Evaluating Effectiveness of sEMG Biofeedback for Posture Training and Scoliosis Management

doi:10.21203/rs.3.rs-4954337/v1

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Evaluating Effectiveness of sEMG Biofeedback for Posture Training and Scoliosis Management

https://doi.org/10.21203/rs.3.rs-4954337/v1

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The vast majority of the global population uses digital devices, in particular, smartphones and tablets. Their use causes the head to tilt forward, and the posture exerts a significant amount of strain onto the neck and shoulders of users. This would normally have adverse effects on a healthy population but poor posture especially exacerbates the spinal deformation of scoliosis patients. As such, this study evaluates the effectiveness of a 30-session surface electromyography (sEMG) biofeedback posture training program for managing the progression of spinal curvature in adolescents with mild scoliosis. The program is designed to reduce imbalanced paraspinal muscle activity and control the progression of the curvature. Prior to the training, significant imbalance is observed in the muscle activity. However, post-training, the muscle activity increases in balance with significant improvements noted in the trapezius and lumbar erector spinae muscles. The study also finds that the training effectively controls the progression of scoliosis. These findings suggest that sEMG biofeedback posture training can be an effective intervention for adolescents with mild scoliosis. Further research is however needed to confirm the findings and explore the long-term effects of the intervention.

Scoliosis

Biofeedback Training

AIS

sEMG

muscle imbalance

The pervasiveness of smartphones and tablets in daily life has inadvertently created a culture of poor posture, particularly among adolescents (Chen et al., 2022; Khoshhal et al., 2019). The habitual forward tilting of the head while using digital devices exerts undue stress onto the cervical spine, which exacerbates musculoskeletal strain and causes spinal misalignment (Pardhan et al., 2022). This biomechanical disadvantage, which is due to improper posture, can compromise spinal stability, resultant of the interplay of muscle forces and intra-abdominal pressure (Adams & Hutton, 1985; Shahab et al., 2017).

Adolescent idiopathic scoliosis (AIS) is a prevalent form of scoliosis among youths during their growth spurt in puberty (Charles et al., 2006). AIS is defined by a lateral spinal curvature that exceeds 10 degrees as per the Cobb's method. The etiology of AIS is multifaceted which involves a combination of genetic, environmental, hormonal, and neuromuscular factors. Research has suggested that AIS may result from a complex interplay of intrinsic and extrinsic factors, including abnormal growth patterns, asymmetrical muscle development, and neurologic abnormalities (Schlösser & Castelein, 2021; Shi et al., 2009; Wang et al., 2013). While the etiology of AIS remains elusive, early intervention with the use of orthoses like hard braces, particularly when the Cobb angle is less than 20 degrees, can halt the progression of the curvature (Negrini et al., 2018; Tang et al., 2024). Despite the efficacy of traditional rigid braces in providing corrective pressure, they are not without their limitations, including discomfort and social inconvenience (Aulisa et al., 2010; Lou et al., 2004). The success of orthotic treatment is also contingent on the postural awareness of the patient and his/her commitment to self-correcting the spinal misalignment (El-Kafy & El-Shamy, 2021, 2022; Naili,2024).

Several alternative treatments have been developed to address the issues associated with traditional scoliosis management. Durmała et al. (2003) proposed an approach that involves active 3D correction by mobilizing the primary curve towards correction by emphasizing on the kyphotization of the thoracic spine and/or lordotization of the lumbar spine. Lehnert-Schroth (2007) developed an exercise regimen centered around specific rotation angular breathing exercises. Romano et al. (2015) proposed a method based on a scoliosis-specific active self-correction technique (SEAS) that is performed without external aids and integrated into functional exercises. These alternative treatments show that with proficient motor control, patients with scoliosis can make immediate and temporary adjustments to their spine. However, these methods require patients to execute specific movements or maintain a fixed posture, with feedback typically provided by an instructor. Given that these alternative treatments involve exercises designed to enhance motor control, the incorporation of a biofeedback system could potentially enhance the effectiveness of such treatments.

