Association Between Forward Head, Rounded Shoulders, and Increased Thoracic Kyphosis: A Review of the Literature

Abstract

Objective

The purpose of this review was to explore the association between forward head posture, rounded shoulders, and increased thoracic kyphosis.

Methods

The PubMed, ERIC, and Cochrane databases were searched using the key words posture, head, shoulder, forward scapular posture, and thoracic kyphosis through December 2016.

Results

Our initial search yielded 6840 research studies, 6769 of which were excluded because they either were duplicates or did not satisfy the inclusion criteria. After the abstracts of the remaining studies were read, 15 were assessed for eligibility, and only 4 papers were included in the present review. Cervical lordosis values were found to be significantly associated with thoracic kyphosis values. Also, there were significant correlations between rounded shoulders and increased thoracic kyphosis.

Conclusion

Forward head posture, rounded shoulders, and increased thoracic kyphosis can exist alone or in any combination.

Introduction

Various occupations require people to assume static postures for long periods, which causes continuous contractions of the head and neck muscles.^{1, 2} The head constitutes 6% of the total body weight, which is linked to the cervical spine and all other joints through the kinematic chain³ by various muscles.

Normally, the cervical spine is lordotic. Other than flexion and extension movements of the neck that take place in the sagittal plane, protraction and retraction movements also come into play in this plane. Protraction movement is a result of extension of the upper cervical spine and flexion of the lower cervical spine, whereas retraction movement results from flexion of the upper cervical spine and extension of the lower cervical spine. If the cervical spine is held in protracted position for prolonged duration, it can lead to alterations in head posture ultimately leading to poor posture known as forward head posture (FHP), which is thought to be a deviation from neutral or normal posture.^{4, 5}

Normal posture is defined as when the line of gravity (LOG) passes through the external auditory meatus, the bodies of the cervical spine, and the acromion and anterior to the thoracic spine⁶ (Fig 1). Normally, the external moment produced by gravity and ground reaction forces at a joint is offset by the internal moment produced by various muscles and other soft tissue structures around that joint. However, presence of postural malalignments may require greater internal forces to balance the external torque produced by gravity, which in turn is exaggerated owing to the altered location of the LOG.^{7, 8, 9}

Fig 1.

Normal posture and line of gravity.

Failure of the head to align with the vertical axis of the body^{3, 10} (Fig 2) can lead to further malalignments in the body, namely, rounded shoulders and increased thoracic kyphosis,^{11, 12} to compensate¹³ for the altered location of the LOG, leading to further impairments.¹⁴ Combination of all these postural deviations is often known as “slouched posture”^{15, 16} or “slumped posture.”^{3, 17}

Fig 2.

Forward head posture. Note that d is the distance between the line of gravity and the external auditory meatus.

According to Kendall et al,⁶ there should be vertical alignment between the midline of the shoulder and the mastoid process. If the acromion processes are more anteriorly positioned compared with the mastoid processes, a condition known as forward shoulder posture (FSP) or rounded shoulders or protracted shoulders^{11, 15} occurs (Fig 3); this condition is characterized by protracted, internally rotated, anteriorly tilted, elevated, and abducted scapula along with winging of scapula.^{15, 18, 19} This poor alignment of the shoulders leads to greater torque production by gravitational forces, which is being offset by greater internal forces generated by muscles and other soft tissues around the shoulder.

Fig 3.

Forward shoulder posture. Note that b is the distance between the line of gravity and the acromion.

Normally, a flexion moment is being created by the passage of LOG anterior to the thoracic spine that is offset by the extensor muscles, ligamentum flavum, supraspinous ligaments, and posterior longitudinal ligament. This gravitational moment would increase if there is an increase in the thoracic spine’s posterior convexity causing increased distance between joint axes and LOG (Fig 4). In such a case, to maintain an upright posture, ligaments and muscles would be required to produce a greater moment to counterbalance the increased gravitational moment,^{7, 8, 9, 20} thus leading to an increase in posterior convexity or kyphosis of the thoracic spine, also known as round back.⁹

Fig 4.

