Tech Neck Isn’t Bad Habit You Need to Fix. It’s a Postural Pandemic Affecting Us All

For most of human history we looked downward as required, when kindling a fire, or making a tool, or any of a host of activities that were the life of a hunter gatherer.  But when screens suddenly took over our lives “tech neck” (AKA head forward posture (HFP)) became our default stance for hours each day.  Unfortunately, our bodies aren’t designed for this sustained stress, and the result has been an epidemic of neck pain.  It isn’t easy to avoid a posture which our tech seems to require, but there are workarounds.

Forward Head Posture: When a natural position becomes a problem

Forward head posture (FHP) describes a posture in which the head shifts forward relative to the body's vertical centerline. In neutral alignment, the ears sit directly above the shoulders, allowing one’s head to balance effortlessly atop the spine. In this neutral position, neck muscles need only make slight, monitoring contractions, and the head can easily move in any direction without preparation.  

Life gets complicated, however, and so the spine has a remarkable ability to reconfigure itself on the fly depending on the task at hand.  The forward head posture is simply one of the spine’s vast repertoire of elegant, natural postures.

However, problems can arise when a single position becomes the default posture for many hours a day.  When the head juts forward the neck muscles must continuously contract to support a roughly 11-pound human head. Moreover, the load on the neck’s musculature progressively increases with the degree of forward tilt. Computer models show that for every inch the head moves forward, approximately 10 additional pounds of force is placed on the cervical spine. Thus, an 11-pound head can exert up to 60 pounds of force when held in a forward position.

Researchers measure the degree of HFP using the craniovertebral angle (CVA). A CVA below 48-50 degrees defines the forward head posture.  And, as mentioned above, the smaller this angle becomes, the bigger the problem becomes.  

And the problem isn’t confined to the neck alone; the whole body responds to compensate for a head forward posture:

Note that as the body attempts to compensate for this sustained demand, a cascade of other postural sacrifices occur: the shoulders round forward, the natural forward curve of the thoracic spine (kyphosis) is accentuated, and the upper neck extends sharply.

Consequences Beyond Aesthetics

The head forward posture has both anatomic and physiologic implications.  As mentioned above, this positioning of the head continuously stresses the neck extensor muscles.¹   Additionally, excessive compressive stress is placed on the facet joints in the neck as well as the intervertebral discs.  While the spine is robust to such stress, over time these surprisingly delicate joints may be damaged, leading to inflammation and eventually neck pain.²  

The head forward position also causes more nuanced harms.  Muscular imbalance is the result of chronic shortening and overuse of cervical extensors while the flexors become elongated and weakened.  This accelerates fatigue and perpetuates self-reinforcing abnormal movement patterns in which the head progressively drifts further forward as deep stabilizers become increasingly unable to counterbalance gravitational forces.³

Additionally, proprioceptive drift can occur in which afferent input from muscle spindles that provide critical position sense information to the central nervous system lose calibration, resulting in greater cervical repositioning errors.  This can be a catastrophic problem because impaired postural stability increases the risk for falls.  Another contributing factor is the compromised coordination between visual, vestibular, and somatosensory systems, which may make postural corrections during daily activities less accurate.⁴

Finally, respiratory function is compromised because the biomechanics of the thoracic bellows are altered, creating compensatory breathing⁵ patterns that rely excessively on upper chest movement rather than efficient diaphragmatic breathing.  This can lead to reduced cardiorespiratory fitness, reducing exercise capacity and contributing to physical deconditioning.⁶

Failed Workarounds for Head Forward Posture

The urge to correct posture is irresistible, and while several approaches have been tried, few effective solutions have emerged.⁷  Some of the earliest attempts to address forward head posture resulted from the Victorian era's obsession with upright carriage, an obsession so over the top that mechanical stretching devices like the infamous "neck swing" came into vogue.  This approach suspended patients by their heads, sometimes for hours, in a misguided attempt to immediately correct posture that had developed over years.  

