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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 135–144 135
DOI 10.3233/BMR-140501
IOS Press
Spinal postural training: Comparison of the
postural and mobility effects of
electrotherapy, exercise, biofeedback trainer
in addition to postural education in university
students
¸Seyda Toprak Çelenay, Derya Özer Kaya∗and Anıl Özüdo˘
gru
Ahi Evran University, School of Physical Therapy and Rehabilitation, Kır¸sehir, Turkey
Abstract.
BACKGROUND AND OBJECTIVE: Spinal posture and mobility are significant for protecting spine. The aim was to compare
effects of different postural training interventions on spinal posture and mobility.
MATERIAL AND METHOD: Ninety-six university students (ages: 18–25 years) were allocated into Electrical Stimulation
(ES) (n=24), Exercise (n=24), Biofeedback Posture Trainer (Backtone) (n=24), and Postural Education (n=24, Controls)
groups. All the groups got postural education. The interventions were carried out 3 days a week for 8 weeks. Spinal Mouse
device (Idiag, Fehraltorf, Switzerland) was used to detect thoracic and lumbar curvatures and mobility (degrees) in standing and
sitting positions. Paired Student’s t-test, one-way ANOVA, and pairwise post-hoc tests were used.
RESULTS: ES decreased thoracic curvature, the exercise decreased thoracic and lumbar curvature and increased thoracic mo-
bility in standing position between pre-post training (p<0.05). Exercise and Backtone improved thoracic curvature in sitting
(p<0.05). In Exercise Group, thoracic curvature decreased compared to Backtone and Education Groups, and thoracic mobility
increased compared to all groups (p<0.05).
CONCLUSIONS: The exercise was effective and superior in improving thoracic and lumbar curves, and mobility among uni-
versity students. ES decreased thoracic curve. Biofeedback posture trainer improved sitting posture.
LEVEL OF EVIDENCE: A prospective randomized controlled trial, Level 1.
Keywords: Back posture, posture education, electrical stimulation, exercise, orthotic device
1. Introduction
The musculoskeletal spinal disorders have been con-
sidered as major health problems [1]. They were de-
clared to trigger physical and psychological problems,
∗Corresponding author: Derya Özer Kaya, Ahi Evran Univer-
sity, School of Physiotherapy and Rehabilitation, Ku¸sdili Mahallesi,
Terme Caddesi, 40200 Kır¸sehir, Turkey. Tel.: +90 386 280 53 73,
+90 532 715 82 20; Fax: +90 386 280 53 71; E-mail: deryaozer
2000@yahoo.com.
generate disability, impair the quality of life, decrease
manpower of the individual, and cause great economic
costs [2,3]. The disorders were mostly associated with
faulty back posture and lack of mobility as a cause or as
a consequence [4–7]. In thoracic spine, kyphotic pos-
ture was declared to be the source of posture origined
pain, lumbo-pelvic posture, decreased spinal extension
mobility, spinal extensor muscle weakness, and sen-
sory deficit [4,5,8,9]. Inactivity, non-ergonomic work-
ing or studying conditions and emotional stress were
strongly associated with the problem [10,11]. Stand-
ISSN 1053-8127/15/$35.00 c
2015 – IOS Press and the authors. All rights reserved
AUTHOR COPY
136 ¸S.T. Çelenay et al. / Comparison of the postural and mobility effects of electrotherapy, exercise, biofeedback trainer
ing and sitting positions in human subjects have been
clearly documented to stress the spine [12–14]. Spend-
ing so much time on sitting postures during studying or
daily living activities, computer usage for long time pe-
riods, inactive lifestyle, inadequate nutrition and stress
turned out the young adult university students to be
a risk group [15–17]. Revealing accurate strategies to
protect public health especially in that risk group have
been extremely significant.
Different interventions to protect and improve spine
health in different populations were occurred in liter-
ature and in daily usage [18–20]. Postural education
programs which were designed to provide information
and advice have been commonly used [21]. However,
contradictory results about the efficiency of the pro-
grams were published [22–25]. Some studies showed
that electrical stimulation (ES) as a different interven-
tion could change spinal posture and mobility as well
as reducing pain, increasing muscle strength, decreas-
ing joint stiffness and spasm in muscles [19,26,27].
