Strategies to Address FORWARD-HEAD POSTURES Part One: Sacrificing Complexity of Movement for Stability by Erik Dalton any injuries in America today result from on-the-job muscle/joine strain and overuse syndromes. Working in a technologically driven so- ciety has caused an explosive and expensive increase in work-related costs, with injuries occurring to categories of workers previously con- sidered low risk for anything more serious than the occasional paper-cut. Often scen as a seructurally subtle body segment, the neck is burdened with the highly difficult cask of supporting the human head. Because of the tension, trau- rma and poor posture inherent in today’s workplace, ic is no surprise that head-on- neck and neck-on-thorax imbalances serve as some of the most common pain generators driving people into our bodywork practices. ‘This ewo-part series is excerpted fiom the author's new textbook, Advanced Myoskeletal Techniques. This issue's segment investigates the causes, conditions and corrections associated with one of the most painful of all postural faults: for- wward-head postures. The battle against gravity Muscles are designed ro glide independently neighboring myofascial tissues as the central nervous system orchestrates a complex array of specified move- ments, When observing professional gymnasts at work, one immediately ree- gnizes the astonishing quality, variety and complexity of their coordinated ovement patterns. Conversely, the elderly foot-shuffler appears to have body areas frozen in time. Sadly, years of tension, trauma and poor posture—com- bined with gravitational exposure—force the human body to sacrifice com- plexity of movement for stability. Today, more than ever, people are inclined to si for hours in isomerrically con- tracted postures without adequate physical activity. When muscles contract, fuel is burned and waste products accumulate. In time, these chemical irritants alter the muscles’ resting length, causing enveloping fascial bags to lose their natural suppleness. Prolonged siting leads to slumping, as people spend countless hours tied co work terminals, home computers, school desks and television sets. As the heavy head slowly drops forward and down, the scapulse externally rorate and protract, increasing thoracic kyphosis and flattening of lumbar lordosis. Exhausted from battling gravity, intrinsic cervical extensor muscles such as semispinalis, longissimus, the suboccipitals and multifidus become toxic from ‘oxygen deprivation. Extrinsic (phasic) muscles (trapezius, rhomboids, posterior rotator cuff, etc.) prefer burning glucose for fuel but the deep intrinsic support muscles require more oxygen. When tension, trauma and faulty posture reduce the amount of oxygen delivered to intrinsic postural muscles, fatigue sets in, caus- the gravitational load to shift o the extrinscs. 9Extrinsic muscles are dynamic and designed to provide quick bursts of energy. Since phasics contain a greater number of Fast- ‘witch fibers, they do not respond well to sustained compression- al loading and quickly give our—and the energy-depleted intr sic muscles are once again made to bear the load. This decompen- sation cycle marks the beginning of a domino effect that struc turally manifests as: reduced flexibility: loss of range of motion; and an unattractive, forward-head, slumped-shouldered posture. The gluing process tigue syndrome are often assigned to describe these achy, energy-de- ficient bodies. Technically speaking, a positive vest for a forward-head posure requices that the aygomatic arch (under the eye) be more than three centimeters forward of the sternoclavicular joint. Re- searchers generally agtce that for every inch the head shifis for- ‘ward in che sagiral plane, the neck’s extensor muscles are required to isomertically restrain (against gravitational force) not only the Seven layers of muscles of the posterior cervical and upper thoracic spini 1. Semispinalis Capitis (head extension & rotation) 2. Tliocostalis Cervicis (extends cervical vertebrae) 3. Longissimus Cervicis (extends cervical vertebrae) 4. Longissimus Capitis (head rotation & extension) 5. Longissimus Thoracis (extends & sidebends vertebral column) 6. Tliocostalis Thoracis (extends & sidebends vertebral column) 7. Semispinalis Thoracis (extends & rotates vertebral column) Figure 1. Deep capital and cervical extensors that commonly "glue" together at the cervicothoracic junction. Interactive Series, Primal Pictures, 2004. Reprinted with permission, ‘The seven deepest myofascial layers traversing the C7-T'l jun tion are particularly