This article has been accepted for publication in a future issue of this journal, but has not been
fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/TBME.2020.2971907, IEEE
Transactions on Biomedical Engineering
TBME-01699-2018
Wearable Sensor Array Design for Spine
Posture Monitoring During Exercise
Incorporating Biofeedback
*
Jorge E. Caviedes, Sr. Member, IEEE, *Baoxin Li, Sr. Member, IEEE, and *Varun C. Jammula
Abstract— Physical therapy (PT) exercise is an evidence-based
intervention for non-specific chronic low back pain, spinal
deformities and poor posture. Home based PT programs are
aimed at strengthening core muscle groups, improving mobility
and flexibility, and promoting proper posture. However, assessing
unsupervised home-based PT outcomes is a generally difficult
problem due to lack of reliable methods to monitor execution
correctness and compliance. We propose a monitoring method
consisting of a wearable sensor array to monitor three geodesic
distances between two points on the surface of the shoulders and
one point on the lower back. The sensor array may be built into a
custom garment or a light weight harness wirelessly linked to a
pattern recognition algorithm implemented in a mobile app. We
use a new type of triangular stretch sensor array design which can
generate a unique signature for a correct spine therapy exercise
when performed by a specific subject. We conducted a pilot test
consisting of three experiments: (i) two exercise patterns simulated
by a mechanical device, (ii) one PT case of a scoliosis therapy
exercise including spinal flexion, extension, and rotation
performed by one volunteer patient, and (iii) a set of three lower
back flexibility exercises performed by six subjects. Overall, the
results of correctness recognition show 70-100% sensitivity and
100% specificity. The pilot test provides key data for further
development including clinical trials. The significance of the
method includes simplicity of design and training method, ability
to test with simulated signals, and potential to provide real time
biofeedback.
Index Terms—biofeedback, soft sensors, spine posture
monitoring, stretch sensors, therapeutic exercise, wearable sensors
I. INTRODUCTION
S pinal exercise physiology deals with improving strength,
flexibility, and stability through therapeutic and fitness
exercises [1]. After training a subject on a given exercise
routine, a physical therapist visually verifies that the exercise
has been performed correctly before the patient leaves to start
the home-based program. Compliance and execution
correctness monitoring for home-based therapeutic exercise
programs depends on patient self-reporting and post-program
clinical evaluation [2]. When the patient is on his/her own, an
automated method to monitor execution, track progress and
provide real-time feedback is not readily available. One study
reported that even though each exercise had been described to
the patients by visually performing it, and a descriptive
*
Authors are with Arizona State University, Tempe, AZ, USA (correspondence e-mail: jorge.caviedes@asu.edu).
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1
brochure was given to each participant, the exercises were still
performed inaccurately [3].
Wearable flexible sensors are presently used to monitor
human activity and human health. Physiological parameters
including physical (e.g. heart rate, blood pressure) and
biochemical parameters (e.g. pH, Sodium, Potassium) can be
monitored using wearable sensors. Sensor networks allow data
transfer from wearable sensors to monitoring components for
analysis. Among the standard data transfer protocols, ZigBee,
Bluetooth, WiFi and WiMax, Bluetooth Low Energy (BLE) is
preferred because of low cost and ease of use, although it may
be limited by its short range and security concerns. A review of
flexible sensors including sensor networks and applications can
be found in [4].
Monitoring spine posture and motion has been tackled using
three types of sensors: stretch, bend and inertial sensors. Papi et
al. conducted a systematic review of the state of the art usage of
wearables for the assessment of spine kinematics and kinetics
[5]. Their results show that there is a broad variety of sensor
types, number of sensors and placement options; they also
indicate that the small number of publications found on portable
assessment of spine motion revealed limited adoption of this
technique, which is at an early stage of development and
translation. The authors conclude that data logging and
processing, systems design and fixation are areas to be
improved to fully exploit the wide applicability of wearable
technologies.
Accurate real time 3D motion capture of the human spine is
of interest for medical diagnosis and rehabilitation of postural
disabilities. A motion sensing system comprised of 3 inertial
measurement units (IMUs) attached to the head, torso and hips
is used in [6], and motion modeling is coupled to a spinal model
which can be animated and monitored in real time. Monitoring
was conducted for regular daily activities such as sit, stand and
pick up objects. Motion analysis for exercise routines
correctness was not included in the study.
A wearable system for spinal posture monitoring while
sitting has been reported in [7]. It consists of a garment-
integrated plastic optical fiber sensor (effectively 3 bend
sensors) and demonstrated comparable accuracy to expert
visual analysis of detection and transition between good and
bad posture. The authors suggest it has potential for
biofeedback but indicate issues with inaccuracy of the expert
visual analysis used as reference criteria. A more recent paper
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Transactions on Biomedical Engineering
TBME-01699-2018 2

