Skip to main content
Log in

The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis

  • Hot Topics
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Purpose of Review

Forward head posture (FHP) is the most common cervical postural fault in the sagittal plane that is found with different severity levels in almost all populations. Despite claims that FHP may be related to neck pain, this relation seems to be controversial. Thus, our purpose is to determine whether FHP differs between asymptomatic subjects and those with neck pain and to investigate if there is a relationship between head posture and neck pain.

Recent Findings

A total of 15 cross-sectional studies were eligible for inclusion for this systematic review and meta-analysis. Ten studies compared FHP between a group of asymptomatic participants and a group of participants with neck pain and an overall mean difference (MD) of 4.84 (95% CI = 0.14, 9.54), indicating a significant between-group difference, contrary to adolescent (MD = − 1.05; 95% CI = − 4.23, 2.12). Eight studies showed significant negative correlations between FHP and neck pain intensity (r = − 0.55; 95% CI = − 0.69, − 0.36) as well as disability (r = − 0.42; 95% CI = − 0.54, − 0.28) in adults and older adults, while in adolescents, only lifetime prevalence and doctor visits due to neck pain were significant predictors for FHP.

Summary

This systematic review found that age played an important role as a confounding factor in the relation between FHP and neck pain. Also, the results showed that adults with neck pain show increased FHP when compared to asymptomatic adults and that FHP is significantly correlated with neck pain measures in adults and older adults. No association was found between FHP and most of neck pain measures in adolescents.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Fejer R, Kyvik KO, Hartvigsen J. The prevalence of neck pain in the world population: a systematic critical review of the literature. Eur Spine J. 2006;15(6):834–48.

    PubMed  Google Scholar 

  2. Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24(6):783–92.

    CAS  PubMed  Google Scholar 

  3. • Genebra CVDS, Maciel NM, Bento TPF, Simeão SFAP, de Vitta A. Prevalence and factors associated with neck pain: a population-based study. Brazilian J Phys Ther. 2017;21(4):274–80 This study includes the update of neck pain prevalence and its assossiated risk factors.

    Google Scholar 

  4. Guzman J, Frcp C, Hurwitz EL, Carroll LJ, Haldeman S, Co P, et al. A new conceptual model of neck pain linking onset, course, and care: the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Eur Spine J. United States. 2010;33(4):14–23.

    Google Scholar 

  5. Mikkelsson M, Salminen JJ, Kautiainen H. Non-specific musculoskeletal pain in preadolescents. Prevalence and 1-year persistence. Pain. 1997;73:29–35.

    CAS  PubMed  Google Scholar 

  6. Australian Acute Musculoskeletal Pain Guidelines Group. Australian Academic Press; Brisbane. Evidence-based management of acute musculoskeletal pain: a guide clinicians Available from [Google Sch [Ref List. Australia: Australian Academic Press Pty. Ltd.; 2004;35–43.

  7. McLean SM, May S, Klaber-Moffett J, Sharp DM, Gardiner E. Risk factors for the onset of non-specific neck pain: a systematic review. J Epidemiol Community Health England. 2010;64(7):565–72.

    Google Scholar 

  8. Paksaichol A, Janwantanakul P, Purepong N, Pensri P, van der Beek AJ. Office workers’ risk factors for the development of non-specific neck pain: a systematic review of prospective cohort studies. Occup Environ Med England. 2012;69(9):610–8.

    Google Scholar 

  9. Cagnie B, Danneels L, Van Tiggelen D, De Loose V, Cambier D. Individual and work related risk factors for neck pain among office workers: a cross sectional study. Eur Spine J Berlin/Heidelberg: Springer-Verlag. 2007;16(5):679–86.

    CAS  Google Scholar 

  10. • Gustafsson E, Thomee S, Grimby-Ekman A, Hagberg M. Texting on mobile phones and musculoskeletal disorders in young adults: a five-year cohort study. Appl Ergon. 2017;58:208–14. https://doi.org/10.1016/j.apergo.2016.06.012It shows the short-term and long-term effects of texting on neck pain.