vulnerable co sustained isomertic contraction from forward-head postures (Figure 1). With time, the slick lubri cating fluid designed to provide smooth gliding of individual fas- cial sheaths dehydrates, thickens and becomes adhesive. The 1e- sult: fascial adhesions, myospasm and muscle concraccures. Living in a healthy body with pain-free range of motion requires that every upper quadrant muscle maintain its own independent yer communal contribution during head-and-neck movements. When “sticky” fascial layers bond, specialized (efficent) muscle movemenc is lost. The semispinalis,splenius, longissimus and erapezius fisciae are often guilty of clinging and dragging on neighboring muscles. Myofascial restrictions not only waste precious energy but also re duce flexibility and range of motion. An exaggerated example ofthis condition is often seen in persons forced ro turn their entire trunk 10 look to the side. This population usually presents with protracted shoulders and forward-drawn heads evolved from years of slumped. sitting, repetitive movement patterns, trauma, and limbic system (emotional) stressors. Names such as fibromyalgia and chronic fa- 100 massage Magazine January / February 2096 head's weight, but also an extra 10 pounds for each inch of for- ward head migration. Therefore, a 12-pound head that moves three inches forward of the thorax forces the cervical extensor ‘muscles to support a 42-pound head against the incredibly formi- dable influence of gravity. The neurology of forward heads ‘The human body's bony framework and supporting soft tissues are densely populated with proprioceptive and pain-sensing sen- sory receptors that serve as the frontline of awareness. Faulty pos- ture, micro- and macro-trauma, gravitational stress and resultant inflammation cause a breakdown of the smooth self-regulating function of these receptors. Soon the person begins to experience painful spasmodic episodes, as caustic waste products such as his- tamines, bradykinins and lactic acid collect in the tightened, nu- trient-depleted muscle bellies. Prolonged toxic buildup stimulates sensitive chemoreceptors that flood the spinal cord and brain with noxious messages setting off neurologic inflammatory responses.Sustained isometric muscle contraction not only excites in- flammation-sensitive chemoreceptors, but also. specialized mechanoreceptors designed to monitor excessive stretching or compression of joint capsules, ligaments, discs, fascia and spinal rotator muscles. As chemoreceptors and mechanorecep- tors bombard the spinal cord with perpetual streams of noxious stimuli, the cord finds itself unable to handle the increased sen- sory input and quickly recruits pain-signaling nociceptors. The tiny non-myelinated nociceptors can fast-track sensory mes- sages to the thalamus, warning the brain of the possibility of ac- tual tissue damage. Typically, the brain reacts by layering the af- fected area with protective muscle spasm. This marks the begin- ning of stubborn pain/spasm/pain cycles that refuse ro be bro- ken until che forward-head posture is improved and normal proprioceptive activity restored. Interestingly, excessive cortical stimulation causes recruitment of specific sets of muscles "hard-wired" co fire in a predetermined order to guard the vulnerable area. Unfortunately, the firse mus- cles enlisted are often the very same tissues responsible for creat- ing the head-forward posture to begin with; namely, the stern- ‘ocleidomastoids (SCMs), suboccipitals and anterior scalenes. As these highly innervated soft tissues tighten and shorten, the head and neck are drawn even farther forward resulting in increased myospasm and protective guarding. The brain quickly calls up the next battalion of troops to help counter this intolerable forward- head drag. Below is a brief analysis of typical muscle imbalance patterns resulting from this tenacious bate. Deeper structural impact Sagittal plane observations shown in Figure 2 illustrate a ‘guy-wire arrangement of cer- vical antigravity muscles that, when working prop- erly, allows the neck and head optimal structural support through what is termed a “dual-tent” sys- tem. This anterior/posteri- or cervical muscular sup- pore configuration was first described by ) Joseph Maynard, % DC., in the carly i 1950s1. His keen observations pared the com- neck’s Figure 2. The dual-tent antigravity system. First, visualize che SCMs anchoring the front of the cervical spine and head with splenius capitis counterbalancing posteriorly. The second guy- wiee arrangement has the anterior scalenes working in perfect bal- anced opposition with levator scapula. MediClip, Lippincore, Williams 8 Wilkins. Copyright 2005. Reprinted with permission. 