 

Less dramatic but more intrusive were frames strapped to the torso that forced the head and chin upward.  These interventions and others in retrospect seem extreme and likely did more harm than good.

 

The 20th century brought a more scientific approach, and led to more effective therapies that included cervical braces, postural correctors, and scapular stabilization braces.  And these devices were modestly effective: a recent systematic review of 10 studies found they could significantly improve craniovertebral angle (CVA) when combined with rehabilitation exercises.  Unfortunately, the improvements were modest, typically only 3-5° CVA improvement.  More problematic, these devices had to be worn continuously, making them so unpopular with patients that the authors of this study ruefully concluded "better device design is needed to improve usability".⁸

Exercises specifically designed to ameliorate HFP can be also be effective.  A 2018 systematic review found that therapeutic exercises can improve craniovertebral angle.⁹ Crucially, however, a more recent paper emphasized that addressing the entire spine is more effective than neck exercises alone.¹⁰ Since the lumbar spine and pelvis dictate head position, it makes sense that addressing the lower back and core would improve routines limited to the neck alone.  The authors conclude: "Incorporating a lumbopelvic into the cervicothoracic protocol was more effective in reducing short-term neck pain and disability than a cervicothoracic protocol alone. A comprehensive spine program may be a clinically beneficial rehabilitation protocol for FHP to improve neck pain and disability"

“An Ounce of Prevention is Worth a Pound of Cure”.  B Franklin

Of course, the best solution to FHP is simply not to develop this posture in the first place. So, rather than try to enforce better posture after FHP is established, finding ways to encourage a balanced head position throughout the day is likely a far more effective solution. 

Primary prevention strategies begin with optimizing workstation ergonomics: adjusting the top of one’s monitor to be at eye level with viewing distances of 20-26 inches to maintain the neck balanced and upright.  Frequent breaks, every 20-30 minutes, if possible, can help avoid the tendency to become locked in a single posture.  On a larger scale, incorporating movement variability into daily routine such as alternating between sitting and standing, changing positions frequently, and performing brief stretching exercises may also be helpful but may prove impractical for many desk-bound workers.

Devices specifically designed to increased positional variety in sitting have also been proposed.  A 2021 paper introduced an ingenious pneumatic cushion that induces movement using a computer-controlled pump to force air into various parts of a seat pad placed under participant’s buttocks.¹¹   This gradual pressure change tips the pelvis, subtly prompting the seated person to adjust their body position to restore balance and so creates a postural shift without conscious effort or interrupting work.  This device was highly effective, reducing neck pain and back pain by 60% and 80% respectively.  However, the complexity, noise, and expense seem to have prevented this computer controlled pneumatic cushion from becoming a commercial product.

More recently the same group of researchers has found that a simple inflated cushion facilitated movement even more effective than the much more complicated computer-controlled cushion used in their initial study.¹²  Importantly, the authors’ concluding by observing that “… it is plausible that similar results could be achieved with other dynamic interventions that promote regular movement, thus reducing prolonged static sitting.”

What other dynamic interventions are might be available?  It turns out that for years several companies (CoreChair in Canada, MiShu and Swopper in Germany, and QOR360 in the United States) have been producing chairs designed for active sitting.  Using different mechanisms all these chairs create slightly unstable seat surfaces that encourage, even require, continuous postural rebalancing while sitting.  Although it seems not to have been formally studied, these constant postural changes likely prevent neck and back pain in the same way pneumatic cushions do.  

So, is active sitting the solution for problems brought on by the forward head posture (FHP, AKA tech neck)?  Without carefully done cross-over studies we can’t say.  But the success of a simple pneumatic cushion suggests that the more mature active sitting technology will be helpful in preventing of the consequences of HFP for many, possibly most, people.  

In the meantime, active sitting has other well-established benefits, such as better metabolic health¹³,  increased metabolic rate¹⁴, and stronger core musculature¹⁵, that have been validated in peer reviewed journals.  But these are stories for other blogs.

 

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