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Manual Therapy xxx (2015) 1e9

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Can neck exercises enhance the activation of the semispinalis cervicis


relative to the splenius capitis at specific spinal levels?
Jochen Schomacher a, Joachim Erlenwein b, Angela Dieterich b, Frank Petzke b,
Deborah Falla b, c, *
a
Alte Landstrasse 142, Küsnacht ZH, Switzerland
b
Pain Clinic, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Go€ttingen, Go
€ttingen, Germany
c
Department of Neurorehabilitation Engineering, Bernstein Focus Neurotechnology (BFNT) Go €ttingen, Bernstein Center for Computational Neuroscience,
University Medical Center Go€ttingen, Georg-August University, Go
€ttingen, Germany

a r t i c l e i n f o a b s t r a c t

Article history: The deep cervical extensor, semispinalis cervicis, displays changes in behaviour and structure in people
Received 26 August 2014 with chronic neck pain yet there is limited knowledge on how activation of this muscle can be
Received in revised form emphasized during training. Using intramuscular electromyography (EMG), this study investigated the
31 March 2015
activity of the deep semispinalis cervicis and the superficial splenius capitis muscle at two spinal levels
Accepted 8 April 2015
(C2 and C5) in ten healthy volunteers during a series of neck exercises: 1. Traction and compression, 2.
Resistance applied in either flexion or extension at the occiput, at the level of the vertebral arch of C1 and
Keywords:
of C4, and 3. Maintaining the neck in neutral while inclined on the elbows, with and without resistance at
EMG
Semipsinalis cervicis
C4. The ratio between semispinalis cervicis and the splenius capitis EMG amplitude was quantified as an
Splenius capitis indication of whether the exercise could emphasize the activation of the semispinalis cervicis muscle
Therapeutic exercise relative to the splenius capitis. Manual resistance applied in extension over the vertebral arch empha-
Cervical spine sized the activation of the semispinalis cervicis relative to the splenius capitis at the spinal level directly
caudal to the site of resistance (ratio: 2.0 ± 1.1 measured at C5 with resistance at C4 and 2.1 ± 1.2
measured at C2 with resistance at C1). This study confirmed the possibility of emphasizing the activation
of the semispinalis cervicis relative to the splenius capitis which may be relevant for targeted exercise
interventions for this deep extensor muscle. Further studies are required to investigate the clinical ef-
ficacy of these exercises for people with neck pain.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction In contrast to the similar effects on clinical symptoms, neuro-


muscular changes in response to training are typically specific to
Exercise is an effective treatment for people with chronic neck the mode of exercise performed. For instance, craniocervical flexion
pain (Miller et al., 2010). Several neck exercises have been shown to exercise, designed to emphasise the activation of the deep cervical
alleviate pain including motor control training (Jull et al., 2002; flexors and minimise activation of the superficial flexors (Jull et al.,
Falla et al., 2013) and resistance training (Bronfort et al., 2001; 2008; Falla et al., 2012) enhances the activation of the deep cervical
Ylinen et al., 2003) probably by facilitating endogenous analgesia flexors (Jull et al., 2009) which are often less activated in patients
via different mechanisms (Bialosky et al., 2009). Furthermore, ex- with neck pain (Falla et al., 2004). Moreover, this exercise reduces
ercise may have positive psychological effects including reduced the activation of the sternocleidomastoid muscle (Jull et al., 2009)
pain castastrophizing (Slepian et al., 2014). Therefore various which is often overactive in association with reduced deep cervical
training approaches are appropriate for pain management. flexor activity (Falla et al., 2004; O'Leary et al., 2011b). Enhanced
activation of the deep cervical flexor muscles was not achieved with
general resistance training of the neck (Falla et al., 2007a; Jull et al.,
2009), despite comparable changes in pain.
* Corresponding author. Pain Clinic, Center for Anesthesiology, Emergency and
The deep cervical extensor muscle, semispinalis cervicis, may
€ ttingen, Robert-Koch-Str. 40, 37075,
Intensive Care Medicine, University Hospital Go
Go€ ttingen, Germany. Tel.: þ49 (0) 551 3920109; fax: þ49 (0) 551 3920110. also display reduced activation in people with neck pain
E-mail address: deborah.falla@bccn.uni-goettingen.de (D. Falla). (Schomacher et al., 2012b, 2013; Schomacher and Falla, 2013).

