Forward head posture symptoms and complications

Ross Hauser, MD

If you suffer from forward head posture you do not need an explanation as to what the condition is further than the image below. Most people who contact us will immediately identify that their head sits far in front of their shoulders. What causes this? In many people, it starts when the cervical ligaments, the bands of connective tissue that hold the cervical vertebrae in place, weaken, and the natural cervical lordotic curve of the neck is lost and the plumb line (and thus weight) of the head falls in front of the cervical curve. As the head continues to gradually slide forward, the continued and increased strain causes more stretching and tearing on the back of the neck supporting structures and puts nerves and veins in the front of the neck at risk for herniation, compression, and injury. As the cervical spine destabilizes and moves forward, so do the vital structures (nerves, arteries, veins) within the neck undergo torsion, stretch and compression including the autonomic nervous system nerves (which can cause dysfunction in heart rate, digestion, breathing among other symptoms) and blood vessels on their way to or from the brain. (Possibly causing issues with dizziness and fainting). This combination of symptoms is frequently discussed in people’s communications with us.

Looking for answers.

A person’s story: Cervical spondylosis without myelopathy with forward head posture. I have been having symptoms for many years and they are getting progressively worse. I can trace these symptoms back to having fever like symptoms without a fever, slight swallowing problem and fatigue. Lower cervical upper back slight pain and tightness, MRI showed cervical arthritis. Now having constant fatigue, slight facial burning sensation, brain fog, dysautonomic symptoms and lower cervical slight pain, etc. Have been tested for Multiple Sclerosis, Lyme Disease, Hypothyroid, Testosterone levels and all negative. Looking for answers.

A theory in search of answers.

A person’s story: I have been suffering from more than 40 symptoms for the last four years. Symptoms vary in severity. The main symptom is severe fatigue that comes in waves. I also suffer from brain fog, dizziness, cognitive problems, gastroparesis, difficultly swallowing, blurry vision, tinnitus which coincides with the fatigue, unexplained emotions, anxiety attacks, and more. I work long hours in front of the computer and to offset this I do weight training. I have spoken to many doctors and specialists with no luck. After researching I find strong evidence that virtually all symptoms are caused by poor posture, specifically effecting the vagus nerve through forward head posture.

CREEP

How does this happen? One explanation is that flexion and extension of the cervical spine generate tension and pull on the brain stem, medulla, and cranial nerves V-XII (The vagus nerve mentioned above is cranial nerve X). The many and varied symptoms this causes are further discussed below. In this condition, when a person looks down, the brain stem may make contact with the anterior wall of the foramen magnum (the opening in which the brain stem and other vital arteries, veins, and nerves pass). This could block cerebrospinal fluid dynamics (flow) and the symptoms of intracranial pressure. When the neck is flexed even the lumbosacral nerve roots move contributing to low back and extremity pain in the legs.

Cervical ligament laxity can slowly develop through many repeated hours of forward head posture, such as practiced when working on the computer or bent over a smartphone. This phenomenon, defined as the elongation of a ligament under constant or repetitive stress, is known as CREEP.

The caption reads: How heavy is your head?

For every inch of forward head posture, the force on the spine increases by an additional 10-12 pounds. A forward head posture causes a slow stretching of posterior neck ligaments which is a phenomenon known as ligament creep. On the right, the head weight pressure of the neck is equal to balancing a 42-pound weight. This is where neck problems accelerate.

Creep does not occur in an acute way; on the contrary, the problem develops and evolves over time. While this gradual ligament degenerative disease represents a “low level” sub-failure ligament injuries, I contend that they represent the vast majority of cervical instability cases and can potentially incapacitate people (from a pain and disability standpoint) with unremitting pain and vertigo, tinnitus, and the host of potential symptoms that occur from cervical instability. Therefore ligamentous cervical instability (neck instability caused by stretched ligaments), especially upper cervical instability caused by ligament stretching, is often the missing structural cause and/or co-morbidity for many chronic disabling symptoms and diagnoses.

In this article and video, I will be discussing the cervical spine ligaments, the importance of the lordotic (natural) curve of the neck, and how cervical degenerative disc disease and cervical instability can be caused by slow capsular ligament stretching (creep) caused by the forward head/facedown lifestyle of looking at cell phones. We will see how excessive computer and cellphone usage can lead to a breakdown of the cervical curve (called cervical dysstructure) progresses.

