311- Forward Head Posture and Chronic Low Back Pain

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. And on today's episode, we're back with the research and this is a really, really cool study that came out in 2021. So this is a brand new one and it's all about the relationships between forward head posture and lumbopelvic sagittal alignment in older adults with chronic low back pain. Great study, really pragmatic bunch of take home messages. We'll break it down and more on today's episode. Before we get started, let me say a few words about Novopulse. If you have not checked out Novopulse, I don't know what you're waiting for. This is where recovery meets performance. Please check out novo-pulse.com recovery that's novo-pulse.com Recovery and learn more about this new tech that reduces pain and inflammation while improving function to help get your patients back to the activities they enjoy. It is a really, really cool piece of technology and it's probably not something you've seen or used in your practice to date. I'll drop that link down in the show notes. But as I said at the top on today's episode, we're breaking down. A brand new study came out in Journal of Bodywork and Movement Therapies. And again, the title at the top is Relationships between Forward Head Posture and Lumbopelvic Sagittal Alignment in Older Adults with Chronic Low Back pain. So this is something I know all of us see all day, every day, right? We see chronic low back pain, we see forward head posture, and we probably see sagittal alignment issues as well. So the question becomes, how do these things play together? Does it really matter? Do they impact each other? And how can then you go about your clinical decision making in a way that gets maximum benefit? So if we start right at the top, we know low back pain is one of the largest and most challenging disorders out there right now. It represents the leading cause of disability worldwide and the second cause of medical consultations. Think about that. Not only I know, we've heard it for years, the leading cause of disability. It's like, yeah, that's okay. That's. What does that mean? This is the second leading cause of medical consultations. You want to talk about people spending money and people Going in to see their doctor, maybe you, maybe somebody else. This is the number two reason why people visit medical providers. And between a 5 to 10% is the really the progression of low back pain that will go into chronic low back pain. So 5 to 10%. Now just take one step back and just think about the magnitude of this leading cause of disability. Point prevalence of 30%. There's 6 billion people on planet Earth and 5 to 10% of those individuals will develop chronic low back pain. So if you don't think, let me put it this way, sometimes I think us as chiropractors think of low back pain as boring. Well, it might not be the most exciting thing on planet earth, but if you did a really, really good job promoting yourself as sort of this spinal expert in your community, which I think all of us are, but I just don't think we tell that story to the level we need to, because there's infinite people out there that could utilize your services. So if you're lacking in new patients, you're not positioning yourself in your marketplace appropriately because people clearly aren't putting one to one together. So anyhow, chronic mechanical low back pain results often from bad habits, the researchers say, such as poor posture. Now, some people might take exception to that, but it's the truth. Abnormal posture can create abnormal stress over time and strain on spinal structures, and it's considered a predisposing factor for pain. So if you have altered posture, it doesn't mean that everybody has the same posture or that there is this perfect that all of us need to live up to. But what it does mean, I think of this like we have, we all have, you know, a certain weight, right, where we can try to lose weight and we might push our weight down a little bit, but you know, it's not gonna go down below X amount or you. We might not be eating well and we kind of put on some weight, but we kind of sit within this bucket or this zone and I view that same thing. When we think about posture, we all have this zone of normalcy, so to speak. It might not be perfect, but it might be the zone of normal for us. However, when we start to push beyond that zone of normal now we can really start to see some things take effect negatively in terms of pain, in terms of dysfunction, as days become weeks, become months, become years. So bottom line is, patients with forward head posture, it's something we see all day, every day. And we know this is when the head is in a front position relative to the plumb line indicated by the cranio vertebral, excuse me, craniovertebral angle, the cva. This increases stress and strain placed upon the muscles of the head, neck and shoulders and results in joint dysfunction and abnormal afferent inflammation or disaffrontation. So it's a big deal. And this is a big deal. As we talk about tec neck each year within the smart chiropractor, we talk about how much weight. It's just like a lever system. As that chin protrudes forward, as that head pushes forward, we see the weight of the head on the structures of the cervical spine go exponentially up. And again, we could get away with that for a certain amount of time. But as days become weeks, become months, become years, it starts to really challenge the tissue under the weight of gravity. You mix in some injuries along the way and you end up having these chronic issues. So if the head is placed too far in front, there's so much of a forward head posture, the pelvis will actually tilt anteriorly to balance the center of gravity. This is why all of these things play together. And even when we're talking about low back pain, chronic low back pain, oftentimes these things can be traced back to maybe not. They started with cervical issues, but there's an interplay of a cervical issue associated with it. So as that head goes forward, that pelvis tilts anteriorly, the now we start to get these compounding compensations. So abnormal lumbopelvic sagittal arrangement is one of the four most etiological components related to low back pain, according to these researchers. So is this a big deal? Yes. Head goes forward, pelvis tilts anteriorly, abnormal lumbopelvic sagittal arrangement becomes one of the leading factors to low back pain. So all of these things are just playing together. So is it important to check these things out on your patients? Absolutely. Is it important to have them understand how something in their neck could be affecting their low back or vice versa, and how these things play together? Absolutely. Now, you might not use terms like lumbopelvic sagittal arrangement when you talk with your patients, but you might talk about pelvic tilt, you might talk about, hey, notice that forward head posture. These are things that many people are somewhat in tune with with their bodies, but probably haven't been explained very well in terms of how these various things that might seem totally unrelated to them play together. So in this study, they looked at 135 subjects and the inclusion criteria were chronic mechanical low back pain, with symptoms lasting