Electromyographic Activity of Sternocleidomastoid Muscle in Individuals With Neck Pain and Healthy Volunteers: A Reliability and Between-Group Differences Examination

Published:October 14, 2022DOI:



      The purpose of this study was to evaluate the electromyographic activity of the sternocleidomastoid muscle during the performance of the craniocervical flexion test (CCFT) in individuals with neck pain and healthy volunteers, assess the reliability of this method, and examine possible between-population differences.


      Electromyographic activity of the sternocleidomastoid muscles of 22 individuals with neck pain and 22 healthy participants was recorded during the 55 stages of the CCFT. Pain (visual analog scale) and disability (Neck Disability Index) levels and pain duration were recorded for the participants with neck pain. Reliability of electromyography was evaluated with the intraclass correlation coefficient, standard error of measurement, and minimum detectable change.


      Within-day reliability indices of electromyographic activity were very good to excellent (intraclass correlation coefficients, 0.86-0.98; standard error of measurement, 1.8%-7.6%; minimum detectable change, 5.0%-21.1%). For the head-lift normalization method, 2-way analysis of variance revealed significant between-group differences (P < .02); however, these were not clinically significant when reliability test-retest error was considered. Differences between contraction levels were significant (P < .001); however, the group by contraction level interaction factor was nonsignificant. Therefore, the between-groups electromyographic increases noted with increasing contraction levels were similar. No correlation was identified between participants’ electromyography data and pain or disability.


      In participants with moderate pain, disability, and pain duration, no clear alterations in electromyographic activity of the sternocleidomastoid could be detected with the CCFT. Reliability of the test used was very good.

