Effect of Dynamic Neuromuscular Stabilization on Balance, Trunk Function, Falling, and Spasticity in People With Multiple Sclerosis: A Randomized Controlled Trial

Published:October 03, 2022DOI:



      To compare the effects of core stabilization (CS) and dynamic neuromuscular stabilization (DNS) on balance, trunk function, mobility, falling, and spasticity, in people with multiple sclerosis (PWMS).


      Two-group randomized controlled trial.


      General community and referral center.


      A total of 64 PWMS, between 30 and 50 years old, and an expanded disability status scale between 2 and 5, participated in this study (N=64).


      Participants were randomly assigned to CS (n=32) and DNS (n=32) groups. Both groups received a total of 15 sessions of CS or DNS exercises, 60 minutes per session, 3 times a week during the 5 weeks.

      Outcome Measures

      Balance function was measured as the primary outcome measure. Trunk function, postural stability, falling rate, fear of falling, falling index, mobility, and spasticity were measured as secondary outcomes.


      DNS group had significant improvement in Berg balance scale, trunk impairment scale, postural stability, activities-specific balance confidence, reduced falling rate, the timed Up and Go (TUG), multiple sclerosis walking scale-12, and multiple sclerosis spasticity scale in PWMS compared with the CS group, (P<.0001) after 5 weeks of intervention and 17 weeks of follow-up. Except for the modified Ashworth scale (MAS), significant improvements were seen in all outcome measures in both groups after 5 weeks of intervention.


      This is the first clinical evidence to support the importance of DNS exercise in improving balance, trunk function, and fall prevention in PWMS. This study provides clinical evidence that DNS may be more effective for PWMS than CS.


      List of abbreviations:

