The Posture Window Part 2

Using Posture to Guide Assessment and Treatment

By Yoni Whitten, DC

As we discussed in “The Posture Window” (September/October 2017, page 48), a head held in flexion, as with forward-head posture (FHP) and “text neck,” can increase the functional weight of the head many times over. In fact, the increase in weight can be as much as 60 pounds at the extreme end of the spectrum! The burden of all that extra weight on the body is tremendous and unyielding; it has to be carried around whenever a person is in an upright position. It is only a matter of time before the increase in functional weight creates widespread negative effects on the body.

It is these negative effects or symptoms that typically bring clients into our offices. The classic FHP client will present with neck, upper back, or headache pain (or all of the above), usually of an unknown origin. The onset of pain is commonly later in the day. When we dig a little into the health history of the client, they will often express that fatigue is, on some level, taking a toll on their life. Of course it is! Carrying around an extra 20-plus pounds all day, every day is exhausting! These clients typically feel better in the morning because those muscles have been allowed to rest while they lie down at night.  
In Part 1, we talked about how bodyworkers can often be drawn into the trap of spending a great deal of time and energy focusing on the tight, tender, overworked muscles that are responsible for supporting the additional weight of a head held in forward posture. But this approach is unlikely to yield any type of long-term gain because as soon as the client goes from the nonweight-bearing position of lying on your treatment table to an upright posture, the muscles that you’ve spent so much time softening/decreasing their resting tension will have to rapidly ramp the level of tension right back to the level necessary to accommodate the extra weight of the head in FHP.
The body ramps up tension in those muscles for a reason: to accommodate the extra weight of the head in FHP. Our clients do not carry out their lives in a nonweight-bearing position. Unless we can reduce the weight those muscles are required to hold, all the great work we do on the table will be undone shortly after the client stands up and their functional and symptomatic fate is sealed. This leads to a frustrating cycle for both the client and the bodyworker in which the client makes good progress during the session, but always slips backward between visits.
We discussed in Part 1 the importance of speaking with our clients to identify any lifestyle or environmental factors that could be contributing to the issue that brought them in. We can benefit tremendously, as clinicians and bodyworkers, by having a strong background in the etiology of the most common postural problems. By knowing which lifestyle factors create the environment where structural deterioration and postural deformities thrive, we can more effectively guide our clients toward functionality and health.

How Postural Deformities Grow
If you had a goal to grow the biggest, juiciest tomatoes in your backyard garden, wouldn’t you want to know which specific conditions are required to reach that goal? You would want to find out which type of soil to use, exactly how much water to give them, and the precise location to plant in your yard to ensure the plants received the proper amount of sunlight.
“Growing” postural deformities is the same concept: there is a recipe that leads to postural deformities. In the modern world, that recipe tends to have four main ingredients:
1. Physical inactivity
2. Too much time spent sitting
3. Smartphone/tablet/computer use
4. Improper footwear       
Physical Inactivity
Throughout human history, physical activity has been the norm. We had to move each and every day to secure food, water, and shelter for ourselves. We, as modern human beings, have inherited this legacy of daily physical activity from our ancestors. Any departure from the traditional activity patterns of our ancestors seems to be accompanied by certain undesirable consequences. According to the Journal of Applied Physiology, “Humans inherited genes that were evolved to support a physically active lifestyle,” and “physical inactivity in sedentary societies directly contributes to multiple chronic health disorders.”1    
With each leap in technological advancement, dating back to the late 18th century, we have seen a significant reduction in physical activity levels. We have now reached a point where only 1 in 3 children are physically active every day and only 1 in 3 adults receive the recommended amount of physical activity each week.2 Over one-fourth of the population has no physical activity whatsoever outside of their “normal job-related activities.”3 The word here is atrophy—muscles and body processes that are not used will not be maintained; they will shrivel up and disappear.  