Increased kyphosis. Note that t is the distance between the line of gravity and thoracic spine.

Posture can be assessed using different methods such as a plumb line, photography, photogrammetry, radiography, Flexicurve, moiré topography, and an electromagnetic tracking device. Any of these methods can be used to detect the presence of abnormal posture.^{21, 22, 23} Electromyography is also very commonly used in postural assessment studies to ascertain the changes in muscular activities that occur as a result of postural changes.²⁴

Most previous studies mention the causes and consequences of FHP, rounded shoulders, and increased thoracic kyphosis. However, there is a dearth of studies focused on the association between forward head, rounded shoulders, and hyperkyphosis. Therefore, the aim of this review was to explore the relationship between FHP, FSP, and increased kyphosis of the thoracic spine.

Methods

Studies were included if they reported association between FHP and FSP, or between FHP and thoracic kyphosis, or between FSP and thoracic kyphosis, and if they were available in free full text online entirely in the English language. Review articles, conference papers, and unpublished dissertations were excluded, as were studies that involved subjects having pain or some pathology other than a postural problem. Studies were also excluded if they described the impact of exercise training or any other modality on posture.

PubMed, ERIC, and Cochrane databases were searched using the key words posture, head, shoulder, forward scapular posture, and thoracic kyphosis in various combinations to find and describe an association between forward head, forward shoulders, and increased kyphosis. The last search was performed in December 2016.

Results

Figure 5 illustrates the numbers of articles retrieved, read, and rejected. Only 4 research studies^{12, 25, 26, 27} were found to best explain the objective of this study. Other studies used in this review do not explain any relationship among the 3 pathologies, that is, FHP, FSP, and increased kyphosis of the thoracic spine, but instead focus on 1 of the pathologies. Information obtained from such studies has been condensed in Tables 1 and 2. Table 3 summarizes studies that present associations between forward head, rounded shoulders, and increased thoracic kyphosis.

Fig 5.

Search strategy.

Table 1.

Effect of Different Habits/Occupations/Pathologies on Head, Neck, and Thoracic Posture

