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954-577-6161

Case Study

Title: Response to Text Neck and Mobile Phone Viewing Angle: A Case Study
Authors: Dean L. Fishman, D.C., B.S.E.S, The Text Neck Institute, Founder
Daniel McGee, D.O., The Text Neck Institute, Medical Director

Disclaimer: Disclaimer: These case studies are brought to you for educational purposes only. The information is sometimes related to interpretive diagnostic opinions, and is not intended to represent the “standard of care.” The views are those of the contributors.

Abstract:
This patient had presented to our office with complaints of headaches, torticollis, neck and shoulder pain. Upon x-ray examination a loss of the normal cervical curve was noted with forward head posture (FHP) also known as “text neck”. While reviewing activities of daily living it is uncovered that this patient uses text messaging as her primary source of communication, and spends several hours per day on a lap top or desk top computer. A specific treatment protocol was administered and the patient was asked to change the angle that she views her mobile phone. The patient had a significant improvement in her lateral cervical curve upon x-ray and symptoms decreased. It was concluded that treatment as well as altering the viewing angle of the head while texting, improved the signs of text neck.

Case Presentation:
A 25 year old female pharmaceutical student presented to the clinic complaining of recurrent headaches, torticollis, with generalized neck and shoulder pain. She stated that she suffered with these symptoms of neck and shoulder pain for six months. Headaches were frequent and she had a history of suffering from frequent episodes of torticollis. She took ibuprophen over the counter as needed with some temporary relief of her symptoms. The patient stated that her pain radiated from the lateral cervical musculature, right side more than the left, to the right shoulder blade. She described the pain as having an intensity of moderate levels ranging from a 5 to 7 out of 10. She also stated that when the pain is particularly severe, she felt numbness in the area of the left trapezius muscle.


This patient noted that she suffered from a similar problem several years ago and was treated at that time with manipulative therapy resulting in improvement of the symptomatology. Later, as she began graduate school, she found herself using a hand held mobile device and lap top more frequently than in the past. Her neck and shoulder pain has increased in frequency over the past year, presently occurring an average of three to four days per week. Ibuprophen provided her with some relief. She has not sought any other treatment for her recent symptoms.


The patient denied any other significant past medical, surgical, or family history, does not use any other medications and has no known drug allergies. Examination revealed an otherwise well developed, well nourished and healthy young female with a notable anterior carriage of the head. George’s Test did not produce nystagmus or dizziness. Cervical compression of the neck in the neutral position did not create discomfort. However, Jackson’s Compression of the neck bilaterally, produced some right neck and trapezius pain. Cervical Distraction relieved some of the symptoms. Shoulder Depression was negative. Cranial nerve examination was normal. Upper extremity motor, sensory and reflex functions were within normal limits. The patient demonstrated full active range of motion of the cervical spine which were painless except for some slight restriction of t right lateral bending and rotation of the head to the right with mild pain and discomfort.


Prior to initiating treatment, a goniometer was used to measure the normal angle that the patient holds her cell phone while texting. It was measured to be a 24 degree angle from the floor. It was apparent that she had a pronounced forward head tilt while viewing the screen of her hand held device.


Beginning of Care Diagnostics:


Lateral cervical x-rays revealed a -7 degree curve, using the posterior vertebral body of C2 and the posterior vertebral body of C7. A 33 mm forward head posture was measured using the inferior posterior vertebral body of C7 in relationship to the inferior posterior vertebral body of C2.


Digital dynamometer muscle testing was used to show a deficit in strength between the flexors and extensors. A deficit is based on a 4:1 normal ratio of extensors to flexors (1).


Digital dynamometer muscle testing revealed:


Computed average of cervical flexion was 3.0 kg and cervical extension was 3.1kg. Which is approximately a 1:1 ratio


The differential of the extensors to flexors during the digital dynamometer testing can be attributed to this patient having her head in an anterior head carriage and forward head tilt for extended periods of time.


Digital inclinometer testing was used to show the degree of movement in a particular plane of motion. To determine the patient’s performance deficiencies, a comparison is made between their test results and the AMA Guidelines.


Digital inclinometer testing revealed:


Computed cervical flexion was 57 degrees (normal being 50 degrees) or 114% of normal.


Computed cervical extension was 43.0 degrees (normal being 60 degrees) or 71.7% of normal.


The digital inclinometer testing revealed that this patients neck was hyperflexive, possibly due to the repetitive motion of looking downward at the hand held mobile device.


The patient was diagnosed with TEXT NECK (forward head posture) due to chronic postural strain.

