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Association Between Forward Head, Rounded Shoulders, and Increased Thoracic Kyphosis: A Review of the Literature

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Objective: The purpose of this review was to explore the association between forward head posture, rounded shoulders, and increased thoracic kyphosis. Methods: The PubMed, ERIC, and Cochrane databases were searched using the key words posture, head, shoulder, forward scapular posture, and thoracic kyphosis through December 2016. Results: Our initial search yielded 6840 research studies, 6769 of which were excluded because they either were duplicates or did not satisfy the inclusion criteria. After the abstracts of the remaining studies were read, 15 were assessed for eligibility, and only 4 papers were included in the present review. Cervical lordosis values were found to be significantly associated with thoracic kyphosis values. Also, there were significant correlations between rounded shoulders and increased thoracic kyphosis. Conclusion: Forward head posture, rounded shoulders, and increased thoracic kyphosis can exist alone or in any combination.
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LITERATURE REVIEW
Association Between Forward Head,
Rounded Shoulders, and Increased
Thoracic Kyphosis: A Review of the
Literature
Deepika Singla, MPT Sports, BPT, and Zubia Veqar, PhD, MPT Ortho, BPT
ABSTRACT
Objective: The purpose of this review was to explore the association between forward head posture, rounded
shoulders, and increased thoracic kyphosis.
Methods: The PubMed, ERIC, and Cochrane databases were searched using the key words posture, head, shoulder,
forward scapular posture, and thoracic kyphosis through December 2016.
Results: Our initial search yielded 6840 research studies, 6769 of which were excluded because they either were
duplicates or did not satisfy the inclusion criteria. After the abstracts of the remaining studies were read, 15 were
assessed for eligibility, and only 4 papers were included in the present review. Cervical lordosis values were found to
be significantly associated with thoracic kyphosis values. Also, there were significant correlations between rounded
shoulders and increased thoracic kyphosis.
Conclusion: Forward head posture, rounded shoulders, and increased thoracic kyphosis can exist alone or in any
combination. (J Chiropr Med 2017;16:220-229)
Key Indexing Terms: Posture; Kyphosis; Shoulder
INTRODUCTION
Various occupations require people to assume static
postures for long periods, which causes continuous
contractions of the head and neck muscles.
1,2
The head
constitutes 6% of the total body weight, which is linked to
the cervical spine and all other joints through the kinematic
chain
3
by various muscles.
Normally, the cervical spine is lordotic. Other than flexion
and extension movements of the neck that take place in the
sagittal plane, protraction and retraction movements also
come into play in this plane. Protraction movement is a result
of extension of the upper cervical spine and flexion of the
lower cervical spine, whereas retraction movement results
from flexion of the upper cervical spine and extension of the
lower cervical spine. If the cervical spine is held in protracted
position for prolonged duration, it can lead to alterations in
head posture ultimately leading to poor posture known as
forward head posture (FHP), which is thought to be a
deviation from neutral or normal posture.
4,5
Normal posture is defined as when the line of gravity
(LOG) passes through the external auditory meatus, the
bodies of the cervical spine, and the acromion and anterior
to the thoracic spine
6
(Fig 1). Normally, the external
moment produced by gravity and ground reaction forces at
a joint is offset by the internal moment produced by various
muscles and other soft tissue structures around that joint.
However, presence of postural malalignments may require
greater internal forces to balance the external torque
produced by gravity, which in turn is exaggerated owing
to the altered location of the LOG.
7-9
Failure of the head to align with the vertical axis of the
body
3,10
(Fig 2) can lead to further malalignments in the
body, namely, rounded shoulders and increased thoracic
kyphosis,
11,12
to compensate
13
for the altered location of
the LOG, leading to further impairments.
14
Combination of
all these postural deviations is often known as slouched
posture
15,16
or slumped posture.
3,17
According to Kendall et al,
6
there should be vertical
alignment between the midline of the shoulder and the mastoid
process. If the acromion processes are more anteriorly
positioned compared with the mastoid processes, a condition
Centre for Physiotherapy and Rehabilitation Sciences, Jamia
Millia Islamia, Jamia Nagar, Okhla, Delhi, India.
Corresponding author: Deepika Singla, MPT Sports, BPT, Centre
for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia,
Jamia Nagar, Okhla, Delhi 110025, India. Tel.: +91 8586976427.
(e-mail: dpkasingla@gmail.com).
Paper submitted October 17, 2016; in revised form March 29,
2017; accepted March 29, 2017.
1556-3707
© 2017 National University of Health Sciences.
http://dx.doi.org/10.1016/j.jcm.2017.03.004
known as forward shoulder posture (FSP) or rounded shoulders
or protracted shoulders
11,15
occurs (Fig 3); this condition is
characterized by protracted, internally rotated, anteriorly tilted,
elevated, and abducted scapula along with winging of
scapula.
15,18,19
This poor alignment of the shoulders leads to
greater torque production by gravitational forces, which is
being offset by greater internal forces generated by muscles and
other soft tissues around the shoulder.
Normally, a flexion moment is being created by the
passage of LOG anterior to the thoracic spine that is offset
by the extensor muscles, ligamentum flavum, supraspinous
ligaments, and posterior longitudinal ligament.
