Forward Head Posture Correction

Forward head posture is a pathological structural abnormality in which the head is translated anterior in relation to the rest of the body. The normal static upright posture for the skull is where the center of mass of the skull [generally at the external auditory meatus] is aligned over the center of mass of the thorax [generally the midpoint of the shoulder].

There are many reasons why people develop forward head posture. The incidence of this problem has grown exponentially with the advent of the personal computer and video games. There is also a direct correlation between whiplash injuries (due to acceleration-deceleration trauma in an auto accident), and the incidence of forward head posture. There is no data to support whether it is more prevalent in males or females, or what age brackets are most affected.

Because of gravitational stress, it is important that there is normal alignment with regard to the skull on the thorax and the thorax on the pelvis. Research has shown for every one inch of anterior head translation, there is a doubling of gravitational compressive loading exerted on the muscles and joints of the cervical and thoracic spine. For example, if the head weighs 10 pounds, if there is a one inch anterior translation, the result is 20 pounds of gravitational stress being exerted on the body; two inches of anterior head posture = 30 pounds of gravitational stress. This accounts for why people who have forward head posture have chronic suboccipital pain, as well as pain in the traps, rhomboids, and other muscles which help to maintain the posture. These muscles are fatigued and end up developing spasms and trigger points. Additionally research has shown forward head posture is damaging to the joints (resulting in arthritis, degenerative joint disease and degenerative disc disease).

The normal anatomical configuration for the lateral (saggital) cervical spine is a lordosis (or forward curve). The ideal-normal curve is 42 degrees of a circle (as measured between C2 and C7). There is a strong relationship between forward head posture and the loss of a normal cervical curve (and/or a reversal of the normal cervical curve). In the most severe instances, there is a multiple harmonic configuration (where within the span of C2 to C7, there are multiple curves). This is pathological and unstable.

There is a legitimate and scientifically founded reason to rehabilitate the cervico-thoracic spine to correct structural abnormalities (such as forward head posture) even going beyond the resolution of pain. This runs contrary to the current medical model which is symptom specific only (in other words – you stop treating once the patient is asymptomatic). Structural correction of the spine is more akin to orthodontics for the teeth. The clinical goal is not the simple amelioration of pain, but rather the correction of abnormal and pathological posture (which will result in chronic and permanent damage to soft and hard spinal tissues).

People suffering with forward head posture have sought a variety of treatments including medicine, chiropractic care, massage therapy, physical therapy and acupuncture. I have found the most effective treatment plan must involve a combination of modalities which serve to restore motion, alignment and strength. The first issue that needs handled is the restoration of motion (to the joints and the muscles). The most effective way to accomplish this is via chiropractic adjustments, stretching (active assisted and proprioceptive neurofascilitation or “PNF” stretching). Additionally, a variety of muscle and soft tissue therapies (such as Nimmo Ischemic Compression, Active Release Technique, Graston and Kinesiotaping) all have proven to be useful for the restoration of normal motion.

Once the patient’s full, pain-free range of motion has been restored, the alignment may be addressed. The most effective way of correcting the forward displacement is via two-way extension-compression traction. The two way traction exerts forces on the patient in two different vectors. One part exerts force on the patient’s forehead, gently pulling the head posterior (backward). It moves the skull back over the center of mass of the shoulder. The second force is applied to the back of the patient’s neck, gently pulling it anterior (forward) to restore the curve in the neck). Research has shown the most effective results occur when this traction is done for a minimum of seven minutes to a maximum of twenty minutes. After twenty minutes, no further clinical benefits are obtained. The traction can be thought of as a long-slow adjustment. The purpose of it is to structurally deform the ligaments which are responsible for maintaining the saggital (lateral) shape of the spine (most notably the anterior longitudinal ligament). It takes time to overcome the hysteresis and creep properties of the elastic cartilage. The patient is to traction their own neck at home every day (seven days per week, and doing multiple sessions per day).

While the alignment is being addressed via traction, there must also be restoration of the strength and stability of the cerviothoracic spine. This is accomplished via a variety of specific exercises. The exercises are designed to build endurance and strength in all planes of movement. The patient is to start the exercise campaign doing isometric contractions followed by gentle proprioceptive exercises (which stimulate the joint mechanoreceptors and assist in building stability). Stability and endurance must be developed before strength. After this, the patient needs to build strength through isokinetic exercises. The areas to be addressed include the neck, upper back, chest and shoulders. The patient needs to be evaluated for asymmetrical contractions, cross body patterns and abnormal firing patterns.

When the patient has full, pain-free range of motion, no anterior translation of the skull on the thorax, a 42 degree cervical lordosis and has excellent strength & stability they are then “normal” and to be discharged from care. Intermittent follow up examinations (wellness checkups) are advised to make sure there hasn’t been any regression.