Supplementary Table.
Study characteristics.
| Author, Year and location | Study Design | Sample size | Population | Intervention | Outcome Measures | Results |
|---|---|---|---|---|---|---|
| Changes in neural (cortical and subcortical) sensorimotor control mechanisms in response to DNS | ||||||
| D.H. Kim et al., 2016[30] South Korea | Exp. study design. | Single case | 25 years old female with non-symptomatic core instability | Participant was trained for 4 exercise tasks with real time ultrasound guidance X 30 minutes/each day X 3 consecutive days before the experimental fMRI* for Identification of activated neural substrates during 4 exercise tasks: 1. Conscious ADIM (Abdominal Drawing -In Maneuver) 2. Conscious ADIM with hip flexion and extension (ADIM-HFE) 3. Subconscious hip flexion & extension (HFE) 4. Subconscious DNS-based HFE With a period of rest in between them | 3T Functional MRI (fMRI) BOLD (Blood Oxygen-Level Dependent) signal recording | Subconscious HFE and DNS-based HFE activated subcortical motor control network whereas “voluntary” conscious ADIM and ADIM- HFE motor tasks utilized cortical motor network |
| D.H. Kim et al., 2018[29] South Korea | Non randomized Experimental study | (n=5) | Non-symptomatic adults with core instability | Investigated the comparative effects of conscious (ADIM) and subconscious (DNS) core stabilization exercises on cortical changes in adults with core instability. Participant practiced the two different core exercises for 30 minutes/day for three consecutive days with real time ultrasound feedback | fMRI blood BOLD analysis | Subcortical and cortical activation pattern during the DNS exercises, whereas the cortical motor networks were activated during ADIM performance |
| Changes in Core Stability Variables | ||||||
| J. Novak et al., 2021[41] Czech Republic | Cross sectional | (n=31) Sample size was calculated. | Asymptomatic participants 15 male, 16 females mean age = 26.77 ± 3.01 yrs. | Evaluated the relationship between intra-abdominal pressure measured as anorectal pressure with objective abdominal wall tension recorded by mechanical-pneumatic-electronic sensors (DNS Brace) during five different standing postural-respiratory situations: resting breathing, Valsalva maneuver, Müller’s maneuver, instructed (DNS) breathing, loaded breathing when holding a dumbbell. | Anorectal manometry, sensors attached to a trunk brace (DNS Brace) | There is a strong correlation between intra-abdominal pressure and abdominal wall tension in all positional situations. |
| Madle et al., 2022[40] Czech Republic | Cross sectional | (n=30) Sample size was calculated. | Healthy individuals. 15 male, 15 females mean age = 22.73 ± 1.91 yrs. | Investigated the difference in abdominal wall tension (AWT) with respect to 5 basic DNS postures such as sitting, supine with legs raised, squat, bear and hang position. First, spontaneous AWT was measured, then again after manual and verbal instructions following DNS principles. | Sensor based Ohm belt device to record the abdominal wall activation | AWT increased significantly with DNS based instructions in comparison to spontaneous activation. Significant increases in activity were noted in the supine leg raise position and in the bear position compared to spontaneous activation in sitting. There were no statistically significant differences between women and men in any position. |
| Yoon H.S. & You J.S.H. 2017[42] Korea | Cross sectional design | (n=10) | First-ever stroke Mean months: 2.80 ± 0.83 Healthy: 5 males; 5 females Stroke: 2 females; 3male Mean Age: 50.8 ± 6.8 yrs. | Observed the effects of DNS and NDT* exercises in 5 healthy and 5 hemiparetic stroke individuals. All participants practiced both NDT* and DNS core stabilization exercise for 20 minutes per each session over 3 consecutive sessions before the post measurement | Core stability by Pressure biofeedback unit (PBU), muscular activity (TrA*, IQ*, EO* & RA*) and thickness (TrA & IO) with surface EMG* and ultrasound imaging respectively | DNS exercises had superior results compared to NDT both for healthy and hemiparetic stroke patients in all outcomes of interest. |
| Son et al., 2017[37] South Korea | A single-arm, Pretest-posttest clinical trial. | (n=15) | Spastic diplegic CP participant (7 females, 8 males) mean age (± SD) = 14.9 ± 3.4 yrs. | DNS intervention in the form of progressive lower extremity movement in baby rock position along with chest zone manual stimulation & real time US & EMG Biofeedback for accurate activation of diaphragm -abdominal core muscle chain. Time: 30 minutes/day, Frequency: 3 days a week, Duration: 4 weeks. | (GMFM-88*), ultrasound, & EMG were used to measure Gross motor function, diaphragm caudal movement and core muscle activity (EO, IO/TrA) respectively. | GMFM scores of standing, walking, and jumping domains; diaphragm descending movement and activation of the internal oblique and transversus abdominals were remarkably increased after the intervention |
