Relationships Between Forward Head Posture
and Lumbopelvic Sagittal Alignment in Older
Adults with Chronic Low Back Pain

This section is compiled by Frank M. Painter, D.C.
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FROM:   J Bodywork & Movement Therapies 2021 (Oct); 28: 150-156 ~ FULL TEXT


Aliaa M Elabd, Omar M Elabd

Basic Science Department,
Faculty of Physical Therapy,
Pharos University
Alexandria, Egypt.

Background:   Abnormal posture creates abnormal stress and strain in many spinal structures which are considered predisposing factors for chronic mechanical low back pain.

Purpose:   To examine the relationships among pain intensity, forward head posture (decreased craniovertebral angle) and lumbopelvic sagittal alignment (pelvic incidence, pelvic tilt, sacral slope, and lumbar lordosis) in chronic mechanical low back pain patients.

Methods:   A cross-section correlational study was conducted on one hundred patients. A numerical-pain-rating scale was used to determine pain intensity. Standardized standing lateral radiographs were analyzed to measure the spinopelvic angles. Reported data were analyzed using correlation coefficients, and regression analyses.

Results:   Lumbar lordosis had very strong positive correlations with each pain intensity and sacral slope. Pain intensity had a strong positive correlation with sacral slope. Moderate positive correlations highlighted between pelvic tilt and craniovertebral angle. Moreover, the pelvic incidence had weak positive correlations with each sacral slope and pelvic tilt. Negative correlations were strong between pelvic tilt and each of pain intensity, lumbar lordosis and sacral slope. Craniovertebral angle had moderate negative correlations with each of pain, lumbar lordosis, and sacral slope. However, the pelvic incidence had no relations with pain, craniovertebral angle lumbar lordosis. Overall, an association of demographic data and measured variables had a significant effect on the pain multi-regression equation prediction model. They accounted for 76.60% of the variation in pain.

Conclusion:   Abnormal spinopelvic posture relates to chronic mechanical low back pain. There are significant associations among pain intensity, FHP and lumbopelvic sagittal alignment in chronic mechanical low back pain patients.

Keywords:   Chronic low back pain; Head position; Lumbosacral Region; Postural Balance.

From the FULL TEXT Article:


Low back pain (LBP) is one of the most enormous and challenging disorders (Vassilaki and Hurwitz, 2014). LBP represents a leading cause of disability worldwide and the second cause of medical consultations. Moreover, between 5.0% and 10.0% of LBP patients will develop chronic LBP (Izzo et al., 2015; Meucci et al., 2015).

Mechanical Low Back Pain (MLBP) is the general term that refers to any type of back pain caused by placing abnormal stress and strain on muscles and soft tissues of the vertebral column. Typically, Chronic Mechanical Low Back pain (CMLBP) results from bad habits, such as poor posture. It incorporates a complex aetiology and numerous related risk factors. Difficulty of understanding its cause may limit its treatment (Delitto et al., 2012; Herndon et al., 2015; Will et al., 2018). Furthermore, centering on pathoanatomy as an etiological factor of CMLBP and ignoring the significant part of dysfunction may be related to common challenges the clinicians face in its management (Ting et al., 2015).

Abnormal posture creates abnormal stress and strain in many spinal structures which are considered predisposing factors for pain (Dolphens et al., 2012; Lee et al., 2015). Spino-pelvic sagittal alignment activates a chain of spinal responses; the shape and orientation of any fragment influence the adjoining portion to preserve a steady posture with minimal energy consumption (Berthonnaud et al., 2005). Thus, sagittal spinopelvic parameters are useful to be considered for the management of CMLBP (White and Panjabi 1990; Vialle et al., 2005; Nakipoglu et al., 2016). In patients with Forward Head Posture (FHP) when the head is in a front position in relation to the hypothetical plumb line indicated by small Cranio-Vertebral Angle (CVA), increased strain is placed upon the muscles of the head, neck, and shoulders resulting in joint dysfunctions and abnormal afferent information (dysafferentation) (Grod and Diakow 2002; Yip et al., 2008).

