Accepted Manuscript

Stretching position can affect levator scapular muscle activity, length, and cervical
range of motion in people with a shortened levator scapulae

Hyo-Jung Jeong, PT, MS, Heon-Seock Cynn, PT, PhD, Chung-Hwi Yi, PT, PhD,
Jang-Whon Yoon, PT, PhD, Ji-Hyun Lee, PT, PhD, Tae-Lim Yoon, PT, PhD, Bo-Been
Kim, PT, MS
PII: S1466-853X(17)30133-5
DOI: 10.1016/j.ptsp.2017.04.001
Reference: YPTSP 806

To appear in: Physical Therapy in Sport

Received Date: 27 June 2016

Revised Date: 30 March 2017
Accepted Date: 3 April 2017

Please cite this article as: Jeong, H.-J., Cynn, H.-S., Yi, C.-H., Yoon, J.-W., Lee, J.-H., Yoon, T.-L.,
Kim, B.-B., Stretching position can affect levator scapular muscle activity, length, and cervical range of
motion in people with a shortened levator scapulae, Physical Therapy in Sports (2017), doi: 10.1016/
j.ptsp.2017.04.001.

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 ACCEPTED MANUSCRIPT
Title: Stretching Posture Can Affect Levator Scapular Muscle Activity, Length, and Cervical Range of

Motion in People with a Shortened Levator Scapulae

We wish to confirm that there are no known conflicts of interest associated with this publication and

there has been no significant financial support for this work that could have influenced its outcome.

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We confirm that the manuscript has been read and approved by all named authors and that there are no

other persons who satisfied the criteria for authorship but are not listed. We further confirm that the

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order of authors listed in the manuscript has been approved by all of us.

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Prior to participation, the subjects read and signed an informed consent form.

The investigation was approved by Yonsei University Wonju Institutional Review Board (1041849-

201501-BM-008-01).
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Corresponding Author:
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Heon-Seock Cynn, PhD, PT

Department of Physical Therapy, The Graduate School, Yonsei University,Wonju, Gangwon-do, South
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Korea, 220-710
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Phone: +82-33-760-2427

Email: cynn@yonsei.ac.kr
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 ACCEPTED MANUSCRIPT

Stretching Position can Affect Levator Scapular Muscle Activity, Length, and Cervical

Range of Motion in People with a Shortened Levator Scapulae

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ABSTRACT

Objectives: Levator scapulae (LS) muscle stretching exercises are a common method of lengthening a shortened

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muscle; however, the appropriate stretching position for lengthening the LS in people with a shortened LS remains

unclear. The purpose of this study was to compare the effects of different stretching exercise positions on the LS and

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introduce effective stretching exercise methods to clinicians.

Participants: Twenty-four university students (12 men, 12 women) with a shortened LS were recruited.

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Methods: LS muscle activity, LS index (LSI), and cervical range of motion (ROM) were measured pre (baseline)
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and post three different stretching exercise positions (sitting, quadruped, and prone).

Results: The LSI and cervical ROM exceeded the minimal detectable change and had significant changes. The LSI
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was greater in the sitting position than at the baseline (p = 0.01), quadruped position (p < 0.01); the LSI in the prone

position presented a higher increase than the quadruped position (p = 0.01). The cervical ROM increased in the
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sitting position when compared to the baseline (p < 0.01) and quadruped position (p < 0.01).
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Conclusions: Stretching the LS in the sitting position was the most effective exercise for improving LS muscle

length and cervical ROM.

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Keywords: Electromyography, Levator scapulae, Muscle stretching exercises, Neck

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1. Introduction

Length deficiency of the levator scapulae (LS) may affect movements and alter muscle balance, leading to

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motion impairments (Sahrmann 2002). LS is prone to becoming shortened and dominant in muscle activations when

compared with the scapular upward rotators that may result in imbalanced scapular alignment and muscle

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coordination (Sahrmann, 2002; Grant, 1988). A shortened LS may cause abnormal scapular elevation (Mottram

1997) and loss of cervical flexion and contralateral rotation (Diener 1998) in addition to causing headache, upper

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cervical pain (Grant 1988), increased shear force, and compressive load in the cervical region (Ha, Kwon et al.

