women have relatively weak neck muscles , which can be a primary cause of chronic fatigue 
 syndrome related to the muscular system , resulting in higher risk of chronic neck pain1 . in relation
to pain a study by fisher found 
 that 62% of women wear heels that are over 5  cm , and the ones who enjoy wearing high heels 
 are reported to suffer from foot , knee , and back pain , as well as an alteration of the 
 normal gait patterns2 . according to 
 previous studies , wearing high - heeled footwear
can alter the static posture and dynamic 
 movements of the body , and is regarded as a cause of musculoskeletal problems related to the 
 spine3,4,5 . walking in high - heeled shoes changes the 
 kinetic characteristics of the lower extremity joints , causing a reduction in ankle plantar 
 flexor muscle moment , and power during stance phase and increases in forefoot peak pressure . 

walking in high heels produces an upward displacement of the center of mass of the body and 
 possibly a more unstable posture compared to that producted by low - heeled walking6,7,8,9 . 

additionally , shock and ground reaction forces can lead to increased axial pressure onto the 
 intervertebral discs , resulting in increased erector spinal muscle activation10 . walking in high - heeled shoes produce an 
 increase in the ground reaction force compared to flat heeled shoes . in theory
, the increase 
 in ground reaction force with increased height may result from decreased subtalar joint 
 pronation at heel strike and a lengthened tibiofemoral lever arm . as a result
, trunk muscle 
 activity increases with increasing heel height , which changes the posture and ground 
 reaction force , leading to discomfort of the back muscle in women who wear high heels11 .
in addition , the effects are magnified 
 with increased activation of the erector spinae muscles , which contribute to compression of 
 the spine .
therefore , wearing high heels for an extended period can lead to an increase in 
 paraspinal musculature activation of the lumbar and cervical spine , causing prolonged 
 overload and fatigue in the trunk and neck muscles1 .
a recent study reported that walking in heels induced a significant increase in the 
 activation of cervical muscles in healthy subjects .
this study was conducted in order to examine the 
 effects of wearing high heels during gait on the cervical and lumbar musculature in patients 
 with chronic neck pain and in healthy women .
thirteen healthy women were recruited for this study . an information leaflet describing the 
 study method and procedure was used for the recruitment of subjects .
the inclusion criteria 
 for patients were as follows : ( 1 ) history of neck pain for the past three months or less , 
 ( 2 ) between the age of 2045 years , ( 3 ) not experiencing orthopedic or neurological problems 
 other than neck pain , and ( 4 ) able to wear high heels without pain .
this study excluded 
 subjects who felt acute worsening of pain symptoms during their maximal effort or who were 
 in an unstable condition with an acute flare up during the time of testing .
table 1table 1.demographic data of the collective intention to treat ( n=13)variablemeanstandard deviationage ( yrs)31.56.6height ( cm)161.14.2body mass ( kg)55.17.5 shows a list of common characteristic of the participants in this study .
a 
 test on the general characteristics of the subjects was filled out prior to conduct of this 
 study . to determine the effects of the different heights of heels on the muscle activation
, 
 the paraspinalis cervicis ( cervical spine ) and erector spinae ( lumbar spine ) were measured 
 at the time of heel strike and toe off during gait . after preparing the skin by shaving , 
 cleaning with alcohol , and sanding ,
two differential surface electrodes were placed at a 
 distance of 2  cm from each other .
surface electromyography ( emg ) electrodes were placed on 
 the paraspinalis cervicis and erector spinae of the subjects dominant side .
all electrodes 
 were placed over the muscle mass , which was visible during maximally resisted voluntary 
 contraction .
two foot switches were placed and attached on the shoe exterior , underneath the 
 first metatarsal head area and the heel of the shoe on the dominant side . to familiarize the subjects to the testing condition with surface electromyography ( emg ) 
 attached to their body ,
they were instructed to walk down the walkway three times prior to 
 the testing condition .
each subject was instructed to walk naturally at a self - selected 
 velocity on a flat and even surface under three different testing conditions ( barefoot , 4  cm 
 stiletto heels , and 10  cm stiletto heels with a base of 1  cm ) .
prior to each gait trial , subjects were 
 instructed to stand still with their feet together in a comfortable position , and then were 
 asked to look straight up and walk down the 10  m walkway in front of them . to prevent 
 muscular fatigue ,
emg data collected during the 10  m walk , the data during the middle 6  m block was used for 
 analysis .
data from the three trials were averaged for analysis using the heel strike and 
 toe off events for each gait trial .
all subjects with neck pain were in a stable condition 
 without an acute flare up during the time of testing .
differences in the emg activity of the paraspinalis cervicis and erector spinae in patients 
 with neck pain during heel strike and toe off during gait were assessed using the spss 12.0 
 program ( spss inc . ,
a one - way repeated anova was used for the 
 identification of significant differences among the barefoot , 4  cm high heel , and 10  cm high 
 heel conditions ; and a post - hoc test using the least - significant - difference ( lsd ) method was 
 employed for comparing the conditions .
muscle activation in the paraspinalis cervicis and erector spinae at heel strike and toe 
 off ( except that of paraspinalis cervicis at toe off event ) differed significantly with the 
 10  cm high heels , compared to the barefoot condition . at heel strike , muscle activation of 
 the paraspinalis cervicis was significantly greater with the 10  cm high heels as compared to 
 that with the 4  cm high heels ( table 
 2table 2.muscle activation ( % mvic ) in normal subjects under the three conditions ( n = 
 13)musclesgait cyclebarefoot4 cm high - heeled10 cm high - heeledcervical paraspinaeheel strike7.62.17.72.49.43.2toe off7.51.87.11.68.22.5erector spinaeheel strike24.78.229.510.531.212.3toe off28.310.530.311.136.218.3meansd .