Moreover, many postural reflexes are located or occur in the head and neck region. Thus, subjects with FHP possibly have a problem with the repositioning sense and neurologic regulation of static upright posture. Pelvo-ocular reflex controls the neuromotor response of the pelvic girdle and lower to orient the body region in response to head position and anticipatory visual cues. If the head is placed too far in front, the pelvis will tilt anteriorly to balance the center of gravity (Morningstar et al., 2005).

The abnormal lumbopelvic sagittal arrangement is one of the foremost important etiological components related to LBP (Chal–eat-Valayer et al., 2011). Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), and Lumbar Lordosis (LL) are the most common parameters used to indicate sagittal lumbopelvic arrangements (Chun et al., 2017; Tatsumi et al., 2019).

Pelvic incidence denotes the sacral plate position with the femoral heads. It is a unique structural anatomical feature to each individual regardless of its position. The angle of PI is the algebraic sum of them (Le Huec et al., 2011). PT determines the spatial orientation of the pelvis that varies according to the position. PT increases when the pelvis rotates backward (retroversion); when the pelvis rotates forward (anteversion), PT decreases. When PT increases, the sacral plateau becomes increasingly horizontal, while the body of the sacrum becomes vertical. Further, Lumbar Lordosis (LL) refers to inward curvature of the lumbar spine and it is directly proportional to SS (Le Huec et al., 2011).

Given and the importance of lumbopelvic sagittal alignment parameters in the management of CMLBP (Chal–eat-Valayer et al., 2011; Tatsumi et al., 2019), There is a gab of evidence to examine the relations between FHP and lumbopelvic sagittal alignment in patients with CMLBP in spite of the high incidence of FHP (Worlikar and Shah 2019) and its importance for the treatment of CMLBP (Elabd et al., 2020). Thus, this study was conducted to examine the relationships among FHP and lumbopelvic sagittal alignment parameters (SS, PT, LL, and PI) in older adult patients with CMLBP.

Materials and methods

      Design of the study

A cross-section correlational study was conducted to examine the relationships among studied variables (back pain intensity, craniovertebral angle as an indicator of FHP, and lumbopelvic sagittal alignment parameters (LL, SS, PT and PI). This study was conducted in understanding with the 1964 Helsinki affirmation and related afterwards corrections, affirmed by the research ethics committee of the Faculty of Physical Therapy. Participation was voluntary and written consent was gotten from each participant before inclusion in the study.


Patients with CMLBP ranged in age from 40 to 55 years were the focus of this study. They all were diagnosed by an orthopaedist with CMLBP and had FHP. After the general invitation, a total of 135 subjects participated in the baseline survey. They received a standardized physical examination (Nelson 1991) and were screened for eligibility criteria by the first author who has more than 10 years' experience.

Inclusion criteria were CMLBP with symptoms lasting longer than 3 months duration, mild to moderate disability concurring to the Oswestry Disability Index (up to 40%), and Cranio-Vertebral Angle (CVA) less than 50. Exclusion criteria were: Current physical therapy or medical treatment for LBP, contracture or surgery affecting the lumbar spine, scoliosis, pathologies such as inflammatory diseases, skin diseases, congenital diseases, neurological diseases, dislocations, neoplasms, disc prolapse, and visual or auditory problems.

From 135 subjects who participated in the baseline survey, 35 subjects were excluded due to various causes (19 subjects did not fulfill the inclusion criteria, 12 subjects were excluded due to current treatment for LBP, and four subjects refused to continue). Finally, one hundred patients (mean ± SD age, 27.08 ± 5.21 years; BMI, 26.96 ± 2.04; 46 males and 54 females) satisfied the eligibility criteria, and signed the consent form, participated in the study after full explanation about the study procedure and risks.


