A Modern Epidemic of Poor Posture, Neck Pain, Shoulder Pain, Arm/Hand Neurological Symptoms and Accelerated Spinal Degenerative Arthritis
[“Text Neck” and “Tech Neck” are synonymous]
On Monday, March 3, 2018, the front page of the newspaper USA Today printed a “snapshot” noting that “US consumers spend an average of 7.8 hours each day engaging with digital content.”
Representative Background Story #1
On April 14, 2017, reporter Carolyn Crist wrote an article, published in Reuters Health, titled (1):
Leaning Forward During Phone Use May Cause ‘Text Neck’
In this article, Ms. Crist makes the following points:
- Spine surgeons are noticing an increase in patients with neck and upper back pain, likely related to poor posture during prolonged smartphone use.
- Young patients who should not have back and neck issues are reporting disk hernias and spinal alignment problems.
- “In an X-ray, the neck typically curves backward, and what we’re seeing is that the curve is being reversed as people look down at their phones for hours each day,” said Dr. Todd Lanman, a spinal neurosurgeon at Cedars-Sinai Medical Center in Los Angeles.
- “By the time patients get to me, they’re already in bad pain and have disc issues,” he told Reuters Health. “The real concern is that we don’t know what this means down the road for kids today who use phones all day.”
- People often look down when using their smartphones, particularly when texting as compared to browsing online or watching videos.
- Studies have found that people hold their necks at around 45 degrees forward when using their smartphones.
- When in a neutral position looking forward, the head weighs about 10 to 12 pounds. At a 15-degree forward flexion position, it functions as if it weighed 27 pounds.
- At 60 degrees of forward flexion, the stress on the spine increases to about 60 pounds.
- These prolonged abnormal stresses on a growing spinal column may lead to abnormal spinal development with dire long-term spinal health consequences in adulthood.
- Simple lifestyle changes are suggested to relieve the stress from the “text neck” posture, including holding cell phones in front of the face while texting, and using two hands and two thumbs to create a more symmetrical and comfortable position for the spine.
- Also, people who work at computers or on tablets should use an elevated monitor stand so it sits at a natural horizontal eye level.
- Take frequent rest breaks and/or engage in some physical exercise that can strengthen the neck and shoulder muscles. 1) Lie on a bed and hang one’s head backward over the edge, extending the neck to restore the normal arc in the neck. 2) While sitting/standing, attempt to align the neck with the ears over the shoulders and the shoulders over the hips.
Representative Background Story #2
This week (March 5, 2018), reporter Kirsten Fleming wrote an article that was published in The New York Post, titled (2):
Tech is Turning Millennials Into a Generation of Hunchbacks
In this article, Ms. Fleming profiles the situation of a young man, CY, who began suffering from upper-back pain and neck soreness while in his late teens, subsequent to a habit of hunching over his cellular phone. As his symptoms progressed he developed constant pain, he hunched his shoulders, and the pain caused him to wake up numerous times throughout every night, causing constant fatigue. His upper back and neck would become incredibly tight; his neck was always bent forward.
After a decade of suffering, CY’s chiropractor diagnosed him with “tech neck,” explaining that the cause was the forward/bent neck posture he assumed while using his laptop and iPhone. “Tech neck” is a painful forward head syndrome. It is an increasingly common condition caused by slumping over devices for hours a day, leading to a reversal of the natural neck spinal curve and triggering a physiological imbalance in the upper body.
“Previously seen in middle-age or older desk jockeys and dentists who hunch over patients, it’s now materializing in younger generations who grew up with smartphones, tablets and other personal devices.” Not only does the syndrome cause structural problems in the neck and back, it can also spark breathing and panic issues.
The loss or reversal of the normal cervical curve is easily diagnosed with postural x-rays.
“As posture worsens, the upper back muscles stretch out, while the muscles in the front of the body become weaker and the neck creeps forward.” Young women are particularly susceptible to the condition because they have lower muscle density in their upper body.
“iPhone-obsessed millennials poring over Instagram and Snapchat all day don’t want to admit that their precious electronic lifelines might be detrimental to their health.”
