Musculoskeletal consequences of refractive errors: posture, cervical joint position sense, neck disability, musculoskeletal discomfort, and quality of life

Abstract

Background

Refractive errors (RE) affect posture, musculoskeletal health, and quality of life due to compensatory head and neck adjustments. However, their specific musculoskeletal effects remain unclear. This study aims to investigate the impact of RE on posture, cervical joint position sense (CJPS), neck disability, musculoskeletal discomfort, and quality of life to identify their distinct effects.

Methods

This cross-sectional study included 71 participants (mean age 35.67±10.78 years) : 20 controls, 20 with myopia, 14 with hyperopia, and 17 with astigmatism. Posture was assessed using forward head posture (FHP), pectoralis minor tightness, thoracic kyphosis, lumbar lordosis, and the New York Posture Rating Scale (NYPR). CJPS was measured with a CROM device. Neck disability was evaluated using the Neck Disability Index (NDI), musculoskeletal discomfort with the Cornell Musculoskeletal Discomfort Questionnaire (CMDQ), and quality of life with the Short Form-36 (SF-36) survey.

Results

All RE groups showed increased FHP (p = 0.003), lower NYPR scores (p = 0.001), and greater neck discomfort (p = 0.004) compared to controls. Myopia had higher neck disability scores (p = 0.002, Cohen’s d = 1.21), while hyperopia (p = 0.006, Cohen’s d = 1.21) and astigmatism (p = 0.003, Cohen’s d = 1.12) exhibited greater thoracic kyphosis and CMDQ back scores compared to controls. Hyperopia also had elevated CMDQ low back scores (p = 0.004, Cohen’s d = 0.74). Hyperopia had lower general health perception (p = 0.005, Cohen’s d = 1.03), while both myopia and hyperopia showed greater role limitations due to physical problems (p = 0.002, Cohen’s d = 1.04; p = 0.001, Cohen’s d = 1.16, respectively). No significant differences were found in CJPS (p > 0.05).

Conclusions

All refractive RE groups experienced postural changes and musculoskeletal discomfort, with distinct effects depending on the type of impairment. Interventions should be tailored to address neck disability in myopia, thoracic alignment issues in astigmatism, and musculoskeletal adaptations extending to the lower back in hyperopia. A multidisciplinary approach, combining ophthalmology, physiotherapy, and ergonomics, is crucial for developing effective rehabilitation strategies and understanding the long-term musculoskeletal impact of RE.

Background

Vision, one of the most fundamental senses that enables individuals to interact with their environment, is a crucial factor that directly affects quality of life. Visual impairments are widespread globally, with refractive errors (RE) being among the most common vision problems. RE such as myopia (nearsightedness), hyperopia (farsightedness), and astigmatism (blurred or distorted vision at all distances) can be corrected with glasses, contact lenses, or surgical interventions. However, they can also have significant effects on the musculoskeletal system [1].

In individuals with visual impairments, adjustments in head and neck positions made to achieve clearer vision can lead to postural changes and musculoskeletal problems over time. It has been reported that compensatory head positions are frequently observed in individuals with RE [2]. Specifically, individuals with myopia tend to tilt their heads forward to obtain a clearer view, which places excessive strain on the cervical region and may lead to neck pain [3]. Similarly, other RE such as hyperopia and astigmatism can also result in postural adaptations, causing imbalances in the musculoskeletal system [4].

The most common hypothesis regarding postural adaptations in individuals with visual impairments is the increased proprioceptive load, which creates additional stress on the musculoskeletal system [5]. Proprioception is one of the fundamental mechanisms that allows the body to perceive its position in space. This system works in coordination with the vestibular and visual systems, playing a crucial role in maintaining posture and balance [6]. The interaction between the neck muscles and the visual system is directly linked to the proprioceptive system. Proprioceptors located in the neck muscles continuously interact with visual stimuli to stabilize head position.

It has been shown that individuals with RE such as myopia, hyperopia, and astigmatism adjust their head and neck positions to maintain visual focus, which affects cervical range of motion and leads to restrictions in neck range of motion [7]. Studies have found that surgeons with visual impairments experience increased muscle activity and muscle fatigue in the neck and shoulder muscles during simulated surgical tasks [8].

