Forward head posture and text neck

Ross Hauser, MD

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 degenerative disc 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.

Billions of people are using cell phone devices on the planet, essentially in poor posture

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.

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.

In this video:

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) 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.”

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.

Forward head posture from hours of computer work and texting

Symptoms of cervical spine neck ligament Creep

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

muscle pain and muscle tightness from the forward head posture

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

A July 2020 study in the International Journal of Occupational Medicine and Environmental Health (2) 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.”

Forward head posture makes it hard to breath

A May 2020 study (5) 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; the 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, 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.

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

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 to 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 a 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 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 phone position.

The image below will help explain the angles. The patients in this study who had a greater than 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.

This image below will help explain the angles. The patients in this study who had a greater than 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 habitual position represented by the two images to the right, between 45 degrees and 60 degrees. 

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. (6) 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.

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

A patient case history was presented in the Journal of physical therapy science (7)  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 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 a 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 (8). 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).

References

1 Hansraj KK. Assessment of stresses in the cervical spine caused by posture and position of the head. Surg Technol Int. 2014 Nov 1;25(25):277-9. [Google Scholar].
2 Szczygieł E, Fudacz N, Golec J, Golec E. The impact of the position of the head on the functioning of the human body: a systematic review. International Journal of Occupational Medicine and Environmental Health. 2020 Jul 23;33(5):1-0. [Google Scholar]
3 Chu EC, Lo FS, Bhaumik A. Plausible impact of forward head posture on upper cervical spine stability. Journal of Family Medicine and Primary Care. 2020 May;9(5):2517.  [Google Scholar]
4 Sarraf F, Varmazyar S. Comparing the effect of the posture of using smartphones on head and neck angles among college students. Ergonomics. 2022 Feb 24(just-accepted):1-3. [Google Scholar]
5 Solakoğlu Ö, Yalçın P, Dinçer G. The effects of forward head posture on expiratory muscle strength in chronic neck pain patients: A cross-sectional study. Turkish Journal of Physical Medicine and Rehabilitation. 2020 Jun;66(2):161. [Google Scholar]
6 Chu EC. Preventing the progression of text neck in a young man: A case report. Radiology Case Reports. 2022 Mar 1;17(3):978-82. [Google Scholar]
7 Wickstrom BM, Oakley PA, Harrison DE. Non-surgical relief of cervical radiculopathy through reduction of forward head posture and restoration of cervical lordosis: a case report. Journal of physical therapy science. 2017;29(8):1472-4. [Google Scholar]
8 Oakley PA, Ehsani NN, Moustafa IM, Harrison DE. Restoring cervical lordosis by cervical extension traction methods in the treatment of cervical spine disorders: a systematic review of controlled trials. Journal of Physical Therapy Science. 2021;33(10):784-94. [Google Scholar]

This article was updated May 24, 2022

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