Forward Head Posture and Low Back Pain

Posted on: September 1st, 2016

Article review: Forward Head Posture and Low Back Pain

By Ryan Winslow DC

This is one of my favorite papers. It compares typical physical therapy for low back pain to therapy focusing on reducing Forward Head Posture (FHP). The best parts of this study are that it takes place over 2 years, has an excellent spread of outcomes and demonstrates which treatment is superior in the long term. This is an important examination of which treatment has true long term benefits, since many treatments provide immediate relief which does not continue over time.

Moustafa, I. M., & Diab, A. A. (2015). The Effect of Adding Forward Head Posture Corrective Exercises in the Management of Lumbosacral Radiculopathy: A Randomized Controlled Study.

Link to full-text PDF article, click here

Quick Takeaways:

1: Reducing FHP produces lasting reductions in low back pain.

2: Typical physical therapy treatments like core strengthening and general conditioning do not appear to produce long term improvements.


4: One of the best indicators for long term improvements is the amount of FHP seen on a lateral radiograph (x-ray).


This article is an in-depth investigation into the long term benefit of correcting forward head posture (head being too far forward) for patients who have low back pain which radiates down one leg (unilateral lumbosacral radiculopathy). Forward Head Posture AKA “Text Neck” or “Anterior Head Carriage” is a common dysfunctional posture. Other research studies  have demonstrated that forward head posture puts biomechanical tension on the low back through a lever arm effect, and also puts tension on the spinal cord itself (review research by Alf Breig and Renee Caillet). The general treatment strategies employed by most therapists today focus on the area of pain, which is the low back in this case. Treating a non-symptomatic area of the body to improve biomechanics and reduce stress on the painful area is not a common treatment strategy. This is why this article is so great. It compares the two strategies head-to-head, and then compares the long term effects of each.


The study participants are split into two groups who are similar in age, weight, height, duration of pain, etc… Each group contained 77 people. All of the study participants have confirmed L5-S1 disc herniations through MRI evaluation. Additionally, all of the study participants have more than 15 mm of Forward Head Posture, as measured by an x-ray taken from the side. Pain medication use was monitored before the study, after 10 weeks of treatment and again at 2 years post-treatment.

In a nutshell, these are patients with shooting low back pain, a loss of the curvature in their low back and forward head posture… which is the typical pattern that we see in patients whose posture has broken down over time.


The two groups received different treatments:

1: The standard care group received a functional restoration program supervised by a physical therapist. Treatment which included core strengthening, mobility activities, psychological strategies and general conditioning. Strategies like activating the transversus abdominis, lumbar multifidus, and pelvic floor muscles were included. Stabilization though controlled walking while maintaining proper upright posture, or performing controlled 15 cm step ups were used. General conditioning of the upper limbs was accomplished by simple dumbbell exercises like curls, forward raises and side raises. A more detailed description of the functional restoration program can be found HERE.

2: The experimental care group received the same functional restoration program as the standard care group, but also received corrective treatments which focused on reducing forward head carriage. These corrective treatments included exercises to strengthen the neck flexors and shoulder retractors and stretches for the neck extensors and chest muscles. This exercise and stretching routine was performed 4 times per week for 10 weeks, and each session lasted for 30 minutes, for a total of 20 hours of therapy. More detailed descriptions can be found in previous papers HERE and HERE.

Outcomes and Results:

Radiographic analysis:

Lateral radiograph

Anterior Head Translation (AHT) was measured using the Vertical Axis Line (VAL). AHT is measured in mm from the intersection of a vertical line from the posterior-inferior body margin of C7 and a horizontal line from the posterior mid margin of C2.

Anterior Head Translation Pre-study after 10 weeks after 2 years P value
Standard 25.7 ± 4.1mm 24.6 ± 4.1mm 24.9 ± 3.9mm <.0005
Experimental 26.6 ± 5.6mm 18 ± 4.9mm 19.4 ± 5.0mm <.0005

Looking at the results for AHT, we can clearly see that the corrective treatment reduces forward head carriage, whereas functional restoration does not. The effect is well maintained over two years.

Formetric Scan:

Formetric Scan

The Formetric scanner utilizes stereo optical imaging to create a 3-D image of the surface of the back.  The system includes software to produce a model of the spine from this information. Learn more about the Formetric Scanner HERE.

The surface scanning parameters measured in this study included a measure of the curve of the low back area (lumbar lordosis), a measure of the rotation of the trunk (surface rotation), a measure of the curve of the upper back (trunk kyphosis), a measure of the forward lean of the trunk (trunk inclination) and a measure of the side to side imbalance of the trunk (trunk imbalance). In an effort to keep this review short, I am including the specific measurements here. Suffice it to say that this exact measuring technique showed that both groups showed improvements at 10 weeks, with the experimental group being larger, and that only the experimental group help those improvements after two years. View the data in Table 3 of the study.

