Text Neck Posture. Permission Joseph E. Muscolino. www.learnmuscles.com.

Does the Condition Text Neck Exist?

“Text Neck”

Text Neck Posture. Permission Joseph E. Muscolino. www.learnmuscles.com.

Text Neck Posture. (BTW, the younger boy to the right has what might be described as “text back”!) Permission Joseph E. Muscolino. www.learnmuscles.com.

“Text neck” is defined as neck pain caused by the flexed/forward head posture during texting (or reading) on a smart phone. Following are some statements that ostensibly seem to refute the existence of text neck.

My Soapbox Speech Comments…

When TerraRosa.com.au out of Australia asked me if I would like to address this article, I said yes specifically because the “implications” of this article and the research study herein are antithetical to my entire philosophy of how we should approach clinical orthopedic manual and movement assessment and treatment. So I wanted to use this article as a “soapbox” for me to counter the train of thought and implications here, hence my “comments”. Pardon me if I am a bit too preachy here, but I strongly believe in using fundamental anatomy, physiology, and biomechanics to critically think and creatively apply how we approach the wonderful and powerful fields of manual and movement therapy!

Text Neck Posture. Permission Joseph E. Muscolino. www.learnmuscles.com.

Permission Joseph E. Muscolino. www.learnmuscles.com.

No Such Thing as Text Neck?

While text neck is of a concern and referred as a public health issue, some state that there is no such thing as a text neck. An article has said that there isn’t any strong or good evidence suggesting that text neck is a reliable indicator for neck or back pain; the human neck can withstand a tremendous amount of sustained pressure.

Note by Joseph Muscolino:

It is so disconcerting to me to read or hear people make a claim about something based on the lack of “evidence.” I understand the need and desire for “evidence-based learning.” I understand and appreciate the importance of research studies; I am a strong supporter of research. But… research is essentially nothing more than proving the reliability of something. Someone states that “ Condition X” causes pain, so a research study compares a group of people with Condition X to see if they have more pain that a “control group” without Condition X. Wonderful! But the absence of research does not prove the absence of the correlation between Condition X and pain. Just because we do not yet have studies to prove that text neck causes pain, it does not prove that it does not. We simply do not yet have the research. So what do we do in the meantime? We use our common sense of biomechanics and look at the physical stresses that the posture of text neck places on our body! The forward flexed posture requires isometric contraction of the cervicocranial extensor musculature. And at four+ hours per day, how can this “use/overuse” not cause pain in the long run??? And it compresses the anterior cervical spinal joints, effectively loading the anterior discs… How can this not cause pain or dysfunction in the long run? Herein, may lie one of the problems: the “long run.” We are not yet at the effects in the long run because the pervasive use of digital devices is still relatively young. See later note for more on this…

Even the Chartered Society of Physiotherapy of UK said the use of phones is likely to be “incidental” to the development of neck pain. The way people look at phones is the same as reading a book, which we have done for centuries with few alarms.

Note by Joseph Muscolino:

Oh my goodness. Yes. The forward flexed posture of text neck is not necessarily any different than how we read a book. But… we are spending a LOT more time today on digital devices than we ever spent in the past reading books! Certainly the posture of text neck is nothing new. Anything that requires us to work down in front of ourselves mimics the dysfunctional posture of text neck. The problem lies in the extreme overuse of digital devices today.

Text Neck Posture. Permission Joseph E. Muscolino. www.learnmuscles.com.

“Text Neck Posture” with both digital device AND paper. But how many hours do we now spend with digital devices compared to hours spent in the past with paper? Permission Joseph E. Muscolino. www.learnmuscles.com.

Text Neck Posture. Permission Joseph E. Muscolino. www.learnmuscles.com.

Permission Joseph E. Muscolino. www.learnmuscles.com.


