Effects of Breathing Techniques Applied During Dynamic Neuromuscular Stabilization on Respiratory Function, Gait, and Body Self-Esteem in Women with Abdominal Obesity

Kim, Dong-Ju; Kwon, Hae-Yeon; Dong-Ju Kim; Hae-Yeon Kwon

doi:10.15857/ksep.2025.00591

Exerc Sci > Volume 35(1); 2026 > Article

Kim and Kwon: Effects of Breathing Techniques Applied During Dynamic Neuromuscular Stabilization on Respiratory Function, Gait, and Body Self-Esteem in Women with Abdominal Obesity

Original Article

Exerc Sci. 2026; 35(1): 96-110.

Published online: Feb 9, 2026

DOI: https://doi.org/10.15857/ksep.2025.00591

Effects of Breathing Techniques Applied During Dynamic Neuromuscular Stabilization on Respiratory Function, Gait, and Body Self-Esteem in Women with Abdominal Obesity

Dong-Ju Kim MS¹

, Hae-Yeon Kwon PhD²

¹Dong-Eui Medical Center, Busan, Korea

²Department of Physical Therapy, College of Nursing and Healthcare Science, Dong-Eui University, Busan, Korea

Corresponding author: Hae-Yeon Kwon Tel +82-10-4546-3383 Fax +82-52-238-5844 E-mail sunlotus75@deu.ac.kr

Received Oct 19, 2025 Revised Nov 14, 2025 Accepted Nov 24, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

PURPOSE

To investigate the effects of integrating diaphragmatic breathing (DB) with dynamic neuromuscular stabilization (DNS) exercises on respiratory function, gait parameters, and physical self-esteem in middle-age women with abdominal obesity.

METHODS

Using a single-blind design, 36 middle-age women ≥50 years of age with abdominal obesity were randomly assigned to db and ndb group. Both groups participated in a six-week DNS exercise program conducted in one-on-one sessions twice per week, each lasting 50 min. Respiratory function (peak expiratory flow [PEF], forced vial capacity [FVC], forced expiratory volume [FEV₁]), and gait parameters, and body self-esteem were measured before and after the intervention to analyze changes. Statistical analyses were performed using IBM SPSS Statistics version 29.0 (IBM Corp., Armonk, NY, USA), using descriptive statistics and nonparametric tests at a significance level of 0.05.

RESULTS

The experimental group exhibited significantly greater improvements in all respiratory function indicators (i.e., PEF, FVC, and FEV₁) and physical self-esteem than those the control group. They also exhibited significantly greater reductions in forward head posture and trunk leaning angles during gait, indicating improved postural alignment. While both groups exhibited significant reductions in horizontal center-of-gravity movement and step width, the intergroup differences were not significant. Stride length was significantly increased in the experimental group but remained unchanged in the control group. The increase in the left-stride length was significantly greater in the experimental group than that of the control group, although right-stride length exhibited no significant intergroup differences.

CONCLUSIONS

The study results emphasize the effectiveness of focusing on breathing stabilization during exercise. Applying DNS diaphragmatic breathing feedback to DNS exercises demonstrated synergistic effects on respiratory function, gait parameters, and selfesteem in middle-aged women with abdominal problems.

Keywords: DNS breathing, Gait, Abdominal obesity, Women’s Health, Respiratory function

INTRODUCTION

According to the World Health Organization (WHO), obesity has more than doubled in prevalence since 1990, making it a critical global health issue [1]. In particular, the prevalence of abdominal obesity among Korean women aged 40 to 60— the demographic targeted in this study— increased from 19.9% in 2009 to 27.2% in 2019, highlighting a significant upward trend among this high-risk group [2].

Middle-aged women, especially those approaching or undergoing menopause, experience a significant physiological and psychosocial transition marked by the cessation of reproductive function and notable changes in physical, psychological, and social roles [3,4]. During this period, women are particularly vulnerable to negative perceptions of body image and often report reduced physical self-esteem [3,5]. At the same time, participation in regular physical activity declines by up to 40%, while menopause-related decreases in basal metabolic rate and muscle mass contribute to increased risks of obesity and metabolic disorders [6,7]. Therefore, home-based exercise programs that are not limited by location or weather are essential not only for improving the physical health of obese women but also for enhancing their psychosocial wellbeing, adaptability, and physical self-esteem [3].

Obesity can lead to several medical complications. Even in the absence of respiratory disease, obesity can impair pulmonary function, directly affecting respiratory health [8]. It can restrict thoracic movement and negatively impact lung function by increasing respiratory rate and minute ventilation, while reducing thoracic contribution to breathing [9,10]. Obesity also contributes to muscle mass and strength loss, thereby impairing skeletal muscle performance and reducing mobility [11]. This dysfunction of the respiratory muscles leads to decreased trunk stability, which is essential for balance and mobility [12]. In addition, impairments in gait and balance are major contributors to falls in older adults, leading to increased morbidity, mortality, and loss of independence [13].

The study by Shaw & Shaw (2011) demonstrated that diaphragmatic breathing training improves pulmonary function and the mechanics of abdominal and thoracic movement, emphasizing the importance of respiratory-based core stabilization principles [14]. Dynamic Neuromuscular Stabilization (DNS) is a rehabilitation approach based on developmental kinesiology, aiming to correct inappropriate movement patterns by applying the principles of infant motor development to adults, with optimal intra-abdominal pressure, and simultaneously optimizing the motor system. This exercise therapy approach aims to provide dynamic stabilization of the spine [15,16]. In other words, DNS exercises involve performing movements such as lying down, prone positioning, sitting, rolling, walking, and rising from a seated position, based on the motor development patterns of children, accompanied by respiratory control [15]. In DNS, creating stability in each joint is called joint centration, which refers to the state in which the muscles that stabilize the joint (stabilizers) and the agonists and antagonists are coordinated. Therefore, it plays an important role in learning the position of the joint where optimal stability is required and neuromuscular efficiency, enabling effective and efficient functional movement in humans [15,17].