Too Much Sitting
Research shows that people are sitting for as much as 15 hours a day. Furthermore, we spend 60 percent of our time engaged in sedentary pursuits. This establishes poor postural habits and weakens the muscles that hold us upright. Like anything we do repeatedly, we adapt to it so we can do the activity more efficiently (i.e., with less energy expenditure). Repetitively sitting for long periods of time conditions our bodies for sitting and necessarily deconditions our bodies for standing and moving.

Smartphone/Tablet/Computer Use
Americans spend nearly 11 hours a day in front of screens.4 Much of this time is spent looking down. Placing the neck in a flexed position when looking down increases the functional weight of the head by as much as 60 pounds. Exerting that extra force on the body for over 10 hours a day adds up very quickly. We are now seeing children as young as 10 years old with postural problems reminiscent of people in their 60s from just a few generations past.

Improper Footwear
Wearing shoes with an elevated heel forces the body’s center of gravity forward of its normal position. As the center of gravity moves forward, the body senses that it is off balance and takes immediate action to prevent what it perceives as falling forward. In this case, the body’s response is to ramp up activation of the erector spinae and the cervical paraspinalis. As a result of this activation, the neck is pulled into extension, thus moving the head into a balanced position over the trunk and keeping us upright.5 While this adaptive position does accomplish the short-term goal of allowing us to operate while in these types shoes, the long-term effects are all too often undesirable effects, like pain, up and down the kinetic chain.

Knowledge Into Practice
Knowing the four main ingredients for postural problems is one thing, but putting that knowledge into practice requires four key components.                                                   
1. Recognition. It is important to recognize several factors when dealing with this type of client. First and foremost, we need to understand that the position they are in is not normal. If the position is not normal, how could they possibly feel normal (i.e., pain-free) or function normally?    
2. Response. Look at the sum picture of all the input. Understand that the position the client is in didn’t happen spontaneously. In all likelihood, this position developed slowly, over time, in response to something (or perhaps, many things) that the client is (or was) doing.
The important part here is understanding that the output—in this case, the client’s posture—is a reflection of what’s being put into the system. Therefore, if we can change the input into the system, we can change the system’s output (the response).
3. Stack the Deck. Know the odds that you are up against. If the client engages in some activity for 7–8 hours a day, seven days a week, their body is going to alter its shape to adapt to performing that activity more efficiently. How effective is 60 minutes of bodywork going to be if the pattern we are working on has been engrained over thousands of hours and many years?
4. Force Multipliers. To have any chance of permanently resolving problems stemming from a postural issue, we must take advantage of every opportunity to enhance the in-office work we do with our clients between visits. One of the easiest and most effective ways to do this is with targeted exercises that can be performed daily by the client.
For example, one of the most common findings on palpation in a client with FHP (think anyone complaining of chronic neck or upper-back pain) is short, mechanically advantaged extensor muscles in the suboccipital region. The client would no doubt benefit significantly if we were to release and lengthen these muscles during their session.

Getting the client on board
We could enhance the effect of our work significantly by teaching the client a chin tuck (see “Chin Tuck Exercise,” page 72). This simple exercise can be used to prevent the upper cervical extensors from shortening by engaging and strengthening the deep neck flexors.   
The chin tuck has several unique ways of helping us help our clients. First, it can be used as a tool to increase the client’s awareness of their abnormal head position. Second, it has the ability to increase the strength and endurance of the deep neck flexors, while at the same time actively stretching the suboccipitals (and scalenes). Third, this exercise takes advantage of the principle of reciprocal inhibition in order to reduce the tone of the exact muscles we targeted with our in-office work, the suboccipitals. Using this technique amplifies and reinforces the effects of our in-office work and creates a powerful tool for normalizing the position of the head and neck.
The important thing to remember when recommending exercises for your client is that an exercise is only as useful as the client’s ability to perform it, consistently and correctly.
As such, the use of complicated, multipart movements in positions that are difficult to get into/out of, or exercises that require fancy equipment, are not recommended. Instead, we should focus on simple movements that can be performed almost anywhere without the use of any specialized equipment. The chin tuck fits those criteria nicely.
The more advanced the FHP, the more difficult and exhausting this exercise will be for the client. Your job is to tailor the exercise recommendation for the person in front of you. When performed properly, clients with FHP will most often feel an intense stretch at the base of the skull, pressure underneath the chin (near the Adam’s apple), and tension or intense stretching in the mid- or upper-thoracic spine.    
When I begin working with a client that is in chronic pain, I recommend they think of the chin tuck exercise as Advil for their head, neck, or mid-back pain. Any time they experience even the smallest hint of their pain, they are instructed to stop what they are doing and perform this exercise.
In this way, the client will be trained in the crucial skill of listening to their body. They will come to understand that they are doing something (or perhaps many things) that are contributing to their symptoms, and pain. Perhaps more importantly, they will learn that if they change what they are doing, they will change the results they are getting. That understanding is incredibly empowering, and fostering it is arguably the highest goal we, as bodyworkers, can achieve with a client.

