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 balance disorders, current pregnancy, surgery to the low back or lower extremities in the past year, or an open wound in the abdominal area where the transducer must be placed.
1. Ultrasound setup and data collection
<ol>
	<li>Open and turn on the ultrasound device (see Table of Materials) using the On/Off button.</li>
	<li>Press the Patient button on the keyboard to add a new patient and select New Patient on the left side of the screen.
	<ol>
		<li>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. 
		NOTE: Ultrasound settings in MSK Abdominal Preset, B-mode: B color = Tint Map D, Write Zoom Height = 4, Write Zoom Width = 4, Thermal Index = Tls, ATO Level = Low, Focus Number = 2, Focus Number CrossXBeam = 2, Focus Depth = 50, Depth (cm) = 3, Compression = 1, Focus Width = 1, Focus Width CrossXBeam = 1, Line Density = 3, Line Density CrossXBeam = 3, Suppression = 0, Frame Average = 4, From Average CrossXBeam = 2, CrossXBeam 2, CrossXBeam # = Low, CrossXBeam Type = Mean, Edge Enhance = 3, B Steer = 0, Gray Scale Map = Gray Map C, Gain = 34, Dynamic Range = 69, Rejection = 0, Frequency (MHz) = 12.</li>
	</ol>
	</li>
	<li>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 (see Table of Materials). Next, apply one to two foam blocks to secure the transducer in its place.
	<ol>
		<li>Apply ultrasound gel (see Table of Materials) to the linear transducer. Position the transducer on the lateral abdominal wall, approximately 10 cm lateral to the umbilicus8.</li>
		<li>Secure the belt to the participant using the hook and loop fasteners. Ensure the belt is tight enough so that the transducer is secured perpendicular to the lateral abdominal wall8.</li>
		<li>Adjust the depth and gain (brightness) of the ultrasound if necessary to obtain a clear image of the fascial borders and muscle thickness of the external oblique, internal oblique, and transverse abdominis. Ensure that the fascial border of the transverse abdominis is visible on the edge of the screen in this longitudinal view (Figure 1)8. 
		NOTE: The depth will depend on the size of the individual being measured, but ensure that the deep fascial border of the transverse abdominis is visible and the image is clear.</li>
		<li>Once the image is clear, position the patient in a manner that mirrors the task they will complete. For example, if they perform a golf swing, have them stand in their setup position. Press Freeze, then Store to capture a static image, save it to the patient&#39;s exam, and measure in real time or access it later to measure the resting muscle thickness. 
		NOTE: See Figure 1 for an example of a clear image of the lateral abdominal wall using B-mode ultrasound.</li>
	</ol>
	</li>
	<li>Select Freeze again to return to live imaging. Press Store to begin recording in B-mode video. 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. Instruct the participant to take a full golf swing once the recording has begun.
	<ol>
		<li>Press Store again to end the video and save it to their exam. 
		NOTE: Saved images and videos will appear below the active image, with up to five visible per row. Select the cursor to scroll through or select previous images.</li>
	</ol>
	</li>
	<li>Repeat step 1.4 as many times as necessary for the study. Adjust the positioning of the ultrasound probe within the foam block as needed if the image becomes blurry. 
	NOTE: Typical protocols comparing biofeedback and non-biofeedback conditions use between 3 and 10 repetitions per condition11,17.
	<ol>
		<li>After each trial, review the video for image clarity. If the image becomes anechoic (entirely black) at any point, it indicates that the ultrasound probe moved during the swing. In such a case, exclude the trial and re-measure.</li>
	</ol>
	</li>
	<li>Following each swing, have the patient positioned where they can view the ultrasound screen. Open the most recent trial.
	<ol>
		<li>Provide a brief overview and description of the muscles of interest (for a rotational task, this will include the external and internal obliques). Describe how the muscles should get thicker during the movement and show them their trial, providing education based on each attempt.</li>