The outcomes of these alternative treatments vary, but they generally aim to improve the spinal alignment and reduce the progression of the curvature. Drawing on insights from these interventions, biofeedback is proposed as a complementary tool rather than as an exercise itself (Berdishevsky et al., 2016). Biofeedback provides real-time data on physiological functions, which allows patients to increase awareness of their postural habits and muscle activation patterns. By integrating biofeedback with therapeutic exercises, patients may achieve more precise control over their movements, which results in more effective and sustained corrections in their spinal posture (Kamelska-Sadowska et al., 2019).

Building on these therapeutic strategies, Cheung et al. (2022) proposed a novel posture training program that integrates surface electromyography (sEMG) biofeedback to monitor and train spinal muscle groups independently. Preliminary findings from their pilot study suggest that biofeedback-facilitated posture training can mitigate imbalanced paraspinal muscle activity (Cheung, 2023; Cheung et al., 2022). In this study, the aim is to evaluate the impact of a 30-session sEMG biofeedback posture training program on paraspinal muscle balance and management of spinal curvature in adolescents with mild scoliosis. We hypothesize that after the intervention, the participants will exhibit more balanced muscle activity and stabilization of curvature progression. Additionally, the study explores the influence of specific paraspinal muscles on the trajectory of scoliosis.

Participants

A total of 25 adolescents (female = 16, male = 9), between 9 and 14 years old (mean = 11.88, SD = 0.971), were selected as subjects through a school screening program. During this program, the angle of trunk rotation (ATR) in the thoracic and lumbar regions was measured by using a scoliometer during the Adam’s forward bend test. Subjects with an ATR greater than 4 degrees underwent further evaluation, which included EOS imaging of the entire spine. The subjects with a Cobb’s angle that ranges from 10 to 20 degrees were invited to participate in this study. Details of their profiles are provided in Table 1. Participation was voluntary, with informed consent obtained from the adolescents themselves and written informed consent from their parents. Ethics approval was received from the ethics committee of the university of the authors.

sEMG Measurement Prior to and Post-Training

The activity of the spinal muscles was measured by using a preamplifier sensor, MyoScan (model T9503M, Thought Technology Ltd., Canada), and a data acquisition system, FlexComp Infiniti (model T7555M; Thought Technology Ltd., Canada). The sEMG electrodes were positioned on the paraspinal muscles, specifically the trapezius, latissimus dorsi, thoracic erector spinae, and lumbar erector spinae muscles in pairs to assess muscle activity along the spine during habitual sitting postures (see Fig. 1). The skin of the subject was cleaned with an alcohol wipe to reduce impedance to less than 5 kΩ, which was verified by an impedance test built into the BioGraph Infiniti software (Thought Technology Ltd., Canada). The sEMG signals were sampled at a rate of 2048 Hz with a 10–500 Hz band-pass filter and a 60 Hz notch filter to eliminate artifacts and noise.

Biofeedback Posture Training Set-up

All of the participants underwent an assessment before and after the biofeedback posture training. During each assessment, they were asked to sit for 3 minutes in a relaxed state to measure their muscle activity via sEMG signals. The baseline measurement protocol was administered by using BioGraph Infiniti, with measurements taken 3 times for 3 minutes each time.

