WHAT IS FORWARD HEAD POSTURE (FHP)?
Forward head posture (FHP) is an abnormality that can be identified by examining the position of their head with respect to the cervical spine (CS). Interestingly in FHP, not only does the head project anteriorly over the CS, but simultaneous tilting of the head in a posterior direction also occurs promoting hyperextension of the upper CS (Patwardhan et al., 2018). The backward rotation of the head on the CS is a compensation that enables an individual with FHP to look straight ahead instead of towards the ground . If FHP becomes chronic, it can place large stresses on the muscles and connective tissue in the neck. As with other postural and movement dysfunctions throughout the body, FHP often results in movement compensations due to regional musculature becoming excessively inactive or overactive. The muscles that tend to become inactive in individuals with FHP include the deep neck flexors, cervical erector spinae, lower trapezius, and rhomboids (Clark et al., 2014). Inactivity in these muscles contribute to the inability to maintain an upright position of the CS. Muscles that often become overactive in those with FHP include the upper trapezius, levator scapula, scalenes, sternocleidomastoid, and suboccipitals (Clark et al., 2014). Overactivity of these muscles facilitate forward head migration, as well as in some cases, rounding of the shoulders. The adult human head weighs approximately 10-12 pounds, however when the neck flexes forward to look down at a cell phone , the relative stress placed on the neck increases significantly. When the neck is flexed to 15 degrees, the relative stress on the neck can increase to approximately 30 pounds; 30 degrees of neck flexion can increase the relative stress to 40 pounds; 45 degrees can increase the relative stress to 50 pounds; and 60 degrees of neck flexion increases the relative neck stress to 60 pounds.
NEGATIVE IMPACTS OF FORWARD HEAD POSTURE Advanced stages of FHP can contribute to upper CS compression which significantly reduces the ability of the first cervical vertebrae (C1) to rotate around the second vertebrae (C2) as it normally would. If the upper CS loses its ability to rotate, the middle and lower segments of the CS must attempt to make up for this restriction which predispose them to becoming hypermobile (having the ability to move past a normal range of movement) . This can result in an increased risk for spinal instability, degeneration, and pain (Pop et al., 2018). Other conditions associated with FHP include myofascial trigger points, anterior neck tightness/pain, temporomandibular joint (TMJ) disorders, rounded shoulders, as well as its promotion of respiratory inefficiency. MYOFASCIAL TRIGGER POINTS AND HEADACHES: Myofascial trigger points (MTP) are painful regions within a tight band of skeletal muscle and also give rise to referred pain (pain perceived at a different location than the source) (Simons et al., 1999). FHP results in increased load bearing on the musculature in the upper CS which can reduced pain thresholds as well as predispose MTP . Overactive musculature and MTP’s in the upper CS can predispose and contribute to the development of cervicogenic headache . TEMPOROMANDIBULAR JOINT (TMJ) DISORDERS: A link also exists between FHP and TMJ function (Chaves et al., 2014; Zafar, et al., 2000). FHP contributes to the development of pain in the TMJ region by altering length- tension relationships in head and neck musculature (Chaves et al., 2014). FHP creates excessive tension in the muscles above the hyoid bone which, in turn, places greater force demands on the muscles that close the jaw (An et al., 2015). Over time, excessive force demands on the jaw muscles can lead to the development of myofascial trigger points and TMJ pain.
ROUNDED SHOULDERS AND UPPER BACK Many individuals with FHP also demonstrate anterior rounding of the shoulders and of the upper back as well. As FHP is associated with overactivity of the upper trapezius and levator scapulae muscles. This condition can not only contribute to rounded shoulders, but negatively impact the normal movement patterns of the humerus and scapula (Dr. Mark’s term called scapular rhythm ). Rounding of the shoulders also predisposes the development of shoulder pain and impingement . If both FHP and rounding of the shoulders is occurring at the same time, this postural distortion is known as upper crossed syndrome (Janda, 2002). RESPIRATORY INEFFICIENCY Another negative influence of sustained FHP is the promotion of respiratory inefficiency. Normal inspiration (breathing in) is initiated by contraction of the primary respiratory muscles- the diaphragm and external intercostal muscles . However, in individuals with FHP, muscle activity and function of the diaphragmmay decrease, which can reduce lung expansion during inspiration . To make up for impaired muscle power of the diaphragm, individuals with FHP may compensate by utilizing accessory respiratory muscles such as the sternocleidomastoid (SCM) muscle to inspire air . Excessive SCM activity when breathing at rest can cause an individual’s shoulders and rib cage to move up and down rather than remaining in their normal stationary position . Correction of FHP has been demonstrated to improve respiratory function and efficiency (Kim, et al., 2015).
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