		<li>For example, if the obliques stay relatively the same size throughout the task, instruct them to focus during the next attempt to contract their core muscles forcefully throughout the movement instead of passively rotating the trunk. 
		&#8203;NOTE: Emphasis on trunk rotation as a power source during a golf swing is a common trait of higher-skilled golfers18. During rotational movements, it is generally not feasible to provide biofeedback during the task. Therefore, providing feedback following each trial is thought to be acceptable19.</li>
	</ol>
	</li>
	<li>Repeat the biofeedback trials for as many attempts as desired. Provide the ultrasound images as well as verbal cueing or instruction following each attempt, adjusting the cueing as needed.</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64333/64333fig01.jpg" /> 
Figure 1: Image of the right lateral abdominal wall during quiet standing. (A) External oblique. (B) Internal oblique. (C) Transverse abdominis. <a href="https://www.jove.com/files/ftp_upload/64333/64333fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
2. Resting image processing
<ol>
	<li>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.
	<ol>
		<li>Click on Measure once to open the measurement tool. Click on Enter when the cursor is over the superior fascial border of the muscle of interest. 
		NOTE: For the present study, the external and internal obliques were measured as they are the muscles of interest, but one can also measure the transverse abdominis in this view.</li>
		<li>Click on Enter again once the cursor is over the inferior fascial border. 
		NOTE: The length of the measured segment will appear on the bottom-left portion of the screen, measured in centimeters. Record this length in a spreadsheet organized to include the participant or patient name/number and resting muscle thickness.</li>
	</ol>
	</li>
	<li>Repeat steps 2.1.1-2.1.2 for all the images needed to measure for both the external and internal obliques.</li>
</ol>
3. B-Mode video processing
<ol>
	<li>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.</li>
	<li>Adjust the viewing frame within the B-mode video until the first frame is reached. Determine the desired sampling rate. 
	NOTE: Previous literature has used 10% intervals of the total frames from 0%-100% for analysis, but one may wish to use more or less depending on the aims20.</li>
	<li>Once there is the desired frame open, use the Measure tool. Click the button once to open the tool, place the cursor on the superior fascial border of the muscle of interest, and click on Enter to place the first end of the measurement.</li>
	<li>Drag the measurement line to the inferior fascial border of the muscle of interest and click on Enter again to complete the measurement. 
	NOTE: The distance measured will appear on the bottom-left portion of the screen.</li>
	<li>Press Store to save the measured image.</li>
	<li>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 (step 3.2).</li>
	<li>Scroll to the next frame to be analyzed. For example, if one is sampling 11 time points (10% intervals from 0%-100%) of a swing that captured 100 frames, one will now use frame 10 (i.e., 10/100 corresponds to frame 10 out of 100 total frames).
	<ol>
		<li>Repeat steps 3.3-3.4 to measure the next frame.</li>
	</ol>
	</li>
	<li>Repeat step 3.7 until all the desired frames are measured.</li>
	<li>Move to the next video and repeat steps 3.1-3.8 until all the videos are measured. 
	&#8203;NOTE: See Figure 2 for a compilation of the processed frames throughout phases of a golf swing.</li>
</ol>
4. Activation ratio calculation
NOTE: An activation ratio is commonly used to determine the degree of muscle thickness change8,9,11. The formula for the activation ratio is contracted thickness (cm)/resting thickness (cm).
<ol>
	<li>To determine the activation ratio at a specific time point, measure the thickness by following step 3. Divide this value by the resting image thickness obtained from step 2.</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64333/64333fig02.jpg" /> 
Figure 2: Frame-by-frame analysis of a B-mode video on the trail side (right) lateral abdominal wall of a right-handed golfer. EO = external oblique; IO = internal oblique. <a href="https://www.jove.com/files/ftp_upload/64333/64333fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