| Kim S.K. et al., 2017[31] Korea | RCT | (n=19) Sample size was calculated | 6 months post- stroke individuals Mean age: ≥59years ADIM M/F: 6/4. DBM M/F. :7/2 | Compared the effects of the ADIM (n=10) and the DBM (Diaphragmatic Breathing Maneuver (n=9) on abdominal muscle thickness, trunk control, &balance in patients with chronic stroke. Protocol: three times per week for 4 weeks. | Ultrasonic imaging for TrA, IO & EO thickness, Trunk Impairment Scale (TIS) & Berg Balance Scale (BBS) | Both groups improved compared to baseline, however TIS score was sig. better in DBM in comparison to ADIM |
| Lee et al., 2018[32] South Korea | RCT | (n=28) | Chronic hemiparetic stroke patients 17 females; 11 males, Mean Age ≥57years | Evaluated the comparative effectiveness of DNS exercises and conventional CSE chronic hemiparetic stroke patients. Patients of both groups underwent respective exercises for 30 minutes/day, 5 days a week for 4 weeks. | APA (Anticipatory Postural Adjustment) time with EMG during rapid shoulder flexion, TIS*, BBS* and Falls Efficacy Scale (FES) | APA times for core muscles were shorter following DNS exercises in comparison with conventional exercises. Both groups improved in BBS, TIS scores and FES when compared with baseline scores |
| Yoon H.S. et al., 2020[33] Republic of Korea | RCT | (n=31) | Sub-acute stroke individuals (17 males, 14 females; mean age: 60.4 ± 14.58 yrs. Post-stroke onset, 7.22 ± 2.21 wks. | Evaluated comparative efficacy of DNS (n=16) & conventional NDT (n=15) exercises Both groups had respective treatment • Time: 30 minutes/day, • Frequency: 3sessions/ week • Duration: 4 weeks |
Abdominal muscle thickness and Diaphragm movement; postural control and gait ability were measured using Ultrasound imaging, TIS, BBS, FAC (Functional Ambulatory Category) respectively. | Superior effects of DNS over NDT were noted for all outcome measures except the TIS |
| Kuo et al., 2021[38] Taiwan | Cross-sectional | (n=30) Sample size was calculated | Non-specific low back pain individuals. Mean age: 26.7 ± 7.0 yrs. | Compared the immediate effects on lumbar stabilization muscles during the performance of DNS-based Abdominal Expansion (AE), Abdominal drawing-in (AD) and natural breathing (NB) strategies in three different body positions. | The muscle thickness and activity of the lumbar multifidus and lateral abdominal wall muscles by Ultrasonography and surface electromyography (EMG) respectively. | As AE and AD strategies both produced similar and higher EMG activity in lumbar stabilizers in comparison to NB strategy, it was suggested that AE could be an alternative strategy in improving the lumbar spine stability by facilitating the co-contraction of lumbar spine stabilizers in individuals with NSCLBP |
| Park et al., 2021[34] Republic of Korea | RCT (single-blind) | (n=36) | Healthy adults (8 females) Mean age: 24.16 ± 3.63 yrs. | Compared the effects of the DNS breathing technique and the abdominal bracing (AB) technique on upper trapezius (UT), anterior deltoid (AD), pectoralis major (PM), bilateral TrA, IO, and EO motor control in healthy participants during horizontal shoulder adduction. The DNS and AB core stabilization techniques were practiced for 30 min per day, five times a week for two weeks. | TrA/IO, EO, PM, UT, and AD muscle amplitudes during core stabilization was measured using Surface EMG. | DNS promoted significantly higher left and right IO/TrA activation while reducing UT, AD, and PM activation than during AB. DNS was found to effectively promote deep muscle activation and superficial muscle deactivation. Hence, promotes core chain dynamic stabilization and movement control. |
| Jung et al., 2021[35] Korea | RCT (Single blind) | n=14) | Acute COPD (6 women) Mean age, 69.4 ± 13.34 years | Examined the comparative effects of diaphragmatic breathing and respiratory and core-postural stabilization (DNS breathing) on diaphragmatic movement and pulmonary function test (PFT). Total 20 sessions with 30 minutes of session were carried out | Fluoroscopy radiographic measurement was done to measure diaphragmatic movement. mMRC (Modified Medical Research Council) measured dyspnea. Spirometry volume measurement was done for pulmonary function | Respiratory and core-postural stabilization was more effective in increasing diaphragmatic movements than abdominal breathing P. PFT revealed more significant differences in the forced vital capacity (FVC (%) predicted with DNS breathing. mMRC score was significantly reduced within the DSN breathing group |