http://dx.doi.org/10.1016/j.math.2015.04.010
1356-689X/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Schomacher J, et al., Can neck exercises enhance the activation of the semispinalis cervicis relative to the
splenius capitis at specific spinal levels?, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.04.010
2 J. Schomacher et al. / Manual Therapy xxx (2015) 1e9

Moreover, studies have shown higher levels of superficial extensor Ethical approval for the study was granted by the ethics com-
muscle activation in people with neck pain including that of the mittee of the medical faculty of the Georg-August-University,
splenius capitis (e.g. Lindstrom et al., 2011). Training of the deep Go€ttingen, Germany (21/2/14). All procedures were conducted ac-
spinal muscles is generally considered to be an important compo- cording to the Declaration of Helsinki. All subjects provided
nent of a multimodal intervention for low back (Hodges et al., 2013) informed consent.
and neck pain (Jull et al., 2008). Yet there is limited knowledge on
how the activation of the deep semispinalis cervicis can be facili- 2.2. Electromyography
tated with training whilst minimising the activation of the splenius
capitis muscle, that is, an exercise analogous to craniocervcal Intramuscular EMG was acquired from the semispinalis cervicis
flexion exercise used to emphasize the activation of the deep cer- and splenius capitis muscles at the level of the 2nd and 5th spinous
vical flexor muscles relative to the superficial flexors. processes on the right side (Fig. 1). Teflon-coated stainless steel fine
A recent study showed that the activity of the semispinalis wire electrodes (diameter: 0.1 mm) were inserted in each muscle
cervicis recorded at the level of C3 can be enhanced relative to using a prefabricated 27-gauge hypodermic needle with a single
the splenius capitis in patients with chronic neck pain by wire inside (SEI EMG s.r.l., Cittadella, Italy). Approximately 3e4 mm
applying localized resistance over the vertebral arch of C2 of insulation was removed from the tip of the wire to obtain an
compared to resistance applied at the head and over C5 interference EMG signal, which was acquired in referenced
(Schomacher et al., 2012c). However, measurements were per- monopolar mode. Needle insertion was guided by ultrasound (Lee
formed at one spinal level only (C3), and given that synaptic et al., 2007) (LS 128, Telemed, Vilnius, Lithuania) with a linear
input is distributed independently and non-uniformly to transducer (HL9.0/40) set between 8 and 9 MHz. Ultrasound is a
different fascicles of the semispinalis cervicis (Schomacher et al., reliable tool to visualize the neck muscles (Kristjansson, 2004;
2012a), it is necessary to consider whether the activity of the Stokes et al., 2007).
semispinalis cervical can be enhanced relative to the splenius Subjects were lying prone with the head in a slightly flexed
capitis at different spinal levels. position. The ultrasound transducer was placed transversally lateral
Emphasizing the activation of muscles at selected spinal levels to the spinous processes of C2 and C5 to image the extensor mus-
may be clinically relevant since movement dysfunction is often cles. The identification of the echogenic (bright, reflective) laminae
observed at single segments. For example, the physiological limits and the spinous process are the main bony landmarks for locating
of extension are often exceeded in the lower cervical spine during the cervical extensors which are separated by echogenic fascia
whiplash trauma (Bogduk and Yoganandan, 2001) causing facet layers (Stokes et al., 2007). The deep cervical artery was visualized
joint injuries most frequently in C5eC6 and C6eC7 segments with Doppler sonography prior to needle insertion. It lies in the
(Pearson et al., 2004). Furthermore, people with traumatic onset of fascia separating semispinalis capitis from semispinalis cervicis
neck pain have an increased prevalence of combined rotational and muscle. Following an exploratory scan of the muscles and the ar-
translational hypermobility in the segments C3e4 to C5e6 tery, the spinous process of the second cervical vertebrae was
(Kristjansson et al., 2003). In addition, reduced cross sectional area located by palpation as the first bony landmark caudal to the
was noted for the semispinalis cervicis muscle at the spinal levels of occiput. Similarly, the spinous process of the fifth cervical vertebrae
C3, C5 and C6 levels in people following a whiplash injury (Elliott
et al., 2008). Considering possible changes in semispinalis cervicis
activation and structure in people with neck pain, targeted exercise
interventions to enhance the activation of the semispinalis cervicis
muscles may be relevant.
In this descriptive and exploratory study we evaluate the acti-
vation of the semispinalis cervicis and splenius capitis muscles at
two spinal levels (C2, C5) in healthy volunteers during various neck
exercises. The aim was to evaluate whether neck exercise could
enhance the activation of the semispinalis cervicis relative to the
splenius capitis muscle thus the ratio between the amplitude of
activity of the semispinalis cervicis and the splenius capitis muscle
was calculated and compared across exercises.

