Exercise Guidelines for Enhancing Mobility and Stability in Individuals with Severe Obesity

Abstract

Severe obesity is frequently accompanied by restricted joint mobility and chronic pain, both of which compromise quality of life and functional independence. Despite well-documented benefits of exercise in managing severe obesity, adherence remains low due to perceived physical limitations and discomfort. This study identified primary physical limitations faced by individuals with severe obesity and proposed evidence-based, accessible exercise modalities tailored to their needs. A systematic literature search was conducted using Scopus, PubMed, Web of Science, and Google Scholar. Search terms included combinations of ‘obese,’ ‘severe obesity,’ ‘exercise,’ ‘training,’ ‘stability,’ ‘mobility,’ and ‘pain.’ Ten studies examining effects of exercise interventions on mobility, stability, and pain in severely obese individuals were selected based on predefined inclusion criteria. Findings consistently indicated that low-impact exercise modalities such as yoga-based stretching, core training, and stabilization exercises using balance pads, chairs, and gym balls significantly improve mobility, enhance postural stability, and reduce musculoskeletal pain over intervention periods as short as 4 weeks. Interventions incorporating core muscle stretching and instability-based training were particularly effective in improving functional outcomes and balance control. This review highlights prevalent musculoskeletal and neuromuscular impairments associated with severe obesity and underscores the functional role of core musculature in mitigating these limitations. Based on synthesized evidence, we propose a set of low-complexity, high-accessibility exercise strategies feasible in both clinical and home-based settings. These recommendations provide a practical framework for improving physical function and reducing pain among individuals with severe obesity, supporting more sustainable engagement in physical activity.

INTRODUCTION

Obesity is a persistent and escalating global public health challenge. Over the past three decades, the average body mass index (BMI) has increased by approximately 0.4 kg/m² per decade, reflecting the increasing prevalence of overweight and obesity worldwide.¹ In South Korea, the Korean Society for the Study of Obesity (KSSO) classifies BMI as follows: normal weight (18.5–22.9 kg/m²), pre-obese (23.0–24.9 kg/m²), obese class I (25.0–29.9 kg/m²), obese class II (30.0–34.9 kg/m²), and obese class III (≥35.0 kg/m²).² Individuals with class III obesity, often referred to as severe or morbid obesity, are at markedly elevated risk for metabolic disorders, including hypertension, dyslipidemia, and type 2 diabetes mellitus.³ Severe obesity also restricts joint mobility, particularly in the shoulder, lumbar spine, hip, knee, and ankle, and contributes to pain and postural imbalances, impairing everyday activities such as sitting, standing, dressing, and walking.^4,5

While exercise is a widely recommended and potent intervention for managing severe obesity, more than 65% of individuals in this category remain physically inactive.⁶ Given that exercise is more effective when combined with other treatments such as surgery, medication, and dietary improvements, exercise guidelines that encourage voluntary participation among individuals with severe obesity is critical.⁷ However, most studies on severe obesity and exercise have focused chiefly on metabolic outcomes—such as weight loss⁸ and insulin sensitivity⁹—while detailed investigations into this population’s biomechanical, functional, and neuromuscular characteristics, as well as sustainable, tailored exercise interventions, remain scarce.

Therefore, this review aims to equip healthcare providers and exercise professionals with evidence-based scientific information into the specific structural and functional characteristics of severe obesity and to develop safe, effective exercise interventions. Furthermore, by promoting practical and sustainable exercise practices among individuals with severe obesity, it seeks to contribute to long-term solutions for obesity management.

METHODS

This review was conducted following a structured approach based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.¹⁰ The primary objective was to identify and synthesize clinical trials and controlled interventions evaluating the impact of physical exercise on mobility, stability, musculoskeletal function, and pain among severely obese adults (BMI ≥25 kg/m²).

Search strategy and selection criteria

For the data collection in this study, a comprehensive literature search was performed using academic databases of Scopus, Google Scholar, PubMed, and Web of Science. The search terms included combinations of ‘obesity,’ ‘severe obesity,’ ‘morbid obesity,’ ‘exercise,’ ‘physical activity,’ ‘training,’ ‘pain,’ ‘stability,’ ‘mobility,’ and ‘lifestyle.’ This review focused on experimental studies published between January 2000 and September 2023 that examined the effectiveness of exercise interventions in adults (aged ≥18 years) with obesity.

