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Journal of Back and Musculoskeletal Rehabilitation -1 (2016) 19 1

DOI 10.3233/BMR-160735
IOS Press

The clinical and EMG assessment of the

effects of stabilization exercise on nonspecific
chronic neck pain: A randomized controlled
trial
Fariba Ghaderia, Mohammad Asghari Jafarabadib and Khodabakhsh Javanshirc,
a
Physiotherapy Department, Faculty of Rehabilitation, Tabriz University of Medical Sciences, Tabriz, Iran

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b
Medical Education Research Center, Department of Statistics and Epidemiology, Faculty of Health, Tabriz

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University of Medical Sciences, Tabriz, Iran

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c
Mobility Impairment Research Center, Physiotherapy Department, Babol University of Medical Sciences, Babol,

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Iran
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Abstract.
BACKGROUND: Neck pain is an important cause of disability. In spite of its high prevalence rate, treatment of the disorder is
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a challenging topic. Stabilization exercise has been the topic of many studies.
OBJECTIVE: To compare the effects of stabilization and routine exercises on chronic neck pain.
METHODS: Forty patients were randomly assigned into either stabilization or routine exercise groups and undertook a 10-week
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training program. Electromyographic (EMG) activity was recorded from Sternocleidomastoid (SCM), Anterior Scalene (AS) and
Splenius Capitis (SC) muscles bilaterally. Endurance time of deep flexor muscles was measured by chronometer.
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Pain and disability were measured using Visual Analogue Scale (VAS) and neck disability index (NDI) questionnaire, respectively
before and after training period.
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RESULTS: Findings revealed significant decreased pain and disability in both groups after intervention (P < 0/001). Flexor
muscles endurance of stabilization group was significantly increased compared with that of routine (P < 0/001). Also EMG
activity of SCM, AS and SC muscles were significantly decreased in stabilization group compared with routine (P < 0/001).
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CONCLUSION: Increased deep flexor endurance and decreased EMG activity of SCM, AS and SC muscles suggest an impor-
tant role for stabilizing exercises on reducing the activity of superficial muscles in chronic neck pain.
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Keywords: Neck pain, electromyography, stabilization exercise

1 1. Introduction neck pain during their life [2]. Also, neck pain as a 5

prevalent disorder has a considerable economic impact 6

2 Neck pain is the second prevalent musculoskeletal on health care systems [2]. 7
3 disorder that is considered as an important cause of dis- In spite of high prevalence and important effects of 8
4 ablement [1]. About 67% of people may suffer from
neck pain on human life, its diagnosis and treatment is 9

a challenge even today [3,4]. The anatomic source and 10

Corresponding author: Khodabakhsh Javanshir, Mobility Impair- cause of neck pain is not clear in most cases, so the 11

ment Research Center, Physiotherapy Department, Babol Univer- treatment plan often is based on clinical findings [5]. 12
sity of Medical Sciences, Ganjafrooz Street, Babol 47176-47745,
Iran. Tel.: +98 11 2199594; Fax: +98 11 32225035; E-mail: kjavan- Use of red flags for potentially serious situations and 13

shir@yahoo.com. classifying nonserious conditions as simple or non- 14

ISSN 1053-8127/16/$35.00 
c 2016 IOS Press and the authors. All rights reserved
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2 F. Ghaderi et al. / The clinical and EMG assessment of the effects of stabilization exercise on nonspecific chronic neck pain

15 specific neck pain is an approach proposed by some 2. Methods and materials 66

16 researchers [6].
17 Neck muscles have important role in normal mobil- 2.1. Study design 67

18 ity and stability of cervical spine. The cervical mus-

An Experimental Randomized Controlled Trial 68
19 culature may be the source of pain as well. Docu-
(RCT) considering Consolidated Standards of Report- 69
20 ments suggest that weakness or fatigue of neck mus-
ing Trials CONSORT guidelines 70
21 cles may be related to neck pain [710]. According to
22 Panjabis model of stability, about 80% of spinal sta- 2.2. Subjects 71
23 bility is based on muscular activity [11]. Flexor and
24 extensor muscles of cervical spine are like a sleeve The participants were selected from accessible sam- 72

