The purpose of this article is multifold. We will first explore the biomechanics of forward head posture (FHP). We will then explore how it, and indeed other postural distortion patterns, are being viewed with relationship to pain and dysfunction. And finally, we will take a step back and use the context of FHP to look at how we know what we know.
Forward Head Posture
Forward head posture (FHP) is the name given to a sagittal-plane postural distortion pattern in which, as the name implies, the head is held forward. This usually involves excessive flexion of the neck at the cervical spinal joints, as well as excessive forward translation and extension of the head at the atlanto-occipital joint. The net result is the center of weight of the head is anterior to the trunk.
Whenever a body part is not centered on the body part below, there is an imbalance such that the body part should fall with gravity. In the case of FHP, the head and neck should fall into flexion due to the force of gravity (until the chin hits the chest). To prevent this, an equal force of extension must be occurring to counterbalance gravity’s flexion force. This extension force is usually created by contraction of the cervicocranial extensor musculature in the back of the neck (Image 1). Muscles such as the upper trapezius, splenius capitis and cervicis, semispinalis capitis, and others will have to isometrically contract to oppose gravity (Images 2A–2B, page 56–57).
So, whenever the person is sitting or standing, which is probably between 16–18 hours a day, cervicocranial neck extensor musculature must isometrically work every second of every minute of every one of these hours, every day of every year of every decade. This use/overuse/misuse/abuse of the extensor musculature of the neck will likely result in neck pain.
The mechanical effects of FHP are not limited to the posterior extensor musculature. The chronic posture of holding the head forward will result in adaptive shortening of the flexor musculature of the cervical spine in the front of the neck, and chronically tight posterior and anterior musculature would then result in decreased range of motion. And, if the anteriorly located scalenes lock short, then the possibility of anterior scalene syndrome (a version of thoracic outlet syndrome) arises.
Tight scalenes might pull the first rib up, approximating it toward the clavicle, and thereby decreasing the costoclavicular space and predisposing the person toward costoclavicular syndrome (another version of thoracic outlet syndrome). The adaptive shortening of the anterior hyoid musculature, with its pull on the mandible, might even precipitate temporomandibular joint (TMJ) syndrome. Chronically tight cervical extensor musculature also predisposes the person to tension headaches, cervical spine osteoarthrosis, and disc pathology. None of these effects must follow, but the likelihood of these biomechanical sequelae increases with FHP.
Now, will a person with FHP necessarily experience pain and/or dysfunction? No. The human body has the ability to deal with a great deal of structural asymmetry without necessarily spilling over into patterns of pain and dysfunction. Further, it would make sense from a mechanical point of view that this repetitive physical stress would take many years before tissues are overloaded to the point that pain and dysfunction would occur.
FHP with Dysfunction But No Pain
I have posited that the counterbalancing extension force to prevent the head and neck from falling into flexion is created by isometric contraction of the cervicocranial extensor musculature in the back of the neck. However, that is not necessarily true. And I discovered this with an octogenarian patient who presented to me with the most pronounced FHP that I had ever seen, stemming largely from an incredibly hyperkyphotic thoracic spine (see Upper-Crossed Syndrome, page 58). I fully expected upon palpation examination to find that the muscles in the back of the neck would be extremely tight. But they weren’t. In fact, they were extremely loose. And he had zero neck pain. Why?
I found out during joint mobilization examination that my client’s cervical spinal joints were effectively locked with no range of motion. I did not have the benefit of an X-ray or any other radiographic imaging to view, but I would venture to say that his body had probably taken the load off his neck musculature by having increased fibrosis of his posterior cervical fascial tissues, including the facet joint capsules, and perhaps osteoarthritic bony fusion throughout his cervical spine. With the adhesions and fusing of these “passive” tissues, his “active” musculature was relieved of all work and responsibility to maintain the otherwise imbalanced posture of his head. Certainly, this individual would be an example of a person with FHP (indeed, even severe FHP) who had no pain at all, but, with all ranges of motion lost, did have quite severe dysfunction.
The Relationship Between FHP and Pain
Now let’s turn our attention to the relationship between FHP and pain. In a previous Massage & Bodywork article, I addressed the advent of what I term negative ideologies, examining the ideology that certain muscles cannot be stretched (“Muscles That Can’t Be Stretched?,” May/June 2020, page 58). I would like to address here another somewhat new negative ideology. This new ideology states that FHP, and indeed most all postural distortion patterns, do not cause pain.
I always try to be careful with my verbiage. I do not believe that FHP must cause pain, or that it must cause dysfunction. In fact, I believe function is much more important than structure, including good and bad postures. Clinically, I often counsel my patients that a small degree of scoliosis, or pronated feet, or FHP for that matter, are rarely important to their quality of life.