Article Summary:

The stretching of the cervical neck ligaments in forward head posture.
A Cause of Forward Head Posture: Cell phone use.
Excessive neck bending could exaggerate the stretch of the cervical spine and all of the spinal structures below it.
The effect of the posture of using smartphones on head and neck angles.
Symptoms of cervical spine neck ligament Creep.
Abnormal or forward head posture has a significant effect on the entire body
Forward Head Posture and low back pain in older patients
- Forward Head Posture and neck pain in older patients.
Forward head posture makes it hard to breathe.
Stabilizing the scapular and thoracic spine helps respiration in forward-head posture patients.
Forward head posture and sleep apnea.
TMJ, Forward Head Posture, Reduced Airways.
The drawing nearer of the chin to the third cervical vertebra. The hyoid bone and facial pain.
The development of headaches and neck muscle spasms in forward head posture.
Injections and physical therapy for forward head posture headaches and migraines.
Exercise and physical therapy in forward head posture headaches.
The shoulders pull on the neck in a forward head posture.
“Manual therapy can be recommended to improve forward head posture, thoracic kyphosis, and pelvic alignment in the short and medium term.”
Improving posture while texting, cervical manipulation, and extension traction therapy.
Balance Body Tape and Forward Head Posture.
“Resolution of radiculopathy and significant improvement in neck pain level.”
Treating cervical ligament weakness and starting the journey to restoring proper cervical curves.

The stretching of the cervical neck ligaments in forward head posture

In the image below the caption reads: When a person looks up, the cervical vertebrae move closer together as the posterior cervical muscles and ligaments tighten. When a person faces down, as when we look at cell phones, the muscles relax and the vertebrae spread apart as the posterior cervical ligaments stretch and lengthen.

A Cause of Forward Head Posture: Cell phone use

As most human activities are in front of the body and involve the head and neck being forward and flexed, all the ligaments except for the anterior longitudinal ligament are at risk of being injured by creep’s slow stretching over long periods of time. The cervical intervertebral disc is subjected to creep forces during flexion as well. These ligaments are also injured during the flexion portion of a whiplash injury. The anterior longitudinal ligament is stretched during the extension portion of a whiplash injury. Since the capsular ligaments are the main restraints to axial rotation, they are especially vulnerable to injury when a force is applied with the head forward and the neck turned to the side.

In the video below I describe how as our neck gets more flexed, (bent forward) the pressure on the neck ligaments and the neck muscles to keep our head aligned (our ear is over our shoulder) is increased. To explain this please see the image below. In this video, I will describe how forward head posture from hours of computer work and cell phone usage can result in cervical ligament laxity and the problem of stretched-out cervical spine/neck ligaments. In this stretched-out ligament condition, the neck will bend forward, eventually leading to arthritic degeneration of the cervical spine and the loss or even reversing the loss of the natural cervical curve. The slow stretching of ligaments is called CREEP.

The video also discusses a 2014 paper by Dr. Kenneth K Hansraj of the New York Spine Surgery & Rehabilitation Medicine New York published in the journal Surgical Technology International. (1). Since its publications, over sixty research papers have cited the paper’s data. The paper begins: “Billions of people are using cell phone devices on the planet, essentially in poor posture. The purpose of this study is to assess the forces incrementally seen by the cervical spine as the head is tilted forward, into worsening posture.”

More recently a February 2023 paper (2) by Italian researchers cited this research and wrote: “There are real concerns about the influence of head posture and workplace ergonomics on health among IT (Information technology) professionals. We consider that it is necessary to adopt preventive measures to address neck disability and improve workspace ergonomics.”

The caption of this image reads Forward head posture from hours of computer work and texting, resulting in cervical ligament laxity. “Creep” which is a term signifying the slow stretching of ligaments, most commonly occurs by a forward head posture from computer work or looking at a smartphone.

Excessive neck bending could exaggerate the stretch of the cervical spine and all of the spinal structures below it.

The caption reads MRI of the entire spine sagittal view. This MRI shows common findings that occur with forward head posture including loss of cervical lordosis, exaggerated thoracic kyphosis, and decreased lumbar lordosis.

A May 2020 study in the Journal of Family Medicine and Primary Care (3) examined how excessive neck bending could exaggerate stretching (hyper stretching) of the cervical spine and all of the spinal structures below it. The researchers noted that “forward head posture can cause a multitude of disorders including cervical radiculopathy, cervicogenic headaches, and cervicogenic dizziness. Most of these conditions manifest with clusters of painful symptoms and spine dysfunctions.” The researchers also noted: “The cervical spine is responsible for allowing mobility and stability to the head and neck. Any deviation to the center of gravity of the head results in an increase in cantilever loads (excessive loads at the front and back of the neck), which can be particularly damaging to the upper cervical joints. ”

What these researchers did was take images of three random patients with symptoms of neck pain and related disorders who had undergone cervical adjustment for cervical pain. Specifically, they looked at the joint space between the occipito-axial (C0-C2) and atlanto-axial (C1-C2) joints. By comparing the radiographs of before-and-after intervention of each patient, a regressive (hyper stretching was being reversed) joint spacing was observed.

