Health Articles

Improvement of Cervical Lordosis and Reduction of
Forward Head Posture with Anterior Head Weighting
and Proprioceptive Balancing Protocols

E. Stephen Saunders, D.C.1 Dennis Woggon B.S, D.C.2
Christian Cohen B.S. D.C.3 David H. Robinson, PhD.4

ABSTRACT
Background and Objectives: Evidence of the kinesiopathological
component of the vertebral subluxation complex
is frequently apparent in observation and assessment of posture.
Postural distortion from loss of the normal cervical lordosis
has been referred to as forward head posture (FHP) and
may precipitate pain, decreased ranges of motion and other
health problems. FHP can be quantified by measurement of
neutral lateral cervical radiographs. The objective of this study
was to determine if the use of head weighting and balancing
protocols could improve the cervical curvature and head carriage.
Methods: One hundred and thirty one patients from six Chiropractic
clinics in the United States, two in Canada and one
in the Russian Federation participated in the study. Study participants
were randomly selected and assessed with neutral
lateral cervical radiographs. These patients performed motion
activities while wearing three or five pounds of weight
on the front of their heads for five minutes then a weighted
stress lateral cervical film was taken.
Results: A comparison of the measured results from the two
films was made considering the cervical lordosis and FHP.
Average improvements in the cervical lordosis of 34% (p <
.0001) and in FHP 14mm (p < .0001) were noted after the
head weighting protocol was preformed with five pounds. Improvement
of cervical lordosis of 31% (p < .001) and in FHP
18mm (p < .0001) was recorded in a group using three pounds
of weight.
Conclusion: Head weighting may prove to be a useful therapeutic
tool in addressing FHP and the concurrent loss of the
normal cervical lordosis.
Key words: cervical lordosis, forward head posture, anterior
head weighting, proprioceptive retraining, wobble chair,
vertebral subluxation.
Introduction
The biomechanical ideal configuration for the human cervical
spine is a posterior concave arc or lordosis.1,2,3 This positions
the center of gravity of the skull over the mid cervical
vertebrae.4 The loss or reversal of the normal cervical lordosis
and attendant forward head posture has long been identified
with numerous consequential health problems5 including decreased
vital lung capacity,6 cervical, interscapular and headache
pain,7,8 and temporomandibular disorders.9 Many symptoms
may be moderated or eliminated by improving posture.10
Chiropractors and other health care professionals have attempted
to measure and correct these postural problems through spinal
adjustments and rehabilitative protocols. Successes in changing
forward posture through spinal adjusting and other therapeutic
activities have been reported but routine predictable
changes have not. Published opinion and unpublished clinical
research has suggested that purposefully attached external
weights can cause the body’s righting reflexes to react and correct
posture to a more ideal state.10,11 Proprioceptive balance
activities have been used therapeutically in recent times and
studies show that stimulation of sensory receptors in spinal ligaments
elicits reflex activity in the paraspinal muscles and contributes
to maintaining spinal stability.11,12,13 There are five righting
reflexes14 that relate to proprioception (orientation in time
and space). See Table 1, page 2.
To our knowledge, no literature exists that combines proprioceptive
activities with corrective external weighting protocols
to produce postural improvements that are measurable on
radiographs.
Methods and Materials
One hundred and thirty one patients from six Chiropractic
clinics in the United States, two in Canada and one in the Russian
Federation participated in the study. Eighty female and
1. Locum tenens, Seattle Washington
2. Private Practice St. Cloud, Minnesota
3. Private Practice Kankakee, Illinois
4. Professor and Chair, Department of Statistics, St. Cloud State University,
St. Cloud, Minnesota
Improvement of Cervical Lordosis J. Vertebral Subluxation Res., April 27, 2003 2
fifty-one male patients were tested. There ages ranged from 11
to 92 years. Patients were consecutively selected for the study
from the pool of incoming new patients in each field practice.
They were evaluated before any therapeutic intervention. Neutral
lateral cervical views were taken. Films were analyzed and
loss of the cervical curve measured, using Jackson’s Angles.2
George’s lines were extended down from the posterior margin
of the second cervical vertebral body and up from the posterior
margin of the seventh cervical vertebral body.15 The angle of
intersection of these two lines was measured. The loss of curve
was calculated by converting the angle to a percentage of loss
by ascribing 2.25 percent loss per degree less than the fortyfive
degree normal lordosis.2,16 Kyphotic curves were recorded
in percentages greater than 100% and double or triple buckled
curves had the separate percentage losses added together.14 Forward
head posture was calculated by measuring the distance
between the anterior quarter of the C4 - C5 inter-space and a
gravity line that was constructed perpendicular to the superior
border of the film that bisected the anterior margin of the sella
tursica.4
Patients were then fitted with a five- pound anterior head
weight made up of chilled lead shot in a cloth headband. Participants
in the Russian federation used 1500 grams or approximately
three pounds of weight. The headband was velcroed
securely around the head with the weight over the frontal and
temporal bones. The patient wore this weight while seated on a
proprioceptive training chair, The Wobble Chair.™ The chair
seat is freely movable on a pivotal axis and allows 20 degrees
of pivot off its vertical center, to each point of the compass.
