Pathophysiology Section

Neck pain is the 4th leading cause of disability in the US (Cohen, 2015) and can cause individuals to have difficulty with driving, working and participating in social endeavors (Hoy et al., 2010).  The prevalence of neck pain has been reported to be between 15-50% each year, and peaks with middle-aged adults.  Females have a higher precedence of neck pain than males.  There is a positive relationship between obesity and neck pain, possibly because of increased mechanical stress and weaker muscles (Cohen, 2015).  Additionally, there are many factors that can contribute to cervical pain such as occupation, poor work environment, sedentary lifestyle and psychosocial factors (Hoy et al., 2010).  Specifically, office and computer workers have a 57% incidence of neck disorders in the US (Côté, 2004).  Risk factors for neck pain in an office include increased hours spent on the computer, prolonged static postures and poor ergonomic work environment (Ehsani, Mosallanezhad, and Vahedi, 2017).  Due to the functional limitations that the neck pain can cause, it is important to identify and target the individual contributing factors in order to treat the patient.

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The source of neck pain can be neurogenic, involving a peripheral nerve, mechanical, or secondary to another cause (Cohen, 2015).  Differentiating the type of neck pain will guide the clinician’s treatment, prognosis of the patient and overall plan of care.  Cervical postural dysfunction is a type of mechanical impairment.  Pain occurs due to the innervation of nociceptive sensitive structures of the cervical spine, such as ligaments, muscles and walls of blood vessels.  Loaded positions combined with postural malalignment, including forward head posture (FHP), stretches these sensitive structures which can lead to compression of the nerve ending and causes the person to feel pain.  The pain is diminished when the mechanical stress is removed, such as when a person changes position.   Increased and continuous stress to the system can cause a breakdown of tissues and may lead to an inflammatory response in the body, even though no apparent trauma or injury occurred.  Therefore, it is important to address postural dysfunction before it progresses and causes more damage to the body and person.

A specific type of cervical postural syndrome is upper crossed syndrome (UCS), which was introduced by Dr. Vladmir Janda.  This syndrome occurs when deep neck flexors and lower scapular stabilizers are lengthened and weakened, and the opposite anterior chest muscles and posterior neck muscles are shortened and become tight (Joshi and Srivastava, 2016).  This syndrome follows a cycle of poor posture and repetitive movements causing muscle tightness and weakness which leads to scapular winging, elevation and protraction of the shoulder and FHP (Dutton, 2016, p.326).  FHP is defined as increased extension of the atlanto-occipital and atlanto-axial joints and increased flexion of the lower cervical spine (Kim et al., 2018).   One measurement of FHP is the craniovertebral angle (CV angle), which is the angle of the intersection of a horizontal line from the spinous process of C7 and a vertical line from the tragus of the ear.  The CV angle of a person with good postural alignment is between 55-65° and the CV angle of a person with FHP < 55° (Dalawale and Pimpale, 2018).  The smaller the angle, the greater the severity of the FHP.  There are several dysfunctions associated with FHP and UCS including tension headaches, decreased respiratory function due to increased thoracic flexion narrowing the area of the lungs (Joshi and Srivastava, 2016), and shoulder-neck pain (Shih et al., 2017).  Improving posture can decrease these associated impairments and prevent future occurrences (Shih et al., 2017).

 Tension headaches are defined as recurrent headaches that can last from minutes up to one week (Chowdhury, 2012).  Typical symptoms include bilateral aching or tightening pain around the head and symptoms are not made worse by physical activity (Palmer, 2017).  There is no definite understanding of the etiology or pathophysiology of tension headaches, but there are several proposed theories.  One theory is that excessive muscle tightness and ischemia in the head and neck muscles contribute to increased nociceptive stimulation.  Prolonged stimulation can cause hypersensitivity and sensitization of neurons in the central nervous system which will increase the frequency of the tension headaches.  Potential causes of tension headaches include poor posture, stress, and bad eating habits (Chowdhury, 2012) thus people who work stressful office jobs may be at higher risk (Palmer, 2017). Pharmacotherapy combined with physical therapy and behavioral therapies can be an effective treatment and prevention program for tension headaches.  Physical therapy interventions include relaxation techniques, craniocervical training and postural improvement (Chowdhury, 2012). 

 Shoulder pain is often associated with neck pain due to the anatomical relationship and musculature attachment between these two joints.  One common form of shoulder dysfunction is subacromial impingement (Lewis, 2005).  Shoulder impingement can be caused by extrinsic factors, such as bony anomalies and posterior capsule tightness or intrinsic factors including rotator cuff weakness and fatigue (Pheasant, 2016).  Other potential contributors to shoulder impingement are postural imbalances, repetitive overhead movements and muscle imbalances (Dutton, 2016, p.680-681).  FHP can specifically contribute to shoulder impingement due to increased tension on the scapulothoracic muscle which alters scapular and glenohumeral mechanics and ultimately leads to narrowing of the subacromial space (Alizadehkhaiyat et al., 2017).  Shoulder impingement pain occurs during active shoulder abduction between 60-120° because that is when the head of the humerus contacts the coracoacromial arch and impinges on the rotator cuff tendons and other structures there due to faulty biomechanics (Pheasant, 2016).  In an individual with a healthy shoulder, the rotator cuff and deltoid muscles stabilize the head of the humerus during abduction and prevent this impingement from occurring.