The effect of the posture of using smartphones on head and neck angles

A May 2022 paper in the journal Ergonomics (4) aimed to compare the effect of the posture of using smartphones on head and neck angles among eighty college students. The Severity of Neck Pain (SNP) and the head and neck tilt angles, the gaze angle, (this is the angle of the eye’s line of vision within the orbit. If your head is looking down but you shift your eyes upwards to observe something, that is the gaze angle. The gaze angle is important in helping to stabilize upright balance) and the amount of change in the forward head posture was determined.

Most of the participants (51.3%) in this study reported moderate and severe neck pain. The angles during using smartphones had a significant difference in different positions so that the best head and neck tilt angles and gaze angles were in the sitting position with leaning on the backrest of the chair. Head and neck tilt angles and the forward head posture have the worst posture in sitting position on a chair without a backrest while the gaze angle has the most awkward posture in standing. The researchers were able to connect the neck and back pain The angles during using smartphones had a significant difference in different positions. The gaze angle was most negatively affected in the head down looking at the phone position.

The image below will help explain the angles. The patients in this study who had a greater than the 51-degree angle in the triangle created by the C7, ear landmark, and a horizontal line were considered patients suffering from forward head posture. These would be patients whose heads would be in the habitual position represented by the two images to the right, between 45 degrees and 60 degrees.

Symptoms of cervical spine neck ligament Creep

As discussed above, Creep is a medical condition that results from the elongation of the ligaments that hold our bones together due to long-term tension upon them. This can be caused by various types of bad posture, including the forward head posture involved in text neck. In our neck, we have seven vertebrae that are held together by ligaments. Text neck causes these ligaments to get too loose, to the point where they can no longer hold these seven vertebrae together. The bones shift and can pinch other nearby structures causing tightness across the shoulders, headaches, and neck soreness. Also pain in the back, arms, fingers, hands, wrists, and elbows. Some sufferers may also notice numbness and tingling in their upper extremities.

The major cervical ligaments that are over-stretched slowly and daily by the text neck, and forward head posture are those of the posterior ligament complex (PLC), especially the capsular ligaments of the facet (zygapophyseal) joints, as these are the major joints in the cervical spine. While there are many types of motions and forces damaging cervical ligaments, they have a propensity to hit the capsular ligaments.

In the image below we see the various types of neck injuries that can cause neck ligament injuries. The fourth image from the left is hyperflexion. This is the chronic injury of the head down face forward lifestyle and the head snap forward as seen in whiplash-associated disorders.

Abnormal or forward head posture has a significant effect on the entire body

As we discussed, the current ever-prevalent face-down lifestyle looking at cell phones, causes a destabilization of the normal cervical curve and a loss of the normal architecture of the cervical lordotic curve, caused by a stretch of the cervical ligaments causing symptoms. The cervical spine because of face down – forward head posture goes into a state of flexion (kyphosis), pushing the upper cervical vertebrae to the front to their normal plumbline position and forcing them into hyperextension. Gradually this altered neck posture, affects the neurovascular tissues at the craniocervical junction, especially around the atlas (C1) and axis (C2), as they undergo torsion, shear, stretch, and compression. Some of these structures are in the carotid sheath including the vagus nerve, glossopharyngeal nerve, spinal accessory nerve, internal jugular vein, and carotid artery, as well as other neck structures including the various cervical sympathetic ganglion, vertebral arteries, and veins, spinal cord, brainstem especially the medulla and spinal nerve roots.

A July 2020 study in the International Journal of Occupational Medicine and Environmental Health (5) offered such research. Here researchers took the data results from 16 studies to show that “the position of the head has a significant effect on the human body. Research findings show that abnormal head position changes affect muscle activity, proprioception (the sense of how to move, walking without thinking about how to take steps), the pattern of breathing, and neck pain.” The researchers noted in their study that “this is the first systematic review of the relationship between the head posture, and the functioning of the human body. The results of this study seem to be promising if used in therapeutic practice.”