also reports a 3 IMU based system to diagnose progressive

disease of the spine by detecting spine curvature and incorrect
posture leading to neck pain [8]. The system allows posture
monitoring and prescribes therapeutic exercises but does not
support monitoring of their correct execution.
While wearable IMUs can monitor motion, to monitor
physiological muscle activity wearable electromyography
(EMG) sensors have been developed. EMG biomechanical
biofeedback is most widely used in rehabilitation and therapy
for applications including cardiovascular accident
rehabilitation and low back pain (LBP) treatment [9]. EMG
biofeedback is primarily used in sport performance Fig. 2. Two-loop sensor system for posture monitoring [14].
improvement as part of sports psychology programs [10].
Products such as biosuits by Athos ™ incorporate EMG sensors
Modern posture and motion monitoring systems for spinal
to monitor major muscle group activity (see Fig. 1) and
deformities are tightly linked to biomechanical spine models.
performance has been benchmarked against research grade
EMG systems [11]. Corrective and therapeutic exercise methods for scoliosis
treatment are very important options to avoid worsening that
may lead to hard bracing and surgery [16]. The two main
approaches to assess progress during treatment are (i) non-
invasive measurements related to static posture and (ii) real
time monitoring during exercise. Progress has been reported on
non-radiological methods for static posture monitoring and
evaluation [17]. Research on modeling the spine curve from the
surface of the back offers an alternative to invasive imaging
[18]. Optical or surface measurements, namely moiré fringe
topography and surface mapping have been used to evaluate
static posture and to measure spinal curve [19].
A product to model the spine from a static back-surface scan,
Fig. 1. Biosuits use EMG monitoring during exercise2. Idiag M360 ©, has been commercialized (see Fig. 3). The
device previously known as “spinal mouse” records the inter-
New work on wearable EMG sensors built into garments as vertebral distances and positions in 3D along the patient spinal
a method to monitor scoliotic posture has been reported by curvature, and then an anatomical spine model is assigned the
Kwok et al [12]. However, modeling posture and spinal parameters measured from the spinal curve in different postures
dynamics during exercise using EMG signals is very
and visualized as a 3D static model.
challenging given the nature of the EMG signal, i.e., it only
detects muscle fiber activity, and not the complex neurological
and musculoskeletal mechanisms that link muscle firing to
spinal posture and dynamics. The role of individual torso
muscles during spinal rehabilitation exercise has been studied
using EMG and kinematic markers and the difficulties of
modeling the complex interaction and synergies that take place
during spinal stabilization exercise have been discussed in [13].
The early use of stretch sensors was reported in a paper on
scoliosis posture monitoring by Dworkin et al. [14]. The system Fig. 3. Static model of the spine from Idiag M3603
consists of two elastic loops, one to measure spine length (loop
A) and the other (loop B) to measure and correct for the effect Currently, the most efficient method to obtain the true patient
of breathing noise as shown in Fig. 2. When the length of the specific spine model uses 3D reconstruction from biplanar
spine was reduced below a threshold as a result of bad posture, radiographs [20]. Dorsal rasterstereography methods to model
an audible signal was produced. More recently, an equivalent spinal curvature will be discussed in the next section.
method has been implemented in a T-Shirt to monitor posture The research we have reviewed indicates that motion
using inductive copper wire sensors built into the fabric [15]. tracking related to posture changes during everyday activity
have been successfully addressed with a combination of IMU
and torsion sensors. Such systems exhibit a large number of
variables and have not been demonstrated for correct exercise
detection. Moreover, the role of wearable EMG sensors in
rehabilitation exercise appears to be complementary to IMUs.
2
https://www.liveathos.com/
3
https://www.idiag.ch/en/idiag-m360-en/

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A key enabling technology to recognize correct execution is  Check the number of contours
the algorithmic component to process sensor signals and  Assess heights of left and right shoulder
recognize the unique signature of a given exercise for a specific  Measure the angle of left and right shoulders
subject. Research in human activity recognition (HAR) using  Measure the distance between right and left shoulders
on-body inertial sensors addresses the challenge of general based on pelvic reference line
methods suitable for machine learning (ML) algorithms,  Estimate interval between pelvic reference line and neck
namely that they can only be trained if large amounts of data reference line, and
are available [21], [22]. HAR methods are useful to recognize  Estimate misalignment between thoracic and lumbar
human gestures, actions, and behaviors using data intensive spines against a set of reference values
feature engineering and multidimensional classifiers [23], [24]. Although, the sensitivity of this technique as a screening
Individualized biomechanical sensor data of low tool is good (74%), Asamoah et al. have reported that its false-
dimensionality are preferred and are well suited for the use of negative values between 17–25% can be improved by other
single or multi-class classifiers. In order to improve robustness, non-invasive methods such as ultrasound [27].
biomechanical sensor designs must be complemented by data
preprocessing such as denoising, signal normalization and
alignment. Biomechanical events and exercise routines can be
treated as bio signal patterns analog to simple ones like those
characteristic of cardiac and neurologic activity (see for
example ECG preprocessing methods used to improve classifier
performance reported in [25]).
From the introductory review in this section we can highlight
the following gaps and opportunities:
1. There is room to further reduce the complexity of
wearable sensor arrays that will benefit the development
of personalized mobile systems.
2. Algorithms to detect correct execution of at-home PT
routines may fill the expert supervision gap and may
enable real time biofeedback.
3. Progress in dynamic, personalized spine modeling has the Fig. 4. Moiré fringe topography of a normal subject and image
potential to support immersive, biomechanical analysis [19].
biofeedback, i.e. "when technology offers the possibility
to obtain information that is out of the reach of human In general, rasterstereography allows an analysis not only of
senses or the information that is beyond human senses the posterior torso surface, e.g. to assess cosmetic changes due
capabilities [26]." to the deformity, but also of the underlying spine. Dynamic
In this paper we will address recognition of correct rasterstereography has been used to analyze dynamic spinal
therapeutic exercise execution using a sensor array simpler than curvature during gait [28]. As shown in Fig. 5, a set of markers
other published methods and argue for its potential to enable placed in triangular fashion is used during scoliotic gait
biofeedback and augmented biofeedback. The method includes analysis. The method allowed measuring the sides of the four
a triangular sensor array design, a pattern recognition triangles with high accuracy while the subjects walked on a
algorithm, and a mobile app implementation. treadmill. Motion analysis in turn allows quantification of
The remaining sections are organized as follows: Section II spinal mobility and flexibility. Another study by the same
describes the sensor array design, Section III presents the researchers indicates that in dynamic conditions the use of only
pattern recognition algorithm, Section IV provides details of the three markers, one over the spinous process of the 7th cervical
experimental method, Section V includes a summary of the vertebra and two over the lumbar dimples (shown in dashed
results, Section VI discusses performance validation of the lines connecting points 0-10-11 on left side of Fig. 5), are
mobile app, Section VII presents a discussion of the work, and sufficient for an accurate reconstruction of the back surface
Section VIII provides our conclusions. across time [29]. To prove the concept, they used a simulator
consisting of a wooden surface marked with the 3 fixed
II. STRETCH SENSOR ARRAY anatomical landmarks driven by a robotic arm programmed
with several motion patterns (see right side of Fig. 5).
Accurate measurement of spinal curvature, necessary to
determine appropriate treatment, is obtained by methods
including radiological exam and biomechanical tests. Moiré
topography rasterstereography is a method used for mass
screening for scoliosis (see Fig. 4). A 3D surface of the shape
of the trunk is acquired and by the following steps, a specialist
or an automated method determines presence and extent of the
deformity [19]:

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A. Stretch sensor signal capture, calibration and

preprocessing
The sensors used in the experiments are made by
StretchSense ©5. The stretch sensing element is bonded onto
lycra to allow sewing into garments. The sensor specs provided
by the manufacturer are shown in the tables below.