2011). The shortened LS is also associated with a forward head posture and a rounded shoulder posture, which alter

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the scapular position, thereby decreasing the scapular upward rotation (Lynch, Thigpen et al. 2010).
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Stretching exercises are a common method of lengthening a shortened muscle. Stretching exercises for the

LS have been often suggested (Diener 1998, Sahrmann 2002, Kisner and Colby 2007); however, the effects of
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different LS stretching positions on the LS length remain unclear. Because different positions may lead to different

muscular effects, stretching positions for lengthening the LS may be important. Additionally, the identification of an
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optimal stretching position for the LS seems to be essential for clinicians achieve effective stretching exercises for
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patients. To test this possibility, we suggest three posture positions for stretching the LS: sitting position (SP),

introduced by Kisner and Colby (2007); quadruped position (QP), recommended by Sahrmann (2002); and prone

position (PP). The PP is a modified stretching exercise that is thought to stabilize the patient’s body by increasing
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the base of support. The PP may be the optimal position that provides stable conditions for lengthening only the LS

without compensatory motions which may not affect other adjacent joints (Sahrmann 2002).
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Previous studies investigated the LS muscle activity with scapular upward rotators to examine the

imbalanced muscle coordination between the scapular upward and downward rotators. A reduced activation of LS

muscle represents a decreased scapular downward rotator activation that suggests a balanced muscle coordination

during performance (Choi, Cynn et al. 2015, Castelein, Cools et al. 2016). The stretching exercises may positively

affect shoulder elevation, thereby resulting in decreased LS muscle activation during shoulder elevation that may

contribute to balanced scapular motions. The effectiveness of LS stretching might result in less LS muscle
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activations during maximal arm elevations; therefore, we hypothesized that there would be a decreased LS muscle

activity after stretching exercise among three different positions.

Measurement of the muscle length is often used to describe muscle flexibility, and muscle length can be

assessed using the maximal range of motion (ROM) of the muscle (Janda, 1993). Therefore, the measures of the

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muscle length and maximal ROM, may provide data on the effectiveness of LS stretching as manifested by a

lengthening of the muscle. To detect the muscle length changes after the stretching exercises, the LS index (LSI) can

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be measured because LSI is an accessible assessment tool for measuring LS length with a good reliability (Lee,

Cynn et al. 2016). The current study was the first to analyze the effectiveness of interventions in participants with a

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shortened LS; a previous study only measured LSI in people with and without scapular downward rotation

syndrome (Lee, Cynn et al. 2016). An increase in the LSI would indicate the effectiveness of the stretching methods

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and consequently, the increased LS length. The cervical ROM can also be measured because a lengthened LS is
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associated with an increased cervical ROM (Diener 1998). Improving the cervical ROM is important because LS is

associated with cervical problems that influences activities of daily living (Blazevich, Cannavan et al. 2012). An
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increased LS length after stretching may increase the cervical ROM during contralateral rotations. Thus, we

hypothesized that the LSI score and cervical ROM after the stretching exercises would increase in the three different
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positions.
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To our knowledge, no studies have measured the LS length to define the shortness of this muscle. Further,

previous studies did not quantitatively measure the effectiveness of LS stretching exercises on muscle activation and
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flexibility. Therefore, the purpose of this study was to compare the effects of the three different LS stretching

positions on LS muscle activity, LSI, and cervical ROM in people with a shortened LS. We hypothesized that the
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effective stretching exercise would result in decreased LS muscle activity, greater LSI score, and increased cervical

ROM outcome measures. We also hypothesized that the outcome measures would differ among the baseline and
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after three LS stretching positions.

2. Methods

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2.1 Participants

Table 1 shows the participants’ descriptive data. Before starting the investigation, the LS resting length of

56 healthy volunteers was measured (12.6 ± 1.3 cm). To establish a standard score to determine the “shortened LS”,

the LSI score was calculated using the following formula: LSI = (RL / h) * 100, where RL is the resting length, and h

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is the height, both in cm. The mean of all samples was calculated (7.5 ± 0.6), and the LSI cutoff was set at -1 SD.

Therefore, to be eligible, participants should have an LSI score ≤ 6.9. Thereafter, 157 participants showed interest in

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the study and underwent examinations at the university. Twenty-four university students (12 men, 12 women) met

the inclusion criteria. All volunteers and participants were recruited through advertisements in the campus.

