Elsevier

Manual Therapy

Volume 13, Issue 2, April 2008, Pages 148-154
Manual Therapy

Original article
The relationship between head posture and severity and disability of patients with neck pain

https://doi.org/10.1016/j.math.2006.11.002Get rights and content

Abstract

Study Design

A cross-sectional correlation study.

Objectives

To investigate the relationship between head posture with pain and disability in patients with neck pain.

Method

Sixty-two subjects with neck pain and 52 normal subjects were recruited by convenience sampling. The forward head posture was measured via the craniovertebral (CV) angle by using the Head Posture Spinal Curvature Instrument (HPSCI). The Chinese version of Northwick Park Neck Pain Questionnaire (NPQ) and Numeric Pain Rating Scale (NPRS) were used to assess neck pain disability and severity. The difference in CV angles between the two groups and Pearson's correlation coefficient between the CV angle, NPQ and NPRS were determined.

Results

There was a significant difference in the CV angle between subjects with and without neck pain. CV angle was negatively correlated with NPQ (rp=-0.3101, p=0.015) and NPRS (rp=-0.329,p=0.009). It was also negatively correlated with age (rp=-0.380,p=0.002). When age was taken into account, the CV angle was negatively correlated with NPQ (rp=-0.3101,p=0.015) but showed no significant correlation with NPRS (rp=-0.1848,p=0.154).

Conclusion

The CV angle in subjects with neck pain is significantly smaller than that in normal subjects. There is moderate negative correlation between CV angle and neck disability. Patients with small CV angle have a greater forward head posture, and the greater the forward head posture, the greater the disability.

Introduction

Proper posture is believed to be the state of musculoskeletal balance that involves a minimal amount of stress and strain on the body. Although correct posture is desired, many people do not exhibit good posture (Haughie et al., 1995). An ideal posture is considered to exist when the external auditory meatus is aligned with the vertical postural line. The vertical posture line, as seen in a side view, passes slightly in front of the ankle joint and the centre of the knee joint, slightly behind the centre of the hip joint and through the shoulder joint and the external auditory meatus (Haughie et al., 1995). Forward head posture is one of the common types of poor head posture seen in patients with neck disorders (Haughie et al., 1995, Hickey et al., 2000, Good et al., 2001, Chiu et al., 2002).

Forward head posture means that the head is in an anterior position in relation to the theoretical plumb line, which is perpendicular to a horizontal line through the centre of gravity of the body. Therapists rate the severity of the anterior positioning of the head as minimal, moderate or maximal without any objective or numeric values. A decision regarding normality or otherwise is then based on clinicians’ experience and perception of what constitutes a normal or “ideal” posture, and is therefore considered to be a potential source of error (Griegel-Morris et al., 1992).

One objective method of assessing head posture is through measuring the craniovertebral (CV) angle (Watson, 1994). It is the angle between a horizontal line through the spinous process of C7 and a line from spinous process of C7 through the tragus of the ear forming the CV angle (Fig. 1). Neutral position and resting head posture are synonymous with “natural head posture” (Hickey et al., 2000). It is attained by asking the subject to perform large amplitude cervical flexion and extension gradually decreasing to rest in the most comfortably balanced position (Watson, 1994). The CV angle appears to be a representative measurement of a combination of an anterior or posterior position of the lower cervical spine and the associated upper cervical flexion or extension. It is imperative that the instrument and method chosen to assess head posture clinically are reliable, objective, easy to use and produce immediate results when assessing a patients’ condition as well as measuring the progress of the patient after therapeutic intervention (Wilmarth and Hilliard, 2002).

There are many instruments to assess head posture, including the Rocabado Posture Gauge, the Cervical Range of Motion (CROM) Instrument, the plumb line and photographic imaging. However, they all have disadvantages such as a complicated procedure, an expensive cost and being inconvenient to use clinically. The Rocabado posture gauge cannot be used to measure the CV angle. It measures the horizontal distance from the tangent of the most posterior thoracic spinous process to the most anterior cervical spinous process (Willford et al., 1996). The plumb line method is simple but is limited by the subjective nature of determining forward head posture (Wilmarth and Hilliard, 2002). Therapists rate the degree of anterior translation of the head as minimal, moderate or maximal without objective and numeric values though the inter-tester reliability is moderate (ICC=0.738) (Wilmarth and Hilliard, 2002). The CROM instrument with an extension arm for head posture measurement is cumbersome (Garrette et al., 1993). Photographic imaging although accurate is time-consuming and does not allow immediate feedback of results (Wilmarth and Hilliard, 2002).

