The present protocol was part of a study approved by the Institutional Review Board at the University of Central Florida. Informed consent was received from all human participants for the present study. To be included in the study, participants had to be between 18 years and 75 years of age, play golf at least once per month for the past year or once per week for the past 2 months, have played golf for at least 2 years, and have had at least two episodes of low back pain in the past 12 months. The exclusion criteria were...

<ol>
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The authors have no relevant disclosures to report.

Providing ultrasound biofeedback following a rotation-based sports movement such as a golf swing can be used to increase the muscle thickness of the lateral abdominal wall. As shown in the representative results, a single trial of ultrasound biofeedback can lead to short-term increases in oblique muscle activity throughout a golf swing.
Previous research has also used B-mode ultrasound secured with an elastic belt during dynamic tasks20. This was measured while individu...

The muscles of the lateral abdominal wall include the external oblique, internal oblique, and transverse abdominis. The external obliques perform lateral flexion and contralateral&#160;trunk rotation, while the internal obliques perform ipsilateral&#160;trunk rotation. The transverse abdominis is the deepest layer of the abdominal musculature, and it functions to increase intra-abdominal pressure and increase the segmental stability of the spine1. The proper function of these muscles is important to reduce low back pain risk and improve athletic performance as core stability allows for increased strength and power through the extremities2.
During sports with an emphasis on trunk rotation, such as golf, tennis, baseball, or softball, there is a high demand for the core muscles. For example, during a golf swing, the obliques on the trail side of the body peak at 64% of the maximal voluntary isometric contraction (MVIC) when measured using surface electromyography, while the lead obliques peak at 54% MVIC3. Trunk rotation is a key contributor to the distance and accuracy of golf shots4. The stresses of the golf swing and the high demand for core muscle activity may contribute to low back pain, which is the most common injury in golf5. Additionally, in elite golfers with low back pain, the timing of external oblique activity is delayed during the golf swing compared to healthy individuals6. Another study using electromyography found golfers with low back pain have an earlier onset of the erector spinae than golfers without low back pain7, suggesting a focus on anterolateral muscles may be beneficial. Therefore, measuring the extent and timing of abdominal muscle activity during a golf swing is important to improve performance and reduce the risk of low back pain.
Rehabilitative ultrasound is commonly used to assess lateral abdominal wall muscles due to the layered nature of this musculature8,9,10. There is no difference in transverse abdominis activation in college golfers with and without low back pain in the supine position or in a more functional golf swing setup position11. However, transverse abdominis activity is only one component of a golf swing, and rotation may be more important for this population. Previous literature has used an elastic belt and foam block to secure the ultrasound transducer to the abdomen, allowing for ultrasound assessment of the core musculature during dynamic movement such as a single leg squat or gait8. Applying ultrasound during dynamic movements has been shown to have acceptable to excellent reliability12. This technique can be applied to measure thickness changes in the lateral abdominal wall during a golf swing or other sport-specific task. While surface electromyography is commonly used to measure the electrical activity of muscles, this is less feasible in the abdominal region. The layered anatomy leads to cross-talk between the muscles and does not allow for a visual representation of the individual muscle layers of the core13. Ultrasound provides an advantage over alternatives like surface electromyography for the core musculature because it allows for a representation of each individual muscle while also giving an image for feedback14.
Since ultrasound provides an image of the muscles of interest in real time, it can also be used as a tool for visual biofeedback. Ultrasound biofeedback has improved the ability to increase the muscle thickness of the transverse abdominis and lumbar multifidus compared to verbal cueing alone15,16. Additionally, in golfers with and without low back pain, real-time ultrasound biofeedback increases transverse abdominis thickness in supine and in the golf-setup position11. Biofeedback training in supine also translates to upright loaded tasks17. More research is needed to determine the required frequency and duration of biofeedback training, as most studies are single-session or short-term training protocols15. Since ultrasound has been applied during functional tasks and there is evidence that golfers can increase deep muscle pre-activation in the setup position, research should next investigate the use of ultrasound biofeedback to increase oblique muscle thickness during the golf swing.
Therefore, this methodology aims to use ultrasound as a feedback mechanism to improve the activation and timing of the abdominal obliques during the golf swing.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Aquasonic 100</td>
			<td>Parker</td>
			<td>BT-025-0037L</td>
			<td>Ultrasound gel</td>
		</tr>
		<tr>
			<td>GE NextGen Logig e Ultrasound Unit</td>
			<td>GE Healthcare</td>
			<td>HR48382AR</td>
			<td></td>
		</tr>
		<tr>
			<td>Linear Array Probe</td>
			<td>GE Healthcare</td>
			<td>H48062AB</td>
			<td></td>
		</tr>
		<tr>
			<td>Velcro straps</td>
			<td>VELCRO</td>
			<td></td>
			<td>Fasteners for the elastic belt used to secure the ultrasound transducer</td>
		</tr>
	</tbody>
</table>