As the habitual forward head posture causes changes throughout the body including protracted and medial rotated scapula, as well as increased pressure on the cervical facet joints by forces that lead to upper cervical extension, lower cervical flexion, and exaggerated thoracic kyphosis and lumbar lordosis. All of these faulty positions keep the head in front of the center of gravity so the head and eyes are level and looking forward. It leads to numerous dysfunctional musculoskeletal scenarios. It ends up costing the person a lot, including the development of:

Cervical instability
Temporomandibular Joint Syndrome. Please see my related article TMJ, cervical neck instability, neck muscle spasms, myofascial pain, breathing problems, digestive disorders, and dizziness.
Upper Crossed Syndrome. When shoulder, neck, and chest muscles are not in sync or out of balance with some muscles being too tight and other muscles being too weak.
Occipital and trigeminal neuralgia
myofascial pain syndrome
thoracic, lower back, and pelvis abnormalities and physical complaints.

As noted above: A habitual forward head posture makes the point that deviation in one part of the body long-term will lead to a deviation in another part of the body in an attempt to maintain the correct center of gravity so the body feels somewhat balanced and the eyes can look forward. The habitual forward head posture and all of the negative ramifications of it are the most common postural deviation seen. Even on the pelvis, the effects are enormous. With exaggerated lumbar lordosis, there is an increase in the pelvic angle to 40o (normal is 30o) as well as anterior pelvic tilt, both of which put increased strain on the sacroiliac and iliolumbar ligaments—a very common cause of low back pain. This is another example of how any type of instability leads to compensatory changes in adjacent and distant musculoskeletal structures and may all need to be addressed to resolve a person’s chronic pain.

Forward Head Posture and the Brain Stem

All spinal postures will deform the neural elements within the spinal canal and close to it, with flexion causing the largest canal length changes and hence, the largest nervous system deformations. Flexion on any part of the spinal column (but especially the neck) can generate axial tension in the entire cord, brainstem, and nerve roots. With the advent and excessive use of cellular mobile devices, malrotations of the cervical spine cause stresses and strains on the cervical spinal cord and brain stem, and all the cranial and peripheral nerves that connect to it. Excessive motions of the craniocervical junction and cervical spine, especially when motion is combined with postural loads with the forward head being one of them, cause tremendous deformations on the cervical spinal cord, brainstem, and neural tissues that connect to them.

Forward Head Posture and low back pain in older patients

An October 2021 study in the Journal of Bodywork and Movement Therapies (6) assessed the impact of forward head posture on low back pain in older patients. Here are the summary findings.: “Abnormal spinopelvic posture relates to chronic mechanical low back pain. There are significant associations among pain intensity, Forward Head Posture, and lumbopelvic sagittal alignment in chronic mechanical low back pain patients.”

Forward Head Posture and neck pain in older patients

A December 2019 paper from Cairo University published in the journal Current Reviews in Musculoskeletal Medicine (7) found that “age played an important role as a confounding factor in the relation between forward head posture and neck pain. Also, the results showed that adults with neck pain show increased forward head posture when compared to asymptomatic adults and that forward head posture is significantly correlated with neck pain measures in adults and older adults.”

Forward Head Posture and cognitive decline

Numerous studies have indicated that loss of hand grip and pinch strength, (generalized loss of muscle strength) in the elderly would provide evidence of the onset or development of dementia. Yet an April 2023 paper in the Journal of Clinical Medicine (8) offered this assessment of the current medical research. “To our knowledge, there is no study examining the association of forward head posture with cognition, hand grip strength, and pinch strength, and the mediator role of forward head posture on the association of cognition with hand grip and pinch strength in older adults. Considering that forward head posture is one of the most common postural deviations related to advanced age in older adults, this is remarkable.”

This study was able to suggest and support “the hypothesis that “higher cognitive function would be associated with better head posture, and better head posture, in turn, would be associated with greater hand grip and pinch strength.”

Forward Head Posture makes it hard to breath

A May 2020 study (9) from the Ankara University School of Medicine in Turkey investigated the relationship between forward head posture and respiratory dysfunctions in patients with chronic neck pain. To do this they examined 99 patients (11 males, 88 females; an average age of 54 with the youngest person being 38 and the oldest 75). What they found was that the people who had worse head posture, were in part measured by the C7 vertebrae angle position. Based on measurements of the chest exhaling and inhaling the researchers concluded that on our study results, Forward Head Posture is associated with expiratory (exhale) muscle weakness in chronic neck pain patients.

Treatment: Stabilizing the scapular and thoracic spine helps respiration in forward head posture patients

A September 2021 paper in the Turkish Journal of Physical Medicine and Rehabilitation (10) investigated how exercise programs not directly applied to the cervical spine affect office workers with forward head posture.