 Pharmacological treatment of acute neck pain includes non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants (Cohen and Hooten, 2017).  However, there is little evidence that these medications, along with manual therapy, decrease pain and offer functional improvements when compared to other conservative treatments such as postural education and exercise (D’Sylva et al., 2010).  Other forms of conservative treatment include trigger point injections for muscle tightness (Cohen, 2015) and pulsed electromagnetic therapy to reduce pain (Aker et al., 1996).  Some treatments that are used for back pain are being considered for chronic neck pain, such as stem cell therapy, but more research and trials need to be done to see the efficacy of these interventions.

Citation:

Article 1: Shih, H., Chen, S., Cheng, S., Chang, H., Wu, P., Yang, J., . . . Tsou, J. (2017). Effects of kinesio taping and exercise on forward head posture. Journal of Back and Musculoskeletal Rehabilitation, 30(4), 725-733. doi:10.3233/BMR-150346

Article 2: Kim, J., Kim, S., Shim, J., Kim, H., Moon, S., Lee, N., . . . Choi, E. (2018). Effects of McKenzie exercise, kinesio taping, and myofascial release on the forward head posture. Journal of Physical Therapy Science, 30(8), 1103-1107. doi:10.1589/jpts.30.1103

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Search Terms

Forward head posture OR upper crossed syndrome AND interventions

Summary of Study

Study Design:

Article 1: Prospective randomized controlled study

Article 2: Randomized control study

Population or sample:

Article 1: The target population of this study was participants in the community above 20 years old who had FHP and NDI > 5.  A convenience sample of 60 participants from the Taiwan community and Fooyin University was recruited and assigned into three groups: a control group, an exercise group (EG), and a taping group (TG).  Exclusion criteria included:

1. Age below 20 years old

2. NDI < 5

3. Horizontal distance between the ear lobe and the acromion process < 3.5 cm,

4. History of acute neck injury or cervical surgery

5. Diagnosis of cervical radiculopathy or myelopathy

6. Any allergies to the kinesiotape

Article 2: The target population of this study were undergraduate students at Kangwon National University with FHP.  A convenience sample of 28 students participated in this study.  Inclusion criteria for this study was that the center of the ears > 2.5 cm anterior to the center of the shoulders (A-T length), NDI < 14, no cervical fractures, surgery in the last 3 months, vascular diseases and psychiatric problems that would prevent understanding of the surverys. Exclusion criteria was:

1. Bone fractures

2. Neuromyopathy

3. Inflammatory disease

4. History of disc surgery

Procedure

 Article 1:  All groups participated in a 10-minute posture education program which provided information on what is good posture and how to maintain it in sitting and standing.  These participants also practiced a proper posture by performing scapular retraction and adduction and chin while maintaining a natural lumbar lordosis in sitting or standing. 

The EG participated in a low-load endurance training program in addition to the postural education.  The exercises consisted of resisted isometric chin-in in sitting, isometric chin-in in sitting and upper trunk extension with chin-in in prone.  Each exercise was held for 10 seconds and repeated 10-20 times.  The exercise program was performed for 30 minutes, 2x a week, for 5 weeks.

The TG had 3 pieces of tape applied to their skin. One Y strip of tape was placed on elongated position of the semispinalis capitis to facilitate muscle contraction (15-25% tension).  Another Y strip was placed on the trapezius muscles to release the tight upper trapezius (10% tension) and facilitate the contraction of the middle trapezius in an elongated position (15-25% tension).  A third I strip was placed on the middle of the neck horizontally to induce a guiding force for correcting FHP mechanically (50-75% tension) by placing the neck in a lordosis and a chin-in position.  The participants were educated on how to use the tape.  The tape was placed on the patients 2x/week for 5 weeks and each application lasted between 2-3 days.  

Article 2: In this study, participants were divided into three groups: Group A received McKenzie exercises and myofascial release (MFR), Group B received McKenzie exercises and Kinesio taping, and Group C received McKenzie exercises, MFR and Kinesio taping.  The interventions were administered 3x/week for 4 weeks.

 The McKenzie exercise program consisted of 7 exercises: retraction of neck in sitting, extension of neck in sitting, sidebending of head, rotation of head, flexion of neck in sitting, chin tuck of neck in supine and extension of neck in supine.  Each exercise was maintained for 7 seconds with 15 repetitions. 

 The MFR group received myofascial release with a lacrosse ball on the upper trapezius, neck extensors and levator scapula in the prone position and pectoralis major and minor in the supine position.  3 sets of 15 repetitions were done on each muscle.  The MFR was performed on both sides of the muscle.

 The Kinesio taping group received two diagonal I tapes around the C7-T1 junction.  The tape was applied in a neutral position while the participant was gazing forward.  The participants were instructed to leave the tape on for 8 hours after each intervention. 

Outcome Measures:

Article 1:

Static posture – horizontal forward displacement (HFD), upper and lower cervical angle (UCA and LCA)

Dynamic mobility – AROM of the cervical spine

Neck function – NDI

These measures were taken at baseline, after the 5-week intervention and at a 2-week follow up after the intervention was completed.

Article 2:

Distance between the acromion and tragus of the ear (A-T length)

Craniovertebral angle (CVA)

Cranial rotation angle (CRA)

Neck disability index (NDI)

A pre-test measurement was done 3-5 days prior to the intervention and a post test measurement was done on the day of study completion, 2 weeks after the intervention was completed. 

Results

Article 1: The EG and TG showed a significant decrease in horizontal forward displacement, and lower cervical angle when compared to the control group at post-treatment.  However, at the follow-up measure, HFD improvements were lower and there was no difference in the LCA.  Additionally, the EG had greater improvement in AROM of side-bending and rotation at the post-treatment measure, but again no significant difference compared to the other groups at the follow-up measurement. 

Article 2: All three groups showed a significant change in the A-T length, Group C showed a significant change in CVA, but no group showed a significant change in CRA after 6 weeks.

Comments And Relationship to Clinical Scenario

Article 1: Overall this study had a thorough procedure and well-defined interventions for correcting FHP.  The researchers demonstrated that Kinesio taping and exercising have a significant effect on reducing FHP when compared to postural education alone.  However, performing cervical retraction exercises had a greater effect on dynamic mobility of the neck compared to the Kinesio taping group.  A strength of the study was that it did a follow up measure 2 weeks after the intervention to see if the results were maintained after the intervention was completed.  Unfortunately, the improvements were reduced.  This may indicate that correcting FHP cannot be done in just 1 month, but rather needs an ongoing program.  Additionally, it is possible that the interventions in the study were not intense and long enough to invoke a last response.  Another limitation of this study was that these interventions did not have a significant effect on functional activity, measured by the neck disability index.  The authors proposed that since the mean NDI score was a 7 before the interventions, indicating a mild disability, it was difficult to discriminate any change in symptoms.  A future study of these interventions for people with moderate neck disability might yield more meaningful data regarding the clinical scenario.  Additionally, the activity level of the participants was not recorded, and this may have been a confounding factor in the study. 

 Overall, it seems that both Kinesio taping and therapeutic exercises are potential treatments for correcting static FHP and can be applied to a patient with cervical postural dysfunction.  However, a more intense and longer duration program should be given to the patient so that she can experience more lasting results.  The participants in this study were relatively young and match the age of the patient in the clinical scenario.

Article 2:  The purpose of the article compared the combined efficacy of McKenzie exercises, MFR and Kinesio taping.  The results showed that the combination of these three treatments were more effective than the individual intervention, but all interventions had positive findings.  However, the outcome measures of the study were all focused on FHP measurement changes and did not discuss functional outcome measures.  Even though NDI was an outcome measure, the pre-test/post-test difference was not reported. 

One strength of this study was well defined interventions; however, the intensity and duration of the interventions was small.  Additionally, the small sample size makes it difficult to generalize the findings.  Since all participants in the study had a NDI < 14, the patient from the case study would not have been included in the study and therefore it is difficult to generalize the results to the clinical scenario.

Clinical Bottom Line II:  Cervical stabilization and strengthening exercises appear to be the most effective intervention for reducing FHP and possibly providing pain relief to patients.  Kinesio taping and MFR can also have a positive effect on reducing FHP, therapeutic exercises deliver the longest lasting results.  The interventions in both studies were only moderate intensity (2-3x/week) and had a short duration of 4-5 weeks.  Perhaps this affected the effects of the interventions.  Therefore, in the case study, the intensity of the therapeutic exercises was increased to 5x/week for at least 6 weeks (until the re-evaluation). 

References

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Alizadehkhaiyat, O., Roebuck, M. M., Makki, A. T., & Frostick, S. P. (2017). Postural alterations in patients with subacromial impingement syndrome. International Journal of Sports Physical Therapy, 12(7), 1111-1120.

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Shih, H., Chen, S., Cheng, S., Chang, H., Wu, P., Yang, J., . . . Tsou, J. (2017). Effects of kinesio taping and exercise on forward head posture. Journal of Back and Musculoskeletal Rehabilitation, 30(4), 725-733. doi:10.3233/BMR-150346

TAE-WOON, K. I. M., DA-IN, A. N., HYE-YUN, L. E. E., HO-YOUNG JEONG, DONG-HYUN, K. I. M., & YUN-HEE SUNG. (2016). Effects of elastic band exercise on subjects with rounded shoulder posture and forward head posture. Journal of Physical Therapy Science, 28(6), 1733-1737.