But biomechanics, and therefore these pathomechanics, do matter. The presence of any structural condition—any asymmetry of hard or soft tissues—must, by definition, place physical stress forces into the body. The only question is whether they will accumulate to reach a threshold tipping point that impacts the person’s life with pain and/or dysfunction.
When a person presents with a small postural distortion pattern, I do not alarm them about all the horrible things that must inevitably befall them with the condition. I do not try to scare or convince them that they need long treatment programs because of the postural distortion pattern they have. Instead, I reassure them their condition is mild and need not impact their life. But . . . I do explain to them that if they do not take the healthful steps to improve their health, their condition might progress to the point that it will cause pain and/or dysfunction.
Again, biomechanics do matter. They must matter. Structure must inevitably affect function, at least in most cases. Like dominoes falling, if a condition like FHP is allowed to progress, the person will most likely experience some type of pain or dysfunction. And when it finally surfaces, it will likely be much harder to treat, and the prognosis for improvement will be diminished.
New Study
My motivation for writing this article is the release of a 2019 research study1 that examines the correlation between FHP and neck pain. I feel this study, and its interpretation, are the perfect example of what is so wonderful and at the same time so frustrating to me about evidence-based research and its place in the clinical world of manual and movement therapy. Advocates who believe there is no correlation between postural distortion and pain have used this study to advance their ideology. So, let’s explore this study.
A review of previously done studies (a metastudy) concluded that there is no correlation between the presence of FHP and neck pain. Hmm . . . this seems to back up the new negative ideology that there is no correlation between posture and pain. Isn’t research wonderful?
But wait. There was a problem with the analysis of the data because the presence of neck pain was also related to the age of the person. So, it depends on the criteria of the study and the interpretation. Isn’t research problematic?
So, the results for the adolescents and adults were separated out and, lo and behold, there is a correlation between FHP and neck pain in adults. But there is not in adolescents. Isn’t research wonderful again?
So why do adults with FHP have neck pain but adolescents with FHP do not? The authors make a few proposals, both of which I feel are reasonable. Perhaps the degree of FHP is greater in adults, and adults may have an imbalance of deep versus superficial muscle activity.
But here is where I find research problematic again! Because proposing reasons for the difference between these age groups comes back to interpretation, it’s here that I feel researchers missed the biggest and most likely interpretative reason for this difference: FHP posture is an overuse repetitive injury.
FHP places an increased physical stress load on the tissues to support an imbalanced posture, and stress load builds up over time. This increased physical stress was mentioned in the study, but the concept of physical stress being like a repetitive-stress microtrauma that accumulates was not.
I think the idea of accumulated physical stress is the most obvious explanation, and I believe that most any manual therapist or movement professional would likely come to this conclusion. As professionals, we pay attention to the mechanics of the human body—specifically the mechanics of the musculoskeletal system (or perhaps, more inclusively, it should be called the myo-fascio-skeletal system, or perhaps even better, the neuro-myo-fascio-skeletal system).
If this does not make sense, perhaps a good comparison might be why adolescents who smoke do not die from lung cancer or heart attack, but adults do. It takes time for the cumulative effects of a chronic stressor to impact the person’s health. And I believe there is no doubt that FHP is a chronic stressor to the tissues of our body. There is an old adage that I believe applies here: “If we do not change our direction, we are likely to end up where we are headed.”
There was one more piece of information that should have made the authors come to the idea of overuse accumulated stress as the most obvious reason. The authors of the study state: “In adolescents, forward head posture is associated with lifetime neck pain prevalence and doctor visits due to neck pain.”2 In other words, adolescents with FHP will be more likely to have neck pain later in life. However, even with this information, the correlation was missed. This is another reason I sometimes find evidence-based research to be frustrating. Although research can give us some wonderful data, we need to also be able to critically think by understanding and applying the principles of the structure and function of the body.
Role of Evidence-Based Research
So, I have devolved into a discussion of evidence-based research and its role in the world of manual and movement therapy. I must say this first . . . I love research. Scientific evidence-based research shows reproducibility, and that is extremely important. True unbiased research is an excellent antidote to the increasing tendency in our modern world for confirmation bias because it helps keep us honest and points us toward safe and effective means of assessment, prevention, and treatment.
Evidence-based research is not flawless, though. Ultimately—even if an entire study is carried out flawlessly as a gold-standard, double-blind study, with random sample populations, excellent inclusion and exclusion criteria, and appropriate treatment and placebo sham treatment, there still must be interpretation. And as we have seen with this study, I believe the interpretation here was lacking. Further, most people read only the abstract of an article, wherein it is hard for us to take any conclusion other than the interpretative conclusion of the authors of the study.