A total of 32 office workers with forward head postures (13 males, 19 females; average age 36.63 years were equally randomized either to experimental or control groups. Scapular stabilization and thoracic extension exercises were applied to the experimental group and cervical stabilization and stretching exercises to the control group.

Results: “The combination of scapular stabilization and thoracic extension exercises, not directly applied to the cervical spine, has an effect on improving the posture, respiration, neck pain, and disability in office workers with forward head posture.

Forward head posture and sleep apnea

In February 2020, researchers (11) wrote in the Frontiers in Medicine of their findings connecting obstructive sleep apnea syndrome, abnormal spinal curvature, and the pathological interaction between posture and ventilatory (getting air into the lungs) functions.

The researchers wrote: “This study provides evidence for abnormal spinal alignment and disturbances of balance in obstructive sleep apnea syndrome patients, and calls for these to be sought in clinical practice in order to mitigate their consequences. The determination of posturo-respiratory coupling allows early screening for postural dysfunction and refines the understanding of its obstructive sleep apnea syndrome-related character. Finally, the potential correlation between the specific postural dysfunction of obstructive sleep apnea syndrome, the changes in the mechanical properties of the upper airways, and respiratory cortical adaptation to waking and cognitive problems mean that correcting mechanical anomalies of the upper airways should be considered.”|

In other words, instability in the cervical spine, what the researchers called “cervical hyperextension with an anterior projection of the head (forward head posture)” causes respiratory instability and sleep apnea.

TMJ, Forward Head Posture, Reduced Airways

A December 2020 study in the Journal of Oral and Maxillofacial Surgery (12) discussed the connection between Temporomandibular (TMJ) joint osteoarthritis, airway dimensions, and head and neck posture.

In total, 114 temporomandibular disorders patients participated in this research.;
- Among 114 patients, 28 had no pathologic bony changes in the TMJ condyles, 45 had progressive TMJ osteoarthritis, and 41 demonstrated TMJ osteoarthritis which had not progressed for 12 months.

The volume change of the oropharynx (the rear third of the tongue, the soft palate, the throat’s side and back walls, and the tonsils) in the supine position was more prominent in the progressive TMJ osteoarthritis than in the TMJ osteoarthritis which had not progressed but no significant differences in changes in the pharyngeal airway while in an upright position were detected. The retrognathic facial profile (the lower jaw is set back further) became more remarkable at T1 in the progressive TMJ osteoarthritis and not progressive TMJ osteoarthritis compared to those at T0. The forward head posture seemed to be progressed in the progressive TMJ osteoarthritis than in either the not progressive TMJ osteoarthritis or no pathologic bony changes (bone spur formation) in the TMJ condyles.

Conclusion: progressive TMJ osteoarthritis may have associations with retrognathia (the law jaw moving back further) and decreased oropharyngeal airway volume in the supine position but not in the upright position. Progressive TMJ osteoarthritis may be related to altered head posture in the upright position to compensate for reduced airway dimensions.

In the image below we see muscle pain and muscle tightness from the forward head posture.

More on muscle tightness and pulling on the cervical spine

These muscles are extremely tight in forward head posture. Since the carotid sheath, which houses the vagus nerve, also basically sits on this muscle, it is easy to imagine this and other nerves undergoing destructive traction on them with the cervical instability-induced collapse of the cervical curve.

A December 2022 study (13) suggests that among the many problems and ways forward head posture can cause cervicogenic dizziness is the impact on the correct tension the posture creates on the myodural bridges of suboccipital muscles. Myodural bridge issues are associated with cervicocephalic headaches, cervicocephalic pain syndromes, sensorimotor function, and postural control. Also noted is that the suboccipital muscles might work as a pump via the myodural bridge to provide power for cerebrospinal fluid circulation.

The drawing nearer of the chin to the third cervical vertebra. The hyoid bone and facial pain

In March 2020, doctors at the MedCenter TMJ, TMD/Orofacial Pain Clinic, Michael E. DeBakey Veterans Affairs Medical Center, University of Texas Health Science Center, School of Dentistry, and Louisiana State University, School of Dentistry investigated changes in hyoid bone position in patients suffering from myofascial pain. (14)

In this study, 30 female patients who received treatment for and had resolved myofascial pain were reviewed. The resolution of their myofascial pain showed a drawing nearer the chin to the third cervical vertebra (reduction in forward head posture) and a release of the hyoid bone away from the floor of the mouth. They concluded: “These findings suggest resolution of myofascial pain may correlate with decreased forward head posture and relaxation of suprahyoid musculature. The potential for change in oropharyngeal dimension and airway is evident.”

