Abstract
Forward head posture (FHP) is a typical postural deviation which is increasingly prevalent in contemporary populations and is accompanied by serious musculoskeletal and psychological implications. This literature review focuses on the biomechanical nature of FHP and its connection with the tissue mechanosensitivity, chronic neck pain, and psychological health. It has been shown that changes in cervical position enhance mechanical loading, which causes muscle imbalance, peripheral sensitization, central sensitization, and low pain thresholds. Other psychological factors like stress, anxiety and fear-avoidance are also players in the process of interacting with the pain mechanisms to produce a biopsychosocial cycle. Knowledge of these interactions helps to justify the importance of thorough evaluation and multimodal/biopsychosocial rehabilitation interventions in order to achieve better clinical outcomes.
References
- Lotfian S, Fesharaki MJ, Shahabbaspour Z et al. The impact of forward head posture on neck muscle endurance and thickness in women with chronic neck pain: a cross-sectional study. BMC Musculoskelet Disord. 2025 May 13;26(1):468. doi: 10.1186/s12891-025-08705-w
- Rafique D, Heggli U, Bron D et al. Effects of increasing axial load on cervical motor control. Sci Rep. 2021 Sep 20;11(1):18627. doi: 10.1038/s41598-021-97786-3
- Hoe VC, Urquhart DM, Kelsall HL et al. Ergonomic interventions for preventing work-related musculoskeletal disorders of the upper limb and neck among office workers. Cochrane Database Syst Rev. 2018 Oct 23;10(10):CD008570. doi: 10.1002/14651858.CD008570.pub3
- Khan HTA, Addo KM, Findlay H. Public Health Challenges and Responses to the Growing Ageing Populations. Public Health Chall. 2024 Jul 21;3(3):e213. doi: 10.1002/puh2.213.
- Kaiser JT, Reddy V, Launico MV et al. Anatomy, Head and Neck: Cervical Vertebrae. [Updated 2023 Oct 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539734/
- Javdaneh N, Barati A, Shojaedin S et al. Is chronic neck pain related to scapular dyskinesia? A systematic review. BMC Musculoskelet Disord. 2025 Jul 2;26(1):585. doi: 10.1186/s12891-025-08916-1.
- Alvarez D, Sillevis R, Cuenca Zaldívar JN et al. Neural tension patterns during cervical spine rotation: diagnostic implications from a cadaveric study. Chiropr Man Therap. 2025 Oct 9;33(1):41. doi: 10.1186/s12998-025-00608-w
- Tomschi F, Schmidt A, Brühl M et al. T. Reference Values of Joint-Specific Pressure Pain Thresholds in Healthy Male Individuals: A Retrospective Study. Eur J Pain. 2025 Jul;29(6):e70050. doi: 10.1002/ejp.70050
- Shah JP, Thaker N, Heimur J et al. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. PM R. 2015 Jul;7(7):746-761. doi: 10.1016/j.pmrj.2015.01.024
- Vadivelu N, Kai AM, Kodumudi G, Babayan K, Fontes M, Burg MM. Pain and Psychology-A Reciprocal Relationship. Ochsner J. 2017 Summer;17(2):173-180 .