2. Methods

2.1. Participants

Ten healthy volunteers (3 men and 7 women; age, mean ± SD:


30.7 ± 7.4 years; height: 170.0 ± 8.8 cm; weight: 67.6 ± 24.8 kg)
were recruited from the University Medical Center Go € ttingen,
Germany, via e-mail and advertisements on the university's notice
board. The experiment was conducted at the Laboratory for Spinal
Pain Research, Center for Anesthesiology, Emergency and Intensive
Care Medicine, University Hospital Go € ttingen, Germany.
Subjects were included if they were aged between 18 and 50
years and free of any neck pain. Subjects were excluded if they had
any complaints of neurological symptoms, a history of cervical
spine surgery, any known risk of infection following needle inser- Fig. 1. Illustration of the electrode locations in the semsispinalis cervicis and splenius
tion or of coagulation disorders, and if they were taking medica- capitis muscles at the level of the 2nd and 5th cervical vertebrae (C2 and C5
tions which could affect coagulation, such as aspirin. respectively).

Please cite this article in press as: Schomacher J, et al., Can neck exercises enhance the activation of the semispinalis cervicis relative to the
splenius capitis at specific spinal levels?, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.04.010
J. Schomacher et al. / Manual Therapy xxx (2015) 1e9 3

was identified. Although reliability and validity of the palpatory 2.4. Signal analysis
location of cervical spinous processes may be poor (Robinson et al.,
2009) it was considered sufficient for the purpose of this study. The amplitude of the EMG was estimated as the root mean
Marks were placed with a surgical pen on the left side of C2 and C5 square (RMS) of the signal in non-overlapping intervals of 250 ms
spinous processes, and 1.5 cm to the right of the midline at the level and averaged over each 10 s contraction. The average RMS
of the occiput and approximately C7. The crossing of the imaginary computed during each exercise was obtained as an average across
extension of these lines indicated the insertion points. the two repetitions of each exercise and was normalized with
The needle was inserted without skin anesthesia at the spinal respect to the peak RMS (non-overlapping intervals of 250 ms,
levels C2 and C5 vertically into the semispinalis cervicis muscle 10 ms increments) obtained during the MVC and expressed as a
(Kramer et al., 2003) and at a 45 angle into the splenius capitis, percentage. Since the manual resistance could not be standardized
2e3 mm caudal to the former one. Once the needle tip was iden- across conditions, the ratio between the normalized RMS of the
tified in the target muscle belly via ultrasound, the needle was semispinalis cervicis and splenius capitis muscle was also calcu-
removed leaving the wire in the muscle for the duration of the lated and compared across conditions, an approach performed
experiment. Needle insertion was performed under sterile pro- previously (Schomacher et al., 2012c) to evaluate the relative acti-
cedures and the ultrasound transducer was enclosed in a sterile vation of different neck muscles when force cannot be
plastic envelope. standardised.
A reference surface electrode for each wire was placed adja-
cently (mastoid process, spinous process C7 for the levels C2 and C5 2.5. Statistical analysis
respectively) and a further common reference electrode was placed
around the wrist. EMG signals were amplified (EMG-USB2, 256- A three way ANOVA (Analysis of Variance) was conducted on the
channel EMG amplifier, OT Bioelettronica, Torino, Italy; normalized RMS values for seminspinalis cervicis and splenius
10 Hze450 kHz), sampled at 2048 Hz, and converted to digital form capitis, both at C2 and C5, with direction (flexion, extension),
by a 12-bit analog-to-digital converter. location of resistance (occiput, C1, C4) and muscle (seminspinalis
cervicis, splenius capitis) as factors. Furthermore, a two way ANOVA
2.3. Procedure was conducted to evaluate the ratio between semispinalis cervicis
and splenius capitis activity, both at C2 and C5, with factors di-
Following electrode placement, the participant was seated in a rection (flexion, extension) and location of resistance (occiput, C1,