Let’s explain the image below beyond the caption:

The hyoid bone, as you can see in the image below is located at the front of the neck, below the lower jaw. It supports the tongue and plays a critical role in speech and swallowing.

A forward head posture shows one mechanism by which passive tension in selected suprahyoid and infrahyoid muscles (the muscles that help elevate the hyoid bone to allow swallowing) alter the resting position of the mandible. The mandible is pulled inferiorly (downward) and posteriorly (backward) changing the position of the condyle within the TMJ. Note the interrelationship between the cervical spine and the scapula of the shoulder.

The development of headaches and neck muscle spasms in forward head posture

A story:

I have chronic neck and shoulder pain. This is traced back to a forward head posture following years of computer work. I few years back I started having chronic headaches with an increased number of migraines each month. Last year I went on disability because the constant headaches increased to level 7 with the migraines coming 3 – 4 days apart. I had physical therapy on my neck for 6 months I changed my sitting position to one of proper posture position. Unfortunately, it did not solve my problems. I’ve had neck ablations which help reduce the neck pain but it did not help my headaches. The ablations only lasted a few months before the neck pain was back. I’ve tried all the usual medications for migraine including botox with no results.

The symptomatology of headache can be caused by (and surely is made worse by) a habitually forward head posture causing shortening of the anterior neck muscles (sternocleidomastoid, longus colli, longus capitis, rectus capitis anterior and lateralis, scalene, and multiple hyoid muscles). When these muscles are shortened, the craniocervical region has to be in the protracted position to keep the head looking forward, as in viewing a computer screen, smartphone, or television. This excessive shortening of the anterior neck muscles then stretches and “stresses” the extensor muscles including the levator scapula, semispinalis capitis, and suboccipital muscles such as the rectus capitis posterior major. The ‘stressor’ on these muscles is having to continually contract to “level” the head and eyes. This forward head posture moves the center of mass from on top of the cervical spine to in front of it. This necessitates compensatory contraction of the posterior neck musculature including the suboccipital muscles, semispinalis capitis, and levator scapulae muscles to contract in order to counterbalance the weight of the head. Over time, the muscles fatigue and spasm, developing trigger points that can refer pain to the head, scalp, and face.

Most headaches are in the posterior head region, specifically in the suboccipital region where many small muscles attach to the C1 and C2 vertebrae. Most people with headaches have muscle tightness and tenderness in the suboccipital muscles. When a person has a forward head posture causing a decrease in cervical lordosis, the upper cervical spine has to go into hyperlordosis (excessive curvature). This is an additional factor that makes the upper cervical ligaments more prone to stretch injury. The combination of upper cervical hyperlordosis, instability, and resultant suboccipital muscle spasms can lead to irritation or compression of one of the occipital nerves and occipital neuralgia. When asked where their headaches start, most people will point to the suboccipital region.

Why someone can have neck-related symptoms but NOT have neck pain. Part 1: Jugular vein

A summary transcript and explanatory notes of this video are available here: Why someone can have neck-related symptoms but NOT have neck pain. Part 1

Treatment: Injections and physical therapy for forward head posture headaches and migraines

Below we will discuss the use of Prolotherapy (dextrose) injections. In a March 2022 paper (15) from the Department of Medical, Surgical and Health Sciences, University of Trieste in Italy, doctors compared the effect of physiotherapy to onabolulinumtoxin-A, and their combination, in relation to cervical and headache parameters in patients with chronic migraine and identified with forward head posture.

This study was conducted on 30 patients with chronic migraine.
The patients were distributed in three groups of treatments for three months:
- onabolulinumtoxin-A only,
- physiotherapy only, and
- onabolulinumtoxin-A plus physiotherapy.

Results: After 3 months of each treatment, the scores obtained for the headache-related disability and the frequency of migraine decreased significantly for all groups, but the pain intensity scores changed significantly only in the onabolulinumtoxin-A and in the onabolulinumtoxin-A plus physiotherapy groups. On the other hand, the forward head posture was reduced significantly in the physiotherapy and in the onabolulinumtoxin-A plus physiotherapy groups. The cervical range of motion increased significantly in certain directions in the physiotherapy group and in the onabolulinumtoxin-A plus physiotherapy groups. The researchers concluded: “it can be said that the combined treatment was more useful than a mono-therapy alone. From our results, it can be concluded that onabolulinumtoxin-A plus physiotherapy could be a good option in the management of chronic migraine.”