The examined variables included lumbopelvic sagittal alignment parameters (LL, SS, PI, and PT) pain intensity, and CVA. Toshiba Rotande unite model DRX3724 HD/2009 was used to obtain standardized lateral views radiographs in a neutral standing position for the whole spine. The same distance was kept between each subject and the source of radiography. Views were analyzed using the reliable and valid AutoCAD software (version 2017); to examine intra-rater reliability for current study measurements, analyzed through AutoCAD software, the radiographs of 8 patients were analyzed twice by the same assessor with one week time interval. All measurements exhibited excellent intra-rater reliability (ICC ranged from 0.83 to 0.98). AutoCAD has the property to measure both angular and linear parameters, snapped the points, draw the perpendiculars, determine the mid between two points. So, planes and points were obtained easily and variables could be measured precisely (Eslam 2012; Cohen et al., 2017).

Lumbar lordosis was measured from the L1upper endplate to the L5 lower endplate. This angle has excellent inter-rater and intrarater reliability (ICC = 0.98 and 0.97 respectively) (Hicks et al., 2006; Lee et al., 2013). SS was measured as the angle between the horizontal plane and the sacral plate, angle of PT was measured between the gravity line, and the line connecting the midpoint of the sacral plate to the axis of the femoral heads. The angle of PI was measured between the perpendicular line to the sacral plate at its midpoint and the line connecting that point to the middle axis of the femoral heads (Endo et al., 2012) (Fig. 1). These measurements have excellent inter-rater reliability (ICC = 0.84, 0.92, and 0.78 respectively) and intra-rater reliability (ICC = 0.93, 0.86, and 0.89 respectively) (Kyr€ol€a et al., 2018).

The craniovertebral angle was measured between the line from the external auditory meatus to the seventh cervical vertebra and a horizontal line through the seventh cervical vertebra (Fig. 2). CVA measurement in radiographs proved reliable and has been considered as an accurate indicator of FHP (ICC = 0.99 for interrater and intra-rater reliability) (Gadotti et al., 2013). Finally, the intensity of back pain was measured by the Numerical Pain Rating Scale (NPRS) (range, 0 representing no pain to 10 representing most extreme pain). NPRS has shown high correlations with other pain assessment tools. The feasibility of its use has also been proven (Farrar et al., 2001; Childs et al., 2005; Hjermstad et al., 2011).

      Statistical analysis

Reported data were analyzed utilizing Statistical Package for Social Sciences (SPSS) computer program (version 23) (Charles R Flint, New York, USA). Spearman ranked correlation coefficients were computed between the dependent variable (pain) and 5 independent variables (LL, PT, PI, SS, and CVA). Pearson correlation coefficients were computed between each other of 5 variables. They were placed in five categories; (1) 0.00 to 0.19: very weak, (2) 0.20 to 0.39: weak, (3) 0.40 to 0.59: moderate, (4) 0.60 to 0.79: strong and 0.80 to 1.0: very strong (Chanplakorn et al., 2012). Moreover, simple and multiple regression analyses were conducted to determine the best fit model regression equation. Statistically, significance was set when p < .05.


Subjects' demographic characteristics and measured variables are summarized in Table 1. The correlation matrix among the measured variables is shown in Table 2. Pain intensity had a very strong positive correlation with LL (r(98) = 0.82, p < .001) and a strong positive correlation with SS (r(98) = 0.78, p < .001). Moreover, it has a negative strong correlation with PT (r(98) = –0.76, p < .001) and a negative moderate correlation with CVA (r(98) = –0.59, p < .001). However, no significant correlation was found between pain intensity and PI (r(98) = 0.10, p < .32).

There was a very strong positive correlation between LL and SS (r(98) = 0.83, p < .001). Further, there were a negative strong correlation between LL and PT (r(98) = – 0.78, p < .001) and a negative moderate correlation between LL and CVA (r(98) = –0.54, p < .001). However, there was no significant correlation between LL and PI (r(98) = 0.17, p = .098). PT had a negative strong correlation with SS (r(98) = – 0.74, p < .001), a positive weak correlation with PI (r(98)= 0.25, p= .012), and a positive moderate correlation with CVA (r(98) = 0.57, p < .001). In contrast, PI had a significant weak positive correlation with SS (r(98) = 0.38, p < .001) without correlation with CVA (r(98) = 0.15, p = .149). Further, the correlation between SS and CVA was negatively moderate (r(98) = – 0.43, p < .001).

