“Text neck” is a term used to describe neck pain from looking down at your mobile phone too frequently or for too long. Recently there has been a lot of coverage describing “text neck” as a public health issue. Is there any evidence to back this claim up?
Debunking “text neck” with Science has been done very well before here, here, and here. This article will outline the arguments used by believers of “text neck” when they attempt to refute the latest evidence.
By breaking down these arguments, we can see whether they are good or not. This in turn will allow you to determine what explanation is most likely to be true, this will then allow you to choose the best treatment intervention to help your patients with neck pain.
Not only will this help you get better results with your patients but it will also help improve your reputation as you help your patients both short-term and long-term with their pain and activity levels.
The argument made in support of “text neck” can be summarised as follows:
More people are using mobile phones.
There has been an increase in the prevalence of neck pain.
When people use their phone they have a more forward head posture.
A forward head posture may increase the mechanical load on the muscles, joints and ligaments of the neck.
Therefore, using a mobile phone increases your risk of developing neck pain which may result in irreversible damage.
In a word, no. A great article has already been written outlining the bad science and fear mongering of “text neck” which you can read here but to summarise:
These good arguments should be enough for any good critical reasoning Physiotherapist to move on and apply their focus on what is more likely to work for neck pain. However, some Physios find the cognitive dissonance hard to take and will often counter with more arguments which reject the science.
Here are the most common arguments that people give when shown the science refuting “text neck”:
A Physio’s job is to get patients back to normal.
Forward head posture is not normal.
Therefore a Physio’s job is to correct forward head posture.
One of the primary roles of a Physio is to help their patient in pain to improve their pain tolerance and movement. Really good Physios will even try to encourage their patients to address lifestyle factors with the idea of minimising the risk of their pain coming back.
Although it may be well intentioned, encouraging patients to fix “abnormal” posture is a poor choice of intervention.
The first problem with idea fixing abnormal posture is defining what “normal” posture is as there is no gold standard. Although very similar, humans possess an amazing amount of individual variance and despite some textbooks attempting to define normal, this is based on nothing more than guesswork.
The Appeal to Normality fallacy is when people use social norms to determine what is good or bad, based on the assumption that these social norms are the standard of goodness.
In the Physiotherapy world, the “normal” postures outlined in textbooks are what many Physios assume to be the standard of goodness. This is fallacious because these social norms are not based on Science nor are they based on the norms that are synonymous with the ideal function of a system, in this case, the patient.
Therefore in Physiotherapy, “normal” may be better defined as the ideal function of a system, the patient i.e. what does the patient need or want to be able to physically do that they cannot currently do because of their pain.
If it’s normal for them to walk 2 miles a day, then that is the “normal” we should be helping them to achieve. Or perhaps they have a sore shoulder and they aren’t sure what normal is, we can use their good shoulder’s level of function as a reference for their normal.
These are the norms which are synonymous with the ideal function of the patient as defined by them, not you.
It may also be wise to influence their norms by selling them the benefits of being more active in line with the WHO recommendations whilst we have the opportunity. Helping to improve a patient’s activity levels in line with the principles of exercise, may help minimise their risk of pain in the future by increasing variety, building tolerance, building confidence and building physical capacity.
This is patient-centred care and works best when you listen to the patient to find out what their normal is. Instead of trying to fix patients, Physios would be more successful in treating patients by selling them the benefits of a healthy lifestyle, in particular exercise, nutrition, sleep, stress and mindset.
Quality programs are built, not by going from intervention methods up, but by going from pain principles down.
This decision-making process when designing treatments to help patients get back to their normal may be based on the following series of questions:
It’s important to acknowledge that there is nothing wrong with improving posture for aesthetics. However, this is not the role of a Physiotherapist and would perhaps be more suited to the role of a Personal Trainer. The points raised above refer to people trying to improve posture for health and/or performance reasons.
For argument’s sake, however, let’s say a Physio did help someone with their posture for aesthetic reasons, you would be back to the WHO recommendations of 150 minutes of activity with two days a week resistance training to produce enough of a stress response to change anyone’s posture.
As Eyal Lederman states, “In the context of postural-structural-biomechanical (PSB) factors, it is expected that tremendous forces, well above the daily physical stresses, would be required to reposition/adjust/correct any structural misalignments.”
Person A is (or has claimed to be) an authority on the issue of neck pain.
Person A claims that “text neck” is true.
Therefore, “text neck” must be true.
If you Google “text neck” the first page is full of advice on how to avoid “text neck overuse syndrome” and there is even a text neck institute. On each of these websites are professional looking blogs with quotes from various Doctors, Surgeons and self-proclaimed experts in this new made up syndrome.
A common argument is that if all of these websites with quotes from such highly trained doctors and surgeons say it’s a thing, then it has to be true. This bad argument is known as the Appeal to Authority.
If all the doctors in the world were confident that there are fairies at the bottom of the garden, that wouldn’t make it any more likely to be true. To confirm if there are fairies at the bottom of the garden and to confirm that “text neck” is a condition to be worried about, then we would need hard proof. In both cases there is none.
