For which patients with neck pain is posture analysis most relevant?

Abstract

The absence of evidence to support the concept that individuals with neck pain have head postures that differ from those without symptoms, is not surprising. Many of the studies reviewed in this paper found no difference in posture between groups, and where differences were identified the magnitude of the difference was very small. In discussing this finding, the authors allude to the limited detail of the patient group provided in many studies. I consider this to be the most important factor contributing to the outcome of this review. Posture analysis is most relevant to patients with neck pain related to sustained postures and postural loading activities. This group accounts for about 20% of all patients with non-traumatic, chronic neck pain. Therefore, evaluation of posture may be relevant to only a limited subgroup of all patients with postural neck pain. Determination of the relevance of postural measurement should be based on the influence of head posture, and postural modification on the symptoms. Only two studies included in this review selected patients on this basis. Importantly, even when the influence of posture on the symptoms was considered, the differences in head posture between these patients and matched asymptomatic subjects were small. These findings have important implications for future studies in this area. The nature of the postural changes leading to, or maintaining neck pain, is poorly understood. Not all patients with posturerelated neck pain may have the same postural changes. Factors that need to be considered are the nature of the postural adjustment (head protraction or retraction), level of muscle activity (overor underactive), changes in kinaesthetic awareness and the patient’s understanding or beliefs about ‘good posture’. Since the development of neck pain is likely to be multifactorial, these issues may need to be considered together rather than in isolation. Complicating this issue further are environmental and work-related factors that may also be important aetiological factors for posture-related neck pain. The neck postures associated with a specific task may change over time, body position and support will influence neck posture, and the time at task may be as important in the development of pain as the posture itself. When all these issues are considered, it is not surprising that limited insight into this issue is gained given the relatively simplistic approach adopted in most of the studies reviewed. This review provides an important summary of what is known about head posture in patients with neck pain. This should provide a platform for the development of future studies that can progress our understanding of postural factors in patients with neck pain. It would certainly be disappointing if a similar review conducted a decade from now ended with the now familiar ‘insufficient good quality evidence’ conclusion.