Abstract
Introduction
Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional spinal deformity affecting young adults aged 10 years and above. Severity of scoliosis usually increase with aged, and hence early detection of scoliosis is crucial for conservative treatment to avoid surgery and preserving health-related quality of life. This study aim to evaluate the effectiveness of Dynamic Neuromuscular Stabilization (DNS) approach in gait, abdominal core stability and lumbopelvic functional stability in individual with AIS.
Methods
24 targeted AIS participants will be randomly allocated into two group for 12-week interventions, three times per week including 2 non-supervised sessions. Outcome measure will be assessed using measuring tape, stabilizer pressure biofeedback, wearable sensor BTS G-walk® with treadmill. Paired t-test will be used to assess within groups and independent t-test will be used to assess the efficacy of intervention between groups.
Results
This study protocol hypothesizes that DNS approach will have a more significant impact on improving the gait, core stability and lumbopelvic stability among AIS.
Conclusion
DNS approach can be effectively implemented in clinical settings to enhance the physical and functional mobility AIS patients.
Keywords: Adolescent idiopathic scoliosis, Dynamic neuromuscular stabilization, Stability
Graphical abstract
Specifications table
| Subject area | Neuroscience |
| More specific subject area | Physiotherapy / Rehabilitation |
| Name of your protocol | The Effects of Dynamic Neuromuscular Stabilization (DNS) approach in Gait, Lumbopelvic Functional Stability and Abdominal Core Strength among Adolescent Idiopathic Scoliosis (AIS): A randomized controlled trial study protocol |
| Reagents/tools | -BTS G-Walk©R (G-Sensor 2) -The Stabilizer Pressure Biofeedback™ -h/p/cosmos® h/p/cosmos instrumented treadmill |
| Experimental design | A single blind randomized controlled trial will be used as the study design to identify the effectiveness of the DNS in addition to core stabilization exercises on scoliosis individuals |
| Trial registration | Australian New Zealand Clinical Trial Registry (ACTRN12624000507583) |
| Ethics | The study has approved by the Universiti Tunku Abdul Rahman (UTAR) Scientific and Ethical Review Committee (U/SERC/56(B)-29/2024). Participants with scoliosis will be selected from UTAR students, and those who volunteer will be provide informed consent before intervention begin. |
| Value of the Protocol | Scoliosis is a musculoskeletal condition that affects the general population globally, an earlier detection of scoliosis with a proper treatment can avoid the progression of the condition, therefore this study aim to establish a DNS approach in addition to core stability exercise in scoliosis population. Including DNS in the study allows for the exploration of its potential benefits in this context, also contributing to the growing body of evidence in scoliosis management. |
Background
Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional spinal deformity defined by a lateral curvature of the spine with a Cobb angle ≥10°, typically emerging between the ages of 10 and 18 years, and occurring without a known etiology [1]. It affects approximately 2–4 % of the adolescent population [2]. As the curvature can worsen with growth and age, early detection is vital to enable conservative interventions, potentially preventing the need for surgery and helping to preserve health-related quality of life [3]. Management strategies include observation, bracing, surgery, and physiotherapy-based treatments such as Physiotherapeutic Scoliosis-Specific Exercises (PSSE) [4].
The principles of most physiotherapeutic scoliosis-specific exercises (PSSE) are based on individualised auto-correction and exercise contraction techniques, often combined with stabilising exercises such as neuromotor control, proprioceptive training, and balance exercises depending on the specific PSSE school [4]. These exercises are typically incorporated into activities of daily living and practised at home under supervision [5]. Corrective exercise-based therapy is probably better than other options to improve the pain, self-perceived image and mental health quality of life dimensions [6]. Untreated scoliosis may consequence to further progression of spinal deformity and impact on the physical flexibility, strength and can have a negative impact on their quality of life, as they may have to wear braces for long periods or undergo surgery, which can be invasive and have significant risks [7]. Therefore, it is crucial for healthcare providers to carefully consider each patient's individual needs and circumstances when determining the appropriate course of treatment for AIS. They should also regularly monitor the effectiveness of the treatment and make adjustments as necessary to ensure the best possible outcome for the patient while minimising the impact on their quality of life [4,8].
