Biofeedback
Volume 40, Issue 4, pp. 142–149
DOI: 10.5298/1081-5937-40.4.03
ÓAssociation for Applied Psychophysiology & Biofeedback
www.aapb.org
FEATURE ARTICLE
Dysponesis Awareness Training: Surface
Electromyographic Training for Increased Awareness
and Facilitated Neck Muscle Relaxation
Richard Harvey, PhD, Erin Thorne, BA, and Jourdan McPhetridge, BA
San Francisco State University, San Francisco, CA
Winter 2012 | Biofeedback
Keywords: sEMG, dysponesis, somatic awareness, sports, biofeedback training
142
This study investigated a simple biofeedback-assisted
training protocol for increasing somatic awareness as well
as reducing dyponesis. Twelve normal, healthy volunteers
with no known musculoskeletal impairments (mean age of
23.8 years) were trained to increase awareness of ‘‘wasted
effort’’ in the neck muscles during a simple bending task.
Surface electromyography (sEMG) signals were recorded
from the midcervical paraspinal muscles (C-5) while the
subject performed a forward fold, also described as a ‘‘toe
touch’’ movement. The quantitative measures of sEMG
activity were compared to a subjective measure of neck
muscle tension. During the pretraining measurements, 11
of 12 participants reported no subjective awareness of
increased neck muscle tension while bending in a forward
fold ‘‘toe touch’’ position. After approximately 10 minutes
of ‘‘dysponesis awareness training,’’ all participants had
measurable reductions in neck muscle tension, as well as
reductions in the subjective sense of tension while
performing the forward fold exercise, as compared to
pretraining. The 11 participants who increased their selfawareness following training reported not only feeling
decreased neck muscle tension but also increased general
relaxation levels. The findings suggest that most individuals may be unaware of increased muscle tension during
simple activities such as a forward bend, yet may rapidly
learn how to reduce dysponesis, such as unnecessary neck
muscle overexertion during a forward bend. Furthermore,
sEMG dysponesis awareness training could be adapted to
rapidly train individuals such as athletes to reduce
unnecessary muscle use.
‘‘I didn’t realize that my muscles were so tense until after the
training. I feel a lot better.’’—H.L.
‘‘Great experience! I’m leaving with more confidence in
myself because I can hold less tension in unneeded areas.’’—
C.F.
Introduction
The Importance of Neck Muscle Awareness
The muscles of the neck contribute importantly to
awareness of body posture and position. For example,
‘‘articular receptors in the cervical spine’’ communicate
information such as head orientation and movement. As
well, the neck muscles contribute to proprioceptive
processes related to the vestibulospinal and vestibulocular
reflexes necessary for stabilizing the spine and orienting the
eyes during head motion, respectively (Armstrong,
McNair, and Taylor, 2008). The midcervical paraspinal
muscles located at C-5 were selected as a useful surface
electromyography (sEMG) recording location because they
are related to activity in the upper extremities such as
movement of the elbow, arm, shoulder, and head (Salvi,
Jones, and Weigert, 2006).
Low awareness of unintended neck muscle fatigue, such
as when people are unaware of unnecessarily tensing the
neck muscles while bending to touch the toes, contributes
to decreased neck muscle flexibility and regeneration
(Madeleine, 2010; Schmid and Schieppati, 2005). Neck
muscle fatigue due to overuse has been associated with
various forms of discomfort, illness, and injury. For
example, Edmondston et al. (2011) described increasing
degrees of neck muscle extensor and flexor fatigue
contributing to increasing reports of neck muscle pain and
pathology. Although high awareness of head and neck
muscle fatigue contributes to increased functioning, low
awareness of head and neck muscle fatigue contributes to
slowed recovery during neck muscle rehabilitation (Arm-
Harvey et al.
strong et al., 2008). For example, during rehabilitation of
neck muscles following acute injuries, due to high-impact
sports injuries caused by football and hockey accidents, or
whiplash injuries caused by automobile accidents, patients
with low levels of head and neck position sense had slowed
recovery times (Armstrong et al., 2008). In contrast to acute
‘‘whiplash’’ injuries, chronic neck muscle injury often
contributes to degenerative processes leading to various
diseases of the joints of the spine (e.g., spondylarthropathy), particularly in the neck regions of the spine (Tsirikos
et al., 2001).
Proper conditioning of the neck muscles, as well as raised
awareness of neck muscle fatigue, has been shown to be an
important contributor to reducing neck region cervical
spine injury (Almosnino, Pelland, and Stevenson, 2010).
