Forward head posture is the excessive protraction of the head in relation to the shoulder girdle. It usually accompanies rounded shoulders and kyphosis, characteristics of upper cross syndrome and lower cross syndrome. Forward head posture garnered much media attention in the 2010s, spreading the term “text neck” or “text neck syndrome,” which was coined by an American chiropractor in 2012.
In 2014, a New York surgeon wrote a research paper that further spread the idea that smartphone usage is the main cause of text neck and neck pain. Although the research was poorly written and conducted and it was never replicated, the term got more popular and most of the public and media were sold to text neck. However, much of the research before and after the popularity of text neck contradicts what many clinicians believe.
Forward head posture and neck muscle pain
A 2017 review found that forward head posture and other “upper cross syndrome” postures may cause stress and “weakness” upon some muscles alone the thoracic spine, including the serratus anterior, trapezius, and rhomboids.
“The scapula has been found to be anteriorly tilted, downwardly rotated, and protracted during elevation of the arm in persons with [forward head posture],” the researchers described. “A decrease in serratus anterior activity has been observed in persons with [forward head posture] while doing arm elevation and lifting activities. This reduction in serratus anterior activity leads to anterior tilting of the scapula, as well as winging of the scapula.”
However, this review does not examine the relationship between forward head posture and neck pain.
What causes forward head posture?
Forward head posture—sometimes called “nerd neck”—is often blamed from heavy usage of smartphones, hand-held games, and computers where the person’s head is looking down or protracted forward. While there is some evidence that supports this idea, such as a 2013 South Korean study that compared the neck angle of 30 computer workers vs. 30 workers who rarely work with a computer, research prior to the smartphone era suggests that neck pain is just as prevalent as after 2006.
A 1997 study in Finland found that half of the 1,600 third and fifth graders examined had neck and chest pain at least once a week. The research team, led by Dr. Marja K. Mikkelsson, found that girls had a higher prevalence of neck, upper back, and chest than boys. Those who had these pains also tend to have the same type of pain a year later.
The team followed up with the students in 2004 and 2007 found similar results. “Psychosomatic symptoms, rather than physical factors, predict future non-traumatic pain, while both physical and psychosomatic factors predict future traumatic pain,” they concluded.
While Mikkelsson et al. did not examine biomechanical and postural factors, they emphasized that family and beliefs could affect children’s musculoskeletal pain, such as the reason they have pain is because it “runs in the family.”
A similar study was conducted in 1985 in Norway among more than 300 teenagers where it found that girls also had a higher prevalence of neck pain and other musculoskeletal pain than boys. “On the whole, this study does not give definite evidence that posture deviations are risk factors for cervical pain,” the researcher Arthur Hertzberg wrote. He also found that pelvic tilts did not increase the risk of low back pain.
He also noticed that those teenagers who had visited a physical therapist “had a greatly increased morbidity of cervical pain during the follow-up period” than those who did not go to a physical therapist. One possibility, he suggested, is that since the students were at a “high risk” group for neck pain, clinical visits may reinforce negative beliefs about themselves, which causes a circular cycle of pain.
Among office workers, 169 women in Finland in 2004 were tested for neck strength (extension, flexion, rotation) to see its relationship with chronic neck pain and disability. While the researchers do not find a strong relationship between neck pain and range of motion, they found an inverse relationship between neck strength and pain. However, there is a caveat to this study.
“Part of the difference may be explained by neural inhibition caused by pain felt during test efforts, which do not normally cause any pain,” they wrote. “Local allodynia on the neck area may also prevent patients from producing full force, because of conscious or subconscious fear of hurting themselves. Thus neck strength tests do not produce reliable results with regards to true maximal strength.”
Neck curvature and forward head posture
The shape of the neck is thought to cause neck pain and muscle strain in the upper trapezius, rhomboids, suboccipitals, and other neck and shoulder muscles. However, most research finds a lack of strong cause-and-effect relationship between neck posture and neck pain.