However, the evidence for corrective exercise based conservative management of Adolescent Idiopathic Scoliosis is not strong because the mechanism that leads to the improvement in such outcome measure is not known accurately and also due to the poor methodological quality [9], indicating the need for study protocol. Although Physiotherapeutic Scoliosis-Specific Exercises (PSSEs) have shown positive outcomes in managing AIS, particularly in terms of improving posture, reducing curve progression, and enhancing quality of life, there remains variability in their effectiveness especially in consistently targeting neuromuscular control and deep core stabilizers such as the transversus abdominis and diaphragm [3,4].
Dynamic Neuromuscular Stabilization (DNS), grounded in the principles of developmental kinesiology, presents a complementary approach by promoting reflexive activation of deep stabilizing muscles, including the diaphragm, transversus abdominis, multifidus, and pelvic floor. This method emphasizes optimal joint centration, stabilization, and retraining of physiological motor patterns based on developmental postures and movement sequences [10]. DNS has been associated with improved postural alignment, balance, and trunk control in populations with neurological disorders and musculoskeletal dysfunctions [11,12]. However, clinical evidence specifically supporting DNS in the AIS population remains limited, highlighting the need for rigorous, controlled studies to establish its effectiveness in this context.
Study goal and objective
The primary goal of this study is to evaluate the effectiveness of integrating Dynamic Neuromuscular Stabilization (DNS) into a physiotherapy protocol for individuals with Adolescent Idiopathic Scoliosis (AIS) on enhancing gait patterns, abdominal core strength, and lumbopelvic functional stability. Specifically, this randomized controlled trial aims to determine whether a DNS-based intervention produces significant improvements in spatiotemporal gait parameters compared to conventional core stabilization exercises. Secondary objectives include assessing the impact of DNS on lumbopelvic stability using the Single Leg Squat and Stabilizer Pressure Biofeedback methods, evaluating changes in core muscle activation, and examining the feasibility, safety, and participant adherence to the 12-week intervention protocol. By addressing gaps in conservative management of AIS, this study contributes to evidence-based practice in physiotherapy and rehabilitation.
Methods
A single blind randomized controlled trial will be used as the study design to identify the effectiveness of the DNS in addition to core stabilization exercises on scoliosis individuals. This study will be conducted at Universiti Tunku Abdul Rahman Physiotherapy centre, Malaysia. A pilot study will be conducted to identify the feasibility of the DNS added physiotherapy protocol before the main study commences.
The study participants will be selected from Universiti Tunku Abdul Rahman Physiotherapy centre using a simple random sampling method from the participants registry maintained by the scoliosis screening team. Males and females, aged between 18 and 25 years old, with IS (the perception of IS will be screen by trained physiotherapist), who is not using any brace and voluntary participation will be included in the study. Participant will be excluded if they have history of surgical correction of the spine [13], currently receiving other exercise for scoliosis [5] and taking medication on regular basis [14]. A participation screening form with five questions which were related to the inclusion and exclusion criteria had been provided to the participants to further ensure the eligibility of the participants to participate in this study.
The experimental pilot study involved 24 participants which is considered adequate to assess the feasibility of a pilot intervention [15]. The sample size of 24 will be obtained using G*Power (Version 3.1.9.4) and based on repeated measure analysis of variance (ANOVA) within and between interactions test with used a medium effect size of 0.30 [16], significance level P < 0.05 and study power 80 %. Considering the drop-out rate of 15 % and aiming to increase the statistical power of the results, a total of 28 participants (14 for each group) will be recruited into the study.
The participants allocation will be conducted by an independent researcher using a sealed envelopes with unique identifiers. Sequentially, unique identifiers within the sealed envelopes will be used to assign the participants into either an experimental group (DNS approach) or a control (core stabilization exercises). In order to minimize potential bias, the study recruited a single-blinded design, who is unaware of the group allocation, ensuring that the outcome measurements were conducted impartially.