Furthermore, neck muscle conditioning exercises coupled
with increased sense of head and neck fatigue reduces the
chances of concussions in contact sports (Viano, Casson,
and Pellman, 2007). For example, Meyers and Laurent
(2010) describe injury awareness among rodeo athletes,
suggesting that both physical conditioning and psychophysiological conditioning exercises, such as muscle awareness training, are necessary to reduce rodeo-related neck
injuries.
Treating Neck Muscle Pain and Injury Using Biofeedback Raises Awareness
Biofeedback techniques have been used to treat pain and
injury associated with neck muscle fatigue, as well as for
preventative efforts such as raising awareness of neck
muscle fatigue for improving neck muscle conditioning (Ma
et al., 2011). Whereas preventing the likelihood of
traumatic injury is possible among athletes through muscle
awareness and conditioning exercises (Schmid and Schieppati, 2005), it is also possible to reduce injury by employing
biofeedback techniques for raising awareness of unnecessary neck muscle exertion (Madeleine, 2010; Schleifer et al.,
2008).
Biofeedback | Winter 2012
Biofeedback-Assisted Dysponesis Awareness Training
Whatmore and Kohli (1974) used the term dysponesis to
describe types of unnecessary muscle effort such as
tightening of muscles unrelated to the task. For example,
it is unnecessary to maintain neck muscle tension while
hanging down in, or after rising up from, a toe-touching
task (Shedivy and Kleinman, 1977; see Figure 1). Low
somatic awareness contributes to ongoing dysponesis or
misuse of muscles unrelated to a task. Dysponesis has been
categorized into four different groups: 1) excessively
tightening muscles used for task performance, 2) uninten-
tionally tightening muscles unnecessary for task performance, 3) maintaining muscle tension after the task has
been completed, and 4) not allowing muscles to relax
momentarily during task performance to allow ongoing
regeneration (Peper, Booiman, Tallard, & Takebayashi,
2010). In the case of groups 3 and 4, sustained muscle
contractions not only increase energy expenditures but can
also cause chronic myofascial pain, tension headaches,
backaches, joint pain, and cervical dystonia and have been
highly correlated with stress (Lundberg et al., 1994).
Whatmore and Kohli (1968, 1974) typically used the term
dysponesis when describing patients, clients, and research
subjects experiencing pathologic pain. This article intends to
broaden using the term dysponesis to include not only
people with pathological conditions, but also normal people
who exhibit misplaced muscle effort or overexertion outside
of their awareness, possibly leading to subclinical experiences of pain resulting from temporary forms of neck
muscle dysponesis. The article intends to suggest that
through biofeedback training, normal populations may
achieve increasing levels of awareness and control of neck
(or any) muscle activity and reduce inefficient muscle use,
avoiding pain and or injury. Some brief examples of ways
that sEMG biofeedback training has been used to increase
awareness of dysponesis follows. Surface electromyography
is an effective way to monitor the electrical signals produced
by striated muscles and is a significant clinical tool in
teaching patients sensitivity bodily sensations, increasing
somatic awareness, muscle conditioning, and ongoing
control and monitoring of dysponesis. Training to increase
awareness of unnecessary/dysponetic muscle effort is
possible through biofeedback, and dysponesis awareness
training (DAT) has been described in various forms and
protocols by several researchers who have successfully used
biofeedback training techniques to address dysponetic
muscle effort (Harvey and Peper, 2012). For example,
Shumay and Peper (1995) described biofeedback training to
reduce muscle strain and dysponesis among musicians who
overexerted neck and shoulder muscles with little or no
awareness of excess neck and shoulder activity while
playing an instrument. Wilson, Peper, and Gibney (2004)
described biofeedback techniques designed to foster an
‘‘aha’’ moment of awareness while reducing dysponesis
among repetitive strain injury clients. Sella (2010) described DAT techniques in the context of neuromuscular
education. Harvey and Peper (2012) described using wideranging biofeedback techniques for educating clients to raise
awareness and reduce dysponesis. Moss and Wilson (2012)
discussed types of athletic DAT in relation to avoiding
143
Dysponesis Awareness Training
Winter 2012 | Biofeedback
Figure 1. Representative head position during pretraining and posttraining procedures. (a) Representative participant trying to touch the toes. Observe that without
training, the subject is unconsciously holding up the head, exerting strain on the neck muscles. (b) Representative participant after training trying to touch the toes.
Note that the head is hanging down in a relaxed position.
