Section Iv Painful Conditions

Forward Head Posture Fix

Forward Head Posture Fix

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Muscle problems associated with pain in the posterior neck are essentially of two types: one associated with muscle tightness and the other with muscle strain. Symptoms and indications for treatment differ according to the underlying fault. Both types are quite prevalent. The one associated with muscle tightness usually has a gradual onset of symptoms, whereas the one associated with muscle strain usually has an acute onset.


Neck pain and headaches associated with tightness in the posterior neck muscles are most often found in patients with a forward head and a round upper back. As shown on pages 152 and 153, the compensatory head position associated with a slumped, round upper back results in extension of the cervical spine.

The faulty mechanics associated with this condition chiefly consist of undue compression posteriorly on the articulating facets and posterior surfaces of the bodies of the vertebrae, stretch weakness of the anterior vertebral neck flexors, and tightness of the neck extensors, including the upper trapezius, splenius capitis and semi-spinals capitis.

Headaches associated with this muscle tightness are essentially of two types: occipital headache and tension headache. The greater occipital nerve, which is both sensory and motor, supplies the semispinalis and splenius capitis muscles. It pierces the semispinalis capi-tis and the trapezius near their attachments to the occipital bone. This nerve also innervates the scalp posteriorly up to the top of the head. In the occipital headache, there usually is pain and tenderness on palpation in the area where the nerve pierces the muscles as well as pain in the scalp in the area supplied by the nerve. In a tension headache, in addition to the faulty postural position of the head and neck and the tightness of the posterior neck muscles, an element of stress is also involved. This makes the condition tend to fluctuate with times of increased or decreased stress. In any event, the tight muscles usually respond to treatment that helps these muscles to relax.

Symptoms in addition to pain may occur with tension headaches: "Occasionally, muscle contraction headaches will be accompanied by nausea, vomiting and blurred vision, but there is no preheadache syndrome as with migraine" (12).

From another source comes the statement that this forward-head position has been found "to cause an alteration in the rest position of the mandible, upper thoracic respiration with subsequent hyperactivity of the respiratory accessory muscles, and mouth breathing with a loss of the rest position of the tongue ... and may lead to eventual osteoarthrosis and remodeling of the tem-poromandibular joint" (13).

On palpation, the posterior muscles are tight. Movements of the neck are often limited in all directions except in extension. Pain may be of lower intensity when the patient is recumbent, but it tends to be present regardless of the position the patient assumes.

The patient should use a pillow that permits a comfortable position of the neck. The patient should not sleep without a pillow, because the head will drop back in extension of the neck. On the other hand, the use of too high a pillow should be discouraged, because this can result in an increased forward-head position. A commercially available or home-made cervical pillow can provide the needed comfort and keep the neck in good position. The pillow should be flattened in the center to provide support both posteriorly and laterally.

Active treatment consists of heat, massage and stretching. The massage should be gentle and relaxing at first, then progress to deeper kneading. Stretching of the tight muscles must be very gradual, using both active and assisted movements. The patient should actively try to stretch the posterior neck muscles by efforts to flatten the cervical spine (i.e., pulling the chin down and in). (See p. 163.) This action compares with the effort to flatten the lumbar spine in cases of lordosis and may be done in the supine, sitting, or standing position but not in the prone position. Exercises that hyperextend the cervical spine are contraindicated.

Because the faulty head position is usually compensatory to a thoracic kyphosis, which in turn may result from postural deviations of the low back or pelvis, treatment frequently must begin with correction of the associated faults. Treatment for the neck may need to begin with exercises to strengthen the lower abdominal muscles and with use of a good abdominal support that permits the patient to assume a better upper back and chest position.

Unilateral tightness in posterolateral neck muscles is increasingly common as a result of people holding a telephone on the shoulder. In this position, the shoulder is elevated, and the head is tilted toward the same side. (See p. 161.) The scapular muscle that is the most direct opponent of the upper trapezius is the lower trapezius, which acts to depress the scapula posteriorly. The most direct opponent of the upper trapezius acting to depress the shoulder and the shoulder girdle directly downward in the coronal plane is the latissimus dorsi. Tests of the strength of this muscle often reveal weakness on the side of the elevated shoulder, and exercises to strengthen this muscle are indicated, along with other exercises to stretch the lateral neck flexors. (See p. 163 for the latissimus exercise and for exercises to stretch the lateral neck flexors.)


The upper trapezius is that part of the trapezius muscle extending from the occiput to the lateral h of the clavicle and the acromion process of the scapula. A strain of this muscle results in pain, usually acute, in the posterolateral region of the neck.

The stress that gives rise to this condition is often a combination of tension on and contraction of the muscle. Stretching sideways to reach for an object while tilting the head in the opposite direction can cause such an attack (e.g., someone on the floor reaching to recover an object that rolled under a desk, or someone sitting in the front of a car reaching to recover an object from the backseat). The abduction of the arm requires scapular fixation by action of the trapezius, and the sideways tilt of the head puts tension on the muscle.

The muscle develops a "knot" or a cramp, which is better described as a segmental spasm in the muscle. (See p. 35.) Application of heat or massage to the entire area tends to increase the pain, because the muscle is strained. The part to be treated is the part that is in spasm. Because it is difficult to localize heat effectively to such a small area, massage alone is indicated. Start with a gentle, kneading massage, and then increase as tolerated.

Either an improvised collar or a sling (or both) may be used if the condition remains very painful and does not respond favorably to the massage.

A simple collar can be made from a small towel folded lengthwise to the correct width. The towel is wrapped securely around the neck and then held in place by a strip of strong tape. The collar can be made mote firm by placing a strip of cardboard inside the towel. The collar may be needed for only 2 or 3 days.


Arm pain caused by cervical nerve root pressure is basically a neurological problem. Faulty posture of the cervical spine may act as a contributory factor when the onset is not associated with sudden trauma. Extension of the cervical spine as seen in a typical forward-head position (see p. 152) produces undue compression on the facets and posterior surfaces of the bodies of the cervical vertebrae.

When the condition is acute, significant relief may be obtained by the use of moist heat (comfortably warm) to relieve protective muscle spasm, gentle massage to help relax the muscles, and low-level manual or mechanical traction to relieve compression. The use of a collar is often necessary in the early stages. It can provide appropriate support to help immobilize the cervical spine, prevent hyperextension and transmit the weight of the head to the shoulder girdle. When symptoms are subacute or chronic, treatment should also include exercises to correct any muscle imbalance and underlying faults in alignment. Conservative treatment may be adequate, or it may be an adjunct to surgical measures.


Increased dependence on computers in many work situations is frequently the cause of neck and upper back discomfort and headaches if basic ergonomic rules are ignored. The office set-up below was chosen as an example of how to correct alignment and relieve strain. The key to improving posture is a well-fitting chair that adjusts for proper height, arm support and back support. Use of a phone headset relieves neck strain.

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