Chin Tuck Exercise
To help combat your clients’ forward-head posture, offer them this homework.
1. Have the client stand with their back up against a wall.
2. The client’s feet should be positioned in front of them, approximately 12 inches from the base of the wall.
3. The client’s knees should have a very slight bend (approximately 10°–25°).
4. While keeping the back pressed against the wall, have the client slowly attempt to pull the back of the neck into contact with the wall by tucking their chin to achieve a neutral head position.
5. The client holds this position for 5–30 seconds.
6. The client should repeat this process 5–10 times throughout the day.

The Client’s Position
When providing instruction on this exercise, pay close attention to the client’s position. It is important to ensure that the client doesn’t:
• Raise the shoulders to call into action already overtaxed accessory muscles.
• Break the anterior stability line by hyperextending the lumbar spine and/or elevating the rib cage.

Chin Tuck Exercise Modifications
This exercise may be quite difficult or even impossible for clients with advanced FHP. There are certain modifications we can make to the exercise and/or the client’s position to make things easier for those who cannot perform the motion.
• For those clients with mild to moderate FHP, we can simply have them move their feet farther away from the wall—the farther the feet move from the wall, the easier the exercise becomes.
• For those with moderate to advanced FHP, we can have the client perform the movement in the supine position. This way, we can use gravity to assist them in accomplishing the contraction.
• For those with advanced FHP, we can elevate the client’s feet while they are supine.
• For those with severe FHP, we can use a small pad/cushion to elevate the upper portion of the skull (thus reducing the mechanical disadvantage of the deep neck flexors).

Chin tucks should be done first thing in the morning, to start the day with the goal of creating awareness around proper head position and strengthening the muscles that will lead to that goal. The chin tuck can be reinforced throughout the day almost anywhere, such as during a standing break at the office or even seated in the car while waiting at a red light.

1. Frank W. Booth et al., “Waging War on Physical Inactivity: Using Modern Molecular Ammunition Against an Ancient Enemy,” Journal of Applied Physiology 93, no. 1 (July 2002): 3–30.
2. U.S. Department of Health & Human Services, “Facts & Statistics: Physical Activity,”, last updated January 26, 2017, accessed November 2017,
3. America’s Health Rankings, “2015 Annual Report,” accessed November 2017,
4. Jacqueline Howard, “Americans Devote More Than 10 Hours a Day to Screen Time, and Growing,”, July 29, 2016, accessed November 2017,
5. Kisu Park et al., “Effects of the Height of Shoe Heels on Muscle Activation of Cervical and Lumbar Spine in Healthy Women,” Journal of Physical Therapy Science 28, no. 3 (2016): 956–9.

Yoni Whitten, DC, is a native of San Diego, California. He has been studying wellness and human performance for over two decades. He holds a bachelor of science in kinesiology with a specialization in nutrition and health, and a doctorate of chiropractic. For more information on using the science of posture to improve your clinical outcomes, help more clients, and have more fun, go to Contact Whitten at