144
injury and to increasing playing field advantage. The
common aspects of all DAT techniques are represented in
the steps taken to raise somatic awareness, reflecting the
part of biofeedback training that increases sensitivity to
physical sensations and bodily experiences, especially
related to muscle use (Cioffi, 1991). Dysponesis awareness
training may occur through noninstrumented techniques,
such as having a practitioner observe behavior and provide
verbal feedback or through instrument-assisted techniques
such as using biofeedback equipment to provide an objective
measure of muscle use during training (Harvey and Peper,
2012).
Within the large body of literature (e.g., Geisser et al.,
2005) on measurement of muscle tension in the neck and
spine, the flexion-relaxation phenomenon (FRP) is of
particular interest to this discussion. As described by Yoo,
Park, and Lee (2011), the FRP is a normal part of muscle
activation that ‘‘originates from the lumbar region and is
defined as an electrical silence response in the erector spinae
muscles during a full forward-bending trunk posture.’’
Watson, Booker, Main, and Chen (1997) developed a
measure called the flexion-relaxation ratio, ‘‘a comparison
of the maximal sEMG activity during 1 s of forward flexion
with activity in full flexion.’’ Pialasse, Lafond, Cantin, and
Descarreaux (2010) studied speed of movement as well as
loading effects on the flexion relaxation phenomenon in the
cervical/neck region of the spine. They found that
‘‘although the cervical FRP seems to share similarities with
what has been described in the lumbar region, it may be
modulated by different factors’’ such as loading of the
cervical spine. It should be noted that whereas the FRP
related to lumber or cervical spine studies is an important
factor, especially when investigating pain patients, this
study was more focused on the application of biofeedback
training in normal populations to raise awareness of
unnecessary muscle tightening, such as in the neck during
a simple forward bend toe-touching exercise.
This study describes a biofeedback-assisted DAT protocol for increasing subjective awareness of neck muscle
tension while performing a simple toe-touch body fold with
the goal of reducing dysponetic neck muscle activity. For
this study, DAT focused on increasing awareness of
Harvey et al.
unintentionally tightening muscles unnecessary for the
toe-touching task and maintaining muscle tension after the
task had been completed.
Subjects and Methods
Subjects
Twelve students attending San Francisco State University,
ages 19 to 31, volunteered for extra credit as part of a class
project following the guidelines set forth by Institutional
Review Board (IRB) of the Office of Human and Animal
Protections to ensure the well-being of research participants. Inclusion criteria stipulated that all participants be
normal, healthy adults. As some participants regularly
engaged in various physical activities ranging from yoga
and dance to skateboarding and surfing, only those with no
known neck or back injury could participate. Additionally
there were no exclusion criteria based on age or sex because
awareness of neck muscle activity (e.g., position, stability,
or repositioning accuracy) does not appear to vary by age or
gender (Armstrong et al., 2008).
Psychological and Physiological Equipment Measures
Physiological signals were recorded using a Procompe
physiological recording instrument running Biographe 2.0
software (Thought Technology, Ltd.). Surface electromyography was recorded with a MyoscanProe sensor with the
band pass filter set between 100 and 200 Hz. An sEMG
triode electrode was placed on the left midcervical paraspinal
muscles positioned at C-5, with the grounding electrodes
pointing away from the vertebrae. A subjective measure of
somatic awareness in the neck was used for this study, with
participants rating their neck and back muscle tension level
on a scale from 0 ¼ none to 10 ¼ maximum tension.
Results
Objective sEMG Measurements
Median sEMG measures, measured in microvolts (lV), for
the parts of the DAT protocol are presented in Table 1.
After performing a one-way ANOVA with repeated
measures on the effects of DAT protocol on sEMG during
the toe-touching forward bend task, the following was
observed:
(1)
Pretraining standing relaxed—there was no significant effect of DAT on sEMG muscle tension measures
while standing relaxed pretraining, F(1, 23) ¼ 0.089, p
¼ .76, n.s.
Biofeedback | Winter 2012
Methods
Each participant completed an intake evaluation packet, which
included demographic details, questions about neck and back
injuries, current physical/sports activities, and subjective
ratings of their current level of neck and back muscle tension
on a scale of 0–10 (0 ¼ none; 10 ¼ maximum tension). After
the sEMG sensor was attached, the DAT protocol consisted of
a pretraining measurement, sEMG awareness training, and
posttraining measurement as follows.
Dysponesis Awareness Training procedures, part 1: pretraining measures. The subject was asked to stand relaxed
while facing away from the biofeedback monitor to ensure
that the participant did not receive any visual feedback.