The use of eyeglasses can also lead to changes in head and neck positions, resulting in excessive loading on the neck muscles and alterations in the proprioceptive system. This is particularly evident in individuals who use bifocal or multifocal glasses, as they often need to adjust their head position to achieve clear vision at different distances. Such frequent adjustments can cause chronic tension in the neck muscles, pain, and movement restrictions [9].

Although there are a limited number of studies in the literature examining the effects of RE on posture, musculoskeletal health, and quality of life, existing data suggest that individuals with visual impairments experience negative impacts on their musculoskeletal system and overall quality of life. However, most studies tend to address RE as a whole, without sufficiently investigating compensatory mechanisms based on key variables such as the type and degree of impairment or the use of corrective eyewear. Furthermore, considering that the body functions as a kinetic chain, identifying postural adaptations solely in the cervical region may not provide comprehensive information. Additionally, the hypotheses proposed regarding these adaptations require validation through studies with extensive evaluations. In this context, the present study aims investigate the effects of RE on posture, cervical joint position sense, neck disability, musculoskeletal discomfort, and quality of life.

Methods

Design and setting of the study

This cross-sectional observational study with a control group investigated the effects of RE on posture, cervical joint position sense (CJPS), neck disability, musculoskeletal discomfort, and quality of life. A cross-sectional design was chosen for its efficiency in comparing groups at a single time point, making it suitable for identifying associations rather than causality.

The study was conducted under standardized and controlled conditions. A single-blind approach was used to minimize bias, with assessors blinded to participants’ RE type during evaluations.

The study was carried out between May and June 2024, with ethical approval from the Zonguldak Bülent Ecevit University Ethics Committee (No. 2024-09/10) in accordance with the Declaration of Helsinki.

Study population

A total of 71 individuals participated in the study, including 20 without RE (control group), 20 with myopia, 14 with hyperopia, and 17 with astigmatism. Participants were voluntarily recruited from the general population through public announcements, social media, and meetings. Those interested were screened based on the inclusion criteria before enrollment.

The sample size was determined through a priori power analysis using G*Power software (effect size = 0.85, α = 0.05, β = 0.80), indicating a required total of 88 participants (22 per group). However, due to recruitment challenges, limited eligible participants, and logistical constraints, the study was conducted with 71 participants. A post-hoc power analysis confirmed that, despite the reduced sample, statistical power remained adequate for analyses and meaningful interpretation.

Inclusion criteria required participants to be 18–65 years old, to have undergone an RE check-up in the past year, and to have had a confirmed RE diagnosis for at least six months. Individuals with severe vision loss, blindness, neck and shoulder pathologies, or chronic rheumatological, musculoskeletal, and neurological disorders were excluded.

Before participation, all individuals were informed about the study’s objectives, methodology, and potential risks. Written informed consent was obtained from all participants before data collection.

Assessment and outcome measures

Each participant underwent a single evaluation session, where demographic and clinical data were systematically collected. This included RE type and degree, total years of eyeglass use, and daily usage duration.

Experienced physiotherapists conducted all assessments under controlled conditions, following standardized protocols to minimize external influences. Validated measurement tools ensured accuracy and reliability. The evaluation covered posture, CJPS, neck disability, musculoskeletal discomfort, and quality of life.

Posture

Forward Head Posture (FHP) was measured as the distance (cm) from the tragus of the dominant side to the wall while the participant stood upright with heels touching the wall, providing an objective assessment. The tragus-wall distance measurement has demonstrated good intra-rater (ICC = 0.88) and inter-rater reliability (ICC = 0.83) in non-pathological adults [10].

Pectoralis Minor Tightness was assessed in the supine position with arms relaxed and palms up. The distance (cm) from the acromion to the bed was measured to determine muscle shortening. This measurement approach has demonstrated acceptable intra- and inter-rater reliability, with intraclass correlation coefficients (ICC) ranging between 0.84 and 0.92 for intra-rater reliability and between 0.80 and 0.90 for inter-rater reliability, indicating good to excellent reliability for clinical decision-making [11].

Thoracic Kyphosis and Lumbar Lordosis were assessed using a flexicurve ruler (Staedtler Mars Inc., Nurnberg, Germany), which conforms to spinal contours. C7, T12, and S2 spinous processes were identified via palpation before molding the ruler along the spine from C7 to S2. The curve was transferred to paper, and kyphosis and lordosis degrees were calculated using reference points. Measurements were taken in a neutral upright stance with feet shoulder-width apart. The flexicurve method has demonstrated excellent validity compared to radiographic measurements (ICC = 0.906) and high inter-rater reliability (ICC = 0.94) [12].