device for the measurement of neck muscle force (Cervical-Multi C4). A t-test for dependent samples was used to compare the ratio
Unit, BTE Technologies, USA). Their back was supported, the pelvis between semispinalis cervicis and splenius capitis muscle activity
strapped to the seat with a belt and their hands resting in a relaxed across the following two conditions: the ratio of muscle activity
position on the thighs. The occiput was positioned against the recorded at the level of C2 when resistance was applied in exten-
frame of the device. sion at the level of C1 versus the ratio of muscle activity at C5 when
Following a period of familiarization with the measuring device, resistance was applied in extension at the level of C4.
three isometric maximal voluntary contractions (MVC (Maximal A three way ANOVA was used to compare the normalised RMS of
Voluntary Contraction)) of neck extension were performed each the semispinalis cervicis and splenius capitis during traction and
lasting ~ 5 s, separated by 30 s rest. Verbal encouragement was compression with direction of force (traction, compression), level
provided to the subject. The highest value of force recorded over (C2, C5) and muscle (seminspinalis cervicis, splenius capitis) as
the 3 maximum contractions was selected as the maximal force. factors. A two way ANOVA was used to compare the ratio of sem-
Then subjects performed isometric exercises against manual inspinalis cervicis and splenius capitis muscle activity with condi-
resistance in sitting resisting axial traction and compression tion (traction, compression) and level (C2, C5) as factors.
(Fig. 2), extension and flexion (Fig. 3) and, standing in front of a A three way ANOVA was used to compare the normalised RMS of
table propped up on both forearms, in extension (Fig. 4). For a full the semispinalis cervicis and splenius capitis during extension
description of the exercises see Appendix 1. Each exercise was while leaning on elbows with condition (no resistance, resistance),
repeated twice and each was sustained for ~10 s during which EMG level (C2, C5) and muscle (seminspinalis cervicis, splenius capitis)
activity was recorded. The intensity of the resistance was applied as factors. Finally, a two way ANVOA was used to compare the ratio
with the maximal force that each subject could counteract without of seminspinalis cervicis and splenius capitis muscle activity with
discomfort e.g. from the investigators hand/fingers over the neck. condition (no resistance, resistance) and level (C2, C5) as factors.

Fig. 2. The subject was seated upright comfortably on a chair with their back supported and their hands resting in a relaxed position on their thighs. The therapist applied traction
(A) and compression (B) of the cervical spine asking the subject to resist and to pull the head downwards or push it upwards respectively.

Please cite this article in press as: Schomacher J, et al., Can neck exercises enhance the activation of the semispinalis cervicis relative to the
splenius capitis at specific spinal levels?, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.04.010
4 J. Schomacher et al. / Manual Therapy xxx (2015) 1e9

Fig. 3. The therapist stabilized the patients trunk with one hand and provided resistance with the other hand in extension at the occiput (A), at the level of the vertebral arch of C1
(B) and C4 (C) and in flexion at the occiput (D), against the ventral aspect of the right transverse process at the level of C1 (E) and C4 (F). The subject was asked each time to resist
and to hold the head/neck still.

Significant differences revealed by ANOVA were followed by of normalized RMS for both muscles, at both levels compared to
post-hoc Student-Newman-Keuls (SNK) pair-wise comparisons. compression (SNK: P < 0.01) (Fig. 5 A,B). No differences were
Results are reported as mean and SD. Statistical significance was set observed between muscles or between spinal levels. The ratio of
at P < 0.05. semispinalis cervicis and splenius capitis muscle activity showed
no difference between levels or between conditions (compression,
3. Results traction).

