Facebook Pixel
Brookbush Institute Logo

Tuesday, June 6, 2023

Correcting Forward Head Posture affects Lumbosacral Radiculopathy

Brent Brookbush

Brent Brookbush


Research Review: Correcting Forward Head Posture affects Lumbosacral Radiculopathy

By Jinny McGivern, PT, DPT, Certified Yoga Instructor

Edited by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Moustafa, I. M., & Diab, A. A. (2015). The Effect of Adding Forward Head Posture Corrective Exercises in the Management of Lumbosacral Radiculopathy: A Randomized Controlled Study. Journal of manipulative and physiological therapeutics, 38(3), 167-178. ABSTRACT

How interdependent are the segments of the spine? - http://www.familychiropractic.com.sg/wp-content/uploads/spinal-cord.jpg

Why is this relevant?: Low back pain is one of the most common, if not the most common orthopedic issues diagnosed and treated in the united states. Various physiological, environmental, psychological and social factors may contribute to the disability and pathology associated with low back pain. This research demonstrates the importance of considering posture and alignment of the entire spine (especially of the cervical spine), regional interdependence, and perhaps the continuity of the nervous system when assessing and planning interventions for individuals with chronic low back pain.

Study Summary

Study Design Prospective Randomized Controlled Study
Level of Evidence Level II - Evidence from a well designed RCT
Subject Demographics
  • Subjects were randomly assigned into experimental treatment (EXTx) & standard treatment (STTx) groups by a blinded outside consultant.
  • Age: 49.1 +/- 4.9 yrs (EXTx); 50.5 +/- 4.8 yrs (STTx)
  • Gender: 47 male/30 female (EXTx); 53 male/24 female (STTx)
  • Characteristics: 154 individuals met inclusion/exclusion criteria.  Duration of pain at baseline was 25 +/- 8 weeks (EXTx) and 26 +/- 8.6 weeks (STTx). They participated in a 10 week intervention, then had a 2 year follow-up. 154 completed 10 week follow up. 131 completed 2 year follow up (65 in EXTx & 66 in STTx).
  • Inclusion Criteria: L5/S1 radiculopathy affecting unilateral distribution of the S1 nerve root for greater than 3 months (confirmed via MRI showing L5/S1 disc prolapse, symptoms including unilateral leg pain, observed lumbar hyperlordosis, Oswestry Disability Index Score of up to 40% (mild-mod disability), H reflex testing with the affected side having increased latency (>1ms latency & prolonged latency >30ms); minimum of 15mm of anterior head translation (AHT) as viewed in lateral radiograph of cervical spine
  • Exclusion Criteria: history of lumbosacral surgery, metabolic system disorder, cancer, cardiac problems, peripheral neuropathy, hx of upper motor neuron lesion, spinal canal stenosis, rheumatoid arthritis, osteoporosis, any lower extremity (LE) deformity that might interfere with global postural alignment.
Outcome MeasuresAll outcome measures were collected at baseline, post intervention (10 weeks) and post follow up (2 years).
  • Oswestry Disability Index (ODI)
  • Anterior Head Translation (AHT) distance
  • 3-D spinal postural parameters
    • Sagittal Plane: lumbar angles, thoracic angles & trunk inclination
    • Frontal Plane: trunk imbalance & lateral deviation
    • Transverse Plane: vertebral surface rotation, pelvis torsion

  • Peak to Peak Amplitude of the H Reflex (H reflex is produced via electrical stimulation of a sensory nerve associated with a muscle spindle. EMG recording is then taken of the subsequent muscle contraction. It assesses the integrity of the "sensory input, motor output" pathway between sensory nerves, spinal cord, motor nerves & muscle).
  • Latency of the H Reflex
  • Intensity (0-10 Numeric Pain Scale (NPS)) of back pain - 0= no pain; 10=worst pain.
  • Intensity (0-10 NPS) of leg pain - 0= no pain; 10=worst pain.
ResultsBold and Italics = Statistically significant At baseline:
  • There were not statistically significant differences in the make up of EXTx and STTx groups with respect to age, height, weight, sex, duration of pain, past physiotherapy, or use of medications for back pain.