Exercise approaches, especially spinal stabilization ex-
ercises have been popular for treating and preventing
musculoskeletal spinal disorders, lately [28,29]. Pre-
vious studies relating to spinal stabilization exercises
were investigated variable parameters such as postu-
ral stability, pain, function and spine mobility [20,30,
31]. However, effectiveness of the exercises on spine
posture and mobility has not been well documented.
Moreover, some orthotic and biofeedback trainer de-
vices were introduced and commonly recommended to
maintain upright posture, provide proprioceptive input,
support trunk, prevent pain-producing events, ensure
training of the necessary muscles [32–34]. However, it
has not been clearly declared if the devices were more
effective than other interventions for the treatment and
prevention of spine posture and mobility.
Although many different interventions have been
widely used in physiotherapy clinics, few studies were
observed evaluating the effects of these programs on
spinal posture and mobility, and no studies were de-
tected comparing to each other [24,30,35]. Therefore,
the aims of the current study were to investigate the
effects of postural education on posture and mobility,
and to assess and compare the effects of electrother-
apy, exercise, biofeedback trainer in addition to postu-
ral education in university students. The following hy-
potheses were investigated: 1. Different postural train-
ing programs affect spinal posture and mobility in uni-
versity students, 2. None of the different postural train-
ing programs has had superiority to each other.
2. Methods
2.1. Design
A prospective randomized, blind, controlled trial de-
sign was used. This study was conducted in accordance
with the rules of the Declaration of Helsinki. Written
informed consent was obtained from each participant.
It was approved by the Human Research Ethics Com-
mittee of the University (Approval number: 12/12-1).
2.2. Participants
Healthy and voluntary participants aged between
18–25 years who had not performed any regular phys-
ical activity for at least one year were recruited. The
total 125 numbers of university students were as-
sessed. The employed exclusion criteria were as fol-
lowed: (i) having a systemic pathology including in-
flammatory disease; (ii) having musculoskeletal injury,
trauma, pathology or structural deformity related to
spine and extremities; or (iii) having active interven-
tion including corticosteroid or any medication in the
last 3 months. One hundred and two volunteers out of
125 were eligible for the study.
2.3. Randomization
Prior to commencing the study, the volunteers were
randomly divided into four groups: Group 1. Postural
Education +Electrical Stimulation Group (ES), Group
2. Postural Education +Thoracic Spinal Stabilization
Exercise Group (Exercise), Group 3. Postural Educa-
tion +Biofeedback Trainer Device Group (Backtone),
Group 4. Only Postural Education Group (Education).
At the end of eight weeks, 96 participants (ES:n=24,
X±SD: 19.66 ±1.16 years; Exercise: n=24, X ±
SD: 21.00 ±1.06 years; Backtone: n=24, X ±SD:
19.95 ±1.04 years; Education: n=24, X ±SD: 20.08
±1.01 years) completed the study. Details of included
and excluded subject numbers into the study through
the final data analysis have been provided in Fig. 1 as
flowchart.
2.4. Outcome measures
Assessments related to spine posture and mobility
was applied previously to join the training program,
after finishing the program at the 8th week. All eval-
uations were conducted by the same physical thera-
pists (AO), who used a standardized protocol to en-
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¸S.T. Çelenay et al. / Comparison of the postural and mobility effects of electrotherapy, exercise, biofeedback trainer 137
Assessed for eligibility (n= 125)
All participants referred to the participating were assessed with
questionnaires for eligibility to the exclusion criteria.