“Undoing the damage is a process that includes breaking bad habits, taking standing breaks and doing exercises such as yoga, foam rolling and stretches that promote good carriage and strengthen core and upper body muscles. Experts also advise patients to hold mobile devices with their elbows at 180 degrees so the screen is in front of their faces.”
Treatment options outlined by Ms. Fleming include chiropractic, restorative postural traction, postural and core exercises.
Consulting chiropractors made the following comments pertaining to tech neck:
- “We’re seeing it in younger and younger children because they’re getting their phones at a younger age.”
- “Now, 20-year-olds have the spine health of a 30- or 40-year-old. It’s an epidemic.”
Understanding the Biomechanics of Text/Tech Neck
The understanding of the biomechanics of text/tech neck requires the understanding that upright posture, and the holding of one’s head upright, is a first-class lever mechanical system. In a first-class lever, the fulcrum is in between the load and the effort. An example of a first-class lever is a teeter-totter or a seesaw:
In all first-class lever mechanical systems, the fulcrum is the point of greatest mechanical stress. Excessively large loads with excessively large balancing efforts will cause the lever to break at the fulcrum. When the fulcrum is exposed to excessive prolonged sub-catastrophic loads, the fulcrum itself suffers from wear and tear damage.
The effective load on the fulcrum is greater than the sum of the weight of the load plus the counterbalancing effort because the distance they are from the fulcrum is mechanically multiplied:
If a 10-pound load is 10 inches from the fulcrum, the effective load on the fulcrum is 100 pounds. The addition of the counterbalancing effort would bring the effective load on the fulcrum to 200 pounds.
In the human body, upright and on two feet, the fulcrum is the spinal column, specifically the vertebrae, and more the vertebral joints (the disc and the facets). In the text/tech neck position, the head is no longer ideally positioned over the fulcrum (the spinal column and vertebrae); rather the head is displaced forward of the fulcrum.
If the weight of the head is 10 pounds and the head is displaced forward by 3 inches, the load on the spinal fulcrum (the vertebrae) is 30 pounds (10 pounds X 3 inches). The required counter balancing muscle contraction on the opposite side of the fulcrum (the vertebrae) would also be 30 pounds. The net total increased fulcrum (spinal vertebral) load is 60 pounds. This exposes the spinal column (vertebrae) to chronic wear and tear damage. The common lexicon for this wear and tear damage is degenerative joint disease, or more simply, spinal arthritis.
When the head is chronically bent forward, the muscles (the effort) on the opposite side of the spinal column must chronically contract to prevent the person from falling forward and to maintain balance (3).
The chronic counterbalancing muscle contraction results in chronic inflammation, pain, muscle tissue fibrosis, and functional disability (3). The syndrome associated with this sequence of events has been termed myofascial pain syndrome (4, 5, 6).
Chronic forward bending of the head/neck causes a number of clinical problems, including:
- Chronic contraction of the muscles at the back of the head, neck, shoulders, and upper back. This causes muscle fatigue, soreness, tightness, inflammation, and pain. This is called myofascial pain syndrome (4, 5, 6).
- The chronic muscle contraction often results in headaches (7, 8).
- Acceleration of degenerative joint disease (arthritis) of the spinal joints (9, 10, 11, 12).
- Spinal Cord Tethering (13, 14): this is an abnormal elongation (stretching) of the spinal cord that can result in both spine neuron dysfunction and/or spinal cord vascular compromise. These can result in both autonomic and musculoskeletal symptoms.
- Spinal Cord Demyelination (15): chronic forward head compromises the blood flow to the spinal cord with a long-term consequence of the loss of the insulation (demyelination) of the neurons of the spinal cord.
- Vertebral Artery blood flow compromise (16): the vertebral artery is the pipeline carrying blood, nutrients and oxygen to the brainstem. The vertebral artery resides inside the cervical spine vertebrae in an opening called the foramen transversarium. There is evidence that loss of cervical lordosis (kyphosis, forward head) results in a compromise of blood flow from the heart, through the vertebral artery in the foramen transversarium and into the brain stem. This would adversely affect cranial nerve and other vital function.