DNS emphasizes diaphragmatic breathing during inhalation and eccentric abdominal contraction, increasing Intra-Abdominal Pressure (IAP), which is maintained during exhalation to stabilize trunk-limb coordination. Re-education and correction of the DNS breathing pattern are essential for maintaining proper posture and performing functional movements, for which the functional coordination of the diaphragm, pelvic floor muscles, and abdominal muscles, which regulate IAP, is important [15,16]. The central strategy of this breathing method is to improve diaphragmatic efficiency, help re-learn optimal movement patterns within the central nervous system, and improve postural alignment and the quality of movement [18,19].

Mahdieh et al. [20] found that DNS exercises improved dynamic balance and reduced the risk of injury in athletes compared to groups performing sprinting, shuttle runs, planks, and push-ups. This approach is based on developmental kinesiology, aiming to normalize or develop posture, breathing, and movement patterns. Furthermore, DNS exercises have been applied to improve daily living functions and enhance the performance of athletes.

Frank et al. [15] reported that DNS can positively affect the cervical spine alignment in individuals with forward head posture by inducing the correct simultaneous contraction of deep extensor and flexor muscles in the neck and back, as well as the pelvic floor muscles and the transverse abdominal muscle Son et al. [21] also indicated that dynamic neuromuscular stabilization exercises have a positive impact on breathing improvement and postural control in patients with cerebral palsy.

Gait, the most fundamental form of human movement, requires dynamic balance and coordination for safe and efficient mobility [22]. Research has shown that spontaneous breathing patterns can enhance gait stability [23]. Because balance is closely tied to dynamic stability, core strength—particularly via the modulation of IAP— is well known to be crucial. IAP fluctuates depending on posture and activity, such as standing, sitting, walking, or running, and typically peaks with foot contact during gait. It also increases significantly when lifting heavy loads, helping to reduce spinal loading [24]. Therefore, understanding the interaction between IAP and trunk muscle activity across various daily activities and disturbances is essential for injury prevention and rehabilitation.

DNS a rehabilitation approach rooted in developmental kinesiology, applies the principles of normal infant motor development to adults to correct maladaptive movement patterns [15]. DNS emphasizes diaphragmatic breathing during inhalation and eccentric abdominal contraction to increase IAP, which is then maintained during exhalation to stabilize trunk-limb coordination. Re-education and correction of DNS breathing patterns are essential for maintaining proper posture and executing functional movements. Functional coordination of the diaphragm, pelvic floor, and abdominal muscles— which regulate IAP— plays a vital role in this process [19,25]. Shaw & Shaw [14] demonstrated that diaphragmatic breathing training improves pulmonary function and the biomechanics of abdominal and thoracic movement, underscoring the importance of breathing-based core stabilization. This breathing-centered strategy improves diaphragm efficiency, supports the re-learning of optimal movement patterns by the central nervous system, and enhances posture alignment and movement quality [26,27].

From the biomechanical perspective, DNS increases intra-abdominal pressure to enhance trunk stability, thereby improving the gait efficiency of sedentary middle-aged women. However, activating a single element of the trunk stabilization complex is insufficient for generating adequate IAP during dynamic conditions [21]. In many cases, exercises performed without understanding proper breathing patterns and IAP regulation may be ineffective. Moreover, there is a lack of studies that simultaneously analyze the effects of breathing-focused DNS training on respiratory function, gait ability, and physical self-confidence in middle-aged women with abdominal obesity. Breathing-centered DNS exercise may improve abdominal and trunk stability, which can lead to enhanced gait and balance, and ultimately increased physical self-esteem. This integrative approach holds promise for improving gait patterns in physically inactive middle-aged women [28].

Therefore, the aim of this study is to analyze the effects of a six-week, breathing-focused DNS training program on respiratory function, gait performance, and physical self-esteem in middle-aged women with abdominal obesity.

METHODS

1. Study design

All participants underwent baseline assessments including body composition, waist circumference, pulmonary function, gait parameters, and physical self-esteem prior to the intervention. Both groups participated in a 6-week exercise program, consisting of two 50-minute sessions per week.

While both the experimental and control groups performed the same DNS protocol, the control group did not receive diaphragmatic breathing (DB) instruction, whereas the experimental group was trained in specific breathing techniques. Participants in the DB group were instructed to maintain IAP through diaphragmatic breathing during each DNS movement. In contrast, the control group performed the DNS exercises without any specific instructions regarding breathing. All sessions were conducted in a one-on-one format. For the experimental group, manual facilitation was provided to guide and monitor IAP during each movement. The control group received no such facilitation or breathing cues. Post-intervention assessments were conducted using the same methods as the pre-assessments, and changes were analyzed between groups.

2. Participants

Participants were recruited through women’s centers, apartment community centers, and women’s associations in Ulsan, South Korea. Inclusion criteria were: women aged 40 to 60 years, waist circumference of ≥ 85 cm, low physical activity within the last 6 months, having at least one child, and no history of hysterectomy. The required sample size was calculated using G*Power (version 3.1.9.4) with an alpha level of 0.05, statistical power of 0.95, and an effect size of 0.3. Based on this analysis, a minimum of 36 participants was required.