Table 1

Participant profile and their spinal deformity angles before and after biofeedback posture training.
Subject no.	Age	Sex	Height (cm)	Weight (kg)	BMI	Major curve angle (before training)	Major curve angle (after training)	Diffe-rence
1	12	M	165	57.1	21	11.7°	20.7°	9°
2	12	M	153	41	15.9	17.6°	21.7°	4.1°
3	12	F	153	37.3	17.5	21.1°	26.9°	5.8°
4	13	F	155	43.5	18.1	16.3°	6°	-10.3°
5	11	F	150	39.1	17.4	16.2°	20°	3.8°
6	13	F	167	49	17.6	17°	16°	-1°
7	11	F	143	31.4	15.3	13.2°	7.6°	-5.6°
8	11	F	159	38.9	15.4	14.7°	19°	4.3°
9	9	F	146	37.4	17.7	15°	26°	11°
10	12	M	152	43	18.6	17.5°	17°	-0.5°
11	11	F	153	38.5	16.4	14.4°	11°	-3.4°
12	12	M	167	46.9	17.1	16°	9.7°	-6.3°
13	11	M	155	59.2	24.6	12.5°	6°	-6.5°
14	12	F	158	37.5	15.3	17.2°	18°	0.8°
15	13	M	168	51.8	18.4	13.9°	12°	-1.9°
16	11	M	158	59.8	23.8	13.5°	14°	0.5°
17	13	F	162	39.4	15	11.3°	17°	5.7°
18	12	F	141	34.2	17.2	19°	25°	6°
19	12	F	149	36.4	16.4	12.6°	9°	-3.6°
20	12	F	142	40.6	20.1	12.4°	9°	-3.4°
21	12	F	160	46.9	18.3	12°	15.3°	3.3°
22	14	F	160	43.3	16.9	15°	9.9°	-5.1°
23	12	M	164	56.2	20.9	11°	10°	-1°
24	12	M	166	53.5	19.4	13.2	11.3	-1.9
25	12	F	155	40.0	16.6	12.3	13.4	1.1

Each adolescent completed 30 training sessions, which was delivered once a week over a period of approximately 6 months. Prior to each training session, an impedance check was performed after the placement of the sEMG electrodes. During posture training, the participants were instructed to sit in their ideal position and relax the four pairs of paraspinal muscles for 5 minutes. Videos on the biofeedback screen were shown to them when the sEMG values of the paraspinal muscles and the RMS sEMG ratio of the pairs of paraspinal muscles fell below the threshold of specific individual requirements. The aim of the training was to reduce the RMS sEMG ratio between the left and right sides of the four pairs of muscles towards 1 and the individual sEMG values of each of those muscles to less than 5 µV. The exact threshold was individually tailored for an overall success rate of approximately 80%, which also served to motivate the adolescents to engage in the training. Increased relaxation of the paraspinal muscles and balance of the muscle activity of the four pairs of paraspinal muscles resulted in an increase in the video playback time. This posture training routine was repeated five times in each session, with a 2-minute rest given between each repetition. Each training session lasted approximately 60 minutes. The sEMG biofeedback posture training protocols were developed by using BioGraph Infiniti.

Statistical calculations

All of the statistical analyses were performed by using SPSS Statistics 25 for Windows (IBM Corp., Armonk, NY) and RStudio 2023.12.1 + 402 "Ocean Storm" Released for Windows. The ratio was calculated for the root mean square (RMS) of the sEMG signals from the four pairs of paraspinal muscles by using:

$$\:r\:=\:\frac{RM{S}_{convex}}{RM{S}_{concave}}$$

Since each pair of muscles was measured three times, the mean of the ratios for each pair was subjected to one-sample -tests to identify any imbalance (deviation from the test value of 1) in sEMG signals over the trapezius, latissimus dorsi, thoracic erector spinae, and lumbar erector spinae muscles, before and after the biofeedback training. One-sample t-test was also performed for the mean of the ratios. A repeated measure analysis of variance (ANOVA) was conducted to compare the RMS sEMG ratios of the four pairs of muscles before and after the training, followed by a post hoc pairwise comparison if the multivariate results were significant. The level of significance was set at 0.05. Then, a survival analysis was conducted by using the Cox proportional-hazards model to evaluate the effect of paraspinal muscle asymmetry on the progression of AIS. In this model, indexes are used instead of RMS sEMG ratios, in order to provide a better quantitative description of the muscle asymmetry. The indexes are calculated as follows:

$$\:index\:=1\:-\left|\frac{1\:-\:r}{1\:+\:r}\right|\:$$

where r is the RMS sEMG ratio of each pair of paraspinal muscles.

