Prevalence of Forward Head Posture in Electronic Gamers and Associated Factors: Esports Medicine

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Prevalence of Forward Head Posture in Electronic Gamers and Associated Factors: Esports Medicine

In the field of esports medicine, there are many common issues seen. Forward Head Posture (FHP), characterized by hyperextension and forward translation of the upper cervical vertebrae, can lead to symptoms such as craniofacial pain, cervicogenic headaches, neck pain, shoulder pain, and decreased range of motion and tenderness of the neck and shoulders and is a common diagnosis. Lowering one’s head below eye level for extended periods of time has been shown to lead to forward head posture. Given the association of this type of head posture with electronic gamers, the purpose of this study was to assess the prevalence of FHP in e-gamers in Malaysia and evaluate any associated conditions and predispositions.

In 2020, Ashok, Purushothaman, and Muniandy published this cross-sectional study that evaluated 160 e-gamers for FHP and associated risk factors. Inclusion criteria included age 18-40 and  playing games for 1+ hours per day on Xbox, PlayStation, desktop, or laptop. Exclusion criteria included known musculoskeletal spinal deformities, previous spinal injuries, and congenital anomalies. The craniocervical angle (CCA) was measured for each participant as the angle between a line from the spinous process of C7 to the tragus of the ear and a line parallel to the ground at the level of C7’s spinous process. These landmarks were determined by the same physiotherapist, using pictures taken laterally by a webcam. Participants also provided information regarding their smoking status, hours of playing per day, usage of a posture chair, and several other factors. Normality was tested with the Shapiro-Wilk test. Cross tabulation was used to measure the prevalence of FHP, and Pearson’s correlations were measured to establish associations between FHP and risk factors.

The results of this study indicated that most gamers with FHP are female, aged 21-25, and play for 3+ hours. There was no correlation between the system/console use and FHP (p = 0.97) or taking breaks between gaming and FHP (p = 0.31). There was a moderate correlation between duration of gaming and FHP (p <  0.01).

The authors suggested that females may be more prone to developing FHP, as they develop a few more degrees of neck flexion compared to males. They also proposed that smokers are predisposed to FHP as smoking damages muscles, increases inflammation, and decreases endurance capacity of neck flexors and extensors. They suggest that prolonged muscle activity leads to muscle fatigue and FHP due to increased intramuscular pressure and electrolyte homeostasis disruptions.

Some pros of this study include using the same physiotherapist to measure the landmarks for the CCA, accounting for bias, as well as stratifying based on the device/console used, which helps shed light into the different postures used for different consoles. However, the authors did not define the CCA used to determine FHP, nor did they correlate CCA with risk factors. The authors also included participants who lie down when they play, which involves a completely different posture compared to the rest of the participants. There was also limited data for several categories, including aged 26-30, Xbox players, and participants who sit on a sofa. Finally, the authors did not account for the number of years spent gaming, how FHP changes throughout a gaming session, or if they experienced symptomatic FHP.

Future studies can look into differentiating further between the types of games played and types of controllers used. The differences between handheld controllers and arcade stick-type controllers would be especially interesting. The CCA could also be measured dynamically over the course of a gaming session to evaluate fatigue of the neck muscles and subsequent compensatory posturing. Posture modifications can be explored regarding their effects on CCA and FHP. Finally, should FHP become symptomatic, treatment options can be explored in randomized control trials, evaluating methods such as decreasing the number of hours played per day or quitting smoking.

Unfortunately, not many conclusions or real-world applications can be made from this article, though this study does provide some risk factors that may predispose to FHP, mainly female gender, smoking, and using a laptop.

Clinical Takeaways for Health or Performance Professionals in Esports:

  • Educate gamers on the potential risks of Forward Head Posture (FHP) and its associated symptoms, including craniofacial pain, cervicogenic headaches, neck pain, shoulder pain, and decreased range of motion and tenderness of the neck and shoulders.
  • Encourage gamers to maintain good posture during gaming sessions, including keeping their head aligned with their spine and avoiding hyperextension and forward translation of the upper cervical vertebrae. This can help prevent the development of FHP.
  • Consider the duration of gaming sessions as a potential risk factor for FHP. Longer gaming sessions may increase the risk of developing FHP, so it may be beneficial to encourage gamers to take breaks, stretch, and change their posture periodically during extended gaming sessions.
  • Consider the type of gaming console or device used as a potential factor in FHP development. Different consoles may require different postures, so it may be helpful to evaluate and educate gamers on the optimal posture for their specific gaming setup.
  • Consider the dynamic changes in neck posture and muscle fatigue during gaming sessions. Future studies could investigate how neck posture changes over the course of a gaming session and how muscle fatigue may contribute to the development of FHP. This information can help inform posture modification strategies for gamers.
  • Continue to conduct research on FHP in esports, including differentiating between types of games played, types of controllers used, and other relevant factors. This can help further understand the risk factors and optimal strategies for prevention and treatment of FHP in the gaming population.

In conclusion, as FHP is a potential health issue among esports gamers, health or performance professionals should be aware of the risk factors and symptoms associated with FHP, and provide education, interventions, and further research to prevent and manage this condition in the gaming population.


Ashok, Kenneth & Purushothaman, Vinosh Kumar & Muniandy, Yughdtheswari. (2020). Prevalence of Forward Head Posture in Electronic Gamers and Associated Factors.

Summarized by Arjun Malhotra

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