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The exclusion criteria were: 1) positive shoulder impingement tests (Hawkins, Neer, and Jobe tests) (Choi,

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Cynn et al. 2015); 2) history of or clinical examination revealing pain or dysfunction and compromised shoulder

motion during activities of daily living and on clinical examination (Ludewig, Hoff et al. 2004); 3) history of
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thoracic outlet syndrome reported by the participant (Ludewig, Hoff et al. 2004); 4) scoliosis-positive result on the

Adam’s forward bend test (Choi, Cynn et al. 2015); and 5) history of shoulder surgery within the last 6 months (Hsu,
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Chen et al. 2009). Prior to data collection, the participants were informed about the experimental protocol and

signed an informed consent form. This study protocol was approved by the Yonsei University Wonju Institutional
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Review Board.
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2.2 Sample size

The G*power software package (ver. 3.1.6; Franz Faul, Kiel University, Kiel, Germany) was used to
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conduct the power analyses. The required sample size of 18 was calculated from nine participants with a shortened
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LS to satisfy a power of 0.80, effect size of 0.29, and alpha level of 0.05.

2.3 Procedures

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All measurements (muscle activity, LSI, and cervical ROM) were performed by two independent

examiners to collect data at baseline and after each exercises. The same sequence of outcomes data acquisition was

used for all participants. The side with the lower LSI score was selected for the stretching exercises. After baseline

measurements, the experimental stretching interventions were initiated. For the three different LS stretching

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positions (SP, QP, and PP), a randomized plan was generated for each participant using an online algorithm

(http://www.randomization.com) to avoid order effects (Portney and Watkins 2009). Each stretching exercise was

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performed in 10 repetitions (held for 30 seconds, with 30-second rest between trials) (Williams, Laudner et al.

2013). After completing all 10 repetitions for a given stretching position, a 30-minute rest period (3 min × 10 trials)

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was provided as a “wash-out” period (DePino, Webright et al. 2000).

2.3.1 Measurement of muscle activity

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Surface electromyography (EMG) signals denoting LS muscle activity were collected using the
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NoraxonTeleMyo DTS system (Noraxon Inc., Scottsdale, AZ, USA) and the MyoResearch Master Edition software

package (ver. 1.06 XP; Noraxon Inc.). Prior to the data collection, the skin was shaved and cleaned with alcohol to
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optimize electrical conductance by reducing skin impedance. Disposable Ag/AgCl surface electrodes were placed

bilaterally with a 2-cm inter-electrode distance to the muscle fibers. The electrode placement was between the
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posterior margin of the sternocleidomastoid muscle and the anterior margin of the upper trapezius (Ludewig and

Cook 1996). Maximum voluntary isometric contractions (MVICs) were obtained to normalize the EMG data using
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the following manual muscle testing position: sitting position with the head rotated and side-bent to the testing side

and the shoulder elevated. Manual resistance was applied against the participants’ shoulder upon elevation and the
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participant was requested to exert maximal effort within 5 seconds by the examiner (Choi, Cynn et al. 2015). The
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first and last seconds were discarded for analysis purposes. Three trials were performed, and a 2-minute rest period

between trials was given to reduce muscle fatigue (de Oliveira, de Morais Carvalho et al. 2008, Lee, Cynn et al.

2015). The data were sampled at 1,000 Hz, with a band-pass filtering of 20–450 Hz, notch-filtered at 60 Hz, and the

root-mean-square was calculated using a moving window of 50 ms. The intra-class correlation coefficient (ICC) for

the MVIC of the LS was 0.90 (95% confidence interval [CI], 0.77–0.96).

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The LS muscle activity, expressed as a percentage of the mean MVIC (%MVIC), was measured during

maximal arm elevation in the scapular plane (45° frontal to the coronal plane) until the wooden target bar leveled

with the styloid process to indicate the maximal achievable range (Watson, Balster et al. 2005). A plastic pole was

used as a guide to maintain the scapular plane throughout the motion. The participants held their arms in this

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position with full elbow extension, wrists in neutral, and thumbs directed superiorly (Wang, McClure et al. 1999),

for 6 seconds. The elevated position was maintained without compensatory motions such as, head rotation, and

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confirmed visually by the examiner (Fig. 1). Maximal arm elevation was performed twice for 6 seconds each. The

first and last seconds of each trial were discarded, thereby, the remaining 4 seconds were used for data analyses

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(Watson, Balster et al. 2005, de Oliveira, de Morais Carvalho et al. 2008, Ha, Kwon et al. 2012).

