Correcting any anterior head carriage is never going to be accomplished overnight.  It takes a long time for the body to adapt to a new posture (I think it’s thousands of repetitions to learn a new motion pattern) and correcting your own posture is next to impossible as it involves conscious thought which is really difficult to maintain for any length of time and do some work at the same time. 

 But how is it mended?

Firstly get in and see your chiropractor to get your neck working well as there is no point of learning new posture with a rotated neck – why? as this will then become the default posture for your neck and you’ll try to revert to it.  A visit will also reduce some symptoms (if you have any) but this will only be temporary because without a change in posture, the body will go right back to its previous position creating the problem again.  So we must tackle the ‘why’ bit of the problem.

Anterior head carriage affects those that sit all day, usually in front of a computer or at a desk.  Most people in these cases find themselves leaning over a desk to read or are hunched at a computer typing all day.  Take a look around you; you’ll see them out there, like this cracking example of it in Drew barrymore – no less. 

If your posture is correct then the red Centre of Gravity (CoG) line should pass through your ear hole.  What happens in AHC is that the head comes forward of the CoG and starts to slow-fall to the keyboard.  The only thing stopping this fall are the muscles of the neck and shoulders, such as the traps and the lev scaps.  

However, once the neck is working well and the shoulder and neck muscles are functioning again it is time to start the anterior head carriage stretches to combat the damage done by peering into the computer for years.

I’ll add this on the blog once I get some decent photos of the stretch so hold your horses,  get it working right by seeing your chiro and by the time it is I’ll have the stretch ready.

RMSC

How common is neck pain?
Well, you are certainly not alone – Hill and co-workers report that in the UK many as 31% of adults have had neck pain in the last month (the adult population of the UK has got to be over 50 million people so, as hey say in the US, “Go do the math”) and 48% of neck pain patients report persistent pain a year later.
- Hill J, Lewis M et al. (2004) Predicting Persistent Neck Pain. Spine 29:1648-1654

What’s going wrong?
Well, this is trickier. Liebenson, Skaggs et al. say that it is ‘difficult to pinpoint the specific pain-generating tissue’ of neck pain and even if you can the reasons why ‘are often elusive’. Now, in my experience the most common neck problem we see is ‘Posterior Facet Syndrome’, one of the mechanical neck pains, and it is caused by compression of the facet joints as a result of anterior head carriage commonly aggravated by peering into the computer for eight hours a day.

Though, try Googleing ‘Posterior Facet Syndrome’ and see what comes up as it is a hotly debated subject with some denialists saying it doesn’t exist though how can this be as I treat it daily and it responds very well.

In trying to describle what I am treating I say that PFS is similar to an ankle sprain but of the neck joints and that, like an ankle sprain, a whole raft of different tissues may be involved in the injury depending on how it was done. This seems pretty plausible to me and covers all the bases and, as long as we are treating these tissues, we should have some impact on the problem – yes?

There are some even stranger things happening out there in neck land. Up to 71% of patients who have chronic pain following whiplash have undetected vertebral end plate fractures at the spinal levels associated with the pain that were overlooked on standard medical imaging.
- Michael Freedman Dec 2001.
Not surprisingly, I suspect that this has some impact on the way things progress in a neck but, surprisingly, there may well be nothing that can be done about it and that even if the information was available it would not change the way the neck was managed anyway.

Neck pan can be split into these broad categories:

Grade 1 – neck pain with little or no interference with daily activity.
Grade 2 – limits daily activity.
Grade 3 – neck pain with accompanied radiculopathy (pinched nerve pain, weakness and/or numbness in the arm)
Grade 4 – neck pain with serious pathology – tumour, infection or systemic disease.

