SPINE Volume 33, Number 5, pp 555–563
©2008, Lippincott Williams & Wilkins
Neck Movement and Muscle Activity Characteristics in
Female Office Workers With Neck Pain
V. Johnston, BPhty (Hons),* G. Jull, PhD,* T. Souvlis, PhD,* and N. L. Jimmieson, PhD†
Study Design. Cross-sectional study.
Objective. To explore aspects of cervical musculoskel-
etal function in female office workers with neck pain.
Summary of Background Data. Evidence of physical
characteristics that differentiate computer workers with
and without neck pain is sparse. Patients with chronic
neck pain demonstrate reduced motion and altered pat-
terns of muscle control in the cervical flexor and upper
trapezius (UT) muscles during specific tasks. Understand-
ing cervical musculoskeletal function in office workers will
better direct intervention and prevention strategies.
Methods. Measures included neck range of motion;
superficial neck flexor muscle activity during a clinical
test, the craniocerivcal flexion test; and a motor task, a
unilateral muscle coordination task, to assess the activity
of both the anterior and posterior neck muscles. Office
workers with and without neck pain were formed into 3
groups based on their scores on the Neck Disability Index.
Nonworking women without neck pain formed the con-
trol group. Surface electromyographic activity was re-
corded bilaterally from the sternocleidomastoid, anterior
scalene (AS), cervical extensor (CE) and UT muscles.
Results. Workers with neck pain had reduced rotation
range and increased activity of the superficial cervical
flexors during the craniocervical flexion test. During the
coordination task, workers with pain demonstrated
greater activity in the CE muscles bilaterally. On comple-
tion of the task, the UT and dominant CE and AS muscles
demonstrated an inability to relax in workers with pain. In
general, there was a linear relationship between the work-
ers’ self-reported levels of pain and disability and the
movement and muscle changes.
Conclusion. These results are consistent with those
found in other cervical musculoskeletal disorders and
may represent an altered muscle recruitment strategy to
stabilize the head and neck. An exercise program includ-
ing motor reeducation may assist in the management of
neck pain in office workers.
Key words: office workers, neck pain, neck movement,
electromyography, craniocervical flexion test. Spine 2008;
33:555–563
From the *Physiotherapy Division, School of Health and Rehabilita-
tion Sciences, The University of Queensland, Australia; and †School of
Psychology, The University of Queensland, Australia.
Acknowledgment date: January 26, 2007. First revision date: July 2,
2007. Second revision date: August 27, 2007. Acceptance date: August
27, 2007.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Foundation funds were received in support of this work. No benefits in
any form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Supported by a grant from the Physiotherapy Research Foundation,
Australia.
Address correspondence and reprint requests to Venerina Johnston, Phys-
iotherapy Division, Level 7, Therapies Building 84A, The University of
Queensland, St Lucia, QLD 4072; E-mail: v.johnston@shrs.uq.edu.au
Neck pain is a common problem in the workplace for
computer users.1–3 Excess loading of the muscles of the
shoulder girdle is thought to be the source of work-
related neck or shoulder pain particularly in low-load
repetitive work.4 The physical demands placed on the
muscles in this region during computer work are low,
less than 5% maximum voluntary contraction.5,6 Thus,
muscle strains are an unlikely cause of neck pain in this
group,7 although the way the trapezius and other mus-
cles function may certainly contribute to the pain state.
Most studies investigating work-related neck or
shoulder pain have concentrated on the trapezius muscle
almost exclusively. There has been difficulty in demon-
strating significant associations between trapezius mus-
cle activity level and neck or shoulder pain among work-
ers undertaking similar work.8 –10 We contend that the
neck or shoulder pain in office workers reflects a broader
involvement of the cervical musculoskeletal system. Var-
ious impairments in the musculoskeletal function have
been documented in association with cervical disor-
ders,11–13 yet the role of cervical musculature in com-
puter users with neck pain has largely been ignored as
has other measures such as range of movement.
This research aimed to gain a broader perspective of
cervical musculoskeletal function in office workers with
neck pain. Office workers are of particular interest be-
cause computer use in the workplace and home is in-
creasing14 and the prevalence of neck pain in this occu-
pational group remains high3,15–17 although regulatory
authorities have developed recommendations for pre-
vention of musculoskeletal problems in this group of
workers.18 –24
We examined 3 features in which impairments have
been documented in other neck disorders. The first was a
measure of neck range of movement, a generic sign of a
cervical musculoskeletal disorder, recorded in neck pain
of both insidious and traumatic onset.25–27 The second
measure was a muscle test, the craniocervical flexion test
which tests the anatomic action of the deep longus capitis
and colli muscles, muscles important for the support of
the cervical joints and posture.28 Higher levels of activity
of the superficial cervical neck flexor muscles have been
measured in patients with neck disorders in this test,29 –31
which has been shown to be in compensation for lesser
measured activity in the deep neck flexor muscles in neck
pain patients compared with controls.29 The third test
was a unilateral muscle coordination task which has
been used to evaluate muscle activity of the upper tra-
pezei in occupational studies,32–34 in patients with whip-
lash13,35 and idiopathic neck pain.36 Significant differ-
555
556 Spine • Volume 33 • Number 5 • 2008

