Episode 344
344. Text Neck Isn’t Causing Your Neck Pain
Studies mentioned in this episode:
- 2025 longitudinal study finds text neck is not associated with future neck pain here
- 2023 systematic review of interventions for neck pain finds strengthening works here
- 2017 Chen et al. systematic review finds neck strengthening is the most effective intervention for workplace neck pain - more effective than posture or ergonomic advice here
This podcast uses the following third-party services for analysis:
AdBarker - https://adbarker.com/privacy
Transcript
Text neck has been i think
::firmly put to bed it's not a thing a
::new study has been released in december 2025 as of recording this in january
::2026 that's around one month ago it was a 12 month longitudinal study with over
::400 participants about 390 of them completed the study and found no association
::between neck posture when using a smartphone,
::and neck pain over the ensuing one-year period.
::So we're going to dive into that study and look at the broader literature on
::neck alignment, neck loading, and neck pain, and think about how it applies
::to Pilates specifically.
::So when I was trained up, and very likely, dear listener, same for you,
::when you were trained up, you were probably taught that neutral
::cervical or neck alignment is the
::default safe position and this
::manifests in safety cues
::and protocols like make sure you always put the headrest down on your reformer
::when you're doing shoulder bridge never over quote over flex the neck and what
::i was taught it's actually one of the principles of stott pilates that when
::you do a back bend that the cervical or a forward bend that the cervical spine,
::which is capable of about 90 degrees of extension in most people,
::should follow the line of the thoracic spine, which is capable of about 10 degrees
::of extension in most people.
::So we would really taught probably most of us to avoid the end ranges of the
::neck and specifically to avoid them under load, which is kind of weird considering
::that Joseph Pilates' instructions in his book, Return to Life Through Contrology,
::explicitly say that the chin should be on the chest in a lot of the flexion-based exercises.
::And in the extension-based exercises like swan dive, he specifically says,
::look up at the ceiling, your neck should be extended as far as possible.
::So we were taught that neutral cervical alignment is a default safe position.
::You know, don't put your headrest up in shoulder bridge. We're also taught many
::of us to avoid quote overusing the quote bad neck muscles, the sternocleidomastoids,
::those sort of muscles down the side and front of your neck here, the apotrapezius,
::And that we should avoid overusing those muscles and that we should instead
::focus on using the deep neck flexors, which you can't see from the outside.
::They're located on the very front, deep inside the neck, the very front of the
::vertebral bodies in front of the anterior longitudinal ligament.
::And they are the quite good muscles of the neck. And essentially that the neck
::is treated as fragile and to be protected.
::Now, of course, relatively speaking, the neck is comparatively fragile and very
::precious because our spinal cord,
::our vertebral arteries that feed the brain all go through there.
::So obviously it's very important not to, you know, not to catastrophically injure your neck,
::but the, I think there's very clear evidence that we weigh over value avoiding
::load and avoiding end positions.
::And actually that that causes a detriment that actually is harmful to our clients to do that.
::All right, so the first thing I want to point out here in terms of thinking
::about the way we think about the neck in Pilates is that there are two double standards in effect.
::The first double standard is around the way we treat the neck in different contexts.
::And the second double standard is about how we treat the neck versus how we
::treat many other joints in the body.
::So the first one is how we treat the neck in different contexts.
::So, you know, I'm sure, dear listener, that you've seen the, the, the, the,
::the graphic that has the person sitting up straight, then with their neck bent,
::you know, forwards, and then a little bit more forwards, a little bit more forwards
::until the neck, the chin is resting on the chest.
::And there's like some kind of amount of force or weight or load associated with it.
::So, you know, when the head's bent fully forward and the chin's on the chest,
::you know, the head is like four times heavier or something. I don't know the
::number, but you know, whatever, I'm sure you've said it.
::And that that is, you know, by implication is a quote, bad thing.
::Uh that you know so floating the neck in flexion
::whilst sitting i.e you know the way that you
::look down at your phone when you're scrolling is bad
::because it loads the neck um but so when you're you know when your head's parallel
::to the when your neck's parallel to the floor you know the head is weighs four
::times what i can't remember what the actual number is but you know a lot right
::and yet when we're in a plank or even just plain old vanilla quadruped position
::you know hands and knees on the box or on the floor or on the reformer carriage.