Management and Outcome:


The patient underwent a four week course of treatment consisting of prone cervical and upper thoracic spinal manipulation three times per week. Manipulation was accompanied by trigger point therapy to the trapezius and rhomboid muscles as well as stretching of the upper trapezius. The patient also performed a specific program of routine of strengthening exercises designed to improve overall strength and stability of the posterior cervical and interscapular musculature. She was instructed to perform the exercises on her own two days per week. Additionally the patient was instructed to hold the mobile phone between 70-90 degrees when using it to text, browse the web, and while writing and reading email. Furthermore, advice was provided concerning proper posture while sleeping.


The exercises the patient performed consisted of:


Prone neck extensions: Lying on stomach with forehead on the floor or examination table. Raise head and shoulders up as if looking up at the ceiling. Hold for ten seconds. Lower. Repeat.


Shoulder stability-straight arms: Lying on stomach over the top of a stability ball, or off of the end of an examination table with the chest up off of the ball or table. Retract the shoulder blades back towards the spine. Extend the arms out perpendicular (90 degrees) from the body with the thumbs pointing up towards the ceiling. While keeping the head in a neutral position the arms move down toward the floor but always have the shoulder blades retracted. Repeat.


Shoulder stability-arms at 90 degrees: Lying on stomach over the top of a stability ball, or off of the end of an examination table with the chest up off of the ball or table. Retract the shoulder blades back towards the spine. Bend the arms at the elbows (90 degrees). While keeping the head in a neutral position, externally rotate the upper arms. The hands should be reaching towards the ceiling. Return to the starting position. Always have the shoulder blades retracted. Repeat.


Snow angels: Stand with the back and heals against the wall, arms raised overhead. Keeping the forearms and hands in contact with the wall at all times, slowly slide the arms down the wall, bending at the elbows as you squeeze the shoulder blades together.


During the last two weeks of care she experienced no headaches and reported feeling generally more energetic than before commencing care. Following a total of four weeks of care (12 treatments) she was discharged and instructed to continue the same frequency of exercising on her own and to continue to hold her hand held mobile device at an angle of 70-90 degrees from the floor.


End of Care Diagnostics:


Lateral cervical x-rays revealed a +15 degree curve, using the posterior vertebral body of C2 and the posterior vertebral body of C7. A 28 mm forward head posture was measured using the inferior posterior vertebral body of C7 in relationship to the inferior posterior vertebral body of C2


Digital dynamometer muscle testing was used to show a deficit in strength between the flexors and extensors. A deficit is based on a 2.5:1 normal ratio of extensors to flexors (1).


Digital dynamometer muscle testing revealed:


Computed average of cervical flexion was 3.7 kg and cervical extension was 3.8 kg


The treatment protocol resulted in an increase in strength of the cervical flexors by 19% and the cervical extensors by 18%.


Digital inclinometer testing was used to show the degree of movement in a particular plane of motion. To determine the patient’s performance deficiencies, a comparison is made between their test results and the AMA Guidelines.


Digital inclinometer testing revealed:


Computed cervical flexion was 74.0 degrees (normal being 50 degrees) or 146% of normal.
Computed cervical extension was 54.0 degrees (normal being 60 degrees) or 88.3% of normal.
The treatment protocol resulted in an increase of the cervical flexors range of motion by 20% and the cervical extensors by 18%.


Discussion:
The distinction between headache, torticollis, neck and shoulder pain and text neck (forward head posture) is not always clear. However, this case demonstrates several features. This case demonstrates a classical presentation of text neck (forward head posture) which improved dramatically in a very short period of time with a course of spinal manipulation, supportive soft-tissue therapy, exercise and most importantly, altering the repetitive stress of looking down at the hand held device.
When comparing the data of pre and post treatment, range of motion and muscle testing, x-ray curvature, the angle that she now utilizes her mobile phone, and decreased symptomatology, there was a tremendous change for the better. The patient improved with her cervical range of
motion. The patient improved with her cervical muscle strength with in all planes. When reviewing her lateral cervical x-rays this patient had a +22 degree change in her cervical curvature and a +4 millimeter change in her forward head posture, in one month.
These objective and subjective findings were expected, because any time that you stop a repetitive motion, such as a forward head tilt while looking down at your hand held mobile device, laptop, PC or gaming device, and begin a routine of care which includes reorganization of the spine and strengthening of the postural muscles, the body will adapt.


References:
1. A review of functional outcome measures for cervical spine disorders: literature review. André Bussières

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