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The Neurology of Forward Head Posture and How It Can Impact Individuals with Brain Injury

Man in pain holding his neck

Did you know that Forward Head Posture (FHP) has been shown to affect the brain negatively? Research shows that “90% of the stimulation and nutrition to the brain is generated by the movement of the spine” (1). With a blow to the head, neck, or back causing a concussion or mild traumatic brain injury
(mTBI), the musculoskeletal system is impacted and may lead to a reduction in cervical curvature and
decreased spinal motion. This reduction in curvature creates a position of Forward Head Posture and
can result not only in neck and shoulder pain, stiffness, and numbness of the arms and hands, but can
also have neurological effects that impact your blood flow, breathing, proprioception, balance, memory
and cognition, and even your mood. More importantly, less cervical movement results in less nutrition
to the brain which is essential after a trauma to allow for healing, proper metabolism and immune
function, and a reduction of inflammation. Ten percent of the brain is responsible for thinking,
metabolism, and healing. Consequently, Forward Head Posture will rob the brain of energy for these
important functions in order to deal with abnormal gravity/posture relationships and processing.
Furthermore, after an injury to the head and neck, systems of the body that work together to keep the
body upright and functioning properly can also be affected (autonomic, vestibular system, visual system,
and sensorimotor system).

Forward Head Posture results when the head tilts forward at varying degrees, and the amount of
pressure on the cervical spine multiplies. This position of Forward Head Posture can be seen in two
positions, either where the neck is flexed forward in an anterior position, or anteriorly translated
forward and extended. When an individual has healthy posture and is standing completely upright, you
will see their ear located directly over their shoulder at 0 degrees. In this position, the head weighs
approximately 10-12lbs. With every 15-degree tilt forward, the weight of the head will be distributed in
such a way on the neck that the head will actually weigh more. With a 15-degree forward head carriage
the head weighs 27lbs, at 30 degrees the head weighs 40lbs, at 45 degrees the head weighs 49lbs, and
at 60 degrees head will weigh an incredible 60lbs (2)!

Forward head posture decreases the lungs ability to expand

As mentioned above, when the normal cervical spine curvature is reduced due to Forward Head
Posture, there is an imbalance and tension in neck muscles, as well as a decrease of blood flow from
arteries in the neck to the head, which causes changes to blood flow in the brain. The autonomic
nervous system is the system responsible for the regulation of normal blood pressure, heart rate and
respiration, especially with change in body position. When there is alteration in body position due to an
imbalance in posture, this system can be affected. “Loss of cervical lordosis may be associated with
changes of the Circle of Willis and cerebral artery hemodynamics, resulting in decreased blood flow in
the brain” (3). The brain needs blood to help with clear thinking, to increase healing and reduce
inflammation, especially from a concussion or brain injury, and to communicate with the body
appropriately. Furthermore, research states “Forward Head Posture reduced forced vital capacity for
respiration due to abnormal muscle recruitment of the accessory muscles of respiration” (4) and that
“Forward Head Posture is associated with morphological changes of the thorax causing decreased
respiratory function.” In other words, when the head is forward and the neck curvature is reduced,
biomechanically the mid back overcompensates by increasing its curvature causing the shoulders to become more rounded and “hunched”. This in turn decreases the ability of the lungs and diaphragm to
expand when an individual breathes in. With less lung expansion, the body must use accessory muscles
and more energy to breathe resulting in poor respiration and decreased oxygen to the body. This can
lead to fatigue, poor circulation, and in some cases hyperventilation due to shallow but rapid breathing
associated with an increase in the sympathetic nervous system or “fight or flight” response.

Leads to postural instability due to incorrect inputs from the vestibular, visual, and proprioception systems

Neurologically, an increased sympathetic response can cause constriction of certain blood vessels,
elevated heart rate and blood pressure, cause lack of sleep, decreased bowel motility, increased
sensitivity to light and sound, as well as increased perceptions of stress and anxiety-- all symptoms
concussed individuals may tend to experience.

Compelling evidence exists that links Forward Head Posture with vestibular deficits, increased fall risk,
and impaired cervical proprioception (the ability to know where your body is in space based on the
location of your neck and head) (5). The vestibular system is responsible for balance (equilibrium) and
upright posture (utilizing extension to resist gravity) through vestibular receptors (otoliths and
semicircular canals) and vestibular projections (vestibular-ocular, vestibular-cerebellar, vestibulospinal
tracts of the brain and spinal cord). The visual system is responsible for head posture (seeking to keep
the eyes parallel with the horizon) and orienting the body in space. Forward Head Posture, regardless of
pain, also has been shown to increase the amount of joint position error. As a result, “mechanical
stability and normal kinematics are reduced (6).” Moreover, “Forward Head Posture has a negative
effect on the muscle spindle activity involved in proprioception, resulting in cervical repositioning errors
and deficits of dynamic balance ability (7).” In other words, having your head in too forward of a
position, as well as having an increase in your midback curve (referred to as postural hyperkyphosis) can
lead to postural instability due to incorrect inputs from the vestibular, visual, and proprioception
systems. These incorrect inputs to the brain contribute to inaccurate perception of where the head and
body are in space. This then causes a tendency towards balance issues and falls.

