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Plausible impact of forward head posture on upper cervical spine stability

May 2020
Journal of Family Medicine and Primary Care 9(5):2517-2520

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New York Medical Group

The cervical spine is responsible for allowing mobility and stability to the head and neck. Any deviation to the center of gravity of the head results in an increase in cantilever loads, which can be particularly damaging to the upper cervical joints. Excessive neck bending also exaggerates stretching through the cervical spine and all of the spinal structures below. It has been reported that forward head posture (FHP) can cause a multitude of disorders including cervical radiculopathy, cervicogenic headaches and cervicogenic dizziness. Most of these conditions manifest with clusters of painful symptoms and spine dysfunctions. The purpose of this case study is to describe the radiographic imaging considerations and to illustrate the potential impacts in symptomatic adults with FHP. We randomly selected radiographs of three individuals with FHP who had undergone cervical adjustment for cervical pain. The occipito‐axial (C0‐C2) and atlanto‐axial (C1‐C2) joints were assessed via the C0‐2 distance from the C2 base to the McGregor line (Redlund‐Johnell criterion) and the Ranawat C1‐2 index, in addition to subjective radiographic parameters. By comparing the radiographs of before‐and‐after intervention of each patient, a regressive joint spacing was observed from both indices. Such a long‐lasting stretching concordant with FHP was assumed to be hazardous to joint stability. A definite conclusion, however, cannot be drawn due to the small sample size and a lack of convincing measurements.

Cervical spine lateral view of Case 2. (a) Prior to treatment lateral radiograph displayed a reverse cervical lordosis, degenerative spondylosis with ankylosis of the C7/T1 facet joints (red circle). The cervical gravity line (blue dotted line) just touched the anterior body of the C7. (b) The repeat lateral radiographs 9 months later exhibited improved general cervical lordosis. A smooth vertical alignment of each posterior body corner was noted. The cervical gravity line fell within the C7 vertebra. Redlund-Johnell criterion (white dotted line) was reduced by 6.55% and Ranawat index (red dotted line) was reduced by 8.88%

…

X-ray comparison of pre- and post-intervention in Case 1. (a) The initial X-ray displayed a loss of cervical lordosis, backward subluxation of the C4 on C5 (red circle), and an occipital enthesophyte (white arrow). The cervical gravity line (blue dotted line) fell forward of the C7 suggestive of anterior head placement. (b) The 9 months follow-up X-ray showed the correction of both the neck curve and the forward head posture. The cervical gravity line fell within the C7 vertebra. Redlund-Johnell criterion (white dotted line) was reduced by 11.11% and Ranawat index (red dotted line) was reduced by 13.72%

…

Open mouth radiographs of Case 2 (a) and of Case 3 (b) at initial presentation. There was symmetrical spacing of lateral zygapophyseal (C1-C2) joints and of odontoid-lateral mass intervals. Note a deviation of the C2 spinous process with respect to the alignment of the dens, a suggestive finding of C2 rotation

…

Initial and follow-up radiographs of Case 3. (a) Initial radiograph showed a loss of cervical lordosis, osteophytic lipping of the vertebrae, narrowing of the joint space of the C7/T1, and facetitis of the right C5/C6 and C7/T1 facet joints. (b) The repeat radiography 2 years later exhibited improved general cervical lordosis. There was a smooth vertical alignment of each posterior vertebral corner. Redlund-Johnell criterion (white dotted line) was reduced by 6.34% and Ranawat index (red dotted line) was reduced by 10.41% FHP (Forward head posture)

…

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Introduction

Ithasbeenreportedthatforwardheadposture(FHP)cancause

a multitude of disorders including cervical radiculopathy,[1]

cervicogenic headaches,[2] and cervicogenic dizziness.[3] The

purpose of this report is to shed light on the potential impacts

of  FHP on upper cervical stability in symptomatic adults.

Radiographic parameters used in this report included the

following: The center of gravity of the head was approximated

by using the anterior portion of the external auditory canal as

the initial point for the plumb line,[4] cervical gravity line is a

plumb line drawn through the apex of the dens. Both gravity

lines allow a gross assessment of the gravitational stresses.

McGregor’slineisthelinedrawnbetweenthehardpalateand

the most caudal occipital point, and is used to assess a vertical

displacement of the C2 relative to insert proper parameter.

Redlund‑Johnell criterion is the distance from the base of C2

totheMcGregor’sline(males>34mmandfemales>29mm).

Ranawat’s line is the perpendicular distance between the midpoint

of the base of C2 and a line drawn along the axis of the C1

vertebra,(males>23.7 mm, females>24.2mm).[5] Swischuk’s

line is the line drawn between the laminae of C1 and C3 on a

lateralX‑ray.C2shouldbewithin1.5–2mmof thisline.There

are several radiographic parameters commonly used to assess

the cervical alignment including lordotic angle, cranio‑vertebral

angle, neck tilt, etc., However, a gross angle measurement may

be obliterated by the effect of segmental deformities, as those

Plausible impact of forward head posture on upper

cervical spine stability

Eric C. P. Chu1, Fa Sain Lo1, Amiya Bhaumik2

1New York Chiropractic and Physiotherapy Centre, New York Medical Group, Hong Kong, China, 2Faculty of Sciences, Lincoln

University College, Kelantan, Malaysia

Abs tr Ac t

The cervical spine is responsible for allowing mobility and stability to the head and neck. Any deviation to the center of gravity of

the head results in an increase in cantilever loads, which can be particularly damaging to the upper cervical joints. Excessive neck

bending also exaggerates stretching through the cervical spine and all of the spinal structures below. It has been reported that forward

head posture (FHP) can cause a multitude of disorders including cervical radiculopathy, cervicogenic headaches and cervicogenic

dizziness. Most of these conditions manifest with clusters of painful symptoms and spine dysfunctions. The purpose of this case

study is to describe the radiographic imaging considerations and to illustrate the potential impacts in symptomatic adults with

FHP. We randomly selected radiographs of three individuals with FHP who had undergone cervical adjustment for cervical pain.

