The Relationship between Forward Head Posture and Neck Pain Depends on Age

Forward head posture (FHP) is a common posture on the neck which can be found almost everywhere in the modern world. Traditionally, forward head posture is believed to lead to neck pain; however, this view has been challenged in recent years. Another belief is that all posture is normal, and human has adapted to various head positions all the time.

Studies have identified that socioeconomic factors may be a stronger predictor of neck pain rather than posture, with a higher prevalence on female, older age, being an ex-smoker, high job demands, and low social or work support. Nevertheless, physical factors also have an important role with risk in people with neck in a forward bent posture for a prolonged time and making repetitive movements (quite obvious).

There is conflicting evidence on the relationship between forward head posture and neck pain. So, a group of researchers from Egypt and Portugal conducted a review of scientific studies to see if there is a relationship between head posture and neck pain. The study was published in Current Reviews in Musculoskeletal Medicine.

The authors included 10 studies that compared forward head posture between a group of participants with neck pain and another group who are asymptomatic.

Seven studies (a total of 677 participants) compared craniovertebral angle (CVA, the angle between the line from the external auditory meatus to the seventh cervical vertebra, and a horizontal line at the level of the seventh cervical vertebra) between asymptomatic and neck pain subjects. These studies with a variety of age group participants showed overall no statistical difference between forward head posture and neck pain.

However a closer look at the data, the researcher found that the age of participants is an important factor. Thus, the authors split the data into studies with adolescents and adults. The study with adults (3 studies, n = 203) showed a high variation in the data but, there is an overall significant difference in FHP between adults with neck pain and asymptomatic adults; i.e., adults with neck pain showed a more forward head posture than asymptomatic adults. However, in studies with adolescents,  (3 studies, n = 405), the overall mean showed no statistical difference in FHP between adolescents with and without neck pain.

Eight studies showed a significant correlation between forward head posture and neck pain intensity as well as disability in adults and older adults. In adolescents, forward head posture is associated with lifetime neck pain prevalence and doctor visits due to neck pain.

The findings of the study indicate that increasing forward head posture in adults is associated with neck pain but not in adolescents.

Several factors affect this result. Adults may assume a more flexed posture than young adolescents when performing the same task. Maintaining a high flexion angle of the neck during work leads to an increase in the weight of the head which puts extra load on the spine and leads to changes in ligaments, tendons, and muscle.

Increasing forward head posture in adults with neck pain may be associated with lower endurance of the deep neck flexors and extensors and with a higher activity of superficial muscles.

Adults also showed progressively decreased cervical ROM through aging, especially in their 30s and 40s. Differences in ROM between subjects with and without neck pain are different in adults and adolescents. Adults with neck pain have significantly decreased ROM for all cervical movements when compared with asymptomatic participants. Meanwhile, in adolescents, neck pain is associated with decreased ROM for some neck movements, but not all.

However, for adults aged 50 years or older, one study found was no difference for FHP between asymptomatic and neck pain subjects. This result may be explained by the progressive deterioration of the cervicothoracic posture with age in both subjects with and without neck pain.

While adolescents may spend more time with neck flexion on electronic devices, the short-term effects are not noticeable. Nevertheless, a study indicated that long-term effects could cause decreased neck flexibility and endurance.

In summary, this systematic review found that age has an important role as a confounding factor in the relation between forward head posture and neck pain. Adults with FHP showed increased neck pain show when compared to asymptomatic adults. FHP is significantly correlated with neck pain measures in adults and older adults. For adolescents, there is no association between FHP and neck pain.