Professional Documents
Culture Documents
M
usculoskeletal pain is the This is a major practical problem dur- The inclusion criteria were: (1) pain
most common condition ing rehabilitation because handgrip or discomfort in the neck/shoulder
treated by physical therapists and low back strength may become region for more than 30 days during
and contributes substantially to limiting factors in handling these the past year but no more than 3
health care costs and sick leave. The heavy weights in shrug exercises. bodily regions of pain or discomfort
occurrence of neck muscle pain has Furthermore, for home-based reha- in order to exclude generalized mus-
been increasing in recent decades.1 bilitation, it may be more convenient culoskeletal diseases; (2) the sub-
Neck pain originating from the up- to have dumbbells in the range of 3 ject’s pain or discomfort should be
per trapezius muscle (trapezius my- to 8 kg for exercises such as the rated at least “quite a lot” on a
algia) is common in female office lateral raise, reverse fly, and upright 5-point ordinal scale (“a little,”
workers and occurs in other occupa- row compared with 20 to 30 kg for “somewhat,” “quite a lot,” “much,”
tions that involve repetitive and mo- the shrug exercise. Therefore, it is and “very much”); (3) the pain or
notonous work tasks.2– 4 Sustained relevant to investigate whether other discomfort should be frequent (at
activity of low-threshold motor units strengthening exercises with lower least once a week on an ordinal scale
of the trapezius muscle day after day absolute weights but longer external of “seldom,” “once a week,” “2–3
leads to disturbances in the intramus- moment arms can induce levels of times per week,” “almost all the
cular biochemical milieu, and myal- muscle activation in the trapezius time”); and (4) the intensity of the
gia often develops.5–7 muscle that are as high as those of pain or discomfort should be rated at
the shrug exercise. least 2 on a scale from 0 to 9, where
Interventions that aim to relieve 0 is “no pain” and 9 is “the worst
muscle pain often involve physical The aim of this study was to deter- imaginable pain.”20 –22
activity,8 and various forms of phys- mine the level of muscle activation
ical training are known to relieve of the neck and shoulder muscles A clinical diagnosis confirmed that
neck muscle pain to a certain ex- with surface EMG during selected 69% of the questionnaire-defined
tent.9 –14 Recently, high-intensity strengthening exercises in women neck/shoulder cases had trapezius
strength (force-generating capacity) undergoing rehabilitation for trape- myalgia. The main clinical criteria for
training specifically for the neck and zius myalgia. This was done by com- trapezius myalgia were: (1) pain in
shoulder muscles for as little as 20 paring responses in 5 different types the neck area, (2) tightness of the
minutes 3 times a week was shown of exercise, all of which are thought upper trapezius muscle, and (3)
to markedly reduce pain in women to be effective in the activation of palpable tender spots in the upper
with trapezius myalgia.15 The results neck/shoulder muscles: (1) shrugs, trapezius muscle.2,23 Women with
of that study along with a recent re- (2) one-arm rows, (3) upright rows, serious conditions such as previous
view16 suggest that a high level of (4) reverse flys, and (5) lateral raises. trauma, life-threatening diseases, fi-
activation of the painful muscles (ie, bromyalgia, whiplash, or arthritis in
a high training intensity) plays an im- Materials and Method the neck and shoulder were ex-
portant role in the rehabilitation pro- Subjects cluded. The included subjects—all
cess. Based on functional anatomy of This study was part of a large inter- with a clinical diagnosis of trapezius
the neck/shoulder complex, it is vention study performed in Copen- myalgia—were randomly assigned to
likely that isolated shoulder eleva- hagen, Denmark, during the period 1 of 3 intervention groups, of which
tion (“shrugs”) is the most specific from September 2005 to March one group performed specific
exercise for the upper trapezius mus- 2006.15 Briefly, a questionnaire was strength training with the exercises
cle,17 a conclusion that also is sup- sent to 802 female workers between described below for 20 minutes 3
ported by electromyographic (EMG) the ages 30 and 60 years from 7 times a week with relative loadings
measurements.18,19 workplaces. The work tasks at these of their 8 –12 repetition maximum
companies were monotonous and (RM).