::The neck is at 90 degrees to gravity. Like the exact same loads are on the neck
::in that position as when your neck is flexed 90 degrees when you're upright.
::So the exact same load in that plank exercise or in quadruped is considered absolutely fine.
::But when we're sitting with our head flexed forward, that's somehow bad.
::So the same load is considered good or bad in different situations.
::And the same with.
::There are multiple exercises where we move our neck or load our neck in different
::positions and where it's considered fine and safe and good, but then when we
::do it in other exercises, it's considered bad or to be avoided.
::For example, in the roll-up, you load the neck in flexion, you load the sternocleidomastoid,
::that is considered to be a fine exercise.
::It is a fine exercise, objectively, it's a fine exercise.
::The second double standard is the way that we treat the neck differently to
::every, or not every other joint, but most of the other joints in the body.
::We load most of, I mean, Pilates and any form of resistance training.
::Pilates, you know, is a form of resistance training. It also involves flexibility
::training. It also involves movement skill training.
::So strength, flexibility, and skill are the three core elements that we work on in Pilates.
::And they're the same elements that we work on in every other form of training,
::if it's a well-balanced form of training. We just do it a little bit differently in Pilates.
::And so we take it for granted that
::we will move joints through range of
::motion under load in most other joints in the body for example how
::would you strengthen someone's biceps well you'd give them
::something to hold in their hand that involves some load like a spring or a band
::or a weight or something and then you would move
::that joint through range under load and what range would you go through you'd
::straighten the elbow all the way down and then you'd flex the elbow all the way up
::like you'd take it through full extension to full flexion and we would we just
::treat that as a complete matter of course how do you strengthen and stretch
::the calf muscles i mean we do it every session most of us when we teach reformer
::and you do your uh lift and lower on the foot bar you know at the end of your
::footwork sequence where you have your the balls of your feet on the bar,
::your legs are in parallel and feet are feet are close together and you let your
::heels stretch under the bar.
::So you go into deep dorsiflexion and then you lift up as high as you can,
::both of your heels, and you go into your maximum plantar flexion.
::And we just repeat that and we do reps and it's under load.
::We're dorsiflexing and plantar flexing. We're going through full range in the
::calf muscle. And nobody thinks twice about, oh, that's dangerous for the ankle.
::And I could add so many more examples, the triceps, the leg curls, knee extensions.
::There are so many movements that we just completely take it for granted that
::moving a joint through its full range under load is a good thing.
::And yet, when it comes to the neck, we suddenly think it's bad.
::We suddenly think, oh, don't flex your neck under load. If I take that and take
::the word neck and substitute it for elbow, don't flex your elbow under load.
::Don't flex your knee under load. Don't flex your hip under load. It sounds ridiculous.
::Don't flex your shoulder under load. It sounds ridiculous. Well,
::the neck is just bones, ligaments, joint capsules, tendons, muscles, fascia,
::exactly the same components as your elbow, your hip, your knee, your ankle.
::And just like all of those other structures, your neck, the tissues respond
::to progressive load over time by becoming stronger.
::And that is in fact what exercise is. It's the deliberate, structured application
::of load to body tissues to stimulate a response.
::And the response is increasing strength and slash or flexibility.
::So the third paradox there is that if we think of the neck as fragile and we
::think of it as to be protected,
::Well, paradoxically, the best protection is to become less fragile.
::Man, that seems kind of self-evident to me.
::And how do you make any body part less fragile?
::Well, think about a frail resident of an assisted care facility,
::someone in their 90s with, you know, imagine no muscle tone,
::you know, thighs you could put a finger and a thumb around.
::No muscle tone. And then think of a 26-year-old rugby player,
::a Samoan rugby player, legs thick as tree trucks, a neck as thick as most people's torsos, right?
::Which one of those people is more fragile and why
::is the elderly person more fragile not because they're elderly like there's
::nothing inherent in age that makes you fragile it's the
::things that accompany age that make you more fragile you lose
::bone density you lose muscle mass you lose tissue strength
::you know because the tissues become uh smaller and why do they become smaller
::well it's partly uh hormonal uh but it's mainly disuse we we don't load tissues
::as we get older and so the way to make somebody less fragile is to systematically
::and deliberately load their tissues over time,
::to stimulate them to become more massive and stronger.