    Article  PubMed  Google Scholar 

  11. Kang J-H, Park R-Y, Lee S-J, Kim J-Y, Yoon S-R, Jung K-I. The effect of the forward head posture on postural balance in long time computer based worker. Ann Rehabil Med. 2012;36(1):98–104 Available from: file:///C:/Users/ECA/AppData/Local/Mendeley Ltd./Mendeley Desktop/Downloaded/Kang et al. - 2012 - The effect of the forward head posture on postural balance in long time computer based worker.pdf.

    PubMed  PubMed Central  Google Scholar 

  12. Kendall FP, McCreary EK, Provance PJG, Rodgers MM, Romani RA, et al. Muscles testing and function with posture and pain. Fifth Edition. Lippincott Williams & Wilkins. 2005;49–118.

  13. Quek J, Pua Y-H, Clark RA, Bryant AL. Effects of thoracic kyphosis and forward head posture on cervical range of motion in older adults. Man Ther. 2013;18(1):65–71 J. Quek, Department of Physiotherapy, Singapore General Hospital, Singapore 169608, Singapore, Scotland. Available from: http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L52193547.

    PubMed  Google Scholar 

  14. De-la-Llave-Rincón AI, Fernández-de-las-Peñas C, Palacios-Ceña D, Cleland JA. Increased forward head posture and restricted cervical range of motion in patients with carpal tunnel syndrome. J Orthop Sport Phys Ther. 2009;39(9):658–64 Professor, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Therapy Medicine, Universidad Rey Carlos, Alcorcon, Madrid, Spain: American Physical Therapy Association, Orthopaedic Section; Available from: http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=105428756&site=ehost-live.

    Google Scholar 

  15. J-H LEE. Effects of forward head posture on static and dynamic balance control. J Phys Ther Sci. 2016;28:274–7.

    Google Scholar 

  16. Harrison A, Barry-Greb T, Wojtowicz G. Clinical measurement of head and shoulder posture variables. J Orthop Sport Phys Ther. 1996;23(6):353–61.

    CAS  Google Scholar 

  17. Visscher CM, Boer WDE, Lobbezoo F, Habets LLMH. Is there a relationship between head posture and craniomandibular pain? 2002;(1992). Available from: file:///C:/Users/ECA/AppData/Local/Mendeley Ltd./Mendeley Desktop/Downloaded/Visscher et al. - 2002 - Is there a relationship between head posture and craniomandibular pain.pdf.

  18. Hanten WP, Olson SL, Russell JL, Lucio RM, Campbell AH. Total head excursion and resting head posture: normal and patient comparisons. Arch Phys Med Rehabil [Internet]. 2000;81(1):62–6 Available from: http://www.sciencedirect.com/science/article/pii/S0003999300902235.

    CAS  Google Scholar 

  19. Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain. Phys Ther. 2007;87(4):408–17.

    PubMed  Google Scholar 

  20. Lau HMC, Chiu TTW, Lam T-H. Clinical measurement of craniovertebral angle by electronic head posture instrument: a test of reliability and validity. Man Ther. 2009;14(4):363–8. Available from:. https://doi.org/10.1016/j.math.2008.05.004.

    Article  Google Scholar 

  21. Yip CHT, Chiu TTW, Poon ATK. The relationship between head posture and severity and disability of patients with neck pain. Man Ther Scotland. 2008;13(2):148–54.

    Google Scholar 

  22. Silva AG, Sharples P, Johnson MI. Studies comparing surrogate measures for head posture in individuals with and without neck pain. Phys Ther Rev. 2010;15(1):12–22. Faculty of Health, Leeds Metropolitan University, UK, School of Health, University of Aveiro, Portugal. Email: asilva@ua.pt: Taylor & Francis Ltd; Available from:. https://doi.org/10.1179/174328810X12647087218631.

