Text Neck and Other 'Awkward' Postures: Visually painful but not the cause of pain

Text neck, if you listen to the storylines of mainstream media and fitness, would seem like a massive epidemic that has struck our population and doomed us to a life of pain and running into door frames (the latter may actually be true). Anyone who has looked into the topic is probably familiar with the graphic below:


It is a nice looking graphic that no doubt you have probably seen a countless number of times. It states that with increased neck flexion (trying to catch Pidgeys on Pokemon GO), there is an increased amount of stress and force through the surrounding structures of the cervical spine. But what does this really mean? Would this predispose a person to neck pain? Should certain postures be avoided entirely? Or does this image unnecessarily discourage certain postures (tagging them as 'bad') while encouraging fear-avoidance behaviors?

Is this a necessary posture or just aesthetically pleasing?

Is this a necessary posture or just aesthetically pleasing?

Greg Lehman actually has an excellent write-up regarding the study that came out with the aforementioned graphic: [LINK]. I strongly encourage readers to take a look (Hint: He isn’t a fan of it).

The fact is if a person has neck or back pain, static posture may very likely be the first thing you look to assess and correct. Seems easy enough; we all learned the plumb line assessment in school. They've got rounded shoulders, forward head, decreased lumbar lordosis - what a mess! Get them started with some chin tucks, prescribe some other exercises to improve periscapular muscle strength, 'open up' their chest with a doorway stretch 3 sets x 30 seconds. Okay then.

But is a person's wonky static posture THE reason for their pain? Let's take a look at what some research can tell us:

  • Roffey et al: A systematic review of the literature that aimed to establish a causal relationship between awkward occupational postures and low back pain (utilizing the Hill's Criteria for Causation). These occupations included: firefighters, policemen, nurses, scaffolders, and various types of supervisors and administrators - all of which are occupations that place a person in a fair amount of prolonged not-perfect postures. Six high quality studies reviewed yielded the conclusion that there was no association between awkward postures and low back pain. Per the paper's authors, "the results [...] indicate that working in awkward postures did not meet any of the objective criteria required to establish causation for low back pain."
  • Grob et al: This study recruited 107 volunteers (all >45 years old) that were reporting to an outpatient facility for unrelated lower extremity orthopedic issues. Sagittal radiographs of the cervical spine were taken (to assess global curvature between C2-C7 and each segmental angle). Questionnaires were also completed to ascertain neck pain and disability within the past year. Using the questionnaires, the researchers divided the subjects into 'with pain' and 'without pain' groups. No significant difference between the groups (with pain vs. without pain) could be found in relation to global curvature, segmental angles, and incidence of straight spine or kyphotic deformity.
  • Richards et al: Recruited 1108 adolescents (17-year-old cohort) and took sagittal view photographs of their seated posture. Also had them fill out questionnaires for occurrence of neck pain, headaches, and documentation of lifestyle/psychosocial factors. Subjects with slumped thorax/forward head posture were found to be NO different than other posture presentations when it came to the occurrence of neck pain. 

Interestingly, subjects with this slumped thorax/forward head posture were at higher odds for mild, moderate, or severe depression symptoms. In fact, there's been a growing amount of evidence relating back pain more with psychological and lifestyle factors, more so than actual specific static postures [here, here, and here] - such as job dissatisfaction, high stress, exhaustion, etc.

The same article from Richards had this interesting line:
"This finding is consistent with findings from systematic reviews that the association between neck pain and posture is weak. In contrast, previous studies showed that factors such as genetics, female sex, depressed mood, stress, and sleep patterns are associated with neck pain. These findings suggest that neck pain is associated with changes in pain regulatory mechanisms rather than biomechanics, which supports calls to consider and manage neck pain from a broader biopsychosocial perspective."


Based on this information, it would seem that neck and back pains previously attributed to poor postures may be influenced by other factors in a person's life - going above and beyond the typical biomechanical view. 

So what is the take-home here? Truthfully, I believe it indicates a need to be more sensitive when it comes to matters of educating people on their posture. A friend of mine was absolutely convinced by his physician that lumbar flexion in particular (i.e. tying his shoes) will cause a slipped disc and sideline him for life - which we can likely all agree is ridiculous. The body is designed for movement. Enough said. As far as the opinions of clinicians with whom I've spoken, I have seen this information used as a reason to not address posture at all - which I frankly think is also excessive.

Personally, I plan to use these findings to hopefully instill confidence in people and their ability to move; we shouldn't be teaching others that the human body is brittle and unable to adapt to varied demands and environments. This is far from the truth and just encourages behaviors like kinesiophobia and pain catastrophizing. In the same vein, I'm very much a large proponent of improving postural AWARENESS - especially when it comes to factors such as injury prevention, optimizing muscle force production, and increasing diaphragmatic excursion. For example, in the case of a LOADED movement (e.g. picking up a heavy box of books), optimal postural alignment is incredibly important and should be driven home.

What other pieces of research have you found regarding posture and pain? What are your thoughts? Feel free to comment below.