<ol>
	<li>Betts, J. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Anatomy and Physiology. , (2017).</li><li>Saeterbakken, A. H., vanden Tillaar, R., Seiler, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+core+stability+training+on+throwing+velocity+in+female+handball+players.">Effect of core stability training on throwing velocity in female handball players.</a> Journal of Strength and Conditioning Research. 25 (3), 712-718 (2011).</li><li>Pink, M., Perry, J., Jobe, F. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electromyographic+analysis+of+the+trunk+in+golfers.">Electromyographic analysis of the trunk in golfers.</a> The American Journal of Sports Medicine. 21 (3), 385-388 (1993).</li><li>Cole, M. H., Grimshaw, P. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+biomechanics+of+the+modern+golf+swing:+Implications+for+lower+back+injuries.">The biomechanics of the modern golf swing: Implications for lower back injuries.</a> Sports Medicine. 46 (3), 339-351 (2016).</li><li>McHardy, A. J., Pollard, H. P., Luo, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Golf-related+lower+back+injuries:+An+epidemiological+survey.">Golf-related lower back injuries: An epidemiological survey.</a> Journal of Chiropractic Medicine. 6 (1), 20-26 (2007).</li><li>Horton, J. F., Lindsay, D. M., Macintosh, B. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Abdominal+muscle+activation+of+elite+male+golfers+with+chronic+low+back+pain.">Abdominal muscle activation of elite male golfers with chronic low back pain.</a> Medicine and Science in Sports and Exercise. 33 (10), 1647-1654 (2001).</li><li>Cole, M. H., Grimshaw, P. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trunk+muscle+onset+and+cessation+in+golfers+with+and+without+low+back+pain.">Trunk muscle onset and cessation in golfers with and without low back pain.</a> Journal of Biomechanics. 41 (13), 2829-2833 (2008).</li><li>Mangum, L. C., Henderson, K., Murray, K. P., Saliba, S. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+assessment+of+the+transverse+abdominis+during+functional+movement.">Ultrasound assessment of the transverse abdominis during functional movement.</a> Journal of Ultrasound in Medicine. 37 (5), 1225-1231 (2018).</li><li>Sutherlin, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Changes+in+muscle+thickness+across+positions+on+ultrasound+imaging+in+participants+with+or+without+a+history+of+low+back+pain.">Changes in muscle thickness across positions on ultrasound imaging in participants with or without a history of low back pain.</a> Journal of Athletic Training. 53 (6), 553-559 (2018).</li><li>Teyhen, D. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+ultrasound+imaging+of+the+abdominal+drawing-in+maneuver+in+subjects+with+low+back+pain.">The use of ultrasound imaging of the abdominal drawing-in maneuver in subjects with low back pain.</a> Journal of Orthopaedic &amp; Sports Physical Therapy. 35 (6), 346-355 (2005).</li><li>Skibski, A., Burkholder, E., Goetschius, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transverse+abdominis+activity+and+ultrasound+biofeedback+in+college+golfers+with+and+without+low+back+pain.">Transverse abdominis activity and ultrasound biofeedback in college golfers with and without low back pain.</a> Physical Therapy in Sport. 46, 249-253 (2020).</li><li>Mangum, L. C., Sutherlin, M. A., Saliba, S. A., Hart, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+of+ultrasound+imaging+measures+of+transverse+abdominis+and+lumbar+multifidus+in+various+positions.">Reliability of ultrasound imaging measures of transverse abdominis and lumbar multifidus in various positions.</a> PM&amp;R. 8 (4), 340-347 (2016).</li><li>Stokes, I. A. F., Henry, S. M., Single, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surface+EMG+electrodes+do+not+accurately+record+from+lumbar+multifidus+muscles.">Surface EMG electrodes do not accurately record from lumbar multifidus muscles.</a> Clinical Biomechanics. 18 (1), 9-13 (2003).</li><li>Valera-Calero, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+imaging+as+a+visual+biofeedback+tool+in+rehabilitation:+an+updated+systematic+review.">Ultrasound imaging as a visual biofeedback tool in rehabilitation: an updated systematic review.</a> International Journal of Environmental Research and Public Health. 18 (14), 7554 (2021).</li><li>Cha, H. -. G., Kim, M. -. K., Shin, Y. -. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effects+of+visual+biofeedback+using+ultrasonograpy+on+deep+trunk+muscle+activation.">The effects of visual biofeedback using ultrasonograpy on deep trunk muscle activation.</a> Journal of Physical Therapy Science. 28 (12), 3310-3312 (2016).</li><li>Van, K., Hides, J. A., Richardson, C. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+real-time+ultrasound+imaging+for+biofeedback+of+lumbar+multifidus+muscle+contraction+in+healthy+subjects.">The use of real-time ultrasound imaging for biofeedback of lumbar multifidus muscle contraction in healthy subjects.</a> The Journal of Orthopaedic and Sports Physical Therapy. 36 (12), 920-925 (2006).</li><li>McPherson, S. L., Watson, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Training+of+transversus+abdominis+activation+in+the+supine+position+with+ultrasound+biofeedback+translated+to+increased+transversus+abdominis+activation+during+upright+loaded+functional+tasks.">Training of transversus abdominis activation in the supine position with ultrasound biofeedback translated to increased transversus abdominis activation during upright loaded functional tasks.</a> PM&amp;R. 6 (7), 612-623 (2014).</li><li>Burden, A. M., Grimshaw, P. N., Wallace, E. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hip+and+shoulder+rotations+during+the+golf+swing+of+sub-10+handicap+players.">Hip and shoulder rotations during the golf swing of sub-10 handicap players.</a> Journal of Sports Sciences. 16 (2), 165-176 (1998).</li><li>Magill, R. A., Anderson, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Motor Learning and Control: Concepts and Applications. , (2014).</li><li>DeJong, A. F., Mangum, L. C., Hertel, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Gluteus+medius+activity+during+gait+is+altered+in+individuals+with+chronic+ankle+instability:+An+ultrasound+imaging+study.">Gluteus medius activity during gait is altered in individuals with chronic ankle instability: An ultrasound imaging study.</a> Gait &amp; Posture. 71, 7-13 (2019).</li><li>Hume, P. A., Keogh, J., Reid, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+biomechanics+in+maximising+distance+and+accuracy+of+golf+shots.">The role of biomechanics in maximising distance and accuracy of golf shots.</a> Sports Medicine. 35 (5), 429-449 (2005).</li><li>Smith, J., Finnoff, J. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+and+interventional+musculoskeletal+ultrasound:+Part+1.+fundamentals.">Diagnostic and interventional musculoskeletal ultrasound: Part 1. fundamentals.</a> PM&amp;R. 1 (1), 64-75 (2009).</li><li>Smith, J., Finnoff, J. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+and+interventional+musculoskeletal+ultrasound:+Part+2.+clinical+applications.">Diagnostic and interventional musculoskeletal ultrasound: Part 2. clinical applications.</a> PM&amp;R. 1 (2), 162-177 (2009).</li><li>Ribeiro, D. C., M&#261;cznik, A. K., Milosavljevic, S., Abbott, J. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effectiveness+of+extrinsic+feedback+for+management+of+non-specific+low+back+pain:+A+systematic+review+protocol.">Effectiveness of extrinsic feedback for management of non-specific low back pain: A systematic review protocol.</a> BMJ Open. 8 (5), 021259 (2018).</li></ol>