This gravitational moment would increase if there is an
increase in the thoracic spines posterior convexity causing
increased distance between joint axes and LOG (Fig 4). In
such a case, to maintain an upright posture, ligaments and
muscles would be required to produce a greater moment to
counterbalance the increased gravitational moment,
7-9,20
thus leading to an increase in posterior convexity or
kyphosis of the thoracic spine, also known as round back.
9
Posture can be assessed using different methods such as
a plumb line, photography, photogrammetry, radiography,
Flexicurve, moiré topography, and an electromagnetic
tracking device. Any of these methods can be used to
detect the presence of abnormal posture.
21-23
Electromy-
ography is also very commonly used in postural assessment
studies to ascertain the changes in muscular activities that
occur as a result of postural changes.
24
Most previous studies mention the causes and conse-
quences of FHP, rounded shoulders, and increased thoracic
kyphosis. However, there is a dearth of studies focused on
the association between forward head, rounded shoulders,
and hyperkyphosis. Therefore, the aim of this review was to
explore the relationship between FHP, FSP, and increased
kyphosis of the thoracic spine.
METHODS
Studies were included if they reported association
between FHP and FSP, or between FHP and thoracic
kyphosis, or between FSP and thoracic kyphosis, and if they
were available in free full text online entirely in the English
language. Review articles, conference papers, and unpub-
lished dissertations were excluded, as were studies that
involved subjects having pain or some pathology other than
a postural problem. Studies were also excluded if they
described the impact of exercise training or any other
modality on posture.
Fig 1. Normal posture and line of gravity. Fig 2. Forward head posture. Note that d is the distance between
the line of gravity and the external auditory meatus.
221Singla, VeqarJournal of Chiropractic Medicine
Head, Shoulder, and Thoracic PostureVolume 16, Number 3
PubMed, ERIC, and Cochrane databases were searched
using the key words posture,head, shoulder,forward
scapular posture,andthoracic kyphosis in various
combinations to find and describe an association between
forward head, forward shoulders, and increased kyphosis.
The last search was performed in December 2016.
RESULTS
Figure 5 illustrates the numbers of articles retrieved, read,
and rejected. Only 4 research studies
12,25-27
were found to
best explain the objective of this study. Other studies used in
this review do not explain any relationship among the 3
pathologies, that is, FHP, FSP, and increased kyphosis of the
thoracic spine, but instead focus on 1 of the pathologies.
Information obtained from such studies has been condensed
in Tables 1 and 2.Table 3 summarizes studies that present
associations between forward head, rounded shoulders, and
increased thoracic kyphosis.
Forward Head Posture
FHP can be linked to computer use,
28
carriage of
backpacks,
29
use of smartphones,
16
headache,
30
mouth
breathing, bad habit,
31
or shoulder overuse
15,23,32
(Table 1).
FHP has been associated with shortened levator
scapulae, sternocleidomastoids, upper trapezius, and pos-
terior cervical spine muscles,
18
that is, suboccipital
muscles.
30
FHP has been linked to chronic tension-type,
cervical, and tension type headaches.
30,33
Watson and Trott
33
reported a significantly smaller craniovertebral angle value
in the headache group than in the non-headache group.
Lesser craniovertebral angle meant poorer FHP. The
headache group also had lesser isometric strength of the
upper cervical flexors as well as a lesser isometric endurance
of these muscles when compared with the non-headache
group.
Apart from headache, a greater FHP has also been
reported to be associated with trigger points in the
Fig 3. Forward shoulder posture. Note that b is the distance
between the line of gravity and the acromion.
Fig 4. Increased kyphosis. Note that t is the distance between the
line of gravity and thoracic spine.
222 Journal of Chiropractic MedicineSingla, Veqar
September 2017Head, Shoulder, and Thoracic Posture
suboccipital muscles (rectus capitis posterior minor and
major and oblique capitis superior).
30
Trigger points
associated with taut bands of suboccipital muscles can give
rise to referred pain over the occipital and temporal aspects of
the head, which is perceived as headache. This headache is
thought to be mediated through the spinal cord and trigeminal
nucleus caudalis of the brainstem. This means that FHP
(shortened suboccipital muscles) leads to the activation of
trigger points and, thus, causes tension-type headache.
30
FHP can cause accumulation of nociceptive substances
in the muscles that counteracts FHP, increased compression
of cervical facet joints and posterior vertebral bodies,
stretching of anterior neck musculature, and shortening of
posterior neck musculature.
32,34
Increased compression of
the zygapophyseal joints can result in the inception of
degenerative changes leading to spondylosis. The greater
and lesser occipital nerves might be compressed because of
a reduction in the intervertebral space, leading to stimula-
tion of the trigeminal nerve. This, in turn, can lead to facial
pain and headache.
31,35
Shoulder pain, neck pain, interscapular pain, craniofacial
pain, radiating pain to the scalp, temporomandibular
disorders, subacromial impingement syndrome, thoracic
outlet syndrome, restricted range of motion at the cervical
spine and scapula and shoulder dyskinesis,
4,11,12,31,32,35-38
decreased respiratory capcities,
2
poor static balance,
13
and
so on (Table 2) can also occur. Assumption of a neutral
head posture might be biomechanically beneficial while
performing loaded isometric shoulder flexion activities to
reduce work-related neck and shoulder pain.
