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Break it Down: Forward Head 

Break it Down: Forward Head 

By Tracy Pomeroy, PT; Penny Stone, PT; Kim Byrd-Rider, PT, DPT 



The forward head postureis a scenario of strong/short mid-lower cervical flexors and strong/short upper cervical extensors. The upper cervical extensors become short and strong to accommodate horizontal gaze when the head angles down from excessive mid-lower cervical flexion (Khayatzadeh, Kalmanson, Schuit, Havey, Voronov, Ghanayem, & Patwardhan, 2017). Forward head posturetypically appears in two populations: people who sit for long periods and elderly adults. According to a systematic review by Neupane and colleagues,a new population may be added (2017).The team of researchers found that cell phone use leads to forward head posture. Forward head posture, no matter the instigating condition, is the most common cause for neck pain (Neupane, Ali, & Mathew, 2017). 



On a deeper level, poor cervical muscle conditions may have a physiological and patho-physiological effect on the entire spinal cord and nervous system.When compared, a twenty-six study systematic review showed strong evidence of a soft tissue connection and communication between the dura mater (outer layer of the brain and spinal cord) and the rectus capitis posterior minor (upper cervical extensor), rectus capitis posterior major (upper cervical extensor/rotator), and the obliquus capitis inferior (upper cervical rotator) muscles (Palomeque-del-Cerro, Arráez-Aybar, Rodríguez-Blanco, Guzmán-García, Menendez-Aparicio, & Oliva-Pascual-Vaca, 2017). Controversial evidence exist for a soft tissue communication between the spinal cord’s dura mater and the rhomboids minor, upper trapezius, serratus posterior superior and splenius capitis (cervical extension, rotation, lateral flexor) muscles via the ligamentum nuchae (Palomeque-del-Cerro, et al., 2017). The review researchers comment that these soft tissue connections may explain some previously unexplainable positive results of alternative-type cranio-cervical therapies. Forward head postures may contribute to nervous system issues.  

ligamentum nuchae 



The condition of older ligaments and tendons needs to be examined in the research literature before building a forward head program for aging adults. After a thorough review of the current literature, we conclude the research does not support a specific aging process for ligaments and tendons which would require a set protocol for any particular age group over 50. Controversial, age and gender related changes in ligaments and tendons exist in the literature. Osakabe and colleagues (2001) describe age related decreases of matrix components consisting of elastin, elastin cross-links, fibrillin, collagen and glycoprotein. Mineral content increases with age; calcium and phosphorus. McCarthy and Hannafin (2013) claim aging alters tendon and ligament mechano-transduction, biology, healing capacity, and biomechanical function. Collagen increases but become more disoriented. Contrarily, Svensson and colleagues (2016) state that tendon fibril diameter, collagencontent and whole tendon size appear to be unchanged with aging but glycation-derived cross-links increase substantially. They add that exercise tends to counteract the effects of aging tendons and ligaments. Nairci and Maganaris (2006) found that as people age the tendons become stiffer but the muscle fascicle length increases to compensate. Thus, the decreased tendon extensibility caused by tendon stiffness is accommodated by longer muscle fibers. Both McCrum and colleagues (2018) and Nairci and Maganairis (2006) found muscle and tendon improvements in the aging to be similar to younger adults following training interventions. 

When considering these research parameters, building a safe tendon and ligamentous program for people over 60 years old would have the same considerations as building a program for people under 60. The length and strength of the muscle, tendon and ligament units must be evaluated and a program then developed according to the length and joint range restrictions or laxity. From there, the person progresses, strengthening and stretching as tolerated with the understanding that the ligaments and tendons are normalizing as exercise continues. 


All of the previous research listed here was synthesized into the following yoga exercise program for forward head. Stretching of the anterior chest, anterior shoulder, hamstrings and psoas muscles (posterior pelvic tilt) is necessary.Strengthening of the upper-mid back, neck, posterior shoulder and all muscle attaching to the shoulder blade (scapula) must be accomplished.Abdominal exercises must be added to the beginning of each program for optimal outcomes with postural support.Chair options are very necessary for this population. Many people with this posture work in chairs and need easy access to exercise they can do in their workplace chair. Also, some elderly people do not like to get on the floor for fear of not being able to get back up, supine positions induce vertigo or standing is too strenuous. 