The chair allows 360 degrees of rotation. Each patient was
instructed to rock backward and forward, from side to side and
rotate in circular motions while on the chair. They were instructed
to look straight ahead and keep their head and shoulders
relatively still while performing these maneuvers. After
the subject was timed, continuing these activities for five minutes,
a neutral lateral stress radiograph was taken while the patient
continued wearing the head weight. This weighted view
was analyzed in the same manner as the neutral view and the
results were compared. Thirty of the study participants x-rays
were consecutively sampled and lines were drawn parallel with
the hard palate and the bite line. These were then compared to
the edge of the film in the initial and subsequent radiographs to
determine if the patient’s head and cervical spine were in the
neutral position.18
Table 1: The Five Righting Reflexes
Labyrinthine (inner ear) maintains the head’s orientation in
space (medulla)
Optic (ocular) keeps the head in proper
orientation to its gravitational
environment (occipital cortex)
Neck righting (joints of keeps the body orientated to the
reflex the neck) head (medulla).
Body righting (body surface orientates the body in space
reflex receptors) (medulla).
Body righting keeps the head, oriented to the
reflex #2 body (midbrain).
Patient performs proprioceptive exercises on Pettibon Wobble
Chair™ with five pounds of anterior head weight for five minutes.
Results
The average loss of the cervical curve was 94% in the North
American cohort. 35 of the 97 subjects had kyphotic or kyphotic
S curves of the cervical spine. Forward head posture
averaged 1.2 inches or 31mm for the 97 subjects. Average loss
of curve was 76% in the smaller sample from the Russian Federation.
FHP averaged 30mm or 1.1 inches in this smaller
sample. Films taken after the proprioceptive training activity,
with the subjects weighted, demonstrated average loss of curve
improved from 94% to 58% loss, a 34% improvement, in the
North American study group.
A paired t-test showed this improvement to be highly significant
in a statistical sense (t = 7.20, p < .0001). Data from
the Clinic in Vladivostok identified average improvements from
76% loss of curve to 45% loss of the cervical lordosis, a 31%
improvement. A paired t-test showed this improvement to also
be highly significant in a statistical sense (t = 3.92, p < .001).
Forward head posture improved from an average of 31 to 17
mm, for a total of 14 mm improvement of anterior head translaImprovement
of Cervical Lordosis J. Vertebral Subluxation Res., April 27, 2003 3
Discussion
Case reports in the chiropractic literature have demonstrated
positive changes in the cervical lordosis as a result of specific
chiropractic care. Wallace et al have reported a close association
between changes in the cervical curve and decreased subjective
symptoms.17
A comparison of the data from the North American sites and
the Russian Federation revealed a surprising consistency and
has suggested that there is a range of weight that produces beneficial
changes. Prior to the trial, clinical observations had suggested
that three pounds was insufficient to produce the desired
changes in individuals with significant degenerative joint
disease in the cervical spine. Due to the fact that the Russian
participants were younger and with less pathology, this may
suggest utilizing a 3-pound head weight on a non-pathological
cervical spine and a 5-pound head weight where osteoarthritic
degenerative changes are present. The amount of the weight
may also be varied based on patient strength, stature and comfort.
One subject demonstrated a significant worsening of the
lordosis and the magnitude of forward head posture. It is speculated
that this individual was of slight stature and with her relatively
small muscle mass, the cervical spine buckled with the
five-pound weight.
An important and pertinent finding from this study was that
the changes in the cervical curve and forward head posture were
produced within five minutes without any other therapeutic intervention
other than the proprioceptive activity while wearing
the head weight. The study did not evaluate whether the changes
were apparent after the subject removed the head weight or
whether the protocol produced lasting changes. Further study
is necessary to evaluate these questions.
It was also noted that the kyphotic and kyphotic S-curved
necks responded better than a lordotic S-curve or a hypolordotic
curve. It is unknown why individuals with kyphotic or kyphotic-
S curves showed such large improvements during the
head weighting protocol. This may simply be a product of the
magnitude of the percentage loss of curve calculated in the kyphotic-
S configurations. It may represent rapid adaptation to
the imposed demands of the weight with an unstable spine and
demonstrate the spines ability to alter structure to a more efficient
configuration.