- Yang S, Boudier-Revéret M, Yi YG et al. Treatment of Chronic Neck Pain in Patients with Forward Head Posture: A Systematic Narrative Review. Healthcare (Basel). 2023 Sep 22;11(19):2604. doi: 10.3390/healthcare11192604
- Woolf CJ. What is this thing called pain? J Clin Invest. 2010 Nov;120(11):3742-4. doi: 10.1172/JCI45178
- Pedro Costa A, da Silva Brito I, Mestre TD et al. Meshing Anxiety, Depression, Quality of Life, and Functionality in Chronic Disease. Healthcare (Basel). 2025 Mar 2;13(5):539. doi: 10.3390/healthcare13050539
- Cramer H, Mehling WE, Saha FJ et al. Postural awareness and its relation to pain: validation of an innovative instrument measuring awareness of body posture in patients with chronic pain. BMC Musculoskelet Disord. 2018 Apr 6;19(1):109. doi: 10.1186/s12891-018-2031-9
- Kak A, Batra M, Erbas B et al. Psychological factors associated with pain and function in adults with hallux valgus. J Foot Ankle Res. 2025 Mar;18(1):e70030. doi: 10.1002/jfa2.70030
- Fietze I, Rosenblum L, Salanitro M, Ibatov AD, Eliseeva MV, Penzel T, Brand D, Westermayer G. The Interplay Between Poor Sleep and Work-Related Health. Front Public Health. 2022 Jul 7;10:866750. doi: 10.3389/fpubh.2022.866750
- Witkower Z, Tracy JL. How and why head position changes the perception of facial expressions of emotion. Emotion. 2022 Aug;22(5):931-944. doi: 10.1037/emo0000846
- Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004 Nov-Dec;2(6):576-82. doi: 10.1370/afm.245
- Kamkin A, Kiseleva I. Mechanosensitivity of Cells from Various Tissues. In: Kamkin A, Kiseleva I, editors. Mechanosensitivity in Cells and Tissues. Moscow: Academia; 2005. Available from: https://www.ncbi.nlm.nih.gov/books/NBK7493/
- Smania N, Picelli A, Munari D et al. Rehabilitation procedures in the management of spasticity. Eur J Phys Rehabil Med. 2010 Sep;46(3):423-38. PMID: 20927008.
- Leccese A, Severo M, Ventriglio A et al. Psychological Interventions in Patients with Physical Pain: A Focus on Catastrophizing and Resilience-A Systematic Review. Healthcare (Basel). 2025 Mar 7;13(6):581. doi: 10.3390/healthcare13060581
- Yong MS, Lee HY, Lee MY. Correlation between head posture and proprioceptive function in the cervical region. J Phys Ther Sci. 2016 Mar;28(3):857-60. doi: 10.1589/jpts.28.857. Epub 2016 Mar 31
- Kim DH, Kim CJ, Son SM. Neck Pain in Adults with Forward Head Posture: Effects of Craniovertebral Angle and Cervical Range of Motion. Osong Public Health Res Perspect. 2018 Dec;9(6):309-313. doi: 10.24171/j.phrp.2018.9.6.04.
- Pires L, Santos N, Lana JV et al. Upper Crossed Syndrome and Scapulae Upper-Trapping: A Mesotherapy Protocol in Cervicoscapulobrachial Pain-The 8:1 Block. Bioengineering (Basel). 2024 Nov 13;11(11):1142. doi: 10.3390/bioengineering11111142
- Kang T, Kim B. Cervical and scapula-focused resistance exercise program versus trapezius massage in patients with chronic neck pain: A randomized controlled trial. Medicine (Baltimore). 2022 Sep 30;101(39):e30887. doi: 10.1097/MD.0000000000030887
- Stokes IA, Iatridis JC. Mechanical conditions that accelerate intervertebral disc degeneration: overload versus immobilization. Spine (Phila Pa 1976). 2004 Dec 1;29(23):2724-32. doi: 10.1097/01.brs.0000146049.52152.da
- Peng B, Yang L, Li Y, Liu T, Liu Y. Cervical Proprioception Impairment in Neck Pain-Pathophysiology, Clinical Evaluation, and Management: A Narrative Review. Pain Ther. 2021 Jun;10(1):143-164. doi: 10.1007/s40122-020-00230-z