Total posture was evaluated using New York Posture Rating Scale (NYPR). NYPR evaluates postural deviations across 13 body regions, including posterior and lateral alignments. Each segment is scored on a five-point scale (5 = correct alignment, 3 = slight deviation, 1 = pronounced deviation), with total scores ranging from 13 to 65, where higher scores indicate better alignment. The scale has demonstrated acceptable to good reliability in previous research. In a garment study, inter-rater reliability coefficients were reported as 0.77 for photographs and 0.91 for body scans, supporting its use in research settings [13].

Cervical joint position sense

Cervical joint position sense (CJPS) was assessed using the Cervical Range of Motion (CROM) device (CROM Deluxe, Performance Attainment Associates, Roseville, MN, USA). Participants were seated upright in a standardized position with hips and knees at approximately 90°, feet flat on the floor, and arms relaxed alongside the trunk. The thoracic spine was supported by the chair backrest to minimize trunk movement, and participants were instructed to avoid compensatory shoulder or trunk motion during testing. The CROM device and magnetic collar were secured according to manufacturer guidelines to ensure consistent alignment.

Participants were passively guided to a predetermined target angle (cervical flexion, extension, or rotation), held for 5 s to allow proprioceptive encoding, and then returned to the neutral position. With eyes closed, they actively attempted to reproduce the target position (Fig. 1). Three repetitions were performed for each direction, with brief rest intervals to reduce fatigue. The absolute joint position error (in degrees) was calculated as the mean deviation from the target angle across three trials.

Fig. 1.

Assessment of Cervical Joint Position Sense Using the CROM Device

The CROM device has demonstrated acceptable to excellent test–retest reliability (ICC = 0.66–0.93) in asymptomatic individuals [14].

Neck disability

The Neck Disability Index (NDI) was used to assess the impact of neck pain on daily activities. Developed by Vernon and Mior [15], it comprises 10 sections covering pain intensity, personal care, lifting, reading, work, driving, sleeping, and recreation. Each section is scored from 0 to 5, with a total score of 50, where higher scores indicate greater disability. The Turkish version has been culturally adapted and demonstrated excellent test–retest reliability (ICC = 0.979) and good construct validity in patients with neck pain [16].

Musculoskeletal discomfort

The Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) was used to assess musculoskeletal discomfort across body regions. The CMDQ measures discomfort severity, frequency, and impact on work performance over the past week. Severity is rated on a 5-point Likert scale, while frequency and work impact use a 3-point Likert scale. Total scores are calculated by multiplying individual question scores, with higher scores indicating greater discomfort. This study focused on three regions—neck, back, and lower back—to evaluate discomfort distribution and intensity. The Turkish version of the CMDQ has demonstrated good validity and reliability, with substantial to almost perfect test–retest agreement (Kappa = 0.564–0.972) and high internal consistency (Cronbach’s α = 0.875–0.895) [17].

Quality of life

Quality of life was assessed using the Short Form-36 (SF-36) Health Survey, a widely recognized tool for evaluating health-related quality of life. It measures eight subdomains: Physical Functioning (PF), Role Limitations Due to Physical (RP) and Emotional Problems (RE), Vitality (VT), Mental Health (MH), Social Functioning (SF), Bodily Pain (BP), and General Health Perception (GH).

The SF-36 consists of 36 items, with subdomain scores ranging from 0 to 100, where higher scores indicate better quality of life. The instrument has demonstrated strong internal consistency (Cronbach’s α values generally > 0.80 across domains) and good test–retest reliability in primary care populations. It is extensively used in clinical and research settings to assess the impact of health conditions on overall well-being [18].