Text/Tech Neck Studies From the Scientific/Medical Literature
The explosion of text/tech neck health problems has not gone unnoticed in the scientific/medical literature:
Kenneth K. Hansraj, MD, is Chief of Spine Surgery, at the New York Spine Surgery & Rehabilitation Medicine facility. In 2014, Dr. Hansraj, published an article in the journal Surgical Technology International, titled (17):
Assessment of Stresses in the Cervical Spine
Caused by Posture and Position of the Head
In this article, Dr. Hansraj notes that billions of people are using cell phone devices on the planet, essentially in poor posture. Consequently, the purpose of this study was to assess the forces incrementally seen by the neck (cervical spine) as the head is tilted forward, into worsening forward head posture. Dr. Hansraj notes that this data is necessary for cervical spine surgeons to understand in the reconstruction of the neck.
Dr. Hansraj indicates that an average person spends 2-4 hours a day with their heads tilted forward reading and texting on their smart phones / devices, amassing 700-1400 hours of excess, abnormal cervical spine stress per year. A high school student may spend an extra 5,000 hours in poor posture per year.
Dr. Hansraj created a cervical spine model to calculate the forces experienced by the cervical spine when in incremental flexion (forward head position). His mathematical analysis used a head weight of 13.2 pounds. He claims that there are no other prior studies assessing the stresses about the neck when incrementally moving the head forward. His calculations are as follows:
Dr. Hansraj makes the following key points in his study:
“Poor posture invariably occurs with the head in a tilted forward position and the shoulders drooping forward in a rounded position.”
“The weight seen by the spine dramatically increases when flexing the head forward at varying degrees.”
“Loss of the natural curve of the cervical spine leads to incrementally increased stresses about the cervical spine. These stresses may lead to early wear, tear, degeneration, and possibly surgeries.”
In January of 2017, researchers from the Department of Occupational and Environmental Medicine, University of Gothenburg, Sweden, published a study in the journal Applied Ergonomics, titled (18):
Texting on Mobile Phones and Musculoskeletal
Disorders in Young Adults: A Five-year Cohort Study
The aim of this study was to examine whether texting on a mobile phone is a risk factor for musculoskeletal disorders in the neck and upper extremities in a population of young adults, aged 20-24 years. The study duration was 5 years.
The authors indicate that young adults today have grown up with mobile phones as an evident part of their lives. Access to mobile phones was 99% in the group of young adults they studied. In the United States, text messaging is the most frequently used type of communicative medium.
The authors note that text messaging places a repetitive physical exposure on the neck, shoulders, arms and thumbs. Studies have identified musculoskeletal disorders in the forearm and thumb, tendonitis, tenosynovitis, and first carpometacarpal (CMC) arthritis, in relation to excessive texting on a mobile phone. “Texting can be associated with musculoskeletal disorders of the neck and upper extremity.”
In the subjects with symptoms, almost all individuals had the neck flexed forward and did not support their arms. “This causes static muscular load in the neck and shoulders. Furthermore, they held the phone with one hand and used only one thumb, implying increased repetitive movements in hand and fingers. This distinguished them from the group without symptoms, in which it was more common to sit with a straight neck, to support the forearm, to hold the phone with two hands and to use both thumbs.” The authors concluded:
“Sitting with the head bent forward while texting was more common among those with musculoskeletal symptoms.”
“Associations were found between text messaging and reported pain in the neck/upper back, shoulder/upper extremities, and numbness/tingling in the hand/fingers for both men and women.”
“There were clear associations between the highest category of text messaging and pain in the neck/upper back.”
“Sustained neck flexion may be a risk factor for developing pain in the neck, shoulder, and upper extremities.”
“Sitting with the head bent forward without supporting the arms causes a static load in the neck and shoulder muscles, which could explain the reported pain from neck/upper back.”
“Sustained muscle load and posture are considered to be risk factors for developing musculoskeletal disorders.”
“Associations with neck and upper extremity pain were found at levels of text messaging as low as 6 texts/day.”
“The strongest associations with neck/upper back and shoulder pain concerned the highest exposure category (>20 texts/day) in both men and women.”
“A prospective study with a working population showed that flexing the neck >20° for more than 40% of the working day was a risk factor for sick leave due to neck pain.”
These authors believe that the associations between cell phone use and health symptoms are underestimated because they did not include data on how much the participants use their mobile phones for other activities, e.g. gaming.