Middle-aged obese women, the subjects of the study, were randomly assigned to either the experimental or control group with equal probability using sealed opaque envelopes (envelope concealment), and there were no dropouts. To minimize bias caused by participants’ expectations regarding treatment efficacy, a single-blind design was employed. All participants provided informed consent after receiving a detailed explanation of the study’s purpose and procedures. The study protocol was reviewed and approved by the Institutional Review Board (IRB) of Dong-Eui University in accordance with the Bioethics and Safety Act (IRB approval number: DIRB-202504-HR-E-19).

3. Implementation of DNS-based diaphragmatic breathing

The experimental group focused on forming IAP through diaphragmatic breathing prior to performing DNS exercises. Participants were taught to adopt proper breathing patterns using verbal instruction and manual guidance by a trained therapist, who carefully monitored thoracoabdominal movement. Inhalation was guided to produce symmetrical and proportional expansion of the lower rib cage and abdominal wall in 360 degrees (anterior, lateral, and posterior directions). The therapist placed their hands on specific anatomical landmarks (e.g., groin area, lower ribs) to palpate and monitor the movement. Participants were instructed to feel their abdominal wall push outward against the therapist’s hands during inhalation, with emphasis on symmetrical and strong expansion.

Attention was given to maintaining a neutral position of the chest, pelvis, and spine throughout the movement, avoiding compensatory patterns such as shoulder elevation or excessive rib flaring. During exhalation, participants were instructed to actively contract the abdominal wall to maintain IAP and stabilize the trunk. They were guided to gently press against the therapist’s hands using abdominal pressure during exhalation, which helped train core control based on sustained IAP. Diaphragm function was also assessed by instructing participants to exhale while pushing against the clinician’s fingers, checking for abdominal wall tension. The entire training emphasized trunk stabilization through diaphragmatic breathing and IAP control as a prerequisite for all movements, thereby reinforcing its importance in maintaining stable and efficient movement during daily activities and functional tasks [15,20,26-30]. In contrast, the control group performed the DNS exercises without specific instructions or facilitation related to diaphragmatic breathing, and were only guided to perform movements within the neutral range of joint axes.

4. DNS exercise program

DNS exercise is an intervention based on developmental kinesiology, focusing on respiration and trunk stabilization. It is a method of exercise that progresses through the normal developmental stages from the supine position in infancy to walking [15].

The exercise program in this study was reconstructed by referring to the studies of Frank, Mahdieh, and Kobesova [15,20,28]. During DNS exercises, the application of respiration is crucial not only for creating IAP but also for simultaneously creating IAP and trunk stabilization. At this time, the coordinated movement of the diaphragm and core muscle groups induces the activation of spinal stabilization muscles, forming correct biomechanical alignment during exercise [15,20].

In the experimental group, the focus was on forming IAP through diaphragmatic breathing and trunk stabilization before the DNS exercise program. During training, subjects were instructed to acquire and maintain correct breathing patterns through verbal instructions and manual guidance from a skilled trainer, and the examiner closely palpated and observed abdominal and chest movements. The control group performed DNS exercises without clear instructions or signals for diaphragmatic breathing, within a range where the axis of the joints was not misaligned.

The exercise education for both the experimental and control groups was conducted by certified physical therapists who had completed the DNS specialist education program. Before each session, participants received education on correct posture and movement, and continuous verbal feedback and manual assistance were provided throughout the exercise. To ensure safety, a research assistant was present at all sessions to prevent falls and to address unexpected situations.

The program consisted of 10 core exercises designed to progressively enhance neuromuscular coordination.

Exercise difficulty was adjusted to match each individual’s physical abilities and level of movement control, guiding them to perform the movements accurately. The exercise program progressively increased in difficulty. Specifically, the level of exercise was adjusted through changes in posture, starting from a lying position, progressing to lying on the side, then sitting up from a side-lying position, transitioning from a quadruped position to a kneeling position, and finally, standing from a bear position. This was designed to increase the difficulty step-by-step, completing the overall movement. Detailed exercise methods and levels are presented in Table 1. This DNS exercise involved performing the exercise movements from levels 1 to 3 sequentially as one set during weeks 1-2, levels 1 to 4 during weeks 3-4, and levels 1 to 5 during weeks 5-6 [15,20,28].

All sessions were conducted by licensed physical therapists who had completed certified DNS education programs. Before each session, participants were given instruction on proper posture and movement execution. Continuous verbal feedback and manual assistance were provided throughout the sessions. For safety, a research assistant was present during all sessions to prevent falls and handle unexpected situations.

Each session lasted 50 minutes, comprising:

Warm-up (10 minutes): Light stretching targeting the lumbar and core muscles.

Main Exercise (30 minutes): All 10 DNS exercises performed as one sequence, with each movement repeated 4 times on both sides (1 set), for a total of 3 sets. A 30-second rest was provided between sets.

Cool-down (10 minutes): Static stretching and relaxation to release muscle tension and enhance flexibility.

A detailed breakdown of the 6-week DNS exercise program is presented in Table 1 and Fig. 1.

5. Measurement tools

1) Body composition analysis

Body fat mass (kg), body fat percentage (%), and skeletal muscle mass (kg) were measured using a touch-type bioelectrical impedance analysis (BIA) device (InBody 270^®, Biospace, Seoul, Korea). Before the assessment, participants removed their shoes and socks, grasped the electrode handles with both hands, and stood barefoot on the footplate electrodes. Body mass index (BMI) was calculated using the participant’s height and weight (kg/m²). The accuracy of this device has been reported to range from 93% to 96% [31].

2) Waist circumference measurement

Waist circumference was measured using the standardized WHO method. A measuring tape was wrapped horizontally around the midpoint between the lower margin of the last palpable rib and the top of the iliac crest, making sure the tape lay flat on the skin without compressing it. Measurements were taken at the end of a normal exhalation. According to the Korean Society for the Study of Obesity (2018), abdominal obesity is defined as a waist circumference ≥90 cm for men and ≥85 cm for women [32].

3) Pulmonary function test

Pulmonary function was evaluated using a digital spirometer (Pony FX, COSMED Inc., Italy) by measuring peak expiratory flow rate (PEF, L/min), forced expiratory volume in one second (FEV₁, L), and forced vital capacity (FVC, L). Participants were seated comfortably, held the mouthpiece securely with their lips, and were instructed to inhale maximally and then exhale as forcefully and completely as possible. Each test was performed three times, and the average value was used for analysis [27].

4) Body self-esteem

Body self-esteem was assessed using the Body Esteem Scale (BES), developed by Lipowska and Lipowski. This scale consists of 35 items rated on a 5-point Likert scale, yielding a maximum score of 80. Results are categorized into standardized Sten scores (1-3 =low, 4-7=moderate, 8-10 =high). The BES includes three subdomains: appearance/sexual attractiveness (AS), physical condition (PC), and weight control (WC). The scale has been validated across age and gender groups, with reported Cronbach’s alpha values ranging from 0.80 to 0.89, indicating high internal consistency Participants completed the questionnaire both before and after the intervention [33-35].

5) Gait parameters

Gait kinematics were assessed using a motion analysis system (Exbody 6100, Souls Korea) that automatically detects and tracks joint movements without the need for multiple attached sensors. The system captures 2D data through a built-in rear camera (30 Hz), which is then converted into 3D coordinates based on the X, Y, and Z axes. During standardized treadmill walking at a speed of 0.8 m/s for 6 minutes, the system measured trunk tilt, horizontal displacement of the center of gravity (COG), stride length, and step length. The reliability of these measurements was verified using Cronbach’s α, with 90% confidence, and statistical significance was set at p<.05 [36].

6. Data analysis

All data collected in this study were analyzed using SPSS version 29.0 for Windows (IBM Corp., USA), with the significance level set at α = 0.05. Descriptive statistics were used to analyze participants’ general characteristics. The normality of variables was tested using the Shapiro-Wilk test. Since the data did not meet normality assumptions, non-parametric tests were employed.

The Wilcoxon signed-rank test was used to compare pre- and post-intervention differences within each group (experimental vs. control) in respiratory function, gait, and body esteem. The Mann-Whitney U test was used to compare between-group differences in the changes observed after the 6-week intervention.

RESULTS

1. General characteristics of each group

A Shapiro-Wilk normality test was conducted to assess the general characteristics of the participants, and the results showed that the data from both groups did not satisfy normality (p<.05). Therefore, a nonparametric test, the Mann-Whitney U test, was used. A total of 36 participants were included in the study, with an average age of 56.44±5.97 years, average height of 160.64±4.59 cm, average weight of 74.11±6.66 kg, average waist circumference of 92.43±6.53 cm, and average BMI of 28.65±1.74. A homogeneity test for the baseline characteristics between the experimental and control groups revealed no statistically significant differences, indicating that the two groups were comparable. Detailed values are presented in Table 2.

2. Comparison of respiratory function

To compare pre- and post-intervention changes in respiratory function and body esteem between the experimental and control groups, the Shapiro-Wilk test was used to verify the normality of data, and both groups were found to not meet normality assumptions (p<.05). Accordingly, the Wilcoxon signed-rank test and the Mann-Whitney U test were applied. For respiratory function, peak expiratory flow (PEF) significantly increased from 4.29±0.31 L/s to 4.99±0.57 L/s in the experimental group (p<.001), and from 4.06±0.30 L/s to 4.47±0.47 L/s in the control group (p<.001). FVC significantly improved from 2.91±0.45 L to 4.03±0.73 L in the experimental group (p<.001) and from 2.81±0.50 L to 3.22±0.72 L in the control group (p<.001). FEV₁ also significantly increased from 2.85±0.56 L/s to 3.59±0.75 L in the experimental group (p <.001) and from 2.76±0.29 L to 3.06±0.37 L in the control group (p<.001).

When comparing the amount of change between the two groups, the experimental group showed significantly greater improvements. The mean change in PEF was 0.70±0.39 L/s in the experimental group and 0.41±0.30 L/s in the control group. The change in FVC was 1.11±0.48 L for the experimental group and 0.48±0.41 L for the control group. Similarly, the change in FEV₁ was 0.74±0.51 L in the experimental group and 0.30±0.18 L in the control group, showing statistically significant differences favoring the experimental group. These results are detailed in Tables 3 and 4.

3. Comparison of body self-esteem

The changes in body esteem scale before and after the intervention were also examined using the Wilcoxon signed-rank test and the Mann-Whitney U test, since normality was not met in either group (p<.05). In terms of body esteem scale, the experimental group showed a significant improvement from 112.06±7.91 to 126.56±5.70 (p<.001, from Wilcoxon signed-rank test), while the control group also improved significantly from 113.56±9.58 to 123.00±8.04 (p<.01, from Wilcoxon signed-rank test). The amount of change in body esteem scale was 14.50±7.69 in the experimental group and 9.44±7.49 in the control group, indicating a statistically significant difference between the two groups, with the experimental group demonstrating a greater increase (p <.05, from Mann-Whitney U test). The results are summarized in Tables 5 and 6.