32
Forward Shoulder Posture
FSP can be linked to, among other factors, repetitive
overhead activities, backpack carriage, bad habit, mouth
breathing, computer and laptop use, and prolonged study
hours
19,29,39,40
(Table 1).
FSP could lead to muscle imbalance in the form of
shortening of the anterior shoulder muscles such as the
pectoralis minor and major, serratus anterior, and upper
trapezius and lengthening of the posterior shoulder muscles,
middle and lower trapezius and rhomboids.
7,19
This muscle
imbalance leads to alteration in the scapular and glenohum-
eral orientation, as well as kinematics,
41,42
thus increasing the
risk of developing neck, shoulder, and nonspecific arm pain.
Also, reduction of range of motion and loss of function have
been reported.
14,17,43
This sequence of events has been well
demonstrated in the research report presented by Borstad,
who reported that reduced pectoralis minor muscle length
would alter the scapular kinematics, which can predispose the
person to subacromial impingement syndrome.
14
Patients
with subacromial impingement also present with increased
scapular abduction, elevation, anterior tilting, and internal
rotation, which is very similar to the postural alterations that
occur with FSP
15
(Table 2).
A protracted shoulder has been implicated in the restricted
sliding of the cords of the brachial plexus, thus increasing
strain on the various nerves passing through the shoulder
region, especially the median nerve.
17
Also, coracoid pain
and malposition, scapular dyskinesis, and prominent infer-
omedial border of the scapula have been reported (described
as SICKscapula). The scapula of the dominant side has
been found to be more anteriorly tilted and protracted in
overhead athletes because of high training volume and
repeated overhead activities, reflecting an association
between scapular position, scapular dyskinesis and shoulder
pathology is there. Decreased range of motion, decreased
strength, and diminished performance with respect to velocity
and accuracy can be the manifestations of shoulder pathology
in sports persons.
44
In a study conducted on 372 players
involved in upper arm sports events such as basketball,
badminton, gymnastics, swimming, squash, tennis, table
tennis, volley ball, and field events, 163 players were having
shoulder problems such as shoulder pain, crepitus, weakness,
and decreased range of motion.
45
Thoracic Kyphosis
Increased thoracic kyphosis has been thought to be 1 of
the most frequently seen abnormalities in patients with
Records identified through
database searching
(n = 6840)
Records screened
(n = 71)
Full-text articles
assessed for eligibility
(n = 15)
Studies included in
qualitative synthesis
(n = 4)
Fig 5. Search strategy.
223Singla, VeqarJournal of Chiropractic Medicine
Head, Shoulder, and Thoracic PostureVolume 16, Number 3
Table 1. Effect of Different Habits/Occupations/Pathologies on Head, Neck, and Thoracic Posture
Research Sample Method Used Investigation Done Result
Jung et al, 2016
16
25 in group 1 (used smartphones for b4h/d),25
in group 2 (used smartphones for N4 h/d), mean
age = 21 ± 2.41 y, gender not mentioned
Photogrammetry, scapular index Effect of duration of smartphone
usage on head and scapular posture
Poorer FHP and rounded shoulder posture
in group 2
Vakili et al, 2016
1
96 dental staff, age not mentioned, both genders Questionnaire, plumb line, flexible
ruler, checkerboard
Prevalence of postural disorders of
head, shoulder, and spine among dentists
FHP and rounded shoulder posture prevalent
among dental staff
Guedes and Joao,
2014
22
36 in basketball group (mean age = 14.33 ± 1.20 y), 38 in
control group (mean age = 14.61 ± 1.31 y), only males
Photogrammetry Postural differences between
basketball players and nonplayers
Basketball players have lesser values of forward
head, shoulder protrusion, and thoracic kyphosis
Neiva et al, 2009
40
21 MB, 21 NB, aged 8-12 y, only males Stereophotogrammetry Head and thoracic spine posture, scapular
orientation and position in MB and NB children
Scapula positioned more superiorly in MB children
Straker et al, 2007
28
884 adolescents, mean age = 14 ± 0.2 y, both
genders
Questionnaire, computer use
duration
Association between computer
usage and habitual posture
Increased use of computer leads to
increased neck and head flexion
Borstad, 2006
14
25 with long pectoralis minor resting length
and 25 with short pectoralis minor resting
length, 18-40 y old, both genders
Electromagnetic motion
capture system
3-D orientation of scapula in relation to
trunk during arm elevation, thoracic
posture, scapular posture
There is a relationship between
pectoralis minor length and posture
Fernández-de-las-Peñas
et al, 2006
30
20 with CTTH (mean age = 38 ± 18 y) and 20
controls without headache (mean age = 35 ± 10 y),
both genders
Photographs to assess FHP,
palpation to identify TrPs,
headache diary
Subjects with CTTH possess both
suboccipital TrPs and FHP
Relationship of FHP and TrPs with
headache frequency, intensity, and duration
CTTH is associated with suboccipital
TrPs and FHP
Direct relationship exists between FHP and
headache variables along with presence of TrPs
Borstad and
Ludewig, 2005
42
25 with short pectoralis minor and 25 with long
pectoralis minor, 2040 y old, both genders
Electromagnetic motion capture
system
3-D orientation of scapula in relation to
trunk during arm elevation
Anterior tipping of scapula at higher angles
of arm elevation in the group with shorter
resting length of pectoralis minor
Hinman, 2004
48
25 in premenopausal group (21-51 y old), 26 in
postmenopausal group (66-88 y old), only females
Flexicurve, IK (measure of degree
of thoracic kyphosis), IK ratio
