that posture affects and moderates every physiologic function from breathing to normal hormonal production. Spinal pain, headache, mood, blood pressure, pulse, and lung capacity are among the functions most easily influenced by posture.

The most significant influences of posture are upon respiration, oxygenation, and sympathetic function. Ultimately, it appears that homeostasis and autonomic regulation are intimately connected with posture.”  Taken from the January 1994 issue of the AJPM (American Journal of Pain Management).  Dr. Norman Shealy of Springfield, MO (M.D. / Ph.D / neurosurgeon) was a co-author of this study.

“The observation of the influence of postural mechanics on physiologic functions and pain has led researchers to conclude that posture plays a significant role in the development of pain and is critical to pain management.  The most significant influences of posture are upon respiration, oxygenation, and sympathetic function, which is a major component of perceived pain.

Ultimately, it appears that homeostasis and autonomic regulation are intimately connected with posture. Many symptoms, including pain, may be moderated or eliminated by improved posture.”  From the April, 2011 issue of the journal Practical Pain Management (The Role of Body Posture In Musculoskeletal Pain Syndromes)

“Forward head posture is a clinical entity that has been identified by multiple authors as a significant factor in a variety of musculoskeletal pain syndromes.  Although some reports are essentially anecdotal, several reports use sophisticated statistical analyses and healthy controls versus painful subjects to establish forward head posture as a real clinical entity with significant musculoskeletal consequences.”  Drs. Seaman and Troyanovich from the April 2000 issue of Dynamic Chiropractic (The Forward Head Posture).  Dr. Seaman is a Functional Neurologist, for whom I have covered many articles (HERE).

It’s not really news that posture is important.  And no posture carries worse connotations than that known as Forward Head Posture (FHP) and sometimes referred to as head forward posture — the posture where the head and shoulders are slouched / slumped forward.  Not only does this posture look terrible, the implications for your health are far worse than you could have imagined.  And none of this is new information.  Over sixteen years ago, the March 2000 issue of the Mayo Clinic Health Letter said that, “long term forward posture leads to muscle strain, disc herniations and pinched nerves.”  But it goes back much farther than this.  The concept of Forward Head Posture was first proposed by the venerable Rene Cailliet over sixty years ago.

Dr. Cailliet (1917-2015) was a giant in the orthopedic rehab community, actually creating the field known today as Physical Medicine and Rehabilitation.   Over the course of his long and illustrious career at both USC and UCLA, he authored books on WHIPLASH, NECK PAIN, SHOULDER PROBLEMS, CHRONIC PAIN, and SOFT TISSUE INJURIES.  He was also a pioneer in postural research.  It was Cailliet who said that…..

“Head in forward posture can add up to thirty pounds of abnormal leverage on the cervical spine.  This can pull the entire spine out of alignment.  Forward head posture (FHP) may result in the loss of 30% of vital lung capacity.  These breath-related effects are primarily due to the loss of the cervical lordosis, which blocks the action of the hyoid muscles, especially the inferior hyoid responsible for helping lift the first rib during inhalation.”

He even talked about the fact that one’s “GUT” (“Gastrointestinal System”) could be irritated by Forward Head Posture to the point of actually diminishing bowel function.  Of course this is nothing new to chiropractors (HERE), but for the medical community to be making these sorts of correlations between the function of the organs and the structure / function of the musculoskeletal system is amazing — particularly the fact that it happened decades ago.

One of the books that was required reading back in my time in Chiropractic College was Dr. I.A. Kapandji’s Physiology of Joints.  It was Kapandji who said that, “for every inch of forward head posture, it can increase the weight of the head on the spine by an additional 10 pounds.”  Think about this for a moment.  The average person has at least an inch or so of FHP, and with people spending their lives online staring at their smart phones and computer screens, it’s not uncommon to see people with as much as 3 or 4 inches of Forward Head Posture.  As you will now see, the implications are staggering.