% mvic : % maximum voluntary isometric contraction . * significant differences compared to barefoot condition .
% mvic : % maximum voluntary isometric contraction . * significant differences compared to barefoot condition .
this study demonstrated the effects of walking in high heels on the muscular activity of 
 the cervical and lumbar muscles in healthy women .
previous studies have reported the muscle 
 activation or biomechanical effects of walking in high heels in healthy women .
mika and 
 coworkers studied the effects of walking on barefoot , 4  cm high heels , and 10  cm high heels 
 on the activation of the cervical paraspinalis in young women ( 2025  years ) and older women 
 ( 4555  years ) .
the results showed a significant increase in cervical muscle activation while 
 walking in 10  cm high heels .
subjects in the older group showed a significant increase in 
 the cervical muscle activation at heel strike while walking in 4  cm high heels and 10  cm 
 high heels .
a higher magnitude of vertical ground reaction force was demonstrated with high 
 heels , and the effects were amplified with the presence of more active erector spinae 
 muscles , which could act partially to compress the spine12 , 13 .
results of previous studies have demonstrated an increase in the compensated muscular 
 activities with an increasing heel height .
wearing high heels changes the overall body 
 posture and loading on the spine and the joints in the lower extremities , resulting in a 
 change in the body s center of mass ( com ) .
snow and williams reported that wearing 
 excessively high heels induces a shift in the body s com anteriorly and superiorly .
ankle is 
 shifted superiorly and anteriorly , and the base of support ( bos ) shifts anteriorly . as the 
 body tries to maintain this posture without falling , compensatory activity of both the 
 erector spinae and the cervical paraspinalis increases14 .
cervical spine movement assists in maintaining the head stability 
 in space , assists in dynamic postural control , and compensates for trunk motion to maintain 
 head stability during gait . with neck extension , the center of mass of the head
neck extension may also 
 assist in balancing the head over the trunk due to the center of mass of the head lying 
 anterior to the cervical spine .
previous studies also attempted to determine the lumbar curve angle , center of mass , and 
 activation of the erector spinae during the gait of healthy women wearing high - heeled 
 shoes6 , 15 .
the results indicated a significant decrease in the lumbar curve 
 angle and , in the vertical movement of the body s center of mass , and a significant increase 
 in activation of the erector spinae .
our results showed a significant increase in muscle 
 activation of the erector spinae at heel strike and toe - off events while wearing 10  cm high 
 heel , as compared to that in barefoot condition in all subjects .
the results of our study demonstrated that wearing high - heeled shoes increases the 
 activation of cervical and lumbar musculature in healthy women16 . according to mika and colleagues , even healthy people 
 wearing high - heeled shoes
experience increased back muscle activity during gait , which could 
 promote local muscle fatigue , in turn leading to tissue deformation , such as swelling or 
 decreased movement13 . in addition
, these 
 symptoms may be more remarkable while wearing stiletto type high heels with unstable 
 balance .
further studies are needed to evaluate the long - term effects between high - heeled shoes and 
 the mechanism of muscle activation of the cervical and lumbar spine .
another limitation of 
 this study was the small number of recruited subjects . for a more accurate observation of 
 the relationship between neck pain and high - heeled shoes , a follow - up study with a longer 
 period of time and
future studies will be 
 necessary to evaluate the effect of high - heels on cervical spine kinematics and muscle 
 fatigue over an extended period of time .
in addition , consideration of changes in body 
 alignment and muscle activation caused by extrinsic factors , such as high - heeled shoes , may 
 be a more effective approach for planning treatment strategies .
 [ purpose ] the purpose of this study was to investigate the effects of different height of 
 high heels on muscle activation of the paraspinalis cervicis and erector spinae in healthy 
 young women . 
 [ subjects and methods ] thirteen healthy women were recruited in this study . 
 to examine the effects of different heights of heels on muscle activation , 
 the 
 paraspinalis cervicis ( cervical spine ) and erector spinae ( lumbar spine ) were measured at 
 the time of heel strike and toe off during gait on three different conditions ( barefoot , 
 4  cm high heels , and 10  cm high heels ) . 
 there are no previous trials or reports that have 
 evaluated this approach in patients with chronic neck pain . 
 [ results ] a significant 
 increase in muscle activation of the paraspinalis cervicis and erector spinae at heel 
 strike and toe off ( except that of the paraspinalis cervicis at toe off in healthy 
 subjects ) was observed in the under 10  cm high heel condition as , compared to that with 
 barefoot condition , in all the subjects . 
 [ conclusion ] the height of the high heels affects 
 to the activation demand of the paraspinalis cervicis and erector spinae in patients with 
 neck pain . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION