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. 2023 Jul 15;22(3):212–221. doi: 10.1016/j.jcm.2023.04.002

Effect of Dynamic Neuromuscular Stabilization and Vojta Therapy on Respiratory Complications in Neuromuscular Diseases: A Literature Review

Fatemeh Falahati Nezhad a, Aliyeh Daryabor b, Mohsen Abedi c,⁎, Joseph H Smith d
PMCID: PMC10461149  PMID: 37644999

Abstract

Objective

The purpose of this study was to review the literature on the effect of dynamic neuromuscular stabilization (DNS)/Vojta on respiratory complications of neuromuscular diseases.

Methods

The search strategy was conducted, based on the population, intervention, comparison, and outcome method, in the PubMed, Embase, ISI Web of Knowledge, ProQuest, and Scopus databases from inception to August 2021. The quality assessment of included papers was performed through the Physiotherapy Evidence Database scale. A narrative analysis was performed since a meta-analysis could not be conducted.

Results

A total of 7 papers were chosen for the final assessment. All studies, except 1, evaluated individuals with neurological disease. Three studies evaluated Vojta therapy effects, and 4 studies evaluated DNS effects on respiratory parameters. Although the studies had limitations in their methodology according to the Physiotherapy Evidence Database scale, 4 were identified as level 1 evidence. None of the studies reported any adverse effects of Vojta therapy or DNS on respiratory parameters. However, not enough clinical trials were found to examine the effect of DNS on respiratory disease.

Conclusion

Although the studies were weak in internal and external validity, this review suggests that Vojta therapy and DNS may influence respiratory parameters, such as blood gases, diaphragm movements, and functional respiratory parameters, in patients with neuromuscular diseases.

Key Indexing Terms: Dynamic neuromuscular stabilization, DNS, Vojta, Respiratory, Neuromuscular

Introduction

Pulmonary complications are the main leading cause of morbidity and mortality in patients with neuromuscular diseases. Most neuromuscular diseases show a relatively rapid progression toward involvement of the respiratory system according to the following 2 main mechanisms: (1) reduction of the nervous control of breathing and (2) alteration of the chest mechanics.1 For example, complications affecting respiratory system function are common following a stroke.2 Respiratory rehabilitation offers a multidisciplinary approach to neuromuscular patients, with the main target of slowing progression to respiratory failure, therefore improving functional ability and quality of life to reduce the number of critical events and admissions to the hospital.1 It is prudent for the rehabilitation program to address respiratory complications by considering both the role of nervous control and chest mechanics, including posture, and respiratory patterns.

The dynamic neuromuscular stabilization (DNS) method, also known as Vojta, is a rehabilitation therapy utilized to manage musculoskeletal disorders.3, 4, 5, 6, 7 The diaphragm is the main muscle of respiration, which also has a stabilizing role in posture.8 Much research has focused on the importance of diaphragmatic movements in patients with musculoskeletal disorders or central nervous system disorders.9, 10, 11 On the other hand, indirect stimulation of the diaphragm through the excitation points of the Vojta approach can affect the movements of the diaphragm during inspiration.12 Therefore, it seems that the Vojta approach can be effective in neuromuscular diseases such as cerebral palsy. The DNS method also appears to be effective in these patients by improving diaphragm coordination.13,14 Vojta therapy has been used since the 1950s and was designed by a pediatric neurologist named Vaclav Vojta6,7 based on observing the evolution of movement in healthy infants.7 The clinical application of this treatment is that certain zones of the body are touched to stimulate predetermined genetic movement patterns in the central nervous system.7 Later, the principles and methods of Vojta therapy were developed by Pavel Kolar, who added the active component, loaded positioning to it, and called it DNS.15 The DNS method is a functional approach that integrates brain stimulation with mobilization, manipulation, breath training, postural awareness, and education.16 Several investigations have demonstrated a relationship between the diaphragm and intercostal muscle activity with postural and respiratory function.17, 18, 19, 20, 21, 22 Numerous researchers believe that correct posture is an imperative requirement for normal respiratory function.23, 24, 25 The training of optimal spine and rib alignment can be integrated for both spinal stability and respiration.17 Thus, in order to train effective breathing exercises, the corrective program should be implemented in various conditions.26 These goals can be achieved by a DNS approach founded on developmental kinesiology models.27 Some fundamental considerations of the DNS approach have been presented. For instance, training muscle coordination in different developmental conditions and combining spinal stabilization and breathing patterns during activities of daily living have been described in the literature.16