Inclusion criteria for the study were (1) peer-reviewed original articles (only experimental studies); (2) adult participants (≥18 years) with BMI ≥25 kg/m² in subgroup analysis; (3) interventions involving physical exercise with reported outcomes related to mobility, balance, range of motion, pain reduction, or neuromuscular control; and (4) outcome measures including validated physical function scales or biomechanical assessments. Exclusion criteria were (1) meta-analyses, narrative reviews, or case reports; (2) studies employing only general exercise modalities (e.g., aerobic or resistance training); (3) studies involving patients with severe obesity-related medical complications; (4) studies using unverified physical functional scales and evaluation tools; and (5) studies deemed inconsistent with the purpose of this study by the consensus of the reviewer.

According to these criteria, 422 articles were initially retrieved from Scopus, Google Scholar, PubMed, and Web of Science. Following PRISMA guidelines, 56 duplicates were removed, leaving 366 unique articles. Titles and abstracts of these papers were independently screened by two exercise physiologists against the predefined inclusion and exclusion criteria. During this stage, 279 studies were excluded for reasons such as non-experimental design (e.g., reviews and protocols); participants outside the target BMI or age range; irrelevant interventions (e.g., dietary studies); or outcomes not related to mobility, balance, range of motion, pain, or neuromuscular control. Thus, 87 full-text articles were retrieved for detailed assessment. Each full-text article was evaluated for eligibility: 23 studies were excluded for lacking subgroup analyses of severe obesity, 26 for employing only general exercise modalities (aerobic/resistance and high intensity), 14 for involving participants with severe obesity-related medical complications, and eight for using non-validated outcome measures. In addition, due to other reasons, six papers were excluded by consensus of the reviewers. Consequently, 10 studies met all eligibility criteria and were included in the qualitative synthesis (Fig. 1). Data extraction was conducted independently by two reviewers using a standardized form capturing study characteristics, participant demographics, interventions, and outcomes; discrepancies were resolved by consensus or third-party consultation.

Figure 1.

Study selection and screening protocol following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Multi-level reviews and cross-checks

All selected studies underwent critical appraisal using the modified National Institutes of Health Quality Assessment Tool for Controlled Intervention Studies.¹¹ Additionally, a multi-level review was conducted by a committee comprising physicians and exercise specialists to validate the accuracy and clinical relevance of the findings. This process involved iterative discussions assessing exercise intervention feasibility, biomechanical validity, and feasibility in practice.

RESULTS

Considerations for severe obesity

Musculoskeletal problems

Severely obese individuals frequently experience impairment in both static and dynamic basic movement control, including compromised posture control and gait function.¹² Research indicates that, compared to individuals of normal weight, those with severe obesity exhibit shorter stride lengths and slower walking speeds, while demonstrating an increased step width between the legs.¹³ The reduction in walking speed observed in individuals with severe obesity decreases the joint flexion and extension moments at the hip, knee, and ankle, as well as the peak absolute joint moment at the hips and knees across both sagittal and coronal planes.¹⁴ These biomechanical alterations contribute to decreased postural stability during walking, resulting in increased lateral trunk oscillations and limited hip flexor range of motion, which restricts knee-raising capacity.¹⁵ In addition, the excessive accumulation of adipose tissue causes mechanical obstruction, limiting the range of motion in the hip and lumbar spine. This leads to compensatory movements, such as straightening the trunk and shifting the supporting leg backward when transitioning from a seated to a standing position.^15,16 Such abnormal movement patterns alter the contact points between weight-bearing joints and cartilage, increasing the risk of degenerative diseases^12,17 and causing widespread pain due to chronic low-grade inflammation.¹⁸ Furthermore, the risk of musculoskeletal issues such as ankle tendinitis, plantar fasciitis,¹⁹ and chronic plantar heel pain is significantly elevated.²⁰ Previous studies indicate that 69% of knee replacement patients and 27% of hip replacement patients were overweight or obese.²¹ Another study, controlling for comorbidities, found a persistent association between obesity and the likelihood of joint replacement surgery, with musculoskeletal problems becoming more pronounced as obesity severity increases.^22,23