The caption of the image below reads Anatomical relation of suboccipital muscles to atlas C1 and axis C2 and occipital nerve. Upper C1-C2 cervical instability can cause suboccipital muscles to contract causing migraine headaches or occipital neuralgia.

Please see my related articles:

Treatment: Exercise and physical therapy for forward head posture headaches

A 2021 paper in the Journal of Back and Musculoskeletal Rehabilitation (16) noted that when compared with healthy people, patients with chronic tension-type headaches are likely to have forward head postures and a higher number of active trigger points on the suboccipital muscle. The purpose of this study was to verify how forward head posture correction exercise can effectively reduce symptoms of chronic tension-type headache patients.

The subjects of this study were 45 individuals with chronic tension-type headaches, divided into three groups of 15 patients each:
- a) the suboccipital muscle inhibition group using the myofascial release technique – interventions twice a week for four consecutive weeks.
  - The technique is when a physical therapist slowly raises the skull to release or relax the suboccipital muscles
- b) the group which received suboccipital muscle inhibition therapy and forward head posture correction exercises; – interventions twice a week for four consecutive weeks and
- c) the control group.
- Both treatment groups went through the headache impact test (HIT-6) and examinations on the pressure pain threshold (PPT) of the headache areas, the type and number of myofascial trigger points, the soft tissue pressure pain threshold, and the posture before and after the intervention.

Results: There was a significant improvement in the headache impact test (HIT-6), the headache pressure pain threshold, the soft tissue pressure pain threshold, the trigger points, and the posture in both treatment group patients. The biggest reduction and increase in the headache impact test (HIT-6) and the headache pressure pain threshold respectively were seen in the suboccipital muscle inhibition therapy and forward head posture correction exercises group.

A March 2021 study in the International Journal of Environmental Research and Public Health (17) “(indicated) that flexion exercise of the deep cervical muscles in patients with tension headaches and forward head posture will improve the quality of life and activities of daily life by mitigating headaches and sleep disorders.

The shoulder’s pull on the neck in forward head posture

The caption of this image reads Shoulder-cervical instability connection. Shoulder instability causes scapulae contraction which can increase the symptoms of cervical instability through its attachment at C1-C4. Sometimes to resolve upper cervical instability, the shoulder instability has to be treated as well.

Forward head posture puts a strain or stretch on the posterior neck muscles, such as the forementioned levator scapula and rectus capitis major, and a tightening of the sternocleidomastoid and scalenus anterior. The scalenus anterior attaches to the anterior transverse processes, putting an anterior translational force on the vertebrae. The levator scapula attaches to the lateral portion of the C1-C4 transverse processes. If a person has right shoulder instability, for example, this would force the right levator scapula to contract more to help stabilize the scapula during shoulder motions. This force then gets translated to the C1-C2 vertebrae, often causing that joint to sublux or move to the right. In this instance, the person would need treatment stabilization of not only the upper cervical vertebrae but also the right shoulder. Treating the C1-C2 vertebrae alone would be helpful but because the shoulder instability was not addressed, most likely the cervical instability would return with continued use of the right arm. For more on this subject see our companion article Is neck instability causing your shoulder pain?

A June 2022 paper in the European Journal of Physical and Rehabilitation Medicine (18) suggested that both scapular stabilization and postural correction exercise increase the craniovertebral angle and pressure pain threshold and decrease muscle activity and disability. Scapular stabilization alone increases craniovertebral angle and pressure pain threshold and decreases muscle activity and disability more than postural correction exercise.

Treatment: “Manual therapy can be recommended to improve forward head posture, thoracic kyphosis, and pelvic alignment in the short and medium term”

A June 2022 paper in the journal Gait Posture (19) comes to us from Brazilian researchers. In this paper, the researchers sought to validate the effectiveness of manual therapy on body posture and forward head posture. To provide this validation the researchers examined previously published studies in which the primary intervention was the use of any manual therapy technique and studies that evaluated the immediate, short, medium, or long-term effects of interventions on body posture. After compiling the data the researchers wrote:

“The results allowed us to conclude with moderate certainty in the evidence that, when compared to no intervention or sham, in the short and medium term, manual therapy reduced the forward head posture (14 studies, 584 individuals), reduced thoracic kyphosis (5 studies, 217 individuals) improved lateral pelvic tilt (5 studies, 211 individuals) and pelvic torsion (2 studies, 120 individuals) and increased plantar (surface) area (decreasing pressure on the foot) (3 studies, 134 individuals). With moderate certainty, there was no significant effect on shoulder protrusion (5 studies, 176 individuals), shoulder alignment in the frontal plane (3 studies, 160 individuals), scoliosis (2 studies, 26 individuals), and pelvic anteversion (5 studies, 233 individuals).”