2.3.2 Measurement of LSI

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Participants stood with their arms resting along the body and feet shoulder-width apart. They were
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instructed to look directly ahead and remain motionless. Moreover, to neutralize and prevent changes in muscle

length due to respiration, the participants were asked to exhale and hold their breath before the measurements were
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taken and then to inhale again afterward. The craniocervical spine position was verified in three planes (frontal,

sagittal, and horizontal) before each measurement. The LSI scores were obtained using a caliper positioned at the
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dorsal tubercles of the transverse processes of the second cervical vertebra and the superior angle of the medial

borders of the scapula (Lee, Cynn et al. 2015) (Fig. 2). Two adhesive circular stickers (2-mm diameter) were used to
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mark the reference points for measuring the LSI scores. Two researchers measured the LSI twice, independently.

The LSI intra-rater reliability was 0.99 (0.98‒0.99), and the LSI inter-rater reliability was 0.72 (0.34‒0.88).
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2.3.3 Measurement of cervical ROM

A cervical ROM measurement device (Performance Attainment Associates, Roseville, MN, USA) was

used to measure the cervical ROM during the contralateral rotations (Audette, Dumas et al. 2010). The participants

sat straight on a plastic chair with their hands resting on their thighs and feet flat on the floor. First, they were

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instructed to look straight ahead and keep their shoulders and trunk still while allowing for neck movements. The

dial was set at zero with the head maintained in a neutral position. Thereafter, the participants were asked to move

their head as far as possible to the opposite direction of the shortened LS. For familiarization, the participants

performed one practice trial prior to the data collection. The participants moved their heads back to the starting

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position once the values were obtained. The ICC for the cervical ROM was 0.97 (0.95 – 0.98)

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2.4 LS stretching positions

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2.4.1 Sitting position (SP)

Participants sat on a stool and contralaterally rotated their head in the direction of the shortened LS. An

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examiner kneeled behind the participant and applied the manual stretch. As the participants exhaled, the examiner
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applied an inferior stretching force to the superior angle of the scapula and elevated the arm on the side of the

shortened LS. Simultaneously, the participants forced their head in cervical flexion and lateral flexion using their
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hand (Kisner and Colby 2007). This position was maintained until the participants felt a “good stretch” had been

achieved on the shortened LS without causing discomfort (Bandy, Irion et al. 1997) (Fig. 3).
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2.4.2 Quadruped position (QP)

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Participants were positioned in the QP, on a table with their chin toward the chest. The hip joints were

maintained at 90° centered over the knees with the ankles in plantar flexion. The participants were instructed to rock
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backward slowly, bringing the buttocks toward both heels according to verbal instructions (Ha, Kwon et al. 2012).
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An examiner leveled the participant’s head and neck with the shoulders and ensured that the spine was flat during

the backward-rocking until the maximal point at which the participants could stay in the position with no

compensatory movements, such as head rotation or neck extension (Sahrmann 2002) (Fig. 4).

2.4.3 Prone position (PP)

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Participants were placed in the PP with their head contralaterally rotated to the side of the shortened LS.

An examiner instructed the participants to hold the participant’s head, then pull it in cervical flexion with their own

hand. An inferolateral force was applied by the examiner to the superior angle of the scapula on the side of shortened

LS until that a “good stretch” had been achieved, without causing any discomfort (Bandy, Irion et al. 1997) (Fig. 5).