To our knowledge, there were 2 previous reviews that focused on techniques to manage pulmonary complications in people with neuromuscular diseases, including utilizing physical aids to assist hygiene of the airway28 and mechanical ventilation approaches29; however, no review article to date has addressed the effect of the DNS method on respiratory parameters. Therefore, this study aimed to systematically review the evidence for the effect of Vojta/DNS on respiratory complications of neuromuscular diseases. Due to the small number of articles in each area of Vojta therapy and DNS separately, based on our inclusion criteria and the similarity of the basic principles of these 2 treatments, we decided to review the effect of both treatments together.

Methods

Search Strategy

The population, intervention, comparison, and outcome method was carried out for the search strategy from inception to December 2021 and followed through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) procedure.30 The databases of PubMed, Embase, ISI Web of Knowledge, ProQuest, and Scopus were searched. First, a literature search for the PubMed database was done and then modified for other databases (Supplementary Appendix). A search strategy was conducted by an investigator (F.F.) and then rechecked by the second investigator (A.D.). Two researchers (.F.F and A.D.) independently reviewed each title, abstract, and full texts after removing duplications by editorial software Endnote (v.20; Clarivate). If the 2 researchers reached different conclusions, the disagreement was reviewed by the third researcher (M.A.), and the final results were formed in consultation. We did not register the protocol of the present systematic review in the PROSPERO (International Prospective Register of Systematic Reviews) database.

Study Types

This review was undertaken on the relationship between DNS training and respiratory complications in neuromuscular diseases. The review included clinical trials, including paired sample, parallel or crossover designs, and unblinded or blinded, without any language limitations. The present review included studies describing individuals who had respiratory complications and problems who were treated with either the DNS or Vojta method and used respiratory variables as dependent variables. Case studies,31 book sections,32, 33, 34 and published papers (as an abstract)35,36 were excluded because of the lack of sufficient evidence-based information and the very high risk of bias in such designs. Also, articles that did not use DNS and Vojta as interventions, did not assess respiratory complications or respiratory variables, or worked on healthy individuals were excluded. The meta-analysis was not performed due to the heterogeneity of data, including the limitation in the number of studies for each special parameter and different statistical methods for analyzing data.37

Methodological Quality Assessment

The Physiotherapy Evidence Database (PEDro) tool was utilized to assess the methodological quality of the included studies.38 The PEDro scale has 11 criteria. They are listed as follows: specified eligibility; random allocation; concealed allocation; group similarity at baseline; participant blinding; assessor blinding; therapist blinding; less than 15% participant dropout; analysis of intent to treat; statistical comparisons between groups; and point data and variability measures. Each article is given a PEDro score, which ranges from 0 to 10.39 Not evaluated in the score but included in the scale criteria to assess external validity is the eligibility criterion. Based on a previous article, a study with a PEDro score ≥6 is considered level 1 evidence (6-8 = good, 9-10 = excellent), and a study with a score ≤5 is considered level 2 evidence (4-5 = acceptable, <4 = poor) for the present study.40

Data Extraction

After selecting the final articles, a researcher (F.F.) extracted the required information from each article and classified them in a table. Then, 2 researchers (A.D. and M.A.) checked the accuracy of the information extracted. The results were tabulated in Table 1 for qualitative comparison of study design, population characteristics (age, sex, clinical features confirming respiratory complication), intervention, comparison group, follow-up time, outcome measured, and results.

Table 1.

Studies’ Characteristics for the Impact of DNS or Vojta on Respiratory Parameters

First Author (Year) Study Design Samples Interventions Comparison Group (Control) Follow-up Time Outcome Measure That Related to Respiratory System Results
Giannantonio (2010)41 Quasi-experimental (1 group before and after clinical trial) 34 preterm newborns with average gestational age of 30.5 wk; birth weight: 1430 g.
2 interventional groups with these characteristics:
Group 1: 21 neonate patients who had hyaline membrane disease, under treatment with nasal CPAP Group 2: 13 neonate patients undergoing oxygen treatment for pneumonia.		 Phase 1 of Vojta method “reflex rolling.” Intervention was provided 3 times per day during the first week of life and thereafter. Internal comparison (within group)
 Not followed up (immediate effect) PtcO2
SatO2
PtcCO2
RR		 Hyaline membrane group changes: increase in
PtcO2 values from 61.7 (12.9) to 73.1 (13.6) after stim and increase in SatO2 values, from 92.2 (3.9) to 94.0 (3.2).
Pneumonia group changes: increase in PtcO2 values from 65.8 (12.9) to 73.6 (15.0) and increase in SatO2 values from 94.7 (3.0) to 97.5 (2.9).
In both groups, PtcO2 and SatO2 were statistically different (P < .001), but no statistically significant difference was found for PtcCO2 or RR.
Kole (2014)42 Single-blinded randomized controlled trial
 60 neonate patients undergoing O2 therapy for RDS and pneumonia with a range of gestational age between 30 and 37 wk.
The demographic data for all the groups did not show any significant difference.		 Group C:
CPT + reflex rolling based on Vojta approach.
20 min/session
at 0, 4, and 8 h, 3 sessions/d, 2 wk.		 Group A:
CPT: vibration on chest.
Group B:
LST + CPT: used both vibration and squeezing technique.
20 min/session at 0, 4, and 8 h, 3 sessions/d, 2 wk.		 Not followed up SpO2
PaO2
SaO2 		Within-group significant improvements (P < .001) in SpO2, PaO2 and SaO2.
Mean differences for reflex rolling group were: SPO2: 7.16, PaO2: 17.57, SO2: 8.18.
No significant difference (P = .480, P = .258) in between-group patients.
Chest x-rays showed re-expansion of the collapsed airways.
Son (2017)11 Quasi-experimental (1 group before and after clinical trial) 15 participants (7 female; mean age: 14.9 y) who had diagnoses of spastic diplegic CP and could follow instructions DNS steps based on the Russell et al43 study consisted of respiratory training at the same time with therapist stimulation in chest zone in 90/90 supine position.
30 min/d, 3 sessions/wk, 4 wk.		 Internal comparison (within group)
 Not followed up Ultrasound
Diaphragm movement (mm)		 Dual respiratory and descending diaphragm movement (9.30 ± 3.31 mm) increased (P < .01) remarkably after DNS exercises.
Ha (2018)12 Open-label randomized controlled trial 10 children with spastic CP; mean age: 4.8 y.
General physiotherapy group (n = 5) and Vojta approach group (n = 5).
Both groups showed no statistical difference in age, height, or body weight.		 Reflex turning (1, 2) and reflex creeping based on Vojta approach.
30 min/session, 3 sessions/wk, 6 wk.		 Trunk-strengthening exercise and gait training.
30 min/session, 3 sessions/wk, 6 wk.		 Not followed up Diaphragm movement during inspiration and expiration Significant changes in diaphragm area in inspiration, unique to experimental group (P < .05, changes: 500.38 ± 884.50).
Diaphragm area changing in expiration was not significant in both groups.