Research	Sample	Method Used	Investigation Done	Result
Jung et al, 201616	25 in group 1 (used smartphones for <4 h/d), 25 in group 2 (used smartphones for >4 h/d), mean age = 21 ± 2.41 y, gender not mentioned	Photogrammetry, scapular index	Effect of duration of smartphone usage on head and scapular posture	Poorer FHP and rounded shoulder posture in group 2
Vakili et al, 20161	96 dental staff, age not mentioned, both genders	Questionnaire, plumb line, flexible ruler, checkerboard	Prevalence of postural disorders of head, shoulder, and spine among dentists	FHP and rounded shoulder posture prevalent among dental staff
Guedes and Joao, 201422	36 in basketball group (mean age = 14.33 ± 1.20 y), 38 in control group (mean age = 14.61 ± 1.31 y), only males	Photogrammetry	Postural differences between basketball players and nonplayers	Basketball players have lesser values of forward head, shoulder protrusion, and thoracic kyphosis
Neiva et al, 200940	21 MB, 21 NB, aged 8-12 y, only males	Stereophotogrammetry	Head and thoracic spine posture, scapular orientation and position in MB and NB children	Scapula positioned more superiorly in MB children
Straker et al, 200728	884 adolescents, mean age = 14 ± 0.2 y, both genders	Questionnaire, computer use duration	Association between computer usage and habitual posture	Increased use of computer leads to increased neck and head flexion
Borstad, 200614	25 with long pectoralis minor resting length and 25 with short pectoralis minor resting length, 18-40 y old, both genders	Electromagnetic motion capture system	3-D orientation of scapula in relation to trunk during arm elevation, thoracic posture, scapular posture	There is a relationship between pectoralis minor length and posture
Fernández-de-las-Peñas et al, 200630	20 with CTTH (mean age = 38 ± 18 y) and 20 controls without headache (mean age = 35 ± 10 y), both genders	Photographs to assess FHP, palpation to identify TrPs, headache diary	Subjects with CTTH possess both suboccipital TrPs and FHP Relationship of FHP and TrPs with headache frequency, intensity, and duration	CTTH is associated with suboccipital TrPs and FHP Direct relationship exists between FHP and headache variables along with presence of TrPs
Borstad and Ludewig, 200542	25 with short pectoralis minor and 25 with long pectoralis minor, 20–40 y old, both genders	Electromagnetic motion capture system	3-D orientation of scapula in relation to trunk during arm elevation	Anterior tipping of scapula at higher angles of arm elevation in the group with shorter resting length of pectoralis minor
Hinman, 200448	25 in premenopausal group (21-51 y old), 26 in postmenopausal group (66-88 y old), only females	Flexicurve, IK (measure of degree of thoracic kyphosis), IK ratio (measure of postural stiffness)	Comparison of thoracic kyphosis and postural stiffness between groups	Kyphosis and stiffness greater in postmenopausal women
Chansirinukor et al, 200129	13 high school students, mean age = 14.8 ± 1 y, both genders	Digital photographs	Effect of carrying backpack over shoulders on neck and shoulder posture	Poorer FHP while carrying backpack having weight equal to 15% of body’s weight than when not carrying backpack
Greenfield et al, 199523	30 with shoulder pain (mean age = 39 ± 13.9 y) and 30 without shoulder pain (mean age = 39 ± 13.7 y), both genders	Photographs	Postural differences between healthy and nonhealthy persons	FHP more pronounced in shoulder pain group
Watson and Trott, 199333	30 with cervical headache, 30 without headache, 25-40 y old, only females	Photographs to assess FHP, passive accessory intervertebral mobility examination, headache questionnaire	Comparison of craniocervical posture between 2 groups	Cervical headache group demonstrated FHP

3-D, three-dimensional; CTTH, chronic tension-type headache; FHP, forward head posture; IK, index of kyphosis; MB, mouth breathing; NB, nasal breathing; TrPs, trigger points.

Table 2.