Simple linear regressions were not significant to predict pain, FHP, and lumbopelvic sagittal alignment parameters based on demographic data (p > .05). However, those calculated to predict pain intensity based on FHP and lumbopelvic sagittal alignment parameters revealed that LL accounted for 67.40% of the variation in pain [pain = –11.339 + 0.303 (LL)]; LL extra degree causes a 0.330 increase in pain. PT accounted for 60.80% of the variation in pain intensity [pain = 13.567–0.576 (PT)]; an extra degree of PT results in a 0.576 decrease in pain. Further, SS accounted for 56.30% of pain variation [pain = –11.331 + 0.491 (SS)]; SS extra degree increases pain by 0.491. Similarly, CVA accounted for 44.70% of pain variation [pain = 18.516–0.305 (CVA)]; an CVA extra degree decreases pain intensity by 0.305. In contrast, no significant regression prediction model was found due to the relation between pain and PI (Table 3; Fig. 3).

Multiple regression equation was significant between dependent variable (pain) and independent variable (demographics with LL); they accounted for 68.50% of pain intensity variation [pain = 858.287–0.06 (age) + 0.421 (weight) e 41.946 (height) –1.123 (BMI) + 0.308 (LL)]. Moreover, demographics and PT accounted for 61.60% of pain variation [pain = 92.298–0.014 (age) + 0.500 (weight) – 46.907 (height) –1.386 (BMI) –0.581 (PT)]. Similarly, demographics with SS accounted for 56.70% of the variation in pain. [pain = 33.097e0.011 (age) ώ 0.276 (weight) – 26.921 (height) – 0.734 (BMI) + 0.494 (SS)]. Additionally, CVA with demographics accounted for 44.90% of pain intensity variation [pain = 28.886–0.010 (age) + 0.074 (weight) – 5.360 (height) – 0.244 (BMI) – 0.306 (CVA)]. In contrast, demographics with PI had no significant multiple regression prediction model for pain (Table 4).

Overall, association of demographic data, FHP, and lumbopelvic sagittal alignment parameters had significant effect on pain multi regression equation prediction model. They accounted for 76.60% of the variation in pain [pain = 66.905–0.020 (age) + 0.410 (weight) – 39.153 (height) –1.138 (BMI) + 0.143 (LL) + 0.024 (PT) – 0.237(PI) + 0.330 (SS) – 0.080 (CVA)] (Table 4).


In spite of growing knowledge and medical development pertaining to spinal disorders, CMLBP remains one of the foremost exorbitant and predominant wellbeing problems worldwide (Izzo et al., 2015; Meucci et al., 2015). To the best of our knowledge, it is the first study conducted to examine the relationships among back pain intensity, FHP (decreased CVA), and lumbopelvic sagittal alignment parameters (LL, SS, PT, and PI) in CMLBP patients. The results suggested the importance of dysfunction such as faulty posture and not just lumbosacral pathoanatomy in CMLBP. Further, spinal posture should be considered globally with special consideration to head posture for the management of CMLBP.

The results highlighted the association between LBP intensity and spinopelvic sagittal alignment; back pain may be increased in patients with FHP and in patients with increased LL or SS and/or decreased PT. Moreover, the results suggested that spinal parameters are interdependent. An alteration in one fragment is associated with an alteration in the reciprocal fragment; FHP is associated with increased LL, increased SS and decreased PT. Furthermore, patients with hyperlordosis may have increased SS and decreased PT.

Our results agree with the previous studies that revealed strong correlations between pelvic morphology (PI) and pelvic orientation (PT and SS), and between pelvic orientation and LL in LBP patients (Chal–eat-Valayer et al., 2011; Berglund et al., 2018). Further, strong interdependence has been confirmed between the pelvis and the lumbar spine to maintain a well-balanced posture (Chanplakorn et al. 2011, 2012). Moreover, the relation between LL and SS was described previously; the more the SS, the more the LL (dynamic back). Horizontal SS was associated with flat lumbar curvature (static back) (Stagnara et al., 1982).