TABLE I
STRETCH SENSOR DIMENSIONS
Zone Length Tolerance Width Tolerance
(mm) (mm) (mm) (mm)
Active Sensing Zone 70.0 ±1.00 10.0 ±1.00
Overall Silicone Zone 85.0 ±2.00 22.0 ±2.00
Fabric Backing 127 ±2.00 35.0 ±4.00
Coaxial Cable Length 1000 ±1.00 0.445

Fig. 5. Left: Marker placement for dynamic rasterstereography TABLE II

STRETCH SENSOR SPECIFICATIONS
[28]. Right: Spinal motion simulator [29]. Parameter Min Typ. Max Units
Base Capacitance 410 445 480 pF
Based on the finding that a minimal set of 3 landmarks on
the surface of the posterior torso can be used for dynamic spinal Sensitivity 3.98 5.30 6.30 pF/mm
analysis during gait, we hypothesize that a single triangle can Noise with Standard 0.13 0.16 0.50 pF
also be used for the study of spinal exercises where, in contrast 10 Chan. Circuit (3σ)
to gait studies, the landmarks are on the shoulders instead of the Operating 10.0 30.0 0
C
lumbar dimples. Thus, resulting in an upside-down triangle. To Temperature Range
continuously track the lengths of the sides of the triangle, the Connection Pitch 2.54 mm
logical approach is to use stretch sensors4. We also hypothesize Base capacitance includes a cable capacitance of 117 ±3pF
that the time dependent sensor signals will be sufficient to
automatically detect correct execution of lumbar exercise
routines used in therapy. TABLE III
Fig. 6 shows the sensor array built into a custom-made TRANSMITTER SPECIFICATIONS
sports garment and an individual sensor with wireless app. The Characteristic Value
BLE transmitter can go in a pocket between the sensors or on a Name (ID) 16G3V1.97
waist belt. The transmitter supports up to 10 sensors. Data Communication SPI (Slave)
Sampling Rate per Channel Config. 5ch–1000Hz; 10ch-500Hz
Sensing Channels 5 - 10
Power Supply External 3.3V supply
*Range (max) 0 – 65535pF
*LSB Resolution (max) 0.001pF
Resolution / channel 16 bit
*These max specifications are not simultaneously available

The capacitance vs. extension curve shown in Fig. 7 shows

the sensor behavior function we use to calibrate the signal in
mm. The curve is obtained by stretching the sensor by 80mm
from the unstretched length, in 10mm increments. The
relaxation curve, needed to check for hysteresis, is very similar,
showing a residual capacitance of 26.97pF.

Fig. 6. Garment with sensor array and sensor with app.

4 5
Stretch sensors are mainly used as actuators in human computer interfaces, www.stretchsense.com
static measurements, and to monitor conditions subject to a threshold.

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numbers of training samples per individual which is not feasible

with spine therapy subjects. Thus, we chose a single class
classifier algorithm working in sensor stretch space calibrated
in mm. To choose the minimum number of training cases we
use the statistical formula to estimate n, the minimum sample
size for a given margin of error:

𝑛= (1)

Selecting a margin of error of 3mm, and standard deviation

Fig. 7. Capacitance vs. extension curve for linear fit.
The data capture method includes:
● BLE connection to laptop and National Instruments
LabView software, or to mobile app to capture data in
comma separated values (.csv) file format. The sampling
period over Bluetooth with PC software is 10ms, and
50ms for Android capture.
● Raw data in .csv format is calibrated (remove baseline
and convert pF values to mm) before analysis.
● Matlab software implementation of pattern recognition
algorithm to process .csv data off-line.
● BLE connected Android or iOS application, which
captures data files and executes the pattern recognition
of 5mm, for a 99% confidence interval (zc=2.576) we obtain a
minimum sample size of 19.
The training data sequences are normalized in length, and
noise filtered as explained before. Our pattern recognition
method uses the Sum of the Point-wise Mahalanobis Distances
(SPMD) between an individual test sequence and the average
of the training sequences as the distance metric. Since we do
not have enough data for a statistical model of the distribution,
we use a heuristic to set the decision boundary. A hard pass/fail
threshold was chosen such that about 80-95% of the training set
is in the pass region unless the training set variance is too small
compared to the range. In such case, we use a threshold a bit
larger than the max error within the set. This rule showed good
results without overfitting.
One execution is called Eij; i is the execution number with a
maximum of n cases, j is the normalized data index, ranging
from 1 to 1200. Thus, the normalized training set is {Eij }|i ϵ [1,n],
j ϵ [1,1200]}, the SPMD between test execution point E m,j and the