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2.5 Statistical analysis

All analyses were performed using the Statistical Package for the Social Sciences software (ver. 21.0,

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SPSS Inc., Chicago, IL, USA). The test-retest reliability of each dependent variable at baseline and in the three

different positions was calculated using ICCs (95% CIs) and standard errors of measurement (SEM) (Beckerman,

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Roebroeck et al. 2001). The minimal detectable change (MDC95) of the measurements was calculated to assess the
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minimal measurement change that can be interpreted as a true difference (Beckerman, Roebroeck et al. 2001). The

formulae for the SEM and MDC95 calculations were as follow: SEM = SD√(1 – ICC); MDC95 = SEM × 1.96√2
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(Beckerman, Roebroeck et al. 2001). One-way repeated measures analysis of variance was used to determine the

differences in the LS muscle activity, LSI, and cervical ROM before (baseline) and after the three different
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stretching positions (baseline vs. SP vs. QP vs. PP). The significance level was set at α = 0.05. If a significant

difference was found, a Bonferroni adjustment was performed at α = 0.05/4 = 0.013 (Portney and Watkins 2009) to
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divide the alpha level by the number of the levels. We divided the alpha level by the number of the levels to ensure

that clinically significant findings were not missed due to the strict statistical analysis parameters (Perneger 1998).
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3. Results
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Table 2 shows the results of the ICC, 95% CI, SEM, and MDC95 of each dependent variable at baseline

and after the three different positions. There was a significant difference in the LS muscle activity (F = 6.566, p <

0.01), LSI score (F = 10.259, p < 0.01), and cervical ROM (F = 9.391, p < 0.01) among baseline and after three

different exercise positions.

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The LS muscle activity significantly decreased after SP (p < 0.01) and PP (p = 0.01) compared to baseline.

The LSI score significantly increased after SP compared to baseline (p = 0.01), QP (p < 0.01), and PP (p < 0.01) as

well as after PP compared to QP (p = 0.01). Cervical ROM was significantly increased after SP compared to

baseline (p < 0.01) and QP (p < 0.01) as well as after PP compared to baseline (p = 0.01) (Table 3, Fig. 6).

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4. Discussion

The purpose of this study was to compare three LS stretching positions with respect to the LS muscle

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activity, LSI, and cervical ROM in people with a shortened LS. We found significant differences in the LS muscle

activity, LSI, and cervical ROM among baseline and three different stretching positions. The outcomes corresponded

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with our hypothesis that resulted in (1) decreased LS muscle activity, (2) increased LSI, and (3) increased cervical
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ROM after stretch exercises. To the best of our knowledge, this study is the first to investigate the immediate effects

of different LS stretching positions in people with a shortened LS.

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LS muscle activity significantly decreased after the SP and PP compared to baseline by 3.1 %MVIC and

2.8 %MVIC, respectively. The SEM and MDC95 were 0.78–1.95 %MVIC and 2.16–5.41 %MVIC, respectively. The
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MDC95 represents the true difference of the measurements (Beckerman, Roebroeck et al. 2001); therefore, there
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were no meaningful differences among the stretch positions in LS muscle activity. Since no previous study assessed

LS muscle activity after LS stretching exercises, there are no comparable results for this study. The imbalanced
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muscle coordination of the scapular upward and downward rotators may result in scapular impairments (Sahrmann

2002, Choi, Cynn et al. 2015); for this reason, several studies have examined LS muscle activity with scapular
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upward rotators during overhead exercises after hypothesizing that decreased LS muscle activities may contribute to

balanced muscle coordination (Choi, Cynn et al. 2015, Castelein, Cools et al. 2016). The reason for the lack of
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detectable difference in our study could be attributed to the increased variability during maximal arm elevation in the

participants. The placement of the participant’s arm at their reachable height may have caused the higher variability.

The ICC values of the LS muscle activity were 0.97–0.99, which show a high reliability; however, the high standard

deviation of muscle activation affected the MDC95 value, which made the results invalid. Thus, the result of our

study showed a significant but not a meaningful decrease in the LS muscle activity after the stretching exercises.