Table 1. Comparison Among Volunteers clusion criteria if they had been in their current position or one
and Nonvolunteers similar for at least 2 years; worked at least 4 hours per day
using a visual display monitor; experienced work-related neck
Respondents Nonrespondents pain with or without arm pain. Exclusion criteria were a his-
Variables (n ⫽ 85) (n ⫽ 248) tory of neck surgery or trauma, diagnosed fibromyalgia, carpal
tunnel syndrome, cervical radiculopathy, systemic illness or a
Neck disability index (0–100) 16.6 (11.6) 15.2 (11.6)
connective tissue disorder to exclude possible nonwork-related
(mean, SD)
Age (age category)* (yr) 40–44 35–39 sources of pain. Employment of at least 2 years was chosen as
Duration of neck pain in last 12 this period of time will allow fair time for symptoms to develop
mo (%) following light work.39
0–30 days 49.4 54 The control group of women (n ⫽ 22) was recruited from
⬎30 days 50.6 46
Body mass index kg/m2 (mean, 26.8 (6.5) 24.7 (5.3) the general community through advertisements. To be in-
SD)* cluded, these participants were not in current paid employment
Years with current employer 9.3 (7.5) 8.3 (7.2) or employed in the previous 12 months; used a VDU less than
(mean, SD) 4 hours per day; had no history of neck pain requiring treat-
Computer use (%)
ment in the last 12 months, were not pregnant and had no
⬍6 h/d 35.3 35.5
⬎6 h/d 64.7 64.5 exclusion criteria as applied to the worker group. Ethical clear-
Mouse use (%) ance was granted by the Institutional Medical Research Ethics
⬍6 h/d 73 67 Committee and written informed consent was obtained from
⬎6 h/d 27 32.8 all participants.
Frequency of sport (%)
Rarely (%) 38.8 44.6
⬎1/wk 61.3 55.5
Range of Movement
Hours worked/wk (%) Active range of neck movement was measured in sitting with a
⬍38 h/wk 33 41 3-dimensional electromagnetic, motion-tracking device (Fas-
⬎38 h/wk 67 59 trak, Polhemius, USA). The Fastrak unit emits a low intensity
General Health Questionnaire-12 12.6 (3.9) 13.6 (4.5) electromagnetic field which is detected by 2 sensors placed in
(0–36) (mean, SD)
Job satisfaction (0–5) (mean, 3.1 (0.9) 3.0 (0.87) field—1 on the forehead and the other over C7. A computer
SD) program was developed to allow real-time viewing of the
movement and storage of data. The Fastrak has been used
*Significant difference between groups P ⬍ 0.05.
previously to investigate cervical range of motion26,40 and has
accuracy to within ⫾0.2°.41
ences exist between subjects with neck pain and controls Electromyography
in the neck flexors and upper trapezius (UT) during this Recordings of electromyography (EMG) activity from the UT,
task suggesting altered patterns of motor control in the cervical erector spinae (CE), sternal head of the sternocleido-
presence of pain.36 In the current study, activity of the mastoid (SCM) and anterior scalene (AS) muscles were made
cervical flexors, the UT and cervical extensor (CE) mus- bilaterally with Ag/AgCl surface electrodes (Myotronics-
cles was measured during the performance of this unilat- Noromed, Inc.) following careful skin preparation and previ-
ously published guidelines for electrode placement.42– 44 A
eral arm task.36 Assessing cervical range of movement
ground reference was placed on the upper thoracic spine. EMG
and muscle activity in different tasks in office workers
signals were amplified (gain, 1000), passed through a 10 to 500
with neck pain may shed light on whether general cervi- Hz band-width filter, and sampled at 1000 Hz.
cal musculoskeletal impairment is a feature of this group, EMG data were collected during standardized maneuvers
which in turn could better direct prevention and manage- for normalization of the EMG amplitude as recommended
ment strategies. when using surface EMG in studies of work-related disor-
ders.45 Each normalization task was held for 10 seconds and
Methods
repeated 3 times with 30 seconds rest between each repetition.
Design For the reference contraction for SCM and AS, the participant
A cross-sectional observational design was used to assess mo- flexed the chin and lifted their head so that it just cleared the
tor features of female office workers with and without neck bed and held the position.36 That for the UT muscles was bi-