We cannot leave our introduction without mentioning Dr. Vladimir Janda and his “UPPER CROSS SYNDROME“.  Like my FATHER IN LAW, in his youth, Janda (from Czechoslovakia) had developed Polio and the complications that went along with it.  This drove him to find therapeutic solutions not only for post-polio syndrome, but a wide array of other musculoskeletal problems as well.  As both a neurologist and physiatrist, as well as an author, teacher, and researcher, even long after his death in 2002, Dr. Janda’s work remains iconic in the field of postural rehabilitation.

FORWARD HEAD POSTURE AND CHRONIC NECK / UPPER BACK PAIN

head forward posture

What is the number one reason people come see me?  That’s easy; pain. Chronic Pain— the sort of pain that you can’t get away from; the kind of pain that makes you understand how a wild animal could chew off its own leg to get out of a trap — is a huge motivator.   Let me show you some of the studies that directly relate Forward Head Posture to pain and DIMINISHED CERVICAL ROM.  Believe me when I tell you that these are only the tip of the iceberg (all conclusions are cherry-picked due to constraints on time and space).  The first thing I want you to notice is that this is not a new concept.

Posture has a huge relationship to balance, and proprioception as well.  When the vertebrae in your neck are either misaligned in relationship to each other (SUBLUXATION or POOR POSTURE) or are not moving freely on each other, the result will always be a loss of proprioception.  PROPRIOCEPTORS (aka mechanoreceptors) sense things like stretch, pressure, tension, compression, and actually feed more information to your brain about balance than your vestibular system (inner ear). 

When your joints don’t work right, your proprioception doesn’t work right either.  Although there are any number of consequences of this (see previous link) the end result is always DEGENERATION.  But remember that FHP is not only about musculoskeletal symptoms.

This concept was cemented by a 2012 study published in the Annals of Rehabilitation Medicine called The Effect of The Forward Head Posture on Postural Balance in Long Time Computer Based Worker.  The authors concluded that,

“Group One (work with computers for over 6 hrs per day) had a relatively more protruded head with extensive neck posture. The center of gravity of group I tended more toward the anterior than that of group II (rarely work with computers). Postural imbalance and impaired ability to regulate movement in forward and backward direction were also found.  The results of this study suggest that forward head postures during computer-based work may contribute to some disturbance in the balance of healthy adults. These results could be applied to education programs regarding correct postures when working at a computer for extended periods of time.” 

Stay tuned because I am going to give you my number one tricks for helping you if you spend lots of time at a computer.

Furthermore, in searching the peer-reviewed literature for this post, I found that Forward Head Posture is intimately related to any number of health problems.  Not surprisingly I found numerous studies linking increased FHP to a decreased ability to breathe (including ASTHMA).  But there were other studies as well — studies on athletic performance, one’s ability to sing, BLOOD PRESSURE, DIGESTION, and any number of others. 

There are even studies linking happiness and self esteem to posture.  For instance, a 2011 issue of the journal Procedia: Social and Behavioral Sciences (Relationship of Self Esteem with Forward Head Posture and Round Shoulder) actually explored this link, as did a 2009 study published in the European Journal of Social Psychology (Body Posture Effects on Self-Evaluation).

And finally, for my good friend Jack — a 20 year Navy combat helicopter pilot who now flies for Air Evac — a study just for you.  One of the things I’ve learned from Jack in the years since his combat flying is that due to the added weight of the night vision, targeting devices, navigation, and other electronic equipment, the helmets worn by today’s combat pilots are heavy — really heavy.  This added weight dramatically increases the mechanical loading of the cervical spine that occurs in combat. 

Case in point, a study from the September 2012 issue of the Journal of Biomechanics (Simulation of the Effects of Different Pilot Helmets on Neck Loading During Air Combat).  “New generation pilot helmets with mounted devices enhance the capabilities of pilots substantially. However, the additional equipment increases the helmet weight and shifts its center of mass forward.”  Forward????  Can anyone say FHP?   When you read the next paragraph Jack, think of yourself in relationship to the “T1-C7 level” (lower neck / upper back) area that has been your “spot” for as long as I’ve known you.