A remarkable difference in changes of inspiration between the 2 groups (P < .05).
Mohammad-Rahimi (2020)16 Quasi-experimental (1 group before and after clinical trial) 26 sedentary male students with poor posture; mean age: 20.6 y; mean BMI: 22.1 kg/m2.
Participants did not attend other courses or physical activities during treatment.		 DNS diaphragmatic breathing exercise according to Kolar approach.
6 sessions/wk, including
3 sessions of supervised exercise and 3 sessions of home-based (unsupervised) exercise per week for 6 wk.
Set 1: 30 s.
Set 2: 90 s.
Set 3: 180 s.		 Internal comparison (within group) Not followed up FVC
FEV1
FEV1/FVC
MVV		 Statistically significant differences between the mean spirometry parameters including MVV, FEV1, FVC, and FEV1/FVC ratio (P < .001).
The changes (%) were:
MVV: 26.2
FEV1: 16.4
FVC: 12.6
FEV1/FVC: 3.2
Yoon (2020)44 Open-label randomized controlled trial 31 patients with sub-acute hemiparetic stroke (17 men, 14 women); average age: 60.4 y.
Average post-stroke onset was 7.22 wk.		 DNS group (n = 16): standardized DNS intervention protocol based on Kolar approach.
DNS focused on descending movement of diaphragm and co-activation with other core muscles.
30 min/d, 3 d/wk, 4 wk.		 NDT group (n = 15): standardized NDT intervention protocol.
NDT focused on selective movements of postural control such as the pelvic tilt.
30 min/d, 3 d/wk, 4 wk.		 Not followed up Paretic diaphragm movement (quiet and deep breathing).
Non-paretic diaphragm movement (quiet and deep breathing).
Asymmetrical ratio of diaphragm movement (quiet and deep breathing).		 Both paretic and non-paretic diaphragm excursions were more significantly increased during DNS compared to NDT (P < .01).
Diaphragm symmetrical ratio significantly decreased after DNS (P < .01).
Effect size analysis for paretic and non-paretic sides of diaphragm movements: 0.27-0.46
Yoon (2020)45 Open-label randomized controlled trial 31 participants with hemiparetic stroke (17 men, 14 women); average age: 60.4 y.
Average post-stroke duration was 7.2 wk.		 DNS group (n = 16): DNS focused on descending movement of diaphragm and co-activation with other core muscles.
30 min/d, 3 d/wk, 4 wk.		 NDT group (n = 15): NDT focused on selective movements of postural control such as the pelvic tilt.
30 min/d, 3 d/wk, 4 wk.		 Not followed up FVC
FEV1
MEP
MIP		 FVC, FEV1, MIP, and MEP were statistically significantly different within each group (P < .01).
Significantly more increase in FVC (P < .01), FEV1, MIP, and MEP in DNS group than in NDT group (P < .05).
Respiratory function analysis showed improvement in DNS group (%) than in NDT group: FVC: 12, FEV1: 13, MIP: 9, MEP: 19.
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CPAP, continuous positive airway pressure; CP, cerebral palsy; CPT, conventional chest physiotherapy; DNS, dynamic neuromuscular stabilization; FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second; LST, lung squeeze technique; MEP, maximum expiratory pressure; MIP, maximum inspiratory pressure; MVV, maximum voluntary ventilation; NDT, neurodevelopmental treatment; PaO2, partial pressure of O2; PtcO2, transcutaneous oxygen tension; PtcCO2, transcutaneous partial pressure of carbon dioxide; RDS, respiratory distress syndrome; RR, respiratory rate; SaO2, arterial oxyhemoglobin saturation; SatO2, oxygen saturation; SpO2, oxygen saturation; stim, stimulation.