The Appeal to Authority fallacy is an example of an error in critical reasoning and should not be confused with “deferring to an authority on the issue”. Legitimate experts and authorities are extremely useful and being critical thinkers themselves they understand there is always a chance they could be wrong.
The cervical spine is stronger in neutral than in a forward position.
The neck is less likely to be painful if it is in a stronger position.
Therefore having the neck in a forward rather than neutral position must be bad.
None of the arguments against “text neck” being a thing argues that the cervical spine is not stronger when in neutral. If loading the neck with weight by doing a headstand for example, then it would not be wise to flex your neck.
When unloaded, the forces experienced by the neck when the head is in a forward posture is not enough to cause tissue damage. The research paper people use to back up the idea of text neck made the calculations using neck + head, which gave an average weight of 60 newtons (6kg or 13.2 pounds).
However, the cervical spine is 45% stronger in compression and 20% in bending strength compared to the lumbar spine. That means the neck can withstand compressive forces in excess of 450 lbs, in which case 60lbs is not that big a deal.
It’s important to remember that loading the neck, just like any other joint is good for us. Pretty much every sport including Rugby, Football, Cycling, Golf all put large loads on the neck. So long as people gradually expose themselves to these activities, then our bodies will adapt to the stress.
Biomechanics matter much less when the loads experienced are low, such as body weight. That’s not to say that biomechanics never matter, it does.
If the argument was that staying in one position repeatedly for prolonged periods of time may cause some mild discomfort, then that would be different. We are meant to move and so staying in any one position for too long may cause mild discomfort. Just think about the last time you had to stay in one position for a long time, perhaps sitting or standing. Or ask a soldier who has had to stand to attention for long periods. Neither are comfortable, but neither is dangerous.
As humans have inherited a genome which means we have to move, just like we have to eat and sleep. This does not mean that we should avoid certain postures, it simply means that we need to move in a variety of ways and build our tolerance and confidence in the activities we want/need to do daily.
I treat lots of people with neck pain.
The majority of patients who I see for neck pain have a forward head posture.
Therefore, forward head posture must be the cause or at least a large contributor to neck pain.
The first problem with this argument is that there is actually a poor correlation between posture and neck pain. But for argument’s sake let’s assume there is a strong correlation, does that prove that posture is responsible for neck pain? No, because correlation doesn’t equal causation.
If you look out the window each day, from your experience it would make sense that the sun revolves around the earth or that the earth is flat. However we have solid evidence that both of these are not true, the earth revolves around the sun and the earth is round. Just because a plausible explanation fits with your current belief system, does not mean it is true. This is also known as confirmation bias, where you are more inclined to look for evidence which fits in with what you already believe.
A good critical thinker and Physiotherapist will look for information which refutes their beliefs because that is how we learn and progress as a profession. By giving up false beliefs and moving forward with Science, we can slowly but surely improve our understanding of pain and rehabilitation. We don’t have all the answers and we never will, but that’s ok. It is progression, not perfection which is important.
Again, for argument’s sake let’s assume that the observation was correct, it would be unwise to assign a high level of confidence to your observations because the anecdotal experience is at the bottom of the hierarchy of evidence. Therefore what you observe in the clinic may be useful and interesting but on its own, it is not good valid reliable evidence.
You must be skeptical of any patterns you think you see because humans are prone to making errors in judgement and decision making.
Try not to take this too personally. Highlighting our human fallibilities does not mean that we are not highly intelligent, just like highlighting medical diseases doesn’t mean that we are not healthy. By exercising your body you can reduce your risk of disease and by exercising your mind, using critical thinking, you can reduce your risk of making poor judgements and decision on what treatments to use.
I see lots of patients with neck pain.
When I change their head posture, their pain goes away.
Therefore, the forward head posture causes neck pain.
Every part of a Physiotherapy appointment could alter the symptoms of a patient, a phenomenon known as “symptom modification”. From the moment you speak to the patient and build rapport with them, you have the potential to modify their symptoms because pain is influenced by many biopsychosocial factors.
Some manipulate joints, some do soft tissue massage, taping, dry needling, exercise, active listening, advice and education etc. They are all types of symptom modification because they all have the potential to modify symptoms and function for a short time period.
Modifying a patient’s symptoms by changing their posture is more likely due to increasing their movement and variety, rather than achieving a made up gold standard posture. It’s not that there is a correct way to stand or sit but rather there is a way to stand or sit that is less painful for them at that point in time. A little bit like when you fidget after sitting for a long time.
In any case, just because you modify someone’s symptoms doesn’t mean that the intervention you used is a good one. You may have just got lucky. Do you want to run a Physiotherapy service using placebo interventions that work 50% of the time in non-specific ways? Or would you rather use clinical reasoning and use interventions which are most likely to help your patient reduce their pain and move more both short AND longer-term?
“But why do we need to know why things work? If they feel better surely that’s all that matters.” some may reply.
Given what we know from Science in the 21st century that approach simply isn’t good enough. If we don’t know why and how things work specifically then we can’t improve them. If we rely on the non-specific effects of placebo then you open your doors to pseudoscience and the quality of care plummets to medieval standards.
For a more in-depth overview of symptom modification and the issues with you can click here.