The more severe is the obesity, the greater are the extent and frequency of pain, complicating the performance of basic daily activities and perpetuating a cycle of declining health and quality of life.²⁴ Given this, lifestyle changes and increased physical activity are strongly recommended as key strategies to prevent further musculoskeletal deterioration and improve overall well-being.²⁵

Limitation of movement

Basic functional tasks such as walking, bending, climbing stairs, sitting and standing up, pushing and pulling doors, and gripping objects require stable posture and balance. Impairments in these fundamental physical activities can significantly limit independence and mobility, imposing substantial constraints on daily life.²⁶ For severely obese individuals, the combination of excessive body weight and a sedentary lifestyle compromises posture control, primarily due to reduced mechanoreceptor sensitivity and diminished mechanical movement function.^5,27

Postural balance control relies on feedback from the proprioceptive system, which includes cutaneous mechanoreceptors that detect pressure and strain on the skin.²⁸ While decreased proprioceptive function is commonly associated with aging or chronic joint instability,²⁹ it is also prevalent among obese individuals. In obese patients, the increased plantar pressures resulting from excessive body weight affects plantar sensitivity, hindering postural balance and increasing the risk of instability.³⁰ The Weber-Fechner Principle postulates that the intensity of mechanical stimulation perceived by skin receptors is proportional to the intensity of the external stimuli.³¹ In this process, Meissner’s corpuscles detect light touch, while Vater-Pacini corpuscles, located deeper in the skin, respond to stronger mechanical stimuli.³² Since the threshold for activation of Vater-Pacini corpuscles is lower than that of Meissner’s, heightened plantar pressure in obese individuals may stimulate these receptors, contributing to postural instability by increasing body vibration.³²

Additionally, the excessive distribution of body fat in severely obese individuals physically restricts the range of motion in certain movements. Due to the mass distribution of fat, compensatory postures may develop to mitigate back pain and spinal compression.³³ Specifically, the concentration of weight on the front of the feet destabilizes the anterior-posterior center of pressure during static and dynamic balance activities.³⁴ This imbalance results in a higher torque demand on the hip joint compared to the knee, impairing vertebral torque function.³⁵ Moreover, the disproportionate distribution of fat exacerbates spinal pressure during weight-bearing activities, increasing the incidence of low back pain.³⁶ Fabris de Souza et al.³⁷ found that 100% of severely obese patients adopted obesity-specific postures compared to normal-weight individuals.

Interestingly, previous studies have shown that obese individuals have greater absolute lean mass and higher absolute isokinetic/isometric strengths in the knee and trunk extensors than their normal-weight counterparts.^38,39 This suggests that the additional weight loading in severely obese individuals may act as a chronic stimulus for muscle adaptation, even in response to moderate intensity exercise.^40-42 However, muscle length specificity, where strength is exerted at a specific joint angle, can influence muscle function in severe obesity. Maffiuletti et al.⁴² confirmed that the skeletal torque, such as knee extension in severely obese adolescents, was considerably higher at shorter muscle length (40° of knee flexion), indicating neuromuscular adaptations due to a restricted range of motion.

Given these challenges, optimal movement function in severely obese individuals requires the complex integration of neural mechanisms, the interaction of large muscle torque with gravitational forces, and biomechanical adjustments.^43,44 Flexibility exercises aimed at improving balance may serve as an initial intervention to enhance postural control and improve health. While balance is often overlooked as a key component of physical fitness, it is critical for maintaining postural stability and ensuring mobility. Therefore, balance training should be considered an essential element in exercise programs designed for severely obese individuals.^45,46

Severe obesity and exercises

Given the complex physiological and biomechanical impairments in individuals with severe obesity, physical activity interventions must be precisely tailored to their unique needs. Conventional exercise prescriptions for obesity often emphasize aerobic or resistance training for metabolic health and weight reduction; however, such paradigms may neglect critical aspects such as postural instability, reduced joint mobility, neuromuscular inefficiency, and pain—factors that significantly hinder exercise participation and adherence in severely obese individuals. To address these challenges, we systematically reviewed 10 empirical studies (Table 1) that evaluated the effects of structured physical activity interventions on key functional domains of flexibility, balance, core strength, pain reduction, and perceived disability among individuals classified as overweight, obese, or severely obese.^47-56 Although several studies included participants across obesity classes, particular emphasis was placed on those with BMI ≥25 kg/m² and interventions explicitly targeting mobility and musculoskeletal outcomes.