      ABC (activities-specific balance confidence), APA (anticipatory postural adjustment), BBS (Berg balance scale), CS (core stability), DNS (dynamic neuromuscular stabilization), MAS (modified Ashworth scale), MSSS-88 (multiple sclerosis spasticity scale), MSWS-12 (multiple sclerosis walking scale), PWMS (people with multiple sclerosis), TIS (trunk impairment scale), TUG (timed up and go)
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        • Motl RW
        • Sandroff BM
        • Kwakkel G
        • et al.
        Exercise in patients with multiple sclerosis.
        Lancet Neurol. 2017; 16: 848-856
        • Dobson R
        • Giovannoni G.
        Multiple sclerosis—a review.
        Eur Jo Neurol. 2019; 26: 27-40
        • Quinn G
        • Comber L
        • McGuigan C
        • Hannigan A
        • Galvin R
        • Coote S.
        Risk factors for falling for people with multiple sclerosis identified in a prospective cohort study.
        Clin Rehabil. 2021; 35: 765-774
        • Beghi E
        • Gervasoni E
        • Pupillo E
        • et al.
        Prediction of falls in subjects suffering from Parkinson disease, multiple sclerosis, and stroke.
        Arch Phys Med Rehabil. 2018; 99: 641-651
        • Cameron MH
        • Lord S.
        Postural control in multiple sclerosis: implications for fall prevention.
        Curr Neurol Neurosci Rep. 2010; 10: 407-412
        • Freund JE
        • Stetts DM
        • Vallabhajosula S.
        Relationships between trunk performance, gait and postural control in persons with multiple sclerosis.
        Neurorehabilitation. 2016; 39: 305-317
        • Raats J
        • Arntzen EC
        • Lamers I
        • Feys P
        • Normann B.
        What is the distribution of trunk impairments and its relationship with disability level in individuals with multiple sclerosis?.
        Mult Scler Relat Disord. 2022; 57103325
        • Massot C
        • Simoneau-Buessinger E
        • Agnani O
        • Donze C
        • Leteneur S.
        Anticipatory postural adjustment during gait initiation in multiple sclerosis patients: a systematic review.
        Gait Posture. 2019; 73: 180-188
        • Carling A
        • Forsberg A
        • Gunnarsson M
        • Nilsagård Y.
        CoDuSe group exercise programme improves balance and reduces falls in people with multiple sclerosis: a multi-centre, randomized, controlled pilot study.
        Mult Scler J. 2017; 23: 1394-1404
        • Fox EE
        • Hough AD
        • Creanor S
        • Gear M
        • Freeman JA.
        Effects of pilates-based core stability training in ambulant people with multiple sclerosis: multicenter, assessor-blinded, randomized controlled trial.
        Phys Ther. 2016; 96: 1170-1178
        • Freeman J.
        • et al.
        The effect of core stability training on balance and mobility in ambulant individuals with multiple sclerosis: a multi-centre series of single case studies.
        Mult Scler J. 2010; 16: 1377-1384
        • Queiroz BC
        • Cagliari MF
        • Amorim CF
        • Sacco IC.
        Muscle activation during four pilates core stability exercises in quadruped position.
        Arch Phys Med Rehabil. 2010; 91: 86-92
        • Frank C
        • Kobesova A
        • Kolar P.
        Dynamic neuromuscular stabilization & sports rehabilitation.
        Int J Sports Phys Ther. 2013; 8: 62
        • Chaitow L
        • Bradley D
        • Gilbert C.
        Recognizing and treating breathing disorders E-Book.
        2nd. Elsevier Health Sciences, 2014: 93-98
        • Mohammad-Rahimi N
        • Mahdavinezhad R
        • Attarzadeh-Hosseini SR
        • Negahban H.
        Effect of dynamic neuromuscular stabilization breathing exercises on respiratory function of sedentary students with poor posture.
        Health Educ Health Promot. 2020; 8: 19-24
        • Bae WS
        • Lee KC
        • Lee DY.
        The effects of dynamic neuromuscular stabilization exercise on forward head posture and spine posture.
        Med Legal Update. 2019; 19
        • Son MS
        • Jung DH
        • You JS
        • Yi CH
        • Jeon HS
        • Cha YJ.
        Effects of dynamic neuromuscular stabilization on diaphragm movement, postural control, balance and gait performance in cerebral palsy.
        Neurorehabilitation. 2017; 41: 739-746
        • Chung EJ
        • Kim JH
        • Lee BH.
        The effects of core stabilization exercise on dynamic balance and gait function in stroke patients.
        J Phys Ther Sci. 2013; 25: 803-806
        • Abadi Marand L
        • Noorizadeh Dehkordi S
        • Roohi-Azizi M
        • Dadgoo M
        Effect of dynamic neuromuscular stabilization on balance and trunk function in people with multiple sclerosis: protocol for a randomized control trial.
        Trials. 2022; 23: 1-9
        • Azad A
        • Taghizadeh G
        • Khaneghini A.
        Assessments of the reliability of the Iranian version of the Berg balance scale in patients with multiple sclerosis.
        Acta Neurol Taiwan. 2011; 20: 22-28
        • Nilsagård Y
        • Carling A
        • Davidsson O
        • Franzén L
        • Forsberg A.
        Comparison of trunk impairment scale versions 1.0 and 2.0 in people with multiple sclerosis: a validation study.
        Physiother Theory Pract. 2017; 33: 772-779
        • Nilsagård Y
        • Carling A
        • Forsberg A.
        Activities-specific balance confidence in people with multiple sclerosis.
        Mult Scler Int. 2012; 2012613925
        • Hobart JC
        • Riazi A
        • Thompson AJ
        • et al.
