Reply

Dear sir We thank Dr Ferrari for his letter and the opportunity to reply. Dr Ferrari has suggested three associations in his letter. They are: that maladaptive forward head postures are a way of initially reducing neck pain and headache, that forward head posture over time may become a contributor to chronic pain and headache by leading to muscle dysfunction detected in the craniocervical flexion test, and that the muscle dysfunction can be alleviated with interventions to correct the postural disorder, such as use of a lumbar roll, chin retraction and back extension exercises. These associations are intriguing but as yet they have not been clearly established.

To our knowledge no study has investigated whether there is an early adoption of a forward head posture in patients with initial onset, acute neck pain and headache, and we are unable to comment on this possible event. There have now been several studies investigating the association between chronic neck pain and headache and an external measure of the forward head posture, the craniocervical angle. The results are equivocal, with no consistent association being provided between an externally observed more forward head posture in patients with chronic neck pain (1–4). Furthermore, Johnson (5) found no correlation between surface measures of head and neck posture and radiological measures of the anatomical alignment of the upper cervical vertebrae and cervical lordosis, even in those subjects who, from external assessment, would have been classified with even an extreme forward head posture. Therefore the relationship between an observed forward head posture and mechanical implications for pain would seem tenuous in light of current knowledge. There appear to be problems in focusing only on the forward position of the head when describing postural anomalies. Grimmer (6) contends that there is as yet no standard for defining poor head posture and many different postural shapes can be observed.

Two studies have found lesser endurance capacity of the cervical flexors in patients with neck pain and headache (3, 4). Of relevance, one determined no difference in forward head postural position between headache subjects and asymptomatic controls (3), while the other found the opposite (4). This latter study did determine a relationship between maximum endurance of the cervical flexors and posture. It would seem therefore that the dysfunction in the neck flexors is the consistent finding, rather than postural shape. Our recent study of patients with whiplash associated disorders (7) also determined a poor performance in the craniocervical flexion test in these subjects, which lends support to this contention. It is possible that it is the neck pain and pathology which leads to this reaction in the deep neck flexors, rather than the postural shape, perhaps in a similar way that pain and pathology in the knee joint inevitably and regularly lead to weakness and atrophy of the quadriceps.

Whether general exercises to correct posture will necessarily address the specific dysfunction in the deep neck flexors identified in the craniocervical test flexion is unknown. However, we are preparing data which indicate that a new exercise regime incorporating specific low load training of the deep neck flexors using the craniocervical flexion action and re-education of postural control, is effective in addressing the muscle dysfunction and relieving patient symptoms of neck pain and headache (Jull et al., unpublished data). There seems to be no change in postural shape associated with the improvement in muscle performance and reduction of symptoms.