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><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...

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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 ...

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1.9K Views.  University of Central Florida. 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.

Video: Providing Visual Biofeedback Using Brightness Mode Ultrasound During a Golf Swing

Vision Training Methods for Sports Concussion Mitigation and Management

There is emerging evidence supporting the use vision training, including light board training tools, as a concussion baseline and neuro-diagnostic tool and potentially as a supportive component to concussion prevention strategies. This paper is focused on providing detailed methods for select vision training tools and reporting normative data for comparison when vision training is a part of a sports management program. The overall program includes standard vision training methods including tachistoscope, Brock&#8217;s string, and strobe glasses, as well as specialized light board training algorithms. Stereopsis is measured as a means to monitor vision training affects. In addition, quantitative results for vision training methods as well as baseline and post-testing *A and Reaction Test measures with progressive scores are reported. Collegiate athletes consistently improve after six weeks of training in their stereopsis, *A and Reaction Test scores. When vision training is initiated as a team wide exercise, the incidence of concussion decreases in players who participate in training compared to players who do not receive the vision training. Vision training produces functional and performance changes that, when monitored, can be used to assess the success of the vision training and can be initiated as part of a sports medical intervention for concussion prevention.

This paper describes a protocol to conduct, quantitatively monitor, and assess the success of vision training initiated as part of a sports medical management program including intervention for concussion prevention and performance enhancement.

There is emerging evidence supporting the use vision training, including light board training tools, as a concussion baseline and neuro-diagnostic tool ...

