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Tuesday, June 6, 2023

Relationship of Forward Head Posture and Cervical Backward Bending to Neck Pain

Brent Brookbush

Brent Brookbush


Research Review: Relationship of Forward Head Posture and Cervical Backward Bending to Neck Pain

By Susan Ackerman DPT, PT, PMA-CPT

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

Original Citation:

Haughie, L. J., Fiebert, I. M., & Roach, K. E. (1995). Relationship of forward head posture and cervical backward bending to neck pain. Journal of Manual & Manipulative Therapy3(3), 91-97. ABSTRACT


Prior research demonstrates that posture and alignment of the neck and upper-body may contribute to neck dysfunction (1-4). This 1995 study from the University of Miami investigates the relationship between forward head posture (FHP), active neck extension range of motion (AROM) and neck pain. The findings demonstrate a correlation between the degree of FHP and the amount of lost AROM, and the severity and frequency of neck pain. Human movement professionals may consider the addition of cervical posture and range of motion assessments during cervical evaluation.

Cervical X-ray - By Nevit Dilmen - Own work, CC BY-SA 3.0,

Study Summary

Study DesignCohort Study (Observational Study)
Level of EvidenceIII Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies
Participant CharacteristicsDemographics
  • Number of participants: 54
  • Age: 45.5 ± 10.9 years
  • Gender: 17 males and 37 females
  •  All office workers: 50 workers were full-time employees, 4-workers part-time

Inclusion Criteria:

  • Actively employed and spent ≥4 hours/day sitting at a computer terminal

Exclusion Criteria:

  • Sought medical attention for neck pain within the last 30-days
  • Medical history including one or more of the following:
    • Neck injury
    • Neck surgery
    • Idiopathic scoliosis
    • Bone cancer

  • Researchers collected the following information from participants:
    • Number of visits to a medical professional for neck pain in the past 12 months
    • Number of days during the past month that subjects experienced pain
    • Level of pain in a typical day
    • Regions of pain using a body diagram for each of the following: posterior cervical, inter-scapular, shoulder, and pectoral regions (a total of 8 regions)

  • Participants were assigned to the case or control group based on the number of reported regions of pain:
    • Case group: individuals with 4 or more regions of pain
    • Control group: individuals with 3 or less regions of pain

  • Cervical Range of Motion Instrument (CROM) was used to collect measurments using the following procedure:
    • Participants sat in a straight back chair with feet flat on the floor and hands on lap
    • A belt was used to prevent upper back movements during testing
    • CROM was placed on the participants head
    • FHP and neck extension AROM were measured in natural sitting and erect sitting postures

  • Two positions were studied, including:
    • Self-selected (natural) sitting posture that is like their posture during work
    • An erect posture as instructed by the investigators

Data Collection and Analysis
  • A Cervical Range of Motion Instrument (CROM, Performance Attainment Associates, Roseville, MN, USA) was used for measurements
  • Wilcoxon Rank Sum Test was used to compare the following between groups:
    • Number of days with pain
    • Number of visits to medical professionals in the previous 12 months
    • Level of pain on a typical day

  • Students’ t-test was used to compare forward head posture and neck extension AROM between groups
  • Statistical significance was set to p < 0.05
Outcome Measures
  • Frequency of neck pain within the previous month
  • History of neck pain (last 12 months)
  • Pain level
  • Body pain diagram
  • CROM of FHP and neck extension AROM
  • 21 subjects were classified into the case group
    • Mean age:46 years old (SD =12)
    • 19.05% males, 80.95% females

  • 23 subjects were classified into the control group
    • Mean age:44 years old (SD =12)
    • 39.39% males, 60.61% females

  • Statistically significant differences noted between groups (p < 0.05):
    • Number of days of pain in the last 30 days was higher in the case group when compared to the control group (p=0.0011)
    • Number of medical professional visits in the last 12 months was higher in the case group when compared to control group (p=0.0167)
    • Pain intensity was higher in the case group when compared to control group (p=0.0096)
    • FHP in natural sitting was greater in then case group when compared to control group (p=0.0386)
    • Neck extension AROM in erect sitting was decreased in the case group when compared to the control group (p=0.0374)