At 10 weeks (post intervention):

  • Both groups demonstrated statistically significant improvements over baseline.
  • ODI scores: No significant differences between groups (p=.08).
  • AHT: Significant difference between groups (p<.0005).
  • 3D Spinal Postural Parameters: Significant differences between groups for surface rotation, lumbar lordosis, trunk kyphosis, trunk inclination & trunk imbalance (p<.0005 for all).
  • H reflex Amplitude: No significant difference between groups (p=.09).
  • H reflex Latency: No significant difference between groups (p=.09).
  • Back Pain: No significant difference between groups (p=.29).
  • Leg Pain: No significant difference between groups (p=.19).

At 2 year follow up:

  • ODI scores: Significant difference between groups favoring EXTx (p<.0005).
  • AHT: Significant difference between groups favoring EXTx (p<.0005).
  • 3D Spinal Postural Parameters: Significant differences between groups favoring EXTx

    for surface rotation, lumbar lordosis, trunk kyphosis, trunk inclination & trunk imbalance (p<.0005 for all).

  • H reflex Amplitude: Significant difference between groups favoring EXTx (p<.0005).
  • H reflex Latency: Significant difference between groups favoring EXTx (p<.0005)
  • Back Pain: Significant difference between groups favoring EXTx (p<.0005)
  • Leg Pain: Significant difference between groups favoring EXTx (p<.0005)
ConclusionsThis research demonstrates that postural dysfunction of the cervical spine may play a role in the pain cycle of chronic low back pain.
Conclusions of the ResearchersThe addition of forward head posture correction to a program of functional restoration demonstrated both short & long term effectiveness in reducing pain and improving function of individuals with L5/S1 radiculopathy.  A functional restoration program, as well as a functional restoration program with a forward head posture correction component were equally effective at 10 weeks.  The true benefit of the forward head posture correction was revealed at 2 year follow up where the group performing the forward head posture corrective activities demonstrated significantly greater reduction in pain & disability over the control group.

Referral Pain Patterns for Radiculopathy originating from Lumbar Spine - https://medacad.wikispaces.com/file/view/Radiculopathy.jpg/190095722/Radiculopathy.jpg

Review & Commentary:

There were many strong components in the methodology and design of this study. The authors selected a prospective randomized controlled trial (RCT) to directly address the question of how individuals with a lumbar radiculopathy might benefit from the addition of cervical postural correction exercises. The RCT is considered to be "the gold standard" of study design for determining the effectiveness of a given intervention; implying greater weight may be given to these results. Subjects were screened for inclusion/exclusion criteria and randomly allocated to the experimental treatment (EXTx) or standard treatment (STTx) groups by an individual not otherwise involved in the study, preventing a selection bias by the principal investigators. The authors utilized clearly defined diagnostic criteria for confirming L5/S1 lumbar radiculopathy. The combination of self reported, observational and neurophysiological parameters provided a well rounded clinical picture of the individuals selected for this study. All methods of measurement and data collection were supported by prior validation studies. A power analysis was performed to determine the necessary sample size to ensure results had statistical power. Because the researchers had the forethought to include 20% more subjects than the power analysis called for, the final sample size (those who completed all parameters including 2 year follow-up, less those who did not complete the study) remained greater than the minimum of what was needed for statistical significance.

In addition to a strong design, this study examined a well rounded intervention. The "functional restoration program" that was administered to both groups consisted of 2-3 meetings per week, for 10 weeks, in groups of up to 5 individuals, focusing on a myriad of topics related to low back pain. The subjects covered included education on the pathology of low back pain, self management strategies, relaxation techniques, stabilization activities, aerobic exercise and progressive resistance training. It was carried out by a psychologist and a physical therapist working together, and behavioral modification was an important component of the program. Both therapists emphasized the importance of the subject being an active participant in their own care, rather than a passive recipient of treatment. In clinic, it is clear that patients who have a more active role in self-management of their own pain, have more successful recoveries. This research supports this concept (although this was not the intervention that the RCT targeted in its analysis). Following the 10 weeks, subjects performed an independent program of low impact aerobic activity, 2 times per week for the following 2 years. The authors monitored compliance via exercise journals that were collected and analyzed every 3 months. The "forward head postural correction" program implemented with the EXTx group consisted of stretching for the pectoral muscles and cervical extensors, as well as strengthening exercise for the deep cervical flexors & scapula retractors. An aside, this study may also have demonstrated the effectiveness of a small group therapy model in the management of chronic low back pain (although again - not the specific intervention compared in the RCT). This is an important consideration in an era where access to healthcare resources is increasingly limited, even if small group therapy doesn't allow for the same amount of individualization or implementation of manual therapy possible with one-on-one care.