        Getting the measure of spasticity in multiple sclerosis: the multiple sclerosis spasticity scale (MSSS-88).
        Brain. 2006; 129: 224-234
        • Ghotbi N
        • Ansari NN
        • Naghdi S
        • Hasson S.
        Measurement of lower-limb muscle spasticity: intrarater reliability of modified modified Ashworth scale.
        J Rehabil Res Dev. 2011; 48: 83
        • McGuigan C
        • Hutchinson M.
        Confirming the validity and responsiveness of the multiple sclerosis walking scale-12 (MSWS-12).
        Neurology. 2004; 62: 2103-2105
        • Sebastião E
        • Sandroff BM
        • Learmonth YC
        • Motl RW.
        Validity of the timed up and go test as a measure of functional mobility in persons with multiple sclerosis.
        Arch Phys Med Rehabil. 2016; 97: 1072-1077
        • Najafabadi M.M.
        • et al.
        Improvement of upper limb motor control and function after competitive and noncompetitive volleyball exercises in chronic stroke survivors: a randomized clinical trial.
        Arch Phys Med Rehabil. 2019; 100: 401-411
        • Gervasoni E
        • Jonsdottir J
        • Montesano A
        • Cattaneo D.
        Minimal clinically important difference of Berg balance scale in people with multiple sclerosis.
        Arch Phys Med Rehabil. 2017; 98: 337-340
        • Lee NG
        • You JS
        • Chung HY
        • et al.
        Best core stabilization for anticipatory postural adjustment and falls in hemiparetic stroke.
        Arch Phys Med Rehabil. 2018; 99: 2168-2174
        • Yasemin AT
        • ÜnlÜer NÖ
        An investigation of knee position sense, balance, and dual task performance in different phases of menstrual cycle in females with multiple sclerosis: a pilot study.
        Mult Scler Relat Disord. 2020; 44102235
        • Akbaş A
        • Marszałek W
        • Bacik B
        • Juras G.
        Two aspects of feedforward control during a fencing lunge: early and anticipatory postural adjustments.
        Front Hum Neurosci. 2021; : 267
        • Huxel Bliven KC
        • BE Anderson
        Core stability training for injury prevention.
        Sports Health. 2013; 5: 514-522
        • Ali AS
        • Darwish MH
        • Shalaby NM
        • Abbas RL
        • Soubhy HZ.
        Efficacy of core stability versus task oriented trainings on balance in ataxic persons with multiple sclerosis. A single blinded randomized controlled trial.
        Mult Scler Relat Disord. 2021; 50102866
        • Güngör F
        • Tarakci E
        • Özdemir-Acar Z
        • Soysal A.
        The effects of supervised versus home Pilates-based core stability training on lower extremity muscle strength and postural sway in people with multiple sclerosis.
        Mult Scler J. 2022; 28: 269-279
        • Fanchamps MH
        • Gensicke H
        • Kuhle J
        • Kappos L
        • Allum JH
        • Yaldizli Ö.
        Screening for balance disorders in mildly affected multiple sclerosis patients.
        J Neurol. 2012; 259: 1413-1419
        • Krishnan V
        • Kanekar N
        • Aruin AS.
        Anticipatory postural adjustments in individuals with multiple sclerosis.
        Neurosci Lett. 2012; 506: 256-260
        • Yoon HS
        • You JS.
        Reflex-mediated dynamic neuromuscular stabilization in stroke patients: EMG processing and ultrasound imaging.
        Technol Health Care. 2017; 25: 99-106
        • Fjeldstad C
        • Pardo G
        • Frederiksen C
        • Bemben D
        • Bemben M.
        Assessment of postural balance in multiple sclerosis.
        Int J MS Care. 2009; 11: 1-5
        • Sæther R
        • Helbostad JL
        • Adde L
        • Brændvik S
        • Lydersen S
        • Vik T.
        The relationship between trunk control in sitting and during gait in children and adolescents with cerebral palsy.
        Dev Med Child Neurol. 2015; 57: 344-350
        • Kolář P
        • Šulc J
        • Kynčl M
        • et al.
        Postural function of the diaphragm in persons with and without chronic low back pain.
        J Orthop Sports Phys Ther. 2012; 42: 352-362
        • Arntzen EC
        • Straume BK
        • Odeh F
        • Feys P
        • Zanaboni P
        • Normann B.
        Group-based individualized comprehensive core stability intervention improves balance in persons with multiple sclerosis: a randomized controlled trial.
        Phys Ther. 2019; 99: 1027-1038
      1. Fleischmann, Channing. "The Parkinson's Patient: Use of Dynamic Neuromuscular Stabilization for Postural Alignment and Fall Risk Reduction." PhD diss., Azusa Pacific University, 2017, Available at: [13.1.2020.]. Accessed October 25, 2022.

        • Balzer J
        • Marsico P
        • Mitteregger E
        • van der Linden ML
        • Mercer TH
        • van Hedel HJ.
        Influence of trunk control and lower extremity impairments on gait capacity in children with cerebral palsy.
        Disabil Rehabil. 2018; 40: 3164-3170
        • Subramanian HH
        • Balnave RJ
        • Holstege G.
        The midbrain periaqueductal gray control of respiration.
        J Neurosci. 2008; 28: 12274-12283
        • Motl RW
        • Snook EM
        • Hinkle ML
        • McAuley E.
        Effect of acute leg cycling on the soleus H-reflex and modified Ashworth scale scores in individuals with multiple sclerosis.
        Neurosci Lett. 2006; 406: 289-292
        • Na EJ
        • Moon SH
        • Kim EK
        • Park DJ.
        Effects of proprioceptive neuromuscular facilitation program combined with dynamic neuromuscular stabilization approach on balance in patient with cerebellum atrophy—case report.
        PNF Mov. 2016; 14: 237-244