Outcome measures
The primary outcome will be the G-walk while the participant walking on the treadmill for 2 min. The spatiotemporal parameters of gait will be measured using the wearable Sensor BTS G-Walk®. The BTS G-Walk©R (G-Sensor 2) is a portable, wireless, inertial system with wearable sensors. The instrument will be able to assess the walking pattern (i.e., speed, cadence, stride length, stride duration, single support, double support, swing duration, stance duration) and pelvic angles (i.e., tilt, obliquity and rotation). G-Walk sensor will be attached with a semi-elastic belt to the L5 spinal segment of the subject while walking on treadmill for 2 min [17].
Secondary outcome will be the Stabilizer Pressure Biofeedback, the ground reaction forces and torques and Single Leg Squat. Lumbopelvic stability will be assessed by The Stabilizer Pressure Biofeedback (The Stabilizer Pressure Biofeedback™). Prone abdominal drawing in test using air-filled pressure biofeedback Device is centered with distal edge of the pad in line with the anterior superior iliac spine, inflated to 70 mm Hg. Motor contraction test should attempt to draw the abdomen off the pad and hold for 10 s. Note the pressure change. A successful test reduces the pressure by 6 to 10 mm Hg. A drop of <2 mm Hg, no change in pressure, or an increase in pressure is considered a poor result.
Hook-lying abdominal drawing in test with air-filled pressure biofeedback; supine biofeedback with varied levels of leg loading. Test is performed by inflating the cuff to approximately 40 mm Hg and positioning the patient in hook-lying position. Begin with low-load tests of short lever leg (bent knee) loading and progress difficulty, using larger load tests (unsupported and extended legs). The patient is asked to precontract the transversus abdominis with the drawing in maneuver, then hold the pressure reading steady during various maneuvers including the single-leg slide with contralateral support, single-leg slide without contralateral support, and unsupported leg slide with contralateral support [18].
The ground reaction forces and torques in three directions will be measured using a treadmill (h/p/cosmos® h/p/cosmos instrumented treadmill). Each participant required to walk barefoot on the treadmill with its surface placed at 0 % (level) The gait protocol included a 2-min walk for familiarization in the predetermined slope/speed and another 2-min walk for the actual test, the data of which were used in the statistical analysis. A 2-min break was given between the familiarization period and the actual test [19].
The Lumbopelvic Stability will be assessed by Single Leg Squat. The clinical rating criteria assess 5 main components to categorize an individual’s lumbopelvic stability. These components include the overall impression, weight transfer, lumbar and pelvic alignment, leg alignment and foot alignment.
The clinical evaluation will depend on whether the participant exhibits more consistently good performance qualities or predominantly poor performance qualities. The participant will be evaluated as having “neither good nor poor stability” if he or she does not clearly fall into any of these 2 categories [20]. The interrater reliability for the rating criteria of Single Leg Squat has been reported with a weighted kappa of 0.73.
Procedure and stages
There will be two group of participants in this study. Both exercises program will be divided into two phases: the first spans the initial three weeks of the program, while the second encompasses the concluding three weeks of the program. Both groups undergo the given intervention for 3 times per week (1 supervised and 2 non-supervised) for 12 weeks, for a total duration of 1 h per session. Monitoring of the participants will be done weekly during the supervised session to ensure adherence to the non-supervised in-home sessions and to assess the occurrence of any adverse effect.
The experimental group will receive DNS session 45 min in addition to core stability engagement and there will be interval rest. A 10-minute warm-up and cool-down will be provided before and after the whole session. Initially, participants received verbal cues, manual guidance, and visual feedback throughout the intervention to facilitate the learning process of adjusting the alignment of the pelvis, spine, ribcage, scapula, and abdominal wall shape in different positions.
The DNS exercises are as follows: ①Deep breathing in sitting, ②Deep breathing in supine with hip and knee at 90–90° position, ③Low quadruped, ④5-month side-lying, ⑤Oblique sitting, ⑥Tripod position, ⑦Bear position and, ⑧Squat position.