Statistical methods

Statistical analyses were conducted using SPSS 21.0 (IBM Corp.). The Shapiro-Wilk test assessed normality, supported by skewness and kurtosis values to determine appropriate statistical methods. One-way ANOVA was used for normally distributed variables, while the Kruskal-Wallis test was applied for non-normally distributed data. Post-hoc comparisons were performed using the Bonferroni correction to control for Type I error in multiple comparisons. The adjusted level of statistical significance was determined by dividing the alpha level by the number of pairwise comparisons (α/number of comparisons). Accordingly, the corrected significance threshold was set at p < 0.008, and this adjusted threshold was applied in the interpretation of post-hoc analyses. Normally distributed data were reported as mean ± standard deviation (SD), while non-normally distributed data were expressed as median (min-max). Power analysis was conducted using G*Power, with Cohen’s d effect sizes ranging from 0.67 to 1.36. Statistical power for group comparisons was between 92% and 96%.

Results

Demographic and clinical characteristics

Upon comparing the demographic and clinical characteristics of the groups, no statistically significant differences were observed in terms of age, gender, and BMI (p > 0.05). Additionally, no significant differences were identified among the groups concerning the degree of RE, duration of eyeglass use (years), and daily eyeglass usage time (hours) (p > 0.05) (Table 1).These findings suggest that the groups are comparable minimizing confounding effects due to these variables.

Table 1.

Comparison of Demographic and Clinical Characteristics of Groups

		Control (n = 20)	Myopia (n = 20)		Hyperopia (n = 14)	Astigmatism (n = 17)	p
Gender (n = 71)	Female	12	14	11		7	0.149
	Male	8	6	3		10
X±SD
Age		33.50±10.03	34.65±9.06	43.28±10.53		33.17±11.72	0.06
BMI		24.67±3.81	24.92±3.84	27.87±3.83		25.24±5.50	0.117
Degree of RE		-	2.85±1.29	2.57±1.35		1.84±0.94	0.456
Duration of eyeglass use/years		-	15.20±8.04	13.14±9.05		11.88±8.84	0.421
Daily eyeglass usage time (hours)		-	12.10±5.04	9.43±6.91		10.59±5.50	0.695

X Mean, SD Standard Deviation, BMI Body Mass Index, RE Refractive Error

The intergroup comparison of outcome measurements revealed statistically significant differences in all parameters except for lumbar lordosis and CJPS. Among the SF-36 subdomains, significant differences were observed in role limitations due to RP and GH (p < 0.05) (Table 2).

Table 2.

Intergroup Comparison of Outcome Measurements

	Control (n = 20)	Myopia (n = 20)	Hyperopia (n = 14)	Astigmatism (n = 17)	p
Posture (Median (Min-Max))
FHP (cm)	14.0 (10.0–18.0)	16.0 (12.0–22.0)	17.0 (11.0–22.0)	16.0 (11.0–23.0)	0.003*
Pectoralis minor tightness (cm)	8.50 (4.0–16.0)	7.0 (4.0–19.0)	13.0 (6.0–19.0)	9.0 (5.0–14.0)	0.016*
Thoracic kyphosis (°)	12.89 (3.57-20.0)	17.36 (7.93-50.0)	23.97 (8.69–34.3)	19.43 (9.23-32.0)	0.006*
Lumbal lordosis (°)	20.75 (6.9–38.6)	16.79 (7.81–43.3)	25.54 (12.38–43.2)	21.58 (7.5–50.0)	NSD
NYPR score	59.0 (33.0–65.0)	48.50 (25.0–57.0)	49.0 (29.0–61.0)	47.0 (37.0–61.0)	0.001*
NDI score	5.0 (0–16.0)	10.5 (4.0–19.0)	9.0 (3.0–23.0)	9.0 (2.0–25.0)	0.017*
CJPS (°)(Median (Min-Max))
Flexion	2.0 (0-5.3)	2.3 (0-16.6)	2.0 (0-10.6)	1.3 (0–20.0)	NSD
Extension	0.35 (0-16.7)	0.8 (0-22.6)	1.4 (0–22.0)	0.6 (0-6.67)	NSD
Right rotation	2.3 (0-8.5)	3.3 (0–10.0)	2.0 (0-9.3)	3.3 (0–20.0)	NSD
Left rotation	1.3 (0-16.6)	2.3 (0–16.0)	2.0 (0.6–10.6)	1.66 (0-11.67)	NSD
Right lateral flexion	0.85 (0–6.0)	1.67 (0–25.0)	2.0 (0–32.0)	2.0 (0–20.0)	NSD
Left lateral flexion	0.8 (0–4.0)	1.66 (0-21.7)	2.0 (0–32.0)	1.66 (0-15.4)	NSD
CMDQ (Median (Min-Max))
Neck	3.50 (3.5–13.0)	6.5 (3.5–16.0)	7.5 (3.5–16.0)	6.5 (3.5–15.0)	0.004*
Back	3.50 (3.5–14.0)	3.5 (3.5–14.0)	5.0 (3.5–15.0)	6.5 (3.5–16.0)	0.01*
Low Back	3.50 (2.00–16.00)	3.5 (2.0–9.0)	7.5 (3.5–16.0)	7.0 (3.5–16.0)	0.005*
SF-36 scores (Median (Min-Max))
PF	97.5 (55.0-100)	80.0 (45.0-100)	70.0 (35.0-100)	95.0 (20.0-100)	NSD
RP	100 (0-100)	50.0 (0-100)	50.0 (0-100)	50.0 (0-100)	0.004*
RE	100 (0-100)	100 (33.3–100)	16.65 (0-100)	33.3 (0-100)	NSD
VT	52.5 (5.0–80.0)	55.0 (15.0–90.0)	32.50 (10.0–75.0)	45.0 (15.0–80.0)	NSD
MH	62.0 (24.0–96.0)	56.0 (20.0–84.0)	46.0 (20.0–92.0)	52.0 (20.0–99.0)	NSD
SF	70.0 (0-100)	56.25 (25.0–75.0)	60.0 (25.0-100)	62.5 (37.5–100)	NSD
BP	72.5 (35.0-100)	56.25 (35.0–80.0)	45.0 (17.5–90.0)	57.50 (12.50–100)	NSD
GH	65.0 (25.0–95.0)	70.0 (25.0–90.0)	45.0 (20.0–85.0)	55.0 (40.0–95.0)	0.019*

