What is text neck?
Text neck syndrome is defined as having a forward head, hunched shoulders, and a rounded upper back, and many clinicians believe that this is a primary cause of back, neck, and shoulder pain. It was first coined in 2012 by Dean L. Fishman, who is an American chiropractor.
Neupane et al. described as a “repetitive stress injury or an overuse syndrome where a person has his/her head hung or flexed in a forward position and is bent down looking at his/her mobile or other electronic device for prolonged periods of time.”
Many news reports throughout the 2010s demonize the posture to cause other problems such as producing ‘horns’ in the back of the skull and cause nerve damage in the cervical spine and “weak muscles” in the anterior neck and chest. Some clinicians even advertise on social media that they can “fix” your text neck.
However, research in the relationship between posture and pain suggests that text neck and neck curvature is not a reliable indicator for neck or back pain.
While the idea of text neck syndrome has been around since the Blackberry was still popular, some news reports cited a study by Dr. Kenneth Hansraj, chief of spine surgery at New York Spine Surgery and Rehabilitation Medicine, who claimed that stress in the cervical spine from texting may lead to “early wear, tear, degeneration, and possible surgeries.” He said that flexing your neck forward at 60 degrees to check your messages places about 60 pounds of pressure upon your cervical spine.
“…individuals should make an effort to look at their phones with a neutral spine and to avoid spending hours each day hunched over,” Hansraj concluded in the paper. (1)
However, there are some problems with the study and its conclusion. There is no description of who the subjects are and how many have participated. In fact, there is no thorough description of the methodology, which would allow other scientists to reproduce the experiment. The claims that Dr. Hansraj and others who believe that text neck syndrome will ruin your spine are not consistent with the vast literature of pain research.
What does the evidence say about text neck and pain?
Our neck can withstand a tremendous amount of sustained pressure at different angles. A team of researchers from the University of Bristol examined how much pressure can the human cervical spine withstand in various directions and angles.
Based on 22 cadaver specimens from elderly subjects, the researchers found that the average compression force that the cervical spine reached their elastic limit at 1.23 kN (276.5 lbs) and can withstand up to 2.4 kilonewtons, or nearly 540 pounds, before reaching breaking point. (2) That is nine times more force than Dr. Hansraj’s “60 pounds.”
Although these researchers noted that cadaveric samples do not always apply well to living people, living tissues (especially from younger subjects) may likely be able to resist and adapt to higher loads than dead and more brittle tissues. Thus, our neck is a lot more robust than some of us believe.
More than 12 years of scientific evidence found weak association between neck posture and pain in the neck and back. A 2019 systematic review that examined the relationship between forward head posture and neck pain found that age is a significant factor in predicting who is likely to have neck pain. Researchers from the University of Cairo in Egypt examined 13 studies and found a “significant difference of [forward head posture] between adults with and without pain and a significant association between [forward head posture] and neck pain in adults. (14)
But they also that such association is lacking among teenagers “except for lifetime prevalence and number of doctor visits.” The study does not indicate a cause-and-effect relationship of forward head posture and neck pain, and it is possible that a forward head posture (and rounded shoulders) could be an adaptation to pain.
A number of moderate to large sample studies compared neck curvature between subjects with neck pain and no neck pain. Not even radiographics alone can tell whether someone has pain (3) or had a previous injury (4).
A 2007 Swiss study that was published in the European Spine Journal found no strong correlation between the lack of a lordotic curve and neck pain among 107 adults. After researchers analyzed X-rays of the neck and measured the subjects’ curvature, they found that patients with normal or less lordotic curvature had neck pain in various degrees. Likewise, they found that subjects with no neck pain had normal or no curves in their neck. (5)
A larger study from Hirosaki University Graduate School of Medicine in Aomori, Japan, also found very little association between neck curvature and neck pain among 762 adults between their twenties and eighties. “We found no association between the sagittal alignment of C2–C7 and neck symptoms in males or females after adjusting for age,” the authors stated. (6)
Among younger populations, like high school students, a 2016 Australian cross-sectional study of over 1,100 17-year-olds found no association between neck curvature and neck pain. (7) Researchers put each student into different “clusters” that are characterized by their posture:
Cluster 1: “Upright.:
Cluster 2: “Intermediate.”