In June 2017, physicians from the Departments of Orthopaedic Surgery and Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA, published a study in The Spine Journal, titled (19):
An Epidemic of the Modern Era of Cell Phones?
The authors note that cellular/smart phones are everywhere. They are being extensively used by people of all ages. A concern to the modern era physician is the potential musculoskeletal consequence of this extensive cell phone usage, especially texting.
Extensive cell phone use and postures cause spondylotic changes consistent with an aged spine, but they are now being found in younger and younger age groups, including:
- Disc herniations
- Kyphotic alignment
- Abnormal imaging studies
As spine surgeons, the authors have been noticing a rise in the number of patients complaining of neck and upper back pain. It is plausible that these increased stresses upon the cervical spine result in accelerated cervico-thoracic disc degeneration. These authors propose that there are significant increases in intradiscal pressure during flexion, and that “chronic increased intradiscal pressure likely contributes to disk degeneration [cervical spondylosis] and herniation.”
These authors cite a finite element analysis that measured the increased loads imparted onto the cervical spine at progressively flexed postures. The findings included:
- While in a neutral position, the head weight on the neck is about 10–12 lbs.
- Flexing the head/neck forward 15° increases the weight on the cervical spine to 27 lbs.
- Flexing the head/neck forward 30° increases the weight on the cervical spine to 40 lbs.
- Flexing the head/neck forward 45° increases the weight on the cervical spine to 49 lbs.
- Flexing the head/neck forward 60° increases the weight on the cervical spine to 60 lbs.
These authors also cite a study of over 7,000 young adult subjects (age 20–24) over a 5-year period that showed “persistent neck pain and upper back pain is associated with time spent text messaging.” This same study also showed increased “shoulder pain, numbness, and tingling in the hand or fingers in those subjects who spent the most time texting.”
“It now seems rather clear that repetitive texting, or similar activity while using a forward flexed neck position, may lead to neck pain or ‘text neck’.”
These authors have great concern for the consequences of prolonged cervical spine flexion while texting on the developing (growing) spine. They note that persistent, prolonged forward flexed neck position may lead to anterior ligamentous contractures, accelerating cervical disk degeneration and cervical kyphosis.
These authors make these recommendations to avoid and/or treat text/tech neck:
- Patients hold their cell phone up at or near eye level while texting.
- Texting with two hands and two thumbs may provide more extremity and interscapular muscle symmetry.
- “For patients who spend significant time working at a computer or tablet we recommend the use of elevated stands for desktop monitors so that the monitor is at a natural horizontal gaze level.”
- Subjects should perform basic exercises that stretch and strengthen the cervical and upper thoracic soft tissue.
Chiropractors are expertly trained in the ergonomic avoidance of the postures that lead to text/tech neck, advising and coaching thousands of patients on these issues daily. Chiropractic clinical practice offers a variety of treatment approaches that are very effective in the management of the text/tech neck syndrome (20, 21, 22, 23, 24, 25, 26, 27, 28).
- Carolyn Crist C; Leaning forward during phone use may cause ‘text neck’; Reuters Health; April 14, 2017.
- Fleming K; Tech is Turning Millennial Into a Generation of Hunchbacks; The New York Post; March 5, 2018.
- Cailliet R; Soft Tissue Pain and Disability; 3rd Edition; FA Davis Company; 1996.
- Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual; New York: Williams & Wilkins, 1983.
- Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual: THE LOWER EXTREMITIES; New York: Williams & Wilkins, 1992.
- Simons D, Travell J; Travell & Simons’, Myofascial pain and dysfunction, the trigger point manual: Volume 1, Upper Half of Body; Baltimore: Williams & Wilkins, 1999.
- Seletz E; Headache of Extracranial Origin; California Medicine; November 1958; Vol. 89; No. 5; pp. 314-317.
- Bogduk N; Anatomy and Physiology of Headache; Biomedicine and Pharmacotherapy; 1995; Vol. 49; No. 10; pp. 435-445.
- Garstang SV, Stitik SP; Osteoarthritis; Epidemiology, Risk Factors, and Pathophysiology; American Journal of Physical Medicine and Rehabilitation; November 2006; Vol. 85; No. 11; pp. S2-S11.