Excluded (n= 23)
Not meeting inclusion criteria
(n=12)
Not accepted to participate (n=11)
Analyzed (n=24)
Allocated to Healthy
Spine Education
Program and
Electrical
Stimulation
(n=25)
Enrollment
Randomized
(n=102)
Allocated to Healthy
Spine Education
Program and Thoracic
Spinal Stabilization
Exercise Program
(n=26)
Allocated to
Healthy Spine
Education Program and
Backtone Biofeedback
Trainer Device
(n=25)
Allocated to
Healthy Spine
Education Program
Control Group
(n=26)
Lost to follow up
(n=1)
Left the training
program because of
personal causes and
discontinuing training
Lost to follow up
(n=1)
Left the training
program because of
personal causes
Lost to follow up
(n=2)
Left the training
program because of
personal causes
Lost to follow up
(n=2)
Left the training
program because of
personal causes
Analyzed (n=24) Analyzed (n=24) Analyzed (n=24)
Fig. 1. The flowchart diagram for the participants.
sure the consistency of subject positioning, instruc-
tions, and overall testing procedures. The examiner
himself was blinded to the groups’ intervention. The
physical characteristics including age, gender, exer-
cise, smoking and drinking habits were recorded. Level
of physical activity was assessed by the Turkish ver-
sion of International Physical Activity Questionnaire-
7 (IPAQ-7) [36]. Body composition was evaluated by
Bodystat 1500 Bio-impedance analyzers (Bodystat
Ltd, Douglas, Isle of Man, UK).
Spinal posture and mobility were assessed using
the Spinal Mouse System (Idiag, Fehraltorf, Switzer-
land), a hand-held, computer-assisted electromechan-
ical device. The intra-tester and inter-tester, and day-
to-day reliability of the Spinal Mouse device had been
published previously [37]. The bony landmarks were
firstly determined by palpation and marked on the skin
surface. A rolling sensor head followed the contour
of the spine paravertebrally along the spine from the
7th cervical to the third sacral vertebra. This informa-
tion was then used to calculate the relative positions of
the spine using the software. Measurementswere made
during standing upright position, maximum flexion and
maximum extension positions, respectively. All mea-
surements were also repeated while the participant was
seated on an armless chair first in an upright posi-
tion, then maximally flexed and maximally extended.
Thoracic curvature (T1-2 to T11-12), lumbar curvature
(T12-L1 to the sacrum), thoracic and lumbar mobil-
ity were treated as outcome measures in degreeswhich
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138 ¸S.T. Çelenay et al. / Comparison of the postural and mobility effects of electrotherapy, exercise, biofeedback trainer
Fig. 2. Place of eight electrodes on back. (Colours are visible in
the online version of the article; http://dx.doi.org/10.3233/BMR-
140501)
were calculated by the software. Mobility results were
calculated by examining the differences between max-
imum flexion and maximum extension end positions.
2.5. Interventions
After the baseline assessments all the groups had
one session of postural education seminar by the ex-
perienced physical therapist (DOK). It included basic
anatomy, physiology, and biomechanics of spine. Ideal
posture characterized by a lack of upper trunk displace-
ment, a “normal” lumbar lordosis and thoracic kypho-
sis and activation of deep muscles of the spine were
mentioned [38,39]. The participants were practiced to
control appropriate spinal curves one-by-one during
standing and sitting and were asked to maintain the po-
sitions and contractions during daily activities as much
as possible throughout the day. Education Group was
treated as controls and followed by a timetable once
a week to see how much they care about the postural
positions.
ES was applied to the Group 1 by using muscular re-
inforcement program of Compex Device (Compex 3
Professional, Compex Médical SA, Switzerland). The
program was made up of three sequences of stimula-
tion that automatically run on from one another: The
first sequence consisted of a warm up of 2 minutes
at a frequency of 6 Hz. The second was the work se-
quence including alternate contractions (75 Hz), and
rest (4 Hz) which lasted 4 and 10 seconds, respectively.
After the work sequence, the third part was relaxation
(3 Hz) which lasted 3 minutes. Eight electrodes were
placed on the middle trapezius muscles and T6-T12
levels over erector spine muscles bulks motor points
in prone position (Fig. 2). The intensity of the current
was arranged separately one by one for each partici-
pant until apparent muscle contraction was established
(20–40 mA). They used it during 20 minutes for 3 days
per week for 8 weeks.