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Lee et al. (2016) used the LSI to measure LS length in participants with and without scapular downward

rotation syndrome and reported a good reliability (ICC = 0.75–0.98). The present study showed the intra-rater and

inter-rater reliabilities of the LSI as 0.99 and 0.72, respectively. This result is consistent with that of the previous

study, thereby confirming that measurements of LS length are reliable. The SEM and MDC95 were 0.05–0.08 and

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0.15–0.22, respectively. These results indicate that the LSI score was higher after SP compared to baseline, QP, and

PP by 0.26, 0.44, and 0.21, respectively. Furthermore, the LSI score was significantly higher (by 0.23) after PP than

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QP. The differences in the LSI scores exceeded the MDC95, but not for after SP and PP; therefore, the difference in

the LSI score after SP and PP is not meaningful. An increased LSI score represents a relative increase in the LS

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length, suggesting that after SP and PP are more effective than the QP. Because the SP is the only stretching position

that increased the LS length compared to baseline, the SP is thought to be the most effective method of lengthening

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the LS. The increases in the LS length according to the increased LSI score provide the possibility of resolving LS

shortness after stretching exercises.

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Cervical ROM significantly increased after the SP compared to baseline and the QP by 9.0° and 9.4°,
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respectively. Cervical ROM also increased by 5.9° after PP compared to baseline. The SEM and MDC95 were 2.02–

2.24° and 5.59–6.21°, respectively. The differences in the cervical ROM exceeded the MDC95 except after PP
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compared to baseline. Therefore, the SP is the only stretch position that showed meaningful differences. The
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increased cervical ROM during contralateral rotation compared with that of the shortened LS may indicate an

increased LS muscle flexibility. Numerous previous studies have demonstrated an increased maximum ROM and

flexibility after stretching (Halbertsma and Goeken 1994, Kubo, Kanehisa et al. 2002). One previous study reported
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that the normal range of cervical rotation in healthy participants aged 20–29 years is 52‒83° and 62‒85° in men and

women, respectively (Youdas, Garrett et al. 1992). In the present study, the contralateral cervical rotation (i.e.,
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cervical ROM) in the participants, including both men and women (baseline), with a shortened LS was 47.4 ± 10.6°.
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The decreased cervical ROM in the present study may have occurred because of the LS shortness. After SP, cervical

ROM increased to 56.4 ± 9.83°, reaching the normal range of cervical ROM suggested in the previous study

(Youdas, Garrett et al. 1992). The increased cervical ROM to the normal range might be observed only after the SP

because the SP was performed in a cervical contralateral rotation with an applied force; QP was performed actively

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without a cervical contralateral rotation. The improved cervical ROM in the SP suggests the postural importance of

the stretching positions in these patients.

The results of this study could generally be explained by the participants’ positions. The most effective LS

stretching positions was the SP, which was performed as follows: the examiner knelt behind the participants so a

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downward stretching force could be applied easily to the shortened LS in the direction of gravity. Furthermore, the

stretching force was applied as the participant exhaled. During exhalation, the rib cage descends due to the passive

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recoiling of the inspiratory muscles. Although the LS is not a primary inspiratory muscle, it can act as an accessory

inspiratory muscle. Theoretically, the LS does not contract; rather, it is in a state of relaxation during exhalation.

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Lewit (1991) described a gravity-assisted stretch involving post-isometric relaxation and respiratory augmentation

that were effective in releasing the LS (Lewit 1991). Therefore, applying a stretching force during expiration in the

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context of SP can effectively stretch a shortened LS. Furthermore, in the PP, the examiner was in a standing position,
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from where an inferolateral stretching force was applied to the shortened LS muscle while the participants were in

the PP; this stretching force might have been weaker than the inferior stretching force applied during the SP.
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Moreover, the participant’s upper limb on the shortened LS side was not in an abducted position, compared to the

SP; thus, the shortened LS was in a slackened status after PP stretching. In the QP, the backward-rocking motion
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ceased before the point at which the compensatory movement stretched the shortened LS. However, in contrast to
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the SP and PP, manual stretching of the shortened LS was not used. The QP stretching was essentially a self-

stretching maneuver, the effects of which were likely to be reduced compared to those of the SP and PP stretches. If

manual stretching was applied during backward (quadruped) rocking or at the end of the QP stretch but before the
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compensatory movement occurred, the stretching effect of the QP would likely have differed from what we have

observed.
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This study has several limitations. First, the washout period that we employed was based on the previous
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studies that assessed different muscles using different techniques. Thus, we recommend that the washout period

associated with the LS stretching be investigated in future studies. Second, cervical spine pathology or dysfunction

was not screened prior to the study. Although we did not perform the stretching to a point at which pain occurred, a

history of cervical problems could have influenced the outcomes. Measuring neck pain would suggest the clear

benefits of LS stretch exercises in relation with neck pain. Third, the current study did not measure scapular
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kinematics and scapular upward rotator muscles to examine muscle imbalances between the LS muscle and the

scapular upward rotators. Further investigations are needed to consider the influence of the LS stretching on scapular

kinematics and muscle coordination patterns between the scapular rotators. Fourth, this study employed a cross-

sectional design such that only the immediate effects of the different LS stretching positions were evaluated. A

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longitudinal study is required to examine the long-term effects of the different LS stretching positions.