algorithm in real time. average of the training set { Eij } is

Sensor noise, and noise caused by breathing are considered.
Sensor noise amplitude was measured to be 0.08% of the pF SPMDj (Em,j, { Eij }| i ϵ [1,n]) = (𝐸 − 𝐸 )Σ (𝐸 − 𝐸 )′ (2)
baseline reading, measured for 20s on PC and averaged over the
3 sensors. Breathing noise amplitude was found to be 1.12% of 𝐸 is the mean of the training sequences at index j and 𝛴
the zero-stretch reading, measured for 40s and averaged over is the covariance of the test set values computed at index j.
the 3 sensors of the array. The execution time variance effect is Clearly, the execution data itself, E, is 3 dimensional. For
removed by normalizing the duration of the region of exercise simplicity, we have not included the indices for the 3
activity (i.e. re-sampling it to a fixed duration of 700 or 1200 dimensions in the notation.
samples).
As a generic noise reduction method, we apply low pass IV. EXPERIMENTAL METHOD AND RESULTS
filtering using temporal averaging on a 300ms time window.
In this section, we describe three experiments. The first
Table IV shows the values of sensor noise and breathing noise
experiment presents two cases of simulated exercise data, the
for the 3 sensors. Prior to any test, the sensors initial stretch is
second experiment deals with a complex PT exercise routine
adjusted to minimize sagging during the exercise.
performed by a scoliosis volunteer patient, and the third
TABLE IV experiment is a set of three spine flexibility exercises performed
SENSOR AND BREATHING NOISE VALUES by five subjects.
Sensor Len. pF Noise Noise Std Breathing Breathing
mm baseline Variance Variance Std
A. First experiment: simulated data
S1 120 355.03474 0.0213415 0.1461290 5.6631055 2.3810337
Prior to testing the sensor array on actual subjects, and due to
S2 120 454.31388 0.0351957 0.1876589 4.5033825 2.1232975
the time-consuming process of building custom garment,
S3 120 369.17228 0.0217062 0.1473723 4.5011561 2.1227889
insuring proper setup, data transmission and processing, we
Avg. 120 392.84030 0.0260811 0.1603867 4.8892147 2.2090401
decided to design a simulator device on which we could mount
the sensor array to run the entire process. The signals from the
III. PATTERN RECOGNITION ALGORITHM stretching induced by lumbar spine exercises on the triangular
sensor array would not be exactly simulated but the simulated
As indicated in the introduction, although conceptually data patterns are realistic enough to validate the end-to-end
exercise correctness recognition is a HAR task, it is also a low process and conduct relevant experiments (the simulator,
dimensionality biomedical pattern recognition problem. transmitter and PC data capture are shown in Fig. 8).
Typical methods based on deep learning and clustering
algorithms are also not suitable because of the need for large

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● 3 sequences including one or multiple pauses

● 9 sequences with added or deleted rotation
● One sequence with sections of reverse rotation
● 3 sequences initially correct but swapping data across 2
channels
● 3 sequences with rushed execution
The pattern recognition algorithm and data capture ran on a
laptop PC. With a pass/fail threshold set to include 83% of the
Fig. 8. Mechanical simulator and data capture method. training we obtained the following results:

We placed the vertices of the triangular sensor array on the ● 13/16 true positives or 81.25% sensitivity
periphery of an oval-shaped wooden surface that is rotated ● 27/27 true negatives or 100% specificity
using a manual crank. To create signal patterns resembling ● 1 of 3 fast executions passed
lumbar exercise, the setup corresponds to an isosceles triangle. We also recorded data sequences generated using a different
The triangular array vertices are mounted on 3 spring loaded pattern (lobe-shaped) and tested them. The simulator with the
sliding rollers pressed on towards the surface centroid to keep oval and lobe-shaped patterns is shown in Fig. 10.
them on the outer surface during rotation. When the surface is
manually rotated about its centroid, the data resulting from the
stretching of the 3 sensors in one revolution represent a unique
pattern as shown in Fig. 9. As a result of using an isosceles
triangle to resemble spinal exercise, we can observe that the
signal amplitude for sensor 2 (in orange color) is the smallest
and similar to the inter-shoulder distance, and the others (blue
and gray) exhibit a phase shift and similar to the distances from
the lower back to each shoulder.

Fig. 10. Simulator with 2 test patterns.

We recorded 15 sequences using the lobe-shaped test pattern.

All failed the test, again performing at 100% specificity.
B. Second experiment: scoliosis correction exercise
To demonstrate the feasibility and performance of the pattern
recognition algorithm on actual exercise which could justify
future clinical trials, we selected a therapeutic exercise of
complexity beyond the average low back therapy routine. Low
back therapy routines aimed at increasing strength and
Fig. 9. Plot of simulator raw sensor data.
flexibility typically use a two-phase combination of flexion or
extension, and rotation. The four-phase exercise we tested
The ease of data capture with the simulator may be inferred
consists of shift, rotation, counter-rotation, and elongation of
by the fact that we were able to record 86 training cases for the
the spine, and is part of scoliosis-specific physical therapy for
oval pattern shown on the left side of Fig. 8 in one hour. The
postural correction.
crank was rotated manually at approximately the same speed,
For a comprehensive review of seven major schools of
with a mean cycle time of 12.8 seconds.
scoliosis specific physical therapy see [30]. Scoliosis therapy
For testing, we captured 47 cases including 17 correct
exercises are performed in a variety of positions (e.g. standing,
sequences as follows:
sitting) and in gym setups (standalone and assisted by special
● 13 correct sequences no variations, devices).
● 3 correct sequences with noticeably slow rotation The volunteer patient is a 22-year-old female presenting a
● One correct sequence with jerky rotation double curve, upper to the left and lower to the right. She
And, 30 incorrect sequences including: performed the therapeutic exercise while wearing a
personalized custom-made garment equipped with the sensor
● 6 sequences executed in reverse rotation array. The corrective exercise prescribed by her scoliosis
● 5 sequences with irregular speed including large therapy specialist6 consists of:
variations

6
Dr. Andy Pivonka, http://www.pivonkahealth.com/

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1. Right lateral bend in the lumbar spine which also raises
the left shoulder.
2. Lower rib cage rotation to the right (clockwise looking
from the top).
3. Rotate the upper rib cage to the left against the lower rib
cage (counter-rotation).
4. Left lateral bend in thoracic spine to level her shoulders.
Mean exercise execution time was 11.8s, with a standard
deviation of 2.25s. Fig. 11 shows the x-ray of the spine, the
garment with the sensor array, and a diagram of the corrective
exercise. The stretch sensors are labeled 1 for the left side, 2 for
the top side, and 3 for the right side of the inverted triangle.
improvement with respect to prior experiments in which we
tested mounting the sensor array on a contraption made of
elastic straps to support the stretch sensors. When using the
strapped sensor method, we captured a set of 20 training cases,
and a set of 15 test cases including 7 correct executions
including increased variance in range of motion, and 4 incorrect
executions. In that test, we achieved 70% sensitivity and 100%
specificity.
It is also worth mentioning that attaching the sensor array
directly to the skin using kinesiology tape was also tested but
the method did not appear to be reliable. The anchoring points
could not easily be replicated, and the stretching of the skin
during exercise appeared to introduce excessive variability.
C. Third experiment: lower back flexibility exercises
For the third experiment we chose exercises suitable for
lower back pain therapy and fitness. We selected 3 exercises
involving flexion, extension, bending and rotation of the spine,
as shown by the diagram in Fig. 13.