    Article  Google Scholar 

  23. Edmondston Stephen SJ. For which patients with neck pain is posture analysis most relevant? Phys Ther Rev. 2010;15(2):112 School of Physiotherapy, Curtin University of Technology, Perth, WA, Australia; Email: s.edmondston@curtin.edu.au: Taylor & Francis Ltd; Available from: http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=105114590&site=ehost-live.

    Google Scholar 

  24. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and Meta-analyses: the PRISMA statement. Ann Intern Med Pr. 2009;151(4):264–9.

    Google Scholar 

  25. Thomas BH, Ciliska D, Dobbins M, Micucci S. A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews on Evidence‐Based Nursing. 2004;1(3):176–84.

    CAS  PubMed  Google Scholar 

  26. Olivo SA, Bravo J, Magee DJ, Thie NMR, Major PW, Flores-Mir C. The association between head and cervical posture and temporomandibular disorders: a systematic review. J Orofac Pain. 2006;20(November 2016):9–23.

    PubMed  Google Scholar 

  27. Silva A, Punt TD, Sharples P, Vilas-Boas JP, Johnson MI. Head posture and neck pain of chronic nontraumatic origin: a comparison between patients and pain-free persons. Arch Phys Med Rehabil. 2009;90(4):669–74 the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.

    PubMed  Google Scholar 

  28. Oliveira AC, Silva AG. Neck muscle endurance and head posture: a comparison between adolescents with and without neck pain. Man Ther J. 2016;22:62–7.

    Google Scholar 

  29. Dersimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–88.

    CAS  Google Scholar 

  30. Goh JX, Hall JA, Rosenthal R. Mini meta-analysis of your own studies: some arguments on why and a primer on how. Soc Personal Psychol Compass. 2016;10:535–49.

    Google Scholar 

  31. Cheung CH, Shum ST, Tang SF, Yau PC, Chiu TTW. The correlation between craniovertebral angle, backpack weights, and disability due to neck pain in adolescents. J Back Musculoskelet Rehabil. 2010;23(3):129–36.

    CAS  PubMed  Google Scholar 

  32. Lau KT, Cheung KY, Chan Kwok B, Chan MH, Lo KY, Wing Chiu TT. Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Man Ther. 2010;15(5):457–62. Elsevier Ltd; Available from:. https://doi.org/10.1016/j.math.2010.03.009.

    Article  PubMed  Google Scholar 

  33. Helgadottir H, Kristjansson E, Mottram S, Karduna A, Jonsson HJ. Altered alignment of the shoulder girdle and cervical spine in patients with insidious onset neck pain and whiplash-associated disorder. J Appl Biomech. 2011;27(3):181–91.

    PubMed  Google Scholar 

  34. Nagai T, Abt JP, Sell TC, Clark NC, Smalley BW, Wirt MD, et al. Neck proprioception, strength, flexibility, and posture in pilots with and without neck pain history. Aviat Space Environ Med. 2014;85(5):529–35.

    PubMed  Google Scholar 

  35. 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 J Phys Ther. 2014;18(4):364–71.

    Google Scholar 

  36. Nejati P, Lotfian S, Moezy A, Nejati M. The study of correlation between forward head posture and neck pain in iranian office workers. Int J Occup Med Environ Health. 2015;28(2):295–303.

    PubMed  Google Scholar 

  37. Dunleavy K, Neil J, Tallon A, Adamo DE. Reliability and validity of cervical position measurements in individuals with and without chronic neck pain. J Man Manip Ther. 2015 Sep;23(4):188–96.

    PubMed  PubMed Central  Google Scholar 

  38. Mani S, Sharma S, Omar B, Ahmad K, Muniandy Y, Singh DKA. Quantitative measurements of forward head posture in a clinical settings: a technical feasibility study. Eur J Physiother. 2017;19(3):119–23 Faculty of Health Sciences, School of Rehabilitation Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia; Taylor & Francis Ltd; Available from: http://proxy.cc.uic.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=124127869.