Results

Description of Studies

For qualitative analyses, data from 7 articles were included (Fig 1). The list of excluded studies and reasoning are provided in the supplementary data. Based on the PEDro scale, the methodological quality of the articles is presented in Table 2. Four of the selected studies originated from Korea,11,12,44,45 1 from Iran,16 1 from India,42 and 1 from Italy.41 Generally, the sample sizes were various, ranging from 10 to 60 participants, and only 2 papers reported a sample size calculation (power analysis).11,16 The lower age ranges in samples were related to Vojta therapy.12,42,41 One of the following was included within the randomized controlled trials by the comparators: routine management in common with the experimental group42 and conventional physiotherapy.12,44,45

Fig 1.

Fig 1

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Flowchart showing study selection of the systematic review using PRISMA guidelines. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 2.

Quality Assessment

Physiotherapy Evidence Database Scale/Study Giannantonio41 Kole42 Son11 Ha12 Mohammad-Rahimi16 Yoon44 Yoon45
Q1. Eligibility criteria Yes Yes Yes Yes Yes Yes Yes
Q2. Participant randomization into groups No Yes No Yes No Yes Yes
Q3. Concealing allocation No Yes No No No No No
Q4. Groups were homogenous at baseline regarding the most important prognostic factors Yes No Yes Yes Yes Yes Yes
Q5. Participant blinding No No No No No No No
Q6. Therapist blinding No No No No No No No
Q7. Assessor blinding No Yes No No No No No
Q8. At least 1 main outcome was measured from more than 85% of the individuals initially allocated to groups Yes Yes Yes Yes Yes Yes Yes
9. All participants for whom outcome measures were available received the treatment or control condition as allocated. Data for at least 1 main outcome were analyzed by “intention to treat” No Yes Yes Yes Yes Yes Yes
Q10. Findings of between-group statistical comparisons were presented for at least 1 main outcome No Yes No Yes No Yes Yes
Q11. Providing both point measurements and variability measurements for at least 1 main outcome Yes Yes Yes Yes Yes Yes Yes
Total score 3 7 4 6 4 6 6
Quality status Poor Good Acceptable Good Acceptable Good Good
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According to PEDro scale results, the main problems among the studies were related to internal validity because, with the exception of 1 study that used assessor blinding technique,42 the other 6 trials did not use any type of blinding. Only 1 study42 described adequate allocation concealment. Because of specific characteristics of samples and lots of inclusion criteria, all of the studies had low external validity. Three of the studies, because of their single group design, were not scored on the PEDro scale for between-group statistical comparisons.11,16,41 Based on the PEDro scale, 4 of the studies were level 1 evidence,12,42, 44, 45 and the other 3 were level 2 evidence.11,16,41

The studies included 2 interventions that were based on developmental kinesiology. Four studies used DNS,11,16,44,45 and 3 used Vojta therapy.12,42,41 There was some variability in treatment doses in regard to the length of treatment time and frequency. References of interventions from 5 studies were not well identified.11,12,41, 42, 45 Two of the studies had limitations in controlling the implementation of the intervention.11,16 All studies had a lack of adequate period of follow-up and just assessed the immediate or short-term effect.

Outcome Measures

Outcomes related to the respiratory system were included for qualitative analysis. Two studies monitored blood gases but did not explain the validity and reliability of the instruments that they used.42,41 Three studies measured diaphragm movements by an ultrasound imaging system as a kind of core muscle function but did not discuss the effect on respiratory function.11,12,44 Two studies measured respiratory function parameters by spirometry as the main outcome in the studies.16,45 Respiratory function parameters were forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), maximum voluntary ventilation, FEV1/FVC, maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP).16,45 One study measured respiratory rate.41 Five studies mentioned the validity and reliability of measurement instruments.11,12,16,44,45

Summary of Study Results

Effect of Vojta Therapy on Respiratory Parameters: Blood Gases

Among the articles related to Vojta therapy, 2 articles measured the effect of therapy on blood gases, of which 1 had level 1 evidence (quality: good),42 and the other one was level 2 evidence (quality: poor).41 These articles showed a significant increase in oxygen saturation in the before-after intragroup comparison in the Vojta treatment group (P < .001).42,41 However, in 1 of the 2 articles, which had a control group, no significant difference was found between the Vojta plus conventional physiotherapy group and the conventional physiotherapy plus lung squeezing technique or conventional physiotherapy alone groups.42 This article showed a significant increase in arterial oxyhemoglobin saturation directly measured in the Vojta group after the last day of treatment.42 Also, both studies showed significant increases in blood oxygen pressure but in 2 different measurements; one of them was transcutaneous oxygen tension,41 and another one was partial pressure of oxygen.42 In terms of transcutaneous partial pressure of carbon dioxide and respiratory rate, no significant change was found in the Vojta-treated group in either study.42,41