Table 1.

Impact of exercise on individuals with overweight, obesity, and severe obesity

Author (year)	Participants	Age (yr)	BMI (kg/m2)	Method	Measures	Results
Buttichak et al. (2019)47	Overweight or obese women adults	30–45	23.0–29.9	24 weeks gym ball yoga exercise	Body composition Physical performance	BMI ↓ WHR - Body weight ↓ Flexibility ↑ Balance ↑ Muscular strength & endurance ↑
Puengsuwan et al. (2020)51	Overweight or obese older adults (mixed*)	55–70	27.1–27.4	15 weeks wand stretching exercise	Body composition Serum biochemical	BMI, WC ↓ Fat free mass ↑ Glucose, insulin - LDL-C, HDL-C - Fat oxidation rate -
Vincent et al. (2014)52	Overweight or obese older adults (mixed)	60–85	≥ 25.0	16 weeks body resistance exercise, isolated lumbar extension resistance exercise	Perceived disability Fear-avoidance beliefs Pain catastrophizing scale	Perceived disability↓ Fear-avoidance beliefs ↓ Pain catastrophizing scale ↓
Vincent et al. (2014)50	Overweight or obese older adults (mixed)	60–85	≥ 25.0	16 weeks body resistance exercise, isolated lumbar extension resistance exercise	Physical performance Low back pain severity score	Lumbar extensor strength ↑ Walking endurance ↑ Low back pain severity score ↓
Widjaja et al. (2021)48	Overweight or obese older women adults	55–70	28.0–28.4	8 weeks Thai yoga exercise	Physical performance	Flexibility ↑ Balance ↑ Muscle strength ↑ Walking ability ↑
Güneş et al. (2024)53	Patients scheduled for bariatric surgery (mixed)	20–60	≥ 30.0	32 weeks yoga exercise	6-minute walk test Early clinical outcomes	6-min walk test ↑ Oxygen saturation ↑ Pulmonary function test ↑ Posteroanterior chest X-rays -
Park et al. (2021)49	Severely obese patients (mixed)	20–40	≥ 30.0	4 weeks stabilizing exercise	Body composition Physical function Lumbar instability test Perceived disability Fear-avoidance beliefs TrA thickness	BMI ↓ Balance ↑ Perceived disability ↓ Fear-avoidance beliefs ↓ TrA thickness ↑
Park et al. (2022)54	Severely obese patients (mixed)	20–40	≥ 30.0	4 weeks stabilizing exercise	Balance Pulmonary function Perceived disability Fear-avoidance beliefs Low back pain severity score	Balance ↑ Pulmonary function ↑ Perceived disability ↓ Fear-avoidance beliefs ↓ Low back pain severity score ↓
Lee et al. (2023)55	Obese women adults	45–60	≥ 30.0	8 weeks core exercise+weight loss	Body composition Physical performance Low back pain severity score	WHR ↓ Low back pain severity score ↓ Hip flexor strength ↑ Sensory organization ↑
Park et al. (2014)56	Obese men adults	27–44	28.4–29.1	4 weeks core exercise	Lumbar flexibility Perceived disability Low back pain severity score	Lumbar flexibility ↑ Perceived disability ↓ Low back pain severity score ↓

*This means that the study included participants of both sexes.

BMI, body mass index; WHR, waist-hip ratio; WC, waist circumference; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; TrA, transverse abdominis.