Then the participant performed the following sequence: 1)
Standing quietly and relaxed for 2 minutes. 2a) Bending
gently in a forward fold in an attempt to touch the toes
(toe-touch position); 2b) hanging relaxed for about 20
seconds (see Figure 1); and 2c) slowly returning to standing
upright. 3) Standing relaxed for 2 minutes. Subjective
measures of neck and back muscle tension on a scale from 1
to 10 (none to maximum tension) were obtained for each of
the three parts of the sequence.
Dysponesis Awareness Training procedures, part 2: sEMG
audio biofeedback training. The trainer and participant
reviewed the recorded pretraining sEMG data. Audio
biofeedback was then demonstrated for each subject, where
muscle activity increases were linked to an increasing pitch.
Participants were instructed to explore different positions of
their body to identify how various postures were associated
with excess or unnecessary effort of the neck muscles (e.g.,
dysponesis of the neck muscles) as they moved into a
forward fold position. Then participants were instructed to
allow their head to drop toward their chest as they leaned
forward, and slowly bend down vertebrae by vertebrae. All
subjects learned to relax their neck muscles by allowing the
head to drop/hang forward while bending in a forward fold
to touch the toes. The median DAT time was about 10
minutes per subject. Training continued until each subject
mastered the technique of relaxing neck muscles while
hanging in the forward fold, both with and without feedback.
The posttraining measurement procedure was identical
to the pretraining measurement procedure.
Data were analyzed for violations of normality and
sphericity: No observations of extreme skewness or kurtosis
were observed, and Mauchly’s (1940) test of sphericity (W
¼ 0.163) was not violated. Because there were no violations
to assumptions of normal distribution, variance or sphericity assumptions, it was decided to proceed with a repeated
measures analysis of variance (ANOVA) technique, useful
when there are small yet well-defined samples.
145
Dysponesis Awareness Training
Table 1. Pre- and posttraining sEMG median microvolt levels for Standing, Bending, Hanging, Rising, and Standing
positions.
Standing
Relaxed (1)
Bending
Task (2A)
Hanging
Task (2B)
Rising
Task (2C)
Standing
Relaxed (3)
Pretraining sEMG (lV)
4.14
11.03
10.53
10.65
4.91
Posttraining sEMG (lV)
3.91
3.61
2.16
4.06
4.03
Note. Numbers represent median microvolts (lV) of sEMG activity.
Winter 2012 | Biofeedback
(2A) Bending—there was a significant effect of DAT on
sEMG muscle tension measures while bending
forward to touch the toes, F(1, 23) ¼ 30.55, p ¼
.001, x ¼ 0.74, indicating that as DAT increased,
muscle tension decreased.
(2B) Hanging—there was a significant effect of DAT on
sEMG muscle tension measures while hanging to
touch the toes, F(1, 23) ¼ 15.44, p ¼ .001, x ¼ 0.61,
indicating that as DAT increased, muscle tension
decreased.
(2C) Rising—there was a significant effect of DAT on
sEMG muscle tension measures while rising after
touching the toes, F(1, 23) ¼ 14.03, p ¼ .001, x ¼ 0.60,
indicating that as DAT increased, muscle tension
decreased.
(3) Posttraining standing relaxed—there was no significant effect of DAT on sEMG muscle tension
measures while standing relaxed posttraining, F(1,
23) ¼ 0.842, p ¼ .36, n.s.
146
All subjects learned to relax their neck tension during
the posttraining measurement period as compared with
the pretraining measurement period. Prior to the dyponesis awareness training protocol, median sEMG measurements were 9.4 lV (SE ¼ 0.151), compared to 3.06 lV
(SE ¼ 0.152) after the training as graphically represented
in Figures 2–4.
Subjective Awareness
Mean subjective awareness measures for the parts of the
DAT protocol are presented in Table 2.
There were no significant differences between pretraining and posttraining measures of self-reported muscle
tension at time 1 or time 2A–C.
On average, subjects reported experiencing significantly
less muscle tension while standing at time 3 posttraining
(M ¼ 2.45, SE ¼ 0.578) than standing at time 3 pretraining
(M ¼ 4.27, SE ¼ 0.541), t(11) ¼ 3.76, p ¼ .004, r ¼ 0.62.
Figure 2. Placement of sEMG sensor on the left midcervical paraspinal muscle at C-5.
Harvey et al.
Figure 3. Representative sEMG recording for pretraining procedures.
There were no significant correlations between pretraining measures of self-reported muscle tension and pretraining measures sEMG lV activity.