    Google Scholar 

  39. Lau HMC, Chiu TTW, Lam T-H. Measurement of craniovertebral angle with electronic head posture instrument: criterion validity. J Rehabil Res Dev. 2010;47(9):911–8.

    PubMed  Google Scholar 

  40. Dolphens M, Cagnie B, Coorevits P, Vanderstraeten G, Cardon G, D’hooge R, et al. Sagittal standing posture and its association with spinal pain: a school-based epidemiological study of 1196 Flemish adolescents before age at peak height velocity. Spine (Phila Pa 1976). 2012;37(19):1657–66.

    Google Scholar 

  41. Kim E-K, Kim JS. Correlation between rounded shoulder posture, neck disability indices, and degree of forward head posture. J Phys Ther Sci Japan. 2016;28(10):2929–32.

    Google Scholar 

  42. Subbarayalu A V, Ameer MA. Relationships among head posture, pain intensity, disability and deep cervical flexor muscle performance in subjects with postural neck pain. J Taibah Univ Med Sci [Internet]. A.V. Subbarayalu, Studies & Research Unit, Deanship of Quality and Academic Accreditation, Imam Abdulrahman Bin Faisal University, Saudi Arabia: Elsevier Ltd; 2017;12(6):541–7. Available from: https://doi.org/10.1016/j.jtumed.2017.07.001.

    PubMed  PubMed Central  Google Scholar 

  43. Richards KV, Beales DJ, Smith AJ, Sullivan PBO, Straker LM. Neck posture clusters and their association with biopsychosocial factors and neck pain in Australian adolescents. Phys Ther. 2016;96(10):1576–88.

    PubMed  Google Scholar 

  44. •• Andias R, Silva AG. A systematic review with meta-analysis on functional changes associated with neck pain in adolescents. Musculoskeletal Care. 2019;17:23–36 To our knowledge, this is the first systematic review which demonstrated the functional difference between neck pain and asymptomatic adolescents.

    PubMed  Google Scholar 

  45. Hsiao L, Cho C. The effect of aging on muscle activation and postural control pattern for young and older computer users. Appl Ergon. 2012;43(5):926–32. Available from:. https://doi.org/10.1016/j.apergo.2011.12.014.

    Article  PubMed  Google Scholar 

  46. Hansraj KK. Assessment of stresses in the cervical spine caused by posture and position of the head (Abstract, materials and methods). Surg Technol Int. 2014;25:277–9.

    PubMed  Google Scholar 

  47. Fares J, Fares MY, Fares Y. Musculoskeletal neck pain in children and adolescents: risk factors and complications. Surg Neurol Int. 2017;8:72.

    PubMed  PubMed Central  Google Scholar 

  48. Mikkelsson LO, Nupponen H, Kaprio J, Kautiainen H, Mikkelsson M. Adolescent flexibility, endurance strength, and physical activity as predictors of adult tension neck, low back pain, and knee injury: a 25 year follow up study. Br J Sport Med. 2006;40:107–13.

    CAS  Google Scholar 

  49. • Moreira G, Arthur D, Ferreira S, Alberto L, Nogueira C, José F, et al. Text neck and neck pain in 18–21-year-old young adults. Eur Spine J. 2018;27(6):1249–54. https://doi.org/10.1007/s00586-017-5444-5It shows that the short-term effect of texting is not noticible.

    Article  Google Scholar 

  50. Lee H, Nicholson LL, Adams RD. Neck muscle endurance, self-report, and range of motion data from subjectswith treated and untreated neck pain. J Manip Physiol Ther. 2005;28(1):25–32.

    Google Scholar 

  51. Shahidi B, Johnson CL, Curran-everett D, Maluf KS. Reliability and group differences in quantitative cervicothoracic measures among individuals with and without chronic neck pain. BMC Musculoskelet Disord. 2012;13:215.