Cluster 3: “Slumped thorax/forward head.”
Cluster 4: “Erect thorax/forward head.”
While they hardly found any differences between neck and back posture and pain, the researchers found that Cluster 3 “had higher odds of depressive symptoms,” which was consistent with a previous research that found teens with slumped postures had higher association with depression and anxiety. (8) Although computer and smartphone usage was not much different among the clusters, Cluster 1 are more physically active, which may attribute to a more upright posture.
“The current results do not support the commonly held clinical and societal belief that [neck pain] is related to spinal posture,” the authors said. “This is consistent with findings from systematic reviews that the association between [neck pain] and posture is weak.” (9, 10)
They also acknowledged genetics and psychosocial factors that contribute to neck pain, such as being female, depression, stress, and sleep patterns.
“This suggests that [neck pain] is associated with changes in pain regulatory mechanisms rather than biomechanics. This supports calls to consider and manage [neck pain] from a broader biopsychosocial perspective,” the authors concluded. “Despite strong support for the existence of neck posture subgroups, they were not associated with [persistent neck pain], [neck pain] in sitting or headaches in 17-year-olds. This raises questions regarding the efficacy of generic postural advice for adolescents with and without [neck pain].”
Studies that show positive relationship between text neck and pain
There are a few studies that concluded forward head posture or text neck syndrome is associated with neck pain, but these studies just show an association or correlation, no causation. For example, a 2014 Portuguese study that was published in the Brazilian Journal of Physical Therapy stated, “68% and 58% of the adolescents revealed anteriorization of the head and protraction of the shoulder, respectively. The subjects with neck pain had a more forward head posture. Gender was also found to have an important effect on posture and neck pain, with girls revealing a lower cervical angle and more neck pain.” (11)
If we accept the conclusion at face value and skip the methodology and results, we misguide ourselves into thinking that neck posture matters a lot. First, this study only suggests an association, but this association is only as strong as how the experiment was conducted. Also, the researchers were only examining students with neck pain. Without a control group, no good establish can be made about the association between neck posture and pain. If they were to randomly examine an equal number of students — age and gender matched — the study may tell a different story.
Another study from Tehran, Iran, compared symptomatic and asymptomatic office workers. They found asymptomatic workers spent fewer hours working at a computer than their symptomatic coworkers, and those with neck pain had “a poorer posture of cervical and thoracic spine during working time.” (12)
While this may indicate that there is a relevant association between neck posture and neck pain, we don’t know whether the subjects’ pain is caused by forward head posture or the posture is a result of pain adaptation. The authors acknowledged that there are stress and other psychological factors may contribute to symptomatic workers due to workload and longer hours at the computer, which may be further investigated in future studies.
Good quality studies not only should examine subjects with pain and subjects without pain and compare both groups, but also be up-to-date on the current understanding of pain. It is not simply a biomechanical contributor. Such repeated studies often tell the same story: neck posture alone hardly contributes neck pain.
“If we reconceptualize our views on posture and recognize that any posture that is used repeatedly/prolonged and that we aren’t accommodated to might increase the sensitivity of our system then perhaps there is a good message in there. But this is not the same as saying we need to always stay near an ideal. Instead look for variety, build tolerance, build confidence and develop capacity.” ~ Gregory Lehman
Neck pain existed before “text neck” era
While smartphones and texting are often blamed for text neck and neck pain, some studies had examined the relationship between neck pain and neck muscle strength, posture, and other factors since the 1990s.