The synthesis of these findings revealed a consistent beneficial pattern: improvements in physical function were most pronounced in interventions that incorporated low-impact, body weight-based exercises focusing on trunk stabilization, mobility enhancement, and proprioceptive control. Importantly, these modalities yielded substantial benefits even in the absence of significant weight loss, underscoring their functional utility independent of body mass changes. Drawing from this evidence, we propose a multi-dimensional exercise framework tailored to severely obese individuals, structured into three progressive domains: (1) stretching exercises for improving flexibility and joint range of motion; (2) flexion-dominant exercises for enhancing core activation and pelvic stability; and (3) extension-dominant exercises for promoting lumbar support and dynamic postural control. The exercise protocols designed to promote dynamic postural control and lumbar support are detailed in Tables 2-4, with each selected for its biomechanical accessibility, functional relevance, and supportive clinical evidence.

Table 2.

Stretching exercise

Table 3.

Flexion-dominant exercise

Table 4.

Extension-dominant exercise

Stretching exercises are essential for improving flexibility, which is crucial for performing both simple and complex movements required in daily life. These exercises also address various issues such as decreased mobility, musculoskeletal stability, and pain (Table 1).^57,58 A lack of muscle stretching may result in the involvement of unintended muscle groups or compensatory movements that can lead to instability.⁵⁹ Conversely, excessive flexibility increases the risk of injury to muscles, joints, and ligaments. Therefore, flexibility exercises that enhance muscle strength through body weight loading are necessary. Buttichak et al.⁴⁷ demonstrated that 24 weeks of yoga training using gym balls significantly improved flexibility, balance, muscle strength, and endurance in overweight/obese women aged 30 to 45 years, while also reducing body weight, BMI, waist circumference, and body fat percentage. Similarly, a study by Widjaja et al.⁴⁸ showed significant improvements in functional reach, 8-foot up and go, 6-minute walking test, and knee flexion and extension strength in overweight/obese elderly women after 8 weeks of Thai yoga training.

Excess abdominal fat impairs the function of the abdominal muscles, contributing to lower back pain. Among the deep muscles responsible for stabilizing the trunk, the transversus abdominis play a key role in increasing intra-peritoneal pressure, which stabilizes the lumbar spine.⁶⁰ Stabilization exercises targeting specific muscle groups through contraction not only reduce musculoskeletal pain but also enhance functional capacity. Introducing controlled instability during these exercises can further promote neuromuscular activation, improving muscle strength and balance.⁶¹ A study by Park and Lee⁴⁹ demonstrated significant improvements in BMI, low back pain, physical function, and balance ability after 4 weeks of stabilization exercises performed on unstable surfaces using small tools in 46 adults with severe obesity. Notably, the reduction in BMI achieved through short-term stabilization exercise is a significant outcome, as it is closely linked to the alleviation of musculoskeletal pain and dysfunction in obese individuals.⁴⁹ While traditional paradigms recommend aerobic and resistant exercises for weight loss, these activities often involve complex movements and may exacerbate musculoskeletal pain due to the mechanical load imposed by excess body weight. As a result, these exercises may not be suitable as initial interventions for improving severe obesity. Instead, safe and simple home-based exercise programs can reduce the risk of injury (fall, pain, etc.) while fostering a sense of achievement, encouraging sustained engagement in physical activity. The high accessibility of these programs also promotes long-term lifestyle changes. In recognition of this need, the exercise committee of the KSSO has recently developed and gradually released over 300 exercise programs (https://www.youtube.com/watch?v=-tmrqNdZY38), focusing on various joints (e.g., cervical and thoracic vertebra, shoulders, hip joints, knees, and ankles), muscle groups (e.g., gluteus maximus, abdominal, quadriceps femoris muscle, hamstring, and foot muscles), equipment (e.g., foam rollers, gym balls, massage balls, and chairs), and environments (e.g., office and home). These programs aim to improve the quality of life for individuals with severe obesity. In this context, we propose several mobility-related exercises specifically tailored to severely obese patients.