(Clearly, along with mechanical neck pain there are some real nasties out there; neck pain may be a symptom of meningitis and if any of the following symptoms occur, dial 999 or seek medical attention urgently:
• A rash develops that does not fade when you press it with a glass tumbler or a finger.
• You feel ill or are running a fever as well as feeling neck pain.
• It is to painful to bend the neck forward and put your chin on your chest.
• Light hurts.
• Your neck pain is accompanied by severe headache or continuous vomiting.
• Neck pain is accompanied by severe pain in the back.
And in some cases, neck pain can be a symptom of head injury or disc trouble in the neck, so. If any of the following symptoms occur, dial 999 or seek medical attention urgently:
• Neck pain is the result of a recent head injury and you are becoming drowsy, confused or are vomiting.
• Neck pain is accompanied by headache.
• If there is pain behind one eye.
• Vision, hearing, taste or balance are affected.
• Severe vomiting.
• The muscle power in your arms or legs is reduced.)
Treatment
Here’s the science bit:
Cleland et al. showed that manipulation of the thoracic spine produces immediate analgesic effects in patients with mechanical neck pain.
- Cleland JA, Childs JD et al. (2005) Immediate Effects of Thoracic Manipulation in Patients with Neck Pain: A Randomized Clinical Trail, Manipulative Therapy 10:127-135.
And Liebenson recommends manual therapy with some rehabilitation exercises. This has been supported by one of the strongest research trials in this field carried out by Bronfort, Evans et al. In this trial 191 patients were split into three treatment groups, like this:
• Spinal manipulation and low-tech exercise,
• Spinal manipulation and MedX exercise – receiving dynamic progressive resistance exercises on MedX machines,
• Spinal manipulation.
Outcomes were measured at 5 and 11 weeks and 3, 6 and 12 months after the trial. At the one year follow up the group that were receiving exercises and manipulation did significantly better than the group undergoing manipulation alone.

In a literature review published by Hurwitz, Aker et al. in Spine and Aker, Gross et al. in the British Medical Journal, so hardly slack journals I’d suggest, manipulation and mobilization were both more effective than muscle relaxants and usual medical care in providing pain relief for patients with sub-acute or chronic neck pain. In a study (2003) in Spine Giles and Muller compared acupuncture, joint manipulation and standard medication (NSAIDs). Patients in the acupuncture and medications groups had no significant improvement during the trial on any of the outcome measures and the manipulation group showed significant improvement on all measures with no patient made worse or experiencing side effects. Giles and Muller then followed up their patients a year later and reported that the manipulation group gained ‘significant broad-based beneficial…long-term outcomes’ (I like Giles and Muller).

In a great study by Haneline at Palmer College of Chiropractic, 79% of the patients improved to the point they had only minimal or minor restriction of movement and their satisfaction rates were an astounding 94% – and I suspect few trials can report the same, with 70% indicating they were very satisfied. When asked which provider helped the most 83% replied the chiropractor (this all sounds too much like a dodgy ‘election’ in North Korea for it to sit comfortably with me but….)

However, and there’s always one, here’s what the GP’s advise on http://www.patient.co.uk/:

Exercise your neck and keep active
Aim to keep your neck moving as normally as possible. At first the pain may be quite bad, and you may need to rest for a day or so. However, gently exercise the neck as soon as you are able. You should not let it ‘stiffen up’. Gradually try to increase the range of the neck movements. Every few hours gently move the neck in each direction. Do this several times a day. As far as possible, continue with normal activities.
In the past, some people have worn a neck collar for long periods when a bout of neck pain developed. The problem with collars is that they prevent you from moving your neck properly. Studies have shown that you are more likely to make a quicker recovery if you do regular neck exercises, and keep your neck active rather than resting it for long periods in a collar. Also, if you keep the neck active during a bout of neck pain, it is thought to help prevent chronic (persistent) neck pain from developing.