Behavior

Ultrasound Images of the Tongue: A Tutorial for Assessment and Remediation of Speech Sound Errors

Diagnostic ultrasound imaging has been a common tool in medical practice for several decades. It provides a safe and effective method for imaging structures internal to the body. There has been a recent increase in the use of ultrasound technology to visualize the shape and movements of the tongue during speech, both in typical speakers and in clinical populations. Ultrasound imaging of speech has greatly expanded our understanding of how sounds articulated with the tongue (lingual sounds) are produced. Such information can be particularly valuable for speech-language pathologists. Among other advantages, ultrasound images can be used during speech therapy to provide (1) illustrative models of typical (i.e.&#160;&#34;correct&#34;) tongue configurations for speech sounds, and (2) a source of insight into the articulatory nature of deviant productions. The images can also be used as an additional source of feedback for clinical populations learning to distinguish their better productions from their incorrect productions, en route to establishing more effective articulatory habits.
Ultrasound feedback is increasingly used by scientists and clinicians as both the expertise of the users increases and as the expense of the equipment declines. In this tutorial, procedures are presented for collecting ultrasound images of the tongue in a clinical context. We illustrate these procedures in an extended example featuring one common error sound, American English /r/. Images of correct and distorted /r/ are used to demonstrate (1) how to interpret ultrasound images, (2) how to assess tongue shape during production of speech sounds, (3), how to categorize tongue shape errors, and (4), how to provide visual feedback to elicit a more appropriate and functional tongue shape. We present a sample protocol for using real-time ultrasound images of the tongue for visual feedback to remediate speech sound errors. Additionally, example data are shown to illustrate outcomes with the procedure.

Ultrasound imaging can be used to display the shape and movements of the tongue in real time during speech. The images can be used to determine the nature of speech sound errors. Visual feedback of the tongue can be used to facilitate improvements in speech sound production in clinical populations.

Diagnostic ultrasound imaging has been a common tool in medical practice for several decades. It provides a safe and effective method for imaging ...

A Vibrotactile Feedback Device for Seated Balance Assessment and Training

Postural perturbations, motion tracking, and sensory feedback are modern techniques used to challenge, assess, and train upright sitting, respectively. The goal of the developed protocol is to construct and operate a sitting platform that can be passively destabilized while an inertial measurement unit quantifies its motion and vibrating elements deliver tactile feedback to the user. Interchangeable seat attachments alter the stability level of the device to safely challenge sitting balance. A built-in microcontroller allows fine-tuning of the feedback parameters to augment sensory function. Posturographic measures, typical of balance assessment protocols, summarize the motion signals acquired during timed balance trials. No dynamic sitting protocol to date provides variable challenge, quantification, and sensory feedback free of laboratory constraints. Our results demonstrate that non-disabled users of the device exhibit significant changes in posturographic measures when balance difficulty is altered or vibrational feedback provided. The portable, versatile device has potential applications in rehabilitation (following skeletal, muscular, or neurological injury), training (for sports or spatial awareness), entertainment (via virtual or augmented reality), and research (of sitting-related disorders).

A sitting platform has been developed and assembled that passively destabilizes sitting posture in humans. During the user&#39;s stabilizing task, an inertial measurement unit records the device&#39;s motion, and vibrating elements deliver performance-based feedback to the seat. The portable, versatile device may be used in rehabilitation, assessment, and training paradigms.

Postural perturbations, motion tracking, and sensory feedback are modern techniques used to challenge, assess, and train upright sitting, respectively. ...

A Method for Evaluating Timeliness and Accuracy of Volitional Motor Responses to Vibrotactile Stimuli

Artificial sensory feedback (ASF) systems can be used to compensate for lost proprioception in individuals with lower-limb impairments. Effective design of these ASF systems requires an in-depth understanding of how the parameters of specific feedback mechanism affect user perception and reaction to stimuli. This article presents a method for applying vibrotactile stimuli to human participants and measuring their response. Rotating mass vibratory motors are placed at pre-defined locations on the participant's thigh, and controlled through custom hardware and software. The speed and accuracy of participants' volitional responses to vibrotactile stimuli are measured for researcher-specified combinations of motor placement and vibration frequency. While the protocol described here uses push-buttons to collect a simple binary response to the vibrotactile stimuli, the technique can be extended to other response mechanisms using inertial measurement units or pressure sensors to measure joint angle and weight bearing ratios, respectively. Similarly, the application of vibrotactile stimuli can be explored for body segments other than the thigh.