The normalised RMS values and the ratio between both muscles 3.2. Extension and flexion: normalized RMS
are presented in Table 1 for all exercises.
At the level of C2, the normalized RMS values for the semi-
3.1. Traction and compression spinalis cervicis and splenius capitis muscles were dependent on
the location of resistance (F ¼ 67.0, P < 0.0001) with higher muscle
The amplitude of muscle activity was dependent on the direc- activity observed for both muscles when resistance was applied at
tion of resistance (F ¼ 18.2, P < 0.01); traction evoked higher values the occiput versus C1 and C4 (SNK: both P < 0.0001) and when

Fig. 4. The subject was standing in front of a table and was propped up on both forearms with the head, neck and trunk aligned (A). Resistance in extension was then applied with
the thumb and index finger over the vertebral arch of C4 in a ventral-cranial direction (B). The subject was asked to push back with their neck and not with the head.

Please cite this article in press as: Schomacher J, et al., Can neck exercises enhance the activation of the semispinalis cervicis relative to the
splenius capitis at specific spinal levels?, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.04.010
J. Schomacher et al. / Manual Therapy xxx (2015) 1e9 5

Table 1
Mean ± SD of the normalized RMS values (%) recorded for the semispinalis cervicis (SCerv) and splenius capitis (SCap) muscles measured at the spinal levels of C2 and C5 and
the ratio between SCerv/SCap EMG amplitude (ratio > 1 indicating higher activation of SCerv) for each exercise.

Exercise Normalised RMS(%) Ratio

SCerv C2 SCap C2 SCerv C5 SCap C5 C2 C5

Traction 20.1 ± 15.1 17.9 ± 11.0 20.5 ± 16.2 21.8 ± 13.3 1.2 ± 0.5 1.0 ± 0.6
Compression 14.9 ± 16.6 10.7 ± 12.2 12.9 ± 18.2 14.1 ± 11.9 1.8 ± 1.4 1.5 ± 2.2

Ext. Occ 50.0 ± 16.1 47.9 ± 18.3 54.7 ± 21.1 51.5 ± 14.8 1.2 ± 0.7 1.1 ± 0.4
Ext. C1 26.4 ± 15.2 17.4 ± 12.2 27.6 ± 15.0 21.6 ± 8.18 2.1 ± 1.2 1.3 ± 0.7
Ext. C4 12.6 ± 16.3 9.8 ± 11.6 24.8 ± 16.7 14.7 ± 10.8 1.4 ± 0.6 2.0 ± 1.1

Flx. Occ 43.8 ± 21.8 37.8 ± 14.8 12.2 ± 25.5 14.0 ± 13.1 1.3 ± 0.6 0.6 ± 0.5
Flx. C1 24.3 ± 18.6 20.1 ± 13.5 9.3 ± 20.0 11.6 ± 12.1 1.4 ± 0.9 0.6 ± 0.5
Flx. C4 20.3 ± 16.4 16.7 ± 11.5 8.9 ± 18.8 13.2 ± 12.6 1.4 ± 0.8 0.6 ± 0.4

Extension on elbows 20.9 ± 17.9 17.3 ± 12.3 22.2 ± 17.9 18.1 ± 11.2 1.2 ± 0.4 1.2 ± 0.5
Extension on elbows with resistance at C4 21.4 ± 17.8 19.7 ± 13.1 30.2 ± 17.5 28.5 ± 17.0 1.2 ± 0.6 1.7 ± 1.7