Upper-Crossed Syndrome
FHP rarely occurs in isolation. Usually, it is part of a larger postural distortion pattern known as upper-crossed syndrome (Image 3). Upper-crossed syndrome involves excessive thoracic kyphosis, which then causes excessive flexion of the cervical spine, resulting in the head being held forward (protracted and hyperextended). Upper-crossed syndrome also results in excessive protraction of the shoulder girdles, as well as medially rotated humeri at the glenohumeral joints. Regarding musculature, the name upper-crossed syndrome is given because of the characteristic patterns of locked short and locked long musculature in the upper aspect of the body, forming an “X” (Image 4). Appreciating these relationships is extremely important. It is extremely unlikely that FHP can be improved unless the underlying thoracic hyperkyphosis of upper-crossed syndrome is first addressed and improved.
How Do We Know What We Know?
I believe there are four major models for accumulating knowledge and wisdom: the authority model, the experimental model, the evidence-based research model, and the critical thinking model. Let’s explore each one.
Authority Model
The authority model posits that we follow whatever authority we believe can impart knowledge and wisdom to us. Sometimes the phrase “sage on the stage” is used to describe a seminar or workshop presenter who is the proponent of some technique. Or perhaps “sage on the page” for the author of a book that we read (or even this article). The problem I have with this model is: Authorities often disagree with each other. So, whom do we believe?
Experimental Model
The experimental model involves us trying manual or movement therapy techniques that we have learned. After all, if it is valid, we should see good results with our clients. The problem with this model is two-fold. First, our clients do not necessarily want to be our guinea pigs. Second, and more importantly, when first learning a new technique, we might not have the expertise to carry it out well enough to judge whether it is effective.
Evidence-Based Model
The third model is following evidence-based research. I believe this is an important model but can have the limitations I discussed, as well as others. Recently, I came across an Instagram post that read: “Don’t let ‘the research’ get in the way of LOGIC and CRITICAL THINKING . . . Research is only one piece of the puzzle. Don’t let it blind you.”
Critical Thinking Model
While there is some value in each approach to gaining knowledge and wisdom, I believe critical thinking is the most important. Although we might never know all aspects of how the human body works, our understanding of the fundamentals of the biomechanics of tissues (characteristics like tissue adaptation, elasticity versus plasticity, creep, etc.), as well as the biomechanics of forces and movement (compression, shear, torsion, tensegrity, etc.), and our understanding of how the nervous system organizes the myofascial-skeletal system (proprioceptive neural reflexes, neural facilitation, etc.) are well understood and time-tested.
Ultimately, it is our role to treat and counsel clients about their postural patterns, including FHP. While we can consult what thought leaders in the field say, and we can consult the latest research findings, I believe the most important thing is to take a step back and look at the mechanics of the posture. What muscles are shortened, lengthened, or working harder? What are the loads on the fascial tissues and bones? What are the mechanics? What are the pathomechanics? What are the physical stresses to the tissues? What will be the likely effect of those stressors on the health of the client’s body?
I believe that by integrating fundamental biomechanical principles of anatomy and physiology with our assessment and treatment skills, we are empowered to critically think so we can assess the role of postural distortion patterns such as FHP. We can then creatively apply our manual and movement therapy skills.
Notes
1. Nesreen Fawzy Mahmoud et al., “The Relationship Between Forward Head Posture and Neck Pain: A Systematic Review and Meta-Analysis,” Current Reviews in Musculoskeletal Medicine 12, no. 4 (2019): 562–77, https://doi.org/10.1007/s12178-019-09594-y.
2. Nesreen Fawzy Mahmoud et al., “The Relationship Between Forward Head Posture and Neck Pain: A Systematic Review and Meta-Analysis.”
Dr. Joe Muscolino has been a manual and movement therapy educator for more than 30 years. He is the author of multiple textbooks, including The Muscular System Manual: The Skeletal Muscles of the Human Body (Elsevier, 2017); The Muscle and Bone Palpation Manual with Trigger Points, Referral Patterns, and Stretching (Elsevier, 2016); and Kinesiology: The Skeletal System and Muscle Function (Elsevier, 2017). He teaches continuing education workshops around the world, including a certification in Clinical Orthopedic Manual Therapy (COMT). He has created LearnMuscles Continuing Education (LMCE), a video streaming subscription service for manual and movement professionals, with new video lessons added each and every week. He has also created Muscle Anatomy Master Class (MAMC), the most comprehensive and detailed muscle anatomy online class in the world, with each muscle taught in five distinct video lessons. And he has created Bone And Joint Anatomy Master Class (BAJAMC) and Kinesiology Master Class (KMC). Visit learnmuscles.com for more information or reach him directly at joseph.e.muscolino@gmail.com.