A recent cross-sectional study from Brazil recruited 150 students between 18 and 21 years of age from a public high school in Rio de Janeiro, Brazil to investigate whether there is an association between text neck and neck pain. The participants were first surveyed as to what they believed their texting posture was according to a series of four drawings: two that were considered to be “no text neck” (phones held higher, further away from the body, resulting in a less forward flexed head/neck position), and two considered as “text neck” positions (phones held lower and closer to the body, forcing a forward flexed head/neck position).

In addition, for a more objective measure, participants were photographed while texting on their mobile phone. The pictures were analysed by three physiotherapists and rated as “normal,” “acceptable,” “inappropriate,” or “excessively inappropriate.”

Finally, participants were asked about the occurrence and frequency of neck pain, the amount of time they spent reading, writing, or playing on their smart phones, the degree to which they worry about body posture, and whether they had vision impairments.

Text Neck Posture. Permission Joseph E. Muscolino. www.learnmuscles.com.

It is not only the young who employ “text neck posture”. Permission Joseph E. Muscolino. www.learnmuscles.com.


The results showed that the majority of the participants (77%) reported more than four hours of smart phone use per day. The physiotherapists judged 40% of the participants as having text neck, while 85% of the participants in the study self-reported as having text neck.

The researcher analysed the data using mathematical models, and concluded that text neck, assessed either by self-perception or physiotherapists’ opinion, was not associated with either neck pain or the frequency of neck pain.

Study’s Conclusion

The authors concluded that their results conflict with the idea that the mechanical stress caused by poor posture due to mobile phone use is a threat to cervical spine integrity and challenge the belief that inappropriate neck posture during smart phone texting is the leading cause of the growing prevalence of neck pain.

Note by Joseph Muscolino:

That people as young as 18-21 have not yet begun to experience pain as a result of text neck posture does not surprise me at all. They are simply still too young to experience what the physical stress of the overuse of text neck posture will do to them. It is not the “long run” yet (as I referenced in an earlier note). It is extremely disappointing that the study does not make clear this likely reason for their results. Let’s look at this logic with a different example: A study is done of people aged 18-21 who smoke two packs of cigarettes a day. Amazingly, the study shows that they have no higher incidence of lung cancer, emphysema, and arteriosclerosis than people aged 18-21 who do not smoke. Of course they do not. The cumulative effects of smoking have not caught up with them yet!!! This conclusion should be obvious and should be loudly proclaimed in the study. Instead, the way they interpret their results seems to give people an excuse to not worry about the deleterious effects of text neck posture. Relying on research for evidence-based learning should not give us an excuse to shut off our brain. If a posture or movement activity involves asymmetrical physical forces into our body, and done for excessive amounts of time, there must, on average, be a price to pay at some point in time. The time may simply not have arrived yet.

A Man Jumps Off a 10-Story Building…

One of my favorite sayings:

A man jumps off a 10-story building. As he is hurtling down toward the pavement below, a person inside a third floor window hears him say as he goes flying by: “Well, so far no problem.” …But this person will hit the pavement!

Put another way:

“If we do not change our direction, we are likely to end up where we are headed.”

We need to take a step back and assess the physical forces that any posture or movement activity places into our body, and then multiply that by how often we engage in that activity, and then critically reason through what the likely effects will be, regardless of any research that has not yet occurred, or any research that has been done that involves faulty implications.

Pain Science versus Mechanics

I realize that with the pendulum swinging toward “pain science,” the appreciation of “mechanics” is falling out of favor. But pendulums always seem to swing too far. I strongly believe in pain science, but I also strongly believe in mechanics. They are not mutually exclusive! Mechanics still matter… a lot! The human body is essentially a mechanical structure, even if it is ordered and interpreted by the nervous system. And when physical forces exceed a certain point, they will be, at the least, a predisposition to pain and dysfunction, if not actually result in pain and dysfunction!

This blog post article was created in collaboration with www.terrarosa.com.au.

(Click here for the blog post article: Overview of Physical Examination of the Neck.)