101 Mazeage Magazine January / Fasruacy 2006 anatomy with the balanced guy-wire arrangement of the common four anchor camping tent. Although, the dual-tent system em- bodies only a small piece of the neck’s elaborate counterbalancing, archivectural mechanism, this anaromnical model bese describes the primary support system responsible for protecting the brain’ del- icate neurological contents ‘One can easily visualize why the brain might recruit the broad splenius capitis muscle to anchor the neck posteriorly due to the shared (front and back) attachments with the SCMs at the mas- toid. With this arrangement, the splenius capitis offers a perfect counterforce to the powerful antetior pull of the SCMs. ‘The levator scapulae are also high on the recruitment list due o their common front/back attachments with the anterior scalenes at C1-CA transverse processes. This design offers perfect resistance from the constant drag of typically hypertonic anterior scalenes, When working properly, the antigravity function of this four-muscle, dual-tent system is ideal in allowing che human head to gracefully balance on the neck. However, when structural in- tegrity fails due to traumatic changes, the neck’s intricately de- signed antigravity springing system loses out to compressive grav- itational forces acting on it. As cervical curve diminishes, the sweight burden falls to deep spinal tissues such as apophyseal joints and intervertebral discs...the devastating beginning of what the medical profession loosely calls degenerative disc disease. The silent nerve compression syndrome Biomedical researchers today agree that most neck pain does not directly result From the pinching of nerves. Instead, pain slow- ly develops from increased stimulation of nociceptors due to com- pressed and/or inflamed spinal soft tissues, such as ligaments, joine capsules, intervertebral discs, fasciae, and deep transver- sospinalis muscles.2 Therapeutic client outcomes will dramatical- ly improve once postually minded pain management therapists begin shifting blame away from pinched nerves and begin incor- porating a broader approach that includes pain generated by the sensory receptor system. In a majority of cases, the therapist's in- tent should focus on creating myofascial balance, improving pos- ture and restoring joint play to calm hyperexcited sensory recep- ors in soft tissues forming from the mesoderm. Although most researchers today dismiss the nerve root as a pain-generating structure due to the lack of positive, objective signs (such as paresthesias, sensory deficits and motor loss), is im- portance in the pain-management picture cannot be completely overlooked. Loss of disc height combined with vertebral foramina bone spurring can eventually deform and tether the nerve root. AS the dural sheath and surrounding capillary beds undergo pro- longed mechanical deformation, ischemia, intraneural edema, and loss of axoplasmatic flow of vital nutrients break down ax- cons and pain ensues. Some biomedical researchers3 estimate that 10-15 percent of clients presenting with this type of chronic neck pain suffer from what has been ermed the silent nerve compression syndromeCurves, the jaw—and posture One of the primary postural goals for today’s manual therapist is restoration and maintenance of proper vertebral curves. The contours of the vertebral column exist for a reason: to provide the least amount of strain to muscles, tendons, ligaments and joints s0 they can carry on with daily chores. If compromised in any way, the risk of Futute injury and development of pain/spasm/pain cycles seriously escalates. To enhance forward-head posture assessment, it is beneficial 10 include jaw deviation inthe equation, since the ewo are so intimate- ly related. Any alteration in head/neck/thorax symmetry also pro- foundly affects jaw alignment. The four most common types of rneck-and-jaw (Figure 3) relationships are categorized as follows: Class I, Normal Chass TT, Retrusive Jaw = Extensor-dominant (ED) neck (Class III, Protrusive Jaw = Flexor-dominant (FD) neck ‘Class IV, Rettusive Jaw = Capital extensor-dominant (CED) neck. Figure 4 lists various anterior and posterior cervical muscles re- sponsible for creating aberrant Class Il and III distorted postures, (One can easily visualize how hypertonicity in any of these capital and cervical extensor and flexor groups could initiate asymmetric head, neck and jaw disorders. ‘The following is a brief