Forward Head Posture

Original Editor - Priya Gulla Top Contributors - Priya Gulla, Kim Jackson, Lucinda hampton, Shaimaa Eldib, Lauren Lopez, Vidya Acharya, Tony Lowe, Laura Ritchie, Admin, Wanda van Niekerk, Lilian Ashraf and Seba Mamdouh

Introduction

Because of the rising popularity of media devices such as smartphones and computers, frequent users often exhibit incorrect posture.

Forward head posture (FHP) is a poor habitual neck posture. It often co-exists with Upper Crossed Syndrome

• Defined by hyperextension of the upper cervical vertebrae and forward translation of the cervical vertebrae.
• Thoracic Kyphosis is a complication of the combination of slouched-forward shoulders and rounded upper back.
• Can lead to a painful shortening of the muscles of the back of the neck, as well as compression of the cervical vertebrae—the uppermost portion of the spine that supports the head and protects the spinal cord.

Due to the increased compressive forces through the neck joints and increased muscle tension, pain is the common outcome. Some of the types of problems associated with FHP are:

• Headaches
• Neck discomfort
• Muscle tension in the neck and shoulders
• Discomfort in the mid back
• Chest pain
• Pain, pins & needles and numbness in the arms and hands

Many people develop chronic or recurrent problems because they receive treatment for the pain (e.g. pain killers or anti-inflammatory medication) but never receive treatment for the underlying cause which is their FHP. This 4 minutes video is a brief summary of FHP

Forward Head Posture - Affects on Health

FHP evaluation is clinically important for diagnosis and rehabilitation treatment.

• FHP increases compressive loading on tissues in the cervical spine, particularly the facet joints and ligaments.
• Studies have reported that symptoms including neck pain, headache, temporomandibular pain, and musculoskeletal disorders are related to FHP
• FHP greatly influences respiratory function by weakening the respiratory muscles.
• FHP can have a negative impact on static balance.
• Forward head and round-shoulder postures (FHRSP) can result in shoulder pain and dysfunction because of altered scapular kinematics and muscle activity and consequently, placing increased stress on the shoulder.
• In the posterior cervical muscles there is stretching and weakness of Semispinalis cervicis and overaction with ultimate shortening of Semispinalis capitis. The corresponding flexor muscles in front, namely, Longus cervicis and Longus capitis shorten and lengthen respectively.
• There is newly evidance that there is no relation between FHP and neck pain, additionally individual with neck pain had lower ROM and slower neck movement.

Epidemiology/ Etiology

The overall prevalence of neck pain in the general population is high, reaching 86.8%.

Risk factors associated with forward head posture include female gender, older age, being an ex-smoker, high job demands, and low social or work support.

Etiologies include:

• Occupational posture: forward or backward leaning of head for long durations, slouched or relaxed sitting, faulty sitting posture while using computer or screen.
• Effect of gravity: slouching, poor ergonomic alignment.
• Other faulty postures like pelvic and lumber spine posture.
• Sleeping with head elevated too high.
• Poor posture maintained for long durations.
• Lack of development of back muscle strength.

Clinical Findings

Include

• Muscle ischemia, pain and fatigue
  
• Decreased range of motion of cervical spine
• Early disc degeneration and osteophyte formation
• Temporomandibular joint pain and inflammation
• Tension Headache
• Increase in dorsal kyphosis and decrease in height
• Decrease in vital capacity and range of motion of shoulder and arm
• Possible protrusion of nucleus pulposus and nerve compression

• Mobility impairment in the muscles of the anterior thorax (intercostal muscles), muscles of the upper extremity originating on the thorax (Pectoralis major et minor, Latissimus dorsi, Serratus anterior), muscles of the cervical spine and head that attached to the scapula and upper thorax (Levator scapulae, Sternocleidomastoid, Scalene, upper Trapezius), and muscles of the suboccipital region (Rectus capitis posterior major and minor, Obliquus capitis inferior and superior).
• Impaired muscle performance due to stretched and weak lower cervical and upper thoracic erector spinae and scapular retractor muscles (Rhomboids, middle Trapezius), anterior throat muscles (suprahyoid and infrahyoid muscles), and capital flexors (Rectus capitis anterior and lateralis, superior oblique Longus colli, Longus capitis).
• With temporomandibular joint symptoms, the muscles of mastication may have increased tension (Pterygoid, Masseter, temporalis muscles).

Assessment

Assessment of FHP is important to assess the impact of the therapeutic interventions.

• Clinical assessment of FHP is done through observation of the position of the head relative to the reference anatomical landmarks.
• Radiographic techniques can be used to measure postural angles, but it is not always practical.
• The craniovertebral angle is one of the most reliable methods and common angles for evaluating the FHP. It examines head status relative to the seventh cervical vertebrae (C7).

Physiotherapy Management

• To Decrease Pain:
  
  1. Pain management advice

• Postural Alignment, Balance and Gait:
  1. Cervical Retraction
  2. Scapular Retraction
  3. Balance Training ( If dysfunction presents)

• Range of Motion, Joint Mobility and Flexibility
  1. Cervical Range of Motion Exercises
  2. Shoulder Range of Motion Exercises
  3. Cervical Traction
  4. Thoracic Manual Techniques and exercises
  5. Stretching Exercises of tight structures- Trapezius, Scalenes, SCM, Pectoralis Major and Minor.

• To reduce spasm
  1. Myofacial release
  2. Ischemic Compression
  3. Positional release technique (to relieve tension headache)

• 
  Muscle Strength and Endurance
  1. Cervical isometric strengthening exercises (initial phase) progressing to isotonic and dynamic strengthening exercises.
  2. Strengthening exercises for scapular retractors (Rhomboids, middle Trapezius).

• 

  strength neck ex
  Ergonomic Advice
• correct number of pillows used
  • postural corrections
    

    scapular strength ex
    

    srength ex

Outcome Measures

Occiput to Wall

VAS