(measure of postural stiffness)
Comparison of thoracic kyphosis and
postural stiffness between groups
Kyphosis and stiffness greater in
postmenopausal women
Chansirinukor et al,
2001
29
13 high school students, mean age = 14.8 ± 1 y,
both genders
Digital photographs Effect of carrying backpack over
shoulders on neck and shoulder posture
Poorer FHP while carrying backpack having
weight equal to 15% of bodys weight than
when not carrying backpack
Greenfield et al,
1995
23
30 with shoulder pain (mean age = 39 ± 13.9 y)
and 30 without shoulder pain (mean age = 39 ±
13.7 y), both genders
Photographs Postural differences between healthy and
nonhealthy persons
FHP more pronounced in shoulder pain group
Watson and
Trott, 1993
33
30 with cervical headache, 30 without headache,
25-40 y old, only females
Photographs to assess FHP, passive
accessory intervertebral mobility
examination, headache questionnaire
Comparison of craniocervical posture
between 2 groups
Cervical headache group demonstrated FHP
3-D, three-dimensional; CTTH, chronic tension-type headache; FHP, forward head posture; IK, index of kyphosis; MB, mouth breathing; NB, nasal breathing; TrPs, trigger points.
224 Journal of Chiropractic MedicineSingla, Veqar
September 2017Head, Shoulder, and Thoracic Posture
Table 2. Biomechanical Alterations Associated with FHP, FSP, and Thoracic Kyphosis
Research Sample Method Used Investigation Done Result
Han et al,
2016
2
12 in normal posture group,
14 in FHP group, adults,
both genders
EMG activity of accessory muscles of
respiration (SCM, UT, PM, and ES),
spirometry to measure FVC and FEV1
Effect of FHP on respiratory function
and activity of accessory respiratory
muscles
Decreased FVC and FEV1; Decreased activity of
SCM, PM, and UT in FHP group
Lee, 2016
13
14 in FHP group (mean age = 22.1
± 1.6 y), 16 in control group (mean
age = 21.6 ± 1.1 y), both genders
Photogrammetry, balance calibration
system, body tilt training and
measurement system
Effect of FHP on dynamic and static
balance control
Poorer static balance control in FHP group than
control group; dynamic balance control similar for
both groups
Lee et al,
2016
24
10 healthy people, mean
age = 30.3 ± 2.5 y, only males
Surface EMG of MT, LT, SA, and LD,
inclinometer, Numeric Rating Scale, Shoulder
Pain & Disability Index for intensity of
shoulder pain and shoulder function
90° of shoulder abduction in the
scapular plane during erect and
slouched sitting
Increased MT and LT activities during slouched
sitting
Szczygiel et al,
2015
3
65, mean age = 51 ± 9.8 y, both genders Photogrammetry Relationship between head posture
and chest move ments while breathing in
3 different in stances: (a ) standing in
a relaxed position, (b) ma ximum
inhalation, (c) maximum exhalation
FHP decreases respiratory movements
Kwon et al,
2015
52
13 in NHP group, 14 in IHP group, 13 CHP
group, age and gender not mentioned
Photogrammetry, surface EMG
of SCMs, UT, LT, and SA muscles
of right side
Muscle activities while doing
overhead reach task
Increased SA and UT activities in NHP group as
compared with IHP and CHP groups
Ruivo et al,
2014
18
275 adolescents, 15-17 y old,
both genders
Photogrammetry, ASES questionnaire Relationship between posture and
presence of shoulder pain and neck pain
Association found between FHP and neck pain
Thigpen et al,
2010
5
47 with ideal posture, 45 with FHRSP,
18-60 y old, both genders
Photographs, electromagnetic motion
analysis system, surface EMG
Scapular kinematics and EMG activity
of upper trapezius, lower trapezius, and
serratus anterior during overhead reaching
task and loaded flexion task
Increased internal rotation of scapula and
decreased SA EMG activity during both tasks
Increased upward rotation of scapula and increased
anterior tilting of scapula during loaded flexion in
FHRSP group
Weon et al,
2009
32
21 with FHP, 21 with neutral head posture,
mean age = 21.3 y, gender not mentioned
Surface EMG, plumb line, inclinometer EMG activity of UT, LT, and SA
during loaded isometric shoulder flexion
Increased UT and LT EMG activities and
decreased SA EMG activity with FHP
Ghanbari et al,
2008
19
40 university students, mean
age = 22.4 ± 3.6 y, only females
Digital photography, spirometry Effect of FSP on various lung capacities Subjects with poorer FSP exhibited lesser vital
capacity, expiratory residual volume, and FVC
Huang et al,
2006
50
104 in hyperkyphotic posture group
(mean age = 77.6 ± 8.1 y), 492 in
nonhyperkyphotic posture group
(mean age = 69.1 ± 8.8 y), only females
Measurement of degree of thoracic kyphosis
in supine position, questionnaire to assess
fractures, radiographs for assessment of
vertebral fractures, BMD using DXA scanners
Association between hyperkyphosis
and future fractures independent of
osteoporosis, BMD, or fracture history
Increased risk of fractures in ambulatory elderly
women with hyperkyphotic posture irrespective
of BMD, body mass index, lifestyle, age, or
any fracture history
ASES, American Shoulder and Elbow Surgeons Standardized Shoulder Form Patient Self-Report Section; BMD, bone mineral density; CHP, corrected head posture (corrected by therapist); DXA, dual-energy
X-ray absorptiometry; EMG, electromyography; ES, erector spinae muscles; FEV1, forced expiratory volume in 1 s; FHP, forward head posture; FHRSP, forward head and rounded shoulders posture; FSP,
forward shoulder posture; FVC, forced vital capacity; IHP, ideal head posture (considered ideal by participant); LD, latissimus dorsi; LT, lower trapezius; MT, middle trapezius; NHP, natural head posture
(represents forward head and rounded shoulders); PM, pectoralis major; SA, serratus anterior; SCM, sternocleidomastoid; UP, upper trapezius, UT, upper trapezius.