Postural alteration is considered as one of the LBP risk factors. Altered posture may create a strain on the muscles and ligaments that may affect lumbar spine curvature. Changing in LL depends on the back muscles, abdominal muscles, and pelvic/back ligaments. Changes in LL may have an effect on the management of LBP. It influences the planning of an appropriate exercises program for the abdominal or back muscles (Evcik and Yόcel 2003).

The cervical spine has an imperative role in the whole spinal alignment (Grod and Diakow 2002; Lee et al., 2015). When the head position moves forward away from the body's vertical pivot, increased strain is set upon the muscles of the head, neck, and shoulders leading to abnormal afferent inputs dysafferentation). Reflexive involuntary control contributes to posture maintenance. Many postural reflexes occur or located in the region of the head and neck (Seaman and Winterstein 1998; Morningstar et al., 2005).

Another explanation for FHP as a direct cause of dysafferentation may be that the resultant lack of bloodstream caused by increased strain put upon different spinal muscles forces the muscle to rely on anaerobic metabolism. Metabolites may build up causing excitation of chemo-sensitive pain receptors, and nociceptive afferent information which may result in dysafferentation (Seaman and Winterstein 1998).

Alterations in spine sagittal alignment may be credited to the strong relationship that exists between FHP and pelvo-ocular reflex. This reflex causes an anterior pelvic translation to balance the head's center of mass. Changes in sagittal spinal arrangements have been associated with modifications in pelvic orientation (Comerford and Mottram 2001; Roussouly and Pinheiro-Franco 2011). Similarly, a previous study has suggested that body segment relocation may cause a shift in the center of mass. Thus, the line of gravity shifts in relation to the base of support (Levangie and Norkin 2005).

In the same regard, a correlation was found between changes in cervical lordosis and health-related quality of life improvements in thoracolumbar deformity patients (Protopsaltis et al., 2015). Thus, we agree with the previous studies that highlighted the importance of FHP correction for the management of spinal disorders (Elabd et al., 2020; Moustafa and Diab 2015). Moreover, consideration of the subject-specific spinal sagittal organization should be an important part of the mechanical analysis of the lumbar spine because the spinal alignment may affect the location and magnitude of the load on the spinal components and also may alter the load-sharing and kinematics (Naserkhaki et al., 2016).

In contrast to our findings, a previous study reported minor importance of postural abnormalities (Christensen and Hartvigsen 2008). Moreover, another study was unable to reveal differences between the radiological values for spinal sagittal alignment in LBP patients. Any contradictory results in the previous studies might be due to a lack of uniform classification and measurement (Nakipoglu et al., 2008).

      Limitations of the study

Our study did not include a control group of asymptomatic subjects, thus it may not represent data of the whole population. Moreover, it was not a longitudinal study. Another limitation was the difficulty to exclude the influence of muscles condition. Further, only the sagittal alignment was examined without consideration of frontal or transverse plane parameters. Additionally, measurements were obtained only from the standing position without consideration of the sitting position.


This study has provided objective evidence that dysfunction such as faulty posture and not just lumbosacral pathoanatomy relates to low back pain. Significant associations have been established among pain intensity, FHP and lumbopelvic sagittal alignment parameters in patients with CMLBP. Back pain may be increased in patients with FHP and in patients with increased LL or SS and/or decreased PT.

Clinical relevance

  • Dysfunction such as faulty posture and not just lumbosacral pathoanatomy should be considered during the management of chronic low back pain.

  • Patients with FHP may have a high risk for developing of low back pain.

  • Patients with increased lumbar lordosis or sacral slope and/or decreased pelvic tilt may have a high risk for developing of low back pain.

  • Human spine should be considered globally rather than segmentally.

  • Cervical posture correction should be considered during the management of low back pain.

Funding support

This research received no grant from any funding agency

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


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