Although Table 1 includes studies with a broader obesity classification (BMI ≥25–40 kg/m²), sub-analysis revealed consistent therapeutic mechanisms—namely improved postural control, enhanced lumbar stability, and reduced pain—that are of high clinical relevance for individuals with obesity. These results directly informed the development of the proposed exercise categories in Tables 2–4, which emphasize stretching and flexion/extension-dominant exercise. Our exercise protocols were developed to correspond to the functional domains demonstrated to improve in the studies. For example, studies demonstrating increased flexibility and reduced lumbar pain⁵⁰ provided evidence for the inclusion of pelvis- and hip-focused stretching protocols. Likewise, interventions that enhanced trunk stabilization and reduced fear-avoidance beliefs⁴⁷ justified the emphasis on flexion/extension-dominant exercises. This methodological linkage ensures that the proposed protocols are not only biomechanically sound but also evidence-based, reproducible, and clinically applicable to severely obese populations.

DISCUSSION

Stretching exercise

The effectiveness of aerobic and resistance exercises in addressing obesity has been well-established through numerous scientific studies.^62,63 However, careful consideration is required when applying these exercise modalities to individuals with mobility limitations.⁵¹ Stretching interventions serve as a foundational strategy for enhancing joint range of motion, neuromuscular coordination, and muscular elasticity—key deficits commonly observed in individuals with severe obesity. Excess adipose tissue deposition in the abdominal, hip, and thigh regions imposes mechanical constraints that limit both passive and active flexibility, contributing to compensatory motor patterns and impaired gait mechanics. Moreover, chronic low-grade inflammation and myofascial stiffness often exacerbate musculoskeletal discomfort and restrict mobility, particularly in the lumbopelvic region. Puengsuwan et al.⁵¹ emphasized the importance of exercise programs for obese individuals that enhance mobility by improving flexibility and balance. Our proposed stretching exercise method, which includes 8 weeks of yoga exercises focused on breathing, musculoskeletal stretching, and slow dynamic transitions between poses, has been shown to positively impact flexibility, gait mobility, lower-body muscle strength, and the regulation of resting heart rate and blood pressure.⁴⁸ In addition, 8 weeks of hip stretching exercises have been found to reduce non-specific lower back pain and increase the range of motion in the hip joints.⁶⁴ Despite no significant differences in the lumbar-to-hip ratio between obese and normal-weight individuals across children, adolescents, and adults, obesity is associated with a higher prevalence of lower back pain and reduced body mobility.⁶⁵ This underscores the importance of enhancing hip joint mobility through targeted stretching exercises for obese individuals; to optimize safety and therapeutic benefit, stretching routines should be performed within a comfortable, pain-free range of motion, with gradual progression. Particular attention must be paid to maintaining neutral joint alignment, engaging deep core musculature, and coordinating diaphragmatic breathing to minimize compensatory movement patterns and reduce the risk of symptom exacerbation in those with lumbar instability or hip joint restrictions.

Flexion-dominant exercise

The global muscles, including the longissimus thoracis, rectus abdominis, and external oblique abdominis, are primarily responsible for movement.⁶⁶ These muscles can be strengthened through multisegmental movements, enhancing compressive forces that improve stability and control segmental shear forces when combined with activation of local muscles.⁶⁷ Postural stability refers to the body’s ability to respond appropriately to internal and external forces, maintaining correct posture to prevent falls.⁶⁸ Height and weight are key determinants of postural sway and stability;69 therefore, exercises that utilize body weight in a controlled environment, without the need for specific tools such as dumbbells or barbells, can help ensure stability (e.g., seated knee raises and abdominal twists). Given this understanding, we propose a series of flexor exercises that can be performed in a sitting or standing position, as outlined in Table 3. In fine-tuning postural stability, individuals with obesity are more reliant on neuromuscular integration than mechanical adjustment and require a longer period to adapt to exercise compared to their non-obese counterparts.⁷⁰ Obese individuals exhibit significantly larger plantar contact areas and higher average pressure compared to those with normal weight, which may reduce the quality of sensory information from mechanoreceptors.³⁰ Therefore, stabilization exercises should be structured progressively, introducing stability only after individuals have adapted to safe, stable movements. All initial training sessions should be conducted at moderate intensity. In addition, while stable support is essential to prevent balance-related injuries and facilitate progressive neuromuscular adaptation, it is equally important to introduce adjustable levels of controlled instability within a structured environment to challenge proprioception and promote adaptive neuromuscular responses, enabling individuals to progress safely and independently in their exercise routines.