Exercise Short Description

Cat-cow plus rotation (CCR) Start on hands and knees
- Drop belly towards floor
Fig. 11. Scoliosis patient, x-ray and corrective exercise. and lift chin and chest
- Arch back towards ceiling
Fig. 12 shows typical sensor readings during a scoliosis - With one arm behind
correction exercise routine. Data have been calibrated in mm back, rotate trunk to the
and noise filtered. The four phases of the exercise have been right
labeled. - Rotate trunk to the left
- Return to initial position

Child’s pose 3 way (CP3W) Start on hands and knees

- Lean back to sit on ankles
stretching back
- Shift arms to left side and
stretch
- Shift arms to right side
and stretch
- Shift arms back to center
and then return to initial
position

Fig. 12. Sensor signals for scoliosis correction exercise. Flex 3 way (F3W) Start standing with arms
stretched
- Flex to touch opposite
For the training set, we recorded 35 correct executions. The foot with right arm and
inter-execution signal variance was very low for all three back up
channels, so we chose a threshold of about 1.8 times the max - Flex to touch opposite
SPMD of the training set. For the testing set, we recorded a set foot with left arm and
of 9 expert validated correct executions and 7 recordings of back up
other four-phased spine exercises. - Raise arms straight up and
flex forward
Running the pattern recognition algorithm and data capture - Raise trunk and arms back
on a laptop PC, the results were the following: up and return to initial
position
● 9/9 true positives or 100% sensitivity
● 7/7 true negatives or 100% specificity
The use of a custom garment also showed performance Fig. 13. Lower back exercises and descriptions.

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For this test we introduced a light weight, adjustable elastic
harness as a method to mount the wearable sensors that can be
worn by multiple users, as opposed to the personalized custom
garment shown before. Fig. 14 shows the light harness with
buckles and straps at the ends of the triangular sensor array
which are used to adjust and visually test the initial stretch so
that sagging is minimized. If needed, the initial readings could
be recorded and reproduced at the beginning of each exercise
session. An elastic band around the mid chest is used to keep
the sensor array close to the spine surface.
 For the three exercises, i.e., cat-cow rotation, child’s
pose 3 way, and flex 3 way average sensitivities were
85%, 97% and 85% respectively. The lowest individual
sensitivity for a single subject was 60% for the flex 3
way exercise.
 The average execution times for each of the 3 exercises
were 24, 20 and 15 seconds. The shortest average
execution time was for the flex 3 way exercise.
 Specificities were 100% in all cases. Specificity was
tested with incorrect executions (e.g. incorrect
movement sequence, repeat moves, skip moves), and
different exercises (e.g. same moves executed standing
instead of kneeling, abs exercise such as bird-dog). We
tested 3-5 incorrect executions for each subject. Testing
with a full set of data for a different exercise for the same
subject did not result in any false positives.
 We checked whether the training is subject-specific by
testing with data for the same exercises but performed by
different subjects. In only one case, the child’s pose 3
way, the recognition algorithm for one subject
recognized execution by another subject, recognizing
47% of the executions as correct. In the same reversed
test, the recognition algorithm for the second subject did
not recognize any of the executions of the first one.

V. SUMMARY OF RESULTS
In total, to test the pattern recognition algorithm, the pilot
included three experiments in 3 different categories: simulated
data (2 patterns), scoliosis therapy for one patient (2 wearable
sensor methods), and 3 lower back exercises performed by 6
subjects, for a grand total of 1100 individual executions
including training. For each test we report the size of the data
Fig. 14. Light weight harness with sensor array. set, sensitivity and specificity. Table VI below shows the
summary of the results. The ground truth for each test set is
Even though the sample was not designed to represent any indicated as the total, followed by the number of true positives
specific population or spine condition, the volunteer data (TP) and true negatives (TN).
distribution shows a broad range in age, height and weight.
Table V shows the subject data. Table VI
SUMMARY OF RESULTS
TABLE V Training Test Set
LOWER BACK EXERCISE SUBJECT DATA Test Sensitivity Specificity
Set Size Size
Min. Max. Avg. 47:
Simulator
Age (years) 23 64 37 86 17TP, 81.21% 100%
Oval Pattern
30TN
Height (ft, in) 5’ 5’ 11” 5’ 6”
Simulator
Weight (lb) 112 180 142 86 15TN - 100%
Lobe Pattern
Scoliosis 16:
The 3 exercises were performed by 6 subjects, 4 females and Therapy
2 males. One of the females was the scoliosis patient from 35 9TP, 100% 100%
Exercise
another test, the remaining patients did not report any back (garment) 7TN
condition or undergoing treatment. Training set size was 21 Scoliosis 15:
executions, and test set size was 10 executions in all cases. Therapy
20 7TP, 70% 100%
Overall average execution time per exercise was 20 seconds. Exercise
Each subject performed at least 31 exercises for each case after (strap) 4TN
a short period of stretch, instruction and practice. Data 3 lower back 31 each:
collection sessions including the 3 exercises lasted 2 hours for flexibility 21 each 10TP 89% avg 100%
each subject. Video recordings were made for parts of each test. tests
Test correctness was visually supervised by the scientist (6 subjects) 25TN
administrating the test. Test results were as follows:

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Transactions on Biomedical Engineering
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It is important to take into account that there are four data
types: simulated data, scoliosis exercise with custom garment,
scoliosis with exercise with strapped sensors, and lower back
exercises (5 subjects using light harness, 1 subject using custom
garment). The sensitivity column in Table VI shows maximum
sensitivity for the scoliosis exercise wearing the custom
garment mounted sensors, and the lowest sensitivity when using
strapped sensors at 70%. The lower back exercises using a
lightweight adjustable harness suitable for multiple users,
shows the next best combined specificity of 92% (excluding the
custom garment subject who reports 80% sensitivity). The
overall confusion matrix is shown in Table VII.
Table VII
OVERALL CONFUSION MATRIX
Pass Fail Performance
Correct 162 21 Sensitivity: 88.5%
Incorrect 0 371 Specificity: 100%
A. Android App test
In addition to the pattern recognition algorithm tests, we also
tested the android app which receives data from the sensors and
computes the SPMD giving an audiovisual pass/fail indication
(text message and sound) immediately after the exercise. This
is mainly a test of the hardware and the wireless link in real
time, the pattern recognition is the same as the one used in the
tests before. Fig. 15 shows the interface of the Android app.
Fig. 15. Android app for real-time biofeedback.
The right-hand side shows color bands with real time sensor
readings in pF. Real-time plots of the color-coded sensor
signals are shown on the top-left of the screen. There is a
start/stop touch control at the bottom left of the screen. After
touching start, the label changes to stop. When the exercise is
completed, the user touches stop, and the exercise is analyzed.
Then, a pass/fail message is shown along with an audible
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9
indication. The two check buttons at the bottom of the screen
allow selecting whether the test is for the simulator (SIM) or the
garment (GAR). As indicated before, the pass/fail decision is
based on the normalized test set and the distance threshold
computed during training. The app computes the SPMD
between the test data and the average of the normalized training
sequences.
In order to validate the performance of the pattern
recognition algorithm running on Android, the app has been
tested with the garment as well as the simulator setup. We
conducted two app test sessions using the garment sensors for
the scoliosis patient, the first with 21 executions and the second
with 26 executions. The real-time sensitivity was 80% for the
first test, and 70.37% for the second test. If we combine the app
test and the off-line test results for the scoliosis detection, the
overall sensitivity is 78.6%.
We tested the app with the simulator setup by conducting and
monitoring 15 executions. Sensitivity and specificity were
100% for that test.
VI. DISCUSSION
In this paper we have addressed the challenge of bringing
adherence and correctness of home-based programs to the same
levels as highly supervised therapy programs in a clinical
setting. One study suggested that adherence to an early physical
therapy program in people with acute LBP was associated with
lower subsequent health care costs [31]. In general, the
effectiveness of home-based exercise programs has been linked
to execution performance but reliable compliance and
correctness data for clinical studies has not been readily
available. The challenge is similar for most PT applications
from low back therapy to spinal deformity treatment. A recent
study by Kuru et al., suggests that Schroth exercises performed
in a clinic under supervision are superior to home exercise
programs, with results indicating significant improvement in
Cobb angle, quality of life and trunk rotation [32]. Thus, a
pattern recognition algorithm to enable monitoring compliance
and execution correctness is the key to reliably link exercise
method and execution to clinical outcome.
We believe that the best solution should combine wearable
sensor technology and spine posture monitoring methods into
an efficient design. We propose a design using a simple
triangular stretch sensor array and a classifier-based pattern
recognition app which can collect data on correctness and
adherence for home-based PT exercise programs. Our posture
correctness method originated from specialized PT exercise
therapy for scoliosis and allowed us to first demonstrate our
method on one exercise routine of much higher complexity than
that of the average LBP therapy exercise. We also conducted a
six subject test including 3 lower back flexibility exercises
suitable for LBP therapy, achieving sensitivity and specificity
in the same range as that of the scoliosis therapy test for a single
subject, thus confirming the potential of the method for LBP
exercise as well as for spinal deformity PT. The tests on
simulated exercise data showed that two unique stretching
patterns of the triangular array may be detected with high
accuracy, and there is no limitation to the number of patterns
that can be created.
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/TBME.2020.2971907, IEEE
Transactions on Biomedical Engineering
TBME-01699-2018
The time and effort associated with designing a custom
garment has benefits including simplifying experimental setup
(e.g. attaching straps and sensors to a volunteer is cumbersome
and time consuming) and improving reproducibility (e.g.
kinesiology tape placement could not be easily replicated). The
cost of a custom garment including tailoring, sensors and
transmitter was $1500 and took several weeks to complete. An
alternative solution was found for the 6-subject test in which an
elastic, light weight adjustable harness was used to hold the
sensors as shown in Fig. 14.
The method we have presented is based on tracking 3 points
on the surface of the back during exercise. We acknowledge
that the signals from the stretch sensors contain a pattern that is
unique only in the specific context of a patient performing a
given exercise. However, the high specificity results obtained
in multiple experiments and settings suggest that the solution is
well suited for correctness monitoring.
Data collection required to train and test the system for one
user took an average of 40 minutes per exercise. That may