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5. Conclusion

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This study demonstrated three different stretching positions of the LS (SP, PP, and QP). It is evidenced that

the postural changes have different effects on LS length and cervical ROM. The sitting stretching position was the

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most effective for increasing the LS length and cervical ROM. These findings may help clinicians in selecting the
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most appropriate LS stretching position for the rehabilitation of neck or shoulder disorders.
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6. References
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Blazevich, A. J., D. Cannavan, C. M. Waugh, F. Fath, S. C. Miller and A. D. Kay (2012). "Neuromuscular factors
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Acknowledgments: All authors contributed to the concept, design, data collection and

analysis of this study. We appreciate with all participants in this study.

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Table 1. Participants’ descriptive characteristics expressed as mean ± standard deviation (Mean ± SD).

Mean ± SD

Age (years) 21.2 ± 2.0

Height (cm) 167.7 ± 77.6

Weight (kg) 67.2 ± 10.2

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Body mass index (kg/m2) 22.8 ± 3.2

Levator scapula lindex 6.0 ± 0.6

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Table 2. The intra-class correlation coefficient (ICC), 95% confidence interval (95% CI), standard error of measurement (SEM), and minimal detectable change (MDC95) of the dependent
variables.

ICC 95% CI SEM MDC95

Levator scapular muscle activity (%MVIC) Baseline 0.97 0.92-0.99 1.50 4.15

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Sitting position 0.97 0.94-0.99 1.31 3.63

Quadruped position 0.96 0.89-0.98 1.95 5.41

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Prone position 0.99 0.98-0.99 0.78 2.16

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Levator scapulae index Baseline 0.99 0.98-0.99 0.06 0.18

Sitting position 0.99 0.97-0.99 0.06 0.16

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Quadruped position 0.99 0.97-0.99 0.05 0.15

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Prone position 0.98 0.97-0.99 0.08 0.22

Cervical range of motion (°) Baseline 0.96 0.90-0.98 2.11 5.85

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Sitting position 0.95 0.89-0.98 2.20 6.09

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Quadruped position 0.96 0.90-0.98 2.24 6.21

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Prone position EP 0.95 0.88-0.98 2.02 5.59
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Table 3. Baseline and position-specific values of the dependent variables, expressed as mean ± standard deviation.

Baseline Sitting position Quadruped position Prone position

Levator scapular muscle activity (%MVIC) 14.9 ± 8.64 11.8 ± 7.57 13.6 ± 9.75 12.1 ± 7.79

Levator scapulae index 6.06 ± 0.64 6.32 ± 0.58 5.88 ± 0.54 6.11 ± 0.56

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Cervical range of motion (°) 47.4 ± 10.6 56.4 ± 9.83 47.0 ± 11.2 53.3 ± 9.02
%MVIC, percentage of the maximum voluntary isometric contraction

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Fig. 1. Maximal arm elevation position.

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Fig. 2. Measurement of LSI using a caliper. Resting muscle length was determined between (A) the dorsal

tubercles of the transverse processes of the second cervical vertebra and (B) the superior angle of the medial
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borders of the scapula. The LSI score was calculated by dividing resting muscle length (cm) by subjects’ height
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(cm) and multiplying by 100. LSI, levator scapulae index.

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Fig. 3. Sitting position. As the participant exhaled, an inferior stretching force was applied to the superior angle
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of the scapula from the same side as the shortened levator scapulae muscle.
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Fig. 4. Quadruped position. (A) Start position. (B) End position. Participants were instructed to slowly rock

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backward to bring the buttocks toward both heels as instructed by the examiner.