The occipito‑axial (C0‑C2) and atlanto‑axial (C1‑C2) joints were assessed via the C0‑2 distance from the C2 base to the McGregor

line (Redlund‑Johnell criterion) and the Ranawat C1‑2 index, in addition to subjective radiographic parameters. By comparing the

radiographs of before‑and‑after intervention of each patient, a regressive joint spacing was observed from both indices. Such a

long‑lasting stretching concordant with FHP was assumed to be hazardous to joint stability. A definite conclusion, however, cannot

be drawn due to the small sample size and a lack of convincing measurements.

Keywords: Atlantoaxial joint, cervical adjustment, forward head posture, instability, occipito‑axial joint

Case Report

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DOI:

10.4103/jfmpc.jfmpc_95_20

Address for correspondence: Dr. Eric C. P. Chu,

New York Chiropractic and Physiotherapy Centre, 41/F Langham

Place Office Tower, 8 Argyle Street, Hong Kong, China.

E‑mail: eric@nymg.com.hk

How to cite this article: Chu EC, Lo FS, Bhaumik A. Plausible impact

of forward head posture on upper cervical spine stability. J Family Med

Prim Care 2020;9:2517-20.

This is an open access journal, and articles are distributed under the terms of the Creative

Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to

remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is

given and the new creations are licensed under the identical terms.

For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

Received: 16‑01‑2020 Revised: 12‑03‑2020

Accepted: 15‑03‑2020 Published: 31‑05‑2020

Chu, et al.: Cervical instability in forward head posture

Journal of Family Medicine and Primary Care 2518 Volume 9 : Issue 5 : May 2020

with the S‑shaped cervical curvature [Figure 1a]. The regional

vertebral anomaly must be taken into consideration when dealing

with a gross curve assessment.

Case Reports

This retrospective chart review was exempted from the ethics

committee/IRB approval.

Case 1

A55‑year‑oldmale, ofceworker,presentedwith ahistoryof 

progressively worsening nuchal pain and paresthesias radiating

into the right shoulder and arm of 6 months duration. The

symptoms were worse in the latter part of the day. On clinical

examination,thepatientexhibitedforwardheadposture(FHP),

joint restrictions in upper and mid cervical regions, limited

cervical extension, and sensory deficit consistent with C5

dermatomal distribution. The cervical radiography [Figure 1a]

showed a loss of cervical lordosis, backward subluxation of

the C4 on C5 (red circle), and an occipital enthesophyte (white

arrow). A right C5 radiculopathy was diagnosed, and subsequently

cervical adjustment was commenced. After 12 sessions of

chiropractic treatment, the patient experienced complete

alleviation from nuchal pain and radicular symptoms. At 9 month

follow‑up radiographs revealed a restoration of the cervical

curvature [Figure 1b].

Case 2

A 49‑year‑old female, accounting manager, presented with neck

pain and radicular pain travelling down the right shoulder and

back of the arm and forearm, going into the 4th and 5th digits.

The symptoms were sometimes exacerbated after working on a

computer for long periods. Her primary care physician suggested

that she was suffering from a spinal degeneration and cervical

radiculopathy. The patient underwent physiotherapy and was

prescribed pain medications and herbal remedies over 9 months

duration with only minimal relief. Upon presentation to

our clinic, the patient exhibited FHP. The cervical range of 

motion(ROM)waslimitedto50°rightrotation(normal>90°)

and30°extension(normal>70°).Theintersegmentalrestrictions

were found at C4/5, C5/6, and C7/T1 levels. The cervical

radiography [Figure 2a] displayed reverse cervical lordosis and

degenerative spondylosis with ankylosis of the C7/T1 facet

joints (red circle). In addition, some rotatory displacement of

the C2 was suspected on open mouth view [Figure 3a]. The

patient underwent chiropractic treatment consisting of thermal

ultrasound therapy, spinal mobilization, cervical adjustment, and

cervical extension‑compression traction. The symptoms started

to get better and were resolved at 2 months. The X‑ray indicated

a satisfactory restoration of the cervical lordosis at 9 months

follow‑up [Figure 2b].

Case 3

A 43‑year‑old female, tness trainer,complained of  chronic

nuchal pain and bilateral upper arm pain. Her symptoms

began 2 years prior and had intermittent, insidious symptom

exacerbation. She described the pain as starting from her neck

and extending down to her right shoulder and then to the lateral

forearm. In the absence of  identiable pathology on cer vical

magnetic resonance imaging (MRI), she initiated non steroidal

anti‑inammatorydrugs(NSAID)treatmentanddidnotattain

anysignicantimprovement.Theregularmassagetherapyoffered

some temporary symptomatic relief but no long lasting results.

Approximately one week prior to presenting to our clinic, the

patient had experienced severe, acuteare‑up of  the nuchal

symptoms with shoulder numbness. She sought chiropractic

Figure 2: Cervical spine lateral view of Case 2. (a) Prior to treatment

lateral radiograph displayed a reverse cervical lordosis, degenerative

spondylosis with ankylosis of the C7/T1 facet joints (red circle). The

cervical gravity line (blue dotted line) just touched the anterior body

of the C7. (b) The repeat lateral radiographs 9 months later exhibited

improved general cervical lordosis. A smooth vertical alignment of each

posterior body corner was noted. The cervical gravity line fell within the

C7 vertebra. Redlund‑Johnell criterion (white dotted line) was reduced

by 6.55% and Ranawat index (red dotted line) was reduced by 8.88%

Figure 1: X‑ray comparison of pre‑ and post‑intervention in

Case 1. (a) The initial X‑ray displayed a loss of cervical lordosis,

backward subluxation of the C4 on C5 (red circle), and an occipital

enthesophyte (white arrow). The cervical gravity line (blue dotted line)