Group 2 had Thoracic Spinal Stabilization Exer-
cise program. Thoracic bracing technique with postu-
ral alignment and minimal multifidus muscle activa-
tion with scapular orientation for exercise group was
performed [40]. The participants were asked to main-
tain the positions and contractions during the exer-
cises. The exercise program were composedof 10 min-
warm-up exercises, 20 min stabilization exercises,
10 min-cool-down, and stretching exercises in a group
set-up. The progression included three phases accord-
ing to the stages of motor learning and sensory mo-
tor integration as static, dynamic, and functional [41].
The static phase aimed to maintain short quick mo-
tor control and kinesthetic awareness. The exercises
included workouts of thoracic bracing in neurodevel-
opment stages (supine, prone, side lying, quadripedal,
bipedal). They held the contraction for 10 seconds at
each position for 3 sets of 10 repetitions. Upper and
lower extremity range of motion exercises were con-
ducted while maintaining stabile spine at the specific
positions. All exercise repetitions were increased pro-
gressively from 6 to 15. Dynamic phase’s objective
was to teach conscious motor control and to maintain
stable spine during extremity motions with elastic re-
sistive bands. It started at the third week and lasted
at the end of 5th week. The participants began exer-
cises using the latex red band and a 200-cm-longprecut
section of Thera-Band (Hygenic Corporation, Akron,
OH) at medium tension. They had 10 repetitions of 3
sets each held for 6–10 seconds. When they performed
3 sets of 15 repetitions without significant pain or fa-
tigue, they were progressed to the next color resistive
band in the sequence of green, and blue. The functional
phase aimed to teach unconscious motor control. The
exercises included functional training with elastic re-
sistance and exercise balls on unstable surfaces. They
had 10 repetitions of 3 sets each held for 10–15 sec-
onds. The intervention was carried out 8 weeks and
3 days/week.
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¸S.T. Çelenay et al. / Comparison of the postural and mobility effects of electrotherapy, exercise, biofeedback trainer 139
Group 3 used BackTone Biofeedback Posture
Trainer (BackTone 4000, BackTone Pty Ltd, Aus-
tralia). It consisted of a light webbing harness with
an electronic sensor. The electronic unit placed be-
tween shoulder blades and waist. As soon as individ-
ual sloucheed, the harness pulled on the sensor caus-
ing it to beep or vibrate. When straighten up, the beep
stoped. Proper size of BackTone was given to each
participant. The participants were instructed how to ap-
ply it. They used it for 20 minutes for 3 days per week
for 8 weeks.
2.6. Statistical analysis
The G∗Power package software program (G∗Power,
Version 3.0.10, Franz Faul, Universität Kiel, German)
was used to determine the sample size. It was calcu-
lated that a sample consisting of 24 subjects in each
group, total 96 subjects was needed to obtain 90%
power with f=0.40 effect size, and α=0.05 type I
error.
SPSS 11.5 for Windows (SPSS Inc. Chicago, IL,
USA) was used for the outcomes. The variables were
investigated using visual (histograms, probability
plots) and analytical methods (Kolmogrov-Simirnov
test) to determine whether or not they were normally
distributed. Descriptive analyses were presented using
mean and standard deviation (SD) for the normally
distributed variables, and tables of frequencies for the
ordinal variables. Paired Student’s t-test was used to
compare the measurements at the two time point (base-
line and 8th week) for spinal posture and mobility.
One-way ANOVA was used to compare spinal pos-
ture and mobility parameters among different postural
training groups. Levene test was used to assess the ho-
mogeneity of the variances. An overall p-value of less
than 0.05 was considered to show a statistically signifi-
cant result. When an overallsignificance was observed,
pairwise post-hoc tests were performed using Tukey’s
test.
3. Results
The baseline physical characteristics of the groups
were displayed in Table 1. There were no statistical
differences between the physical activity levels and
body compositions of the groups (p>0.05). The ages
were different, but the range was so small clinically
(p<0.05). Descriptive findings of the participants
were similar among groups. They were represented in
Table 2.