Shrug exercises, therefore, fre- repetitive, and 82% of the employees
quently are recommended to effec- worked at the computer for more In the present study, EMG measure-
tively target the trapezius muscle than three fourths of their working ments (mean⫾SD) were performed
during rehabilitation.18,19 However, time. Of these 802 workers, 306 on 12 of the women in the strength
the small external moment arm re- agreed to participate in the study, training group (mean age⫽43⫾9
sults in training weights that are 4 to 214 declined, and 282 did not reply. years, mean weight⫽73⫾13 kg,
5 times larger than those of other Out of the 306 positive replies, 48% mean height⫽166⫾7 cm). Based on
types of neck or shoulder exercises qualified as neck or shoulder cases the screening questionnaire replies
(eg, shoulder abduction exercises). based on the questionnaire replies. at baseline, 33% of subjects experi-
Intra-day Reliability
For each exercise and muscle, the
peak EMG amplitude of the 2 sets
performed was highly reliable (ICC
[3,1]⫽.94 –1.00, P⬍.001) (Table).
Discussion
In this study, relatively high levels of
muscle activation in the trapezius
and deltoid muscles were found for
several of the exercises used for
treatment of trapezius myalgia.
These results document the effec-
tiveness of the investigated exercises
and suggest that there are several
ways to reach a high level of muscle
activation in women with myalgia.
Figure 3.
A representative raw rectified electromyographic recording from one of the subjects during (A) a lateral raise (LAT) exercise with 5
kg and (B) a shrug (SHR) exercise with 25 kg. The filtered signal is overlaid (red tracing) on the raw recording.
A major finding of the present study Shrug .95 .99 .98 .99
was that the lateral raise exercise in- Upright row .98 .98 1.00 .99
duced similarly high levels of trape-
zius muscle activation compared
with the shrug exercise (Fig. 2A), impingement). Although not specifi- all subjects were highly familiar with
despite the fact that the average cally investigated in the present the technique and proper training
training weight during the lateral study, a combination of the exercises load of each specific exercise. Intra-
raise exercise was only 5 kg com- may be preferable when possible. day reliability of EMG amplitude dur-
pared with 24 kg during the shrug Based on the present findings, we ing the exercises was very high (ICC
exercise. This finding has important concluded that several of the exer- [3,1]⫽.94 –1.00), which indicates
practical relevance for rehabilitation cises used will lead to a marked and that the subjects were highly familiar
of trapezius myalgia, because grip relevant increase in activation of with each specific exercise. In com-
strength and low back strength may muscles with chronic pain and, parison, lower ICCs (.30 –.94) for the
become limiting factors during therefore, contribute to a positive upper trapezius muscle were re-
heavy-load shrugs, especially for treatment effect. ported in a previous study with un-
those with symptoms that also ap- trained subjects.18
pear in the low back and hip or knee. In contrast to the present findings,
During the lateral raise exercise, the Ekstrom and coworkers18 found that The deltoid muscle plays a major role
upper trapezius muscle rotates the shrugs induced higher levels of tra- as a prime mover of the glenohu-
scapula upward,30 and, together pezius muscle activation compared meral joint, and some patients with
with a long external moment arm, with shoulder abduction exercises. neck or shoulder conditions may
this may explain the high level of The subjects in that study, however, need rehabilitation of specific parts
trapezius muscle activation in spite were healthy and untrained. In con- of the deltoid muscle. More impor-
of relatively low external loadings. trast, the women who participated tantly, perhaps, some patients may
Furthermore, the upright row exer- in the present study were clinically need to avoid activation of certain
cise induced levels of trapezius mus- diagnosed with trapezius myalgia parts of the shoulder muscles (eg, in
cle activation that were not signifi- and were part of an ongoing rehabil- severe shoulder disorders such as
cantly lower than the levels of the itation program. Learning and coor- shoulder joint impingement or rota-
shrug and lateral raise exercises. dination of a specific exercise have tor cuff tendinitis). For the posterior
Thus, lateral raise and upright row marked influence on the level of deltoid muscle, the highest level of
exercises may be offered as alterna- muscle activation during the initial activation was achieved by using the
tives to shrugs for patients with lim- weeks of training, especially when exercises that involved a forward in-
ited grip strength and low back and more complex exercises are used.31 cline of the body (ie, reverse flys and
hip or knee symptoms. It is impor- Therefore, training should be per- one-arm rows). The lateral raise ex-
tant to note that shoulder abduction formed for at least a few weeks be- ercise is traditionally considered the
exercises (eg, lateral raises and up- fore measuring the level of muscle most specific exercise for the medial
right rows) can be demanding on the activation to be able to compare the deltoid muscle. However, the re-
rotator cuff muscles and can be asso- long-term benefits of different verse fly exercise induced similarly
ciated with impingement-like symp- exercises. high levels of muscle activation in
toms due to compression of the su- this part of the deltoid muscle. The
praspinatus tendon. In these cases, In the present study, the women had lateral raise exercise appeared to be
shrugs may be appropriate for pa- been undergoing rehabilitation with more specific compared with the
tients who have problems abducting the exercises for 8 to 10 weeks at the other exercises with regard to the
the arm (eg, due to shoulder joint time of testing, which ensured that anterior deltoid muscle, probably
due to outward rotation of the hu- Dr Sjøgaard provided fund procurement, fa- 12 Hagberg M, Harms-Ringdahl K, Nisell R,
cilities/equipment, and institutional liaisons. Hjelm EW. Rehabilitation of neck-shoulder
merus during abduction of the arm pain in women industrial workers: a ran-
Christoffer Andersen, Peter Hansen, and Dr
in this exercise. Sjøgaard provided subjects. Dr Kjær, Dr
domized trial comparing isometric shoul-
der endurance training with isometric
Zebis, and Dr Sjøgaard provided consulta- shoulder strength training. Arch Phys Med
A limitation of the present study is tion (including review of the manuscript be- Rehabil. 2000;81:1051–1058.