In 2004, researchers from Université du Québec à Trois Rivières in Canada examined three groups of subjects with acute neck pain, chronic neck pain, and no neck pain. They found that cervical lordosis is the largest among those with no pain, and chronic neck pain sufferers had the least amount of lordotic angle. Those with acute neck pain are somewhere in between the other groups.
However, the data does not show a causal relationship because the differences in the cervical angle (about 11 millimeters) “are unlikely to affect the cervical lordosis” and “are unlikely to be responsible for the pain differences between the subjects,” the researchers reported.
Another study published in 2006 found no association between the curve of the cervical spine and neck pain. The Swiss researchers analyzed and compared the X-rays of 54 subjects with neck pain and 53 without neck pain, and they found both groups have various curve angles that overlap each other. Thus, there were “no significant differences between the PAIN and NO PAIN groups for either the total curvature or the segmental curvature at any level,” they wrote.
In 2013, a larger study in Hirosaki, Japan, also found very little association between the neck curvature and neck pain among 762 men and women in their twenties to 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 wrote. The authors also wrote that this sample is limited to the rural population in the Aomori Prefecture, which does not represent most of the Japanese population.
Such studies led to some Italian researchers—Laura Lippa, Luciano Lippa, and Francesco Cacciola—to question the prognosis and the relationship between neck posture and pain. “The possibility to correlate clinical outcome with alignment of the spinal column seems appealing but is, however, not as easily translatable into practice as it might seem,” they wrote. They also argued that imaging and measurements of posture still provide “indispensable” objective data to the picture, even if they show a lack of association with pain.
In the bigger picture, research also finds little association between forward head posture and pain. A 2018 meta-analysis from Henan, China, reviewed 21 studies—with a total of more than 15,000 subjects— that examined whether forward head posture is different among subjects without pain or similar symptoms.
They found no significant differences between those with pain and those without pain; the average cervical angle difference was less than two degrees. However, among men, their cervical lordosis angle was higher than women, and aging does not correlate well with the angle either. Overall, about one-third of the sample do not have cervical lordosis.
A year later, another systematic review and meta-analysis reviewed 15 cross-sectional studies that compared—again—the necks of symptomatic and asymptomatic people. Led by Dr. Nesreen Fawzy Mahmoud from the University of Cairo in Egypt, the research team found despite that some studies use different ways to measure the cervical lordotic angle, “there was no statistically significant difference in the [forward head posture] between asymptomatic and neck pain subjects.”
While there is a lack of significant differences among teenagers, adults with pain tend to have forward head posture than those with no pain. It is not clear why there is such a difference, but the authors hypothesized—based on previous research—that perhaps teenagers tend to have higher muscular endurance in the deep neck flexors than adults, and some adults have adopted the forward head posture (or lack of it) far longer than teenagers. One psychosocial they mentioned is that teenagers who had a “lifetime prevalence and number of doctor visits.”
Mahmoud et al. pointed out some limitations in this study, which include the exclusion of non-English studies and unpublished data, low- and moderate-quality methodologies in some of the included studies, and the low number of studies where data about gender, measurement methods, and other qualities could not be analyzed well.
“It remains unknown if [forward head posture] could be the cause or a consequence of idiopathic neck pain in adults,” they reported. “We need high-quality longitudinal studies to investigate this causality and temporality.”
However, these ideas do not explain why many teenagers and children suffer from chronic neck pain regardless of what neck curvature they have nor do they apply psychosocial aspects that influence neck pain.
More forward head posture studies 2019-2020
If the previous systematic review by Mahmoud et al. needs updating, it would likely include these two of these recent studies on forward head posture and neck pain.
Two more cross-sectional studies were published in 2020 also found hardly any relationship between neck posture and text neck with neck pain. A Spanish study examined 96 college students from the University of Acala with 64 students without pain and 32 students with neck pain. The researchers measured neck flexion, extension, and rotation with students in a sitting position. They found that those with forward head posture have higher “tissue mechanosensitivity” and lesser neck range of motion than those with no pain. However, they reported that “forward head posture is not associated with the presence of neck pain, headache, or disability.”