Self-reported muscle tension posttraining was significantly related to sEMG lV activity only when people were
hanging for 20 seconds (2B), r ¼ 0.654, p ¼ .029.
Eleven of 12 subjects reported being completely
surprised that their neck sEMG lV activity showed any
muscle tension because they had rated themselves as
having very little tension. Furthermore all subjects
reported that sEMG feedback increased their self-aware-
Discussion
This study demonstrates that prior to sEMG DAT, subjects
were seldom aware of their actual sEMG muscle activity
while bending forward to touch their toes. This study
Biofeedback | Winter 2012
Figure 4. Representative sEMG recording for posttraining procedures.
ness of neck and back muscle tension and allowed them to
be more deeply relaxed during the forward bend/toe-touch
movement. By the end of the training, all subjects
anecdotally reported that they would apply somatic
awareness to other physical activities outside of the
training setting.
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Dysponesis Awareness Training
Winter 2012 | Biofeedback
Table 2. Self-reports of muscle tension at time 1, Standing; time 2A–C, Bending, Hanging, and Rising; and time 3,
Standing, on a 0 ¼ none to 10 ¼ maximum tension scale.
148
Time 1
Standing
Time 2A–C
Bending, Hanging, Rising
Time 3
Standing
Pretraining self-reported muscle tension (1–10 scale)
4.36
3.73
4.27
Posttraining self-reported muscle tension (1–10 scale)
3.09
2.82
2.45
confirmed that many people unknowingly experience
covert, sustained muscle contractions while performing
various tasks involving neck muscles. More importantly,
the study showed that subjects can rapidly learn to raise
awareness of dysponesis in the neck and back muscles while
folding forward.
When beginning to bend forward to touch the toes, 11 of
12 participants lifted their head slightly, possibly to look
out in front of them, causing an increase in neck muscle
sEMG activity. The one participant who did not show a
significant increase in sEMG activity was a trained ballerina
who from the beginning of the study displayed proper body
mechanics. One explanation of why participants lifted their
head while bending down is a reflexive hypervigilence to
look for danger; however, all of the participants were in a
safe classroom environment, so it is more likely that
participants were reflexively holding their head out in a
‘‘sky diving’’ position (sometimes also referred to as a
‘‘parachute’’ reflex, ‘‘plantar’’ reflex, and/or ‘‘Landau’’
reflex ) rather than anticipating danger. In all cases sEMG
levels in the neck muscles were greatly reduced when
participants allowed their head to drop toward their chest as
they leaned forward, slowly bending down vertebrae by
vertebrae.
Some anecdotal participant reports suggested surprise at
the sharp contrast between their subjective ratings of
muscle tension and the actual sEMG measurements.
Dysponesis awareness training may be used to show people
that they are totally unaware of their muscle tension, which
results in a powerful ‘‘aha’’ experience.
Whereas participants trained in yoga and dance (N ¼ 5)
demonstrated much lower initial sEMG levels prior to
training, in contrast with participants who reported physical
activities with less fluid body mechanics and more quick,
concise movements (i.e., surfing, skateboarding, karate), the
numbers are too small to make a statistical comparison
based on type of physical activity. It was also observed that
participants who had been trained in yoga or dance (N ¼ 5)
required fewer minutes of training.
sEMG feedback can be used in teaching athletes from
yoga practitioners to surfers to promote somatic awareness.
This increased awareness and mastery in reducing dysponesis may also prevent muscle tension headaches, repetitive
strain injury, and other muscle injuries, myofascial
disorders, or cervical dystonias. This study demonstrated
that dysponetic patterns that result from simple movements
such as folding forward to touching the toes can be reduced
with muscle feedback.
Study Limitations
Whereas this pilot study suggests a promising protocol for
reducing dysponesis, there may be a selection bias present
in the participants who were students aiming to please the
researchers. Even though this may be possible, it is more
likely that the participants were unbiased in their
participation because they received extra credit. Another
possible limitation of the study is the small number of
participants; however, the effect size estimates are large
(Kirk, 1996) for the differences in sEMG activity for the
pretraining and posttraining periods, suggesting that the
even a small number of participants could reveal a
practically significant difference between those who receive
and those who do not receive DAT.
It should be noted for future researchers that, even
though this study did not exam deep neck flexor endurance
levels, there has been one report of men compared to
women having greater levels of awareness of deep neck
flexor endurance levels (Domenech, Sizer, Dedrick, McGalliard, and Brismee, 2011). Further investigations are needed
to determine the appropriate sEMG activity in the whole
kinetic chain of muscle activity involved in the simple act of
toe touching.
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