4. Comparison of gait parameters

This study analyzed major gait parameters, including forward head posture (FHP), trunk lean angle, horizontal movement of the COG, step width, and stride length, which are commonly used objective indicators for gait and posture analysis. A Shapiro-Wilk normality test showed that normality was not satisfied in either group (p <.05), so the Wilcoxon signed-rank test and Mann-Whitney U test were employed for analysis. To reduce the risk of Type I error, the Holm method was applied to adjust the significance level.

FHP significantly decreased in the experimental group from 10.33±2.57° to 6.33±2.14° (p<.001), and in the control group from 10.44±2.73° to 8.39 ±3.03° (p <.01). Trunk lean angle also significantly decreased from 11.33±5.05° to 7.61±4.30° in the experimental group (p<.001), and from 9.78±3.78° to 8.33±3.80° in the control group (p<.05). The horizontal movement of the COG on the right side decreased from 5.17±1.15 cm to 3.00±0.97 cm in the experimental group (p>.05), and from 5.11±1.32 cm to 3.22±1.31 cm in the control group (p>.05). On the left side, it decreased from 4.39 ±0.92 cm to 2.72±1.07 cm in the experimental group (p>.05), and from 4.67±1.33 cm to 3.50±1.34 cm in the control group (p>.05). Step width significantly decreased from 13.61±4.51 cm to 11.44±1.89 cm in the experimental group (p<.001), and from 15.61±2.99 cm to 12.06±1.51 cm in the control group (p<.001).

Stride length on the left side significantly increased from 31.33±11.23 cm to 37.68±5.31 cm in the experimental group (p<.001). Although it increased from 27.66±7.06 cm to 29.21±5.54 cm in the control group, the change was not statistically significant (p>.05). For the right side, stride length also significantly increased in the experimental group from 32.86±11.43 cm to 37.81±6.15 cm (p<.001), whereas the control group showed a non-significant increase from 27.94 ±7.34 cm to 28.77±4.60 cm (p>.05).

When comparing the amount of change in gait parameters between the groups, FHP decreased by -4.00 ±1.61° in the experimental group and -2.06±0.94° in the control group, with a significantly greater reduction in the experimental group (p<.01). Trunk lean angle also showed a significantly greater reduction in the experimental group (-3.72±1.99°) compared to the control group (-1.44±1.34°) (p<.01). However, no significant differences were observed between the groups for changes in the horizontal movement of COG (both sides) or step width (p >.05). In contrast, the increase in left stride length was significantly greater in the experimental group (6.35±8.13 cm) compared to the control group (1.55 ±3.81 cm) (p<.05). For the right stride length, although the experimental group showed greater improvement (4.95±17.58 cm) than the control group (0.83±11.94 cm), this difference did not remain statistically significant after applying the Holm correction (p>.05). Full results are presented in Tables 7 and 8.

DISCUSSION

Abdominal obesity is increasingly recognized as a significant factor contributing to decreased pulmonary function even among ostensibly healthy adults. According to the systematic review by Gol & Rafraf [10], abdominal obesity negatively affects lung function via mechanical factors, such as restriction of diaphragm movement and reduced thoracic expansion capacity. Such impairments in respiratory function extend beyond simple changes in spirometer measures to influence overall physical activity capacity and postural control. In this context, the clinical trial by Stephens et al. [37] provides early evidence that diaphragmatic breathing patterns can positively affect balance ability, supporting the hypothesis that training in diaphragmatic breathing contributes to improvements in postural control and stability.

Madle et al. [38] objectively demonstrated a significant increase in abdominal wall tension (AWT) in various postures when applying the principles of DNS. This suggests that DNS can induce the coordinated activation of deep core muscle groups through proper diaphragmatic breathing and the rehabilitation of developmental postural patterns, thereby enhancing core stability and efficient intra-abdominal pressure regulation mechanisms. These mechanisms provide important evidence that DNS can positively impact the maintenance of physical function, particularly for middle-aged women who are prone to core function weakening and postural instability due to physical changes such as childbirth and menopause, through an integrated approach of breathing enhancement and postural stabilization.

Research by De La Plaza San Frutos et al. [39] and Sanchez-Ruiz et al. [40]. Inefficient breathing patterns weaken the stabilizing function of the diaphragm and disrupt intra-abdominal pressure regulation, leading to deactivation of deep core muscles. This can be linked to the potential mechanism of impaired respiratory function and subsequent balance-related functional decline, which can also occur in middle-aged women. DNS exercises utilize an integrated approach to breathing and posture, training optimal diaphragmatic breathing to efficiently regulate intra-abdominal pressure and induce coordinated activation of deep core muscle groups, thereby restoring central stability. Consequently, DNS exercises can be effectively used not only to improve function in MS patients but also to enhance balance and maintain and improve physical function in middle-aged women by improving respiratory efficiency and ensuring core stability.

In this study, a 6-week intervention period was established as the minimum time required for neuromuscular system reorganization and the learning of new movement patterns. DNS training enhances postural stability through deep stabilization and intra-abdominal pressure control, promoting neuromuscular adaptation through repetitive stimulation. The study by Ghavipanje et al. [41], which demonstrated the significant effects of a 6-week DNS program on lower back pain relief and functional improvement, supports its clinical validity. Furthermore, Bentley et al. [42] emphasized that repeated respiratory training interventions are essential for autonomic nervous system balance and mental stability, suggesting that 6 weeks is a suitable period for the neurophysiological acquisition and stabilization of breathing patterns. Therefore, a 6-week intervention can be considered an appropriate duration for achieving clinical effects through structural and functional reorganization of the neuromuscular system and improvement of respiratory function.