pain. Workers were grouped on the basis of scores on the neck lateral arm abduction at 90° with the elbows straight and
disability index.37 A parallel group of women without neck pain palms facing downwards while standing.5,13 For CE muscles,
who did not participate in paid employment were included as true participants raised and held the head 20 mm above the bed in
controls. No inducement was offered to any of the volunteers prone lying.46
for participating in this research.
Craniocervical Flexion Test
Participants The craniocervical flexion test has been described in detail else-
Eighty-five volunteer female office workers were recruited from where29,31 and shown to have good internal reproducibility.12,30
333 participants who had previously completed a survey inves- The participant lay in supine and slowly nodded the head to 5
tigating risk factors for neck pain in this population.38 Table 1 progressive inner range positions of craniocervical flexion,
presents a comparison between those workers who volunteered guided by feedback from an air filled pressure sensor (Stabi-
and those who did not in relation to assessed variables. Volun- lizer, Chattanooga, USA) placed suboccipitally behind the neck
teers were slightly older and had a higher body mass index than and inflated to a baseline of 20 mm Hg. The participant nodded
those who did not. Symptomatic workers met this study’s in- to increase the pressure to 22 mm Hg and maintain this posi-
 Characteristics in Female Office Workers With Neck Pain • Johnston et al 557
tion for 10 seconds. This action was repeated with the target set
at 24, 26, 28, and 30 mm Hg. A 10-second rest was provided
between each target pressure. Two trials of the craniocervical
flexion test were performed with the second used for analysis.
Baseline EMG was collected for 10 seconds before commence-
ment of the task while the participant lay quietly and relaxed.
The maximum root mean square (1sRMS) in the SCM and AS
muscles was extracted using a 1 second sliding window over
each 10 seconds of the 5 stages of the craniocervical flexion test
using Matlab7 software (Math Works, Inc.). The maximum
1sRMS value was standardized against the maximum 1sRMS
head lift task after subtracting baseline. This methodology has
been used previously.29,31 The normalized EMG data were
used for analysis.
Unilateral Muscle Coordination Task
The coordination task was used as a measure of unilateral
non-keyboard task to assess the activity of the anterior and
posterior neck muscles bilaterally during a dynamic arm activ-
ity unrelated to workplace actions. The participant sat at a
standard desk in an adjustable chair without arm rests and
adjusted the seat and back rest to a comfortable position. The
participant moved a pen with the dominant (referred to as
right) hand between 3 circles (diameter of 70 mm and 230 mm
apart in an equilateral triangle) in an anticlockwise direction.
The task was performed to the beat of a metronome set at 88
beats/min for 5 minutes. The subject’s nondominant forearm
rested on the desktop motionless.
The 1sRMS was calculated for each muscle using a 1 second
sliding window over 5 second epochs at baseline, 10, 60, 180,
and 300 seconds into the task and 10 seconds after completion
of the task36 (Matlab7 software, Math Works, Inc.). The EMG
amplitude at each epoch was normalized against a reference
contraction and expressed as a percentage of the maximum
1sRMS values obtained during the reference voluntary contrac-
tions after subtracting baseline.
Discomfort Measures
Neck and shoulder discomfort was rated by participants on
completion of the coordination task. This was measured using
a 100-mm visual analogue scale anchored with the words “no
pain” and “worst pain imaginable.” Subjects moved a marker
along the scale to a point that best represented their current
level of pain. Perceived tension was recorded after the muscle
coordination task on a 100-mm visual analogue scale with the
end points of “not at all” and “very tense.”43
Questionnaires
The office workers completed the neck disability index in the
original survey of work and provided personal demographics.