that EMG measurements were per- fore submission). 13 Randløv A, Ostergaard M, Manniche C,
et al. Intensive dynamic training for fe-
formed only after 8 to 10 weeks of This article was received October 7, 2007, and males with chronic neck/shoulder pain: a
training. Therefore, it is not known was accepted February 4, 2008. randomized controlled trial. Clin Rehabil.
1998;12:200 –210.
whether similarly high levels of mus- DOI: 10.2522/ptj.20070304 14 Ylinen J, Takala EP, Nykänen M, et al. Ac-
cle activation were achieved during tive neck muscle training in the treatment
the initial weeks of training. Further- of chronic neck pain in women: a random-
more, to quantify the level of muscle References ized controlled trial. JAMA. 2003;289:
2509 –2516.
1 Hakala P, Rimpelä A, Salminen JJ, et al.
activation, EMG activity during the Back, neck, and shoulder pain in Finnish 15 Andersen LL, Kjær M, Søgaard K, et al. Ef-
dynamic exercises was normalized adolescents: national cross sectional sur- fect of two contrasting types of physical
veys. BMJ. 2002;325(7367):743. exercise on chronic neck muscle pain.
to measurements of EMG activity Arthritis Rheum. 2008;59:84 –91.
2 Juul-Kristensen B, Kadefors R, Hansen K,
during the static MVCs. Given the et al. Clinical signs and physical function 16 Ylinen J. Physical exercises and functional
inherent methodological limitations in neck and upper extremities among el- rehabilitation for the management of
derly female computer users: the NEW chronic neck pain. Eura Medicophys.
associated with surface EMG, only a study. Eur J Appl Physiol. 2006;96: 2007;43:119 –132.
rough estimate of the level of muscle 136 –145. 17 Bojsen-Moller F. Bevægeapparatets
activation can be inferred using this 3 Côté P, Cassidy JD, Carroll LJ, Kristman V. Anatomi. 12th ed. Copenhagen, Den-
The annual incidence and course of mark: Munksgaard; 2002.
method.32 neck pain in the general population: a 18 Ekstrom RA, Donatelli RA, Soderberg GL.
population-based cohort study. Pain. Surface electromyographic analysis of ex-
2004;112:267–273.
Conclusion ercises for the trapezius and serratus ante-
4 Larsson B, Björk J, Elert J, et al. Fibre type rior muscles. J Orthop Sports Phys Ther.
The lateral raise and upright row ex- proportion and fibre size in trapezius mus- 2003;33:247–258.
ercises can be used as alternatives to cle biopsies from cleaners with and with- 19 Hintermeister RA, Lange GW, Schultheis
out myalgia and its correlation with ragged JM, et al. Electromyographic activity and
the shrug exercise during rehabilita- red fibres, cytochrome-c-oxidase-negative applied load during shoulder rehabilita-
tion of chronic neck muscle pain fibres, biomechanical output, perception tion exercises using elastic resistance.
of fatigue, and surface electromyography Am J Sports Med. 1998;26:210 –220.
(trapezius myalgia) because they re- during repetitive forward flexions. Eur
sult in relevant and marked increases J Appl Physiol. 2001;84:492–502. 20 Kryger AI, Andersen JH, Lassen CF, et al.
Does computer use pose an occupational
in trapezius muscle activation com- 5 Sjøgaard G, Lundberg U, Kadefors R. The hazard for forearm pain; from the
role of muscle activity and mental load in NUDATA study. Occup Environ Med.
pared with the shrug exercise. These the development of pain and degenerative 2003;60(11):e14.