Chair Version of Downward Boat Picture From Our Forward Head HEP Sheet 

Entire Program Available at 


Strengthening and stretching appropriate muscles to obtain neutral spinal alignment which supports proper head placement is the primary training emphasis for forward head. The exact muscles will vary from patient to patient depending on which maladaptive muscle patterns the patient uses. The typical stretching and strengthening components necessary to counter forward head are as follows. 

  1. Stretch internal rotators of the shoulder: pectoralis major, anterior deltoid, teres major, subscapularis, latissimus dorsi. Stretch pectoralis minor for improved scapular resting position. Low body stretches to counter poster tilt: hamstrings, psoas, gastric/soleous complex, plantar fascia. 

  1. Strengthen: all spinal extensors, rhomboids, entire trapezius. Strengthen shoulder external rotators: infraspinatus, teres minor, and rear deltoid.Low body strengthening: overall stabilizing L/E muscles.  

  1. Cervical:  

  1. Neck stretching and strengthening of cervical rotators, scalenes, levators and upper trapezius. 

  1. Stretching of mid-lower cervical flexors and upper cervical extensor muscles. This is the opposite of the forward head condition and counters the forward head scenario (Khayatzadeh, Kalmanson, Schuit, Havey, Voronov, Ghanayem, & Patwardhan, 2017). 

  1. Strengthening of mid-lower cervical extension muscles and upper cervical flexion muscles. This is the opposite of the forward head conditionand counters the forward head scenario(Khayatzadeh, Kalmanson, Schuit, Havey, Voronov, Ghanayem, & Patwardhan, 2017). 


Stork Picture From Our Forward Head HEP Sheet 

Entire Program Available at 


Taking into account the necessities of the previous muscle lists, the following yoga exercises were chosen: relaxed chest stretch, bridge, sphynx/cobra, downwardboat,rabbit, straddle with forward bend,stork, head lean, triangle/extended side angle and knee down spinal rotation. All muscle activities needed are encompassed by the totality of these yoga poses.During the choice process, great consideration was given to each exercise’s multiplicity potential for muscle activations to ensure the best results with the least amount of exercises. Sequencing was greatly considered for logistics (i.e. standing exercises together), psychological imprint (i.e. starting and ending with a relaxation exercise), and mobility work before stability work accommodations. The muscleneeds, listed in the previous research, are addressed several times with a variety of gravitational and stabilizing demands for improved and comprehensive outcomes.  

Table 1 














pectoralis major, anterior deltoid, teres major, subscapularis, latissimus dorsi 

relaxed chest stretch, bridge, downward boat, stork, triangle/extended side angle w/rot., knee down spinal rotation 




pectoralis minor, rhomboids, entire trapezius, levators, scalenes 

relaxed chest stretch, bridge, rabbit, stork, triangle/extended side angle, knee down spinal rotation 



hamstrings, psoas, gastric/soleous complex, plantar fascia 

bridge, straddle with forward bend, triangle/extended side angle, knee down spinal rotation 





mid-lower cervical flexors: sternocleidomastoid, anterior and middle scalene muscles 


upper cervical extensor muscles: semispinalis capitis, longissimus capitis, splenius capitis, suboccipital muscles 

bridge, sphynx/cobra, downward boat, rabbit, straddle with forward bend, stork, head lean, triangle/extended side angle 




lateral flexors:obliquus capitis superior, longus coli,rectus capitis lateralis, sternocleidomastoid, scalenus anterior, scalenus medius, scalenus posterior, upper trapezius 

triangle/extended side angle 





rotators:sternocleidomastoid, splenius capitis, splenius cervicis, 

longissimus capitis, semispinalis thoracis, semispinalis cervicis, semispinalis capitis, rectus capitis posterior major and minor, obliquus capitis superior, trapezius (upper) 

head lean w/rot., triangle/extended side angle, knee down spinal rotation 








infraspinatus, teres minor,rear (posterior) deltoid 

bridge, sphynx/cobra, downward boat, triangle/extended side angle 




all spinal extensors, rhomboids, entire trapezius, levators, scalenes 

bridge, sphynx/cobra, downward boat, head lean, stork, triangle/extended side angle 




generalized L/E jointstabilizing muscles.  