providing visual biofeedback using brightness mode ultrasound during a golf swing

Using ultrasound biofeedback in conjunction with verbal cueing can increase muscle thickness more than verbal cueing alone and may augment traditional rehabilitation techniques in an athletic, physically active population. Brightness mode (B-mode) ultrasound can be applied using frame-by-frame analysis synchronized with video to understand muscle thickness changes during these dynamic tasks. Visual biofeedback with ultrasound has been established in static positions for the muscles of the lateral abdominal wall. However, by securing the transducer to the abdomen using an elastic belt and foam block, biofeedback can be applied during more specific tasks prevalent in lifetime sports, such as golf. To analyze muscle activity during a golf swing, muscle thickness changes can be compared. The thickness must increase throughout the task, indicating that the muscle is more active. This methodology allows clinicians to immediately replay ultrasound videos for patients as a visual tool to instruct proper activity of the muscles of interest. For example, ultrasound can be used to target the external and internal obliques, which play an important role in swinging a golf club or any other rotational sport or activity. This methodology aims to increase oblique muscle thickness during the golf swing. Additionally, the timing of muscle contraction can be targeted by instructing the patient to contract the abdominal muscles at specific time points, such as the beginning of the downswing, with the goal of improving muscle firing patterns during tasks.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Non-feedback</td>
			<td></td>
			<td></td>
			<td>Biofeedback</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Swing Duration</td>
			<td>External Oblique Thickness (cm)</td>
			<td>Internal Oblique Thickness (cm)</td>
			<td>Combined Oblique Thickness (cm)</td>
			<td>External Oblique Thickness (cm)</stron...

Watch this Scientific Journal Video about Providing Visual Biofeedback Using Brightness Mode Ultrasound During a Golf Swing at JoVE.com

Providing Visual Biofeedback Using Brightness Mode Ultrasound During a Golf Swing

Brightness mode ultrasound can be used to provide visual biofeedback of the muscles of the lateral abdominal wall during a golf swing. Post-swing visual and verbal instruction can increase the muscle activation and timing of the external and internal obliques.

Using ultrasound biofeedback in conjunction with verbal cueing can increase muscle thickness more than verbal cueing alone and may augment traditional ...

