Forward head posture

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Forward head posture (FHP) [1] is an excessively kyphotic (hunched) thoracic spine. It is clinically recognized as a form of repetitive strain injury.[ citation needed ] The posture can occur in dentists, [2] surgeons, [3] and hairdressers, [4] or people who spend time on electronic devices.[ citation needed ] It is one of the most common postural issues. There is a correlation between forward head posture and neck pain in adults, but not adolescents. [5]

Contents

Having both forward head posture and rounded shoulders is known as upper crossed syndrome. [6]

(1) Overworked muscles down the back of the neck strengthen, strain, scar and shorten; (2) middle and lower back support muscles weaken; (3) hunching upper back joints eventually freeze like that; (4) muscles at the front of the neck work less and weaken, so chin pokes out. Technology stress hunch.png
(1) Overworked muscles down the back of the neck strengthen, strain, scar and shorten; (2) middle and lower back support muscles weaken; (3) hunching upper back joints eventually freeze like that; (4) muscles at the front of the neck work less and weaken, so chin pokes out.

Overview

Indications are that the prevalence of upper back and neck pain has increased dramatically in the decade leading up to 2016. [7] [8] This increase has been attributed to the corresponding widespread adoption of laptop computers, tablets, smartphones and other small portable digital devices.

Because their screens do not separate from their keyboards these small devices cannot be set up ergonomically correctly (unless an extra screen or extra keyboard is added). They are unlike personal desk top computers (PCs) in this respect. Most commonly, the user hunches to operate them, often for many hours a day. [9]

Hunching increases the effective load on the neck up to several times more than does erect posture, due to increasing moment arm. [10] Local pain, cervicogenic headache and referred pain extending down the arms can arise from the sustained muscle strain, cervical facet joint (or apophyseal, or zygapophyseal joint) compression and diminution of the cervical foraminal nerve exits.

Treatment may include analgesic and/or anti-inflammatory medications, regular breaks while using the small devices, muscle strengthening and stretching, massage, spinal manipulation and mobilisation, posture instruction and spinal fulcrums.[ citation needed ] Biomechanical analysis suggests a combination of approaches is best and gives more lasting results.

Signs and symptoms

In a neck with perfect posture (as seen for instance in young children) the head is balanced above the shoulders. In this position the load on each vertebra of the cervical spine is spread evenly between the two facet (apophyseal) joints at the back and the intervertebral disc and vertebral body at the front.

The condition is characterised by a posture with vagi at the head sitting somewhat forward of the shoulders (i.e., the ear lobe is anterior to a vertical line through the point of the shoulder (acromion process)). This can be very marked, with the back of the skull positioned anterior to the breastbone (sternum). The chin is poked forward.

When the patient is asked to look up at the ceiling, the hunched-forward upper thoracic curve does not change as viewed from the side. Rather, the lower cervical spine 'hinges' backward at C5/6/7, a movement pattern known as 'swan-necking'.[ citation needed ]

This indicates that the upper back vertebrae have frozen in their habitual flexed positions, with the surrounding collagen of the ligaments, joint capsules and fascia shortening to reinforce this hypomobility. (This is the dowager's hump of the elderly of earlier generations, now observable in modern (2016) late teenagers. [11] )

Symptoms include overuse muscle pain and fatigue along the back of the neck and reaching down to the mid-back, often starting with the upper trapezius muscle bellies between the shoulders and neck. Cervicogenic headache from the joints and muscle attachments at the top of the neck is common. [12] [13]

The compressive load on the cervical facet joints predisposes to acute joint locking episodes, with pain and movement loss. [14] In older patients with already diminished cervical foramina spaces and/or osteophytes, nerve root irritation and impingement can trigger referred pain down the arm(s). [15]

Causes

The human spine is well suited to erect upright posture, with the increased heart rate from movement shunting a good blood supply to the muscles. This is clearly not the case for vast numbers of sedentary humans spending many hours daily bent over laptops, tablets, smartphones and similar. A biomechanical assessment of thoracic hunching shows the abnormal spinal loading and other effects which plausibly account for the recent steep rise in thoracic and cervical pain in step with the ubiquitous adoption of the small IT devices.