225Singla, VeqarJournal of Chiropractic Medicine
Head, Shoulder, and Thoracic PostureVolume 16, Number 3
Table 3. Studies Illustrating the Impact of FHP, FSP, and Thoracic Kyphosis on Head and/or Shoulder and/or Thoracic Posture
Research Sample Method Used Investigation Done Result P
Pearsons
Correlation
Coefficient, r
Lee et al, 2015
26
18 with FScP, mean
age = 33.78 ± 11.15 y,
both genders
Pm index, thoracic spine
angle (using digital
photogrammetry), SA strength
(using dynamometer), gleno
humeral horizontal adduction and
internal rotation tests
Correlation between FScP and Pm
length, SA strength, thoracic spine
kyphosis, and tightness of posterior
shoulder
There is an association between FScP and
decreased Pm length, decreased SA strength,
decreased thoracic spine kyphosis, and
increased tightness of posterior shoulder
.001 0.72
Erkan et al, 2010
53
68 with loss of cervical
lordosis, 160 with
physiological cervical
lordosis, 13-72 y
old, both genders
Radiographs, Cobb method Influence of cervical lordosis
angle on thoracic kyphosis angle
Less pronounced thoracic kyphosis in
subjects with lesser cervical lordosis angles
when compared with subjects having
physiological cervical lordosis
.001
Kebaetse et al, 1999
25
34 healthy participants, mean
age = 30.2 y, both genders
Skeletal analysis system
(3-D electromechanical
digitizer)
Measurement of thoracic
flexion and scapular orientation
during erect sitting and
slouched sitting along with
arm movement at the side and
abduction in the scapular plane
Increased scapular elevation (between 0°
and 90° abduction); decreased posterior
tilting of scapula (beyond 90° abduction)
and decreased range of shoulder abduction
in slouched posture
0
Raine and Twomey, 1994
12
39, 17-48 y old,
both genders
Photographs Association between various
measurements of head, neck,
shoulder, and thoracic posture
Significant correlations between
forward head position, forward
shoulder position, and increased
thoracic kyphosis
0.35-0.43
3-D, three-dimensional; FHP, forward head posture; FScP, forward scapular pressure; FSP, forward shoulder posture; Pm, pectoralis minor; SA, serratus anterior.
226 Journal of Chiropractic MedicineSingla, Veqar
September 2017Head, Shoulder, and Thoracic Posture
lumbar lordosis,
9
low back pain,
46
and osteoporosis
47
as
well as in postmenopausal women
48
(Table 1).
Christie et al
46
measured head position, shoulder
position (relative measure of protraction and retraction),
shoulder height discrepancy, and thoracic kyphosis of
subjects with low back pain and without low back pain.
Subjects with low back pain were experiencing either
chronic pain or acute pain. Thoracic kyphosis was found to
be significantly greater in the acute pain group compared
with the control group in both standing and sitting
positions. Also, the acute pain group exhibited an increased
forward head position compared with the control group in
standing position only. It is noteworthy that the values for
thoracic kyphosis and shoulder position were always
greater in the back pain groups than in the control group,
in both standing and sitting positions, irrespective of the
existence of significant differences between the groups.
With increased kyphosis at the thoracic spine, anterior
longitudinal ligament and upper abdominal muscles are
shortened and the anterior aspect of vertebral bodies is
compressed, leading to increases in intradiscal pressures.
Also, the extensor muscles and posterior ligaments of the
dorsal spine are stretched along with the capsules of the
facet joints and the posterior fibers of the annulus fibrosus.
7
The condition might lead to pain,
49
expansion of rib cage,
poor balance, and, thus, the risk of falls in geriatric
participants.
20
With increasing age, gradually the connec-
tive tissues lose their elasticity and become inefficient in
counteracting the torque produced by gravity.
48
However,
kyphosis associated with increasing age is mild and does
not cause much of a problem.
4
However, an excessive degree
of kyphosis (hyperkyphotic posture) might be a risk factor for
fractures (Table 2). Hyperkyphosis might lead to complications
such as poor respiratory function, compromised physical
function, and increased mortality.