(So good, reasonable advice so far but then…)

Medicines
Painkillers are often helpful. It is best to take painkillers regularly until the pain eases. This is better than taking them now and again just when the pain is very bad. If you take them regularly, it may prevent the pain from getting severe, and enable you to exercise and keep your neck active.
• Paracetamol at full strength is often sufficient. For an adult this is two 500 mg tablets, four times a day.
• Anti-inflammatory painkillers. Some people find that these work better than paracetamol. They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac, naproxen, or tolfenamic need a prescription. Some people with asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers.
• A stronger painkiller such as codeine is an option if anti-inflammatories do not suit or do not work well. Codeine is often taken in addition to paracetamol. Constipation is a common side-effect from codeine. To prevent constipation, have lots to drink and eat foods with plenty of fibre.
• A muscle relaxant such as diazepam is sometimes prescribed for a few days if your neck muscles become tense and make the pain worse.
(Awww, and they were doing so well. The problem in your neck has nothing to do with a lack of pain-killer in your blood so don’t do it. The evidence doesn’t support it so why advise it unless there is some other reason and I am not going to suggest that we are a drug reliant NHS, oh no. I will suggest that the muscle tightness has a purpose and is not a trick that your neck is doing just to irritate you, perhaps; just perhaps, your brain wants to immobilize the injured joints, just like an ankle sprain then, and is using the muscles surrounding the joint to do this. So why would you want to take a muscle relaxant to stop this happening, why would you want to over ride your clearly stupid brain and let your neck move freely during an acute phase?)
Other advice
Some other advice which is commonly given includes:
• A good posture may help. Brace your shoulders slightly backwards, and walk ‘like a model’. Try not to stoop when you sit at a desk. Sit upright.
• A firm supporting pillow seems to help some people when sleeping.
• Physiotherapy. It is not clear whether this makes much difference to the outcome of mechanical neck pain. Therapies such as traction, heat, cold, manipulation, etc, may be tried, but the evidence that these help is not strong. However, what is often helpful is the advice a physiotherapist can give on neck exercises to do at home. A common situation is for a doctor to advise on painkillers and gentle neck exercises. If symptoms do not begin to settle over a week or so, you may then be referred to a physiotherapist to help with pain relief and for advice on specific neck exercises.
So, manipulation gets one word. Yet the recent report from the Bone and Joint Decade 2000 – 2010 Task Force on Neck Pain and Its Associated Disorders (made up by a staggering 50 researchers in 9 countries comprising of 14 different clinical disciplines and looking at over 31,000 research criterion and over 1000 met relevant criteria.) recommended that neck manipulation, acupuncture and massage are better choices for managing most common neck pain. It also recommended exercises, education and neck mobilization but to be less effective than adjustment.

I know which one I’d chose.

There are several different types of headache. Over 90% of these types of headache are known as primary headaches which have no underlying medical condition. These include all tension-type migraines, cluster and cervicogenic headaches.

What is a cervicogenic headache?

Cervicogenic headaches are headaches where the pain originates in the neck and upper shoulders and are neatly clinically defined as “pain that is present in the head, but which originates in the cervical spine”.

However, cervicogenic headaches, like other types of headaches are different for different people and, depending on who you are, some are more severe and some are less severe, some are present in the head and others have pain behind the eyes.

The ‘classic presentation’ of a cervicogenic headache is where pain starts in the occipital region (the base of your skull at the back) and in the cervical spine and then progressively spreads upwards into the head.

Commonly, with cervicogenic headaches, there will be muscular trigger points in these suboccipital muscles of the neck and in the shoulder muscles. These trigger points can also send shooting pain to the head when they are physically manipulated and will be very, very tender.

Helpfully, there are two key symptoms that are generally exclusive to cervicogenic headaches. Firstly, the headache can be made worse or actually initiated by head or neck movement or passive neck positioning, especially when extended towards the side that is prone to pain and secondly, there is marked tenderness in the suboccipital region.

Who is likely to get them?

In our experience nearly all patients with cervicogenic headaches have abnormal neck posture (this is nearly exclusively Anterior Head Carriage) or have restricted range of neck motion.

And they are caused by?

We see these on a daily basis and in our experience at C1 Chiropractic Health Centre is that these headaches are a by-product of trauma (such as whiplash), neck injury, intervertebral disc disease, progressive joint arthritis, chronic tension or muscle trauma due to poor prolonged posture or severe stress with this last one being the most commonly encountered headache in our clinic.