This article describes a technique for applying vibrotactile stimuli to the thigh of a human participant, and measuring the accuracy and reaction time of the participant&#39;s volitional response for various combinations of stimulation location and frequency.

Artificial sensory feedback (ASF) systems can be used to compensate for lost proprioception in individuals with lower-limb impairments.  Effective design ...

Bioengineering

A Single-Channel and Non-Invasive Wearable Brain-Computer Interface for Industry and Healthcare

The present work focuses on how to build a wearable brain-computer interface (BCI). BCIs are a novel means of human-computer interaction that relies on direct measurements of brain signals to assist both people with disabilities and those who are able-bodied. Application examples include robotic control, industrial inspection, and neurorehabilitation. Notably, recent studies have shown that steady-state visually evoked potentials (SSVEPs) are particularly suited for communication and control applications, and efforts are currently being made to bring BCI technology into daily life. To achieve this aim, the final system must rely on wearable, portable, and low-cost instrumentation. In exploiting SSVEPs, a flickering visual stimulus with fixed frequencies is required. Thus, in considering daily-life constraints, the possibility to provide visual stimuli by means of smart glasses was explored in this study. Moreover, to detect the elicited potentials, a commercial device for electroencephalography (EEG) was considered. This consists of a single differential channel with dry electrodes (no conductive gel), thus achieving the utmost wearability and portability. In such a BCI, the user can interact with the smart glasses by merely staring at icons appearing on the display. Upon this simple principle, a user-friendly, low-cost BCI was built by integrating extended reality (XR) glasses with a commercially available EEG device. The functionality of this wearable XR-BCI was examined with an experimental campaign involving 20 subjects. The classification accuracy was between 80%-95% on average depending on the stimulation time. Given these results, the system can be used as a human-machine interface for industrial inspection but also for rehabilitation in ADHD and autism.

This paper discusses how to build a brain-computer interface by relying on consumer-grade equipment and steady-state visually evoked potentials. For this, a single-channel electroencephalograph exploiting dry electrodes was integrated with augmented reality glasses for stimuli presentation and output data visualization. The final system was non-invasive, wearable, and portable.

The present work focuses on how to build a wearable brain-computer interface (BCI). BCIs are a novel means of human-computer interaction that relies on ...

Engineering

A Human-machine-interface Integrating Low-cost Sensors with a Neuromuscular Electrical Stimulation System for Post-stroke Balance Rehabilitation

A stroke is caused when an artery carrying blood from heart to an area in the brain bursts or a clot obstructs the blood flow to brain thereby preventing delivery of oxygen and nutrients. About half of the stroke survivors are left with some degree of disability. Innovative methodologies for restorative neurorehabilitation are urgently required to reduce long-term disability. The ability of the nervous system to reorganize its structure, function and connections as a response to intrinsic or extrinsic stimuli is called neuroplasticity. Neuroplasticity is involved in post-stroke functional disturbances, but also in rehabilitation. Beneficial neuroplastic changes may be facilitated with non-invasive electrotherapy, such as neuromuscular electrical stimulation (NMES) and sensory electrical stimulation (SES). NMES involves coordinated electrical stimulation of motor nerves and muscles to activate them with continuous short pulses of electrical current while SES involves stimulation of sensory nerves with electrical current resulting in sensations that vary from barely perceivable to highly unpleasant. Here, active cortical participation in rehabilitation procedures may be facilitated by driving the non-invasive electrotherapy with biosignals (electromyogram (EMG), electroencephalogram (EEG), electrooculogram (EOG)) that represent simultaneous active perception and volitional effort. To achieve this in a resource-poor setting, e.g., in low- and middle-income countries, we present a low-cost human-machine-interface (HMI) by leveraging recent advances in off-the-shelf video game sensor technology. In this paper, we discuss the open-source software interface that integrates low-cost off-the-shelf sensors for visual-auditory biofeedback with non-invasive electrotherapy to assist postural control during balance rehabilitation. We demonstrate the proof-of-concept on healthy volunteers.