resistance was applied at C1 compared to C4 (SNK: P < 0.01) during muscle activity (F ¼ 6.9, P < 0.05). In general, resistance applied in
extension (Fig. 6 AeC) and flexion (Fig. 6 DeF) exercises. Further- the direction of extension yielded larger ratios, indicating
more, an interaction between direction and location of resistance increased activation of the semispinalis cervicis relative to the
was observed (F ¼ 9.6, P < 0.01). That is, resistance applied in splenius capitis compared to resistance in flexion (SNK: P < 0.05).
extension at the occiput resulted in the highest RMS values for both Furthermore, there was a main effect for location (F ¼ 4.4,
muscles compared to all other conditions (all SNK: P < 0.001) P < 0.05), with resistance at C1 producing higher ratios compared
(Fig. 6). Higher activity was also obtained with resistance in flexion to resistance at either the occiput or at C4 for extension and for
at the occiput compared to extension at C1 (SNK: P < 0.001), and flexion exercises (both SNK: P < 0.05). No interaction was
extension at C4 (SNK: P < 0.001) with no difference between observed between direction and location of resistance at this level
muscles (F ¼ 2.8, P ¼ 0.12). (P ¼ 0.16).
At the level of C5, the normalized RMS values for the semispinalis At the level of C5, a main effect of direction was also observed for
cervicis and splenius capitis muscles were also dependent on the the ratio between semispinalis cervicis and splenius capitis muscle
location of resistance (F ¼ 53.6, P < 0.0001) with higher activity activity (F ¼ 34.9, P < 0.001) with greater ratios observed for
observed for both muscles when resistance was applied at the resistance in extension compared to flexion (SNK: P < 0.001).
occiput versus C1 and C4 (SNK: both P < 0.001) but not when Moreover, an interaction was observed between direction and
resistance was applied at C1 compared to C4 during extension (Fig. 6 location of resistance (F ¼ 3.7, P < 0.05). That is, the highest ratio
AeC) or flexion (Fig. 6 DeF) exercises. A main effect of direction was was observed when resistance was applied in extension at the level
observed (F ¼ 58.0, P < 0.0001), with higher activity for both muscles of C4, which was significantly greater than the ratios observed
observed when resistance was applied in extension compared to during all other exercises (compared to all conditions where
flexion (SNK: P < 0.001). Similar to the results obtained at the level of resistance was applied in flexion; SNK: P < 0.001, versus extension
C2, there was an interaction observed between direction and loca- at C1; SNK: P < 0.05, and extension at the occiput; SNK: P < 0.01).
tion of resistance (F ¼ 28.8, P < 0.0001). Resistance applied in The ratio obtained with extension resistance applied at C1 was also
extension at the occiput resulted in the highest RMS values for both greater than that observed for flexion resistance applied to the
muscles compared to all other conditions (all SNK: P < 0.001). occiput (SNK: P < 0.05).
A t-test for dependent samples showed no difference between
3.3. Extension and flexion: ratio between muscles the ratio of muscle activity recorded at the level of C2 when
resistance was applied in extension at the level of C1 versus the
At the level of C2, a main effect of direction was observed for ratio of muscle activity at C5 when resistance was applied in
the ratio between semispinalis cervicis and splenius capitis extension at the level of C4 (P ¼ 0.80).

Fig. 5. Mean and SD of the average normalized root mean square (RMS) values (%) of the semispinalis cervicis (SCerv) and splenius capitis (SCap) recorded at the spinal levels of C2
and C5 during traction (A) and compression (B).

Please cite this article in press as: Schomacher J, et al., Can neck exercises enhance the activation of the semispinalis cervicis relative to the
splenius capitis at specific spinal levels?, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.04.010
6 J. Schomacher et al. / Manual Therapy xxx (2015) 1e9

Fig. 6. Mean and SD of the average normalized root mean square (RMS) values (%) of the semispinalis cervicis (SCerv) and splenius capitis (SCap) recorded at the spinal levels of C2
and C5 during extension with resistance at the occiput (A), C1 (B) and C4 (C) and flexion with resistance at the occiput (D), C1 (E) and C4 (F).