At the beginning there were no differences between
groups in standing and sitting for thoracic curvature,
(standing; ES: 43.62 ±1.63, Exercise: 43.33 ±2.17,
Backtone: 42.54 ±2.02, Education: 39.50 ±1.74; sit-
ting; ES: 39.29 ±1.43, Exercise: 35.08 ±1.91, Back-
tone: 33.91 ±2.12, Education: 31.29 ±2.02), lum-
bar curvature (standing; ES: 26.58 ±1.63, Exercise:
29.62 ±1.24, Backtone: 25.66 ±1.53, Education:
25.45 ±1.00; sitting; ES: 1.08 ±2.62, Exercise: 4.20
±1.96, Backtone: 6.04 ±2.66, Education: 2.87 ±
2.05), thoracic mobility (standing; ES: 22.41 ±2.75,
Exercise: 18.75 ±2.69, Backtone: 15.62 ±4.04, Ed-
ucation: 27.50 ±2.85; sitting; ES: 30.50 ±4.01, Ex-
ercise: 32.66 ±2.47, Backtone: 33.16 ±3.60, Edu-
cation: 39.00 ±3.22), and lumbar mobility (standing;
ES: 73.66 ±2.77, Exercise: 72.37 ±2.09, Backtone:
71.66 ±2.38, Education: 75.87 ±1.92; sitting; ES:
49.58 ±2.97, Exercise: 54.12 ±3.61, Backtone: 48.50
±4.44, Education: 52.54 ±4.05); (p>0.05). Tho-
racic curvature decline (Pre: 43.62 ±1.63; Post: 37.01
±2.45) in ES Group, thoracic curvature (Pre: 43.33
±2.17; Post: 34.20 ±2.11) and lumbar curvature de-
cline (Pre: 29.62 ±1.24; Post: 26.58 ±1.49) and tho-
racic mobility increase (Pre: 18.75 ±2.69; Post: 30.75
±1.56) in Exercise Group were found in standing be-
tween pre and post training (p<0.05), (Fig. 3). Signif-
icant decline in thoracic curvature was also observed
in sitting in favor of Exercise (Pre: 35.08 ±1.91, Post:
31.29 ±1.53) and Backtone groups (Pre: 33.91 ±2.12;
Post: 29.66 ±2.35); (p<0.05), (Fig. 4).
The intergroup comparison showed a significant dif-
ference in the thoracic curvature and mobility in stand-
ing among four groups (p<0.05). Thoracic curva-
ture decreased and thoracic mobility increased in Ex-
ercise Group in comparison to Backtone and Educa-
tion groups (p<0.05) (Table 3). Any difference in the
lumbar curvature and mobility in standing and in the
thoracic curvature, lumbar curvature, thoracic mobil-
ity and lumbar mobility in sitting could not be detected
among four groups (p>0.05).
4. Discussion
This study put forward the following outstanding
findings: (i) Electrical stimulation decreased the tho-
racic curve in standing position, (ii) Exercise group
showed the maximum decrease in thoracic and lumbar
curvature, and increase in thoracic mobility in standing
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140 ¸S.T. Çelenay et al. / Comparison of the postural and mobility effects of electrotherapy, exercise, biofeedback trainer
Table 1
Physical characteristics of the participants
Physical characteristics Group 1 ES Group 2 Exercise Group 3 Biofeedback Group 4 Education p
n=24 n=24 trainer device n=24 n=24
X±SD X ±SD X ±SD X ±SD
Age (year) 19.66 ±1.16 21.00 ±1.06 19.95 ±1.04 20.08 ±1.01 <0.001∗
Fat mass (kg) 12.79 ±4.11 12.54 ±5.49 12.56 ±4.67 11.28 ±4.66 0.542
Lean mass (kg) 54.33 ±12.37 52.40 ±11.64 50.21 ±10.36 55.65 ±12.90 0.441
Body mass index (kg/m2) 22.84 ±3.15 22.50 ±3.13 22.31 ±2.27 22.72 ±2.63 0.916
Waist/hip ratio 0.80 ±0.07 0.82 ±0.07 0.81 ±0.06 0.82 ±0.06 0.870
IPAQ-7∗∗ 1713.48 ±1175.72 1788.46 ±1185.14 2007.18 ±1347.23 1849.79 ±1520.23 0.889
∗p<0.05; ∗∗IPAQ-7: International Physical Activity Questionnaire-7.