The gravity of stress on the spine dramatically increases with thoracic hunching, roughly 10 pounds of weight are added to the cervical spine in weight for every inch of forward head posture by looking down at a small IT device. [16] As a consequence there is growing medical concern specifically with children as their head size is larger in relation to their body and thus pose an increased risk group for being affected by musculoskeletal and neurological issues in the neck caused by thoracic hunching. [17] [18]

Hunching has always caused problems, for instance in occupational groups like dentists, [2] surgeons, [3] hairdressers, [4] nurses, [19] chefs, [20] teachers, [21] computer workers and students. [22] Some rheumatoid conditions like ankylosing spondylitis, neurodegenerative conditions like Parkinson's disease, and connective tissue disorders like Ehlers-Danlos Syndrome cause characteristic excessive thoracic kyphosis. What has changed is the amount of hunching in society generally, and especially with the technologically adept young.

Epidemiology

The first laptop was produced in 1981 but it took more than a decade of development for the designs to approach current (2016) levels of portability and capacity, and hence uptake. Apple produced the first smartphone (the iPhone) in 2007 and the first tablet (the iPad) in 2010. In 2015 there were 4.43 billion mobile phone (cellphone) users in the world, of which 2.6 billion had smartphones.[ citation needed ] In the US, 45% owned a tablet computer in 2014 and 92% owned a mobile phone; for younger adults aged 18–29, only 2% didn't own a mobile phone and 50% had tablets. [23]

A large Finnish cross-sectional study on school-age adolescents published in 2012 concluded that more than two hours a day spent on computers was associated with a moderate/severe increase in musculoskeletal pain. [24] In the following year, the average UK 18–24 year-old spent 8.83 hours a day in front of a PC, laptop or tablet. [9] Neck pain per se has been a large problem for a long time, and surveyed repeatedly. [7] A composite review of studies with good methodology by Fejer et al. published in 2006 found that point prevalence (in pain right now) of neck pain in the adult (15–75 years) population ranged from 5.9% to 22.2%, with one study of the elderly (65+ years) finding 38.7% were in pain when surveyed. [25] Generally, more urban populations had more neck pain, e.g. 22.2% of a large 1998 Canadian study had neck pain when surveyed. [26]

Based on these surveys of neck pain prevalence, and adding to them the prevalence of thoracic pain and cervicogenic headache, it is reasonable to estimate that around one adult in six (15%) probably has pain in any, some or all of those areas right now. [27] However the published epidemiological papers draw on raw data from surveys done at least 10 years ago, and there are indications that the numbers have been rising dramatically since then – as rapidly as the adoption of laptops, tablets and smartphones. This is reflected in the recent rise in the number of popular articles, news items and media discussions about the problem. [28] [29] [30]

Pathogenesis

The iHunch is a multi-factorial problem.[ citation needed ]

Treatment

Neck pain generally has been treated with a profusion of approaches and modalities, including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen; pain relief medications (analgesics) such as acetaminophen; low dose tricyclic antidepressants such as amitriptyline for chronic problems; physical therapy (a.k.a. physiotherapy in British-derived cultures) which utilises a wide range of techniques and modalities; spinal manipulation from osteopaths, manipulating physiotherapists and spinal adjustments from chiropractors; [33] [34] massage; muscle strengthening programmes including gyms and Pilates; postural approaches such as the Alexander Technique; stretching approaches such as yoga; ergonomic approaches including setting up desktop computers correctly and frequent breaks; and surgery for severe structural problems such as osteophytic impingement on the cervical nerve roots and cervical disc herniation.

A biomechanical analysis of the iHunch indicates its standard, logical development from much flexed activity and its multi-factorial character. (See Pathogenesis above.)