Biomechanical Alterations Associated with FHP, FSP, and Thoracic Kyphosis

Research	Sample	Method Used	Investigation Done	Result
Han et al, 20162	12 in normal posture group, 14 in FHP group, adults, both genders	EMG activity of accessory muscles of respiration (SCM, UT, PM, and ES), spirometry to measure FVC and FEV1	Effect of FHP on respiratory function and activity of accessory respiratory muscles	Decreased FVC and FEV1; Decreased activity of SCM, PM, and UT in FHP group
Lee, 201613	14 in FHP group (mean age = 22.1 ± 1.6 y), 16 in control group (mean age = 21.6 ± 1.1 y), both genders	Photogrammetry, balance calibration system, body tilt training and measurement system	Effect of FHP on dynamic and static balance control	Poorer static balance control in FHP group than control group; dynamic balance control similar for both groups
Lee et al, 201624	10 healthy people, mean age = 30.3 ± 2.5 y, only males	Surface EMG of MT, LT, SA, and LD, inclinometer, Numeric Rating Scale, Shoulder Pain & Disability Index for intensity of shoulder pain and shoulder function	90° of shoulder abduction in the scapular plane during erect and slouched sitting	Increased MT and LT activities during slouched sitting
Szczygiel et al, 20153	65, mean age = 51 ± 9.8 y, both genders	Photogrammetry	Relationship between head posture and chest movements while breathing in 3 different instances: (a) standing in a relaxed position, (b) maximum inhalation, (c) maximum exhalation	FHP decreases respiratory movements
Kwon et al, 201552	13 in NHP group, 14 in IHP group, 13 CHP group, age and gender not mentioned	Photogrammetry, surface EMG of SCMs, UT, LT, and SA muscles of right side	Muscle activities while doing overhead reach task	Increased SA and UT activities in NHP group as compared with IHP and CHP groups
Ruivo et al, 201418	275 adolescents, 15-17 y old, both genders	Photogrammetry, ASES questionnaire	Relationship between posture and presence of shoulder pain and neck pain	Association found between FHP and neck pain
Thigpen et al, 20105	47 with ideal posture, 45 with FHRSP, 18-60 y old, both genders	Photographs, electromagnetic motion analysis system, surface EMG	Scapular kinematics and EMG activity of upper trapezius, lower trapezius, and serratus anterior during overhead reaching task and loaded flexion task	Increased internal rotation of scapula and decreased SA EMG activity during both tasks Increased upward rotation of scapula and increased anterior tilting of scapula during loaded flexion in FHRSP group
Weon et al, 200932	21 with FHP, 21 with neutral head posture, mean age = 21.3 y, gender not mentioned	Surface EMG, plumb line, inclinometer	EMG activity of UT, LT, and SA during loaded isometric shoulder flexion	Increased UT and LT EMG activities and decreased SA EMG activity with FHP
Ghanbari et al, 200819	40 university students, mean age = 22.4 ± 3.6 y, only females	Digital photography, spirometry	Effect of FSP on various lung capacities	Subjects with poorer FSP exhibited lesser vital capacity, expiratory residual volume, and FVC
Huang et al, 200650	104 in hyperkyphotic posture group (mean age = 77.6 ± 8.1 y), 492 in nonhyperkyphotic posture group (mean age = 69.1 ± 8.8 y), only females	Measurement of degree of thoracic kyphosis in supine position, questionnaire to assess fractures, radiographs for assessment of vertebral fractures, BMD using DXA scanners	Association between hyperkyphosis and future fractures independent of osteoporosis, BMD, or fracture history	Increased risk of fractures in ambulatory elderly women with hyperkyphotic posture irrespective of BMD, body mass index, lifestyle, age, or any fracture history

ASES, American Shoulder and Elbow Surgeons Standardized Shoulder Form Patient Self-Report Section; BMD, bone mineral density; CHP, corrected head posture (corrected by therapist); DXA, dual-energy X-ray absorptiometry; EMG, electromyography; ES, erector spinae muscles; FEV1, forced expiratory volume in 1 s; FHP, forward head posture; FHRSP, forward head and rounded shoulders posture; FSP, forward shoulder posture; FVC, forced vital capacity; IHP, ideal head posture (considered ideal by participant); LD, latissimus dorsi; LT, lower trapezius; MT, middle trapezius; NHP, natural head posture (represents forward head and rounded shoulders); PM, pectoralis major; SA, serratus anterior; SCM, sternocleidomastoid; UP, upper trapezius, UT, upper trapezius.

Table 3.

Studies Illustrating the Impact of FHP, FSP, and Thoracic Kyphosis on Head and/or Shoulder and/or Thoracic Posture

Research	Sample	Method Used	Investigation Done	Result	P	Pearson’s Correlation Coefficient, r
Lee et al, 201526	18 with FScP, mean age = 33.78 ± 11.15 y, both genders	Pm index, thoracic spine angle (using digital photogrammetry), SA strength (using dynamometer), glenohumeral horizontal adduction and internal rotation tests	Correlation between FScP and Pm length, SA strength, thoracic spine kyphosis, and tightness of posterior shoulder	There is an association between FScP and decreased Pm length, decreased SA strength, decreased thoracic spine kyphosis, and increased tightness of posterior shoulder	.001	0.72
Erkan et al, 201053	68 with loss of cervical lordosis, 160 with physiological cervical lordosis, 13-72 y old, both genders	Radiographs, Cobb method	Influence of cervical lordosis angle on thoracic kyphosis angle	Less pronounced thoracic kyphosis in subjects with lesser cervical lordosis angles when compared with subjects having physiological cervical lordosis	≤.001	—
Kebaetse et al, 199925	34 healthy participants, mean age = 30.2 y, both genders	Skeletal analysis system (3-D electromechanical digitizer)	Measurement of thoracic flexion and scapular orientation during erect sitting and slouched sitting along with arm movement at the side and abduction in the scapular plane	Increased scapular elevation (between 0° and 90° abduction); decreased posterior tilting of scapula (beyond 90° abduction) and decreased range of shoulder abduction in slouched posture	0	—
Raine and Twomey, 199412	39, 17-48 y old, both genders	Photographs	Association between various measurements of head, neck, shoulder, and thoracic posture	Significant correlations between forward head position, forward shoulder position, and increased thoracic kyphosis	—	0.35-0.43

