FHP and Neck Pain in Adolescents: Clinical Pearls
BY DONALD DEFABIO, DC, DACBSP, DABCO
Forward head posture (FHP) is the most common postural distortion in the sagittal plane, and is found in both adolescents and adults. Moreover, neck pain can be as high as 86.8 percent in the general population and up to 17.2 percent in adolescents.
FHP is determined by measuring the cranial vertebral angle (CVA). The CVA is the angle formed by the line from the tragus to the tip of the C7 spinous and the line from the tip of C7 spinous to the horizontal. Analysis is easily performed with photographic assessment; the higher the angle, the less FHP is present. Normal measurement is 49.9 degrees.
The mechanical load placed on the cervicothoracic musculature increases significantly with FHP and can lead to alterations in ROM and the cervical lordosis, with a potential to favor degenerative joint changes and intervertebral disc disease. However, the cervical lordosis can be maintained, increased or decreased in FHP. The test of choice to determine the integrity of the cervical lordosis is a lateral radiograph.
Clinical Tip: Cervical hypolordosis requires restoring segmental extension of the cervical spine via CMT, as well as passive extension. Traditional cervical pillows and cervical traction in extension are indicated, but if a normal or increased lordosis is present, flexion-biased exercises are a better choice.
The importance for the adolescent population is the cumulative microtrauma created by FHP on the contractile and non-contractile elements of the cervical spine. FHP creates irregular rotation and gliding movement inside the articular capsule, which results in a decreased number of sarcomeres and muscle fiber shortening. The result is reduced muscular contraction and abnormal movement patterns –patterns that will persist until corrected.
Typically, FHP presents with tightness in the posterior neck muscles, (upper trapezius, suboccipital and levator scapulae) and weakness in the anterior cervical muscles (deep cervical flexors). Therefore, addressing the deep cervical flexors is a common rehabilitative approach. (Readers will recall a previous article ("Chronic Neck Pain Treatment: More Than Just Exercises," that noted the importance of strengthening of the cervical extensors is equally effective.) FHP also creates asymmetrical muscle activation in the trunk and can be demonstrated as a lateral inclination of the pelvis.
Clinical Tip: Activation of an isolated muscle group in the treatment of FHP is not as effective as strengthening all of the weakened muscles and lengthening all of the tight muscles, as proposed by Janda.
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