- Ruch W; Atlas of Common Subluxations of the Human Spine and Pelvis, Second Edition; Life West Press; 2014.
- Uchida K, Nakajima H, Sato R, Yayama T, Mwaka ES, Kobayashi S, Baba H; Cervical Spondylotic Myelopathy Associated with Kyphosis or Sagittal Sigmoid Alignment: Outcome after Anterior or Posterior Decompression; Journal of Neurosurgery: Spine; November 2009; Vol. 11; pp. 521-528.
- Grosso M, Hwang R, Mroz T, Benzel, Steinmetz M; Relationship between degree of focal kyphosis correction and neurological outcomes for patients undergoing cervical deformity correction surgery; Journal of Neurosurgery: Spine; June 18, 2013; Vol. 18; No. 6; pp. 537-544.
- Breig A; Adverse Mechanical Tension in the Central Nervous System; Almqvist and Wiksell; 1978.
- Wing PC, Tsang IK, Susak L, Gagnon F, Gagnon R, Potts JE; Back Pain and Spinal Changes in Microgravity; Orthopedic Clinics of North America; April 1991; Vol. 22; No. 2; pp. 255-262.
- Shimizu K, Nakamura M, Nishikawa Y, Hijikata S, Chiba K, Toyama Y; Spinal Kyphosis Causes Demyelination and Neuronal Loss in the Spinal Cord: A New Model of Kyphotic Deformity; Spine; November 2005; Vol. 30; No. 21; pp. 2388-2392.
- Bulut MD, Alpayci M, Şenkoy E, Bora A, Yazmalar L, Yavuz A, Gulşen I; Decreased Vertebral Artery Hemodynamics in Patients with Loss of Cervical Lordosis; Medical Science Monitor; February 15, 2016; Vol. 22; pp. 495-500.
- Hansraj KK; Assessment of Stresses in the Cervical Spine Caused by Posture and Position of the Head; Surgical Technology International; November 2014; Vol. 25; pp. 277-279.
- Gustafsson E, Thoee S, Grimby-Ekman A, Hagberg M; Texting on Mobile Phones and Musculoskeletal Disorders in Young Adults: A Five-year Cohort Study; Applied Ergonomics; January 2017; Vol. 58; pp. 208-214.
- Cuéllar JM, Lanman TH; “Text Neck” An Epidemic of the Modern Era of Cell Phones?; The Spine Journal; June 2017; Vol. 17; No. 6; pp. 901–902.
- Leach RA. An evaluation of the effect of chiropractic manipulative therapy on hypolordosis of the cervical spine. J Manipulative Physiol Ther. 1983 Mar;6(1):17-23.
- Harrison DD, Jackson BL, Troyanovich S, Robertson G, de George D, Barker WF. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. Journal of Manipulative and Physiological Therapeutics; September 1994; Vol. 17; No. 7; pp. 454-64.
- Troyanovich SJ, Harrison DE, Harrison DD. Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther. 1998 Jan;21(1):37-50.
- Harrison DE, Harrison, DD, Haas JW. CBP Structural Rehabilitation of the Cervical Spine, 2002.
- Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial. Arch Phys Med Rehabil. 2002 Apr;83(4):447-53.
- Morningstar MW, Strauchman MN, Weeks DA. Spinal manipulation and anterior headweighting for the correction of forward head posture and cervical hypolordosis: A pilot study. J Chiropr Med. 2003 Spring;2(2):51-4.
- Harrison DE, Harrison DD, Betz JJ, Janik TJ, Holland B, Colloca CJ, Haas JW. Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial. J Manipulative Physiol Ther. 2003 Mar-Apr;26(3):139-51.
- Ferrantelli JR, Harrison DE, Harrison DD, Stewart D. Conservative treatment of a patient with previously unresponsive whiplash-associated disorders using clinical biomechanics of posture rehabilitation methods. J Manipulative Physiol Ther. 2005 Mar-Apr;28(3):e1-8.
- Oakley PA, Harrison DD, Harrison DE, Haas JW. Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP) publications. J Can Chiropr Assoc. 2000.
“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”