3-D, three-dimensional; FHP, forward head posture; FScP, forward scapular pressure; FSP, forward shoulder posture; Pm, pectoralis minor; SA, serratus anterior.

Forward Head Posture

FHP can be linked to computer use,²⁸ carriage of backpacks,²⁹ use of smartphones,¹⁶ headache,³⁰ mouth breathing, bad habit,³¹ or shoulder overuse^{15, 23, 32} (Table 1).

FHP has been associated with shortened levator scapulae, sternocleidomastoids, upper trapezius, and posterior cervical spine muscles,¹⁸ that is, suboccipital muscles.³⁰ FHP has been linked to chronic tension-type, cervical, and tension type headaches.^{30, 33} Watson and Trott³³ reported a significantly smaller craniovertebral angle value in the headache group than in the non-headache group. Lesser craniovertebral angle meant poorer FHP. The headache group also had lesser isometric strength of the upper cervical flexors as well as a lesser isometric endurance of these muscles when compared with the non-headache group.

Apart from headache, a greater FHP has also been reported to be associated with trigger points in the suboccipital muscles (rectus capitis posterior minor and major and oblique capitis superior).³⁰ Trigger points associated with taut bands of suboccipital muscles can give rise to referred pain over the occipital and temporal aspects of the head, which is perceived as headache. This headache is thought to be mediated through the spinal cord and trigeminal nucleus caudalis of the brainstem. This means that FHP (shortened suboccipital muscles) leads to the activation of trigger points and, thus, causes tension-type headache.³⁰

FHP can cause accumulation of nociceptive substances in the muscles that counteracts FHP, increased compression of cervical facet joints and posterior vertebral bodies, stretching of anterior neck musculature, and shortening of posterior neck musculature.^{32, 34} Increased compression of the zygapophyseal joints can result in the inception of degenerative changes leading to spondylosis. The greater and lesser occipital nerves might be compressed because of a reduction in the intervertebral space, leading to stimulation of the trigeminal nerve. This, in turn, can lead to facial pain and headache.^{31, 35}

Shoulder pain, neck pain, interscapular pain, craniofacial pain, radiating pain to the scalp, temporomandibular disorders, subacromial impingement syndrome, thoracic outlet syndrome, restricted range of motion at the cervical spine and scapula and shoulder dyskinesis,^{4, 11, 12, 31, 32, 35, 36, 37, 38} decreased respiratory capcities,² poor static balance,¹³ and so on (Table 2) can also occur. Assumption of a neutral head posture might be biomechanically beneficial while performing loaded isometric shoulder flexion activities to reduce work-related neck and shoulder pain.³²

Forward Shoulder Posture

FSP can be linked to, among other factors, repetitive overhead activities, backpack carriage, bad habit, mouth breathing, computer and laptop use, and prolonged study hours^{19, 29, 39, 40} (Table 1).