Conclusion significance: “Manual therapy can be recommended to improve forward head posture, thoracic kyphosis, and pelvic alignment in the short and medium term, but not shoulder posture and scoliosis. Manual therapy reduces the height of the plantar arch (making more surface area) and this must be taken into account in physical therapy planning.”

Treatment: Improving posture while texting, cervical manipulation, and extension traction therapy

Dr. Eric Chun-Pu Chu of the New York Chiropractic and Physiotherapy Centre in China presented this January 2022 case study in the journal Radiology Case Reports. (20) A 24-year-old man had a history of a 12-month problem of head and neck pain and paresthesia of the right upper limb. The patient worked as a YouTuber and has been editing and posting videos on the website for three years. . . Based on cervical radiographs, the diagnosis of cervical spondylosis was given. Previous management included pain medication and muscle relaxants. Interventions included repeated physical therapy, cervical traction, and acupuncture, with some temporary relief during the subsequent year. However, a severe flare-up of the symptoms occurred, which was brought about by working for extended periods on his smartphone, for which the patient sought chiropractic attention. X-ray imaging showed cervical kyphosis with C5 vertebral rotation, hypertonicity of the paraspinal muscles, and paresthesia in the right C6 dermatome distribution, which was consistent with text neck syndrome associated with cervical spondylosis and right C6 radiculopathy.

The intervention consisted of improving posture while texting, cervical manipulation, and extension traction therapy. After 9 months of treatment sessions, the patient exhibited symptomatic and functional improvement. Frequent breaks along with correct posture while using smartphones will be the key entities to preventing the occurrence of text neck syndrome. For more on treatments please see my article Dynamic Structural Medicine Ross Hauser MD Review of Treatments for Cervical Spine Instability.

Treatment: Balance Body Tape and Forward Head Posture

A February 2022 study in the journal BioMed Central Musculoskeletal Disorders (21) examined Balance Body Tape a recently developed taping method with the aim to reduce pain and improve posture through change in movement behavior. However, the researchers note, the potential effects of treatment with Balance Body Tape are scarcely documented. Therefore, the aim of their study was to investigate the effect of a three-week Balance body tape treatment on the intensity of perceived neck, shoulder, and back pain and forward head posture. The results the researchers found: “A short treatment period with Balance Body Tape may, compared to no treatment, have a small reducing effect on pain intensity in neck, back and/or shoulders. However, no effect was found on forward head posture in this study.”

“Resolution of radiculopathy and significant improvement in neck pain level”

A patient case history was presented in the Journal of Physical Therapy Science (22) The case report was titled: Non-Surgical Relief of Cervical Radiculopathy Through Reduction of Forward Head Posture and Restoration of Cervical Lordosis. In this case, doctors were able to demonstrate relief of cervical radiculopathy following the dramatic reduction of forward head posture and restoration of the cervical lordosis by the use of a multi-modal rehabilitation program incorporating cervical extension traction.

Here is what the doctors wrote:

“A 31-year-old male patient presented with severe cervical radiculopathy and muscle weakness as well as neck pain. The patient had limited neck range of motion and multiple positive orthopedic tests. Radiography revealed excessive forward head posture with cervical kyphosis. The patient received a multi-modal rehabilitation protocol including mirror image extension exercises, cervical extension traction, and spinal manipulative therapy. After forty treatments over 17 weeks, the patient reported a complete resolution of radiculopathy and significant improvement in neck pain level.”

This case history was used as evidence for this treatment method in a, October 2021 paper also published in the Journal of physical therapy science (23). Here a team of doctors reviewed previously published literature on the use of cervical extension traction methods for increasing cervical lordosis in those with hypolordosis and cervical spine disorders. In the conclusion of their findings, the doctors wrote: “There are several high-quality controlled clinical trials substantiating that increasing cervical lordosis by extension traction as part of a spinal rehabilitation program reduces pain and disability and improves functional measures and that these improvements are maintained long-term. Comparative groups who receive multimodal rehabilitation but not extension traction experience temporary relief that regresses after treatment cessation. (the extension traction experience was seen as a key component of the treatment).

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

Please see the companion articles:

Video of treatments

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

The patient was experiencing vertigo, tinnitus, severe neck pain, migraines, and other problems based on C1-C2 instability.

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This article was updated July 13, 2023