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Fig. 5. Prone position. The examiner applied an inferolateral force to the superior angle of the scapula from the

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same side as the shortened levator scapulae muscle.

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(A)

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(B)

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Fig. 6. Comparison of baseline and stretching positions: (A) muscle activity of the LS in %MVIC; (B) LS index;

(C) cervical range of motion in degrees. * Significant differences at 0.013, + minimal detectable change. LS,

levator scapulae; %MVIC, percentage of maximal voluntary isometric contraction; SP, sitting position; QP,

quadruped position, PP, prone position.

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Highlights

- The effect on levator scapular muscle activity, muscle length, and cervical range of motion varies

according to participant body posture.

- The sitting position was more effective compared to the prone and quadruped positions.

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- Levator scapulae index is a reliable tool for measuring levator scapulae length to determine

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effects of stretch exercises.

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 <Title page>
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A. Title:

Stretching Position Can Affect Levator Scapular Muscle Activity, Length, and Cervical Range of Motion in Subjects with a

Shortened Levator Scapulae

B. Authors full contact details

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1. Hyo-Jung Jeong, PT, MS

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- Affiliation: Movement Science Program, Program in Physical Therapy, Washington University School of Medicine.

- Address: 4444 Forest Park Ave., Suite 1101 St. Louis, MO 63108-2212

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- Telephone: +1-314-286-1400

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- Fax: +82-33-760-2496 AN
- E-mail: phyot@naver.com
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2. Heon-Seock Cynn, PT, PhD

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- Affiliation: Applied Kinesiology and Ergonomic Technology Laboratory, Department of Physical Therapy, The Graduate School,
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Yonsei University.

- Address: Baekwoon-kwan, Yonsei University, 1 Yonseidae-gil, Wonju, Gangwon-do, Republic of Korea.

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- Telephone: +82-33-760-2427

- Fax: +82-33-760-2496
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- E-mail: cynn@yonsei.ac.kr
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3. Chung-Hwi Yi, PT, PhD

- Affiliation: Department of Physical Therapy, College of Health Science, Yonsei University

- Address: Baekwoon-kwan, Yonsei University, 1 Yonseidae-gil, Wonju, Gangwon-do, Republic of Korea.

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- Telephone: +82-33-760-29
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- Fax: +82-33-760-2496

- E-mail: pteagle@yonsei.ac.kr

4. Jang-Whon Yoon, PT, PhD

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- Affiliation: Department of Physical Therapy, Hoseo University.

- Address: Art and Technology Building, Hoseo University, 79 Hoseoro, Asan, Chungnam, Republic of Korea.

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- Telephone: +82-41-540-9972

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- Fax: +82-41-540-9975

- E-mail: jyoon@hoseo.edu

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5. Ji-Hyun Lee, PT, PhD candidate
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- Affiliation: Applied Kinesiology and Ergonomic Technology Laboratory, Department of Physical Therapy, The Graduate School,

Yonsei University.
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- Address: Baekwoon-kwan, Yonsei University, 1 Yonseidae-gil, Wonju, Gangwon-do, Republic of Korea.

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- Telephone: +82-33-760-2497

- Fax: +82-33-760-2496
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- E-mail: jihyun.lee@yonsei.ac.kr
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6. Tae-Lim Yoon, PT, PhD

- Affiliation: Department of Physical Therapy, College of Health Science, Cheongju University.

- Address: 298 Daeseongro, Sangdang-gu, Cheongju, Chungbuk, Republic of Korea.

- Telephone: +82-43-229-8635

- Fax: +82-33-229-8969
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- E-mail: free0829@gmail.com
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7. Bo-Been Kim, PT, MS

- Affiliation: Applied Kinesiology and Ergonomic Technology Laboratory, Department of Physical Therapy, The Graduate School,

Yonsei University.

- Address: Baekwoon-kwan, Yonsei University, 1 Yonseidae-gil, Wonju, Gangwon-do, Republic of Korea.

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- Telephone: +82-33-760-2497

- Fax: +82-33-760-2496

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- E-mail: saminchu@naver.com

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C. Keywords :

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Electromyography, Levator scapulae, Muscle stretching exercises, Neck
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We certify that no party having a direct interest in the results of the research supporting this article has or

will confer a benefit on us or on any organization with which we are associated.

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