fell forward of the C7 suggestive of anterior head placement. (b) The

9 months follow‑up X‑ray showed the correction of both the neck curve

and the forward head posture. The cervical gravity line fell within the C7

vertebra. Redlund‑Johnell criterion (white dotted line) was reduced by

11.11% and Ranawat index (red dotted line) was reduced by 13.72%

Chu, et al.: Cervical instability in forward head posture

Journal of Family Medicine and Primary Care 2519 Volume 9 : Issue 5 : May 2020

care and rated the pain at 4/10 on a numeric pain score. The

cervicalROMwaslimitedto70°bilateralrotation(normal>90°)

and40°extension(normal>70°).Thespinalpalpationrevealed

intersegmental restriction at the cervicothoracic junction. The

cervical radiography [Figure 4a] revealed a loss of cervical

lordosis, narrowing of the C7/T1 interspace, and facetitis of

the right C5/C6 and C7/T1 facet joints. In addition, some

rotatory displacement of the C2 was suspected on open mouth

view [Figure 3b]. She was diagnosed with degenerative spondylosis

with possible right C6 radiculopathy. The treatment included

thermal ultrasound, cervical extension‑compression traction, and

spinal manipulation. Within 3 months of initiating the treatment,

thepatient hadsignicant improvementof  hersymptoms and

continued to receive maintenance chiropractic treatment. The

radiographs obtained 2 years since the beginning of treatment

revealed complete restoration of the cervical curve [Figure 4b].

Discussion

The upper cervical spine (C0‑C2) is responsible for 50% of

total neck exion and extensionas as well as 50% of  overall

cervicalrotation.TheFHPinvolvesincreasedextensionsof the

upper cervical vertebrae, extension of the occiput on C1, and

increasedexionof thelowercervicalvertebraeandtheupper

thoracic regions. While the ligaments act as sensory organs

involvedinligamento‑muscularreexes,jointdisplacement(s)

producepainandmusclespasms.Thereexisemanatedfrom

the ligamentous mechanoreceptors (i.e. pacinian corpuscles,

golgi tendon organs, and rufni endings) and transmitted to

the muscles.[6] In the upper cervical spine, joint instability can

cause a number of biomechanical symptoms including, but not

limitedto,vertebrobasilarinsufciency,cervicogenicdizziness,

head and facial pain, nerve irritation, and cervical radiculopathy.[6]

Therefore,itisreasonabletoassumethatinsomecasesof FHP,

the root cause of complaints may be underlying biomechanical

effects due to joint instability.

A bony spur (enthesophyte) projecting from the external

occipital protuberance [Figure 1a] is a vestigial trait as evidence

for previous enthesitis (insertional tendinitis). The enthesis is

the insertional site of where a tendon or ligament attaches to

the bone. Repetitive biomechanical strain and micro damage

caninducecytokinestotriggeraninammatoryresponseinthe

adjacent synovial tissue leading to synovitis.[7] Substantial immune

responsecontributesto abnormalinductionof brous tissue/

bro cartilage‑bone interactions resulting in radiographically

detectable enthesopathy (insertional tendinopathy).[7,8] In cases of

FHP,longlastingpullonthenuchalligamentandnuchalmuscle

created by abnormal postures can cause insertional tendinitis

and bony spur in the nuchal ligament, which extends from the

external occipital protuberance to the spinous process of the

7th cervical vertebra.

The scientic literature indicates that posture, radiographic

positioning, and radiographic line drawing are all very reliable/

repeatable.[9] There are some limitations for the measurement

of  distance and cervical angle. Firstly,most radiog raphic

lms were obtained retrospectively from clinicians’ referral.

There were technical problems to measure the length of line

segments from hard‑copy lms. Secondly, the patients were

positioned to be routinely desired while taking radiography.

The lordosis angle measurement may be independent of a

resting posture. In addition to the effect of segmental spine

deformity,justmeasuringC2‑C7lordosisangledidnotreecta

gross curvature. The S‑shaped cervical spine may obliterate the

angle measurement by a compensatory backward tilting at the

lower neck [Figure 1a]. However, the afore mentioned biases

would be avoided because the radiographic parameters in this

report were analyzed by comparing the differences between the

before‑and‑after images. Both Redlund‑Johnell (white dotted

line) and Ranawat (red dotted line) indices regressed, with average

Figure 3: Open mouth radiographs of Case 2 (a) and of Case 3 (b)

at initial presentation. There was symmetrical spacing of lateral

zygapophyseal (C1‑C2) joints and of odontoid‑lateral mass intervals.

Note a deviation of the C2 spinous process with respect to the alignment

of the dens, a suggestive nding of C2 rotation

Figure 4: Initial and follow‑up radiographs of Case 3. (a) Initial radiograph

showed a loss of cervical lordosis, osteophytic lipping of the vertebrae,

narrowing of the joint space of the C7/T1, and facetitis of the right C5/C6

and C7/T1 facet joints. (b) The repeat radiography 2 years later exhibited

improved general cervical lordosis. There was a smooth vertical alignment

of each posterior vertebral corner. Redlund‑Johnell criterion (white dotted

line) was reduced by 6.34% and Ranawat index (red dotted line) was

reduced by 10.41% FHP (Forward head posture)

Chu, et al.: Cervical instability in forward head posture

Journal of Family Medicine and Primary Care 2520 Volume 9 : Issue 5 : May 2020

approximation of 8% and 11% respectively. The symptomatic

improvement is the supporting evidence for radiographic

changes. Any pre‑to‑post alignment changes in patients are a

result of the treatment procedures applied.[9]

The most common postural abnormality is the FHP arising

from modern lifestyle. An observational assessment by a

generalpractitionerwilldetectsignicantfaultsintheposture,

e.g. presence of head tilt, forward head posture, uneven shoulders,

spinal misalignment, and spinal curvature deformities. It will

give an overview of the patient’s problems in clinical settings.