Ghavipanje et al. [41] reported that a 6-week DNS training program applied to obese postpartum women with low back pain had significant effects on alleviating low back pain, improving function, and enhancing respiratory function. This is based on the mechanism by which DNS optimizes intra-abdominal pressure and activates deep core muscles through proper diaphragmatic breathing, thereby stabilizing the unstable trunk and increasing respiratory efficiency. In particular, in middle-aged women with impaired core function, such as postpartum women, changes in breathing patterns and postural instability due to aging and hormonal changes are common, so this mechanism of DNS is important. DNS can correct inefficient breathing patterns in middle-aged women and restore the function of the deep core muscles connected to them, thereby improving postural stability and overall functional movement.

In this study, we aimed to ensure research consistency by applying the inherent principles of DNS exercises and standardized protocols based on the Prague School guidelines. However, the DNS approach, which is based on developmental kinesiology principles and aims to improve functional movement through the reactivation of stabilizing muscles via respiration and muscle coordination [15,16], necessitates the guidance of a skilled therapist to induce joint centration and accurately direct the application of breathing. Especially considering the often-overlooked importance of respiration and the differences in individual biomechanical characteristics during DNS exercises, individualized guidance is essential for effective IAP generation and optimal postural alignment. The importance of such individualized guidance is demonstrated by the influence of deep muscle training on posture and breathing quality [43] and the effects of DNS on diaphragmatic movement and gait performance in patients with cerebral palsy [21], acting as a key element for precisely improving neurological respiratory control and functional movement.

In this study, the experimental group that performed DNS exercises combined with diaphragmatic breathing showed statistically significant improvements in PEF, FVC, and FEV₁ values compared to the control group, providing strong evidence of overall improvements in lung function. These findings support those of Yong et al. [44], who reported that diaphragmatic breathing exercises significantly increased functional residual capacity and FVC in healthy adults, thereby improving pulmonary function. Thus, applying DNS with diaphragmatic breathing in middle-aged women with abdominal obesity has important clinical implications: it can enhance respiratory efficiency and lung volume, reduce the respiratory burden during physical activity, and contribute to the improvement of overall physical function. This may be particularly valuable as a preventive or therapeutic strategy for middle-aged obese women who are vulnerable to respiratory issues.

Kolar’s DNS protocol emphasizes optimal breathing, particularly the use of IAP, to restore bodily stability. This aligns with prior research that suggests diaphragmatic breathing may serve as a viable non-pharmacological, self-management intervention (e.g., Hopper et al. [45]). Within this framework, enhancing the diaphragmatic breathing component of DNS in this study was a strategic attempt to address the unique respiratory and stability challenges faced by women with abdominal obesity. Indeed, the experimental group, where diaphragmatic breathing was deliberately induced, showed much more pronounced and statistically significant improvements in respiratory function and related measures compared to the control group. This demonstrates that the application of DNS exercise emphasizing diaphragmatic breathing is very effective for improving respiratory function and overall stability in abdominally obese middle-aged women.

Frank et al. [15] have emphasized that the diaphragm plays a key role in activating primordial movement patterns stored in the central nervous system and in correcting inappropriate movement patterns; in this respect, strengthening diaphragm function is closely tied to improvements in general body control [25,46]. From this perspective, the broadly improved respiratory function seen in this study is consistent with prior findings that respiratory muscles contribute significantly to spinal stability and movement capability. Furthermore, as Stephens et al. [37] showed in their clinical trial, diaphragmatic breathing training may positively influence balance ability; similarly, the training in this study appears to contribute not only to improved lung function but also to enhanced postural control and stability.

Abdominal obesity is also associated with declines in muscle function, reduced mobility, and increased risk of falls, which makes this an especially critical issue in middle-aged women [11,47]. The DNS exercises used here, in line with Kolar’s emphasis, increase IAP from a biomechanical standpoint and thereby enhance trunk stability. DNS retrains central motor patterns, reduces unnecessary trunk sway and asymmetry, and improves gait efficiency. Particularly in overweight and abdominally obese women, the improvements in lumbopelvic stability and core strength translate into better gait symmetry and energy efficiency. In this study, diaphragmatic breathing led to a reduction in FHP by about 38.7% and in trunk lean angle by around 32.8% in the experimental group, considerably greater improvements than those in the control group (which saw about 19.6% and 14.8% reductions, respectively). Such postural alignment improvements are likely due to the core stabilizing role of the diaphragm, working in coordinated activation with the transverse abdominis to effectively increase IAP. These biomechanical mechanisms effectively correct compensatory postural patterns such as FHP or forward trunk lean; such corrections are clinically meaningful especially in abdominally obese middle-aged women [12]. Hence, posture improvement through diaphragmatic breathing is of great clinical value — it substantially enhances trunk stability during gait, improves dynamic balance ability, and helps prevent musculoskeletal pain and functional movement limitations in daily life [48].

With regard to horizontal movement of the COG, the study found significant decreases after the intervention in both the experimental and control groups. This suggests that the exercise intervention positively affects dynamic balance ability and postural control in abdominally obese middle-aged women. The reduction in COG movement is an important clinical indicator [49], for example, have connected reductions in lateral displacement of COG during gait with improved gait stability and reduced fall risk. However, the fact that the experimental group did not show a statistically significant additional improvement over the control group in the horizontal displacement of COG indicates an important implication: integration of breathing in DNS may not yield superior effects for all balance/postural variables. Future research should more precisely analyze the individual role of breathing components in DNS and the optimal conditions under which they change specific gait and balance metrics.