Table 2
Descriptive findings of the participants
Group 1 Group 2 Group 3 Group 4
ES Exercise Biofeedback trainer Education
n% n% devicen% n%
Gender Female 12 50.0 12 50.0 15 62.5 8 33.3
Male 12 50.0 12 50.0 9 37.5 16 66.7
Exercise habit Yes 21 87.5 21 87.5 14 58.3 19 79.2
No 3 12.5 3 12.5 10 41.7 5 20.8
Smoking Yes 3 12.5 0 0.0 2 8.3 8 33.3
No 21 87.5 24 100.0 22 91.7 16 66.7
Alcohol consumption Yes 1 4.2 0 0.0 1 4.2 2 8.3
No 23 95.8 24 100.0 23 95.8 22 91.7
Total 24 100.0 24 100.0 24 100.0 24 100.0
*p<0.05 Standing Position
Fig. 3. Comparison of the thoracic curvature, lumbar curvature, thoracic mobility and lumbar mobility of groups’ pre and post training.
position, (iii) Backtone and Exercise Group indicated
the maximum decrease in thoracic curvature in sitting
position.
Posture was defined as the relative arrangement of
the parts of the body [42] and spinal curvatures were
used to identify ideal postures. The values proposed
by Mejia et al. [43] for thoracic kyphosis. The de-
grees between 20 to 45 degrees were considered neu-
tral in standing. Lower and higher values were classi-
fied as hypo and hyper kyphosis, respectively. Tüzün
et al. [44] declared 20 to 40 degrees for lumbar lor-
dosis as neutral in standing. Biomechanical evidence
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Table 3
Differences between groups’ pre and post training (baseline-8th week): Spinal Mouse results
Parameters Group 1 Group 2 Group 3 Group 4 p Significant
ES (n=24) Exercise (n=24) Biofeedback trainer device Education (n=24) differences
X±SD X ±SD (n=24) X ±SD X ±SD intergroup
Standing position 8th
week-baseline differences
Thoracic curvature −6.61 ±8.59 −9.12 ±5.43 −3.00 ±8.91 −2.08 ±7.68 0.008∗Gr2>3>4*
Thoracic mobility 1.12 ±18.84 12.00 ±12.32 1.37 ±18.47 0.16 ±10.10 0.008∗Gr2>3>1>4*
∗p<0.05. Gr: Group.
*p<0.05 Seating Position
Fig. 4. Comparison of the thoracic curvature, lumbar curvature, thoracic mobility and lumbar mobility of groups’ pre and post training.
showed that increases in thoracic kyphosis were asso-
ciated with significantly higher multi-segmental spinal
loads and trunk muscle forces in upright stance. These
factors were likely to accelerate degenerative processes
in spinal motion segments and contribute to the devel-
opment of dysfunction and pain [45].
The sitting positions in human subjects have also
been clearly documented to assess the stress on spine
posture and mobility as well as standing [12–14,46,
47]. It was reported that adolescents spend a lot of time
in sitting, and those who spend more time in flexed or
slumped positions report more thoracolumbar pain [48,
49]. In adults with low back pain, sitting was declared
as a common aggravating factor [48,50] and accounted
for significant disability [51,52]. For this reason, both
standing and sitting postures were used to assess spinal
posture and mobility in this study.