suggest that it may be feasible to prepare a personalized
exercise program of 5 exercises in about 3.3 hours.
Our system design is not purported to be unique, but highly
efficient and robust for dynamic spinal posture monitoring. It
is, however, the first to demonstrate that a wearable, triangular
stretch sensor array built into a custom garment can be used to
detect PT exercise execution correctness in real time.
The Android app implementation showed the feasibility of
real time monitoring enhanced by a simple biofeedback
mechanism including text message and audio signal. We have
assumed that if a wearable sensor system can monitor correct
exercise execution, then it would be feasible to conduct further
research on biofeedback mechanisms to help improve
correctness rates.
The long-term approach to biofeedback for PT exercise is
probably more complex than a simple audio reinforcement
signal. Visual biofeedback has been reported as the preferred
modality for biomechanical biofeedback [26], and with the
rapid evolution of immersive visualization technology we
expect it to be of relevance to PT exercise as suggested by the
emergence of a physio-games industry [33].
Although the approach presented here is believed to be
sound, there is still room for improvement. Several limitations
remain and will be subject of continuing research and future
development:
1. Develop a clinically approved LBP-PT exercise suite that
can be supported by our design and investigate strategies
to handle special cases such as exercises in which the back
comes in contact with the floor or gym equipment.
2. Scaling the triangular array method and algorithm to
broaden its applicability. Multiple parts of the anatomy
could be monitored simultaneously by using more than
one triangular array, i.e., a lower triangle, between hips
and lower back, could be added for exercises involving
the hips or lower limbs.
3. Incorporating other sensor types. The exercises
considered so far can be monitored efficiently with stretch
sensors. However, we are open to the possibility of
incorporating other types of sensors without sacrificing
simplicity. For example, we may need to simultaneously
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10
monitor balance and motion which would require position
sensors. Signal dimensionality and computational
complexity implications will need to be addressed.
VII. CONCLUSIONS
We have presented a technology and method to monitor
compliance and correctness of therapeutic spine exercise
performed under no supervision in the privacy of the person’s
home. The wearable sensor component proposed may be
designed as a personalized, customized exercise garment, or as
a light harness made of adjustable elastic straps which can be
worn by different subjects without customization. The wearable
sensor solution using a custom garment is ideal for single
subject tests, while multi-subject cases may be suited with the
adjustable light harness approach. The customized solution
would be the fallback if the light harness were not suitable
during future clinical tests.
For the pilot test reported here, all subjects were asked and
indicated no issues regarding comfort and unencumbered
ability to exercise. Moreover, during breaks between exercises,
the subjects were able to move around and behave freely
without need to re-adjust the sensor array before continuing the
exercises. However, we acknowledge that full usability surveys
of the wearable sensor approach must be conducted during the
at-home, unsupervised phase of an exercise program during
future clinical trials.
The pattern recognition algorithm is based on a simple
classifier and associated distance metric and has shown
encouraging performance in terms of sensitivity and specificity.
The sensitivity and specificity obtained were the highest for the
custom garment (100%, 100%) while the simulator reached
81% sensitivity and 100% specificity. For the scoliosis case
using strap mounted sensors we reached 70% sensitivity and
100% specificity and for the light harness method we reached
89% sensitivity and 100% specificity for lower back exercise
case.
Exercise correctness detection enabled implementation of a
simple biofeedback mechanism. The effect of PT on spine
biomechanics, i.e. spine posture and curve changes open the
door to pursuing dynamic visualization of patient specific
models during exercise as a potential form of biomechanical
and cognitive biofeedback.
The results of the pilot test reported are indicative of the
potential of the pattern recognition algorithm and training
method, while the proposed methods to mount the wearable
sensor array did not show issues that would rule out their use in
future clinical trials and product development tests. We
envision a future wearable product that will enable monitoring
PT patients in home-based programs aimed at achieving clinical
outcomes comparable to those of supervised PT. The need for
home based program support is highlighted by multiple studies.
For example, in a study with 74 women, when compliance was
determined by whether the exercise was performed at least 70%
of the prescribed frequency, compliance for the supervised
training program was 70% vs. 38% for the home based program
[34]. We anticipate that accurate monitoring may also support
approaches to improve PT adherence. A review of barriers to
treatment adherence in physiotherapy was can be found in [35].
A key factor leading to a potential breakthrough is the
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/TBME.2020.2971907, IEEE
Transactions on Biomedical Engineering
TBME-01699-2018
availability of patient data on compliance and correctness
which could be correlated with clinical outcomes. New and
improved PT clinical trials will be possible with the proposed
approach including comparison of alternative exercise methods,
combined therapies, and personalized therapy.
ACKNOWLEDGMENTS
This work was supported by seed grants from Arizona State
University Global Sport Institute and the Fulton School of
Engineering Research faculty Support Seed Program. The
scoliosis therapy tests would not have been possible without the
valuable insights, advice and supervision of Dr. Anthony
Pivonka, D.C.
REFERENCES
[1] C. Kisner et al., “The Spine: Posture,” in Therapeutic Exercise:
Foundations and Techniques, 7th ed. Philadelphia, F.A. Davis, 1990, ch.
14, pp. 429-471.
[2] K.S. Bagraith et al., “Self-reported disability according to the