Analysis of step width showed that before the intervention, participants had wider step widths than healthy older adults, likely reflecting compensatory widening of the base of support in response to increased body mass and instability [50,51]. Following the intervention, both groups showed significant reductions in step width. This narrowing of step width likely represents a normalization toward a more efficient and stable gait pattern, which is directly related to improved dynamic gait balance and reduced fall risk [52,53]. Therefore, step width reduction can be considered an important clinical indicator of improved gait control in abdominally obese middle-aged women. Still, the fact that the experimental group did not show a statistically significant additional decrease in step width versus the control group underscores that not all gait parameters respond equally to the addition of diaphragmatic breathing. Detailed investigations of how breathing patterns modify gait mechanics are warranted to delineate these differential effects.

The decrease in stride length in women with abdominal obesity is closely related to trunk instability, and the activation of the diaphragm through DNS exercises enhances trunk stability and improves stride length by strengthening co-contraction with the transversus abdominis muscle [54,55]. In this study, the integrated DNS approach focused on improving the generation of appropriate IAP and the function of the trunk stabilization complex in dynamic situations, rather than simply activating individual muscles [26,56,57]. Indeed, the significant improvement in postural alignment and gait-related indicators observed in the experimental group of this study strongly supports the efficacy of this integrated approach. In particular, the fact that the rate of increase in right stride length (15.0%) was relatively lower than that of the left stride length (20.3%) is an interesting result. Considering that right-footedness affects the recruitment function in unilateral and bilateral contexts, as reported in the study by Hart and Gabbard [58], and that there are many right-footed people in the population, the right lower extremity may have maintained a relatively higher level of functional coordination and efficiency before the intervention, leaving less room for improvement compared to the left lower extremity. These results support that the DNS approach, which focuses on integrated respiratory muscle exercises, is effective in improving body imbalances and inducing positive changes throughout the gait patterns of inactive middle-aged women.

The study also found statistically significant gains in body esteem in the experimental group relative to the control group. This aligns with prior work in respiratory rehabilitation and obesity management, which has shown that improvements in physical function often accompany enhanced self-esteem or body image [59-61]. Just as improved body composition, strength, balance, and respiration have positive psychological effects in obese pregnant women or in other populations, so too in this study, the DNS plus diaphragmatic breathing intervention appears to generate broader psychosocial benefits. While literature directly addressing the causal link between DNS, respiratory training, and body esteem is still limited, the functional improvements and psychological benefits shown here suggest that emphasizing breathing and core stability together provides a comprehensive intervention with significant clinical value for this population.

Overall, the application of a DNS training program with a strong diaphragmatic breathing component among middle-aged women with abdominal obesity produced positive changes in respiratory function, posture, gait, balance, and body esteem. These results suggest that diaphragmatic breathing might be developed as a viable, non-pharmacological, self-management strategy for improving functional capacity and quality of life in this high-risk population. Because few previous studies have combined all of these outcome domains in this population, the present findings are particularly valuable.

CONCLUSION

Existing DNS protocols often emphasize stabilization through breathing, but in practice many interventions neglect proper breathing, focusing instead on movement alone. This study aimed to examine the difference between performing DNS with and without proper diaphragmatic breathing. The results indicate that DNS performed with correctly executed diaphragmatic breathing yields superior benefits in respiratory function, gait ability, and body esteem among middle-aged women with abdominal obesity. Because there were few prior studies using a similar integrated approach, this research offers valuable evidence for the independent effect of breathing training within DNS.

Furthermore, this study underscores the potential applicability of such integrative interventions in rehabilitation and health promotion settings. Emphasizing core stability, breathing efficiency, and overall physical function together may offer strong clinical benefit. For middle-aged women with abdominal obesity, this integrated DNS + diaphragmatic breathing approach could be a key strategy for improving not only physical health but also psychological well-being.

Notes

ACKNOWLEDGMENTS

The authors received no financial support for this article.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTIONS

Conceptualization: DJ Kim; Data curation: DJ Kim; Formal analysis: DJ Kim, HY Kwon; Funding acquisition: DJ Kim, HY Kwon; Methodology: DJ Kim, HY Kwon; Project administration: DJ Kim, HY Kwon; Visualization: DJ Kim, HY Kwon; Writing - original draft: DJ Kim, HY Kwon; Writing - review & editing: DJ Kim, HY Kwon.

Fig. 1.

The program consisted of 10 core exercises designed to progressively enhance neuromuscular coordination. The DNS program used in this study was adapted from prior work by Frank et al. [15], Mahdieh et al. [20], and Kobesova et al. [28].

Table 1.

The 6-week DNS exercise program

Exercise (Time)	Level	Main exercise movements and descriptions	Key objective and developmental area
Warm-up (10 min)	Light stretching for the lower back and core
Main (3 min)	1 Level 3-4.5 months position	1. Baby Rock: Lifting and holding arms and legs simultaneously to build support and coordination.	Initial stability secured: Overall trunk stabilization and activation of deep core muscles.
	2 Level 5-6 months position	2. Rolling (turning the body sideways)	Fundamental of Rotational and Lateral Stability: Training for limb-independent movement and trunk rotation stability.
	2 Level 5-6 months position	3. Side plank transition with bent elbows
	3 Level 7-8 months position	4. Sitting sideways with extended elbows: Enhancing Lateral Stability by Lifting the Body.	Deepening Lateral Stability and Posture Control: Strengthening Lateral Trunk Muscles and Enhancing Balance.
		5. Supported Kneeling
		6. Quadruped position: Improving torso control.
	4 Level 9-11 months position	7. Tripod/Bear Stance: After rolling, lift the hips to transition into a bear stance, developing full-body support and coordination	Whole-body coordination and switching ability: Enhancing whole-body coordination and neuromuscular control.
	5 Level 11-13 months position	8. High Kneeling Position: Maintaining core stability by straightening the spine. (Keep the spine upright and elongated and one leg kneeling)	Functional Movement Integration and Enhancement: Balance and Whole-Body Strength Enhancement, Real Life Application. Functional Movement Integration and Enhancement: Balance and Whole-Body Strength Enhancement, Real-Life Application.
		9. Bear Position: Whole-body coordination and core strengthening.
		10. Returning to Squatting Position: Lower limb function and trunk balance integrated training. (Additional movement: Standing Up & Sitting Down with Arms Overhead): Utilizing functional movements of the whole body.
Cool-down (10 min)	Static stretching and relaxation