“The increased weight and the forward shift of the center of mass of a new generation helmet lead to higher muscle activations and higher joint reaction loads over a wide range of head and neck movements. The muscle activations required to balance the head and neck in extreme postures increased the compressive force at the T1-C7 level substantially…  The lateral neck muscles can reach activations of 100% and cause compressive joint forces up to 1100N during extensive rotations and extensions at high ‘vertical’ accelerations.”

WHAT CAN I DO TO HELP SOLVE MY FORWARD HEAD POSTURE?

Good Posture    
LUCKY LUCIANO: 1931
GOOD POSTURE		Forward Head Posture    
THE UNKNOWN CELEB: 2014
FORWARD HEAD POSTURE

As a Chiropractor, my first question is which con above has the better hair; Luciano on the left, or the “unknown celebrity” on the right?   Secondly, I want to know if the scientific literature has anything to say about adjustments being able to help structurally change Forward Head Posture.  Last May’s issue of the Journal of Physical Therapy Science addressed this issue in a study called The Effects of Cervical Joint Manipulation, Based on Passive Motion Analysis, on Cervical Lordosis, Forward Head Posture, and Cervical ROM….. 

In this study, they not only quoted from previous studies on the effectiveness of various Chiropractic techniques, but concluded that, “manipulation three times a week for four weeks…   was effective in increasing the cervical lordosis, cervical extension ROM, and ranges of flexion and extension motion, and in decreasing FHP.”  Below are some more posts on this topic. 

When it comes to the Chiropractic technique best suited for restoring normal cervical curves, hands down it’s CBP (Chiropractic Bio-Physics).  Interestingly enough, every CBP practitioner I’ve ever met, readily admits that adjustments alone are not enough to restore the proper curvature to the cervical spine.  There will need to be some sort of EXTENSION THERAPY.

I do not do any of this “in house,” choosing instead to have the patients do it at home.  My go-to tool is the DAKOTA TRACTION DEVICE.  I love it because it’s super cheap, super easy to use, and it’s safe —- and most importantly, it works well for most people (I have a “floor model” I use to show people how it works, and to see if they can tolerate extension — just make sure you are SPENDING ENOUGH TIME IN EXTENSION TO MAKE CORRECTION). 

Beyond the stretching of the SCM’s, PLATYSMA, and other muscles that the Dakota Traction Device will help you accomplish, you’ll need to do some exercises to strengthen your neck muscles.  HERE is a picture of all of it put together.

If you are interested in looking at some studies that are directly related to reversing Forward Head Posture and helping restore one’s normal curve via neck stretches and exercises, PubMed is a great starting point.  I found numerous studies, including one showing that restoration of the neck’s normal curve helps those dealing with sciatica due to degenerative lumbar (low back) discs. 

The March 2015 issue of JMPT published a study whose conclusions stated, “The addition of forward head posture correction to a functional restoration program seemed to positively affect disability, 3-dimensional spinal posture parameters, back and leg pain, and S1 nerve root function of patients with chronic discogenic lumbosacral radiculopathy [sciatica due to spinal degeneration].“

As is always the case, never leave out dealing with inflammation.  Lots of people are willing to deal with the biomechanical aspect of their pain, but are either not willing or simply not informed, when it comes to taking care of the underlying INFLAMMATORY PROCESS (I actually talked about this the other day — HERE).  This is critical to understand not only from the perspective of pain, but because Inflammation always leads to Fibrosis / Scar Tissue (HERE).

A WEIRD LITTLE TRICK FOR HELPING MAINTAIN GOOD NECK CURVATURE EVEN THOUGH YOU SPEND YOUR LIFE IN FRONT OF A COMPUTER

Set your screen (monitor) up slightly higher than eye level (a box, a shelf, a small cabinet, etc should do the trick) you can actually induce some lordotic curve into the neck while you work and prevent the “slump” or heightened kyphosis in the mid back.  I started doing this a few years ago and the difference to my CHRONIC UPPER TRAP TRIGGER POINTS has been significant.

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