Exercise intensity based on developmental positions automatically proper activation stereotype of stabilization and breathing of natural postural-locomotion patterns as defined by developmental kinesiology. The following exercise will be progress if only the participants able to achieve DNS exercises concept of at the optimum joint centration and abdominal engagement [11].
The control group will receive exercise only focusing on core stability. Same as experimental group, the control group receive 45 min core stability exercises session and there will be interval rest. A 10-minute warm-up and cool-down will be provided before and after the whole session. Participants received verbal cues, manual guidance, and visual feedback throughout the intervention to facilitate abdominal muscle by holding the abdominal pressure in exercises position.
The core stabilization exercise position are as following: ①Isolated transverse abdominis training., ②Isolated lumbar multifidus training, ③Co-contraction of transverse abdominis and lumbar multifidus in lying position, ④Co-contraction of transverse abdominis and lumbar multifidus in a quadruped position, ⑤Four-point multifidus exercise, ⑥Full front plank, ⑦Full front plank with abduction of lower extremity, ⑧Half-side plank with the knee flexed, ⑨Tall kneeling lift with a medicine ball and, ⑩Half kneeling chop with resistance band.
Participants will be assessed at baseline and at week 13 of interventions by a therapist who is blinded to the group allocation and trained to conduct the standardized tests. The recorded baseline assessment data will not be accessible to the blinded assessor at post-trial assessment in view to avoid assessment bias.
The unique number of each participant will be recorded and stored in Excel sheet before tabulating into results. The data of each participant is private and confidential. Only relevant researchers are allowed to access the data, but researchers are not allowed to share the info with third parties.
Statistical methods
All data will be entered into IBM Statistical Packages for Social Sciences (SPSS) version 25.0. Socio-demography and health profile of the participants will be analysed descriptively and reported as frequencies (percentages) and mean (standard deviation) or median (inter-quartile range). The effects of the interventions will be analysed using mixed model ANOVA and reported as main time, group, and time–group interaction effects. The level of significance will be set as P < 0.05 for all results.
Pilot study
A pilot study was conducted with 15 participants in each of two groups: a control group and an intervention group. The study lasted 4 weeks, using pre- and post-tests to measure lumbopelvic stability. The control group received core stabilisation exercises (CSE) twice a week, while the intervention group received both CSE and Dynamic Neuromuscular Stabilisation (DNS) exercises with diaphragmatic breathing. The intervention group’s sessions were more extended, including additional DNS exercises.
The sample size of 15 participants per group was calculated using G*Power, based on a medium effect size, alpha of 0.05, and 80 % power. Both groups also followed a home exercise program 3 days a week. Pre- and post-test results were compared to assess improvements in stability, measured through single-leg squat (SLS) and dip tests.
During the 4-week intervention, the control group (7 participants) received two 60-minute CSE sessions per week. Each session included a 10-minute warm-up, followed by 30 min of core exercises targeting deep trunk muscles, such as the transversus abdominis and lumbar multifidus, as well as more superficial muscles, including the rectus abdominis and obliques. These exercises aimed to stabilise the pelvis and spine. Phase 1 (weeks 1–2) focused on exercises like transversus abdominis activation, lumbar multifidus training, pelvic bridging, and four-point multifidus exercises. Phase 2 (weeks 3–4) progressed to more challenging exercises, including the full front plank, side plank, and tall kneeling lifts. Each exercise was held for 10–12 s, with three sets of 10 repetitions.
The intervention group (8 participants) followed the same CSE program but also incorporated Dynamic Neuromuscular Stabilisation (DNS) exercises with diaphragmatic breathing. DNS exercises, like deep breathing in crook lying, low quadruped, and tripod positions, were combined with core stabilisation exercises targeting the transversus abdominis, lumbar multifidus, rectus abdominis, and obliques. Phase 2 (weeks 3–4) introduced more advanced DNS positions, including bear and squat positions, which enhanced both core strength and motor control. Home exercises were prescribed 3 times a week to reinforce the training.