Postural education programs were the first step to-
wards adopting healthy postural habits to prevent pos-
tural pain [53]. There was only one study investigating
effects of postural education program on spine curva-
ture [18]. Geldhof et al. [18] found that implementa-
tion of a back education program in elementary school
children resulted in improved trunk muscle endurance,
but there was no significant change in spinal curva-
ture. Similar to this study, our results could not find any
difference in spine curvature with just postural educa-
tion. Moreover, any study which investigated the ef-
fects of postural education program on spinal mobility
could not be detected. The current study did not show
any difference in spinal mobility in postural education
group. The reason of it might be related to the ineffec-
tiveness of the education itself to change the posture.
Previous studies were revealed that ES decreased
kyphosis and the Cobb angle, improved spinal align-
ment in sitting position in neurologic patients, and
was beneficial for spinal mobility in the patients with
chronic low backpain [26,46]. The results of this study
showed decrease in thoracic curvature in standing po-
sition in healthy subjects. Using ES may improve pos-
tural alignment. It may be recommended for differ-
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142 ¸S.T. Çelenay et al. / Comparison of the postural and mobility effects of electrotherapy, exercise, biofeedback trainer
ent musculoskeletal spine disorders for prevention and
treatment in addition to postural education.
Exercise therapy were claimed to be effective in alle-
viating pain and disability as well as increasing spinal
mobility, endurance, proprioception, and strength [35,
54]. In this study, spinal curvature and mobility for
spinal function were taken into account. Thoracic
Spinal Stabilization Exercise decreased thoracic and
lumbar curvature in standing position, decreased tho-
racic curvature in sitting position, and increased tho-
racic mobility. Previous authors have postulated that
abnormal kinematic behavior of the thoracic or lum-
bar spine was associated with back and low back
pain and decreased mobility of the spine may lead
to kyphosis and weakness of the paravertebral mus-
cles, as well as impaired physical function [55–57].
Ball et al. [58] found that spinal extension exercises
could delay the progression of kyphosis angle. Another
study showed that Pilates-based exercise program ob-
served small improvement in the thoracic kyphosis
during standing [47]. Also, it was revealed that more
neutral thoraco-lumbo-pelvic postures were associated
with less back pain [59]. Therefore, our results support
that Thoracic Spinal Stabilization Exercise is an im-
portant intervention for providing more neutral posture
and could be useful for spinal disorders at clinics.
Biofeedback device was another intervention in this
study. Previous studies showed that different brac-
ing methods decreased thoracic kyphosis and im-
proved postural alignment [60,61]. Moreover, there
was only one study investigating effects of biofeed-
back device on spinal posture. Lou et al. [62] found
that Spine-Straight device, a biofeedback device, could
help to correct habitually poor posture, and improve
spinal posture when feedback signals were provided.
BackTone device has highly been recommended by
physical therapists as one of the most popular meth-
ods. However, no evidence about the effectiveness of
such devices on spinal posture and mobility has been
declared up to now. The results revealed that thoracic
curvature decreased in subjects using BackTone de-
vice in sitting position. Thus, this biofeedback device
may be advised for people sitting for a long time at
work in inappropriate positions.
The current study had some limitations. First of all,
the study was conducted on healthy university stu-
dents. Thus, the results could not be generalized for
different age groups or pathologies. However, it might
be a very good base for further studies on different
populations, and groups. Secondly, despite the small
range, the age difference between groups might cause
limitation. Thirdly, although the training intensity, ap-
plication frequency, time and duration arranged similar
for each group, exercise group application might have
been more intense in comparison to others. Moreover,
the results of 8 weeks were represented in the study.
Long term effects should be observed with longer
follow-ups for the future studies.
5. Conclusion
Thoracic Spinal Stabilization Exercises were an ef-
fective and superior intervention on improving tho-
racic and lumbar spinal posture and mobility of uni-
versity students. Electrical stimulation decreased tho-
racic curve, and Biofeedback Trainer Device improved
sitting posture. However, postural education itself was
effective to change neither spinal posture nor mobility.
Acknowledgements
This study was funded by Ahi Evran University, Sci-
entific Research Unit. (Foundation number: 47/2011-
05). The authors would like to thank to the Scientific
Research Unit of Ahi Evran University.
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