A composite approach which covers each component of the problem is therefore likely to be most successful and lasting. Most of the general treatment approaches to neck pain cover only one aspect. A logical response should include as a minimum:

Related Research Articles

<span class="mw-page-title-main">Neck</span> Body part that connects the head and torso

The neck is the part of the body in many vertebrates that connects the head to the torso. It supports the weight of the head and protects the nerves that transmit sensory and motor information between the brain and the rest of the body. Additionally, the neck is highly flexible, allowing the head to turn and move in all directions. Anatomically, the human neck is divided into four compartments: vertebral, visceral, and two vascular compartments. Within these compartments, the neck houses the cervical vertebrae, the cervical portion of the spinal cord, upper parts of the respiratory and digestive tracts, endocrine glands, nerves, arteries⁣⁣ and veins. The muscles of the neck, which are separate from the compartments, form the boundaries of the neck triangles.

<span class="mw-page-title-main">Trapezius</span> Muscle between the lower spine and the shoulder blade

The trapezius is a large paired trapezoid-shaped surface muscle that extends longitudinally from the occipital bone to the lower thoracic vertebrae of the spine and laterally to the spine of the scapula. It moves the scapula and supports the arm.

<span class="mw-page-title-main">Cervical spine disorder</span> Medical condition

Cervical spine disorders are illnesses that affect the cervical spine, which is made up of the upper first seven vertebrae, encasing and shielding the spinal cord. This fragment of the spine starts from the region above the shoulder blades and ends by supporting and connecting the skull.

<span class="mw-page-title-main">Levator scapulae muscle</span> Slender skeletal muscle at the back and side of the neck

The levator scapulae is a slender skeletal muscle situated at the back and side of the neck. It originates from the transverse processes of the four uppermost cervical vertebrae; it inserts onto the upper portion of the medial border of the scapula. It is innervated by the cervical nerves C3-C4, and frequently also by the dorsal scapular nerve. As the Latin name suggests, its main function is to lift the scapula.

<span class="mw-page-title-main">Spondylosis</span> Degeneration of the vertebral column

Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense, it refers to spinal osteoarthritis, the age-related degeneration of the spinal column, which is the most common cause of spondylosis. The degenerative process in osteoarthritis chiefly affects the vertebral bodies, the neural foramina and the facet joints. If severe, it may cause pressure on the spinal cord or nerve roots with subsequent sensory or motor disturbances, such as pain, paresthesia, imbalance, and muscle weakness in the limbs.

<span class="mw-page-title-main">Cervical vertebrae</span> Vertebrae of the neck

In tetrapods, cervical vertebrae are the vertebrae of the neck, immediately below the skull. Truncal vertebrae lie caudal of cervical vertebrae. In sauropsid species, the cervical vertebrae bear cervical ribs. In lizards and saurischian dinosaurs, the cervical ribs are large; in birds, they are small and completely fused to the vertebrae. The vertebral transverse processes of mammals are homologous to the cervical ribs of other amniotes. Most mammals have seven cervical vertebrae, with the only three known exceptions being the manatee with six, the two-toed sloth with five or six, and the three-toed sloth with nine.

<span class="mw-page-title-main">Spinal adjustment</span> Chiropractic technique

Spinal adjustment and chiropractic adjustment are terms used by chiropractors to describe their approaches to spinal manipulation, as well as some osteopaths, who use the term adjustment. Despite anecdotal success, there is no scientific evidence that spinal adjustment is effective against disease.

<span class="mw-page-title-main">Splenius capitis muscle</span> A broad, straplike muscle in the back of the neck

The splenius capitis is a broad, straplike muscle in the back of the neck. It pulls on the base of the skull from the vertebrae in the neck and upper thorax. It is involved in movements such as shaking the head.