A novel low-cost human-machine interface for interactive post-stroke balance rehabilitation system is presented in this article. The system integrates off-the-shelf low-cost sensors towards volitionally driven electrotherapy paradigm. The proof-of-concept software interface is demonstrated on healthy volunteers.

A stroke is caused when an artery carrying blood from heart to an area in the brain bursts or a clot obstructs the blood flow to brain thereby preventing ...

Neuroscience

Multispectral Optoacoustic Tomography for Functional Imaging in Vascular Research

Microcirculatory impairment has been recognized in various disease processes, underlying this growing theme within vascular research. In recent years, the development of live imaging systems has set the (analytical) pace in both basic and clinical research, with the objective of creating new instruments capable of providing real-time, quantifiable endpoints with clinical interest and application. Near-infrared spectroscopy (NIRS), positron emission tomography (PET), computed tomography (CT), and magnetic resonance imaging (MRI) are available, among other techniques, but cost, image resolution, and reduced contrast are recognized as common challenges. Optoacoustic tomography (OT) offers a new perspective on vascular functional imaging, combining state-of-the-art optical absorption and spatial resolution capacities (from micrometer optical to millimeter acoustic resolution) with tissue depth. In this study, we tested the applicability of multispectral optoacoustic tomography (MSOT) for functional imaging. The system uses a tunable optical parametric oscillator (OPO) pumped by an Nd: YAG laser, providing excitation pulses sensed by a 3D probe at wavelengths from 680 nm to 980 nm. Images obtained from the human forearm were reconstructed through a specific algorithm (supplied within the manufacturer&#39;s software) based on the response of specific chromophores. Maximal Oxygenated Hemoglobin (Max HbO2) and Deoxygenated Hemoglobin (Max Hb), Total Hemoglobin (HbT), and mean Oxygen Saturation (mSO2) to vascular density (&#181;Vu), inter-unit average distances (&#950;Ad), and capillary blood volume (mm3) may be measured using this system. The applicability potential found with this OT system is relevant. Ongoing software developments will surely improve the utility of this imaging system.

The present protocol describes the acquisition of multispectral optoacoustic images of in vivo human skin vasculature. These include the quantification of hemoglobin and melanin, regarded as chromophores of interest for functional analysis.

Microcirculatory impairment has been recognized in various disease processes, underlying this growing theme within vascular research. In recent years, the ...

Motor Imagery Using VR Digital Avatars in a Brain-Computer Interface System

Motor Imagery Performance Through Embodied Digital Twins in a Virtual Reality-Enabled Brain-Computer Interface Environment

This study introduces an innovative framework for neurological rehabilitation by integrating brain-computer interfaces (BCI) and virtual reality (VR) technologies with the customization of three-dimensional (3D) avatars. Traditional approaches to rehabilitation often fail to fully engage patients, primarily due to their inability to provide a deeply immersive and interactive experience. This research endeavors to fill this gap by utilizing motor imagery (MI) techniques, where participants visualize physical movements without actual execution. This method capitalizes on the brain's neural mechanisms, activating areas involved in movement execution when imagining movements, thereby facilitating the recovery process. The integration of VR's immersive capabilities with the precision of electroencephalography (EEG) to capture and interpret brain activity associated with imagined movements forms the core of this system. Digital Twins in the form of personalized 3D avatars are employed to significantly enhance the sense of immersion within the virtual environment. This heightened sense of embodiment is crucial for effective rehabilitation, aiming to bolster the connection between the patient and their virtual counterpart. By doing so, the system not only aims to improve motor imagery performance but also seeks to provide a more engaging and efficacious rehabilitation experience. Through the real-time application of BCI, the system allows for the direct translation of imagined movements into virtual actions performed by the 3D avatar, offering immediate feedback to the user. This feedback loop is essential for reinforcing the neural pathways involved in motor control and recovery. The ultimate goal of the developed system is to significantly enhance the effectiveness of motor imagery exercises by making them more interactive and responsive to the user's cognitive processes, thereby paving a new path in the field of neurological rehabilitation.

