The prevalence of forward head posture (FHP) with rounded shoulders is epidemic today due to smartphones, laptops and our sedentary lifestyles. Also described as Janda's upper-crossed postural distortion and "tech neck," it has been related to neck pain, headaches, dizziness, carpal tunnel syndrome and loss of function. The exciting news is that FHP can be effectively treated with chiropractic physical rehabilitation, especially if we turn to the research to improve our results.
Stabilizing exercises for FHP are effective, especially in the adolescent population. From a chiropractic perspective, this is obvious since the adolescent spine has not reached maturity, and plastic deformation of the muscles and ligaments has not occurred. Furthermore, teaching adolescents to "auto-correct" their postural imbalances also fosters a lifetime habit.
Clinical Tip #1: Be sure to educate your adolescent patients in proper spinal hygiene and corrective exercises for FHP. The results are long-standing.
FHP presents with a pattern of muscular and functional imbalances; commonly weakness in the middle trapezius (MT), lower trapezius (LT), serratus anterior (SA) and deep cervical flexors (DCF). Shortening and tightness are found in the pectoralis group (both major and minor) upper trapezius (UT), levator scapulae (LS) and suboccipital (SOC)muscles. Since altered scapulohumeral rhythm and decreased upward rotation of the scapula with humeral elevation is the abnormal movement pattern seen in FHP, the exercises for correction are targeted to restoring scapulohumeral biomechanics.
Clinical Tip #2: To confirm shortening of the pectoralis minor, lay the patient supine and measure the distance from the posterior acromion to the table. Normal is 1 cm.
The best strengthening exercises to treat FHP will provide maximum activation of the MT, LT, SA, and DCF while minimizing activation of the UT, LS and SOC muscle groups. EMG studies document prone external rotation of the arm at 90 degrees elbow and shoulder flexion offer an excellent ratio of MT:UT and LT:UT activation to achieve these goals. Additional exercises include supine wall angels and isolated scapular retraction with depression. When performed properly, scapular retraction and depression reduces UT and LS dominance.
Clinical Tip #3: Be sure the patient is able to properly engage their MT and LT without engaging the UT and LS.
Chin tucks are great for activation of the DCF. Therefore, when possible incorporate chin tucks into other exercises to maximize the patient's time and results. Lee compared isometric cervical flexion and extension and found greater activation of the DCF, as well as favorable UT:LT and pectoralis major:LT activation ratios, in the isometric cervical extension group.
Clinical Tip #4: Isometric cervical extension exercises outperform isometric flexion for treating the muscular imbalances in FHP.
COMMON MUSCULAR IMBALANCES IN FHP
Shortened & Tight
Weakened & Lengthened
Upper trapezius
Middle and lower trapezius
Pectoralis major and minor
Serratus anterior
Sub-occipital group
Deep cervical flexors
Levator scapulae
Rhomboids
The SA is best strengthened with exercises that involve flexion of the arm above 120 degrees in scaption with external rotation. Commonly called the "Y" position of the arms, it can be done prone or standing, with or without external resistance. The push-up plus exercise also activates the SA greater than the UT. A recent study has shown even greater activation of the scapular stabilizer muscles occurs when combined with abdominal breathing.
Clinical Tip #5: Add abdominal breathing to scapular stabilization exercises to increase their benefit.
Equally important to strengthening the scapular stabilizers is myofascial release for the shortened soft tissues. Pin and stretch, post-isometric relaxation, massage stick; in fact, your soft-tissue technique of choice is needed for the pectoralis, UT, LS and SOC muscles. Post-isometric relaxation is a very effective technique in lengthening these contracted tissues. For home, passive stretches and use of a foam roller and a myofascial release ball are also beneficial, so prescribe them.
Several studies have also shown the significance restoring spinal mechanics in treating FHP, and that is where chiropractic outpaces other disciplines in treatment. Of course, the challenge is to adjust the hypomobile segments, leaving the areas of normal mechanics alone. Cho compared FHP patients with neck pain who received neck treatment alone to thoracic spine treatment alone. Interestingly, the thoracic spine-only group fared better results, which underscores the significance of CMT in treating this population. Once mobility is restored with chiropractic adjustments, then the exercises are truly corrective because it re-establishes a new muscle memory with restored spinal mechanics.
Clinical Tip #6: Check and adjust the thoracic spine in your FHP patients and be sure it is moving properly in all planes of motion – perhaps even before you adjust their neck.
The length of time to effect correction in FHP with exercise and CMT is variable. The research studies range in general from six to 13 weeks. Most treatment schedules were 2-3 X/week and incorporated home exercise prescriptions.
Clinical Tip #7: Treating FHP takes time. Be sure to prescribe the treatment the patient needs to provide long-term correction.
As doctors of chiropractic, we are in a position to treat the pain, dysfunction and provide the wellness tools to our patients for long-term correction. In fact, treating the postural asymmetries of FHP is a treatment paradigm that goes beyond the pain management model of health care and fits into any practice style. Start with these aforementioned exercises; it will add another dimension to your practice.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
Some pundits say that the upcoming presidential and congressional races, and many local races, might be the most consequential in our country’s history. We do not have the choice of sitting on the sidelines and hoping our patients will carry our water. Unlike other medical professions such as physical therapists, podiatrists, nurses, etc., the health care class (AMA) will not protect us. We must be in the game.
The most common condition affecting the shoulder is rotator-cuff disease. From acute tears to chronic tendinopathy, it’s common and needs a thorough workup. In fact, even asymptomatic shoulders can have full-thickness rotator-cuff rears in up to 40% of instances. Let’s look at additional conditions that can present to the office with weakness, loss of motion and pain in the shoulder beyond rotator-cuff tears.