      Key Indexing Terms

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Manipulative & Physiological Therapeutics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hurwitz EL
        • Randhawa K
        • Yu H
        • Côté P
        • Haldeman S.
        The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies.
        Eur Spine J. 2018; 27: 796-801
        • Hoy D
        • March L
        • Woolf A
        • et al.
        The global burden of neck pain: estimates from the global burden of disease 2010 study.
        Ann Rheum Dis. 2014; 73: 1309-1315
        • Vos CJ
        • Verhagen AP
        • Passchier J
        • Koes BW.
        Clinical course and prognostic factors in acute neck pain: an inception cohort study in general practice.
        Pain Med. 2008; 9: 572-580
        • Vasseljen O
        • Woodhouse A
        • Bjorngaard JH
        • Leivseth L.
        Natural course of acute neck and low back pain in the general population: the HUNT study.
        Pain. 2013; 154: 1237-1244
        • Bogduk N.
        The anatomy and pathophysiology of neck pain.
        Phys Med Rehabil Clin N Am. 2011; 22: 367-382
        • Dimitriadis Z
        • Kapreli E
        • Strimpakos N
        • Oldham J.
        Do psychological states associate with pain and disability in chronic neck pain patients?.
        J Back Musculoskelet Rehabil. 2015; 28: 797-802
        • Rezasoltani A
        • Ali-Reza A
        • Khosro KK
        • Abbass R.
        Preliminary study of neck muscle size and strength measurements in females with chronic non-specific neck pain and healthy control subjects.
        Man Ther. 2010; 15: 400-403
        • Elliott JM
        • Pedler AR
        • Jull GA
        • Van Wyk L
        • Galloway GG
        • O'Leary SP
        Differential changes in muscle composition exist in traumatic and nontraumatic neck pain.
        Spine (Phila Pa 1976). 2014; 39: 39-47
        • O'Leary S
        • Falla D
        • Elliott JM
        • Jull G.
        Muscle dysfunction in cervical spine pain: implications for assessment and management.
        J Orthop Sports Phys Ther. 2009; 39: 324-333
        • Eckner JT
        • Oh YK
        • Joshi MS
        • Richardson JK
        • Ashton-Miller JA
        Effect of neck muscle strength and anticipatory cervical muscle activation on the kinematic response of the head to impulsive loads.
        Am J Sports Med. 2014; 42: 566-576
        • Oliveira AC
        • Silva AG.
        Neck muscle endurance and head posture: a comparison between adolescents with and without neck pain.
        Man Ther. 2016; 22: 62-67
        • Christensen SW
        • Hirata RP
        • Graven-Nielsen T.
        The effect of experimental neck pain on pressure pain sensitivity and axioscapular motor control.
        J Pain. 2015; 16: 367-379
        • Falla D.
        Unravelling the complexity of muscle impairment in chronic neck pain.
        Man Ther. 2004; 9: 125-133
        • Falla D
        • Jull G
        • Hodges PW.
        Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain.
        Exp Brain Res. 2004; 157: 43-48
        • Falla D
        • O'Leary S
        • Farina D
        • Jull G.
        Association between intensity of pain and impairment in onset and activation of the deep cervical flexors in patients with persistent neck pain.
        Clin J Pain. 2011; 27: 309-314
        • Jull G
        • Falla D.
        Does increased superficial neck flexor activity in the craniocervical flexion test reflect reduced deep flexor activity in people with neck pain?.
        Man Ther. 2016; 25: 43-47
        • O'Leary S
        • Falla D
        • Jull G.
        The relationship between superficial muscle activity during the cranio-cervical flexion test and clinical features in patients with chronic neck pain.
        Man Ther. 2011; 16: 452-455
        • Kamibayashi LK
        • Richmond FJ.
        Morphometry of human neck muscles.
        Spine (Phila Pa 1976). 1998; 23: 1314-1323
        • Cagnie B
        • D'Hooge R
        • Achten E
        • Cambier D
        • Danneels L
        A magnetic resonance imaging investigation into the function of the deep cervical flexors during the performance of craniocervical flexion.
        J Manipulative Physiol Ther. 2010; 33: 286-291
        • Hodges PW
        • Smeets RJ.
        Interaction between pain, movement, and physical activity: short-term benefits, long-term consequences, and targets for treatment.
        Clin J Pain. 2015; 31: 97-107
        • Jull GA
        • O'Leary SP
        • Falla DL.
        Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test.
        J Manipulative Physiol Ther. 2008; 31: 525-533
        • Jorgensen R
        • Ris I
        • Falla D
        • Juul-Kristensen B.
        Reliability, construct and discriminative validity of clinical testing in subjects with and without chronic neck pain.
        BMC Musculoskelet Disord. 2014; 15: 408
        • Falla D
        • Jull G
        • Dall'Alba P
        • Rainoldi A
        • Merletti R.
        An electromyographic analysis of the deep cervical flexor muscles in performance of craniocervical flexion.
        Phys Ther. 2003; 83: 899-906
        • Falla DL
        • Jull GA
        • Hodges PW.
        Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test.
        Spine (Phila Pa 1976). 2004; 29: 2108-2114
        • Boyd-Clark LC
        • Briggs CA
        • Galea MP.