Effect of Vojta Therapy on Respiratory Parameters: Diaphragm Movements During Inspiration and Expiration

Only 1 study (level 1) examined the effect of Vojta therapy on diaphragmatic movements during the inspiration and expiration (quality: good).12 There was a significant difference in diaphragm displacement in the inspiration within the Vojta group in the before-after comparison (P < .05) and also a significant difference between Vojta and control groups (gait training and trunk strengthening exercise) (P < .05). However, the change in diaphragm area during expiration was not significant for either group.12

Effect of DNS on Respiratory Parameters: Diaphragm Movements

Among the articles related to DNS, 2 articles measured the DNS effect on diaphragm movement, and 1 achieved level 1 evidence (quality: good).44 The other achieved level 2 evidence (quality: acceptable).11 Both articles showed that diaphragm movements increased significantly after DNS training (P < .01).11,44 Increase in diaphragm movements in the DNS group was significantly different from the control group (neurodevelopmental treatment) (P < .01), and the symmetry of paretic and non-paretic diaphragm movements after DNS training were also significantly increased (P < .01).44

Effect of DNS on Respiratory Parameters: Respiratory Function Parameters

Among the articles related to DNS, 2 articles measured DNS effect on respiratory function parameters; 1 achieved level 1 evidence (quality: good),45 and the other achieved level 2 evidence (quality: acceptable).16 Both articles showed a significant increase in FVC and FEV1 in the DNS group in pre-test post-test intragroup comparison (P < .01).16,45 Significant increase in FEV1/FVC and maximum voluntary ventilation in pre-test post-test intragroup comparison (P < .01) was also reported.16 Moreover, significant increases in MIP and MEP in pre-test post-test intragroup comparisons in the DNS group (P < .01) were reported. Significant statistical differences between control and DNS groups (neurodevelopmental treatment) in respiratory parameters were also described (P < .05).45

Discussion

Although one of the main components of DNS treatments is training the diaphragm and patient's breathing pattern,46 clinical trials have shown effects of DNS treatment on neurological patients.44,45 However, there is a gap for more studies to examine the effect of these exercises on respiratory patients. According to the results of the PEDro scale, more than half of the articles in this study were level 1 evidence studies (quality: good),12,42, 44, 45 but there was a vacancy of the clinical trial with enough blinding technique, concealment, and long-term effect follow-up in this area.12,42, 44, 45 None of these 7 articles have stated the reasons for choosing their treatment durations.

Oxygen saturation and oxygen blood pressure were improved after Vojta treatment.42,41 Kole and Metgud stated that importance of repeated stimuli sent to the central nervous system ultimately could cause improvement in oxygen saturation, partial pressure of O2, and arterial oxyhemoglobin saturation values.42 However, the study by Giannantonio et al did not provide any analysis of the possible causes of the results.41 Although Kole and Metgud's article had a good level in terms of methodological quality at the PEDro scale, it examined the effect of Vojta in combination with conventional physiotherapy and not Vojta therapy alone. The results indicated no significant difference in the between-group comparison, and this could be due to not considering the isolated effect of Vojta therapy.42 Another article by Ha et al showed a significant improvement in diaphragm inspiration movements in the Vojta group, which did a trunk-strengthening exercise and gait training, compared with a control group.12 The assumption of the Ha et al study was that indirect stimulation of the diaphragm in the Vojta approach might affect the inspirational movement of the diaphragm.12 Therefore, Vojta therapy can be effective in some respiratory parameters (such as oxygen saturation, oxygen blood pressure, and diaphragm inspiration movement). On the other hand, because the samples of 3 studies were infants and children,12,42,41 it was not possible to evaluate pulmonary function tests such as spirometry. Therefore, further studies with the adult sample and evaluation of pulmonary function parameters, such as lung capacity, in the field of Vojta therapy are needed.