FHP Forward Head Posture, NDI Neck Disability Index, NYPR New York Posture Rating Scale, CJPS Cervical Joint Position Sense, CMDQ Cornell Musculoskeletal Discomfort Questionnaire, SF-36 Short Form-36, PF Physical Functioning, RP Role Limitations Due To Physical Problems, RE Role Limitations Due To Emotional Problems, VT Vitality, MH Mental Health, SF Social Functioning, BP Bodily Pain, GH General Health Perception, * p < 0.05 in Kruskal Wallis test, NSD No Significant Difference

Post-hoc analysis and Bonferroni correction were applied for the significantly different outcomes. According to these analyses, a statistically significant difference in favor of the control group was observed between the control group and all three groups in terms of FHP, NYPR, and CMDQ neck scores (p < 0.008).

Additionally, a statistically significant difference was found in favor of the control group in the following comparisons: between controls and individuals with myopia in terms of NDI and RP; between controls and individuals with hyperopia in terms of thoracic kyphosis degree, CMDQ back and low back scores, RP, and GH; and between controls and individuals with astigmatism in terms of thoracic kyphosis degree and CMDQ back scores (p < 0.008) (Table 3).

Table 3.

Pairwise Comparison of Refractive Error Groups with the Control Group

	Myopia vs. Control		Hyperopia vs. Control		Astigmatism vs. Control
	p	Cohen’s d	p	Cohen’s d	p	Cohen’s d
Posture
FHP (cm)	0.004*	1.12	0.004*	0.95	0.002*	1.09
Pectoralis minor tightness (cm)	NSD	0.06	0.011	1.02	NSD	0.30
Thoracic kyphosis (°)	0.015	0.89	0.006*	1.21	0.003*	1.12
NYPR	< 0.001*	1.14	0.003*	0.95	0.005*	1.06
NDI	0.002*	1.21	0.031	1.01	0.031	1.05
CMDQ
Neck	0.004*	0.77	0.001*	1.06	0.007*	0.78
Back	0.05	0.15	0.001*	0.67	0.007*	0.85
Low Back	0.596	0.4	0.004*	0.74	0.054	0.43
SF-36
RP	0.002*	1.04	0.001*	1.16	0.010	0.82
GH	NSD	0.06	0.005*	1.03	NSD	0.18

FHP Forward Head Posture, NDI Neck Disability Index, NYPR New York Posture Rating Scale, CMDQ Cornell Musculoskeletal Discomfort Questionnaire, SF-36 Short Form-36, RP Role Limitations Due to Physical Problems, GH General Health Perception, *p < 0.008 in Mann Whitney U test, NSD No Significant Difference. Effect sizes are reported as Cohen’s d

Pairwise comparisons among individuals with RE revealed that the hyperopia group exhibited greater pectoralis minor tightness (p = 0.006, Cohen’s d = 1.27) and a higher CMDQ low back score (p = 0.003, Cohen’s d = 1.36) compared to the myopia group. No significant differences were found in other parameters in the pairwise comparisons among the RE groups (p > 0.008).