        Comparative histochemical composition of muscle fibres in a pre- and a postvertebral muscle of the cervical spine.
        J Anat. 2001; 199: 709-716
        • Vasavada AN
        • Peterson BW
        • Delp SL.
        Three-dimensional spatial tuning of neck muscle activation in humans.
        Exp Brain Res. 2002; 147: 437-448
        • Falla D
        • Farina D.
        Neural and muscular factors associated with motor impairment in neck pain.
        Curr Rheumatol Rep. 2007; 9: 497-502
        • Falla D
        • Farina D
        • Dahl MK
        • Graven-Nielsen T.
        Muscle pain induces task-dependent changes in cervical agonist/antagonist activity.
        J Appl Physiol (1985). 2007; 102: 601-609
        • Falla D
        • Bilenkij G
        • Jull G.
        Patients with chronic neck pain demonstrate altered patterns of muscle activation during performance of a functional upper limb task.
        Spine (Phila Pa 1976). 2004; 29: 1436-1440
        • Tsang SMH
        • Szeto GPY
        • Xie YF
        • Lee RYW.
        Association of electromyographic activation patterns with pain and functional disability in people with chronic neck pain.
        Eur J Appl Physiol. 2018; 118: 1481-1492
        • Cagnie B
        • Dirks R
        • Schouten M
        • Parlevliet T
        • Cambier D
        • Danneels L.
        Functional reorganization of cervical flexor activity because of induced muscle pain evaluated by muscle functional magnetic resonance imaging.
        Man Ther. 2011; 16: 470-475
        • Vernon H.
        The Neck Disability Index.
        J Musculoskelet Pain. 1996; 4: 95-104
        • Vernon H
        • Mior S.
        The Neck Disability Index: a study of reliability and validity.
        J Manipulative Physiol Ther. 1991; 14: 409-415
        • Paul-Dauphin A
        • Guillemin F
        • Virion JM
        • Briancon S.
        Bias and precision in visual analogue scales: a randomized controlled trial.
        Am J Epidemiol. 1999; 150: 1117-1127
        • Vernon H.
        The Neck Disability Index: state-of-the-art, 1991-2008.
        J Manipulative Physiol Ther. 2008; 31: 491-502
        • Falla D
        • Dall'Alba P
        • Rainoldi A
        • Merletti R
        • Jull G.
        Location of innervation zones of sternocleidomastoid and scalene muscles–a basis for clinical and research electromyography applications.
        Clin Neurophysiol. 2002; 113: 57-63
        • Hermens HJ
        • Freriks B
        • Disselhorst-Klug C
        • Rau G.
        Development of recommendations for SEMG sensors and sensor placement procedures.
        J Electromyogr Kinesiol. 2000; 10: 361-374
        • Cagnie B
        • Danneels L
        • Cools A
        • Dickx N
        • Cambier D.
        The influence of breathing type, expiration and cervical posture on the performance of the cranio-cervical flexion test in healthy subjects.
        Man Ther. 2008; 13: 232-238
        • Portney LG
        • Watkins MP.
        Foundations of Clinical Research: Applications to Practice.
        3rd ed. Pearson Education Ltd, Harlow, Essex, UK2014
        • Kottner J
        • Audigé L
        • Brorson S
        • et al.
        J Clin Epidemiol. 2011; 64: 96-106
        • Guo Y
        • Logan HL
        • Glueck DH
        • Muller KE.
        Selecting a sample size for studies with repeated measures.
        BMC Med Res Methodol. 2013; 13: 100
        • Jull G
        • Kristjansson E
        • Dall'Alba P.
        Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients.
        Man Ther. 2004; 9: 89-94
        • Johnston V
        • Jull G
        • Souvlis T
        • Jimmieson NL
        Neck movement and muscle activity characteristics in female office workers with neck pain.
        Spine (Phila Pa 1976). 2008; 33: 555-563
        • Sterling M
        • Jull G
        • Vicenzino B
        • Kenardy J
        • Darnell R.
        Development of motor system dysfunction following whiplash injury.
        Pain. 2003 May; 103: 65-73
        • Zito G
        • Jull G
        • Story I.
        Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache.
        Man Ther. 2006; 11: 118-129
        • Jesus-Moraleida FR
        • Ferreira PH
        • Pereira LS
        • Vasconcelos CM
        • Ferreira ML.
        Ultrasonographic analysis of the neck flexor muscles in patients with chronic neck pain and changes after cervical spine mobilization.
        J Manipulative Physiol Ther. 2011; 34: 514-524
        • Javanshir K
        • Rezasoltani A
        • Mohseni-Bandpei MA
        • Amiri M
        • Ortega-Santiago R
        • Fernandez-de-Las-Penas C.
        Ultrasound assessment of bilateral longus colli muscles in subjects with chronic bilateral neck pain.
        Am J Phys Med Rehabil. 2011; 90: 293-301
        • Ylinen J
        • Salo P
        • Nykanen M
        • Kautiainen H
        • Hakkinen A.
        Decreased isometric neck strength in women with chronic neck pain and the repeatability of neck strength measurements.
        Arch Phys Med Rehabil. 2004; 85: 1303-1308
        • Prushansky T
        • Gepstein R
        • Gordon C
        • Dvir Z.
        Cervical muscles weakness in chronic whiplash patients.
        Clin Biomech (Bristol, Avon). 2005; 20: 794-798
        • Pearson I
        • Reichert A
        • De Serres SJ
        • Dumas JP
        • Cote JN.
        Maximal voluntary isometric neck strength deficits in adults with whiplash-associated disorders and association with pain and fear of movement.