Concerning the DNS, 2 articles showed a significant positive effect of DNS on diaphragm movement.11,44 However, more attention has been addressed to the postural role of the diaphragm than to its respiratory role. Son et al mentioned that in the DNS method, inactive core muscles are reactivated reflexively based on neurodevelopmental memory. The diaphragm muscle, which is one of the most important core muscles, after the intervention, in terms of both respiratory role and stabilization, became more active.11 The 2 studies demonstrated the positive impact of DNS on respiratory function, where outcomes were pulmonary function parameters and respiratory volume.16,45 Mohammad-Rahimi et al16 believed that an imbalance between the respiratory muscles and obstruction in the respiratory airways or weakness could alter the values of FEV1 and FVC. So, improvements in these values after DNS training may be desirable of the diaphragm and related to neuromuscular coordination. Incremental changes in FEV1/FVC could be a result of increasing and improving the maximum expiratory pressure from expiratory muscle strength. They may also be related to muscular coordination of respiration and the spinal alignment, as function of the exhalation muscles may be facilitated by a neutral spinal position.16 Yoon et al45 showed that based on a previous study, a possible mechanism for improvement in FEV1, FVC, MEP, and MIP was DNS exercise inducing diaphragmatic movements and activating the transverse abdominis/internal obliques by affecting the intra-abdominal pressure.

Limitations and Future Studies

One limitation of this study was that we did not register it prior to initiating the study. Other limitations included that we used limited search terms and, therefore, may have missed other relevant studies.

We found that the main drawbacks of most articles were internal validity and the lack of sufficient blinding, concealment allocation,11,12,16,44,45,41 and the lack of long-term follow-up.11,12,16,41, 42, 44, 45 Another major problem in these studies was the heterogeneity of the interventions and the failure to provide specific references for the exercises, duration, and frequency of the exercises. In fact, only 2 articles provided traceable references to interventions.16,44 The mentioned problem may confuse readers in choosing intervention parameters. In some cases, how to control the implementation of the intervention was not explained.11,16 Other limitations of the conclusion were the limited number of studies and the allocation of most samples to neurological diseases.11,12,41, 42, 44, 45 Therefore, it is better to measure the effect of this therapeutic approach on respiratory diseases. Despite the small number of studies, an effect of DNS on respiratory parameters was shown, but for definite conclusions, more randomized controlled trials should be performed that have evidence-based references for interventions and investigate the effects of DNS on other groups of patients, especially respiratory patients such as chronic obstructive pulmonary disease. More randomized controlled trials should be performed for interventions and investigate the effects of DNS on other groups of patients, especially those with respiratory disease like chronic obstructive pulmonary disease.

We recommend the following: (1) clinical trials with adequate blinding technique, concealment allocation, and long-term follow-up; (2) studies that specify the type, frequency, and duration of the intervention; and (3) samples that are larger and work on more diverse respiratory diseases.

Conclusion

Although the studies were weak in internal and external validity, this review demonstrated that Vojta therapy and DNS might influence respiratory parameters such as blood gases, diaphragm movements, and functional respiratory parameters in neuromuscular disease.

Footnotes

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.jcm.2023.04.002.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): F.F.N., M.A.

Design (planned the methods to generate the results): F.F.N., M.A.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): A.D.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): F.F.N., A.D.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): M.A., A.D.

Literature search (performed the literature search): F.F.N., M.A.

Writing (responsible for writing a substantive part of the manuscript): F.F.N., J.H.S.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): J.H.S.

Practical Applications.

  • •

    We reviewed the literature for effects of dynamic neuromuscular stabilization/Vojta on respiratory complications of neuromuscular diseases.

  • •

    Seven papers were chosen for the final assessment.

  • •

    Our findings suggest that Vojta therapy and dynamic neuromuscular stabilization may influence respiratory parameters.

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Appendix. Supplementary materials

mmc1.docx (23.6KB, docx)

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