Associations between characteristics and outcome measures

The correlation between the demographic data of all participants and the outcome measurement results was examined. A statistically significant negative correlation was observed between age and PF (r = -0.376, p = 0.001) as well as GH (r = -0.330, p = 0.005) (Fig. 2). Regarding the correlation between BMI and outcome measurements, a positive correlation was identified with NDI (r = 0.262) and the CMDQ Neck Score (r = 0.303), whereas a negative correlation was found with the NYPR score (r = -0.293) (Fig. 3).

Fig. 2.

Relationship Between Age and SF-36 PF and GH Subscores

Fig. 3.

Relationship Between BMI and NDI, CMQ- Neck, NYPR scores

Additionally, the correlation between the degree of RE, eyeglass usage duration parameters, and outcome measurements was examined among participants with RE. Analyzing the relationship between individuals’ degree of RE, years of eyeglass use, and daily eyeglass usage time with all outcome measures revealed no statistically significant associations with any of the assessed parameters.

Discussion

This study thoroughly examined the impact of refractive errors, including myopia, hyperopia, and astigmatism, on posture, cervical joint position sense, neck disability, musculoskeletal disorders, and quality of life. The results indicate that all refractive error groups shared common characteristics, such as increased forward head posture, postural misalignments, and heightened neck discomfort. Furthermore, the study highlighted distinct musculoskeletal effects associated with different types of refractive errors. The severity of refractive errors and eyeglass use did not appear to influence musculoskeletal health or quality of life. These findings underscore the need for personalized clinical strategies to enhance musculoskeletal well-being and overall quality of life in individuals with refractive errors.

The impact of refractive errors on posture

The results of this study indicate a significant increase in forward head posture (FHP) and a decline in New York Posture Rating (NYPR) scores across all refractive error (RE) groups, suggesting a strong association between visual impairments and postural adaptations. Literature findings support this connection, with reports indicating that 18–23% of abnormal head positions have an ocular origin [2, 9]. The reduction in NYPR scores in our study suggests that compensatory postural adjustments in individuals with RE extend beyond the cervical region, affecting overall alignment and increasing mechanical strain, particularly in the cervical spine and upper thoracic area. This aligns with previous reviews confirming that visual impairments contribute to alterations in balance and posture [19], further reinforcing the hypothesis that RE may lead to widespread musculoskeletal disturbances.

A more detailed examination of postural changes in our study revealed an increase in thoracic kyphosis in the hyperopia and astigmatism groups. Consistent with our findings, Havertape and Cruz [4] reported that children with high hyperopia exhibited a downward chin tilt, likely as an adaptive mechanism to enhance visual clarity. Similarly, Idres et al. [7] identified decreased cervical lordosis and restricted cervical range of motion in individuals with RE. Our study suggests that hyperopic individuals compensate with a backward head tilt and increased upper back muscle activity, contributing to excessive thoracic spine loading. In astigmatism, the need for frequent head and neck adjustments to maintain visual stability may explain the upper-body postural disturbances observed. However, recent studies specifically addressing postural adaptations in astigmatic individuals are lacking, highlighting a gap in the literature.

Clinically, these findings suggest that the impact of RE on posture varies by type, emphasizing the need for individualized rehabilitation strategies. Hyperopic individuals may benefit from interventions targeting the thoracic spine, pectoralis minor muscle flexibility, and upper-body mobility, while postural realignment programs focusing on upper-body stability could be particularly relevant for those with astigmatism. In contrast, the pronounced cervical strain in myopic individuals underscores the importance of therapeutic approaches addressing cervical spine mobility and neck muscle conditioning. These targeted interventions may help mitigate the musculoskeletal consequences of RE and improve overall postural health.