How’s it treated?

Unlike many common forms of headaches, such as migraine, and cluster headaches, they often do not respond well to over the counter medications such as analgesics or common pain medications such as Panadol. Although the cervicogenic headache sufferer will note some relief from the symptoms of pain experienced when taking a pain relieving medication, once the preparation has worn off, the symptoms, and pain will return. In order to gain relief treating the symptoms simply isn’t enough and a more holistic approach must be taken for long-term pain reduction.

One of the most effective ways of relieving cervicogenic pain is with Chiropractic treatment using Chiropractic Manipulative Therapy (CMT). We manipulate the bones in the neck area that have moved out of alignment to reduce inflammation and irritation and so reduce pain.

A major spine care review was published in 2008. The authoritative report by the Bone and Joint Decade 2000 – 2010 Task Force on Neck Pain and its Associated Disorders which built on the impressive report produced Quebec Task Force on Whiplash. This report follows seven years of literature review and original research from more than 50 researchers and the editor of the Spine journal described it as a “milestone” report.

It covers all aspects of neck pain, including headaches, arm-pain and other neck generated symptoms. Tellingly, it states that neck pain is a “multi-factorial and episodic or recurring problem” and adds that because patients have many differing personal factors underlying their problems best management requires informing and educating patients on their options and respecting their preferences.

It then goes on to add that most patients have grade 1 or 2 neck pain (so low grade and therefore ‘primary headaches’) and that treatments, with similar evidence of safety and effectiveness, are education, exercise, mobilization, manipulation, acupuncture, analgesics, massage and low-level laser therapy. But treatments NOT supported by the evidence are surgery, collars, ultrasound, electrical muscle stimulation, TENS, most injection therapies including corticosteriod injections for the cervical joints.

According to recent studies published in the Journal of Manipulative, And Physiological Therapeutics, the results indicated that spinal manipulation had a significant positive effect in cases of cervicogenic headache. In this study, 53 participants who were sufferers of cervicogenic headaches were studied closely. Half of the subjects were given chiropractic manipulation as treatment, while the other half of the subjects received deep friction, and low laser massage. The study lasted over the course of a three-week period. While the two groups of sufferers did notice improvement with the care given to them, the group that were involved in the soft tissue treatments noted only a significant decrease in the hours per day that they were experiencing headache. The manipulation group showed improvement in all three of the measurement criterion being studied. Those who received chiropractic treatment in the study noticed a 36% decrease in their pain medication usage; their headache hours were decreased by 69% and their headache intensity had also decreased by 36%. At the 12 week point, one month after the trial ended, there was “a clinically important and statistically significant” advantage in pain reduction for the patients receiving chiropractic manipulation. The patients receiving 8 treatments had a 9.4 advantage in pain reduction. Those receiving 16 visits had a 17.2 pain reduction advantage. However, the difference was not statistically significant because of the small trial.

Haas w Peterson et al. (2007) Dose-response of spinal manipulation for cervicogenic headache: short –term outcomes from a randomised trail, Abstract in Proceedings of the WFC’s 9th Biennial Congress, 161-162

If your head hurts on a regular basis, and you suffer from headaches continually, especially if the pain seems to radiate from your spine or upper shoulder area, this may be a sign of cervicogenic headache. This is especially true is you have suffered trauma to your spine or neck such as whiplash or injury. And you should see your Chiropractor, get it diagnosed and sorted and stop complaining.

Seen standing upright from the side someone with perfect posture would have an imaginary centre of gravity line running from just in front of their ear hole through the slight bump on the top-middle of their shoulder.  Normally, the centre of gravity of their head is slightly forward of this line so that a very slight muscle tone is required to keep the head looking forward.  This tone may act to prevent sudden uncontrolled movements of the head, or lolling (you will have personal experienced of this if you have ever fallen asleep sitting up where your head will fall forwards and your inactive muscles suddenly crank up into action and you jerk upright again).  

