Variability of the Forward Head Posture in Healthy Community-dwelling Older Women

Journal of Geriatric Physical Therapy, 2009 by Nemmers, Theresa M, Miller, Janice Williams, Hartman, Merrillyn D

ABSTRACT

Purpose: The purpose of this research was to describe the variability of forward head posture in healthy older women, and to investigate the influence of age on variability.

Methods: This cross-sectional descriptive study included 187 healthy community-dwelling women volunteers ranging in age from 65-96 years. The forward head posture (FHP) measurement was derived from a sagittal photograph. The subjects were asked to perform a series of standing activities, and the photograph was taken while the subjects were performing these activities. Data analysis included descriptive analysis, FHP measurement analysis for normalcy, one-factor ANOVA with FHP by age group, post-hoc Tukey analysis, and trend analysis for the age-FHP relationship.

Results: Three age-group normative FHP means were identified: 48.84� (SE 0.97) for the 65-74 year old group, 41.20� (SE 0.78) for the 75-84 year old group, and 35.60� (SE 1.76) for the 85 year group. Significant differences were found in the FHP between these age groups. A subsequent trend analysis demonstrated a linear relationship between age and the FHP, with older women demonstrating a more severe FHP.

Conclusions: Age-associated variability in the FHP of healthy elderly women has been identified. The FHP values determined by this research may serve as normative guidelines for clinicians when conducting postural assessments, and in clinical decision-making regarding possible interventions.

Key Words: forward head posture, older women, posture variability

INTRODUCTION

Postural deviations among aging adults are often attributed to age-associated changes, and occasionally to gender-associated differences.1-3 Age-associated changes in posture have been frequently described by a cluster of postural deviations that includes a forward head, rounded shoulders, changes in lumbar lordosis, and increased flexion in the hips and knees.1,2 These age-associated postural changes may be attributed to age-related biological and physiological changes, functional or pathological causes, or a combination of these changes.3,4 Clinicians often based their postural assessments upon the standard "ideal" posture as defined by Kendall and associates.1,2,5 The physical therapist's decision to provide therapeutic intervention measures for impaired posture is then typically based upon the amount of variation from "normal" posture. Research literature, however, suggested that asymptomatic individuals demonstrated a range of normal values for posture rather than a single fixed point of reference, and that posture changes in asymptomatic adults may be associated with aging and with gender.6'9 While standard geriatric reference textbooks provided normative values for aging adults in various aspects of the geriatric assessment, there was a distinct absence of normative values relating to posture variables in general, and to the forward head posture specifically.1-3

The forward head posture (FHP) places the head anterior to the vertical ideal as defined by a plumb line measure.5 Kendall and associates indicated that the deviation of the head relative to the ideal plumb line posture should be considered faulty and should be measured in terms of slight, moderate, or marked.5 This type of analysis would suggest that any deviation from the ideal represents an abnormal state, and does not afford an objective and quantifiable measure of the postural deviation. Researchers have described normal head posture in asymptomatic adults using a range of measured values rather than a distinct point,6"9 suggesting that simply having the head anterior to the vertical ideal may not be a pathological condition but rather may be representative of the variation found in the normal population.

Varying methodologies in measuring head postures make direct comparisons of some existing studies difficult.10-14 However, several studies6-9,15,16 have used a similar measurement methodology as described by Braun and Amundson,17 which incorporated a tragus-seventh cervical spinous process(C7)horizontal angle measurement to define the head position in the sagittal plane. Using this measurement, a smaller tragusC7-horizontal angle indicated a more severe forward head position.

Most of the available data regarding the FHP ranges were drawn from small samples of young adults. These small (n

Age-associated differences were identified by Raine and Twomey8 in a study which included a 55 age group with an age range of 55 to 81 years. Although these investigators used the tragus-C7-horizontal angle as the measure of the forward head posture, they reported the measured angle value as the supplementary angle to the technique of Braun and Amundson.17 The average FHP value reported by Raine and Twomey for the 55 group was 131.1� (SD 6.5�).8 By reverse scaling this value to match the angle measure described by Braun and Amundson,17 the average FHP in the Raine and Twomey study was 48.9�. The average value of the older age group differed significantly from younger age groups, suggesting that older adults demonstrated a more acute FHP.8 Hanteen and associates10 did not find age-associated differences in their analysis of total head flexion/extension excursion and resting head posture in 214 subjects. However, these researchers included only individuals under the age of 60. This finding may suggest that age does not play a role in head posture variation until later in adulthood.