analysis of three major types of neck/jaw postures. (In the next installment of this 2-part se- ries, a very common and often debilitating forward-head posture, Class IV, will be described and various ereatment options presented.) Forward | Posterior Vie esa Gass ass 1 class format sGtiNe — \| sotraaive Figure 4 we we EXTENSORS CAPITAL semsplnus apts lenis apis ‘sles cents ous € CERVICAL 4 man C5 FLEXORS CAPITAL suprhiés ——ectBCs w 4 CERVICAL soles ceri tendons s Hypercontracted headineck extensor asc and rerusv jaws gpically occur sustained suboccipital contraction t0 in tandem, The Class IL most commonly seen neckjaw dysfunc tion, preceded only by Cass TVs. Clients joines actualy stare hyperextending at develop this retrusive jawlforwandhead Although the brain still maintains the second cock che head back to level the eyes, the extensor-dominate neck’s facet C4-S. Upper cervical-complex. pain posture when tight and shore capital and patterns are common, as the superior Figuce 3: Necle and jw postural puters. Any alteration ia head/eeldthorax symmetry also profoundly affects jaw align- ment. When compating CsI and Il deviated postures to Class I, Normal, notice how the line of weight bearing flsposcrir to the plum nein Cls I (reeusves) and aneio n CsI pro- teusivs), Class Is requenly experience TM] dysfunction a the mandibular condyles and disc ae crammed inc the os ‘Adapted fiom Ross Pope wih permission, 2003. cervical extensor muscls overpower all the neck’ flexors (exept SCM&). Clients rior counterparts during forced back- presenting with exensordominate necks ward-bending. (Headaches occur in ate easy to spot as shortened extensors Class Hs but are a bigger problem in create a cervical-bowing pattem with the the Class IV neck due to neural and apexof the hyperlordaticeune peaking at vascular compression as the head hy- about C45. All structures at the apex of perextends through the O-A joint.) the cane ae particularly vulnerable to cise, ligament and fice degeneration facer cartilages collide with their infe-Class |, normal Optimal upper-quadrant symmetry requires that the heavy head be balanced evenly on the subtle neck so the eyes maintain a leveling with the horizon. In this relaxed position, the jaw and cranial base are perfectly aligned in the transverse plane. Class Il, retrusive jaw, extensor- dominate neck Figure 5. Tight/short hyoid and digastric muscles. As the ED neck translates the head forward, tonic hyoid and digastric muscles re- sist by pulling posteroinferiorly on the mandible, creating jaw retrusion. MediClip, Lippincott, Williams & Wilkins. Copyright 2005. Reprinted with permission. Regrettably, extensor-dominate neck-bowing also moves the head forward in che sagittal plane, usually leaving the jaw be- hhind due to the strong posteroinferior pull of tonic hyoid and digastric muscles (Figute 5). Recall thar the cranium and the jaw form from separate myotomes at birth. The jaw belongs to the visceral system, not with the cranium. Alchough capital and cervical extensors certainly aren the only muscles responsible for creating Class IT retrusive jaw postures, the brain prefers recruiting chese issues first, due to their resilient ability to barele gravitational forces determined to yank the head down on the chest. Figures 6 and 7 demonstrate ewo very effec- tive techniques for correcting extensor-dominate necks and asso- ciated TMJ problems. Consequently, che facet’ articular cartilages are required to bear more of the heavy head's weight. Facets are possibly the most in- nervated of all spinal structures and are responsible for most non- dermatomal cervical, scapular and brachial pain syndromes seen in bodywork practices today. Figure 9 introduces a facet-pain re- ferral map which helps clinicians immediately identify specific ar- eas where cervical dysfunction may originate.’ Clinical success rates dramatically improve as therapists learn to identify and re- lease short head/neck extensor muscles, while creating tone in overstretched cervical flexors Figure 6. Drag the groove: The client inhales causing the first rib to elevate, This allows the therapist's forearm to “deep-hook” the “upper trapezius fascia ac the clavicular border. As the client raises and lowers the head, the therapist slowly drags the paravertebral tissues inferiorly down the lamina groove, Exhaling during head flexion causes a powerful GTO (Golgi tendon organ) release. This maneuver also helps lengthen and separate adhesive fascial bags relieving conditions such as Dowagers hump. Courtesy of Frik Dalton Figure 7. Modified corkscrew release: The therapist right rotates clienc’s head while his right thumb slowly glides down the groove contacting the common attachment of splenius capitis and cervi- cis, Client gendly attempts left head roration againse therapist’ re sistance to a count of five and relaxes. Therapist’s extended thumb maintains a constant inferior pressure co separate the splenii from semispinalis and crapezius fascia, By slightly altering thumb posi- tions, the therapist can also release fibrotic posterior scalenes, longissimus, and iliocostalis cervicis muscles. Courtesy of Erik Dalton‘When compressive forces dehydrate and flatten cervical discs, the posterior longitudinal ligament becomes lax. Micto- and ‘macto traumas begin tearing away ligamentous fibers from their firm attachments at the vertebral bodies and dise margins, allow- ing internal pressure (within the bone) to fill the tiny cracks wich calcium. This is the precursor to foraminal nerve-root occlusion and spinal stenosis. Local ligamentous laxity is the primary reason C45 and C5-6 discs suffer the greatest number of herniations and ate the most operated on of all cervical segments. Osteophyt- ic bone spurting also likes to deform the non-synovial Joints of Von Luschka. When these tiny structures (designed to safely guide herve roots away from the neck) fill with calcium and hypertro- phy, clients often suffer paresthesias, sensory deficits, motor loss and radicular pain syndromes, The facet and disc dilemma A devascating chain of pathologie events ‘occurs as hyperton- ic extensor-domi- rate muscles fight to level the eyes against the horizon. In clients present- ing with excessive cervical curve, the posterior interverte- bral dise fibers flatten (ar the apex), forcing the superior facet joine co approximate its inferior neighbor (Figure 8). Figure 8. Facets and discs are coupled and interdependent. Facets are possibly the most innervated of all spinal structures and are re- sponsible for mast non-dermatomal pain syndromes seen in clin- ic today. Cervical or lumbar hyperlordosis flattens posterior inter- vertebral disc fibers forcing the superior facet joints to approxi- ‘mate and compress their inferior neighbors. Local hypermobility problems arise atthe apex of the curve resulting in ligament laxi- 15; bone-spurring, and disc degeneration Courtesy of Brit Dalton Footnotes 1, Maynard, J. Healing Hands, Foreman Dowling, Press, pgs. 219-221, 1991 2. Kors, LM. "Clinical Significance of the Facil- inated State." JAOA 54:277, 1955 3. Garfin, S.R., et al. “Spinal Nerve Root Com- pression,” Spine 20:1810, 1995 4, Wilberges, J.B Pang, D. "Syndrome of the Incidental Herniated Intervertebral Disc,” Journal of Neurosugery 59:137, 1983 5. Bogduk, N.; Marsland, A. "The Cervical Zy- gapophysial Joints as a Source of Neck Pain," Spine 13:610, 1988 Excerpted from Erik Dalton’s newly released text, Advanced Myoskeletal Techniques. Available through www.FreedomFromPain.com. In the March/April issue of MASSAGE Maga- zine, common neck pathologies will be examined with a focus on the age-old “straight-neck” contro- versy and related conditions such as osteoarthritis, ‘TMJ dysfunction and Dowagers humps. Erik Dalton, Ph.D, shares bis broad therapeutic background in massage, Rolfing® and osteopathy through innovative pain-management. workshops, books and videos. Developer ofthe Myoskeletal Aign- ‘ment Techniques® and founder ofthe Freedom From Pain Institue, Dalton is dedicated to research and treatment of chronic pain conditions. Freedom From Pain Institute workshops and home-seudy courses are approved by NCBTMB, Florida Board of Health and most state certifying agencies. Visit ww Erik- Dalton.com to subscribe to free monthly pain-man- agement newsletters. In Class ll ED necks, the therapist will palpate hypertonicity, fibrosis, and myospasm in some ‘orall of the following structures: Suboccipitals (rectus capitis major and minor) Semispinaliscoptis/corvieis* Splonius eapitis/corvcis “Longissimus eapitis/eervies + Ligamentum Nuchae Supraspinous ligaments * Upper Trapezius Levator Scapulbe ¢ Stornccleicomastoid + Hycids Digastries « Masseter * Temporalis Figure 9. Facet and Referral Map, joint blockage facilitates (tightens) ot Awell-designer study by Bogduk and inhibits (weakens) associated muscles Marsland tracked and labeled painful in each of the above areas often con- facet referral patterns. The authors found that most head and neck pain stems from C2-3 while shoulder/arm from the journal Spine, 1988, tributing to painful forward head postures, Reprinted with permission pain referred from C 5-6, Prolonged