25 surrounding vertebrae anteriorly and posteriorly [12]. ple referred to Physiotherapy clinic of Rehabilitation 73

26 Impairment of Deep Cervical Flexors (DCF) as well Faculty of Tabriz University of Medical Sciences. With 74

27 as superficial and deep extensors of cervical spine respect to the criteria, they were randomly allocated in 75

28 in patients with neck pain is generally accepted [5]. two groups. Forty males and females with chronic neck 76

29 Also, different neuromuscular dysfunctions including pain participated in this study. 77

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30 decreased activity of deep flexors, increased activity Inclusion criteria were: (i) chronic neck pain without 78

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31 of superficial Sternoclidomastoid (SCM) muscle and neurologic signs for more than 12 weeks, (ii) Severity 79

of pain was not more than 6.5 (or 65 in mm) in Visual

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32 co-contraction of flexors and extensors (instead of co-
33 ordination) have developed in neck pain [5]. Studies Analogue Scale (VAS) to avoid exacerbation of pain 81

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with the strengthening exercises and (iii) right hand 82
34 utilizing Electromyography (EMG) demonstrated im-
dominancy. 83
35 paired co-ordination of deep and superficial cervical
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Exclusion criteria were: (i) history of surgery, frac- 84
36 flexors. The mentioned studies showed increased EMG
ture, trauma, fibromyalgia, disc herniation, or congeni- 85
amplitude of SCM and Anterior Scalene (AS) as su-
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37
tal deformities in neck or shoulder, (ii) history of treat- 86
38 perficial flexors and decreased amplitude of EMG of ments including exercise or manual therapy for neck 87
39 DCF muscles including longus colli and longus capi-
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or shoulder region or any other regular exercise, (iii) 88

40 tis [12,13]. Furthermore, delayed onset activity of both pregnancy and (iv) exacerbation of pain. 89
41 groups in rapid arm movement denoted changed feed- Ethical approval was granted by the Ethics Commit- 90
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42 forward control of cervical spine [14]. tee of Tabriz University of Medical Sciences. Written 91
43 Two different exercise methods are proposed for cer- consent from all participants was taken before partici- 92
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44 vical muscular impairment: general strengthening ex- pation. 93

45 ercise and a low-load exercise program to increase co- The study was done to compare neck spinal stabi- 94
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46 ordination between deep and superficial flexors [15]. lization exercises with routine exercises in improve- 95

47 Previous researches showed decreased cervical pain ment of neck pain and disability and EMG activity of 96
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48 with both exercise methods, but general strengthening selected muscles. 97

49 exercise resulted in less co-ordination between deep

2.3. Exercise interventions
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98
50 and superficial layers. Restoring endurance, strength,
51 and co-ordination of cervical muscles may tend to de-
Subjects were randomized into two groups, namely, 99
52 crease symptoms and prevent recurrence of the disease.
stabilization exercise group or routine exercise group 100
53 There are researches available regarding the effects of
using the randomized permuted blocks of size four. 101
54 low- load and strengthening exercises on cervical pain, The random sequence was generated using Random 102
55 but beside pain or disability as subjective variables, re- Allocation Software by the study statistician [16]. The 103
56 cent researches focused on objective variables such as study was not blinded. Exercise regimes were of 10- 104
57 muscle dimensions which are available on ultrasonog- weeks duration. Each treatment session took 3045 105
58 raphy images or characteristics of muscle contraction min and was done three times a week under the su- 106
59 which can be obtained using EMG devices. pervision of an experienced physiotherapist to evaluate 107
60 So as the first study to assess the effect of different and progress their graded exercises in both groups. 108
61 exercise programs on chronic neck pain (using EMG), All subjects received routine electrotherapy for 10 109

62 the aim of present study was to evaluate and com- sessions including Hot Pack (HP)/Transcutaneous Ele- 110

63 pare the effect of stabilization and routine exercise pro- ctrical Nerve Stimulation (TENS) for 20 min and ul- 111

64 grams on characteristics of muscle contraction includ- trasound (US) for paraspinal muscles for 10 min bilat- 112

65 ing: normalized EMG amplitude and relative latency. erally [17]. 113
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F. Ghaderi et al. / The clinical and EMG assessment of the effects of stabilization exercise on nonspecific chronic neck pain 3