<span class="mw-page-title-main">Rectus capitis posterior minor muscle</span> Tendon

The rectus capitis posterior minor is a muscle in the upper back part of the neck. It is one of the suboccipital muscles. Its inferior attachment is at the posterior arch of atlas; its superior attachment is onto the occipital bone at and below the inferior nuchal line. The muscle is innervated by the suboccipital nerve. The muscle acts as a weak extensor of the head.

Middle back pain, also known as thoracic back pain, is back pain that is felt in the region of the thoracic vertebrae, which are between the bottom of the neck and top of the lumbar spine. It has a number of potential causes, ranging from muscle strain to collapse of a vertebra or rare serious diseases. The upper spine is very strong and stable to support the weight of the upper body, as well as to anchor the rib cage which provides a cavity to allow the heart and lungs to function and protect them.

<span class="mw-page-title-main">Winged scapula</span> Skeletal muscle condition around the shoulder blade

A winged scapula is a skeletal medical condition in which the shoulder blade protrudes from a person's back in an abnormal position.

<span class="mw-page-title-main">Neck pain</span> Medical condition

Neck pain, also known as cervicalgia, is a common problem, with two-thirds of the population having neck pain at some point in their lives.

A GALS screen is an examination used by doctors and other healthcare professionals to detect locomotor abnormalities and functional disability relating to gait, arms, legs and the spine.

Cervicogenic headache is a type of headache characterized by chronic hemicranial pain referred to the head from either the cervical spine or soft tissues within the neck. The main symptoms of cervicogenic headaches include pain originating in the neck that can travel to the head or face, headaches that get worse with neck movement, and limited ability to move the neck.

Passive accessory intervertebral movements (PAIVM) refers to a spinal physical therapy assessment and treatment technique developed by Geoff Maitland. The purpose of PAIVM is to assess the amount and quality of movement at various intervertebral levels, and to treat pain and stiffness of the cervical and lumbar spine.

Natural apophyseal glides (NAGS) refers to a spinal physical therapy treatment technique developed by Brian Mulligan.

<span class="mw-page-title-main">Vertebra</span> Bone in the vertebral column

Each vertebra is an irregular bone with a complex structure composed of bone and some hyaline cartilage, that make up the vertebral column or spine, of vertebrates. The proportions of the vertebrae differ according to their spinal segment and the particular species.

Rounded shoulder posture (RSP), also known as “mom posture”, is a common postural problem in which the resting position of the shoulders leans forward from the body’s ideal alignment. Patients usually feel slouched and hunched, with the situation deteriorating if left untreated. A 1992 study concluded that 73% of workers aged 20 to 50 years have a right rounded shoulder, and 66% of them have a left rounded shoulder. It is commonly believed that digitalisation combined with the improper use of digital devices have resulted in the prevalence of sedentary lifestyles, which contribute to bad posture. Symptoms of RSP will lead to upper back stiffness, neck stiffness and shoulder stiffness. It can be diagnosed by several tests, including physical tests and imaging tests. To prevent RSP from worsening, maintaining a proper posture, doing regular exercise, and undergoing therapeutic treatments could be effective. If the situation worsens, patients should seek help from medical practitioners for treatments. If RSP is left untreated, chronic pain, reduction in lung capacity and worsened psychosocial health are likely to result.

The myodural bridge or miodural ligament is a bridge of connective tissue that extends between the suboccipital muscles and the cervical spinal dura mater, the outer membrane that envelops the spinal cord. It provides a physical connection between the musculoskeletal and nervous systems, and the circulation of cerebrospinal fluid. Its importance has been highlighted by various authors.

References

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  6. ↑ Mujawar, Junaid Chandsaheb; Sagar, Javid Hussain (2019). "Prevalence of Upper Cross Syndrome in Laundry Workers". Indian Journal of Occupational and Environmental Medicine. 23 (1): 54–56. doi: 10.4103/ijoem.IJOEM_169_18 . ISSN   0973-2284. PMC   6477943 . PMID   31040591.
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