International Classification of Functioning, Disability and Health Low
Back Pain Core Set: Test-retest agreement and reliability,” Disabil.
Health J., vol. 10, no. 4, pp. 621-626, Oct. 2017.
[3] S. Ö. Anar, “The effectiveness of home-based exercise programs for low
back pain patients,” J. Phys. Ther. Sci., vol. 28, no. 10, pp. 2727-2730,
Oct. 2016.
[4] A. Nag et al., "Wearable flexible sensors: a review," IEEE Sensors J., vol.
17, no. 13, pp. 3949-3960, July 2017.
[5] E. Papi et al., “Wearable technology for spine movement assessment: A
systematic review.” J Biomech., vol. 64, pp. 186-197, Nov. 2017.
[6] C. Goodvin et al. “Development of a real-time three-dimensional spinal
motion measurement system for clinical practice,” Med. Biol. Eng.
Comput., vol. 44, no. 12, pp. 1061–1075, Dec. 2006.
[7] L. E. Dunne et al., "Wearable monitoring of seated spinal posture," IEEE
Trans. Biomed. Circuits Syst., vol. 2, no. 2, pp. 97-105, June 2008.
[8] A. Fathi and K. Curran, “Detection of spine curvature using wireless
sensors.” J. King Saud Univ. Sci., vol. 29, no. 4, pp. 553–560, Oct. 2017.
[9] O.M. Giggins et al. “Biofeedback in rehabilitation.” J. Neuroeng.
Rehabil., vol. 10, no. 60, June 2013.
[10] N. Pop-Jordanova and A. Demerdzieva, “Biofeedback training for peak
performance in sport - case study,” Maced. J. of Med. Sci. vol. 3, no. 2,
pp. 113-118, Oct. 2010.
[11] S.K. Lynn et al., “Validity and reliability of surface electromyography
measurements from a wearable athlete performance system” J. Sports Sci.
Med., vol. 17, no. 2, pp. 205-215. May 2018.
[12] G. Kwok et al., "Evaluation of myoelectric activity of paraspinal muscles
in adolescents with idiopathic scoliosis during habitual standing or
seating," BioMed Res. Int., vol. 2015, pp. 1-9, 2015.
[13] N. Kavcic et al., "Determining the Stabilizing Role of Individual Torso
Muscles During Rehabilitation Exercises," SPINE, vol. 29, pp. 1254-
1265, June 2004.
[14] B. Dworkin et al., “Behavioral method for the treatment of idiopathic
scoliosis,” Proc. Natl. Acad. Sci., vol. 82, pp. 2493-2497, Apr. 1985.
[15] E. Sardini et al., "Wireless wearable T-shirt for posture monitoring during
rehabilitation exercises," IEEE Trans. Instrum. Meas., vol. 64, no. 2, pp.
439-448, Feb. 2015.
[16] C. Coillard et al., "A new concept for the non-invasive treatment of
adolescent idiopathic scoliosis: the corrective movement principle
integrated in the SpineCor system," Disabil. Rheabil. Assist. Technol.,
vol. 3, no. 3, pp. 112-119, May 2008.
[17] L. Cohen et al., "Non-radiographic methods of measuring global sagittal
balance: a systematic review," Scoliosis Spinal Disord., vol. 12, no. 30,
Oct. 2017.
[18] Y. Santiesteban et al., “A method for detection and modeling of the human
spine based on principal curvatures,” in Progress in Pattern Recognition,
Image Analysis and Applications, Martínez-Trinidad J.F., Carrasco Ochoa
J.A., Kittler J. (eds). CIARP 2006. Lecture Notes in Computer Science,
vol 4225. Springer, Berlin, Heidelberg, 2006.
[19] A. Antal et al. “Virtually and depth sensor generated Moire pictures in
screening and treatment of scoliosis,” Optics, vol. 4, no. 3-1, pp. 24-28,
Aug. 2015.
0018-9294 (c) 2019 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
Authorized licensed use limited to: University of Canberra. Downloaded on April 29,2020 at 17:58:01 UTC from IEEE Xplore. Restrictions apply.
11
[20] L. Humbert et al. “3D reconstruction of the spine from biplanar X-rays
using parametric models based on transversal and longitudinal
inferences,” Med. Eng. Phys., vol. 31, no. 6, pp. 681-687, July 2009.
[21] A. Bulling et al., "A tutorial on human activity recognition using body-
worn inertial sensors," ACM Comp. Surv., Vol. 46, No. 3, Jan. 2014.
[22] H. Cao et al., "An integrated framework for human activity classification,"
in ACM Int. Conf. Ubiq. Comp., Pittsburgh, PA, UbiComp 2012, pp. 331-
340.
[23] T. E. Lockhart et al., "Wavelet based automated postural event detection
and activity classification with single IMU (TEMPO)," Biomed Sci.
Instrum., vol. 49, pp. 224-233, Aug. 2013.
[24] T. Zhigang et al., "MSR-CNN: Applying motion salient region based
descriptors for action recognition," in Int. Conf. on Pattern Rec. (ICPR),
Cancun, Mexico, 2016, pp. 3524-3529.
[25] L. Goras and M. Fira, “Preprocessing method for improving ECG signal
classification and compression validation,” in From Physics to Control
Through an Emergent View, L.Fortuna, A. Fradkov, and M. Frasca, Eds.,
pp. 20-25, 2010.
[26] Kos A., Umek A. (2018) “Biomechanical Biofeedback,” In:
Biomechanical Biofeedback Systems and Applications. Human–
Computer Interaction Series. Springer, Switzerland, 2018, ch. 2, pp. 36-
52.
[27] V. Asamoah et al., “Measuring the surface of the back. Value in diagnosis
of spinal diseases,” Orthopade vol. 29, pp. 480–489, June 2000.
[28] M. Betsch, et al., “Evaluation of a novel spine and surface topography
system for dynamic spinal curvature analysis during gait” PloS one vol.
8, no. 7, July 2013.
[29] M. Betsch et al., “Reliability and validity of 4D rasterstereography under
dynamic conditions,” Comput. Biol. Med., vol. 41, pp. 308–312, Apr.
2011.
[30] H. Berdishevsky et al., “Physiotherapy scoliosis-specific exercises - a
comprehensive review of seven major schools” Scoliosis and spinal
disorders, vol. 11, no. 20, Aug. 2016.
[31] J.M. Fritz et al., “Physical therapy for acute low back pain: associations
with subsequent healthcare costs,” Spine, vol. 33, no. 16, pp. 1800-1805,
July 2008.
[32] T. Kuru et al., “The efficacy of three-dimensional Schroth exercises in
adolescent idiopathic scoliosis: A randomized controlled clinical trial,”
Clini. Rehabil. vol. 30, no. 2, pp. 181–190, 2016.
[33] C. Wibmer et al., "Video-game-assisted physiotherapeutic scoliosis-
specific exercises for idiopathic scoliosis: case series and introduction of
a new tool to increase motivation and precision of exercise performance,"
Scoliosis and Spinal Disord., vol. 11, no. 44, pp. 1-9, Nov. 2016.
[34] H. Bentsen et al. “The effect of dynamic strength back exercise and/or a
home training program in 57-year-old women with chronic low back pain.
Results of a prospective randomized study with a 3-year follow-up
period,” Spine, vol. 22, pp. 1494-1500, July 1997.
[35] K. Jack et al. “Barriers to treatment adherence in physiotherapy outpatient
clinics: a systematic review,” Man. Ther., vol. 15, no. 3, pp. 220-228, June
2010.