- Dilley A, Lynn B, Pang SJ. Pressure and stretch mechanosensitivity of peripheral nerve fibres following local inflammation of the nerve trunk. Pain. 2005 Oct;117(3):462-472. doi: 10.1016/j.pain.2005.08.018
- Mujawar JC, Sagar JH. Prevalence of Upper Cross Syndrome in Laundry Workers. Indian J Occup Environ Med. 2019 Jan-Apr;23(1):54-56. doi: 10.4103/ijoem.IJOEM_169_18
- Chang MC, Choo YJ, Hong K, Boudier-Revéret M, Yang S. Treatment of Upper Crossed Syndrome: A Narrative Systematic Review. Healthcare (Basel). 2023 Aug 17;11(16):2328. doi: 10.3390/healthcare11162328
- Curatolo M. Central Sensitization and Pain: Pathophysiologic and Clinical Insights. Curr Neuropharmacol. 2024;22(1):15-22. doi: 10.2174/1570159X20666221012112725
- Karcz M, Abd-Elsayed A, Chakravarthy K et al. Pathophysiology of Pain and Mechanisms of Neuromodulation: A Narrative Review (A Neuron Project). J Pain Res. 2024 Nov 16;17:3757-3790. doi: 10.2147/JPR.S475351
- Dua A, Chang KV. Myofascial Pain Syndrome. [Updated 2025 Apr 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499882/
- Lavelle ED, Lavelle W, Smith HS. Myofascial trigger points. Anesthesiol Clin. 2007 Dec;25(4):841-51, vii-iii. doi: 10.1016/j.anclin.2007.07.003
- Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011 Mar;152(3 Suppl):S2-S15. doi: 10.1016/j.pain.2010.09.030
- Mahmoud NF, Hassan KA, Abdelmajeed SF et al. The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis. Curr Rev Musculoskelet Med. 2019 Dec;12(4):562-577. doi: 10.1007/s12178-019-09594-y
- Khalil B, Marwaha K, Bollu PC. Physiology, Neuromuscular Junction. [Updated 2025 Feb 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470413/
- Olugbade T, Bianchi-Berthouze N, Williams ACC. The relationship between guarding, pain, and emotion. Pain Rep. 2019 Jul 22;4(4):e770. doi: 10.1097/PR9.0000000000000770
- Sikka I, Chawla C, Seth S et al. Effects of Deep Cervical Flexor Training on Forward Head Posture, Neck Pain, and Functional Status in Adolescents Using Computer Regularly. Biomed Res Int. 2020 Oct 5;2020:8327565. doi: 10.1155/2020/8327565
- Warda DG, Nwakibu U, Nourbakhsh A. Neck and Upper Extremity Musculoskeletal Symptoms Secondary to Maladaptive Postures Caused by Cell Phones and Backpacks in School-Aged Children and Adolescents. Healthcare (Basel). 2023 Mar 10;11(6):819. doi: 10.3390/healthcare11060819
- De La Rosa JS, Brady BR, Ibrahim MM, Herder KE, Wallace JS, Padilla AR, Vanderah TW. Co-occurrence of chronic pain and anxiety/depression symptoms in U.S. adults: prevalence, functional impacts, and opportunities. Pain. 2024 Mar 1;165(3):666-673. doi: 10.1097/j.pain.0000000000003056
- Ashton-James CE, Anderson SR, Mackey SC, Darnall BD. Beyond pain, distress, and disability: the importance of social outcomes in pain management research and practice. Pain. 2022 Mar 1;163(3):e426-e431. doi: 10.1097/j.pain.0000000000002404
- Lopez LD, Reschke PJ, Knothe JM, Walle EA. Postural Communication of Emotion: Perception of Distinct Poses of Five Discrete Emotions. Front Psychol. 2017 May 16;8:710. doi: 10.3389/fpsyg.2017.00710
- Jung JY, Lee YB, Kang CK. Effect of Forward Head Posture on Resting State Brain Function. Healthcare (Basel). 2024 Jun 7;12(12):1162. doi: 10.3390/healthcare12121162