In 2019, a group of Italian researchers, Bertozzi et al., found “no significant correlations” between the number of hours spent looking at a smartphone with neck pain and disability among 238 young medical students. About half of the sample reported to have no neck pain.
They suggested that “neither a targeted health intervention on this population nor the actual widespread fears of parents and relatives are justified.” Any changes to the conclusion would take many years and probably even more studies and data to overturn the existing body of knowledge about the relationship between posture and pain.
This would refer to prior plausibility, which is the reflection of established scientific knowledge about the natural world and the universe. The research behind forward head posture—or any types of posture—is no different. “The amount of evidence necessary to add one small bit of incremental understanding about a phenomenon is much less (and should be less) than the amount of evidence necessary to entirely overturn a well-established theory,” neuroscientist Steven Novella wrote. “Science could not possibly function any other way.”
Meanwhile, Bertozzi et al. suggested that “young people can continue to use their cell phones as they prefer.”
Forward head posture “fix”
While neck posture is poorly associated with neck pain, some studies indicate other factors that are more likely to contribute to pain rather than structure alone.
A large Australian study in 2016, led by Dr. Karen V. Richards from Curtin University, found that the slump sitting posture among more than 1,100 17-year-olds, which often associated with forward head posture, rounded shoulders, and kyphosis, are affected by body mass index (BMI), exercise frequency, sleep quality, stress, and depression.
Rather than lumping all the subjects into one group to evaluate forward head posture and neck pain, Richards et al. divided the subjects into four clusters:
- Cluster 1 (“upright”): has the least neck flexion, head protraction, and thoracic kyphosis;
- Cluster 2 (“intermediate”): same as Cluster 1 but with only slightly more thoracic kyphosis;
- Cluster 3 (slumped thorax/forward head): has the highest amount of thoracic kyphosis and forward head posture;
- Cluster 4 (straight thorax/forward head): same as Cluster 1 but with forward head posture.
Intuitively, one would think that Cluster 3 would have the highest prevalence of neck pain, but the researchers found hardly any differences between neck and upper back posture with pain. Cluster 3, however, had “higher odds of depressive symptoms. Cluster 1’s usage of the computer and smartphone was not much different than the other clusters, but this group is more physically active which may contribute 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 the findings from previous systematic reviews that found a weak relationship between neck pain and posture.
“This suggests that [neck pain] is associated with changes in pain regulatory mechanisms rather than biomechanics,” Richards et al. wrote. “This supports calls to consider and manage [neck pain] from a broader biopsychosocial perspective.”
“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],” they concluded.
Forward head posture exercises
Since persistent neck pain occurs among people with a variety of posture and not just forward head posture and “upper cross syndrome,” some forward head posture exercises may help alleviate tension and pain temporarily while improving range of motion.
A detailed description of the chin tuck exercise as well as what not to do.
Nod your head: Gradually tilt your head back to look up and then look down. Repeat 4 to 5 times or as many as you like until you feel a little “looser.”
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 or as many as you like until you feel a little “looser.”
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 the left. Same repetition guidelines as the previous two exercises.
Do these posture exercises as often as you like. These exercises may or may not change your neck curvature, but you would likely feel less stiff and painful. Movement is a key to reducing pain.
If you have pain, restricted range of motion, or both while performing any of these exercises, consult with a qualified medical profession before further attempting to exercise. These are not substitutions to medical advice or care.
Should I still learn how to fix forward head posture?
Instead of just evaluating and blaming on posture and structural issues, a better alternative would be to treat the person with the help of narrative medicine, not the scan or measurements. However, this does not mean scans and physical evaluations are unimportant; they should be part of the entire system of patient-centered care.
Remember that pain is not just a biomechanical or structural problem. The degree of biological, psychological, sociological, and environmental factors that gives you the pain experience would vary among each person. So, there is not often a “one cause” factor that is the root of your pain, especially in chronic pain.
“It is surely difficult to find definite answers considering that pain as a biopsychosocial phenomenon is probably too vast a problem to be simply reduced to any kind of measures, no matter how sophisticated and appealing such a computation may be,” Lippa et al. wrote.