What you get in anterior head carriage is the centre of gravity of the head moving a significant distance forward of the correct centre of gravity line.  In some cases I have seen this has been up to 6cm forward of the correct line. 

The problem is spectacularly and increasingly prevalent because of what we do in our lives and, I suspect, is set to get worse and worse as the Wii generation grow up.  It is easy to spot, just go and stand next to someone and look to see if their ear hole is forward of the mid-shoulder line.  I suspect you’ll be surprised how prevent it is, in fact I think if you did a statistical analysis of your friends it would be the statistical norm, but still wrong, posture.

How does it occur?

The key cause is computer use, especially laptops.  Carrying heavy bags or back packs, lazy posture and telly time with little or no exercise also don’t help but it is the eight hours a day for 30 years that really does the trick especially if it starts when you are young – say in your teens.  Computer work keeps you in a static position (usually a forward curved position as well) for long periods of time, which is why getting up and moving around every 15-20 minutes will help.

Backpacks also do it by increasing the overall load on the spine as well as by focusing that extra load onto the shoulders, which is where the major muscles that attach to the back of the skull originate, so putting a much larger strain onto the mechanism of anterior head carriage than the weight of the load would indicate.

The other place it I have seen it is in young girls who are tall and they are trying to height hide, though this is getting less common as they don’t fret about it as much as they used to. 

What’s the problem with it?

The way you achieve anterior head carriage is by straightening your cervical spine from C2 to C7 and in some extreme cases I have even seen reverse curving in the neck. 

In terms of skeletal problems this means that you are removing the elegant shock absorbing cervical curve and turning the neck into a column which transfers the weight of the head straight down the neck through the discs and the posterior facets leading to disc damage and facet injury.  This also places the cervical facets in an abnormal position which means they are far more likely to sustain injury.  It is rare for a patient to present at the clinic with non-traumatic acute posterior facet syndrome (you know the sort of thing – the “I don’t know what I did but I woke up like this” cricked neck complaint) who has not got significant anterior head carriage.  Also with anterior head carriage the posterior fibres of the disc annulus get stretched which increases the risk of posterior disc rupture, protrusion or bulge and the subsequent events associated with these grim conditions.

In neurological terms a straight cervical spine means that your spinal cord, and therefore nearly every nerve in your body, is physically straightened.  Now, nerves are designed to take this stretch as you look down but only for a short time and there are some interesting studies out there showing the changed anatomy of the spinal cord in a chronic anterior head carriage patient.  Stretched nerves have been shown to function less effectively and their axoplasmic flow is reduced.  I don’t suspect that there is a great deal of tolerance built into the human system. 

From the perspective of upper cervical care, when your head and neck are no longer in proper alignment to each other, your muscles have to pick up the slack of supporting your head.  This results in a higher muscle tone in your neck and upper back leading to trigger points in the Traps and Lev Scap muscles.  If you think of the force your muscles have to develop to keep your head from pivoting round your low-cervical vertebrae and smashing into your keyboard you can see why your low-cervical vertebrae suffer.  It is similar to the trick of trying to hold a plank up by the thin end – fine when it’s well balanced but once it comes away from the centre of gravity it takes masses of muscle power to keep it there – it’s all to do with levers.  No wonder people have shoulder trigger points that never seem to resolve; the underlying problem hasn’t been resolved and the outcome will remain the same.

The result is neck and upper back pain, restricted cervical biomechanics and all the physiological changes that would be associated with an abnormally functioning neck and upper spine. 

Now in some people I have seen there are no problems at all but in others there have been a raft of neck pain, headaches, upper body fatigue, sleep disorders and the rest.  And I would be willing to bet that more than a few people have been mistakenly diagnosed with migraine head ache or tension headache who, in reality, have anterior head carriage and tragic cervical biomechanics.

Cure

Prevention would be good.  Then if that fails adjust the spine to improve the biomechanics, soft tissue work to help the muscles cope and then some cervical spine stretches to combat the anterior head carriage posture adopted at work.

Just typing this up is making my neck hurt!