2 alternative exercises require less processes at the muscle cell level during
computer work. Eur J Appl Physiol. 21 Kaergaard A, Andersen JH, Rasmussen K,
training weight (3–10 kg) compared 2000;83:99 –105. Mikkelsen S. Identification of neck-
with the shrug exercise (20 –30 kg) shoulder disorders in a 1 year follow-up
6 Kadefors R, Forsman M, Zoéga B, Herberts study: validation of a questionnaire-based
and, from a practical standpoint, may P. Recruitment of low threshold motor method. Pain. 2000;86:305–310.
units in the trapezius muscle in different
be easier to carry out as regular train- static arm positions. Ergonomics. 1999; 22 Von Korff M, Ormel J, Keefe FJ, Dworkin
ing exercises. Finally, it should be 42:359 –375. SF. Grading the severity of chronic pain.
Pain. 1992;50:133–149.
recognized that these exercises are 7 Mork PJ, Westgaard RH. Low-amplitude
trapezius activity in work and leisure and 23 Ohlsson K, Attewell RG, Johnsson B, et al.
to be prescribed for conditions of the relation to shoulder and neck pain. An assessment of neck and upper extrem-
myalgia (ie, pain from the muscles) J Appl Physiol. 2006;100:1142–1149. ity disorders by questionnaire and clinical
examination. Ergonomics. 1994;37:891–
and that the present study did not 8 Taylor NF, Dodd KJ, Damiano DL. Progres- 897.
sive resistance exercise in physical ther-
investigate the effect upon other, apy: a summary of systematic reviews. 24 Laursen B, Jensen BR, Németh G, Sjøgaard
more severe neck or shoulder Phys Ther. 2005;85:1208 –1223. G. A model predicting individual shoulder
muscle forces based on relationship be-
disorders. 9 Ahlgren C, Waling K, Kadi F, et al. Effects tween electromyographic and 3D external
on physical performance and pain from forces in static position. J Biomech.
three dynamic training programs for 1998;31:731–739.
women with work-related trapezius myal-
Lars Andersen, Dr Kjær, and Christoffer gia. J Rehabil Med. 2001;33:162–169. 25 Hermens HJ, Freriks B. The State of the Art
Andersen provided concept/idea/research on Sensors and Sensor Placement Proce-
10 Kadi F, Ahlgren C, Waling K, et al. The dures for Surface Electromyography: A
design. Lars Andersen, Dr Kjær, and Dr Zebis effects of different training programs on Proposal for Sensor Placement Proce-
provided writing. Lars Andersen, Christoffer the trapezius muscle of women with dures. SENIAM Project. Enschede, the
Andersen, Peter Hansen, and Klaus Hansen work-related neck and shoulder myalgia. Netherlands: Roessingh Research and De-
provided data collection. Lars Andersen, Acta Neuropathol. 2000;100:253–258. velopment BV; 1997.
Christoffer Andersen, Dr Zebis, and Klaus 11 Waling K, Sundelin G, Ahlgren C, Järvholm 26 Winter DA. Biomechanics and Motor
Hansen provided data analysis. Lars B. Perceived pain before and after three Control of Human Movement. New York,
exercise programs: a controlled clinical NY: John Wiley & Sons Inc; 1990:11–50.
Andersen, Peter Hansen, Klaus Hansen, and trial of women with work-related trape-
Dr Sjøgaard provided project management. zius myalgia. Pain. 2000;85:201–207.
27 Kraemer WJ, Adams K, Cafarelli E, et al. 29 Jensen C, Vasseljen O, Westgaard RH. The 31 Rutherford OM, Jones DA. The role of
Progression models in resistance training influence of electrode position on bipolar learning and coordination in strength
for healthy adults [American College of surface electromyogram recordings of the training. Eur J Appl Physiol Occup
Sports Medicine position stand]. Med Sci upper trapezius muscle. Eur J Appl Physiol. 1986;55:100 –105.
Sports Exerc. 2002;34:364 –380. Physiol Occup Physiol. 1993;67:266 –273. 32 Farina D, Merletti R, Enoka RM. The ex-
28 Andersen LL, Magnusson SP, Nielsen M, 30 Ebaugh DD, McClure PW, Karduna AR. traction of neural strategies from the sur-
et al. Neuromuscular activation in conven- Three-dimensional scapulothoracic mo- face EMG. J Appl Physiol. 2004;96:
tional therapeutic exercises and heavy re- tion during active and passive arm eleva- 1486 –1495.
sistance exercises: implications for reha- tion. Clin Biomech (Bristol, Avon).
bilitation. Phys Ther. 2006;86:683– 697. 2005;20:700 –709.