50
Thus, it is plausible to say
that this type of posture deserves clinical attention.
DISCUSSION
Alteration in the resting scapular position is thought to
occur with abnormal alignment of the cervical and thoracic
spine.
51
FSP can be associated with FHP,
52
increased
thoracic kyphotic posture,
19,25,26
or both
12,15
(Table 3).
The scapula has been found to be anteriorly tilted,
downwardly rotated, and protracted during elevation of the
arm in persons with FHP. A decrease in serratus anterior
activity has been observed in persons with FHP while doing
arm elevation and lifting activities. This reduction in serratus
anterior activity leads to anterior tilting of the scapula, as well
as winging of the scapula (because the serratus anterior
stabilizes the scapula on the thorax).
32
Increased forward angulation of the scapula can be
observed with an increase in slope of the upper thoracic
spine. The angle formed between the clavicle and the scapula
in the transverse plane increases too much owing to the rib
cage expansion and increased anteroposterior diameter of the
chest caused by increased thoracic kyphosis. Thoracic spine
posture also influences scapular and glenohumeral kinemat-
ics. Increased flexion at the thoracic spine could lead to
reduced elevation range of motion at the glenohumeral joint.
Also, reduced scapular posterior tilting and increased
scapular elevation might be evident while doing elevation
at the shoulder.
15,25,51,53
The thoracic spine is less mobile and, thus, more stable
in comparison to the cervical region. This stability is
attributed to the presence of ribs, lesser intervertebral disk
height, and the plane of facet joints.
7,49
The literature
contains scientific evidence that increased cervical lordosis
can lead to more pronounced thoracic kyphosis. In a recent
study,
27
the amount of cervical lordosis was found to
correlate with the degree of thoracic kyphosis. Two hundred
twenty-eight subjects were divided into two groups based
on the radiological findings. Group 1 subjects were
characterized by loss of cervical lordosis, and group 2
subjects had physiologic lordotic cervical curvature. Whole
(T1-12), lower (T6-12), and upper (T1-6) thoracic kyphosis
was determined using the Cobb method. The mean values
for group 1 were found to be lower for upper, lower, and
whole thoracic kyphosis than the mean values for group 2.
Another study found a significant correlation between FHP
and thoracic kyphosis.
43
The aforementioned studies hence provide evidence of
an association between FHP and rounded shoulders,
5,52
between FHP and thoracic kyphosis,
27,46
and between
rounded shoulders and thoracic kyphosis.
19,25,26
To the best
of our knowledge, only 4 papers were found that best
supported the objective of this review. As can be observed
in Tables 1 and 2, there is heterogeneity in the methods
employed by these studies to observe posture; thus, we
could not reach a definitive conclusion regarding the cause
of FHP, FSP, or thoracic kyphosis, that is, what happens
first among the 3 and what happens next. More research
studies are required to answer the question and report that it
is a cascade of biomechanical changes starting with 1 of the
3 deviations leading to the other 2 deviations.
Although there is consensus on the coexistence of FHP,
FSP, and increased thoracic kyphosis, there remains doubt
about 1 being the cause or the consequence of the other.
Research is required to test the cause-and-effect relationship
between the 3 postural deviations. Researchers are
encouraged to explore the link between forward head,
forward shoulder, and thoracic kyphotic posture so that
these conditions can be treated effectively.
Limitations
This study was limited by the search terms and indexes
searched. Therefore, it is possible that other studies may exist
that were not included. Because so few studies were found,
the conclusions based on the findings are limited as well.
227
Singla, VeqarJournal of Chiropractic Medicine
Head, Shoulder, and Thoracic PostureVolume 16, Number 3
CONCLUSION
On the basis of the literature, there appears to be a
relationship between FHP, FSP, and thoracic kyphosis.
Current evidence limits our understanding of the association
between these 3 conditions. It is unclear whether any of these
3 postural deviations is a cause or a consequence of the other
2 deviations. However, it is clear that 2 or all 3 deviations can
co-exist.
FUNDING SOURCES AND CONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
D.S.
Design (planned the methods to generate the results):
D.S., Z.V.
Supervision (provided oversight, responsible for
organization and implementation, writing of the
manuscript): Z.V.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data): D.S.
Analysis/interpretation (responsible for statistical analysis,
evaluation, and presentation of the results): D.S., Z.V.
Literature search (performed the literature search): D.S.
Writing (responsible for writing a substantive part of the
manuscript): D.S.
Critical review (revised manuscript for intellectual
content, this does not relate to spelling and grammar
checking): Z.V.
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229Singla, VeqarJournal of Chiropractic Medicine
Head, Shoulder, and Thoracic PostureVolume 16, Number 3
... These alterations consequently increase muscle tension and stress in the neck and shoulder, resulting in pain, numbness, loss of function, and other symptoms of neuromuscular disorders [2,3]. Continuous contractions of the head and neck muscles for long periods gradually contribute to joint misalignment, forward head and shoulder posture, thoracic kyphosis, and loss of the normal cervical lordotic curve [4][5][6]. Risk factors of developing FSP include weakened and lengthened lower trapezius (LT) and serratus anterior (SA) muscles, and shortened, pectoralis minor, pectoralis major (PM), and upper trapezius (UT) muscles [7][8][9][10][11]. FSP can lead to abnormal scapulohumeral rhythm, impingement of rotator cuff tendons, acromioclavicular joint degeneration, bicipital tendonitis, and activation of trigger points [6,12,13]. ...