It is proposed that external head weighting is based on adaptive
principals, forcing the body to react in ways that produce a
more optimum posture. The frontal head weight imbalances
the skull, which in turn activates the extensor muscles that then
cause the front of the skull to rotate upward. The upward rotated
skull causes the optic and labyrinthine righting reflexes as
well as the mechanoreceptors and body surface receptors to
bring the optic righting reflex in line with the horizon by activating
the cervical flexor muscles.
Conclusions
Anterior head weighting combined with proprioceptive retraining
activities produced significant and immediate improvements
in forward head posture in a sample group. The encouraging
initial results demonstrate large improvements in static
posture. This suggests that these simple therapeutic protocols
tion in the American cohort. A paired t-test showed this improvement
to be highly significant (t = 13.11, p < .0001). The
Russian sample showed an average of 18 mm improvement,
again highly significant (t = 8.50, p < .0001). The sample of
thirty patients in the American cohort showed an average change
of 2.70 degrees of the hard palate angles from the non-weighted
to the weighted x-rays. This verifies that there was good consistency
with patient positioning.
Further investigation of the relationship of the percentage
loss before and after the training activity continued by examining
the scatterplot of the two % loss variables in the American
cohort. The graph of the 97 subjects is shown in Figure 1.
The patients plotted in the lower right-hand corner of the
graph experienced the greatest improvement (reduction) in %
loss. These are some of the 35 patients exhibiting kyphotic or
kyphotic S curves of the cervical spine. The North American
cohort was then separated into two subgroups. Group 1 was
the 35 subjects with kyphotic or kyphotic S curves (% loss
greater than 100), while Group 2 were the 62 subjects not exhibiting
this condition. (In Figure 1, Group 1 is all points on
the right side and Group 2 is all points on the left side.) Table 2
summarizes the statistical information from the two groups.
Table 2: North American Cohort (training with 5 lb)
Group 1 Group 2 Overall
N = 35 N = 62 N = 97
Before training, Mean % Loss 166% 54% 94%
(Std Error of Mean) (6%) (3%) (6%)
After training, Mean % Loss 93% 39% 58%
(Std Error of Mean) (8%) (4%) (5%)
Separate t-tests were run on the two groups to see if each
group exhibited significant improvement. For Group 1, the
average loss of curve improved from 166% to 93%, a 73% improvement.
The paired t-test showed this to be a highly significant
improvement (t = 7.53, p < .0001). For Group 2, the average
loss of curve improved from 54% to 39%, a 15% improvement.
The paired t-test showed this to also be a highly significant
improvement (t = 4.50, p < .0001). There was no significant
difference in age or gender composition between the two
groups.
Improvement of Cervical Lordosis J. Vertebral Subluxation Res., April 27, 2003 4
31 mm. to 15 mm. 1.2" to .6" 196% to 52%
61mm. to 31mm. 2.4" to 1.2" 134% to 89%
32 mm. to 15 mm. 1.3" to .6" 41% to 7%
20 mm. to 0 mm. .8" to 0" 74% to 32%
(Note Harrington Rod)
69 mm. to 23 mm. 2.7" to .9" 211% to 70%
may be recommended to patients with health problems related
to forward head posture and combined with traditional adjusting
approaches to produce significant postural improvements.
These inexpensive, low-tech activities can be administered as
active care protocols that, after coaching, can be performed by
patients without provider supervision at home. Additional studies
are needed to determine the long-term effects of this adjunctive
rehabilitation to ascertain if this protocol makes lasting
changes to the posture and function of the spine.
Improvement of Cervical Lordosis J. Vertebral Subluxation Res., April 27, 2003 5
Acknowledgments
This study utilized data submitted by Gary C. Lawrence D.C.,
Stillwater Minnesota; David W. Butler B.E.S., D.C., Alexandria
Minnesota; Ian J. Horseman D.C., Toronto Canada; Martin
K. Kuwamoto D.C., Fresno California; William A Watt D.C.,
Sundre Canada; Michael L. Milasich.D.C., Tacoma Washington,
Jeffrey A. Cronk D.C., Seattle Washington and St. Cloud
Chiropractic Clinic, St. Cloud MN. Alexey Ushkov M.D. and
his colleagues made a substantial contribution from "Spine" the
Regional Center for Chiropractic in Vladivostok, Russia. The
Chiropractic Leadership Educational Advancement and Research
Institute in St. Cloud Minnesota funded consulting fees
for David H. Robinson PhD for statistical analysis.
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