Analysis of a patient’s posture offers information about the

muscle endurance and the muscle capability to cope with physical

stressors. Severalrepor ts haveestablished the FHP as a real

clinicalentitywithsignicantmusculoskeletalconsequences.[10]

TheFHPcangetworseovertime,causingspinaldegeneration,

muscle weakness and tightness, entrapment neuropathies, and

the loss of vital lung capacity. The general practitioner provides

immediatemedicalassistancefortheFHPpatientwithabroad

range of complains. The practitioner can become an effective

facilitator for alleviating pain and preventing damage where

abnormal posture is found to be a main contributing factor.

Conclusion

By comparing the radiographs before‑and‑after correction of

theFHPinthreesymptomaticpatients,aregressivejointspacing

was observed from both Redlund‑Johnell criterion ((C0‑C2))

and the Ranawat C1‑2 index. The radiographic parameters

illustrated the potential impacts on upper cervical stability in

symptomatic cases.

Declaration of patient consent

A copy of the written consent is available for review by the

Editor‑in Chief of this journal.

Financial support and sponsorship

Nil

Conflicts of interest

Theauthorshavenoconictsof interesttodeclare.

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insights into pathogenesis, diagnostic modalities, and

treatment. Arthritis Rheumatol 2016;68:312‑22.

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Morphological observation of occipital condyle position in Chinese skulls and potential clinical significance

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Oct 2024

Background: To study the anatomy of the Chinese occipital condyle and its position relative to the occipital foramen and skull. Materials and methods: Measurements were taken from 106 adult Chinese skulls using a Cartesian coordinate system centered on the foramen magnum. Measurements included the longitudinal diameter of the foramen magnum, distances from various points on the occipital condyles to the foramen magnum and skull landmarks, and the occipital condyle classification index (OCI) and skull-occipital condyle classification index (SOCI). Results: OCI categorized the position of the foramen magnum and occipital condyles into three groups: OCI ≤ 0.40 (3 cases, 2.83%), 0.40 < OCI ≤ 0.50 (75 cases, 70.75%), and OCI > 0.50 (28 cases, 26.42%). SOCI categorized the relationship between the skull and occipital condyles into two groups: 0.5 < SOCI ≤ 0.6 (49 cases, 46.23%) and 0.6 < SOCI ≤ 0.7 (57 cases, 53.77%). Four relationship types were identified based on specific measurements: Type I (23 cases, 21.70%), Type II (42 cases, 39.62%), Type III (4 cases, 3.77%), and Type IV (37 cases, 34.91%). Conclusions: Sagittal movement of the occipital condyle affects the cervical spine's curvature. Asymmetry between the occipital condyles and the foramen magnum may misalign the skull with the body's coronal plane.

Recognition of Forward Head Posture Through 3D Human Pose Estimation With a Graph Convolutional Network: Development and Feasibility Study

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Aug 2024

Background Prolonged improper posture can lead to forward head posture (FHP), causing headaches, impaired respiratory function, and fatigue. This is especially relevant in sedentary scenarios, where individuals often maintain static postures for extended periods—a significant part of daily life for many. The development of a system capable of detecting FHP is crucial, as it would not only alert users to correct their posture but also serve the broader goal of contributing to public health by preventing the progression of chronic injuries associated with this condition. However, despite significant advancements in estimating human poses from standard 2D images, most computational pose models do not include measurements of the craniovertebral angle, which involves the C7 vertebra, crucial for diagnosing FHP. Objective Accurate diagnosis of FHP typically requires dedicated devices, such as clinical postural assessments or specialized imaging equipment, but their use is impractical for continuous, real-time monitoring in everyday settings. Therefore, developing an accessible, efficient method for regular posture assessment that can be easily integrated into daily activities, providing real-time feedback, and promoting corrective action, is necessary. Methods The system sequentially estimates 2D and 3D human anatomical key points from a provided 2D image, using the Detectron2D and VideoPose3D algorithms, respectively. It then uses a graph convolutional network (GCN), explicitly crafted to analyze the spatial configuration and alignment of the upper body’s anatomical key points in 3D space. This GCN aims to implicitly learn the intricate relationship between the estimated 3D key points and the correct posture, specifically to identify FHP. Results The test accuracy was 78.27% when inputs included all joints corresponding to the upper body key points. The GCN model demonstrated slightly superior balanced performance across classes with an F1-score (macro) of 77.54%, compared to the baseline feedforward neural network (FFNN) model’s 75.88%. Specifically, the GCN model showed a more balanced precision and recall between the classes, suggesting its potential for better generalization in FHP detection across diverse postures. Meanwhile, the baseline FFNN model demonstrates a higher precision for FHP cases but at the cost of lower recall, indicating that while it is more accurate in confirming FHP when detected, it misses a significant number of actual FHP instances. This assertion is further substantiated by the examination of the latent feature space using t-distributed stochastic neighbor embedding, where the GCN model presented an isotropic distribution, unlike the FFNN model, which showed an anisotropic distribution. Conclusions Based on 2D image input using 3D human pose estimation joint inputs, it was found that it is possible to learn FHP-related features using the proposed GCN-based network to develop a posture correction system. We conclude the paper by addressing the limitations of our current system and proposing potential avenues for future work in this area.