While this study has many strengths, there were also limitations. There was a lack of blinding of the investigators collecting outcome measure data. The authors point out that there may have been a treatment bias towards the EXTx group because of the additional time spent instructing and carrying out the cervical spine postural correction activity. The study was limited to individuals with a very specific lumbar spine pathology and characteristic posture, and the results may not be transferable to individuals with a different pathology (i.e. spinal stenosis or spondylisthesis) or posture (i.e. lateral shift). The authors did not comment on how well the individuals complied with the home program or how this impacted different individual's outcomes, but future research should investigate the impact of compliance on results. Finally there was no discussion of how specific stabilization and therapeutic exercises were progressed over the 10 week or 2 year period.

Forward Head Posture - http://www.blackchiropractic.com.au/wp-content/blogs.dir/21/files/poor-posture.jpg

Why is this study important?

This study demonstrates that pathology of the lumbar spine may not be the sole cause of pain and disability related to the low back. Postural dysfunction of the cervical spine (and potentially the thoracic spine), clearly play a role in the perpetuation of low back pain. This study elegantly illustrates the importance of assessing global movement patterns of individuals complaining of pain, rather than focusing acutely on the individuals complaints. The location of pain may indicate an area of significant inflammation, tissue damage or alterations in motion; however, the dysfunction driving that change may originate or be exacerbated by a different segment. It is also likely that there is not one single cause or driver of low back pain; dysfunction at the location of pain, as well as global factors may all make significant contributions to an individuals' pain experience.

How does it affect practice?

Individuals with mild to moderate disability may seek advice from human movement professionals within a variety of settings. While our interventions may differ based on our scope of practice, every human movement professional should be capable of discussing posture and alignment of the entire spine and how that may affect the painful segment.

How does it relate to Brookbush Institute Content?

The Brookbush Institute considers forward head posture a movement pattern that often occurs as part of the negative sequelae associated with Upper Body Dysfunction . This article invites us to consider a possible link between Upper Body Dysfunction and Lumbo-pelvic Hip Complex Dysfunction. The Brookbush Institute advocates for human movement professionals to use the Overhead Squat Assessment to differentiate which dysfunction is primary at the time of assessment. In the event that Lumbo-pelvic Hip Dysfunction is determined to be the primary dysfunction, it may be advisable to incorporate corrective exercise for forward head posture, although these dysfunctions are not currently explicitly linked.

Further, this study supports a theory of "regional interdependence", an assumption made in all postural/movement impairment models, including the predictive models of dysfunction published on this site. That is, pain and dysfunction may be be contributed to by segments, joints, muscles, nerves and soft tissue adjacent to the affected segment without being symptomatic or identified as painful themselves.

For more information on The Overhead Squat Assessment and deciding which dysfunction to address when there appear to be multiple, videos below:

Introduction to Overhead Squat Assessment

How to Decide Which Dysfunction to Address first?

For more information on the types of corrective exercise recommended by the Brookbush Institute to correct forward head posture, see below:

Levator Scapula Static Release

Levator Scapula Static Stretch

Pectoralis Minor SA Static Release

Crucifixion Stretch

Pectoralis Major and Minor SA Active Stretch

Deep Cervical Flexor Isolated Activation

Deep Cervical Flexor Activation and Progressions for Stabilization

Prone Floor Cobra

© 2015 Brent Brookbush

Questions, comments, and criticisms are welcomed and encouraged -