Correction of Forward Head Posture & Scapular Position Do Not Affect Neck and Shoulder Pain

Physical therapists commonly evaluate sitting and standing posture as part of the management strategy for neck and shoulder pain.1,2 Upper quarter posture is considered ‘normal’ when the scapulae are partially retracted and the ears are vertically in-line with the shoulders;3 however, patients with neck and shoulder pain often demonstrate a “forward head” posture,4,5 which may be a precipitating and maintaining factor in pain syndromes.

Forward head posture creates an imbalance between the posterior neck extensors and the anterior neck flexors and shoulder muscles,6,7 increases the load on posterior cervical structures (i.e. bones, ligaments, muscles, facet joint capsules),8 and changes the osteokinematics of the scapulothoracic articulation.6,9 Traditional treatment strategies have attempted to reverse “poor” posture via “scapular stabilization” and neuromuscular re-education. Classic “motor control” exercises attempt to quiet the activity of the upper and middle trapezius muscle while facilitating the serratus anterior muscle so as to reverse forward head posture and perhaps reduce neck9-12 and shoulder pain.12,13

Notably, the most common treatment for neck pain among physical therapists in Sweden (82% to 94%) was reported to be “improving posture”;14 furthermore,  greater than 75% of physical therapists in India believe that “abnormal motion and improper posture” are significant contributing factors to subacromial impingemnt.15 Nevertheless, a causal relationship between “poor posture” and neck and shoulder pain has not yet been clearly established.16-19  Moreover, for the reduction of pain and disability in the short and long-term, “posture correction” has not yet been shown to be an effective treatment strategy for neck and/or shoulder pain.19-22

NECK PAIN & FORWARD HEAD POSTURE

After studying the relationship between “forward head posture” and “rounded shoulders” in subjects with and without neck pain, a significant correlation between neck pain and “poor work posture” was found; however, the presence or absence of a neutral, forward-looking posture was not related to the incidence of neck pain.23,24 Moreover, the authors concluded that forward shoulder posture was not related to neck pain.23,24 In addition, after review of 109 studies on neck pain in the work place, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders concluded that, “interventions aimed at modifying workstations and worker posture are not effective in reducing incidence of neck pain in workers.”20

While forward head or “turtle neck”25 posture appears increasingly more common due to increased use of smart phones, tablets, and laptop computers, no significant correlations have been found between decreased craniovertebral angle and neck pain.11 In a 2013 study, thirty dentists with chronic neck pain and forward head posture were randomly assigned to receive either deep neck flexor strengthening exercises along with posture correction or conventional isometric strengthening exercises.26 While forward head posture improved more in the deep neck flexor exercise and postural correction group, both groups experienced similar within-group reductions in pain and disability.26

In a 2017 study where 130 adolescents with forward head posture and protracted shoulders were randomly assigned to receive 16-weeks of either physical education combined with postural corrective exercises or physical education alone,27 the group that received postural corrective exercises demonstrated “better posture”; however, there was no significant difference in neck pain between the two groups27—which is the bottom line in truth.  Likewise, in a 2018 study where 90 asymptomatic college students were compared with 50 college students with subclinical neck pain,28 pressure pain thresholds were found to be lower in the students with subclinical neck pain, however, there was no difference in forward head posture between the two groups. As such, the authors conceded,  “these findings are in contrast with the current assumptions on the association between neck pain and forward head posture.”28

SHOULDER PAIN & SCAPULAR STABILIZATION 

Forward head posture theoretically leads to static positional changes and dynamic motion control changes to the neck and shoulder girdle—i.e. changes in motor timing/feed-forward activation delay, thoracic kyphosis, protracted, elevated, anterior tilted, and downwardly rotated scapulae—that may give way to decreased subacromial space, increased through range irritation, increased inflammation and resultant shoulder impingement and pain.29-31

In a 2017 study that compared 51 patients with subacromial impingement to 50 asymptomatic individuals, Land et al. found that patients with impingement had significantly greater increases in thoracic flexion and forward head posture, and this seemed to correspond with decreased upper thoracic motion, passive internal rotation and posterior shoulder range.32 In contrast, Bullock et al. found no difference in levels of shoulder pain in individuals with a slouched sitting posture compared to individuals with an erect body posture.33 Importantly, and in another 2017 study, no relationship was found between the presence of thoracic kyphosis and the incidence of subacromial impingent31, a finding that is consistent with previous studies.16

A more erect posture may facilitate greater ROM but it appears to have no effect on shoulder pain.16 Moreover, in a 2014 review of 10 randomized controlled trials, it was concluded that there is no difference between scapular positioning in patients with subacromial impingement compared with asymptomatic individuals.18  Furthermore, the findings raise “the possibility that deviation from a ‘normal’ scapular position may not be contributory to subacromial impingement syndrome, but part of normal variations.”18 Notably, neither asymptomatic subjects nor patients with subacromial impingement identified as having a forward head posture “follow a set pattern referred to extensively in medical, physiotherapy, and osteopathy textbooks and articles.”19 That is, “postural assessment has a very limited role in the clinical decision-making process in subjects with subacromial impingement.”19

Although a relationship between poor posture and subacromial impingement has yet to be established,31,34 the assessment of static and dynamic posture continues to be common place in entry-level DPT programs and in clinical practice.35,36 Moreover, an effort to “correct posture” in patients with shoulder impingement using muscle strengthening, stretching and mobilization techniques remains a common strategy in physical therapy practice.37,38,39

Although active postural correction and taping may improve shoulder elevation in the scapular plane in both asymptomatic individuals and in patients with subacromial impingement, these improvements in shoulder movement do not amount to significant reductions in actual shoulder pain.30 Furthermore, “scapular stabilization” exercises may improve static posture and shoulder mobility, but they do not improve pain.21 Notably, in a recent meta-analysis of 6 randomized controlled trials, although scapular focused interventions were found to improve shoulder pain and function in patients with impingement, these changes did not persist beyond four weeks.22 Moreover, there was no change in forward shoulder posture following the intervention.22

CONCLUSIONS

While posture may be a contributing factor in neck pain and/or shoulder impingement syndrome, neither “posture correction” exercises nor “scapular stabilization” exercises have been found to reduce neck or shoulder pain in the long-term. Therefore, postural assessment by physical therapists has a limited role in the clinical decision-making process of patients with neck or shoulder pain.

AUTHORS

Courtney Proen, DPT, Dip. Osteopractic, Cert. SMT, Cert. DN
Fellow-in-training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Senior Physical Therapist, First Choice Physical Therapy, Fresno, CA

Raymond Butts, DPT, PhD, MSc (NeuroSci), Dip. Osteopractic
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy

James Dunning, DPT, MSc (Manip Ther), Dip. Osteopractic, FAAOMPT
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy

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