H-Reflex (Nerve conduction study, amplitude and latency):


The neurophysiological findings in this study are based off of nerve conduction studies taken prior to the study, at 10 weeks post treatment and again two years after treatment. This is hard to get information! Nerve studies are NOT comfortable, cheap or easy to perform. The amplitude of the H-reflex is the “strength” of the signal, bigger is better. The latency of the H-reflex is the “speed” of the signal, so small is better. For an improvement in nerve function, we would like to see an increase in amplitude and a decrease in latency.

Amplitude Pre-study after 10 weeks after 2 years P value
Standard 2.1 ± 0.1  2.7 ± 0.4 1.8 ± 0.3 <.0005
Experimental 2.2 ± 0.3 2.9 ± 0.4 2.8 ± 0.3 <.0005

We can see that both groups had a similar amplitude prior to the study. After ten weeks of treatment both groups have a nice improvement, but the experimental group’s is a bit larger. After two years the standard group is worse off than before, whereas the experimental group has a BETTER amplitude than before the treatment. This suggests that correction of forward head carriage may improve nerve function!!

Latency Pre-study after 10 weeks after 2 years P value
Standard  33.8 ± 0.6 32.3 ± 1 34.4 ± 1.6 <.0005
Experimental 33.6 ± 0.7 31.9 ± 0.83 31.6610 ± 1 <.0005

Here we can see that the two groups had similar latencies prior to the study. After ten weeks of treatment both groups have an improvement, again the experimental group is favored. After two years the standard group is again worse than when they started, and the experimental group is again better than before the study.

Combining these two measures, we see that the groups are nearly the same at 10 weeks, and only after two years does the difference between the groups become obvious. The functional program clearly produces short term improvements, which is great. But unfortunately, those improvements are smaller than those in the experimental group, and they do not last after treatment is discontinued. Only the experimental group which had an improvement in forward head posture maintained improvements over a two year period.

Outcome Measures:

Oswestry Disability Index (ODI), Low Back Pain Numerical Rating System, Leg Pain Numerical Rating System and pain medication use over a two year period.

ODI Pre-study after 10 weeks after 2 years P value
Standard 32.4 ± 5.3 19.4 ± 6.4 31.1 ± 7.9 <.0005
Experimental 30.1 ± 5 16.6 ± 5 19.3 ± 4.5 <.0005

Looking at the Oswestry Disability Index results, we can see that both groups make a clinically significant improvement in their scores. However, after two years the difference is startling! The experimental group maintained nearly all of their improvement and the standard care group regressed nearly all the way back to baseline. This is a major result, and follows the same trend that we see in every other category.

Low Back Pain (NRS) Pre-study after 10 weeks after 2 years P value
Standard 4.6 ± 1 3.1 ± 1.3 4.7 ± 1.5 <.0005
Experimental 5.2 ± 0.8 3.2 ± 1.2 2.9 ± 1.6 <.0005

Have you spotted the pattern yet? Both groups make nearly identical improvements, but only the experimental group continues to maintain or improve after treatment is stopped at 10 weeks. In this case, the standard care group has more back pain than prior to the study, while the experimental group is doing better at 2 years than at 10 weeks!

Leg Pain (NRS) Pre-study after 10 weeks after 2 years P value
Standard 6.4 ± 1.2 4.4 ± 1.8 6.1 ± 1.6 <.0005
Experimental 6.9 ± 0.7 4.6 ± 1.6 4.5 ± 1.8 <.0005

Same story here. Both groups see improvements in leg pain, but only the experimental group continues to improve over 2 years, while the standard care group returns to nearly baseline.

Pain Med Use Pre-study after 10 weeks after 2 years
Standard 57% 27% 40%
Experimental 65% 37% 22%

Now this result is important and interesting. The study simply asked if the participants used medication for pain, this could be an Advil or a heavy narcotic. The experimental group started off a bit worse, but there is no significant difference in usage prior to the treatment or immediately after. But at two years a striking difference can be seen: The experimental group is taking less medications to manage their pain, and they are feeling better according to the other outcomes! Again, this is important because there is a growing issue of prescription drug overuse here in America.

What does it mean?

For doctors:

Adding a treatment plan focusing on reducing forward head posture is easy and effective. Considering the spine as a whole may not be the current paradigm of care for our patients, but posture is becoming an important aspect of patient care. Looking at the outcomes from this study, the only predictor of long term improvement is posture. Specifically, the lateral radiographs were the only measurement where the standard care group had no improvement at 10 weeks.

For patients:

If you are only focusing on stretching and strengthening the area of pain, you could be missing a huge part of the problem. Would you rather be in the standard care group, or in the experimental group? If it were me, I’d much prefer to continue feeling better after the treatment is finished. There is lasting value in posture correction. Many therapies produce short term benefit: massage, exercise, injections, chiropractic adjustments, meditation, hot or cold therapies, etc… At the end of the day, you want to invest in something that pays lasting dividends. Your body is not different, why invest in therapies that are not going to make you feel better years after you’ve received them?

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