... Risk factors of developing FSP include weakened and lengthened lower trapezius (LT) and serratus anterior (SA) muscles, and shortened, pectoralis minor, pectoralis major (PM), and upper trapezius (UT) muscles [7][8][9][10][11]. FSP can lead to abnormal scapulohumeral rhythm, impingement of rotator cuff tendons, acromioclavicular joint degeneration, bicipital tendonitis, and activation of trigger points [6,12,13]. ...
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... The previous study revealed that thickness change of Longus colli (LCo) muscle between resting and contraction state was significantly smaller in women with forward head posture compared with control group which this muscle is important in controlling cervical lordosis and maintaining normal posture of the cervical spine (40). Furthermore, Singla and Veqar (39) reported that thoracic kyphosis increased resulting in decreased movement of glenohumeral joints. Accordingly, the theory and principle of biomechanical of lumbar spine and pelvic rhythm, since the pelvic floor is structured next to the sacrum and the upper of sacrum bone attached to the lumbar spine and the lower part is attached to coccyx bone, which likes chain. ...
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Background: Musculoskeletal disorders are common problems among dentists. These conditions may lead to inappropriate postures and impairment in physical and psychological function. On the other hand, poor postures and inappropriate ergonomic may result in a wide variety of musculoskeletal disorders. Objectives: The aim of this study was to investigate the prevalence of common postural disorders of the spine and shoulder girdle among the dentists and possible correlations between demographic, anthropometric and occupational characteristics with these abnormal postures. Patients and methods: In a cross-sectional study, 96 dental staff including academic staff, residents and senior students of Tehran University of Medical Sciences was enrolled. Data were collected using a questionnaire and posture assessment tools such as plumb-line, checkerboard and flexible ruler. Data analysis was done with SPSS version 17. Results: The prevalence of the forward head posture (FHP), rounded shoulder posture (RSP), scoliosis and hyperlordosis were reported in 85.5%, 68.8%, 18.8% and 17.3% of the participants, respectively. A significant correlation was found between gender and FHP (P = 0.04) and also scoliosis (P = 0.009). On the other hand, a significant correlation was seen between weight and hyperlordosis (P = 0.007). Conclusions: Our study revealed a high prevalence of postural disorders especially FHP, RSP and scoliosis among Iranian dental staff. The female dentists were less susceptible to FHP and scoliosis.
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Objective: To compare quantitative muscle activation between erect and slouched sitting postures in the muscles around the scapula, and to investigate the correlation between the angle of thoracic kyphosis and the alteration of muscle activity depending on two different sitting postures. Methods: Ten healthy males participated in the study. Unilateral surface electromyography (SEMG) was performed for serratus anterior, middle trapezius (MT), and lower trapezius (LT), which are scapular stabilizer muscles, as well as latissimus dorsi. Participants elevated their shoulders for 3 seconds up to 90° abduction in the scapular plane, tilting 30° anterior in the coronal plane. They were told to hold the position for 10 seconds and voluntary isometric contractions were recorded by SEMG. These movement procedures were conducted for three times each for erect and slouched sitting postures and data were averaged. Results: Activities of MT and LT increased significantly more in the slouched sitting posture than in the erect one. There was no significant correlation between kyphotic angle and the area under curve of each muscle. Conclusion: Because MT and LT are known as prime movers of scapular rotation, the findings of this study support the notion that slouched sitting posture affects scapular movement. Such scapular dyskinesis during arm elevation leads to scapular stabilizers becoming overactive, and is relevant to muscle fatigue. Thus, slouched sitting posture could be one of the risk factors involved in musculoskeletal pain around scapulae.
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[Purpose] To determine the effects of forward head posture on static and dynamic balance control. [Subjects and Methods] This study included 30 participants who were included into a forward head posture group (n = 14) and a control group (n = 16) according to their craniovertebral angles. Static balance control was assessed according to center of gravity sway velocity and total sway distance using an automatic balance calibration system. Dynamic balance control was assessed using the diagnosis mode of a body-tilt training and measurement system. [Results] Sway velocities on a hard surface with eyes open and closed and those on an unstable sponge surface with eyes closed were significantly higher in the forward head posture group than in the control group. Furthermore, on both the hard and sponge surfaces in the eyes open and closed conditions, total sway distances were significantly higher in the forward head posture group than in the control group. Results of dynamic balance control were not significantly different between groups. [Conclusion] Forward head posture has a greater effect on static balance control than on dynamic balance control.
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[Purpose] This study investigated the effects of forward head posture on forced vital capacity and deep breathing. [Subjects] Twenty-six subjects, divided into the two groups (normal and forward head posture groups), participated in this study. [Methods] Forced vital capacity and forced expiratory volume in 1 second were measured using respiratory function instrumentation that met the American Thoracic Society’s recommendation for diagnostic spirometry. Accessory respiratory muscle activity during deep breathing was measured by electromyography. A Mann-Whitney test was used to compare the measure variables between the normal and forward head posture group. [Results] Forced vital capacity and forced expiratory volume in 1 second were significantly lower in the forward head posture group than in the normal group. Accessory respiratory muscle activity was also lower in the forward head posture group than in the normal group. In particular, the sternocleidomastoid and pectoralis major activity of the forward head posture group was significantly lower than that of normal group. Activities of the other muscles were generally decreased with forward head posture, but were not significantly different between the two groups. [Conclusion] These results indicate that forward head posture could reduce vital capacity, possibly because of weakness or disharmony of the accessory respiratory muscles.