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Full-text available

Aug 2024

Objectives This study was conducted to assess the radiological changes of the temporomandibular joint (TMJ) and cervical vertebrae individually and their correlation in degenerative joint disease (DJD) using a cone-beam computed tomography (CBCT)-based approach. Methodology The study employed a cross-sectional, analytical retrospective design, analyzing one-year data. CBCT scans of 60 patients (120 TMJs) were assessed for degenerative changes using standardized imaging parameters. Eligibility criteria included full field-of-view CBCT scans, excluding those with craniofacial anomalies or prior orthodontic treatment. Radiological assessments of TMJs and cervical vertebrae were conducted by experienced radiologists using the Anjos Pontual method and novel grading system (TMJ Spine Degenerative Severity Index). Results The study included 60 CBCT scans (120 joints), with 31.7% males and 68.3% females. Participants were predominantly aged 31-60 years (58.3%). DJD findings for the right TMJ showed grade 1 changes in 55.0% and grade 2 in 31.7%, while the left TMJ had 46.7% grade 1 and 35.0% grade 2 changes. A strong positive correlation (0.704) was found between bilateral TMJ and cervical vertebrae changes. Age correlated significantly with TMJ alterations but not with cervical vertebrae changes. Conclusion This study demonstrated that there exists a positive association between the radiological changes of TMJ and cervical vertebrae in DJD with age, which can be detected in mild stage of severity on CBCT and can be of use in clinical correlation and application of optimal interventions ensuring better prognosis.

Comparative Evaluation of Temporomandibular Disorders and Dental Wear in Video Game Players

Article

Full-text available

Dec 2024

Background/Objectives: The increasing prevalence of video gaming has raised concerns about its potential impact on musculoskeletal health, particularly temporomandibular disorders (TMDs). This study aims to compare TMD symptoms, mandibular function, and dental wear between gamers and non-gamers among university students. Methods: An observational study included 108 students aged 20 to 23 years, divided into gamers (n = 48) and non-gamers (n = 60). Participants completed questionnaires assessing TMD symptoms, gaming habits, and screen time. Clinical examinations measured mandibular movements, palpation-induced pain, and dental wear using the Smith and Knight Tooth Wear Index. Statistical analyses included independent t-tests, chi-square tests, Pearson’s correlations, and logistic regression. Seven comprehensive tables present the findings with p-values. Results: Gamers reported significantly higher screen time (Mean = 6.5 h/day) compared to non-gamers (Mean = 4.0 h/day; p < 0.001). Maximum unassisted mouth opening was greater in gamers (Mean = 48.31 mm) than in non-gamers (Mean = 46.33 mm; p = 0.04). Gamers exhibited a higher prevalence of pain on palpation of the masseter muscle (45.8% vs. 30.0%; p = 0.05). Dental wear scores were significantly higher in gamers for teeth 2.3 (upper left canine) and 3.3 (lower left canine) (p < 0.05). Positive correlations were found between hours spent gaming and maximum mouth opening (r = 0.25; p = 0.01) and dental wear (r = 0.30; p = 0.002). Logistic regression showed that gaming status significantly predicted the presence of TMD symptoms (Odds Ratio = 2.5; p = 0.03). Conclusions: Gamers exhibit greater mandibular opening, increased dental wear, and a higher prevalence of masticatory muscle pain compared to non-gamers. Prolonged gaming may contribute to altered mandibular function and increased risk of TMD symptoms. Further research is needed to explore underlying mechanisms and develop preventive strategies.

Safety and Efficacy of Traditional Chinese Manual Therapy for Cervicogenic Dizziness: Study Protocol for a Randomized, Controlled, Multicenter Trial

Article

Full-text available

Aug 2024

Background Cervicogenic dizziness is a clinical syndrome characterized by neck pain and dizziness, which has a rising incidence in recent years. In China, manual therapy has been widely used in the treatment of cervicogenic dizziness, but there is no high-quality medical evidence to support its effectiveness and safety. The purpose of this study was to assess the safety and efficacy of Shi's manual therapy (SMT) on the treatment of cervicogenic dizziness. Methods A multicenter randomized controlled trial (RCT) will perform on 106 patients (18≤ages≤65) who meet the diagnostic criteria of cervicogenic dizziness. Patients will be randomly allocated to the intervention group and the control group at a ratio of 1:1. Participants in the control group will be treated with Merislon (Betahistine Mesilate Tablets). Participants in the intervention group will be treated with SMT. The primary outcome is the response rate at week 2, which is defined as the proportion of patients who reduce their disability level measured by the Dizziness Handicap Inventory (DHI) score relative to baseline. Key secondary outcomes include DHI scores at weeks 1, 2, and 6 and changes from baseline, time to disappearance of dizziness symptoms, and recurrence rate of dizziness symptoms. Safety will be assessed by adverse events, physical examination and vital signs. Discussion This trial aims to provide high-quality evidence-based medical data to demonstrate that SMT can reduce dizziness in patients with cervicogenic dizziness effectively and safely. Trial registration Clinical Trial Registration Center NCT05604937. Registered on Nov 3, 2022. Protocol version 1.0, November 20, 2022.

Effectiveness of a Six-Week Multimodal Physiotherapy Program on the Interconnected Nature of Forward Head Posture, Vertigo, and Neck Pain

Article

Full-text available

Jul 2024

The forward head posture (FHP) is characterized by the head tilting forward compared to the shoulders, resulting in pressure on the neck and surrounding muscles, which may lead to chronic neck pain. The study focuses on a 47-year-old female patient with FHP experiencing symptoms such as dizziness and neck discomfort and emphasizes the importance of various treatment options. After six weeks of personalized training designed to improve posture and alignment, the patient's neck pain improved significantly. Evaluations using different assessments showed significant improvements in pain intensity, head and neck alignment, neck pain and function, severity of dizziness, and neck mobility. This case report discusses the role of physical therapy in treating muscle and balance problems to alleviate symptoms of various health conditions and shows lasting positive effects. It emphasizes the interconnection of conditions such as pain and dizziness and their impact on overall recovery and health. The physiotherapy approach aimed to improve patient outcomes and functional abilities by addressing muscular-skeletal and vestibular problems. This study highlights the complex relationship between FHP, vertigo, and neck pain.