The relationship between cervical proprioception and refractive errors

The cervical proprioceptive system plays a crucial role in maintaining postural stability and coordinating head-eye movements through afferent inputs from the neck muscles, ligaments, and joints [20]. Despite significant postural alterations observed in individuals with refractive errors (RE) in our study, cervical joint position sense remained unaffected. This suggests that the proprioceptive system effectively adapts to postural demands imposed by RE without substantial compensatory changes.

One possible explanation is that visual impairments alone may not generate sufficient proprioceptive stress to induce detectable alterations in joint position sense. Previous studies have shown that forward head posture (FHP) is associated with proprioceptive deficits, with greater postural deviations leading to increased joint position errors [21, 22]. However, our findings suggest that the degree of postural adaptation in individuals with RE may not be severe enough to impair proprioceptive accuracy. Additionally, the use of corrective eyewear may contribute to stabilizing head position, potentially reducing the need for proprioceptive adjustments.

The absence of proprioceptive deficits in our study indicates that the cervical sensorimotor system possesses a strong adaptive capacity to accommodate postural deviations related to RE. This aligns with research suggesting that muscle spindle function may be influenced by postural changes, yet other sensory receptors could compensate for these alterations [22]. Clinically, these findings suggest that while RE can lead to significant postural changes, they do not necessarily result in proprioceptive dysfunction, reducing the need for direct proprioceptive interventions in these individuals. Instead, management strategies should focus on addressing postural imbalances and musculoskeletal discomfort through targeted rehabilitation and ergonomic adjustments.

Effects of refractive errors on neck disability and musculoskeletal discomfort

The significant increase in neck discomfort across all refractive error (RE) groups in our study highlights the widespread musculoskeletal effects of altered head and neck positioning. Notably, individuals with myopia exhibited a higher prevalence of neck disability, consistent with findings from Kalajas-Tilga et al. [23] who reported increased cervical discomfort among myopic individuals and eyeglass users. Similarly, Sánchez-González et al. [24] identified a strong link between accommodative dysfunctions, reduced cervical range of motion, and increased neck pain, further supporting the association between visual impairments and cervical spine symptoms.

In contrast, back discomfort was more pronounced in the hyperopia and astigmatism groups, with no significant difference in the myopia group. This pattern may reflect the localized nature of postural adaptations, as myopic individuals primarily exhibited changes in the cervical region, while those with hyperopia and astigmatism demonstrated postural shifts extending into the upper thoracic spine. The resulting increase in thoracic kyphosis likely contributed to the observed back discomfort. Although previous studies have largely focused on cervical symptoms, Thorud et al. [25] reported a broader musculoskeletal impact of uncorrected vision problems, demonstrating an association with neck and shoulder pain in school-aged children, which aligns with our findings.

Another notable observation was the higher incidence of lumbar discomfort in the hyperopia group, which was not evident in the other RE groups. While no direct link between visual impairments and lumbar symptoms has been established in the literature, research on postural stability disturbances suggests that postural misalignments can contribute to spinal discomfort beyond the cervical and thoracic regions [26, 27]. These findings underscore the need for a comprehensive approach to musculoskeletal health in individuals with RE, considering the potential for widespread postural adaptations and discomfort throughout the spine.

Impact of refractive errors on quality of life

The findings of our study indicate that the impact of refractive errors (RE) on quality of life varies depending on the type of RE. While individuals with astigmatism did not exhibit significant changes, those with myopia experienced a decline in role limitations due to physical problems. In contrast, hyperopic individuals showed a more pronounced reduction, not only in role limitations due to physical problems but also in general health perception.

Although previous research has established a negative relationship between RE and quality of life, few studies have explored the distinct effects of different RE types [28, 29]. Our findings suggest that the decline in general health perception observed in hyperopic individuals may be attributed to the more pronounced and widespread postural adaptations and musculoskeletal disorders identified in this group. These structural changes likely contribute to greater physical discomfort, thereby affecting overall health perception more severely than in myopic or astigmatic individuals.

Additionally, demographic analyses in our study revealed that age plays a significant role in quality of life. As age increased, declines in physical functioning and general health perception became more evident. Although there was no statistically significant age difference between the groups, the slightly higher mean age in the hyperopia group may have amplified the negative impact on quality of life.