For some, there was a time delay between completion of the
survey and testing, thus a second neck disability index was
administered at the time of testing. The control group com-
pleted the neck disability index also. Pain intensity was mea-
sured using a 100-mm visual analogue scale for current and
worst neck pain and location of pain was marked by the par-
ticipant on a body map. The neck disability index has been used
as an outcome measure of workplace interventions47 and in-
cludes 10 items which address functional activities, in addition
to items on pain intensity, ability to concentrate, and presence
of headaches. There are 6 possible responses for each item
which are scored from 0 (no disability) to 5 (complete disabil-
ity). A total score is obtained using a percentage of the maxi-
mum score after adding each to give a raw score out of 50 with
a higher score reflecting greater disability. It has good internal
consistency and test–retest reliability.37,48
The General Health Questionnaire (GHQ-12)49 was in-
cluded as a measure of psychological distress and has been
recommended as a quick screen for mental health in occupa-
tional studies.50 This test consists of 12 items, scored using the
Likert-method (0 –3) with the scores added to generate a total
between 0 and 36, with higher scores indicating an increased
likelihood of psychological distress.51 Job satisfaction was
evaluated with 3 items with a 5-point response rating ranging
from very negative, ‘I don’t enjoy it (my job) to very positive, ‘I
really enjoy my job, and couldn’t enjoy it more’.52
Data Management
There were 8 left-handed participants, thus EMG data from all
muscles during the coordination task was analyzed for the
dominant (referred to as right) side. There was a significant age
difference between groups. It was selected a priori as a covari-
ate in all analyses. Univariate ANOVA was used to detect dif-
ferences in neck disability scores, symptom onset, discomfort,
and perceived tension scores during the coordination task.
MANOVA was used to analyze neck motion data. The nor-
malized craniocervical flexion test data were skewed and loga-
rithmic transformation improved the homogeneity of vari-
ance.53 Thus, the logarithm of each normalized 1sRMS value
was entered into a repeated measures general linear model to
examine the effects of group (4 levels between-subject factor) at
the 5 pressure values (within-subject factor). The means were
calculated from the normalized data to demonstrate the results
graphically.
Repeated measures general linear model with group as the
between-subject factor (4 levels), time as within-subject factor
(4 levels) was performed to determine the relationships be-
tween groups for each muscle during the coordination task.
Separate analyses were performed to determine whether there
were differences on completion of each task using the difference
between values at 300 seconds and post-task in a MANOVA.
The normalized data for the coordination task were logarith-
mic transformed to improve the homogeneity of variance53
with the means from the normalized data used to demonstrate
the results graphically. Differences between groups were ana-
lyzed with a priori contrasts.
Data were analyzed using SPSS v.11.5 (SPSS, Chicago, IL).
Significance was set at P ⬍ 0.05 with 95% confidence limits.
Results
The 85 eligible workers were placed into 1 of 3 groups
based on the disability score (out of 100) at the time of
testing: no pain group (neck disability score ⱕ8, n ⫽ 33);
mild pain group (neck disability score 9 –29, n ⫽ 38);
and moderate pain group (neck disability score ⱕ30, n ⫽
14). The group characteristics are presented in Table 2.
The control group was statistically younger than each
worker group. For the workers, there were no statisti-
cally discernible differences between groups in terms of
the duration of symptoms, body mass index, years with
the current employer, computer use per day, or fre-
quency of sport, but those with moderate pain used a
mouse longer at work (P ⬍ 0.03).
Range of Movement
Figure 1 displays the between group differences with a
statistically discernible negative linear trend for left and
558 Spine • Volume 33 • Number 5 • 2008