114 2.3.1. Stabilization exercise group SC: 68 cm lateral to the C4 spine (almost 3 cm 158

115 Stabilization exercises targeted the deep flexor mus- inferior to mastoid process) [19]. 159

116 cles of neck rather than the superficial flexor muscles AS: In the direction of the muscle fibers running 160

117 emphasizing Craniocervical Flexion (CCF). parallel to the lateral border of the clavicular por- 161

118 In the first phase of training, the physiotherapist tion of SCM [20]. 162

119 asked the subject to perform a low and controlled CCF SCM: Over muscle belly, about 1/3rd of the length 163

120 test in the supine position using pressure biofeedback rostral to sternal attachment [19]. 164

121 (Stabilizer TM, Chattanooga Group, USA). AD: About 3 cm below the acromions anterior an- 165

122 The subject initially performed CCF test to sequen- gle [19]. 166

123 tially reach 5 from a baseline of 20 mmHg to the fi- The electrode placement was confirmed by manual 167
124 nal level of 30 mmHg. The physiotherapist controlled muscle testing of selected muscles. The ground elec- 168
125 the subjects not to use superficial neck muscles and trode was placed on the spine of C7. 169
126 identi?ed the target level which the subject could do Signals from Surface Electromyography (SEMG) 170
127 correctly. During 10 weeks of training, exercises were were recorded by ME6000 (Mega electronics Ltd, Fin- 171
128 done in different positions to reach the final level of land). Raw SEMG signal was recorded at the sam-

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129 CCF training. pling rate of 1,500 Hz, amplified (differential ampli- 173

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fier, CMRR > 100 dB, gain 1,000, noise < 1 uV), fil- 174

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130 2.3.2. Routine exercise group tered (using Butterworth filter, effective band width 1 175

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131 Routine exercises consisted of progressive resistive 500 Hz), converted with A/D board of 14 bit and stored 176

132 exercises. These isometric exercises performed with in a PC computer and analyzed by Megawin software. 177
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133 30% of Maximum Voluntary Contraction (MVC) in
134 different positions and progressed with neck postural 2.4.2. Signal analysis 178
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135 control exercises at the last weeks of training. Root Mean Square (RMS) of raw signal calculated 179

with 1 s sliding window and EMG signal amplitude of 180

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each muscle was expressed as a percentage of the 3 s 181

136 2.4. Outcome measures maximum RMS values obtained during a MVC test. 182

MVC test of each muscle was done according to the 183

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137 Primary outcome measures were: manual muscle test positions for 5 s and three times. 184

138 i) Normalized EMG amplitude (%MVC) of se- For calculating the relative latency of each muscle, 185
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139 lected muscles during five stages of CCF test. the onset time of RMS signal was determined using 186

mean + 3SD of baseline period. The onset points were

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187
140 ii) Relative latency (in milliseconds) between onset
141 of selected muscles and that of Anterior Deltoid controlled visually to confirm the validity of calculated 188

142 (AD) during rapid unilateral arm movements. point. Relative latency of each muscle was subtracted 189
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143 iii) Endurance time (in seconds) of deep flexor mus- from onset time of deltoid muscle during rapid move- 190

ments of arm. 191

144 cles in CCFT was measured by chronometer.
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145 Secondary outcome measures were: 2.5. Data analysis 192

146 i) Subjective report of pain on VAS.

147 ii) Disability on Persian validated version of Neck Data analysis was done by SPSS (Version 11.5) 193

148 Disability Index (NDI) [18]. software. To assess the normality of baseline data 194

KolmogorovSmirnov test (KS test) was done. 195

149 All measures were done before and after the inter-
Considering the age, height, weight, VAS, NDI and 196
150 vention period.
endurance variables, the independent t-test was done to 197

compare mean values between the two groups, before 198

151 2.4.1. Electromyography and after intervention. 199

152 After skin preparations and patient education, the To compare the mean values before and after inter- 200

153 surface Ag/AgCl electrodes were used to collect EMG vention and within group analysis, paired t-test was 201