::I mean, how do you improve someone's bone density? How do you improve their
::muscle strength? How do you improve their ligament and tendon strength and their joint health?
::You load those structures systematically over time.
::And yet we apply the opposite logic to the neck. We avoid loading it.
::We avoid putting it through range of motion, which just is the exact opposite. of.
::What we know from basic physiology i mean imagine somebody came into your,
::pilates class and said i've got really weak biceps and you and then you know
::would you say like oh well okay great well we'll make sure we avoid loading
::your biceps for the rest of the time you know forever now it's like well that's
::illogical it doesn't make sense you wouldn't say that presumably and so if somebody
::comes in and says i've got a very weak neck,
::why would you say well great we'll avoid loading your neck forever now like
::if someone came in and said i've got weak biceps you would say like okay great
::no worries we'll start with a lightweight weight and will strengthen up your
::biceps over time and pretty soon.
::You won't have weak biceps, you'll have strong biceps.
::The neck is no different. Start with a lightweight, build it up over time,
::bam, stronger neck. Now you don't have a weak neck.
::And so why is it important, right? Why is it important to do this?
::Well, when we, and coming to the study, the 2025 study and what they found.
::So the study was called cervical flexion posture during smartphone use was not
::a risk factor for neck pain, but low sweet sleep quality and insufficient levels
::of physical activity were a longitudinal investigation by Coheia et al.
::2025 in the Brazilian Journal of Physical Therapy. And I'll link to all the
::studies I'm going to mention here in the show notes.
::So basically what they did in this study was they got like 400,
::about 430 something people, 457 volunteers, male and female,
::between 18 and 65 years old without neck pain. And they...
::Objectively assessed their neck posture in sitting and in standing whilst using a smartphone.
::So they used an inclinometer, which is something that measures the angle of the neck.
::And then they followed them for a year and asked them about their neck pain.
::And what they found was something like 390-something people finished,
::396 people completed the one-year follow-up, and neck pain was reported by 10% of participants.
::I'm just going to read from the result here, quote, multiple logistic regression
::analysis showed that Tex-Nec did not increase the chance of neck pain standing
::or sitting or the frequency of neck pain sitting or standing after baseline.
::However, low sleep quality and
::insufficient level of physical activity increased the chance of neck pain.
::Now, low sleep quality had an odds ratio of 1.76.
::What that means is people who reported that they had low sleep quality were
::1.76 times more likely, so almost double as likely to experience neck pain compared
::to people who didn't report poor sleep quality.
::An insufficient level of physical activity, which they defined as not meeting
::the physical activity guidelines...
::Had an odds ratio of 2.41 almost two
::and a half times more likely to experience neck
::pain so people who don't sleep well and don't exercise
::are way more likely and i don't know what the combination was of people who
::had both of those things uh you know what their odds ratio was but they're at
::least two and a half times more likely if they had both of those things to experience
::neck pain so what is that you know what do we draw from that what can we draw
::from that well firstly tech snack is just not a predictor of future neck pain.
::So this is a well-designed, prospective, longitudinal study design.
::So we looked at Tex-Neck at baseline and then looked at Tex-Neck being the neck
::posture at baseline, and then looked at neck pain over the subsequent years.
::So this study is quite well designed to illuminate causality or lack of causality.
::And we see zero correlation.
::Like they've literally found no correlation between the neck posture and people's
::neck pain or absence of neck pain.
::So what we can see from the study is a pretty large cohort, uh,
::is that there just was not a correlation between text neck and neck pain.
::So text neck does not cause neck pain. Now, is this a hundred percent certain?
::No, you can never be a hundred percent certain.
::And I'll leave my mind open for any future evidence that might emerge.
::But given the totality of evidence that we currently have in my mind,
::it seems like extremely unlikely that text neck does in fact cause neck pain.
::And, you know, when we take the, you know, other evidence that we have in this area,
::we find there was a 2023 systematic review in the Journal of Physical Therapy
::that found moderate certainty evidence
::that neck strengthening reduces the incidence of future neck pain.
::So having a, you know, and that aligns, right, with what we just found,
::what they just found in this 2025 paper, where low physical activity increases
::your chance of neck pain.
