Looking down: Text neck syndrome affects how we see the world

Most of us have had our parents or other authority figures tell us to “look up.” “Watch where you’re going.” My favorite is, “If you don’t look up, the world will pass you by.” 

Perhaps we can agree there are a handful of times when looking down wins. For example, the view of Earth from space or a toddler learning to walk. These are moments of awe and even a touch of fear. Today, looking down is more than a euphemism for disapproval. It’s the result of a technological epidemic, mainly thanks to the rise of the smartphone over the last two decades.  

More than six billion text messages are sent every day in the U.S. alone¹ by the 85% of Americans who own a smartphone.² The U.S. accounts for 45% of the volume of texts sent worldwide.¹ 

We should be afraid as increased smartphone and other device usage has led to a new and concerning condition: text neck syndrome (TNS). 

Text neck syndrome 

“Text neck” was first observed and coined in the early 2000s by an American doctor of chiropractic, Dean Fishman, DC. According to Fishman’s website, TNS is an: 

“Overuse syndrome involving the head, neck and shoulders, usually resulting from excessive strain on the spine from looking forward and downward at any handheld mobile device, i.e., mobile phone, video game unit, computer, MP3 player, e-reader. This can cause headaches, neck pain, shoulder and arm pain, breathing compromise and much more.”³ 

Neck pain is something most DCs are very familiar with. It is likely one of the top three reasons patients visit your clinic.⁴ Between 2009 and 2019, the prevalence of neck pain was reported to be 27 out of every 1,000 people.⁵ This has increased in the last five years due to the work-from-home movement and the use of technology in the classroom, both at the grammar school and university level. Recent estimates put neck pain prevalence at 45.5% for office workers,⁶ 64.7% for those who work from home⁷ and 45.8% to 54.7% for healthcare professionals.⁶ While lower at 21%,⁷ undergraduates may be the fastest-growing group. 

Several studies note “prolonged use” and “addiction” to smartphones as complicating factors.^6,7 

The real dangers of TNS are more complex than we realize. It’s more than just neck pain. It is an entire shift, from our brain to our feet, in how we see our world. 

Let’s start from the top 

A common postural distortion found in those with TNS and neck pain is forward head posture (FHP)⁷ or anterior head carriage.  

It is widely accepted the human head weighs, on average, 10 pounds. A literature review corroborates that for every one inch of FHP, the weight on the cervical spine and supporting structures can increase by 10 pounds,⁸ effectively making the weight of the head about 20 pounds. So, for two inches of FHP, the head feels like it weighs 30 pounds; both to the patient and their neck. 

This increased head weight starts peeling away at the kinetic chain. This condition disrupts the center of gravity, alters the length of the cervical spine muscles and changes the muscles of mastication to keep the mouth closed. The rhomboids, trapezius and hyoid muscles weaken. The glenohumeral joints and femoral-acetabular joints can become unstable. A “swayback” can develop, leading to lower back, hip and even lower extremity pain.⁷ 

Tragically, the damage goes beyond the musculoskeletal system. The change in thoracic kyphosis can lead to decreased respiratory function. TNS can also lead to kinesthesia and distortion of the cervical sensorimotor control, which can affect balance.⁷ 

How does this relate to my comment on how looking down affects how we see our world? Well, it has more to do with eye position than screen time. 

TNS is linked to visual acuity impairment and eye movement dysfunction. The visual system is essential to the neurology of posture and without visual correction, postural imbalances cannot be fully addressed.⁷ Furthermore, research reinforces the “straight-ahead direction” of the visual cortex is ideal.⁹ Our brain likes to look straight ahead. Proper visual input can better support our posture. 