154 signals from SCM, Splenius Capitis (SC), and AS conducted in each group. 202

155 bilaterally and anterior deltoid (AD) at the domi- Multivariate analysis of covariance (MANCOVA) 203

156 nant side. Electrode placement was done according to was conducted to compare the mean values of two 204

157 guidelines [19]: groups before and after intervention during five steps 205
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4 F. Ghaderi et al. / The clinical and EMG assessment of the effects of stabilization exercise on nonspecific chronic neck pain

Table 1
Baseline demographic and clinical characteristics of both groups (Mean and standard deviation)
Stabilization exercise group (n = 20) Control group (n = 20) p
Age (years) 35.97 2.5 36.34 3.06 0.30
Height (cm) 165.53 5.53 163.29 5.63 0.65
Weight (kg) 67.89 9.87 69.33 8.69 0.49
VAS (mm) 61.35 27.95 59.73 22.65 0.86
NDI (%) 31.25 12.11 34.26 14.26 0.97
Endurance (s) 19.53 14.78 20.56 13.68 0.81

206 of CCF test adjusting for baseline values or in consid- Our findings showed that activity level of SCM, AS 243

207 ering confounding factors. In all analyses, p < 0.05 and SC decreased significantly in stabilization exer- 244

208 was considered as statistically significant. cises group, whereas it increased significantly in rou- 245

tine exercises group. Based on Panjabis model of sta- 246

bility, about 80% of spinal stabilization is provided 247

209 3. Results by active element, the muscles [11]. There is different 248

role for deep and superficial muscles in stabilization.

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210 Descriptive characteristics and baseline data of sub- Deep muscles are segmental stabilizers, so they need to

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211 jects in two groups are presented in Table 1. provide stabilization between segments which is nec- 251

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212 According to KS test, all of the measured variables essary as a base for participation of superficial mus- 252

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213 had normal distribution (p > 0.05). cles [5]. Weakness of DCF reported in neck pain might 253

214 Baseline data and descriptive characteristics of the result in increased activity level of superficial flexor 254
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215 two groups were not different before intervention ac- muscles [5]. Previous studies on neck pain showed 255

216 cording to the independent t-test (p > 0.05). altered activity pattern for neck muscles as reduced 256
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217 Results of the comparison between two groups, be- deep muscles activity and increased superficial mus- 257

218 fore and after intervention during five steps of CCF test cles activity during cognitive tasks and functional ac- 258
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219 and relative latencies during shoulder flexion move- tivities. Also, increased activity of superficial flexors 259

220 ments are presented in bar charts (Figs 17). during isometric contraction has been reported in neck 260

221 Pre-post intervention changes in clinical findings of pain sufferers [14]. Lindstrom et al. found higher co- 261
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222 both groups are shown in Table 2 (p < 0.05). contraction of weak SCM and AS in patients with neck 262

pain related to pain and disability. Results of our study 263

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demonstrated different effects of stabilization exercises 264

4. Discussion and routine exercises on motor control of muscles in

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223 265

patients with neck pain [23]. 266

224 This study evaluated the effects of two different ex- According to present findings, stabilization exer- 267
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225 ercise methods including stabilization exercises and cise program may change motor strategy for recruit- 268

226 routine exercises on pain and perceived disability in ment of superficial flexors and extensors so that the 269
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227 chronic neck pain. Also, we assessed EMG changes of increased activity level of superficial muscles in pa- 270

228 superficial flexor and extensor muscles after the two tients with neck pain decreased significantly. However, 271

229 different exercise programs. as expected, routine exercise as known as strengthen- 272

230 Our results showed significant decrease of neck ing isometric exercise increased the activity level of 273

231 pain and perceived disability similarly in both exer- superficial muscles which is an unfavorable effect. On 274

232 cise groups without any significant difference between the other hand, findings revealed increased DCF mus- 275

233 two groups. According to the previous studies, there cle endurance in present study with stabilization exer- 276

234 is a positive effect on pain and disability for different cise. So decreasing superficial muscles activity in the 277

235 exercise programs [6,8,21,22]. As there is a general stabilization exercise group might be the direct result 278

236 weakness of different muscle groups in patients with of increasing the activity level of deep cervical mus- 279