Statistical results

Prior to training, the one-sample t-test results indicated a significant deviation from the ratio of 1 in the RMS sEMG ratios over the pairs of thoracic erector spinae muscles (mean = 1.990, t(24) = 2.381, p < 0.05) and lumbar erector spinae muscles (mean = 1.184, t(24) = 2.093, p < 0.05) in the sitting posture. The results of the nonparametric Wilcoxon signed rank test also showed a similar significant difference for the thoracic erector spinae and lumbar erector spinae muscles (p < 0.05). In contrast, after training, only the RMS sEMG ratio over the pair of thoracic erector spinae muscles (mean = 1.370, t(24) = 2.301, p < 0.05) significantly deviates from the ratio of 1 in the sitting posture. The results of the nonparametric Wilcoxon signed rank test also showed a similar result in which thoracic erector spinae muscles is significantly different from 1 (p > 0.05), whereas the other three muscle pairs are not significantly different from 1.

A repeated-measures ANOVA was used to examine the main effect of the intervention (prior to and post-training) on the relative balance in sEMG activity across the four pairs of paraspinal muscles by comparing the RMS sEMG ratios before and after the training. Additionally, the interaction between intervention and pairs of muscles was also examined.

Regarding the main effect of the intervention, a multivariate test showed that there is no significant difference before and after the intervention, i.e., prior to and post-training (F(1, 24) = 1.971, p > 0.05). In contrast, the multivariate test showed that the main effect of the pairs of muscle is significantly different (F(3, 72) = 3.201, p < 0.05, partial 𝜂² = 0.118).

For the intervention × muscle pair interaction, the multivariate test showed that the interaction is significant (F(3, 72) = 3.304, p < 0.05, partial 𝜂² = 0.121). A post-hoc pairwise comparison revealed that the post-training RMS sEMG ratio of the latissimus dorsi muscles is significantly smaller (M = 1.184, t(24) = 2.079, p < 0.05) than that at baseline (M = 1.990). The results of a student’s paired t-test also showed a significant difference for the latissimus dorsi (t(24) = 1.803, p < 0.05) and thoracic erector spinae (t(24) = 1.929, p < 0.05) muscles.

A survival analysis was conducted using the Cox proportional-hazards model with the post-training sEMG index of all four pairs of muscles. The model showed that the beta coefficient of the post-training sEMG index of the thoracic erector spinae muscles in the sitting posture is negative ($\:\beta\:\:=\:-6.685,\:p\:<\:0.05$). Due to the small sample size, the likelihood ratio test was implemented. The Cox proportional-hazards model is significant ($\:\lambda\:\:=\:11.09,\:p\:=\:0.03$) on 4 degrees of freedom.

The RMS of the sEMG ratios presented in Fig. 2 provides evidence of imbalance in some of the paraspinal muscle activity among the 25 adolescents diagnosed with AIS prior to our posture training. This imbalance is particularly noticeable in the latissimus dorsi and thoracic erector spinae muscles. To elaborate, the average RMS sEMG ratios for these specific pairs of muscles were found to be significantly larger than 1. This statistical finding suggests a clear imbalance in the activity of these two paraspinal muscles before the adolescents underwent our posture training. Ratios larger than 1 indicate a relatively higher level of muscle activity on the convex side of the spine compared to the concave side. Furthermore, the observed asymmetry of the latissimus dorsi muscles is consistent with the results of previous research conducted on AIS patients (Cheung et al. 2022). These studies reveal a larger average RMS sEMG value on the convex side of the trapezius muscles, which is attributed to a lower level of bioelectric activity on the concave side of the muscles (Tam et al., 2022). This agreement with previous findings further validates the presence of muscle asymmetry in AIS patients and underscores the need for targeted interventions to address the imbalance.