Neck pain among teens
A 1997 study of more than 1,600 schoolchildren (third and fifth graders) found that about half of them who had pain at least once a week had the same pain a year later. Mikkelsson et al. found that girls had higher prevalence of neck, upper back, and chest pain than boys. Follow-up studies were made in 2004 and 2007 and found similar results. While these studies did not examine posture and other biomechanical factors, they also mentioned that familial factors could impact the prevalence of musculoskeletal pain and children’s beliefs, such as the belief that pain “runs in the family.”
The researchers considered their study’s follow-up time to be too short because they cited another study from Norway in 1985 that followed up schoolchildren nine to twelve years later.
In that research, muscle tenderness and tension were risk factors for developing neck pain among nine percent of the 302 students. Even among 18 of these students who had thoracic kyphosis and muscular tension, did not add moree risk of cervical pain. “On the whole, this study does not give definite evidence that posture deviations are risk factors for cervical pain,” the authors wrote. Instead, they cited that psychological factors, such as negative self-image reinforcement, is more likely to be higher contributors to persistent neck pain, especially among those who frequently visited a physiotherapist or chiropractor regularly for treatment.
Muscle strength and neck pain
A 2004 study on neck pain among 169 female office workers in Finland found that neck muscle strength testing “may not be reliable for the measurement of maximal neck strength in patients with neck pain, but they may be useful in showing how much the function of painful muscles is reduced under strain.” The researchers also found that subjects with chronic neck pain had various range of motion during passive neck flexibility test, indicating that range of motion is not a reliable factor in determining who has neck pain and why. They suggested that neck pain rehab should help patients increase pain threshold during strain in the neck.
Bottom line: Neck pain has been around for many decades and likely since prehistory like most kinds of musculoskeletal pain. Without data comparing the prevalence and during of neck pain before and after the iPhone-era, it would be difficult to assert that text neck is based on established knowledge.
Related: Do Heavy Backpacks Cause Back Pain in Children?
How to ‘fix’ your text neck syndrome and should you bother?
Given the evidence about neck pain and text neck, there aren’t any specific exercises that you need to do to “fix” it. You may not be able to change your neck curvature, but moving your neck regularly when you are texting or working at the computer can alleviate some pain.
Simple exercises can be the following:
- Nod your head: Gradually tilt your head back to look up and then look down. Repeat 4 to 5 times.
- Look both ways: Turn your head as far as you can to your right, and turn your head to your left. Repeat 4 to 5 times.
- Library books: Tilt your head to your right to bring your right ear toward your right shoulder without shrugging your shoulders like you are looking for a book you want at a library shelf. Then tilt your head to left. Repeat 4 to 5 times.
Do these as often as you like. You can probably come up with your own neck exercises. These exercises would not likely change your neck curvature, but you would likely feel less stiff and painful. Movement is the key to minimize the risk of long-term pain.
Pain stems from many factors other than ‘text neck’
Research in the last 100-plus years reveals that pain is much more complex where your brain and the rest of the nervous system constantly process information from our environment and body to determine how much threat we are facing and how safe we are.
“Pain is the output. Nociception is one of the inputs. All of the inputs are evaluated when we’re talking about pain, I think, according to this question: How dangerous is this? Based on everything I know, which is all of the information available to me right now, how dangerous is this really?” ~ Dr. Lorimer Moseley, pain researcher and physiotherapist, University of South Australia
Given the vast research and weight of evidence that pain is a sum of psychosocial factors, how we feel and react to pain depends on these interactions. Sometimes one factor contributes to pain higher than others under certain circumstances. (13)
For example, in a large study in 2013 of more than 3,900 individual twins in Finland, the researchers found that genetics and specific environmental factors can contribute to the likelihood of pre-teens (and likely later in life) to get persistent neck pain, at least among twins. While there was no significant difference between genders, individual twins who grew up in different households are more likely to get neck pain than those who grew up in the same household. In this case, social and environmental factors have an impact on their psychology and biology.
You could still get neck pain if you stand with a neutral neck and spine for ten minutes like a Buckingham Palace Guard. As for text neck, don’t let social media and news reports make you feel your body is vulnerable to damage or pain. Chances are, your neck is fine. Text neck (or any type of posture) itself probably isn’t the issue; the real issue is how long you spend in any one position, even in the “neutral spine” position.
Take home advice: Spend less time in any one position and give your neck and shoulders more frequent “movement breaks” when texting or working at a computer.
Updated: July 2, 2020. Added section “Neck pain existed before ‘text neck’ era.”
References
1. Hansraj KK. Assessment of stresses in the cervical spine caused by posture and position of the head. Surg Technol Int. 2014 Nov;25:277-9.
2. Przybyla AS, Skrzypiec D, Pollintine P, Dolan P, Adams MA. Strength of the cervical spine in compression and bending. Spine. 2007 Jul 1;32(15):1612-20.
3. Rudy IS, Poulos A, Owen L, et al. The correlation of radiographic findings and patient symptomatology in cervical degenerative joint disease: a cross-sectional study. Chiropractic & Manual Therapies. 2015;23:9. doi:10.1186/s12998-015-0052-0.
4. Beltsios M, Savvidou O, Mitsiokapa EA, Mavrogenis AF, Kaspiris A, Efstathopoulos N, Papagelopoulos PJ. Sagittal alignment of the cervical spine after neck injury. Eur J Orthop Surg Traumatol. 2013 Jul;23 Suppl 1:S47-51. doi: 10.1007/s00590-012-0966-3. Epub 2012 Mar 10.
5. Grob D, Frauenfelder H, Mannion AF. The association between cervical spine curvature and neck pain. European Spine Journal. 2007;16(5):669-678. doi:10.1007/s00586-006-0254-1.
6. Kumagai G, Ono A, Numasawa T, et al. Association between roentgenographic findings of the cervical spine and neck symptoms in a Japanese community population. Journal of Orthopaedic Science. 2014;19(3):390-397. doi:10.1007/s00776-014-0549-8.
7. Richards KV, Beales DJ, Smith AJ, O’Sullivan PB, Straker LM. Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents. Phys Ther. 2016 Oct;96(10):1576-1587. Epub 2016 May 12.
8. O’Sullivan P, Beales DJ, Jenson L, Murray K, Myers T. Characteristics of chronic non-specific musculoskeletal pain in children and adolescents attending a rheumatology outpatients clinic: a cross sectional study. Pediatric rheumatology. 2011;9(3).
9. Brink Y, Louw QA. A systematic review of the relationship between sitting and upper quadrant musculoskeletal pain in children and adolescents. Manual therapy. 2013;18(4):281-288.
10. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA. Incidence ofcommon postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Physical therapy. 1992;72(6):425-431.
11. Ruivo RM, Pezarat-Correia P, Carita AI. Cervical and shoulder postural assessment of adolescents between 15 and 17 years old and association with upper quadrant pain. Brazilian Journal of Physical Therapy. 2014;18(4):364-371. doi:10.1590/bjpt-rbf.2014.0027.
12. Nejati P, Lotfian S, Moezy A, Moezy A, Nejati M. The Relationship of Forward Head Posture and Rounded Shoulders with Neck Pain in Iranian Office Workers. Medical Journal of the Islamic Republic of Iran. 2014;28:26.
13. Melzack R, Katz J. Pain. WIREs Cogn Sci 2013, 4:1–15. doi: 10.1002/wcs.1201.
14. Mahmoud NF, Hassan KA, Abdelmajeed SF, Moustafa IM, Silva AG. The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis. Curr Rev Musculoskelet Med. 2019;12(4):562–577. doi:10.1007/s12178-019-09594-y.
A native of San Diego for nearly 40 years, Nick Ng is an editor of Massage & Fitness Magazine, an online publication for manual therapists and the public who want to explore the science behind touch, pain, and exercise, and how to apply that in their hands-on practice or daily lives.
An alumni from San Diego State University with a B.A. in Graphic Communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014.
When he is not writing or reading, you would likely find him weightlifting at the gym, salsa dancing, or exploring new areas to walk and eat around Southern California.