::Well, doing neck exercises decreases your chance of neck pain.
::You know, and for a lot of us, you know, intuitively that kind of,
::I'm sure, I imagine, makes a lot of sense, right?
::You know, if you're fitter and stronger, you're more resilient. And.
::And they also have a slightly older review from 2017 by Chen et al,
::which was a systematic review and meta-analysis of workplace interventions for neck pain.
::And they found that compared with ergonomics, stretching, breaks,
::postural interventions, the most effective intervention to reduce and prevent
::neck pain was targeted neck and shoulder strengthening.
::So targeting and strengthening the neck actually works best of anything we know,
::as well as getting a good night's sleep, to decrease the incidence of neck pain.
::So when we excessively protect our clients from loading their neck or moving the neck through range,
::when we avoid loading the neck, we actually are doing our clients a disservice.
::We are increasing their future odds of neck pain.
::When we focus excessively on alignment and think that that's going to protect
::them, it's not. It's not, it's not born out by the evidence.
::There's no evidence that neck alignment predicts future neck pain.
::Now, does that mean you shouldn't ever cue neck alignment? No,
::of course you should cue alignment in every exercise. I mean, that's what Pilates is.
::So this is, it's not about not saying like you should never cue people's position,
::but just don't attach it to the idea that you're somehow protecting them by
::putting them in a certain position or avoiding a certain position.
::Cause it's just not true.
::So both things can be true at the same time. It can be true that alignment doesn't
::predict injury. And it can also at the same time be true that it's valuable
::to cue alignment for other reasons, right?
::Which like, for example, going
::into flow state is a very good benefit of focusing on your technique.
::So I'm all for cueing position and alignment. And I'm all for the neck being
::neutral in certain exercises, like in a plank.
::Great. Have a neutral neck. That's where it's meant to be. When you're doing
::spine twist and you're sitting vertically, the neck should be stacked vertically.
::Like that's part of the movement.
::So this isn't, I'm not trying to discourage you from ever having people in a neutral spine.
::I'm not trying to discourage you from queuing neck alignment.
::But what I am trying to, I guess, discourage you from is telling people that
::certain positions or loads are bad or dangerous for the neck.
::You know, when I say certain positions, like, of course, if a semi-trailer ran
::over your neck, that's bad or dangerous, right? That's a lot of load.
::But the loads that we're typically likely to find in a Pilates class,
::like doing shoulder bridge with your headrest up,
::are just way, way within the envelope of what is completely safe for anyone
::who doesn't have osteoporosis, essentially, or some other kind of substantial pathology of the neck.
::So I guess...
::You know, neck pain is, you know, what I want to take,
::what I want you to take away from this, what I take away from this research
::and from this most recent study from 2025 on Tex neck and cervical flexion posture
::and neck pain is that, you know,
::neck flexion is normal, safe and unavoidable in real life.
::We do it all the time in real life.
::And, you know, load is not harmful.
::Insufficient capacity leaves us open to injury.
::So therefore, progressive neck loading through range builds resilience,
::just like in any other body part.
::Neutral cues can be useful for awareness, for entering a flow state,
::for building skill, but they're just not useful or helpful for protection.
::In fact, they can be counterproductive.
::So, you know, to foster and support adaptable, resilient,
::confident humans with the minimum amount of neck pain, load their necks through
::range progressively, starting with what they can tolerate and building it up gradually over time.
::Don't avoid in-range flexion. Don't avoid loaded extension. Don't avoid loaded
::flexion. Just build up their tolerance gradually over time. The neck is not special.
::It's just like any other body part. It's made of the same tissues.
::It adapts like every other body part. But if you want pain-resistant people,
::let them move their necks.
::Load them deliberately, progressively, gradually. Help them get stronger.
::Don't instill fear in your clients. Don't fear loading the neck yourself.
::Think of it like the biceps or the abs. It's just muscles and bones and ligaments
::and tendons. They all get stronger when loaded over time.
::Okay, dear listener, that's all I've got for you today. I hope you found that
::relaxing and it put you to sleep or I hope you found it stimulating and it woke
::you up and you're punching the air right now.
::Or maybe you just found it mildly interesting or entertaining.
::I hope it brought you joy in some form. Much love and I'll see you in the next one.
