The Correlation between Forward Head Posture and Neck Pain, A commentary by Joe Muscolino

A study published in Current Reviews in Musculoskeletal Medicine looked at the Correlation between Forward Head Posture and Neck Pain

This study is the perfect example of what is so wonderful, and at the same time so frustrating, about evidence-based research.

It has classically been assumed that a postural dysfunctional pattern, such as forward head posture (FHP), would lead to pain. Recently, there have been many challenges to many classically held beliefs, including whether poor posture leads to pain. I am always in favor of challenging any ideology or belief to see if it stands up to scrutiny. So let’s explore this study…

A review of previously done studies (a metastudy) was done, and the conclusion was that there is no correlation between the presence of FHP and neck pain. Hmm… That seems to back up the newer “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 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!

But then, why would 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 and I feel that they missed the biggest likely interpretative reason for this difference… that is that FHP posture is an overuse repetitive injury.

FHP places an increased physical stress load on the tissues to support this imbalanced posture, and that stress load builds up over time. This increased physical stress was mentioned in the study, but the concept of physical stress being like a microtrauma that accumulates was not.

Speaking specifically about the stress load on musculature, having the center of weight of the head forward means that the head and neck should fall forward into flexion; but if this does not happen, then something must be creating an equal force of extension. That something will usually be neck extensor musculature (semispinalis capitis, upper trapezius, levator scapulae, and splenius capitis, to name a few of the muscles). So, whenever the person is sitting or standing, which is probably between 16-18 hours a day, their neck extensor muscles have to work every second of every minute of every one of these hours of every day of every year of every decade. It would make sense from a mechanical point of view that this repetitive physical stress would take many years for the musculature to be overloaded and tighten to the degree that pain would occur. 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.

I think that this 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 first because 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).

And actually, there was one more piece of information that should have made the authors of this research study to come to the idea of overuse accumulated stress as the most obvious reason; that is that the authors of the study state that “In adolescents, forward head posture is associated with lifetime neck pain prevalence and doctor visits due to neck pain.” (Emphasis in italics is mine.) 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 why I sometimes find evidence-based research to be frustrating. We need to also be able to critically think by understanding and applying the principles of the structure and function of the body.

I recently came across a post on Instagram that said:

“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.”

Please… I love research. Scientific evidence-based research shows reproducibility. It is extremely important. But it is not flawless. I believe that critical thinking, which allows for creative application of our skills, is even more important!

Dr. Joe Muscolino

PS I once had an octogenarian patient who came in with the most pronounced FHP (stemming largely from an incredibly hyperkyphotic thoracic spine), and his posterior neck extensor musculature was entirely relaxed, and he had zero neck pain. Why? 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, and perhaps osteoarthrotic bony fusion throughout his cervical spine. Something else to consider…