Acta Scientific Orthopaedics (ISSN: 2581-8635) Effect of Extreme use of Mobile on Musculoskeletal System

Article

Full-text available

Feb 2024

Shreya Trivedi Pt

Effect of Extreme use of Mobile on Musculoskeletal System

Effect of Forward Head Posture on Resting State Brain Function

Article

Full-text available

Jun 2024

Forward head posture (FHP) is a common postural problem experienced by most people. However, its effect on brain activity is still unknown. Accordingly, we aimed to observe changes in brain waves at rest to determine the effect of FHP on the nervous systems. A total of 33 computer users (Male = 17; Female = 16; age = 22.18 ± 1.88) were examined in both FHP and neutral posture. For each session, brain waves were measured for 5 min, and then muscle mechanical properties and cranio-vertebral angle (CVA) were measured. Changes in brain waves between the neutral posture and FHP were prominent in gamma waves. A notable increase was confirmed in the frontal and parietal lobes. That is, eight channels in the frontal lobe and all channels in the parietal lobe showed a significant increase in FHP compared to neutral posture. Additionally, FHP changes were associated with a decrease in CVA (p < 0.001), an increase in levator scapulae tone (Right, p = 0.014; Left, p = 0.001), and an increase in right sternocleidomastoid stiffness (p = 0.002), and a decrease in platysma elasticity (Right, p = 0.039; Left, p = 0.017). The change in CVA was found to have a negative correlation with the gamma activity (P7, p = 0.044; P8, p = 0.004). Therefore, increased gamma wave activity in FHP appears to be related to CVA decrease due to external force that was applied to the nervous system and cervical spine.

Posterior Circulation Ischemic Stroke Is Associated with More Severe Forward Head Posture in Patients with Cervicalgia

Article

Jul 2024

Forward head posture associated with reduced cardiorespiratory fitness in psychotic disorders compared to autism spectrum disorder and healthy controls

Article

Full-text available

Jul 2024

Individuals with psychotic disorders often lead sedentary lives, heightening the risk of developing forward head posture. Forward head posture affects upper cervical vertebrae, raising the likelihood of daily discomforts like skeletal misalignment, neck pain, and reduced cardiorespiratory fitness. Improving cardiorespiratory fitness in psychotic disorders is relevant, given its proven benefits in enhancing physical and mental health. This study investigates forward head posture by measuring craniovertebral angles in psychotic disorders and the relationship with reduced cardiorespiratory fitness. To determine whether forward head posture is specific to psychotic disorders, we also included individuals with autism spectrum disorder and healthy controls. Among 85 participants (32 psychotic disorders, 26 autism spectrum disorder, 27 healthy controls), photogrammetric quantification revealed a significantly lower mean craniocervical angle in psychotic disorders compared to autism spectrum disorder (p = < 0.02) and the healthy control group (p = < 0.01). Reduced craniovertebral angle is related to diminished cardiorespiratory fitness in psychosis (R² = 0.45, p = < 0.01) but not in other control groups. This study found reduced craniovertebral angles, indicating forward head posture in psychotic disorders. Moreover, this relates to diminished cardiorespiratory fitness. Further research is needed to examine the underlying causes and to investigate whether this can be reversed through physical therapy.

Cervicogenic dizziness

Article

Full-text available

Dec 2019

Cervical muscles have numerous connections with vestibular, visual and higher centres, and their interactions can produce effective proprioceptive input. Dysfunction of the cervical proprioception because of various neck problems can alter orientation in space and cause a sensation of disequilibrium. Cervicogenic dizziness (CGD) is a clinical syndrome characterized by the presence of dizziness and associated neck pain in patients with cervical pathology. Here, we report a 24-year-old female, who was diagnosed with CGD based on the correlating episodes of neck pain and dizziness. Both symptoms improved with targeted chiropractic adjustment and ultrasound therapy. CGD is a seemingly simple complaint for patients, but tends to be a controversial diagnosis because there are no specific tests to confirm its causality. For CGD to be considered, an appropriate management for the neck pain should not be denied any patient.

Cervicogenic Headache Alleviating by Spinal Adjustment in Combination with Extension-Compression Traction

Article

Full-text available

Jul 2019

Cervicogenic headache (CGH) is a type of secondary headache where the symptoms originate from a dysfunction in the cervical spine. Mechanical cervical spine pathologies and dysfunction in the neck muscles may lead to CGH. This report presents a case of a female with fluctuating headache related to cervical disorders. Her headache was concurrently eliminated with resolution of the cervical disorder following spinal adjustment in combination with extension-compression traction. The efficacious response was attained over a year after completion of treatment. Strategies to release the strain of the supporting cervical extensors can be beneficial for alleviating CGH.

Cervical Radiculopathy Alleviating by Manipulative Correction of Cervical Hypolordosis

Article

Full-text available

Jan 2018
J Med Cases

The purpose of this report is to present an interesting case of cervical radiculopathy in a patient with a prominent cervical hypolordosis treated by chiropractic adjustment. A 55-year-old office worker with severe neck pain and numbness of the right arm sought chiropractic treatment. Following 12 sessions of cervical adjustment, the patient experienced complete alleviation from radiculopathy and full restoration of cervical curvature. Neck pain is common and the cause is usually multifactorial. About 88% of uncomplicated neck pain is self-limiting. Conservative treatment is advocated as initial modality for most patients. Cervical radiculopathy, however, is a potential problem because nerve impingement can cause disability due to numbness or paresthesia, and even weakness, requiring surgical intervention. The best chance for sensorimotor recovery is with prompt intervention to decompress the pinched nerve. Instead of watchful waiting, early application of chiropractic adjustment may help release nerve impingement, and avoid medications and operations in patients with neglected nerve compression.

Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability

Article

Full-text available

Oct 2014
Open Orthop J

The use of conventional modalities for chronic neck pain remains debatable, primarily because most treatments have had limited success. We conducted a review of the literature published up to December 2013 on the diagnostic and treatment modalities of disorders related to chronic neck pain and concluded that, despite providing temporary relief of symptoms, these treatments do not address the specific problems of healing and are not likely to offer long-term cures. The objectives of this narrative review are to provide an overview of chronic neck pain as it relates to cervical instability, to describe the anatomical features of the cervical spine and the impact of capsular ligament laxity, to discuss the disorders causing chronic neck pain and their current treatments, and lastly, to present prolotherapy as a viable treatment option that heals injured ligaments, restores stability to the spine, and resolves chronic neck pain. The capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Chronic neck pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions described herein, including disc herniation, cervical spondylosis, whiplash injury and whiplash associated disorder, postconcussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome. When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches. In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain. In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability. Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Currently, curative treatment options for this type of cervical instability are inconclusive and inadequate. Based on clinical studies and experience with patients who have visited our chronic pain clinic with complaints of chronic neck pain, we contend that prolotherapy offers a potentially curative treatment option for chronic neck pain related to capsular ligament laxity and underlying cervical instability.

Repeatability over time of posture, radiograph positioning, and radiograph line drawing: An analysis of six control groups

Article

Full-text available

Mar 2003
J MANIP PHYSIOL THER

There is debate concerning the repeatability of posture over time, radiograph positioning repeatability, and radiograph line drawing reliability. These ideas seem to negate the use of before-and-after spinal radiographic imaging to detect and correct vertebral subluxations. To review the results of control groups in 6 clinical control trials with before-and-after radiographic measurements taken days, weeks, months, or years apart to accept or reject the hypothesis that radiographic analysis procedures are not repeatable, reliable, or reproducible. Six published control groups from original data. Other data were obtained from searches on MEDLINE, CHIROLARS, MANTIS, and CINAHL on radiographic reliability, posture, and positioning. Comparison of initial and follow-up radiographic data for 6 control groups indicate that measured angles and distances between initial and follow-up radiograph measurements on lateral and anterior to posterior radiographs are not significantly different when utilizing Chiropractic Biophysics radiographic procedures. In 48 out of 50 measurements, the differences between initial and follow-up radiographs are less than 1.5 degrees and 2 mm. These measurements indicate that posture is repeatable, radiographic positioning is repeatable, and radiographic line drawing analysis for spinal displacement is highly reliable. The scientific literature on these topics also indicates the repeatability of posture, radiographic positioning, and radiographic line drawing. Posture, radiographic positioning, and radiographic line drawing are all very reliable/repeatable. When Chiropractic Biophysics standardized procedures are used, any pre-to-post alignment changes in treatment groups are a result of the treatment procedures applied. These results contradict common claims made by several researchers and clinicians in the indexed literature. Chiropractic radiologic education and publications should reflect the recent literature, provide more support for posture analysis, radiographic positioning, radiographic line drawing analyses, and applications of posture and radiographic procedures for measuring spinal displacement on plain radiographs.

Enthesial fibrocartilage - Bone interaction: A radiographic study of selected sites of nonsynovial peripheral enthesopathy

Article

Full-text available

Mar 2003

To assess radiological imaging and prevalence of pelvic (excluding sacroiliac joints), calcaneal, patellar and humeral enthesopathy (EN) in a cohort study. Outpatients attending a state hospital rheumatology clinic for a continuous 4-year period, were consecutively screened for radiographic evidence of peripheral nonsynovial EN in pelvis, ankle, knee and shoulder regions and in particular sites within these regions regardless of symptoms. Imaging and prevalence were assessed in patients suffering from a variety of myoskeletal disorders by applying either of the following two plain X-ray criteria: a) tendon and/or ligament and/or fascia ossification, b) reactive bone proliferation resulting in excrescences and/or sclerosis and/or erosions. A total of 3,670 patients were screened and a cohort of 585 patients (16%) with extraspinal peripheral EN was selected. Plain radiography provided good imaging of pelvic EN at iliac crests, greater trochanters, pubic symphysis and pubic rami, as well as of calcaneal, patellar and humeral head enthesopathic changes. Cohort recruitment by applying the two aforementioned criteria resulted in the formation of 2 groups: Group A, consisting of 169 patients (mean age in years 34 -/+ 8 SD) suffering from inflammatory myoskeletal disease represented by Seronegative Spondyloarthropathies (SSp); and Group B, including 416 patients (mean age 63 -/+ 7) suffering from degenerative/metabolic disorders classified as degenerative disease of the spine, hip or knee (70%), Diffuse Idiopathic Skeletal Hyperostosis (DISH) (11%) and rotator cuff (Rot/Cuff) syndromes (19%). Females were the predominant gender in the cohort and in Group B patients (both p<0.001 vs. males), while the opposite was true for the group of inflammatory diseases. Patients in Group A were younger and had shorter disease duration than those of group B (p<0.001 for both). Pelvic EN was the most frequent localization of EN within the cohort (46%, p<0.001) followed by both multiple site and patellar EN (24% and 22% respectively). Patients in Group A, had a significantly higher prevalence of pelvic EN compared to those in Group B (60% vs. 39%, p<0.001) and the former group was significantly associated with pelvic EN. On the contrary, although pelvis was also the predominant EN site in Group B, patellar and humeral head EN were significantly associated with noninflammatory diseases. In patients with SSps, pelvic EN predominance (60%) was followed by calcaneal involvement (p<0.01 vs. patellar and humeral head). These two were the skeletal sites that were significantly associated with individual diseases within Group A (pelvis with AS and Ps-Sp and calcaneus with RR). Within Group B, patients with knee OA, hip OA and Rot/Cuff showed EN site localization in absolute proximity with disease process, while in those with Deg/Sp or DISH pelvis was the predominant site involved. Plain radiography provides good imaging of peripheral nonsynovial EN at well defined skeletal sites. Within a general rheumatic population, pelvic EN is the most prevalent localization followed by multiple site and patellar reactive bone lesions. Apart from seronegative spondyloarthopathies, degenerative and metabolic myoskeletal disorders contribute substantially to local induction of abnormal fibrous tissue/fibrocartilage-bone interactions resulting in radiographically detectable EN.