FSP could lead to muscle imbalance in the form of shortening of the anterior shoulder muscles such as the pectoralis minor and major, serratus anterior, and upper trapezius and lengthening of the posterior shoulder muscles, middle and lower trapezius and rhomboids.^{7, 19} This muscle imbalance leads to alteration in the scapular and glenohumeral orientation, as well as kinematics,^{41, 42} thus increasing the risk of developing neck, shoulder, and nonspecific arm pain. Also, reduction of range of motion and loss of function have been reported.^{14, 17, 43} This sequence of events has been well demonstrated in the research report presented by Borstad, who reported that reduced pectoralis minor muscle length would alter the scapular kinematics, which can predispose the person to subacromial impingement syndrome.¹⁴ Patients with subacromial impingement also present with increased scapular abduction, elevation, anterior tilting, and internal rotation, which is very similar to the postural alterations that occur with FSP¹⁵ (Table 2).

A protracted shoulder has been implicated in the restricted sliding of the cords of the brachial plexus, thus increasing strain on the various nerves passing through the shoulder region, especially the median nerve.¹⁷ Also, coracoid pain and malposition, scapular dyskinesis, and prominent inferomedial border of the scapula have been reported (described as “SICK” scapula). The scapula of the dominant side has been found to be more anteriorly tilted and protracted in overhead athletes because of high training volume and repeated overhead activities, reflecting an association between scapular position, scapular dyskinesis and shoulder pathology is there. Decreased range of motion, decreased strength, and diminished performance with respect to velocity and accuracy can be the manifestations of shoulder pathology in sports persons.⁴⁴ In a study conducted on 372 players involved in upper arm sports events such as basketball, badminton, gymnastics, swimming, squash, tennis, table tennis, volley ball, and field events, 163 players were having shoulder problems such as shoulder pain, crepitus, weakness, and decreased range of motion.⁴⁵

Thoracic Kyphosis

Increased thoracic kyphosis has been thought to be 1 of the most frequently seen abnormalities in patients with lumbar lordosis,⁹ low back pain,⁴⁶ and osteoporosis⁴⁷ as well as in postmenopausal women⁴⁸ (Table 1).

Christie et al⁴⁶ measured head position, shoulder position (relative measure of protraction and retraction), shoulder height discrepancy, and thoracic kyphosis of subjects with low back pain and without low back pain. Subjects with low back pain were experiencing either chronic pain or acute pain. Thoracic kyphosis was found to be significantly greater in the acute pain group compared with the control group in both standing and sitting positions. Also, the acute pain group exhibited an increased forward head position compared with the control group in standing position only. It is noteworthy that the values for thoracic kyphosis and shoulder position were always greater in the back pain groups than in the control group, in both standing and sitting positions, irrespective of the existence of significant differences between the groups.

With increased kyphosis at the thoracic spine, anterior longitudinal ligament and upper abdominal muscles are shortened and the anterior aspect of vertebral bodies is compressed, leading to increases in intradiscal pressures. Also, the extensor muscles and posterior ligaments of the dorsal spine are stretched along with the capsules of the facet joints and the posterior fibers of the annulus fibrosus.⁷ The condition might lead to pain,⁴⁹ expansion of rib cage, poor balance, and, thus, the risk of falls in geriatric participants.²⁰ With increasing age, gradually the connective tissues lose their elasticity and become inefficient in counteracting the torque produced by gravity.⁴⁸ However, kyphosis associated with increasing age is mild and does not cause much of a problem.⁴ However, an excessive degree of kyphosis (hyperkyphotic posture) might be a risk factor for fractures (Table 2). Hyperkyphosis might lead to complications such as poor respiratory function, compromised physical function, and increased mortality.⁵⁰ Thus, it is plausible to say that this type of posture deserves clinical attention.