237 neck pain, decrease of pain and disability was not un- cles [24]. 280

238 expected with both exercise program [6,8]. Our results We found a decreased latency for onset of con- 281

239 provided further evidence that both stabilization exer- traction of superficial neck muscles including AS, SC 282

240 cises and routine exercises could result in improvement and SCM, associated with arm movement after routine 283

241 of clinical symptoms in patients suffering from cervi- exercise program. Routine exercise program empha- 284

242 cal pain. sizes on general high-load contraction of cervical mus- 285
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F. Ghaderi et al. / The clinical and EMG assessment of the effects of stabilization exercise on nonspecific chronic neck pain 5

Table 2
Pre-post intervention changes in clinical findings of both groups
Stabilization group mean (SD) P# Control group P#
Before After Before After P$ P$$
VAS (mm) 61.35 (27.9) 21.73 (15.9) < 0.001 59.73 (22.6) 20.73 (11.3) < 0.001 0.444 0.488
NDI (%) 31.25 (12.1) 15.25 (9.3) < 0.001 34.26 (14.2) 18.54 (12.5) < 0.001 0.306 0.492
Endurance (s) 19.53 (14.7) 73.59 (17.7) < 0.001 20.56 (13.6) 41.23 (26.9) 0.365 0.436 0.083
Indicatessignificant difference between pre and post intervention data between two groups (P < 0.05); #: Based on Paired t test; $: Based on
independent t test for comaring two groups before intervention; $$: Based on Analysis of covariance for comaring two groups after intervention
and adjusting for baseline values.

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Fig. 1. Normalized RMS values (mean and standard error bars) for the right SCM muscle for each stage of the CCFT. indicates significant
difference between pre and post intervention data between two groups (p < 0.05).
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Fig. 2. Normalized RMS values (mean and standard error bars) for the left SCM muscle for each stage of the CCFT. indicates significant
difference between pre and post intervention data between two groups (p < 0.05).

286 cles [25]. Regarding further weakness of deep mus- gram of patients with neck pain is delayed onset time 291

287 cles compared with superficial ones, it is likely that of deep flexors including longuscapitis and longuscolli 292

288 superficial muscles which are stronger and faster, ini- muscles in association with rapid movement of upper 293

289 tiate movement before deeper muscles in routine ex- extremity [14]. In fact, it is expected to have a quick 294

290 ercise program. Another aspect of altered motor pro- onset for superficial muscles for cervical spine stability 295
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6 F. Ghaderi et al. / The clinical and EMG assessment of the effects of stabilization exercise on nonspecific chronic neck pain

Fig. 3. Normalized RMS values (mean and standard error bars) for the right AS muscle for each stage of the CCFT. indicates significant
difference between pre and post intervention data between two groups (p < 0.05).

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Fig. 4. Normalized RMS values (mean and standard error bars) for the left AS muscle for each stage of the CCFT. indicates significant difference
between pre and post intervention data between two groups (p < 0.05).
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Fig. 5. Normalized RMS values (mean and standard error bars) for the right SC muscle for each stage of the CCFT. indicates significant
difference between pre and post intervention data between two groups (p < 0.05).
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F. Ghaderi et al. / The clinical and EMG assessment of the effects of stabilization exercise on nonspecific chronic neck pain 7

Fig. 6. Normalized RMS values (mean and standard error bars) for the left SC muscle for each stage of the CCFT. indicates significant difference

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between pre and post intervention data between two groups (p < 0.05).

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Fig. 7. Pre-post intervention changes in relative latency of the selected muscles between two groups (mean and standard error bars) during arm
rapid movements. indicates significant difference between pre and post intervention data between two groups (p < 0.05).
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296 when the deep muscles are so weak to provide stability deep flexors. Therefore, it is expected to have increased 312
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297 of cervical spine. endurance of these muscles. 313

298 Our findings showed significantly increased deep Altered motor control in chronic neck pain has 314

299 flexor muscle endurance for stabilization exercise been reported in previous study [5]. Different aspects 315

300 group and also increased endurance for routine exer- were introduced as altered motor control including co- 316

301 cise group. Although difference for endurance was not contraction of agonistic muscles [27], more activity for 317