Ultrasound biofeedback can help increase activation and timing of the core muscles, which is important both for sport performance and for reducing risk of injuries like low back pain. A main advantage of using ultrasound for biofeedback is that it provides a real-time image. This image, along with verbal cues, can help patients use their muscles properly.This method can also be applied directly to other rotational movements, like a baseball or softball swing, or a tennis forehand. To begin, open and turn on the ultrasound device using the on/off button. Then press the patient button on the keyboard to add a new patient, and select New Patient on the left side of the screen.Enter the desired patient ID number, ensure MSK is selected as the exam type, and click on Register. Exit to begin the exam, and enter B-mode. Position the linear array transducer in the elastic belt by placing the head of the linear transducer through a horizontal slit in the middle of the belt.Next, apply one to two foam blocks to secure the transducer in its place. Apply ultrasound gel to the linear transducer. Position the transducer on the lateral abdominal wall, approximately 10 centimeters lateral to the umbilicus.Secure the belt to the participant using the hook and loop fasteners, ensuring that the belt is tight enough so that the transducer is secured perpendicular to the lateral abdominal wall. Adjust the depth and gain of the ultrasound if necessary to obtain a clear image of the fascia borders and muscle thickness of the external oblique, internal oblique, and transverse abdominis, ensuring that the fascia border of the transverse abdominis is visible on the edge of the screen in this longitudinal view. Once the image is clear, position the patient in a manner that mirrors the task they will complete, such as make them stand in their set-up position if they perform a golf swing.Then press Freeze, then Store to capture a static image. Save it to the patient's exam and measure in real-time or access it later to measure the resting muscle thickness. Select Freeze again to return to live imaging.Press Store to begin recording in B-mode video. Provide the verbal cuing or instruction following each attempt, while adjusting the cuing as needed. On the bottom right corner of the screen, check that a timer begins and is highlighted in bright green, indicating that a video is being captured.Press Store again to end the video and save it to their exam. If the image becomes blurry, adjust the positioning of the ultrasound probe within the foam block as needed. After each trial, review the video for image clarity and if the image becomes anechoic at any point, it indicates that the ultrasound probe moved during the swing.Exclude the trial and re-measure. Following each swing have the patient positioned where they can view the ultrasound screen. Open the first resting image to measure.Using the cursor, hover over the desired image from the library below the active image and click on Enter. Click on Measure once to open the measurement tool and then click on Enter when the cursor is over the superior fascia border of the muscle of interest. Click on Enter again once the cursor is over the inferior fascia border.Once the desired number of videos have been captured, open the first video to be processed. Using the cursor, hover over the desired image from the library below the active image and click on the Enter button. Adjust the viewing frame within the B-mode video until the first frame is reached and determine the desired sampling rate.Once there is the desired frame open, use the Measure tool by clicking the button once to open the tool. Place the cursor on the superior fascia border of the muscle of interest and click on Enter to place the first end of the measurement. Drag the measurement line to the inferior fascia border of the muscle of interest and click on Enter again to complete the measurement.Then press Store to save the measured image. Record the measurement in a spreadsheet organized to include participant or patient name/number, frame number, and thickness measurements. Return to the original B-mode video frame and scroll to the next frame to be analyzed.Repeat the measurement steps until all the desired frames are measured. To determine the activation ratio at a specific time point, measure the thickness as demonstrated previously and divide this value by the resting image thickness. To determine whether the combined oblique thickness increased at the 50%time point when biofeedback was provided, activation ratios were calculated.The non-bio feedback trial shows a thickness of 1.685, while biofeedback has a value of 1.739. Thus it can be inferred that the biofeedback led to a small increase in oblique muscle activation at the 50%duration of the golf swing. With ultrasound biofeedback, it's important to be able to use lay terms to help the patient understand the image.Explain that the goal is to rotate through their core to produce power. Following this procedure, we can also look at muscle thickness of the transverse abdominis. This can show us a patient's deep core muscle activity and spinal stability during dynamic movements.

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1.8K visualizações.  University of Central Florida. O biofeedback por ultrassom pode ajudar a aumentar a ativação e o tempo dos músculos do núcleo, o que é importante tanto para o desempenho esportivo quanto para reduzir o risco de lesões, como dor lombar. Uma das principais vantagens do uso de ultrassom para biofeedback é que ele fornece uma imagem em tempo real. Esta imagem, juntamente com pistas verbais, pode ajudar os pacientes a usar seus músculos corretamente.Este método também pode ser aplicado diretamente a outros movi...