Discussion

Alteration in the resting scapular position is thought to occur with abnormal alignment of the cervical and thoracic spine.⁵¹ FSP can be associated with FHP,⁵² increased thoracic kyphotic posture,^{19, 25, 26} or both^{12, 15} (Table 3). The scapula has been found to be anteriorly tilted, downwardly rotated, and protracted during elevation of the arm in persons with FHP. A decrease in serratus anterior activity has been observed in persons with FHP while doing arm elevation and lifting activities. This reduction in serratus anterior activity leads to anterior tilting of the scapula, as well as winging of the scapula (because the serratus anterior stabilizes the scapula on the thorax).³²

Increased forward angulation of the scapula can be observed with an increase in slope of the upper thoracic spine. The angle formed between the clavicle and the scapula in the transverse plane increases too much owing to the rib cage expansion and increased anteroposterior diameter of the chest caused by increased thoracic kyphosis. Thoracic spine posture also influences scapular and glenohumeral kinematics. Increased flexion at the thoracic spine could lead to reduced elevation range of motion at the glenohumeral joint. Also, reduced scapular posterior tilting and increased scapular elevation might be evident while doing elevation at the shoulder.^{15, 25, 51, 53}

The thoracic spine is less mobile and, thus, more stable in comparison to the cervical region. This stability is attributed to the presence of ribs, lesser intervertebral disk height, and the plane of facet joints.^{7, 49} The literature contains scientific evidence that increased cervical lordosis can lead to more pronounced thoracic kyphosis. In a recent study,²⁷ the amount of cervical lordosis was found to correlate with the degree of thoracic kyphosis. Two hundred twenty-eight subjects were divided into two groups based on the radiological findings. Group 1 subjects were characterized by loss of cervical lordosis, and group 2 subjects had physiologic lordotic cervical curvature. Whole (T1-12), lower (T6-12), and upper (T1-6) thoracic kyphosis was determined using the Cobb method. The mean values for group 1 were found to be lower for upper, lower, and whole thoracic kyphosis than the mean values for group 2. Another study found a significant correlation between FHP and thoracic kyphosis.⁴³

The aforementioned studies hence provide evidence of an association between FHP and rounded shoulders,^{5, 52} between FHP and thoracic kyphosis,^{27, 46} and between rounded shoulders and thoracic kyphosis.^{19, 25, 26} To the best of our knowledge, only 4 papers were found that best supported the objective of this review. As can be observed in Tables 1 and 2, there is heterogeneity in the methods employed by these studies to observe posture; thus, we could not reach a definitive conclusion regarding the cause of FHP, FSP, or thoracic kyphosis, that is, what happens first among the 3 and what happens next. More research studies are required to answer the question and report that it is a cascade of biomechanical changes starting with 1 of the 3 deviations leading to the other 2 deviations.

Although there is consensus on the coexistence of FHP, FSP, and increased thoracic kyphosis, there remains doubt about 1 being the cause or the consequence of the other. Research is required to test the cause-and-effect relationship between the 3 postural deviations. Researchers are encouraged to explore the link between forward head, forward shoulder, and thoracic kyphotic posture so that these conditions can be treated effectively.

Limitations

This study was limited by the search terms and indexes searched. Therefore, it is possible that other studies may exist that were not included. Because so few studies were found, the conclusions based on the findings are limited as well.

Conclusion

On the basis of the literature, there appears to be a relationship between FHP, FSP, and thoracic kyphosis. Current evidence limits our understanding of the association between these 3 conditions. It is unclear whether any of these 3 postural deviations is a cause or a consequence of the other 2 deviations. However, it is clear that 2 or all 3 deviations can co-exist.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): D.S.

Design (planned the methods to generate the results): D.S., Z.V.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): Z.V.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): D.S.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): D.S., Z.V.

Literature search (performed the literature search): D.S.

Writing (responsible for writing a substantive part of the manuscript): D.S.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): Z.V.

Practical Applications

• •FHP has been found to be associated with FSP or protracted shoulders and increased kyphosis at the thoracic spine.
• •Combination of all these postural deviations is often referred to as a “slouched posture.”
• •Causes of FHP include computer use, carriage of backpacks, mouth breathing, bad habit, rounded upper back, and rounded shoulders.
• •FHP can lead to headache, shoulder pain, neck pain, craniofacial pain, radiating pain to the scalp, temporomandibular disorders, subacromial impingement syndrome, restricted range of motion at the cervical spine, and scapula and shoulder dyskinesis.

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