  • Non-statistically significant differences noted between groups:
    • Neck extension AROM in natural sitting (p=0.0597)
    • FHP in erect sitting (p=0.5730)

Researchers' Conclusions

The case group demonstrated greater intensity and frequency of neck pain compared to the control group. Furthermore, the case group also demonstrated greater FHP in natural sitting and decreased neck extension AROM in both natural and erect sitting positions.

How this study contributes to the body of research:

Prior research has correlated forward head posture with neck pain (1 - 4). However, these studies did not establish a relationship between the degree of FHP or loss in range of motion, with the frequency and/or intensity of pain. This study suggests that greater forward head posture and decreased cervical extension AROM is correlated with more frequent episodes of pain, more intense pain, and more regions of pain the (cervical, inter-scapular, shoulder and pectoral). Future research is needed to establish threshold levels of FHP and AROM that may increase the risk of future pain and injury.

How the Findings Apply to Practice:

This study identifies a relationship between increased FHP in natural sitting and a reduction in neck extension in natural and erect sitting postures, with increased neck pain. It may be important to assess cervical posture and range of motion when addressing or programing to prevent the occurrence of pain and dysfunction. Human movement professionals may consider building a repertoire of techniques within their scope to address restrictions in cervical range of motion and reduce FHP.


  • The study investigated multiple variables, establishing a relationship between the frequency and intensity of pain, the degree of FHP and the amount of loss of range of motion.
  • The study started to fill a gap in the research by demonstrating that the relationship between cervical posture and pain may be dose dependent (more dysfunction results in more pain)
  • The study stratified groups by participant data rather than arbitrary thresholds or norms.

Weakness and limitations

  • Further research is needed to establish the reliability and accuracy of the Cervical Range of Motion Instrument used to measure cervical range of motion and forward head position in the study.
  • A larger population may have allowed for stratification into more groups, and stronger evidence of a threshold level or dose response relationship.
  • Recording regions of pain in the cervical spine and upper body without an objective measure of upper body range of motion leaves questions regarding the effects of poor sitting posture on the upper body unanswered.

How the study relates to Brookbush Institute Content?

The Brookbush Institute (BI) is continuing to develop and refine its content related to Upper Body Dysfunction (UBD)  and Cervicothoracic Dysfunction (CTD). This study provided additional evidence of a correlation between forward head posture, neck extension ROM and neck pain. Broadly, this study reinforces the hypothesis that posture is correlated and perhaps a contributing factor to pain and dysfunction. The BI will continue to pursue optimal practice by refining its content, using the aggregated results of all available research related to human movement science.

Brookbush Institute Videos:

Deep Cervical Flexor Isolated Activation (Longus Colli, Longus Capitis & Rectus Capitis Anterior)

Lewit Chair Sitting Deep Cervical Flexor Activation:

Deep Cervical Flexor and External Rotation Activation Progression:


  1. Szeto, G. P., Straker, L. M., & O’Sullivan, P. B. (2005). A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work—2: neck and shoulder kinematics. Manual therapy, 10(4), 281-291.
  2. Szeto, G. P., Straker, L., & Raine, S. (2002). A field comparison of neck and shoulder postures in symptomatic and asymptomatic office workers. Applied ergonomics, 33(1), 75-84.
  3. Griegel-Morris, P., Larson, K., Mueller-Klaus, K., & Oatis, C. A. (1992). Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Physical therapy72(6), 425-431.
  4. Braun, B. L. (1991). Postural differences between asymptomatic men and women and craniofacial pain patients. Archives of physical medicine and rehabilitation72(9), 653-656

© 2018 Brent Brookbush

Questions, comments, and criticisms are welcomed and encouraged -