Table 2. Group Characteristics

No Pain (n ⫽ 33) Mild Pain (n ⫽ 38) Moderate Pain (n ⫽ 14) Controls (n ⫽ 22)

Neck disability index (0–100) (mean, SD) 4.2 (2.6) 19.5 (5.9) 33.5 (3.6) 2.9 (2.8)
Age (years, mean, SD) 43 (10.6) 43.8 (9.4) 45.4 (10.3) 37.4 (10.4)
Pain intensity (0–10) (mean, SD) 0.4 (1) 1.5 (1.5) 1.9 (2.4) 0
Symptom duration, years (mean, SD) 4.3 (6.9) 10.7 (8.7) 8 (8.7) —
Body mass index kg/m2 (mean, SD) 26 (5.7) 27.4 (6.6) 27 (6.8) 24.7 (2.3)
Years with current employer (mean, SD) 10.0 (7.5) 9.2 (7.5) 8.4 (7.7) —
Computer use (%)
⬍6 h/d 40 34 30 —
⬎6 h/d 60 66 70 —
Mouse use (%)
⬍6 h/d 85 70 46 —
⬎6 h/d 15 30 54 —
Frequency of sport (%)
Rarely 33 42 43 —
⬎1/wk 67 58 57 —
General Health Questionnaire-12 (0–36) (Mean, SD) 12.9 (3.7) 12.8 (3.9) 11.2 (4.2) 11.4 (4.0)
Job satisfaction (0–5) (mean, SD) 3.1 (0.9) 3.1 (1.0) 3.1 (0.8) —

right rotation from controls to worker groups. Workers
in the mild pain group had significantly less flexion range
of motion than the no pain group (P ⫽ 0.038). Although
there appears to be a general trend for a decrease in
flexion and extension range of motion with increasing
pain, there were no statistical differences between group
means (P ⬎ 0.06). There were no statistically discernible
differences for lateral flexion in either direction.
Craniocervical Flexion Test
Figure 2 displays the mean normalized 1sRMS values for
the anterior cervical muscles bilaterally. For the right
SCM muscle, there were statistically higher measured
levels of activity in the mild and moderate pain groups
compared with the control and no pain groups at 24, 26,
28, and 30 mm Hg pressure during the performance of
the craniocervical flexion test (P ⬍ 0.02). There were no
differences between the mild and moderate pain groups
at any test stage as was the case between the control and
no pain groups. This pattern of increased muscle activity
with progressive stages of the task for the moderate and
mild pain groups was replicated for left SCM and right
and left AS muscles (all P ⬍ 0.001).
Unilateral Muscle Coordination Task
The mean normalized 1sRMS values at each of the 5 time
periods during and 10 seconds after the coordination
task for the neck muscles are displayed in Figures 3 and
4. As main findings, there was a statistically discernible
difference between groups for the CE muscles showing
workers with pain generating greater muscle activity in
these muscles as well as in the right UT, SCM, and AS
muscles compared with controls (P ⬍ 0.05). There were
no differences between the worker groups over any mus-

Controls
80 No Pain
Mild Pain
70 Moderate Pain

60
Range in Degrees

50

40

Figure 1. Mean range of motion 30

and 95% confidence intervals
(controlled for age) for flexion, 20
extension, left rotation (L rot),
right rotation (R rot), left lateral
flexion (L lat flex), and right lat- 10
eral flexion (R lat flex) across the
groups for workers with no pain, 0
mild, and moderate pain and
Flexion Extension L rot R rot L lat flex R lat flex
controls (nonworkers with no
disability). Direction of Movement
 Characteristics in Female Office Workers With Neck Pain • Johnston et al 559

Left Sternocleidomastoid Right Sternocleidomastoid

100 100
90 90
80 80
Normalized EMG

70 70
60 60
50 50
40 40
30 30
20 20
10 10
0 0
22 24 26 28 30 22 24 26 28 30

Right Anterior Scalene

Left Anterior Scalene
100 100
90 90
80 80
Normalized EMG

70 70
60 60
50 50
40 40
30 30
20 20
10
10
0
0
22 24 26 28 30
22 24 26 28 30
Flexion Test (mmHg)
Flexion Test (mmHg)
Figure 2. Normalized EMG values (adjusted by age), means and 95% confidence intervals during the performance of the craniocervical
flexion test for left and right sternocleidomastoid and anterior scalene muscles at each stage of the test.