Result
The dependent t-test revealed improvements within both groups, with p-values <0.05, indicating that both the control and intervention groups experienced significant gains in lumbopelvic stability following the 4-week intervention. The mean difference in pre- and post-test scores confirmed improvement in both groups. The independent t-test also revealed significant differences between groups, with p-values <0.05. The intervention group (DNS + CSE) also demonstrated improvement in stability compared to the control group (CSE only), as indicated by the mean difference in post-test scores.
Discussion
Adolescent Idiopathic Scoliosis presents a significant challenge in musculoskeletal rehabilitation due to its complex three-dimensional spinal curvature and the risk of progression into adulthood. While traditional conservative treatments such as Physiotherapeutic Scoliosis-Specific Exercises (PSSE) have shown varying levels of success, the lack of consistent targeting of neuromuscular control and deep core muscle activation underscores the need for innovative approaches [3,4].
The proposed study introduces a Dynamic Neuromuscular Stabilization (DNS)-based physiotherapy protocol aimed at enhancing gait efficiency, abdominal core strength, and lumbopelvic stability in individuals with AIS. DNS differs from traditional core exercises by focusing on reflexive activation of deep stabilizers (e.g., diaphragm, transversus abdominis, pelvic floor) through motor patterns rooted in developmental kinesiology [10,21]. This approach may promote more natural postural and movement control, which is critical in the management of spinal deformities.
While AIS is typically diagnosed between the ages of 10 and 18, structural and functional impairments can persist into early adulthood, especially in individuals who were not braced or surgically treated. Therefore, the inclusion of participants aged 18–25 years represents a clinically relevant subgroup—young adults with residual AIS who continue to experience symptoms and may benefit from targeted physiotherapy interventions [2,13]. The use of objective and reliable outcome measures including spatiotemporal gait parameters captured via BTS G-Walk®, Stabilizer Pressure Biofeedback, and Single Leg Squat tests strengthens the methodological rigor and ensures quantifiable evaluation of neuromuscular function and postural control [17,22]. If proven effective, this protocol could establish DNS as a cost-effective, non-invasive, and scalable intervention in conservative scoliosis management. It may also lay the groundwork for future large-scale trials and contribute meaningfully to the current body of evidence in physiotherapy for scoliosis.
Limitations
None.
CRediT authorship contribution statement
Deepak Thazhakkattu Vasu: Conceptualization, Methodology, Supervision, Funding acquisition, Validation, Visualization, Writing – review & editing. Kiruthika Selvakumar: Conceptualization, Methodology, Supervision, Funding acquisition, Validation, Visualization, Writing – review & editing. Siti Hazirah Binti Samsuri: Methodology, Supervision, Funding acquisition, Validation, Visualization. Roberta Ong Yi Li: Data curation, Formal analysis, Investigation, Project administration, Writing – original draft. Liow Kai Jun: Data curation, Formal analysis, Investigation, Project administration, Writing – original draft. Mark Isaac Fernandez: Data curation, Formal analysis, Investigation, Project administration, Writing – original draft. Ng Jia Yuet: Data curation, Formal analysis, Investigation, Project administration, Writing – original draft. Imtiyaz Ali Mir: Writing – review & editing. Chan Siow Cheng: Methodology, Resources, Software. Tan Yin Qing: Methodology, Resources, Software.
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
This study is supported by UTAR research fund (UTARRF), grant number IPSR/RMC/UTARRF/2023-C/S03
Footnotes
Related research article
Ong, Roberta Yi Li BPTa; Thazhakkattu Vasu, Deepak PhDa,*; Jun, Liow Kai BPTa; Yuet, Ng Jia BPTa; Isaac Fernandez, Mark BPTa; Selvakumar, Kiruthika MPTa; Ming Zi Goh, Joyce BPTa. Effectiveness of dynamic neuromuscular stabilization approach in lumbopelvic stability and gait parameters in individuals with idiopathic scoliosis: A randomized controlled trial. Medicine 104(12):p e41905, March 21, 2025. | DOI: 10.1097/MD.0000000000041905
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.mex.2025.103529.
Appendix. Supplementary materials
Data availability
Data will be made available on request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data will be made available on request.