Poor gait performance predicts dementia

Poor balance will go on to influence movement and sensorimotor integration in a chain of events.
Interestingly enough, when the brain cannot accurately perceive where it is in space, the quality of motor output or movement is impacted and proper gait biomechanics are inhibited potentially leading
to a fear of moving and walking around. Unfortunately, this chain of events goes even further. One
study shows that “poor gait performance predicts dementia” (8) emphasizing the point that movement
is essential to give input to the brain and without input, the brain can begin to decay. Research also
demonstrates that mobility and upright posture is associated with aspects of cognition including
memory. These results provide the first evidence for a link between postural alignment and cognitive
function in healthy older adults (9). When there is a decline in upright posture and the posture system,
cognitive function and capabilities are impacted as we resist gravity, and hence there is a reduction in
cognitive output (as an example, think of elderly patients suffering with dementia and the posture they
exhibit). With brain injury, people typically do not feel well due to lack of integration between their
autonomic system, visual system (ocular motor function), vestibular system, and cervical spine issues
causing movement patterns to be affected, the vestibular system altered, and posture can change. As a
result, this can affect cognition and memory. With cognition being visualized as the tip of the pyramid of
functioning, with the lower larger levels of the pyramid consisting of the vestibular system, visual
system, autonomic system, and sensorimotor system, if these lower portions of the pyramid are not
integrating well, there will be postural deficits and problems at the top level, and cognition will suffer.

Direct connection between posture and mood

Lastly, Research has shown there is a direct connection between posture and mood. When considerable
stresses are placed on the cervical spine, thus changing the cervical curve and pain threshold of the
muscles around the neck, negative effects on a person’s psychological status can ensue, such as
depression. Typically, when a person has hunched forward posture, they exhibit feelings and emotions
of being closed, depressed, and have less self-perceived leadership. On the flip side, someone with more
upright and open posture is perceived as being more confident, positive, approachable and tends to
express positive self-image, thoughts, and memory recall. There is a correlation between muscle
activation and activation of different areas in the brain and due to this, change in psychological status
and slumped forward posture, is now a diagnostic factor of depression (10).

Since even minor Forward Head Posture was shown to be detrimental in research; from breathing and
heart rate to pain and disability, all health markers that were measured as posture deviations increased
(11), the importance of assessment of posture cannot be underestimated especially in individuals with
brain injury. The autonomic, vestibular, visual, and sensorimotor systems and their proper integration
with the brain and spine depend on it. If identified and treated, individuals can be in a better position to
rehab and heal from any potential neurological consequences. Treatments utilizing modalities such as
gentle chiropractic adjustments, functional neurology, neuro-optometry exercises, physical therapy, etc.
that are focused on improving spinal curvature and rebalancing these systems, can improve function.
“Correcting the loss of cervical lordosis increased cerebral artery parameters, indicating an immediate
increase in blood flow in the brain” (3). As research indicates, improving Forward Head Posture can
allow for better oxygenation and blood flow to the brain while positively affecting breathing, balance,
cognition, memory, and mood. Therefore, anyone who has sustained an injury to the neck, head or
back, especially if it caused a concussion or mild traumatic brain injury, should consider being evaluated
and treated for Forward Head Posture.

1. Quote by Dr. Roger Sperry Nobel Prize Recipient for brain research 1981
2. Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position
of the head. Surg Technol Int, 25(25), 277-9.
3. Katz, E. A., Katz, S. B., Fedorchuk, C. A., Lightstone, D. F., Banach, C. J., & Podoll, J. D. (2019).
Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity
on brain magnetic resonance angiogram following correction of cervical lordosis. Brain
circulation, 5(1), 19.
4).Han, J., Park, S., Kim, Y., Choi, Y., & Lyu, H. (2016). Effects of forward head posture on forced
vital capacity and respiratory muscles activity. Journal of physical therapy science, 28(1), 128-
5) Migliarese, S., & White, E. (2019). Review of forward-head posture and vestibular deficits in
older adults. Current Geriatrics Reports, 8(3), 194-201
6) Raoofi, Z., Sarrafzadeh, J., Emrani, A., & Ghorbanpour, A. (2019). Interaction between
proprioception, forward head posture and neck pain in adult women. Function and Disability
Journal, 2(1), 90-99.
7) Ha, S. Y., & Sung, Y. H. (2020). A temporary forward head posture decreases function of cervical
proprioception. Journal of exercise rehabilitation, 16(2), 168
8) Beauchet, O., Annweiler, C., Callisaya, M. L., De Cock, A. M., Helbostad, J. L., Kressig, R. W., ... &
Allali, G. (2016). Poor gait performance and prediction of dementia: results from a meta-
analysis. Journal of the American Medical Directors Association, 17(6), 482-490.
9) Cohen, R. G., Vasavada, A. N., Wiest, M. M., & Schmitter-Edgecombe, M. (2016). Mobility and
upright posture are associated with different aspects of cognition in older adults. Frontiers in
aging neuroscience, 8, 257.
10) Park, J., Kim, J., Kim, J., Kim, K., Kim, N., Choi, I., ... & Yim, J. (2015). The effects of heavy
smartphone use on the cervical angle, pain threshold of neck muscles and depression. Advanced
Science and Technology Letters, 91(3), 12-17.
11) Schwab, F., Farcy, J., Bridwell, K., Berven, S., Glassman, S., Horton, W., Harrast, J. (2005).
Intervertebral subluxation, lumbar lordosis, but not Cobb angle correlate with surgical rates in
adult thoracolumbar and lumbar scoliosis: a multicenter analysis. The Spine Journal, 5(4), 26-27.

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