3.4. Extension on elbows capitis muscle at different spinal levels for targeted exercise in-
terventions. The results confirm the possibility of emphasizing the
The normalized RMS values for both muscles were dependent activation of the semispinalis cervicis relative to the splenius
on the condition (F ¼ 7.2, P < 0.05) with higher muscle activity capitis.
when extension was performed against resistance at C4 (SNK:
P < 0.05) (Fig. 7A,B). Furthermore, an interaction was observed 4.1. Resistance in extension and flexion
between condition and level (F ¼ 4.9, P < 0.05) showing the highest
EMG amplitude of both muscles at the level of C5 when extension The activation of both muscles at both spinal levels was greatest
was performed against resistance at C4 (SNK: P < 0.05). However, when resistance was applied to the head, for flexion and extension,
no difference in the ratio of semispinalis cervicis and splenius compared to resistance over the vertebral arches. The longer lever
capitis activity was observed between conditions or levels. arm at the occiput relative to the levels of measurement likely re-
quires stronger activation of the extensor muscles for stabilization.
3.5. Comparison between exercises This is supported by the observation that resistance at C1 produced
higher muscle activity at C2 compared to resistance at C4 which has
Comparison of the ratio of semispinalis cervicis and splenius no direct lever on the level of C2. At the level C5 however, the
capitis between exercises are presented in Fig. 8. At the level of C2 resistance at C1 produced the same activity as resistance at C4
(Fig. 8A), resistance applied in extension at the level of C1 produced indicating that also other factors may influence muscle activation.
the highest ratio between the normalized RMS of the semispinalis Interestingly, resistance in flexion at the occiput yielded higher
cervicis and splenius capitis muscle compared to all other exercises activity in both extensor muscles at the level of C2 compared to
(F ¼ 2.1, P < 0.05; all SNK P < 0.05) except for compression resistance at C1 or C4 in extension and flexion. Similarly, resistance
(P ¼ 0.06), resistance at C4 (P ¼ 0.07) and resistance in flexion at C4 in flexion at C1 and C4 evoked higher activity at the level of C2
(P ¼ 0.06), despite trends. compared to resistance in extension at C4, even if the later exercise
At the level of C5 (Fig. 8B), resistance applied in extension at the would be expected to be more specific for an extensor muscle. This
level of C4 produced the highest ratio between the normalized RMS might be explained by coactivation of the cervical extensor muscles
of the semispinalis cervicis and splenius capitis muscle (F ¼ 2.5, as a strategy to stabilise the spine during isometric flexion. How-
P < 0.05; all SNK P < 0.05) compared to exercises with resistance in ever, direct comparison of the normalized RMS values between
flexion. conditions has limitations since the amount of resistance may have
differed across conditions.
4. Discussion The ratio between the semispinalis cervicis and splenius capitis
recorded at C2 was highest when resistance was applied in
This study evaluated, for the first time, the ability to enhance the extension at the level of C1 compared to resistance at the occiput or
activation the semispinalis cervicis muscle relative to the splenius C4. Similarly, when recorded at C5, the ratio of muscle activity was

Please cite this article in press as: Schomacher J, et al., Can neck exercises enhance the activation of the semispinalis cervicis relative to the
splenius capitis at specific spinal levels?, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.04.010
J. Schomacher et al. / Manual Therapy xxx (2015) 1e9 7

Fig. 7. Mean and SD of the average normalized root mean square (RMS) values (%) of the semispinalis cervicis (SCerv) and splenius capitis (SCap) recorded at the spinal levels of C2
and C5 during extension on elbows (A) and with additional resistance in extension at C4 (B).

highest with resistance in extension at C4 compared to the occiput


or C1. This is partially in line with previous observations of higher
activity of the semispinalis cervicis relative to the splenius capitis at
the level of C3 when resistance was applied in extension at the level
C2 compared to resistance at the occiput or at C5 in patients with
chronic neck pain (Schomacher et al., 2012c).
The current findings show that manual resistance placed over
the vertebral arch can emphasize the activation of the semispinalis
cervicis relative to the splenius capitis directly caudal to the loca-
tion of resistance compared to resistance applied at other locations.
This may be clinically relevant when movement dysfunction
(Kristjansson et al., 2003) or structural changes (Elliott et al., 2008)
are identified at specific segments.