Overall, our findings suggest that hyperopia is associated with greater quality-of-life impairments compared to other RE types, likely due to its broader musculoskeletal consequences. While correcting RE may improve quality of life, it may not fully mitigate postural and musculoskeletal challenges, and in some cases, may introduce additional adaptations [29]. This underscores the need for a comprehensive approach that incorporates both vision correction and targeted musculoskeletal interventions to optimize overall well-being in individuals with RE.

Strengths and limitations of the study

This study has several strengths. It is one of the few studies to comprehensively investigate the effects of refractive errors on posture, cervical joint position sense, neck disability, musculoskeletal discomfort, and quality of life. The inclusion of three different refractive error groups (myopia, hyperopia, and astigmatism) alongside a control group allows for a more detailed comparative analysis. Furthermore, the use of validated and standardized assessment tools enhances the reliability and clinical applicability of our findings. The study was conducted under controlled conditions, minimizing external influences and potential biases. Additionally, post-hoc power analysis confirmed that the statistical power remained adequate despite the sample size constraints.

However, some limitations should be acknowledged. The cross-sectional design prevents the determination of causal relationships between refractive errors and musculoskeletal outcomes. Although our sample size was based on power analysis, it was smaller than initially planned due to recruitment challenges, limiting subgroup analyses. Another limitation is that the study focused solely on individuals using eyeglasses, excluding those who use contact lenses or have undergone refractive surgery, which might have provided additional insights. Additionally, factors such as occupational posture habits, screen exposure time, and ergonomic conditions were not assessed, all of which may influence musculoskeletal health. Finally, the study did not explore the potential impact of interventions, such as physiotherapy or postural correction strategies, on mitigating musculoskeletal discomfort in individuals with refractive errors.

Despite these limitations, our findings provide valuable insights into the musculoskeletal consequences of refractive errors and highlight the need for individualized clinical and ergonomic strategies to support musculoskeletal health in individuals with visual impairments.

Future research directions

Future research should employ longitudinal designs to clarify causal relationships between refractive errors and musculoskeletal outcomes. Including more diverse populations in terms of age, occupation, and activity level would enhance generalizability. Comparative studies examining different vision correction methods (eyeglasses, contact lenses, refractive surgery) and interventional trials evaluating physiotherapy, postural training, and ergonomic strategies are warranted. Additionally, advanced neuromuscular and proprioceptive assessments may provide deeper insight into underlying sensorimotor adaptations.

Conclusions

This study demonstrated that refractive errors are associated with postural alterations and musculoskeletal symptoms, with distinct patterns according to refractive type. Myopia was primarily associated with forward head posture and greater neck disability, whereas thoracic kyphosis was more evident in hyperopia and astigmatism. Hyperopia was additionally related to pectoralis minor tightness and lumbar discomfort. Cervical joint position sense was not significantly affected.

Quality of life outcomes varied by refractive type, with greater physical limitations observed in myopia and reduced general health perception in hyperopia. The severity of refractive error and duration of eyeglass use were not significant determinants of musculoskeletal outcomes.

These findings emphasize the importance of individualized and interdisciplinary management approaches integrating physiotherapy and ergonomic strategies to address the musculoskeletal consequences of refractive errors.

Abbreviations

RE

Refractive Error

CJPS

Cervical Joint Position Sense

FHP

Forward Head Posture

NDI

Neck Disability Index

NYPR

New York Posture Rating Scale

CMDQ

Cornell Musculoskeletal Discomfort Questionnaire

CROM

Cervical Range of Motion

SF

36–Short Form–36 Health Survey

PF

Physical Functioning

RP

Role Limitations Due to Physical Problems

RE

Role Limitations Due to Emotional Problems

VT

Vitality

MH

Mental Health

SF

Social Functioning

BP

Bodily Pain

GH

General Health Perception

BMI

Body Mass Index

Authors’ contributions

E.A. conceptualized the study design. Z.S.Y. and H.Y. conducted the data collection and analysis. T.D.Ö., and E.U.E. contributed to manuscript drafting and revisions. All authors read and approved the final manuscript.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was approved by the Zonguldak Bülent Ecevit University Ethics Committee (Approval No: 2024/18 − 09).

Consent for publication

Written informed consent for publication of the images was obtained from the individual.

Competing interests

The authors declare no competing interests.