An instrument, the Head Posture Spinal Curvature Instrument (HPSCI), designed by Wilmarth, was developed to measure both the head posture and the cervical curvature (Wilmarth and Hilliard, 2002). This HPSCI was designed to eliminate the cumbersome use of multiple instruments to provide a more efficient assessment tool with immediate feedback in order to facilitate measurement in a clinical setting. The HPSCI is a non-invasive, inexpensive measurement method which has been demonstrated to produce consistent intra-rater results (ICC>0.9) across days and trials (Wilmarth and Hilliard, 2002).

There were no previous published studies that had identified an association between forward head posture and the level of neck pain severity and disability. Griegel-Morris et al. (1992) identified an increased incidence of cervical pain, inter-scapular pain and headache with forward head posture; however, they did not establish a relationship between the severity of neck pain and the degree of postural abnormalities. Willford et al. (1996) found that there was no significant difference in the forward head posture between groups of subjects with different levels of neck pain, although they did find that subjects wearing multifocal lenses had a greater degree of forward head posture when compared with non-multifocal lens wearers. However, the sample size was small and the validity of the pain assessment tool was questionable in their study. Szeto et al. (2002) showed that there were trends for increased head tilt and neck flexion postures in the symptomatic subjects presenting with neck and shoulder discomfort when compared to the asymptomatic subjects. However, the study by Szeto et al. did not evaluate the relationship between head posture and the degree of disability caused by neck pain. Moreover, the subjects in their study were limited to female clerical staff.

From our clinical experience, we hypothesize that there is a relationship between CV angle and pain and the disability level in patients with neck pain. Thus, the objectives of this study are to determine:

  • 1.

    if there is any difference in the CV angle between subjects with and without neck pain;

  • 2.

    if there is any relationship between head posture as measured by CV angle with neck pain and the disability level in patients with neck pain.

The significance of this study may give clinicians further objective information to evaluate the severity and disability of neck pain by measuring the CV angle using the HPSCI.

Section snippets

Subjects

There were two groups of subjects. The non-neck pain (control) group consisted of 52 subjects (mean age 42.33, SD±11.18) and the neck pain group consisted of 62 subjects (mean age 39.92, SD±10.80). Both groups were recruited from a physiotherapy out-patient department by convenience sampling. Subjects in the non-neck pain group were patients with other problems referred for physiotherapy treatment such as knee pain, sprained ankle, tennis elbow, etc. They had not suffered from neck pain in the

Head posture measurement (CV angle)

For the head posture measurement, subjects from both groups were assessed in their first physiotherapy session before any treatment was given. Their diagnoses were known to the principle investigator and they were recruited according to the inclusion criteria. The subjects were asked to give consent and they were asked not to tell the assessor about their diagnoses. The measurements were taken by an experienced physiotherapist who was blinded to the grouping of the subjects.

During the

Results

A total of 62 subjects (22 males and 40 females) and 52 subjects (16 males and 36 females) were recruited in the neck pain group and non-neck pain (control) group, respectively. The demographic characteristics of these subjects are shown in Table 1. The distribution of male and female subjects in both groups was comparable. Results demonstrated that there was no significant difference in age between the two groups (p=0.916). However, CV angle of the neck pain group (mean 49.93, SD±6.08) was

Discussion

The intra-rater reliability (ICC) of using HPSCI to measure CV angle was ICC=0.98 in this study, which was consistent with the previous finding by Wilmarth and Hilliard (2002) (ICC0.9). The SEM was 1.696 and MDC was 3.61°. This indicated that a given clinician could reliably monitor head posture through the CV angle using HPSCI. Further study on the inter-rater reliability of the HSPCI should be performed as this would give greater flexibility for different therapists or medical professionals

Limitations

The major weakness of correlational research is its inability to establish cause-and-effect relationships. However, in view of the lack of documented evidence that exists concerning these common outcome measures, it is essential to demonstrate how these variables are related in patients with chronic neck pain.

As the three measurements were made on one occasion with only a short interval between repeated measures, assessor recall bias was likely to be high, possibly inflating the level of

Conclusion

Results demonstrate that there is a high degree of test–retest reliability in measuring the CV angle by using the Head Posture Spinal Curvature Instrument (HPSCI). The CV angle in subjects with neck pain is significantly smaller than that in normal subjects. The CV angle is negatively correlated with the disability of patients with neck pain. The smaller the CV angle (that is, the more forward head posture), the higher the NPRS score will be and vice versa. We recommend that CV angle as

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