Our posture can also be supported from the bottom up. A study¹⁰ in 2023 looked at how foot posture changed the static balance of the corresponding knee and ankle in women with a normal arch and women with flexible flatfoot (that is, an arch that collapses when weight-bearing but returns to normal when non-weight-bearing).¹¹ As expected, the balance was poorer in the women with the flexible flatfoot.¹¹  

So, if foot biomechanics directly affect balance and stability, shouldn’t supporting a patient’s feet be as crucial to correcting spinal posture in treating TNS? Yes. A supportive foundation, in addition to chiropractic care, is a rounded treatment option for TNS. Whether your patient is an active university student or a work-from-home warrior, the feet still receive proprioceptive input from the floor. Custom flexible orthotics alone have increased weight-bearing function by more than 30%.¹² 

Final thoughts 

Addressing TNS may be more complex than providing custom orthotics or strengthening the thoracic spine. Still, we can yield far greater results when we address the problem with a holistic, whole-body approach from the feet up. 

Let’s help our patients see their world by addressing TNS from head to toe. 

ERIN STUBBLEFIELD, DC, graduated from Palmer College of Chiropractic in Davenport, Iowa, in 2006. After practicing privately for several years, she transitioned to full-time teaching. Currently, Stubblefield is the owner of Sunflower Consulting LLC, a healthcare consulting and practice management group. She resides outside of Kansas City, Missouri, and is a published author and continuing education presenter. For further information, you can reach her at LLC.sunflowerconsulting@gmail.com. 

References 

1. Texting Statistics. The Local Project. https://www.localproject.net/docs/texting-stats/. Accessed May 29, 2024. 

2. Olia A. Text Message Statistics and Trends for 2024 [And Beyond!]. Intradyn. [Blog]. January 30, 2024. https://www.intradyn.com/text-message-statistics-trends/. Accessed May 28, 2024. 

3. The Text Neck Institute. Text-neck.com. 2016. https://www.text-neck.com/definition-of-text-neck.html. Accessed May 28, 2024. 

4. Bertelsman T. Top Reasons to Visit a Chiropractor. ChiroUp. October 2021. https://chiroup.com/blog/reasons-to-visit-a-chiropractor. Accessed May 28, 2024. 

5. Kazeminasab S, et al. Neck pain: Global epidemiology, trends and risk factors. PubMed. BMC Musculoskelet Disord. 2022; 23(1). https://doi.org/10.1186/s12891-021-04957-4. Accessed May 28, 2024. 

6. Chan LLY, et al. The prevalence of neck pain and associated risk factors among undergraduate students: A large-scale cross-sectional study. Int J Ind Ergon. 2020;76:102934. Science Direct. https://www.sciencedirect.com/science/article/abs/pii/S0169814119301076. Accessed May 28, 2024. 

7. Tsantili AR, et al. Text Neck Syndrome: Disentangling a New Epidemic. Acta Med Acad. 2022;51(2):123-127. PubMed. https://pubmed.ncbi.nlm.nih.gov/36318004/. Accessed May 28, 2024. 

8. Mehregan R. The 40 Pound Head; Damaging Effects of Forward Head Posture. Orthotropics. October 24, 2016. IAFGG. State Admin. https://orthotropics.com/the-40-pound-head-damaging-effects-of-forward-head-posture/. Accessed May 28, 2024.  

9. Bogdanova OV, et al. Dynamics of the straight-ahead preference in human visual cortex. Brain Struct Funct. 2020;225(1):173-186. PubMed. https://pubmed.ncbi.nlm.nih.gov/31792695/. Accessed May 28, 2024. 

10. Ghorbani M, et al. The effect of foot posture on static balance, ankle and knee proprioception in 18-to-25-year-old female student: A cross-sectional study. BMC Musculoskeletal Disord. 2023;24:547. https://doi.org/10.1186/s12891-023-06678-2. Accessed May 28, 2024. 

11. Flexible Flatfoot. Foot Health Facts. ACFAS. foothealthfacts.org. https://www.foothealthfacts.org/conditions/flexible-flatfoot. Accessed May 28, 2024. 

12. Cambron JA, et al. Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2017;98(9):1752-1762. PubMed. https://pubmed.ncbi.nlm.nih.gov/28465224/. Accessed May 28, 2024.