Effectiveness of Therapeutic Exercise on Forward Head Posture: A Systematic Review and Meta-analysis

Article

Aug 2018
J MANIP PHYSIOL THER

Objective: The purpose of this systematic review and meta-analysis was to summarize the results related to the effects of corrective exercises on postural variables in individuals with forward head posture (FHP). Methods: A systematic review of the electronic literature through February 2017 was independently performed by 2 investigators. The electronic databases searched included PubMed, MEDLINE, Web of Science, ScienceDirect, Cochrane Central Register of Controlled Clinical Trials, Google Scholar, and Scopus. Methodological quality was evaluated using the Physiotherapy Evidence Database scale. Meta-analyses were carried out for craniovertebral angle (CVA), cranial angle (CA), and pain intensity. Results: Seven randomized clinical trials comprising 627 participants met the study criteria. The between-groups pooled random odds ratios for CVA, CA, and pain were 6.7 (confidence interval [CI] = 2.53-17.9, P = .0005), 0.7 (CI = 0.43-1.2, P = .2), and 0.3 (95% CI = 0.13-0.42, P < .001), respectively. No publication bias was observed. Level 1a evidence (strong) indicates exercise training can effectively modify CVA, and level 1b evidence (moderate) indicates exercise may improve pain but not CA. Conclusion: The findings suggest that therapeutic exercises may result in large changes in CVA and moderate improvement in neck pain in participants with FHP. The precise nature of the relationship between FHP and musculoskeletal pain, and improvements in both after therapeutic exercise, remains to be established.

Enthesitis: New Insights into Pathogenesis, Diagnostic Modalities and Treatment

Article

Oct 2015

Cervical spine alignment, sagittal deformity, and clinical implications A review

Article

Jun 2013
J NEUROSURG-SPINE

This paper is a narrative review of normal cervical alignment, methods for quantifying alignment, and how alignment is associated with cervical deformity, myelopathy, and adjacent-segment disease (ASD), with discussions of health-related quality of life (HRQOL). Popular methods currently used to quantify cervical alignment are discussed including cervical lordosis, sagittal vertical axis, and horizontal gaze with the chin-brow to vertical angle. Cervical deformity is examined in detail as deformities localized to the cervical spine affect, and are affected by, other parameters of the spine in preserving global sagittal alignment. An evolving trend is defining cervical sagittal alignment. Evidence from a few recent studies suggests correlations between radiographic parameters in the cervical spine and HRQOL. Analysis of the cervical regional alignment with respect to overall spinal pelvic alignment is critical. The article details mechanisms by which cervical kyphotic deformity potentially leads to ASD and discusses previous studies that suggest how postoperative sagittal malalignment may promote ASD. Further clinical studies are needed to explore the relationship of cervical malalignment and the development of ASD. Sagittal alignment of the cervical spine may play a substantial role in the development of cervical myelopathy as cervical deformity can lead to spinal cord compression and cord tension. Surgical correction of cervical myelopathy should always take into consideration cervical sagittal alignment, as decompression alone may not decrease cord tension induced by kyphosis. Awareness of the development of postlaminectomy kyphosis is critical as it relates to cervical myelopathy. The future direction of cervical deformity correction should include a comprehensive approach in assessing global cervicalpelvic relationships. Just as understanding pelvic incidence as it relates to lumbar lordosis was crucial in building our knowledge of thoracolumbar deformities, T-1 incidence and cervical sagittal balance can further our understanding of cervical deformities. Other important parameters that account for the cervical-pelvic relationship are surveyed in detail, and it is recognized that all such parameters need to be validated in studies that correlate HRQOL outcomes following cervical deformity correction.

Craniometric Measurements in the Assessment of Craniovertebral Settling: Are They Still Relevant in the Age of Cross-Sectional Imaging?

Article

Apr 2011
AM J ROENTGENOL

Craniovertebral settling is a serious complication of rheumatoid arthritis, and a number of radiographic measures at the craniocervical junction are in use to enable its diagnosis. However, these measures are hampered by the overlap of relevant bony landmarks. We aim to establish accurate values for these measures on CT to facilitate early diagnosis of this condition on cross-sectional imaging. One hundred men and 100 women who underwent CT that included imaging of the craniocervical junction were retrospectively identified. Patients between the ages of 18 and 49 years were included. Two radiologists reformatted the images in the midsagittal plane and performed a series of measurements as follows: the Wackenheim line, McRae line, Chamberlain line, and McGregor line and measurements obtained using the Redlund-Johnell method and our modification of the method proposed by Ranawat et al. There were significant differences between the CT values and accepted radiographic measurements for the Wackenheim, Chamberlain, and McGregor lines. The McRae line was the easiest to measure, and the odontoid tip did not cross this line in any patient (distance from line: range, 0.6-10.4 mm). The CT measurements obtained using the Redlund-Johnell method were similar to the radiographic values, and we provide normal CT values for the modified Ranawat method (men > 23.7 mm, women > 24.2 mm). We propose that the McRae line should be used over other methods when assessing for craniovertebral settling on cross-sectional studies because it is the easiest measure to understand and remember. If the odontoid tip is eroded, the Redlund-Johnell and modified Ranawat methods are alternatives, and we have provided normal CT values for those measures as well.