- Hall KJ, Van Ooteghem K, McIlroy WE. Emotional state as a modulator of autonomic and somatic nervous system activity in postural control: a review. Front Neurol. 2023 Aug 31;14:1188799. doi: 10.3389/fneur.2023.1188799
- Dydyk AM, Chiebuka E, Stretanski MF, et al. Central Pain Syndrome. [Updated 2025 May 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553027/
- Chu B, Marwaha K, Sanvictores T, et al. Physiology, Stress Reaction. [Updated 2024 May 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541120/
- Alshak MN, Das JM. Neuroanatomy, Sympathetic Nervous System. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542195/
- Park S, Kim K, Kang M. The Effects of Rehabilitation Programs Incorporating Breathing Interventions on Chronic Neck Pain Among Patients with Forward Head Posture: A Systematic Review and Meta-Analysis. Bioengineering (Basel). 2025 Aug 31;12(9):947. doi: 10.3390/bioengineering12090947
- Rosário JL. Biomechanical assessment of human posture: a literature review. J Bodyw Mov Ther. 2014 Jul;18(3):368-73. doi: 10.1016/j.jbmt.2013.11.018
- Vambheim SM, Kyllo TM, Hegland S et L. Relaxation techniques as an intervention for chronic pain: A systematic review of randomized controlled trials. Heliyon. 2021 Aug 20;7(8):e07837. doi: 10.1016/j.heliyon.2021.e07837
- Nejati P, Lotfian S, Moezy A et al. The relationship of forward head posture and rounded shoulders with neck pain in Iranian office workers. Med J Islam Repub Iran. 2014 May 3;28:26
- Martinez-Merinero P, Nuñez-Nagy S, Achalandabaso-Ochoa A et al. J Clin Med. 2020 Feb 27;9(3):634. doi: 10.3390/jcm9030634
- Sung YH. Suboccipital Muscles, Forward Head Posture, and Cervicogenic Dizziness. Medicina (Kaunas). 2022 Dec 5;58(12):1791. doi: 10.3390/medicina58121791
- Nijs J, Malfliet A, Nishigami T. Nociplastic pain and central sensitization in patients with chronic pain conditions: a terminology update for clinicians. Braz J Phys Ther. 2023 May-Jun;27(3):100518. doi: 10.1016/j.bjpt.2023.100518
- Hui N, Phan K, Lee MY et al. The Changes in Cervical Biomechanics After CTDR and Its Association With Heterotopic Ossification: A Systematic Review and Meta-analysis. Global Spine J. 2021 May;11(4):565-574. doi: 10.1177/2192568220922949.
- Subbarayalu AV, Ameer MA. Relationships among head posture, pain intensity, disability and deep cervical flexor muscle performance in subjects with postural neck pain. J Taibah Univ Med Sci. 2017 Aug 12;12(6):541-547. doi: 10.1016/j.jtumed.2017.07.001
- Wilzer E, Zeisel A, Roessner V et al. Association between anxiety, depression and quality of life in male and female German students during the COVID-19 pandemic. BMC Psychiatry. 2024 Mar 18;24(1):212. doi: 10.1186/s12888-024-05611-8
- Takayama A, Sekiya H. Effects of various sitting and standing postures on arousal and valence. PLoS One. 2023 Jun 2;18(6):e0286720. doi: 10.1371/journal.pone.0286720
- Timmers I, Quaedflieg CWEM, Hsu C et al. The interaction between stress and chronic pain through the lens of threat learning. Neurosci Biobehav Rev. 2019 Dec;107:641-655. doi: 10.1016/j.neubiorev.2019.10.007
- Kato F, Abe T, Kanbara K et al. Biopsychosoc Med. 2017 May 12;11:13. doi: 10.1186/s13030-017-0098-4.
- Sattin D, Parma C, Lunetta C et al. An Overview of the Body Schema and Body Image: Theoretical Models, Methodological Settings and Pitfalls for Rehabilitation of Persons with Neurological Disorders. Brain Sci. 2023 Oct 4;13(10):1410. doi: 10.3390/brainsci13101410