    PubMed  PubMed Central  Google Scholar 

  52. Dvorak J, Antinnes JA, Panjabi M, Loustalot D, Bonomo M. Age and gender related normal motion of the cervical spine. Spine (Phila Pa 1976). 1992;17(105):5393–8.

    Google Scholar 

  53. • Stenneberg MS, Rood M, de Bie R, Schmitt MA, Cattrysse E, Scholten-Peeters GG. To which degree differs active cervical range of motion between patients with neck pain, whiplash and healthy controls? A systematic review and metaanalysis. Arch Phys Med Rehabil. 2017;98(7):1407–34. https://doi.org/10.1016/j.apmr.2016.10.003This demonstrates the cervical range of motion decreased in patients with neck pain compared to asymptomatic.

    Article  PubMed  Google Scholar 

  54. Kaur P, Pattnaik M, Mohanty PP. Relationship of cervicothoracic curvature with muscle strength and endurance in subjects with neck pain. Indian J Physiother Occup Ther. 2013;7(3):156–61 Assistant Professor, Amar Jyoti Institute of Physiotherapy, Delhi: Dr. R.K. Sharma; Available from: http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=103805092&site=ehost-live.

    Google Scholar 

  55. Cooke MS, Hons B, Orth D, Eng DRCS, Edin FDSRCS. Five-year reproducibility of natural head posture: a longitudinal study. Am J Orthoo Dentofac Orthop. 1990;97:489–94.

    CAS  Google Scholar 

  56. Raine S, Twomey LT. Head and shoulder posture variations women and men. 1997;78(November). Available from: file:///C:/Users/ECA/AppData/Local/Mendeley Ltd./Mendeley Desktop/Downloaded/Raine, Twomey - 1997 - Head and Shoulder Posture Variations Women and Men(2).pdf.

  57. Sun A, Yeo HG, Kim TU, Hyun JK, Kim JY. Radiologic assessment of forward head posture and its relation to myofascial pain syndrome. Ann Rehabil Med. 2014;38(6):821–6.

    PubMed  PubMed Central  Google Scholar 

  58. Brink Y, Louw Q, Grimmer K, Jordaan E. The relationship between sitting posture and seated-related upper quadrant musculoskeletal pain in computing South African adolescents: a prospective study. Man Ther. Scotland. 2015;20(6):820–6.

    Google Scholar 

  59. Salahzadeha Z, Maroufi N, Ahmadi A, Behtashb H, Razmjoo A, Gohari M, et al. Assessment of forward head posture in females: observational and photogrammetry methods. J Back Musculoskelet Rehabil. 2014;27:131–9.

    Google Scholar 

  60. • Daffin L, Stuelcken M, Sayers M. Internal and external sagittal craniovertebral alignment: a comparison between radiological and photogrammetric approaches in asymptomatic participants. Musculoskelet Sci Pract. 2019;43:12–7. https://doi.org/10.1016/j.msksp.2019.05.003This study showed that CVA does not provide an indication of the exact shape of the cervical spine.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Nesreen Fawzy Mahmoud.

Ethics declarations

Conflict of Interest

Nesreen Fawzy, Karima A. Hassan, Salwa F. Abdelmajeed, Ibraheem M Moustafa, and Anabela G. Silva declare that they have no conflict of interest. However, one of them (AGS) is the author of four of the articles referenced here, two of which were included in this systematic review. To avoid conflict of interest, she was blind in the searching and filtering process and she did not contribute to the quality assessment of those two articles.

Human and Animal Rights

All reported studies with human subjects performed by one of the authors (AGS) have been previously published and complied with all applicable ethical standards.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendix 1

Appendix 1

Table 4 Search strategy and number of founded papers in each database

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mahmoud, N.F., Hassan, K.A., Abdelmajeed, S.F. et al. The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis. Curr Rev Musculoskelet Med 12, 562–577 (2019). https://doi.org/10.1007/s12178-019-09594-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-019-09594-y

Keywords

Navigation