        J Orthop Sports Phys Ther. 2009; 39: 179-187
        • Elliott JM
        • O'Leary S
        • Sterling M
        • Hendrikz J
        • Pedler A
        • Jull G.
        Magnetic resonance imaging findings of fatty infiltrate in the cervical flexors in chronic whiplash.
        Spine (Phila Pa 1976). 2010; 35: 948-954
        • Elliott J
        • Pedler A
        • Kenardy J
        • Galloway G
        • Jull G
        • Sterling M.
        The temporal development of fatty infiltrates in the neck muscles following whiplash injury: an association with pain and posttraumatic stress.
        PLoS One. 2011; 6: e21194
        • De Pauw R
        • Coppieters I
        • Palmans T
        • Danneels L
        • Meeus M
        • Cagnie B.
        Motor impairment in patients with chronic neck pain: does the traumatic event play a significant role? A case-control study.
        Spine J. 2018; 18: 1406-1416
        • Ishida H
        • Suehiro T
        • Ono K
        • Kurozumi C
        • Watanabe S.
        Correlation between deep cervical flexor muscle thickness at rest and sternocleidomastoid activity during the craniocervical flexion test.
        J Bodyw Mov Ther. 2016; 20: 208-213
        • Ghamkhar L
        • Kahlaee AH.
        Are ultrasonographic measures of cervical flexor muscles correlated with flexion endurance in chronic neck pain and asymptomatic participants?.
        Am J Phys Med Rehabil. 2017; 96: 874-880
        • Cagnie B
        • Dickx N
        • Peeters I
        • et al.
        The use of functional MRI to evaluate cervical flexor activity during different cervical flexion exercises.
        J Appl Physiol (1985). 2008; 104: 230-235
        • Muceli S
        • Falla D
        • Farina D.
        Reorganization of muscle synergies during multidirectional reaching in the horizontal plane with experimental muscle pain.
        J Neurophysiol. 2014; 111: 1615-1630
        • Gizzi L
        • Muceli S
        • Petzke F
        • Falla D.
        Experimental muscle pain impairs the synergistic modular control of neck muscles.
        PLoS One. 2015; 10e0137844
        • Hodges PW
        • Tucker K.
        Moving differently in pain: a new theory to explain the adaptation to pain.
        Pain. 2011; 152: S90-S98
        • Hodges PW
        • Coppieters MW
        • MacDonald D
        • Cholewicki J.
        New insight into motor adaptation to pain revealed by a combination of modelling and empirical approaches.
        Eur J Pain. 2013; 17: 1138-1146
        • Ivanenko YP
        • Dominici N
        • Daprati E
        • Nico D
        • Cappellini G
        • Lacquaniti F.
        Locomotor body scheme.
        Hum Mov Sci. 2011; 30: 341-351
        • Tucker K
        • Butler J
        • Graven-Nielsen T
        • Riek S
        • Hodges P.
        Motor unit recruitment strategies are altered during deep-tissue pain.
        J Neurosci. 2009; 29: 10820-10826
        • Kawakami Y
        • Abe T
        • Kanehisa H
        • Fukunaga T.
        Human skeletal muscle size and architecture: variability and interdependence.
        Am J Hum Biol. 2006; 18: 845-848
        • Ahn AN
        • Kang JK
        • Quitt MA
        • Davidson BC
        • Nguyen CT.
        Variability of neural activation during walking in humans: short heels and big calves.
        Biol Lett. 2011; 7: 539-542
        • Hug F
        • Hodges PW
        • Tucker KJ.
        Effect of pain location on spatial reorganisation of muscle activity.
        J Electromyogr Kinesiol. 2013; 23: 1413-1420
        • Claus AP
        • Hides JA
        • Moseley GL
        • Hodges PW.
        Different ways to balance the spine: subtle changes in sagittal spinal curves affect regional muscle activity.
        Spine (Phila Pa 1976). 2009; 34: E208-E214
        • Gizzi L
        • Nielsen JF
        • Felici F
        • Moreno JC
        • Pons JL
        • Farina D.
        Motor modules in robot-aided walking.
        J Neuroeng Rehabil. 2012; 9: 76
        • Hudswell S
        • von Mengersen M
        • Lucas N.
        The cranio-cervical flexion test using pressure biofeedback: A useful measure of cervical dysfunction in the clinical setting?.
        Int J Osteopath Med. 2005; 8: 98-105
        • Jull GA.
        Deep cervical flexor muscle dysfunction in whiplash.
        J Musculoskelet Pain. 2000; 8: 143-154
        • Jull G
        • Barrett C
        • Magee R
        • Ho P.
        Further clinical clarification of the muscle dysfunction in cervical headache.
        Cephalalgia. 1999; 19: 179-185
        • James G
        • Doe T.
        The craniocervical flexion test: intra-tester reliability in asymptomatic subjects.
        Physiother Res Int. 2010; 15: 144-149
        • Arumugam A
        • Mani R
        • Raja K.
        Interrater reliability of the craniocervical flexion test in asymptomatic individuals-a cross-sectional study.
        J Manipulative Physiol Ther. 2011; 34: 247-253
        • Gandevia SC.
        Spinal and supraspinal factors in human muscle fatigue.
        Physiol Rev. 2001; 81: 1725-1789
        • Vlaeyen JW
        • Linton SJ.
        Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.
        Pain. 2000; 85: 317-332
        • Ambusam S
        • Baharudin O
        • Roslizawati N
        • Leonard J.
        Position of document holder and work-related risk factors for neck pain among computer users: a narrative review.
        Clin Ter. 2015; 166: 256-261