Following a regimen of 30 sessions of biofeedback posture training, the RMS sEMG ratios of the paraspinal muscles of the tested subjects approached 1. This suggests a shift towards more symmetric activity of the pairs of muscles compared to the measurements taken prior to the training. Notably, significant improvements were observed in the muscle activity of the latissimus dorsi and lumbar erector spinae muscles post-training. Given that the biofeedback posture training relies on sEMG signals as a feedback mechanism for monitoring posture, it is plausible that the training would have had a significant impact on the sEMG signals post-training. Imbalanced paraspinal muscle activity is widely recognized as a key risk factor for the progression of spinal curvature (Balne et al., 2021). Therefore, to determine the benefits of the biofeedback posture training, another more objective outcome measure, namely spinal deformity, was assessed both before and after the training.

We hypothesized that a reduction in the imbalance of paraspinal muscle activity could potentially have beneficial effects in controlling the progression of the spinal curvature over time. It is important to note that due to potential human error, there could be a five-degree margin of error when measuring the Cobb angle. Therefore, subjects with less than five degrees of progression were considered to show no progression in spinal deformity.

In line with our hypothesis, the RMS sEMG ratio of the latissimus dorsi muscles in the sitting posture of subjects with progression of scoliosis (M = 0.892) is smaller (further away from 1) than those without progression (M = 1.050) when comparing the RMS sEMG ratios of the paraspinal muscles after training. Additionally, the lumbar erector spinae muscles in a sitting posture of the subjects with progression of scoliosis (M = 1.619) are less balanced (further than 1) than those without progression (M = 1.103). These results show that by correcting asymmetry of the paraspinal muscles, spinal deformity could potentially be mitigated. The sample t-test showed that the changes in the curvature angles of the spine are significantly less than five degrees (t(24) = -4.600, p < 0.05), thus indicating that the progression of scoliosis is effectively controlled during the posture training.

The findings in this study suggest that the use of sEMG biofeedback in posture training can effectively reduce the imbalance of paraspinal muscle activity and manage the progression of spinal curvature in adolescents with mild scoliosis. The results show significant improvements in muscle activity, particularly in the trapezius and lumbar erector spinae muscles, following the 30-session training program. The study also finds that the RMS sEMG ratios of all of the paraspinal muscles of the tested subjects approach 1 post-training, thus indicating a shift towards more balanced muscle activity. This suggests that the biofeedback posture training can potentially have beneficial effects in controlling the progression of the curvature over time. However, further research with a larger sample size is needed to confirm these findings and explore the long-term effects of this intervention on the quality of life of adolescents with scoliosis.

Funding

This research was funded by multiple sources. A grant from the Research Grant Council of the Hong Kong Special Administrative Region, China, to The Chinese University of Hong Kong, grant number: CUHK 14607519 (M.C). A research fund from Lee Hysan Foundation to The Hong Kong Polytechnic University, grant number R-ZH3Y (J. Y.), under the project “Non-surgical treatments for Adolescents with Spinal Deformity” (project code: R-ZH3Y). A Research Postgraduate Scholarship from The Hong Kong Polytechnic University.

Author Contribution

Y.H.W., M.C and J.Y contributed to drafting the manuscript and reviewing the content. M.C and J.Y contributed to the conception and design of the research. Y.H.W and M.C conducted the analyses. Y.HW. and M.C contributed to formal analysis and validation. M.C and J.Y contributed to project administration and supervision. Y.H.W., M.C and E.L contributed to conducting and data collection of the research. All authors reviewed the manuscript.

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No competing interests reported.

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Evaluating Effectiveness of sEMG Biofeedback for Posture Training and Scoliosis Management

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Introduction

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Participants

sEMG Measurement Prior to and Post-Training

Biofeedback Posture Training Set-up

Statistical calculations

Statistical results

Discussion

Conclusion

Declarations

Funding

Author Contribution

References

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