bridge, sphynx/cobra, downward boat, straddle with forward bend, stork, head lean, triangle/extended side angle 






mid-lower cervical extension muscles: splenius cervicis, semispinalis cervicis, longissimus cervicis 


upper cervical flexion muscles:longus capitis, suprahyoid muscles 

rectuscapitis anterior and rectus capitis lateralis 


bridge, sphynx/cobra, downward boat, straddle with forward bend, stork, head lean, triangle/extended side angle 


lateral flexors: obliquus capitis superior, longus colli, rectus capitis lateralis, sternocleidomastoid, scalenus anterior, scalenus medius, scalenus posterior, upper trapezius 

triangle/extended side angle 





rotators:sternocleidomastoid, splenius capitis, splenius cervicis, 

longissimus capitis, semispinalis thoracis, semispinalis cervicis, semispinalis capitis, rectus capitis posterior major and minor, obliquus capitis superior, trapezius (upper) 

head lean w/rot., triangle/extended side angle, knee down spinal rotation 











T (1-12) 

relaxed chest stretch, bridge, rabbit, triangle/extended side angle w/ rot., knee down spinal rotation 

Table 1,Reasoning for Yoga Exercise Choice 

In table 1, each of the necessary areas and actions are thoroughly addressed using many yoga exercises, with the exception of cervical lateral flexors. Forward head is a sagittal plane disfunction, thus the decreased emphasis on the lateral cervical flexors.In the previous research review of Palomeque-del-Cerro and colleges (2017), the splenius capitis (cervical extension, rotation, lateral flexor) muscle may play a role in dura mata health so lateral flexion is present in the program. The “kiss your shoulder” cue must be used with the triangle/extended side angle exercise to obtain lateral flexion strengthening and stretching.For a total neck muscle health program, we recommend adding additional lateral flexion yoga exercises. 



Extended Side AnglePicture From Our Forward Head HEP Sheet, “kiss shoulder” 

Entire Program Available at 


We established two separate formats from this list of yoga exercises. The first format follows traditional yoga interpretations of the poses. The second format was established with modified seated versions of the poses to improve patient compliance in the workforce and aging adult population. The forward head yoga home exercise program (HEP) handout with pictures and cues can be purchased in the “Clinic Materials” sections of website. 

The home exercise program is performed in the same order as the yoga exercises listed above. It begins with relaxation and passive chest/UE stretches and gradually progresses to moderate then more intense yoga exercises, ending with a relaxing yoga exercise. We believe this is an excellent home exercise program for the forward head population regardless of age.For the clinic, all clinic time may be billed as therapeutic activity or therapeutic exercise. Functional goals for therapeutic activity billing: 


Interesting Forward Head Functional Goals with Research 

  1. The patient will be able to swallow food during all meals without aspiration, by changing his forward head posture to a neutral cervical posture in four weeks.  

The chin pointing up position of forward head affects the suprahyoid muscle activity leading to aspiration (Goda, Hatta, Kishigami, Ikeda, & Yamada, 2017). 

  1. The patient will be able to hold his head in a neutral cervical position during ambulation to increase balance and decrease fall risk in six weeks.  

Forward head posture significantly affects standing balance as well as balance confidence and physical activity level. There is strong evidence to include forward head postural training into balance programs (Nemmers, & Miller, 2008). 

  1. The patient will decrease intermittent neck pain from 8/10 to 0-2/10 during a typical eight hour work day of typing in 8 weeks. 

Restoring neutral cervical spine alignment from forward head positioning may significantly reduce neck pain and increase quality of life as well as increase autonomic nervous system adaptability (Fedorchuk, Lightstone, McCoy, & Harrison, 2017). 

  1. The patient will decrease low back pain from 7/10 to 0-2/10 by using neutral cervical alignment (head retraction)strategies when lifting boxes from the floor at work in two weeks. 

Achieving neutral cervical alignment by retracting the head during lifting decreases lumbar spine flexion and increases trunk and sternocleidomastoid activation, thus lowering the risk of lumbar spine pain and injury (Rahnama, Abdollahi, Karimi, Akhavan, Arab-Khazaeli, & Bagherzadeh, 2017). 






Fedorchuk, C., Lightstone, D. F., McCoy, M., & Harrison, D. E. (2017). Increased Telomere Length and Improvements in Dysautonomia, Quality of Life, and Neck and Back Pain Following Correction of Sagittal Cervical Alignment Using Chiropractic BioPhysics® Technique: a Case Study. J Mol Genet Med, 11(269), 1747-0862. 

Goda, H., Hatta, T., Kishigami, H., Ikeda, T., & Yamada, S. (2017). The effect of a wheelchair designed to prevent forward head posture on swallowing duration and integrated electromyography of suprahyoid muscles. Integr Mol Med, 4(3), 1-5. 

Khayatzadeh, S., Kalmanson, O. A., Schuit, D., Havey, R. M., Voronov, L. I., Ghanayem, A. J., & Patwardhan, A. G. (2017). Cervical spine muscle-tendon unit length differences between neutral and forward head postures: biomechanical study using human cadaveric specimens. Physical therapy, 97(7), 756-766. 

McCarthy, M. M., & Hannafin, J. A. (2014). The mature athlete: aging tendon and ligament. Sports Health, 6(1), 41-48. 

McCrum, C., Leow, P., Epro, G., König, M., Meijer, K., & Karamanidis, K. (2018). Alterations in Leg Extensor Muscle-Tendon Unit Biomechanical Properties With Ageing and Mechanical Loading. Frontiers in physiology, 9, 150. 

Narici, M. V., & Maganaris, C. N. (2006). Adaptability of elderly human muscles and tendons to increased loading. Journal of anatomy, 208(4), 433-443. 

Nemmers, T. M., & Miller, J. W. (2008). Factors influencing balance in healthy community-dwelling women age 60 and older. Journal of Geriatric Physical Therapy, 31(3), 93. 


Neupane, S., Ali, U. I., & Mathew, A. (2017). Text Neck Syndrome-Systematic Review. Imperial Journal of Interdisciplinary Research, 3(7). 

Osakabe, T., Hayashi, M., Hasegawa, K., Okuaki, T., Ritty, T. M., Mecham, R. P., ... & Seyama, Y. (2001). Age-and gender-related changes in ligament components. Annals of clinical biochemistry, 38(5), 527-532. 

Palomeque-del-Cerro, L., Arráez-Aybar, L. A., Rodríguez-Blanco, C., Guzmán-García, R., Menendez-Aparicio, M., & Oliva-Pascual-Vaca, Á. (2017). A Systematic Review of the Soft-Tissue Connections Between Neck Muscles and Dura Mater: The Myodural Bridge. Spine, 42(1), 49-54. 

Rahnama, L., Abdollahi, I., Karimi, N., Akhavan, N., Arab-Khazaeli, Z., & Bagherzadeh, M. (2017). Cervical Position Sense in Forward Head Posture versus Chronic Neck Pain: A Comparative Study. Journal of Clinical Physiotherapy Research, 2(1), 39-42. 

Svensson, R. B., Heinemeier, K. M., Couppé, C., Kjaer, M., & Magnusson, S. P. (2016). Effect of aging and exercise on the tendon. Journal of applied physiology, 121(6), 1353-1362. 

Wang, M. Y., Sean, S. Y., Hashish, R., Samarawickrame, S. D., Kazadi, L., Greendale, G. A., & Salem, G. (2013). The biomechanical demands of standing yoga poses in seniors: The Yoga empowers seniors study (YESS). BMC complementary and alternative medicine, 13(1), 8. 




I'm Dr. Kim
Byrd-Rider, PT

In our Soul School at Firm Water Road, we are dedicated to helping people create healthy habits that can last a lifetime. Our program combines various modalities, including positive psychology, mystics, physics, and lifestyle medicine, to help our clients achieve optimal wellness. We specialize in Healthcare Workers, Military Members, School Teachers, and Students, but our holistic approach to wellness is beneficial for everyone. Let us help you achieve your health goals today.  Join us at or subscribe to the youtube channel

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