302 significant between the groups, but as mentioned in the superficial flexors and extensors [28], delayed onset 318

303 Result section, the p value was 0.08 which implies an time for neck muscles [14] and weakness of deep mus- 319

cles [5]. The results of current study emphasizes on im- 320

304 important difference between the two groups, meaning
portance of specific exercise program to target the deep 321
305 that stabilization exercise might improve the deep mus-
flexors firstly and then superficials. 322
306 cle endurance. Decreased endurance of deep flexors in
307 neck pain was reported in many previous studies [26].
308 Deep or postural spinal muscles are planned for contin- 5. Limitations 323
309 uous low-load contraction to provide stability of spine
310 in different positions. In stabilization group, firstly, we In this study, it was not possible to record fine wire 324

311 emphasized on low load co-ordinated contraction of EMG activity of deep muscles. But it would be better if 325
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8 F. Ghaderi et al. / The clinical and EMG assessment of the effects of stabilization exercise on nonspecific chronic neck pain

326 ultrasonography or fine wire EMG was used to record [7] Kristjansson E, Leivseth G, Brinckmann P, Frobin W. In- 372

327 deep muscles of neck. creased sagittal plane segmental motion in the lower cervical 373
spine in women with chronic whiplash-associated disorders, 374
328 However, participants with moderate symptoms with grades III: A case-control study using a new measurement 375
329 a severity of pain not more than 6.5 on VAS were cho- protocol. Spine 2003. 28(19): 2215-21. 376

330 sen to avoid exacerbation of pain with the strengthen- [8] Silverman JL, Rodriquez AA, Agre JC. Quantitative cervical 377

331 ing exercise, therefore, acute patients with neck pain flexor strength in healthy subjects and in subjects with me- 378
chanical neck pain. Arch Phys Med Rehabil 1991; 72: 679-81. 379
332 were omitted in our study. The training period of time [9] Kristjansson E. and H Jonsson Jr. Is the sagittal configuration 380
333 was 10 weeks, thus some of the patients were not ac- of the cervical spine changed in women with chronic whiplash 381

334 cepted to complete these weeks of treatment. syndrome? A comparative computer-assisted radiographic as- 382
sessment. J Manipulative Physiol Ther 2002; 25(9): 550-5. 383
335 We didnt take menstruation into account in assess-
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336 ment sessions. But it can be a confounding factor and covery is not automatic after resolution of acute, first-episode 385
337 we recommend to be considered in future studies. low back pain. Spine 1996; 21(23): 2763-9. 386
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tral zone and instability hypothesis. J Spinal Disord 1992; 388
5(4): 390-6; discussion 397. 389
338 6. Recommendation [12] Mayoux-Benhamou MA, Revel M and Vallee C. Selective 390

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electromyography of dorsal neck muscles in humans. Exp 391

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Brain Res 1997; 113(2): 353-60. 392
339 Utilizing ultrasonography or fine-wire electrodes to
[13] Rezasoltani A, Ylinen J, and Vihko V. Isometric cervical ex-

si
393
340 record deep muscles may tend to provide clearer re- tension force and dimensions of semispinalis capitis muscle. 394
sults. Ultrasonography is easier and safer than fine-

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341 J Rehabil Res Dev 2002; 39(3): 423-8. 395

342 wire electrodes. Furthermore, synchronization of elec- [14] Falla D, Jull G, and Hodges PW. Feedforward activity of the 396
cervical flexor muscles during voluntary arm movements is 397
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343 tro goniometer and EMG may enable researchers to ex- delayed in chronic neck pain. Exp Brain Res 2004; 157(1): 398
344 plain motor pattern of deep and superficial muscles in 43-8. 399
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345 CCF test. [15] Falla D, Jull G, Russell T, Vicenzino B and Hodges P. Effect 400
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[16] Asghari-Jafarabadi M, Sadeghi-Bazargani H. Randomization: 403

346 Acknowledgment Techniques and Software Aided Implementation in Medical 404
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ed

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348 cellor for Research (VCR) at Tabriz University of of chronic low back pain with transcutaneous electrical nerve 408
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349 Medical Sciences. stimulation, interferential current, electrical muscle stimula- 409
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33. 411
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