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[Purpose] The aim of this study was to evaluate the changes in posture and respiratory functions depending on the duration of smartphone usage. [Subjects and Methods] Participants were randomly allocated to 2 groups: group 1 (subjects who used smartphones for <4 hours/day, n=25) and group 2 (subjects who used smartphones for >4 hours/day, n=25). The craniovertebral angles of all participants were measured and scapular indices were calculated to assess the change in posture and forced vital capacity, forced expiratory volume in 1 second, the ratio of forced expiratory volume in 1 second to forced vital capacity, and peak expiratory flow were measured to assess changes in respiratory function. [Results] There were significant differences in the craniovertebral angle, scapular index, and peak expiratory flow depending on the duration of smartphone usage. [Conclusion] The result of this study showed that prolonged use of smartphones could negatively affect both, posture and respiratory function.
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Context: Alterations to upper extremity physical characteristics of competitive swimmers (posture, range of motion [ROM], and subacromial-space distance) are commonly attributed to cumulative training load during a swimmer's competitive career. However, this accepted clinical belief has not been established in the literature. It is important to understand whether alterations in posture and associated physical characteristics occur as a result of sport training or factors other than swimming participation to better understand injury risk and possible interventions. Objective: To compare posture, subacromial-space distance, and glenohumeral external-rotation, internal-rotation, and horizontal-adduction ROM between adolescent competitive swimmers and nonoverhead athletes. Design: Cross-sectional study. Setting: Local swimming pools and high school athletic training rooms. Patients or other participants: Forty-four competitive adolescent swimmers and 31 nonoverhead athletes who were not currently experiencing any elbow, shoulder, neck, or back pain that limited their sport activity. Intervention(s): Posture, subacromial-space distance, and glenohumeral ROM were measured using photography, diagnostic ultrasound, and a digital inclinometer, respectively. Main outcome measure(s): Forward shoulder posture, forward head posture, normalized subacromial-space distance, internal-rotation ROM, and external-rotation ROM. Results: No clinically significant differences existed between swimmers and nonoverhead athletes for posture, normalized subacromial-space distance, or external- or internal-rotation ROM. Swimmers presented with less horizontal-adduction ROM than nonoverhead athletes. Conclusions: Factors other than swimming participation, such as school and technology use, play important roles in the adaptation of physical characteristics in adolescents. Adolescents, regardless of swimming participation, presented with postural deviations. It is important to consider factors other than swimming participation that contribute to alterations in physical characteristics to understand injury risk and injury-prevention strategies in competitive adolescent swimmers.
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Purpose: The head represents 6% of total body weight, therefore it can significantly affect the biomechanics of human posture control, movements and activities. When set out of vertical body axis, head position interferes with the work of the other links in the kinematic chain. The aim of our study was to evaluate the effect of head posture on the breathing activities of the chest. Material and methods: The research was conducted on a group of 65 patients (51 years ± 9.8 years), including 48 women and 17 men. Head posture and chest movements were assessed using a photogrammetric method. Results: The results confirmed the existence of a negative correlation between head position in the sagittal plane and movements of lower ribs. Forward head posture resulted in lower amplitude of costal arch motion: for the transverse plane Spearman's R = -0.296, for the frontal plane; -0.273, -0.289. Tilting the head in the frontal plane also influenced the change in the biomechanics of breathing and contributed to a reduction of respiratory movements of the lower ribs Spearman's R = -0.260. Conclusions: Changing the position of the head causes disturbances in the three-dimensional shape of the chest and its respiratory movements.
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There is a growing body of literature associating abnormal scapular positions and motions, and, to a lesser degree, clavicular kinematics with a variety of shoulder pathologies. The purpose of this manuscript is to (1) review the normal kinematics of the scapula and clavicle during arm elevation, (2) review the evidence for abnormal scapular and clavicular kinematics in glenohumeral joint pathologies, (3) review potential biomechanical implications and mechanisms of these kinematic alterations, and (4) relate these biomechanical factors to considerations in the patient management process for these disorders. There is evidence of scapular kinematic alterations associated with shoulder impingement, rotator cuff tendinopathy, rotator cuff tears, glenohumeral instability, adhesive capsulitis, and stiff shoulders. There is also evidence for altered muscle activation in these patient populations, particularly, reduced serratus anterior and increased upper trapezius activation. Scapular kinematic alterations similar to those found in patient populations have been identified in subjects with a short rest length of the pectoralis minor, tight soft-tissue structures in the posterior shoulder region, excessive thoracic kyphosis, or with flexed thoracic postures. This suggests that attention to these factors is warranted in the clinical evaluation and treatment of these patients. The available evidence in clinical trials supports the use of therapeutic exercise in rehabilitating these patients, while further gains in effectiveness should continue to be pursued.