Extension-dominant exercise

Extension-dominant exercises focus on strengthening the posterior chain, particularly the lumbar extensors, gluteal muscles, and deep spinal stabilizers such as the multifidus. These muscle groups are critical for maintaining upright posture, resisting anterior gravitational collapse, and supporting axial loading during ambulation and lifting tasks.^71,72 Given the critical role of voluntary muscle contraction and proprioceptive sensory feedback in stability, a variety of core stabilization exercises is essential. Previous studies have demonstrated that activation of the lumbar multifidus, as measured by electromyography, significantly increases during bridge exercises.⁷¹ This exercise involves extending the spine against gravitational forces by supporting the legs and lifting the hips in a supine position, with the lumbar multifidus functioning as a key lumbar extensor that contributes to segmental stability of the spine.⁷² Stability exercises such as bird dog and dead bug, performed in quadruped or supine positions, enhance trunk muscle activation through asymmetric movements of the arms and legs, challenging the body’s biomechanics by reducing the base of support.^73,74 These exercises, when performed with appropriate control and spinal alignment, improve segmental stability, reduce aberrant spinal motion, and mitigate mechanical back pain. Furthermore, asymmetric limb movements, as featured in the bird dog and dead bug, challenge the base of support and enhance contralateral motor coordination.^73,74 In addition, subtle arm and leg movements during these exercises further enhance muscle activation levels.⁷⁵ Citing reports that these stability exercises positively influence normal movement patterns and reduce low back pain,^76-78 we recommend the series of extensor exercises outlined in Table 4 as an effective intervention for alleviating movement limitations and low back pain associated with severe obesity. Given the neuromuscular delays and proprioceptive impairments commonly observed in individuals with severe obesity, initial training intensity should remain low. To prevent balance-related injuries and facilitate progressive neuromuscular adaptation, exercises should be performed in controlled environments with stable support. Furthermore, because of the increased lumbar load during extension-based movements, exercise dosing and progression must be tailored to individual core strength and vertebral stability, incorporating supportive mats, visual feedback, and gradual amplitude increases to minimize the risk of lumbar strain and ensure optimal neuromuscular engagement.

CONCLUSION

This study synthesizes evidence-based exercise modalities that specifically address the neuromuscular and biomechanical impairments associated with severe obesity. Also, emphasize the critical role of stretching and flexion/extension-dominant core exercises in enhancing lumbar stability, neuromuscular activity, overall mobility in individuals with severe obesity. Unlike traditional exercise interventions focused primarily on metabolic outcomes, the proposed exercise prioritizes improvements in mobility, postural stability, and functional independence. Through structured programming of stretching, flexion-dominant, and extension-dominant exercises, this framework offers an accessible, safe, and clinically relevant approach to initiating physical activity in individuals with significant movement limitations. The exercise protocols herein are designed to minimize musculoskeletal loading while maximizing neuromotor engagement, promoting adherence, reducing pain, and restoring mobility, but should be tailored to each individual’s baseline fitness and physical capabilities to ensure safety and maximize benefit. Furthermore, progressive exercises incorporating equipment such as Bosu balls, elastic bands, gymnastic balls, and foam rollers or those including full-body dynamic movements are encouraged to optimize efficacy and support long-term improvements in mobility and stability.

Meanwhile, several limitations should be acknowledged in this study. First, although we prioritized the inclusion of high-quality studies, significant heterogeneity in intervention duration, exercise intensity, and outcome measures precluded direct quantitative comparisons across studies. Second, a formal meta-analysis was not feasible due to the methodological and population diversity among the selected trials. Third, while the proposed exercise modalities were derived from robust evidence, their practical efficacy among severely obese individuals has not been validated through primary clinical trials. Fourth, publication bias may have favored positive findings, and the language bias introduced by reliance on studies published in accessible languages could have excluded relevant data in other languages. Finally, selection bias may have arisen from the exclusion of gray literature and unpublished trials. Future research should conduct rigorously designed randomized controlled trials in community and clinical settings to empirically validate these exercise protocols and assess long-term adherence and functional outcomes.