cle. On completion of the task, workers with pain re-
laxed at a slower rate than those without pain in the UT
and right CE (P ⬍ 0.02).
Discomfort experienced during the unilateral arm
task was minor although greater for the mild [median ⫽
0, 0 – 80 (2.5th–97.2th percentile)] and moderate pain
(15,0 – 49) group compared with controls (0,0 – 0), and
no pain group (0,0 –25). Perceived tension was again
minor during the coordination task although greater for
workers in the moderate pain group (0,0 –35) and each
of the other groups [control group (0,0 – 0); no pain (0,
0 –1.0); mild pain (0,0 –20) groups].
Discussion
In this study, cervical pain (reduced range of movement
and altered patterns of muscle activity) was associated
with neck pain reported by office workers as has been
found in neck disorders of other provocative causes.26,27,36,54
This study also demonstrated that alterations in muscle
function is widespread, being identified in the neck flex-
ors, extensors, and the UT. Furthermore, the results in-
dicated that in general, there was a linear relationship
between the workers’ self-reported levels of pain and
disability and the level of movement and muscle differ-
ences (craniocervical flexion test and coordination task).
Those who reported higher levels of pain had greater
levels of physical changes.
The associations between self-reported levels of pain
and disability and physical changes were clearly evident
in range of motion measures where office workers with
mild and moderate pain and disability demonstrated re-
duced rotation compared with workers without pain and
controls. Similarly, those with pain generated greater ac-
tivity in the superficial cervical flexors than those with-
out neck pain and controls during the performance of the
craniocervical flexion test. This increase in activity in the
superficial muscles has been shown to be associated with
reduced activity in the deep cervical flexors and is con-
sidered a compensatory strategy for weakness in the deep
flexor muscles.29 This muscle impairment appears char-
acteristic of persons with cervical pain, being docu-
mented in patients with cervicogenic headache,30 whip-
lash associated disorders,25,54 and chronic neck pain.29
In general, there was altered activity in the UT, CE,
and cervical flexor muscles in the coordination task in
office workers with neck pain, although there was some
variability between muscles. More specifically, the re-
sults showed that those with neck pain had greater EMG
activity in the right (dominant) UT during performance
of the coordination task and in both UT on completion
560 Spine • Volume 33 • Number 5 • 2008

Left Cervical Extensor

200 Right Cervical Extensors
200

150
150
Normalized EMG

Normalized EMG
100 10s
100
60s

50
180s
50
300s

0 0 Post-task
Controls No Pain Mild Pain Moderate Pain Controls Mild Pain
No Pain Moderate Pain
Left Upper Trapezius
120
Right Upper Trapezius
120
100

100
Normalized EMG

Normalized EMG
80
80
10s
60
60 60s
40
40 180s

20 300s
20

0 0 Post-task
Controls No Pain Mild Pain Moderate Pain Controls Mild Pain
No Pain Moderate Pain
Pain Group
Pain Group
Figure 3. Normalized EMG values (adjusted by age) during and after the coordination task. Median, 25th and 75th percentile and whiskers
representing 1.5 times the interquartile range for each pain group at the cervical extensor and upper trapezius muscles at each of the
5 time periods.

of the task compared with those without pain. These
results concur with Nederhand et al,13,35 and Falla et
al,36 who examined the same task in subjects with neck
pain of both traumatic and nontraumatic origin. Falla et
al,36 suggested that the increase in activity represents an
altered pattern of motor control to compensate for a
decrease in activity in the painful active UT. Nederhand
et al,35 suggested that the inability for the UT to relax
posttask is due to a “learned guarding response” to pro-
tect against movement and pain which is consistent with
the pain adaptation model.55 However, in both studies
pain intensity during the task was not recorded.
Workers with pain generated greater EMG amplitude
in the CE muscles than both the controls and those with-
out pain during the coordination task. The CEs have an
important antigravity role in head stabilization. How-
ever, it would be expected that the demands for postural
stabilization by the extensors would be the same for all
participants, workers and nonworkers alike, if this was
the only feature to consider. The activity in the cervical
flexors was more variable between groups in the coordi-
nation task. Workers with and without neck pain gener-
ated higher levels of activity in the SCM muscles com-
pared with controls. For the AS muscles, activity in the
left AS did not differ between groups although increased
activity was evident especially in the later stages of the
task for the right AS. These results are consistent with
Falla et al,36 who found an increase in EMG amplitude in
the AS and SCM muscles, albeit bilaterally, during a
similar task for those with idiopathic and whiplash in-
duced neck pain. The reason for the increased activity in
the CE and flexor muscles may parallel the compensation
for decreased activity in the deep neck flexors determined
in the craniocervical flexion test.29 There is also evidence
to indicate the presence of atrophy and widespread
changes in the deep CE muscles in patients with chronic
 Characteristics in Female Office Workers With Neck Pain • Johnston et al 561