longer than three months duration. So they again, they wanted that chronicity, they wanted it to be chronic low back pain patients. It had to have mild to moderate disability concurring to an ODI index and a cranial vertebral angle of less than 50 degrees. So those were really the criteria that they looked at to say, okay, well what are if any, the correlations between what's going on in the head and neck, what's going on in that lumbopelvic angle, and any interplay with chronic low back pain. So the results of this study did highlight the association between low back pain intensity and spinal pelvic sagittal alignment. And back pain may be increased in patients with forward head posture and in patients with increased lumbar lordosis. So all important things to keep in mind. Now why does this happen? Well, the cervical spine has a super, super important role in whole spinal alignment. When the head position moves forward away from your body's vertical pivot, increased strain is placed upon the muscles of head, neck, shoulders, and that leads to that disaffrontation that we highlighted earlier. Now how does this play in? Well, reflexive involuntary control contributes to postural maintenance. So our bodies are constantly, basically our eyes are trying to get to that third forward horizon line and our bodies are doing reflexive controlled movements 24, 7, basically as long as we're upright in terms of looking at the horizon line to maintain proper maintenance. So many of these postural reflexes occur or are located in the region of the head and neck. So this is how the cascade begins and how things play together. Alterations in spinal sagittal alignment, as they say in this study, they might be credited to a strong relationship that exists between forward head posture. This reflex causes an anterior pelvic translation to balance the head center of mass. And changes in sagittal spinal arrangements have been associated with modifications in pelvic orientation. So if you're looking up high, if you're looking in that cervical spine, don't neglect what's going on in the lumbopelvic area. Consequently, if you're looking at somebody with chronic low back pain, the and you're looking really heavily, which you probably are at the lumbo pelvic area, don't discount what's going on up in the cervical spine. Now, one might be a compensation for the other, but it's important to check both out to understand how each are moving and to really coach and train your patients. Especially if you're doing active care in your practice or you're recommending at home exercises. Man, you Gotta hit both aspects of this to get maximum results. So what was the conclusion of the study? The conclusion was the researchers found, quote, significant associations have been established among pain intensity, forward head posture and lumbopelvic sagittal alignment parameters in patients with chronic mechanical low back pain. Back pain may be increased in patients with forward head posture and in patients with increased lumbar lordosis. And that is what we found. Now in terms of clinical relevance, they break down five bullet points. I find this to be super helpful. So I'll read these five bullet points that the researchers found in terms of clinical relevance, which I think is really the take home message for all of us. They found dysfunction such as a faulty posture and not just lumbosacral pathoanatomy should be considered during the management of chronic low back pain. They also found patients with forward head posture may have a high risk of developing low back pain. Important to keep that in mind, patients with increased lumbar lordosis or sacral slope and or decreased pelvic tilt may have a high risk of developing low back pain. The human spine should be considered globally rather than segmentally. And finally, cervical posture correction should be considered during the management of low back pain. So super important for all the keep all of these things in mind. I know I've talked about on this podcast before, look one region away, right? Somebody has a cervical spine issue, make sure you check out their shoulder. Somebody has a low back issue, check out the hip, always check that one region away. This study says, hey, maybe go even a step or two beyond that. If you're analyzing somebody with chronic mechanical low back pain, check out what's going on in the cervical spine because there might be aspects of the cervical spine that are, if not causing, definitely contributing to low back pain. And also just looking at the body globally, I know a couple weeks ago I was coming out of being pretty ill and did a short episode on the three phases of movement, as I like to think of it, segmental movement, regional movement and whole body movement. And these researchers are citing the fact of, hey, take a look at the human spine from a global perspective rather than just segmentally. I'd kind of add in their mind and say, hey, think about it globally, think about it regionally and think about it segmentally. Because if segmental motion is shot, your regional motion and global motion doesn't stand a chance. If your regional motion shot, your global motion doesn't stand a chance, you really have to have optimal segmental motion, regional motion, and that's what's going to contribute to the best possible, the most optimal global spinal motion. So a lot to dive into, you know, a lot to really sink your teeth into in terms of movement. If you're a movement assessment person, if you're checking out x rays, I think this also is important. And the bottom line is I think it is something that we all need to think about and don't become so myopic. I know all of us can become myopic when we have a patient that comes in with a specific complaint. And we're really focused on that complaint, number one, because we're trying to get the patient to function and feel better. But number two, that's why they came into our practice. I'm not discarding that whatsoever, but what I am encouraging you to do is take a step back, think globally, think holistically. And papers like this showcase the fact of our body is so dynamic and how our spine functions is so dynamic and it contributes dynamically to how we live our lives. So don't become super myopic with your care and treatment with the patients in your practice. Take that global viewpoint. If somebody's got chronic mechanical low back pain, nothing's helped them. Check out the other regions of the spine, ensure that the motion's good there, give postural exercises when necessary, adjust those areas when necessary, and help people achieve better function of their spine overall. So that's my big take home message for today. As we wrap things up, I want to encourage you also to check out that link in the episode notes for E Chiro ehr. Every EHR sells features, few have ecairo's expertise. 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And if you are one, and I think you are, if you are listening right now, of the 11,000 plus docs that listen to this podcast each and every week, thank you so much for tuning in. If you have any questions whatsoever or feedback, hit me up. Jeff the evidencebasedchiropractor.com Otherwise, have a fantastic week in practice and I will talk to you soon.

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