| Lee J. et al., 2022[39] Korea | Cross-sectional design | (n=41) | Healthy Participants with core instability 7 females; | Compared the differential effects of ADIM, AB (Abdominal Bracing), and DNS in healthy individuals with core instability. Subjects performed ADIM, AB & DNS in random order | Simi Aktisys, PBU*, Ultrasound & sEMG were used to measure diaphragm movement, abdominal muscle thickness difference, and external abdominal oblique (EO) EMG amplitude. | Diaphragm descending movt. & Thickness of TrA & IO increased significantly with DNS compared to other two whereas IO amplitude was sig higher with AB than other two. |
| Sharma et al., 2023[36] India | RCT (single-blind) pilot study | (n=24) | Women aged 18-40 years with mild to moderate stress urinary incontinence (SUI). | Participants were divided into DNS (n=12) and Kegel exercise groups(n=12). Duration: 12 weeks | Perineometer, EMG and the Urogenital Distress Inventory-6 (UDI-6) were used to measure pelvic floor muscle strength, EMG (average, peak & maximum voluntary contraction) and quality of life respectively. | Both groups improved significantly in all outcome measures from baseline to end of 12 weeks. However, DNS group had significant improvement in all measures compared to Kegel exercises group. |
| DNS efficacy in non-specific chronic low back pain individuals | ||||||
| Ghavipanje V. et al., 2022[43] Iran | RCT (Single-blind: Assessor). | (n=40) Sample size was calculated | Obese postpartum primiparous women with LBP Age Range: 24-34 years BMI: >30 kg/m2 | Investigated the effects of 6 weeks of DNS training (n = 20) or General Exercise (GE, n = 20): • Time (min/d):45-60 min • Frequency (x/wk): 6 (3 supervised and 3 home based) • Duration(wk):6 weeks |
NPRS*, MODQ*, Fear-Avoidance Beliefs Questionnaire (FABQ), Breath Hold Time & Respiratory rate (RR) were used to measure pain intensity, disability, fear avoidance belief and respiratory functions respectively. | The rate of improvement for all outcome measures were significantly higher in the DNS group compared to the GE group. |
| Najafi Ghagholestani et al., 2022[45] Iran | RCT Single blind: (Assessor) | (n=36) | NSCLBP Gender not specified Age range :30-50 years Mean BMI<30 kg/m2 | Compared the effects of 6 weeks DNS (n = 15), Aquatic Exercises (AEs) (n = 15), and No intervention Control (n = 15) among NSCLBP individuals DNS & AE group protocol: • Time (min/d):50 min • Frequency (x/wk): 3 • Duration(wk): 6 weeks * Data was finally analyzed for 12 subjects in each group after 6 weeks subsequent to drop out |
VAS*, ODI*, Pressure biofeedback (during Lumbopelvic control tests performance) and spinal mouse device were used to measure pain intensity, disability, lumbopelvic control and spinal posture respectively. | Both DNS & AE groups showed a significant improvement in pain intensity, disability, and Lumbopelvic control. No changes across groups, nevertheless, were found |
| Mousavi et al; 2022[46] Iran | quasi-experimental study (pretest-posttest design) | (n=20) | Men with chronic non-specific low back pain Age range : 21-62 years | Investigated impacts of (DNS) and core stability (CS) exercises in men with non-specific chronic low back pain. • Time (min/d):45-60min • Frequency (x/wk): 3days/wk • Duration (wk):8 wks |
VAS, Flexibility Box, Y balance test, half sit up & SF-36*, (Persian version) were used to measure pain, hamstring flexibility, balance, abdominal muscle strength, and quality of life (QoL) | Both interventions led to significant improvement in pain, abdominal strength and static balance. However, hamstring flexibility and quality of life were improved specifically within CS and DNS respectively. No statistical difference between both training methods |
| Kararti et al., 2023[44] Turkey | RCT (Single blind: Assessor) | (n=72) | Old adult males having chronic non- specific low back pain with age group above 65 years | Examined the comparative effects of DNS and conventional control interventions in older adults with NSCLBP (36 subjects in each group). • Time (min/d):30-40 min • Frequency (x/wk): 3days/wk • Duration(wk): 6 wks Control group had TENS*, US* and strengthening and stretching exercises whereas experimental group had control along as well as DNS exercises |
FMS, 6- minute walk test (6MWT), TUG* & WHOQOL-OLD* module were used to measure Quality of movement, Exercise capacity, Functional balance & QoL respectively | DNS group had significant effects on total FMS* scoring and Functional balance. Though both groups had similar improvements in other measures. |
*
Abbreviations: fMRI: Functional Magnetic Resonance Imaging; NDT: Neurodevelopment Technique; TrA: Transversus Abdominis; IQ: Internal Oblique; EO: External Oblique; RA: Rectus Abdominis; GGFM: Gross Motor Function Measure; TUG: Timed up and Go test; FMS: Functional Movement Scale; VAS: Visual analogue score; TENS: Transcutaneous electrical nerve stimulation; US :Ultrasound; MODQ: Modified Oswestry disability questionnaire; ODI: Oswestry Disability Index; NPRS: Numeric Pain Rating Score; sEMG: surface Electromyography; SF-36: Short Form-36.