Right Sternocleidomastoid
Left Sternocleidomastoid 80
80

70
70

60
60
Normalized EMG

50
50
10s
40
40
60s
30
30
180s
20
20
300s
10
10
0 Post-task
0 Controls Mild Pain
Controls No Pain Mild Pain Moderate Pain
No Pain Moderate Pain

Left Anterior Scalene Right Anterior Scalene

80 80

70 70

60 60
Normalized EMG

50 50 10s

40 40 60s
30
30 180s
20
20
300s
10
10
0 Post-task
0
Controls Mild Pain
Controls No Pain Mild Pain Moderate Pain
No Pain Moderate Pain
Pain Groups
Pain Groups
Figure 4. Normalized EMG values (adjusted by age) during and after the coordination task. Median, 25th and 75th percentile and whiskers
representing 1.5 times the interquartile range for each pain group at the anterior cervical muscles at each of the 5 time periods.

neck pain conditions.56 –58 It is possible that the in-
creased activity in the superficial CE might be a similar
compensatory mechanism.
Workers with pain perceived greater tension and dis-
comfort than those without pain and controls during the
coordination task. Similar findings have been reported
by other researchers in office workers.59,60 The prevail-
ing hypothesis is that prolonged muscle activity is a pre-
cursor to pain and muscle disorders.7 However, a recent
study found muscle activity did not correlate with sub-
jective reports of pain, tension, or fatigue in patients with
chronic neck or shoulder pain.61 The scores of tension
and discomfort reported by workers in this study were
low (1 on a 0 –100 scale), which although statistically
significant may not be clinically significant. In addition,
even though there was increased activity in the SCM, no
worker in this study reported anterior neck pain.
A unique feature of this study was that the control
group consisted of women who did not work. It is thus
notable that there was less activity in all muscles in the
coordination task in this group compared with the no
pain worker group. This may support the evidence to
suggest that employment, in particular, low load repeti-
tive work, may sensitize muscles leading to alterations in
movement, force production, and higher EMG activity62
which in turn could predispose to the development of a
cervical disorder. However, no information on the phys-
ical activity or fitness levels of the control group partici-
pants was recorded such that a potential bias in the EMG
amplitudes may have been introduced. A strength of this
study is the inclusion of a variety of neck muscles evalu-
ated. Many studies investigating neck pain in the work-
ing population focus on the UT muscles32,63– 65 with few
exploring the role of the cervical flexors and extensors. It
is interesting to note that neck pain in this group of office
workers displayed similarities with neck pain of different
origins. It is possible that response bias for those who
volunteered for this study may have contributed to the
findings. However, there were few differences between
those who volunteered and did not in the variables as-
562 Spine • Volume 33 • Number 5 • 2008
sessed although not all possible confounders were con-
trolled for such as socioeconomic status or comorbidity.
A limitation of cross-sectional studies is the inability to
determine the causal nature of the relationship between
pain and impairments. Another limitation of this study is
the use of nonfunctional tests to assess muscle activity in
workers with neck pain. Future studies should consider
the role of these muscles during functional tasks such as
keyboard work.
In conclusion, workers with neck pain demonstrated
signs of movement and cervical flexor and extensor mus-
cle changes consistent with a cervical disorder. There
was a linear relationship between the magnitude of self-
reported pain and degree of physical changes. Office
workers without pain demonstrated higher levels of cer-
vical muscle activity in the coordination task than non-
working control subjects which could infer a risk of de-
veloping a work-related cervical disorder in computer
users. The specific findings in the muscle system would
suggest that an exercise program inclusive of motor re-
learning may be required for the amelioration of neck
pain in computer users in the workplace.66
Key Points
● Female office workers with self-reported neck
pain demonstrated reduced rotation movement, in-
creased activity in the superficial neck flexors dur-
ing the craniocervical flexion test, increased activ-
ity in the CE during the arm task with UT, and
dominant CE and anterior scalene muscles unable
to “switch off” at the end of the arm task.
● In general, there was a linear relationship be-
tween the workers’ self-reported levels of pain and
disability and the level of movement and muscle
impairment (craniocervical flexion test and coordi-
nation task).
● The physical changes may represent an altered
muscle recruitment strategy to stabilize the head
and neck suggesting neck muscle reeducation may
assist in the management of neck pain in office
workers.
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