4.2. Extension on elbows

The aim of this exercise is to emphasize activation of the lower


cervical extensor muscles (Jull et al., 2008). Therefore, for this ex-
ercise resistance was only applied at C4. As confirmed in the current
study, the additional application of resistance over the vertebral
arch of C4 further increased the activity of both muscles at both
levels but more so at C5 compared to C2. This exercise may be
useful for patients who present with a forward head posture (Falla
et al., 2007a) which requires extension of the lower cervical spine
for correction (O'Leary et al., 2009).
However, the ratio between the deep and superficial extensor
did not differ between conditions indicating that the additional
resistance did not further facilitate the semispinalis cervicis relative
to the splenius capitis muscle. Notably, the ratio of muscle activity
recorded at the level of C5 was higher compared to the exercises
when resistance was applied in flexion suggesting that extension
on elbows can nevertheless be used as an exercise to activate the
semispinalis cervicis in the lower cervical region.

4.3. Traction and compression

Higher activity for both muscles and at both spinal levels was
observed during traction compared to compression. Flattening of
the cervical lordosis occurs during traction (Panjabi et al., 1978)
which may prompt activation of all extensor muscles. Compression
on the contrary tends to increase the cervical lordosis, which
Fig. 8. Ratio between semispinalis cervicis (SCerv) and splenius capitis (SCap) nor-
cannot be limited by extensor muscle contraction. The activation of
malised EMG amplitude at the spinal levels of C2 (A) and C5 (B) during the different both the semispinalis cervicis and splenius capitis during
exercises. The horizontal lines indicate significant differences P < 0.05. compression may reflect coactivation with the cervical flexors

Please cite this article in press as: Schomacher J, et al., Can neck exercises enhance the activation of the semispinalis cervicis relative to the
splenius capitis at specific spinal levels?, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.04.010
8 J. Schomacher et al. / Manual Therapy xxx (2015) 1e9

muscles which are likely more activated (Falla et al., 2007b). the only way to perform this exercise as the application of bilateral
Anatomically, all muscles around the spine can limit destabilization resistance would imply the application of pressure over the throat.
of the cervical spine occurring during traction and compression. Apart from some slight pain during the insertion of the fine wire
This might explain why the ratio between muscles was not electrodes, the subjects did not experience pain during the exer-
different between the two conditions despite trends for greater cises thus pain did not have an influence on muscle activation.
selectivity of deep extensor activity during compression versus
traction. 5. Conclusion
Overall, the results of this study highlight the possibility of
inducing relative selective activation of different fascicles/regions This study showed that manual resistance applied in extension
of a muscle with exercise. This is line with previous studies over the vertebral arch emphasized the activation of the semi-
demonstrating a non-uniform distribution of muscle activity (e.g. spinalis cervicis muscle relative to the splenius capitis at the spinal
trapezius, lumbar erector spinae) with the possibility of activating level directly caudal to the site of resistance. These findings suggest
different muscle regions depending on the task performed (Falla that this exercise may be useful to enhance the activation of the
and Farina, 2008; Falla et al., 2014). seminspinalis cervicis muscle for targeted exercise interventions in
people with neck pain showing signs of impaired activation of this
muscle on clinical testing. Further studies are required to investi-
4.4. Methodological considerations gate the clinical efficacy of these exercises.

The invasive nature of the experiment limited the sample size Acknowledgement
and although small, it is in line with sample sizes in similar invasive
EMG studies (Blouin et al., 2007; Falla et al., 2010; Schomacher The authors are grateful to Dr. Leonardo Gizzi for his technical
et al., 2012c). New technologies such as muscle functional MRI assistance during the experiments.
(Magnetic Resonance Image) (O'Leary et al., 2011a) and tissue ve-
locity ultrasound imaging (Peolsson et al., 2014) might offer new
Appendix A. Supplementary data
ways of investigation in the future allowing larger samples.
The wires electrodes may have moved during the exercises but,
Supplementary data related to this article can be found at http://
due to the thinness of the wires, it was not possible to view their
dx.doi.org/10.1016/j.math.2015.04.010
location once the needle was removed. However, the hook at the
end of the wire reduced the possibility of movement. Execution of
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Please cite this article in press as: Schomacher J, et al., Can neck exercises enhance the activation of the semispinalis cervicis relative to the
splenius capitis at specific spinal levels?, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.04.010