Author Spotlight: Enhancing Neurorehabilitation Through EEG, Motor Imagery, and Virtual Reality

Motor imagery in a virtual reality environment has wide applications in brain-computer interface systems. This manuscript outlines the use of personalized digital avatars that resemble the participants performing movements imagined by the participant in a virtual reality environment to enhance immersion and a sense of body ownership.

This study introduces an innovative framework for neurological rehabilitation by integrating brain-computer interfaces (BCI) and virtual reality (VR) ...

Objectively Assessing Sports Concussion Utilizing Visual Evoked Potentials

A portable system capable of measuring steady-state visual-evoked potentials (SSVEP) was developed to provide an objective, quantifiable method of electroencephalogram (EEG) testing following a traumatic event. In this study, the portable system was used on 65 healthy rugby players throughout a season to determine whether SSVEP are a reliable electrophysiological biomarker for concussion. Preceding the competition season, all players underwent a baseline SSVEP assessment. During the season, players were re-tested within 72 h of a match for either test-retest reliability or post-injury assessment. In the case of a medically diagnosed concussion, players were reassessed again once deemed recovered by a physician. The SSVEP system consisted of a smartphone housed in a VR-frame delivering a 15 Hz flicker stimulus, while a wireless EEG headset recorded occipital activity. Players were instructed to stare at the screen's fixation point while remaining seated and quiet. Electrodes were arranged according to the 10-20 EEG-positioning nomenclature, with O1-O2 being the recording channels while P1-P2 the references and bias, respectively. All EEG data was processed using a Butterworth bandpass filter, Fourier transformation, and normalization to convert data for frequency analysis. Players SSVEP responses were quantified into a signal-to-noise ratio (SNR), with 15 Hz being the desired signal, and summarized into respective study groups for comparison. Concussed players were seen to have a significantly lower SNR compared to their baseline; however, post-recovery, their SNR was not significantly different from the baseline. Test-retest indicated high device reliability for the portable system. An improved portable SSVEP system was also validated against an established EEG amplifier to ensure the investigative design is capable of obtaining research quality EEG measurements. This is the first study to identify differences in SSVEP responses in amateur athletes following a concussion and indicates the potential for SSVEP as an aid in concussion assessment and management.

A portable system capable of measuring steady-state visual-evoked potentials was developed and trialed on 65 amateur rugby players over 18 weeks to investigate SSVEP as a potential electrophysiological biomarker for concussion. Players' baselines were measured pre-season, with retesting for reliability, concussion, and recovery assessment being conducted within controlled time-periods, respectively.

A portable system capable of measuring steady-state visual-evoked potentials (SSVEP) was developed to provide an objective, quantifiable method of ...

Restoring Post-Stroke Motor Function by Motor Imagery Brain-Computer Interface

Motor Imagery Brain-Computer Interface in Rehabilitation of Upper Limb Motor Dysfunction After Stroke

The rehabilitation effect of patients with moderate or severe upper limb motor dysfunction after stroke is poor, which has been the focus of research owing to the difficulties encountered. Brain-computer interface (BCI) represents a hot frontier technology in brain neuroscience research. It refers to the direct conversion of the sensory perception, imagery, cognition, and thinking of users or subjects into actions, without reliance on peripheral nerves or muscles, to establish direct communication and control channels between the brain and external devices. Motor imagery brain-computer interface (MI-BCI) is the most common clinical application of rehabilitation as a non-invasive means of rehabilitation. Previous clinical studies have confirmed that MI-BCI positively improves motor dysfunction in patients after stroke. However, there is a lack of clinical operation demonstration. To that end, this study describes in detail the treatment of MI-BCI for patients with moderate and severe upper limb dysfunction after stroke and shows the intervention effect of MI-BCI through clinical function evaluation and brain function evaluation results, thereby providing ideas and references for clinical rehabilitation application and mechanism research.

Author Spotlight: Using Motor Imagery Brain-Computer Interface to Improve Motor and Cognitive Function in Stroke Patients

The purpose of this study is to provide an important reference for the standard clinical operation of motor imagery brain-computer interface (MI-BCI) for upper limb motor dysfunction after stroke.

The rehabilitation effect of patients with moderate or severe upper limb motor dysfunction after stroke is poor, which has been the focus of research ...