Table 2.

General characteristics of each group

	Experimental (n=18)	Control (n=18)	Z	p
Age	56.11±5.97	56.78±5.45	-0.30	.767
Height (cm)	161.28±4.66	160.00±4.56	-0.75	.462
Weight (kg)	74.23±7.15	73.99±6.35	-0.24	.815
Waist Circumferenc (cm)	92.10±5.92	92.76±7.26	-0.08	.938
BMI	28.44±1.97	28.85±1.51	-0.78	.443

Quantitative data (age, height, waist circumference, BMI) are presented as mean±standard deviation and were analyzed using Mann-Whitney U test.

Table 3.

Comparison of respiratory function

Variances		Group	Pre	Post	Z	p
Respiratory function	PEF (L/s)	Experimental	4.29±0.31	4.99±0.57	-3.72	.00^***
	PEF (L/s)	Control	4.06±0.30	4.47±0.47	-3.72	.00^***
	FVC (L)	Experimental	2.91±0.45	4.03±0.73	-3.72	.00^***
	FVC (L)	Control	2.81±0.50	3.22±0.72	-3.66	.00^***
	FEV₁ (L)	Experimental	2.85±0.56	3.59±0.75	-3.72	.00^***
	FEV₁ (L)	Control	2.76±0.29	3.06±0.37	-3.59	.00^***

^*** p<.001, Quantitative data (respiratory function) are presented as mean±standard deviation. Quantitative data (respiratory function) were analyzed using Wilcoxon signed rank test.

PEF, peak expiratory flow rate; FVC, forced vital capacity; FEV₁, forced expiratory volume in one second.

Table 4.

Difference in respiratory function changes between groups

Variances		Experimental	Control	Z	p
Respiratory function	PEF (L/s)	0.70±0.39	0.41±0.30	-2.79	.005^**
	FVC (L)	1.11±0.48	0.48±0.41	-4.56	.000^***
	FEV₁ (L)	0.74±0.51	0.30±0.18	-3.48	.000^***

^** p<.01,

^*** p<.001, Quantitative data (respiratory function) are presented as mean±standard deviation. Quantitative data (respiratory function) were analyzed using Mann-Whitney U test.

PEF, peak expiratory flow rate; FVC, forced vital capacity; FEV₁, forced expiratory volume in one second.

Table 5.

Comparison of body self-esteem

Variances	Group	Pre	Post	Z	p
Body self-esteem	Experimental	112.06±7.91	126.56±5.70	-3.62	.00^***
Body self-esteem	Control	113.56±9.58	123.00±8.04	-5.35	.00^***

^*** p<.001, Quantitative data (body self-esteem) are presented as mean±standard deviation. Quantitative data (body self-esteem) were analyzed using Wilcoxon signed rank test.

Table 6.

Difference in changes in body self-esteem between groups

Variances	Experimental	Control	Z	p
Body self-esteem	14.50±7.69	9.44±7.49	-2.33	.020^*

^* p<.05, Quantitative data (body self-esteem) are presented as mean±standard deviation. Quantitative data (body self-esteem) were analyzed using Mann-Whitney U test.

Table 7.

Comparison of gait parameters

Variances	Group	Pre	Post	Z	p
FHP (º)	Experimental	10.33±2.57	6.33±2.14	-3.75	.00^***
FHP (º)	Control	10.44±2.73	8.39±3.03	-3.76	.00^***
Trunk lean angle (º)	Experimental	11.33±5.05	7.61±4.30	-3.64	.00^***
Trunk lean angle (º)	Control	9.78±3.78	8.33±3.80	-3.27	.00^***
Horizontal movement of COG RT (cm)	Experimental	5.17±1.15	3.00±0.97	-3.77	.00^***
Horizontal movement of COG RT (cm)	Control	5.11±1.32	3.22±1.31	-3.78	.00^***
Horizontal movement of COG LT (cm)	Experimental	4.39±0.92	2.72±1.07	-3.62	.00^***
Horizontal movement of COG LT (cm)	Control	4.67±1.33	3.50±1.34	-3.52	.00^***
Step Width (cm)	Experimental	13.61±4.51	11.44±1.89	-2.50	.01^*
Step Width (cm)	Control	15.61±2.99	12.06±1.51	-3.44	.00^***
Stride Length Lt (cm)	Experimental	12.33±4.42	14.83±2.09	-2.58	.01^**
Stride Length Lt (cm)	Control	10.89±2.78	11.50±2.18	-1.71	.10
Stride Length Rt (cm)	Experimental	12.94±4.50	14.89±2.42	-2.05	.04^*
Stride Length Rt (cm)	Control	11.00±2.89	11.33±1.81	-0.98	.35

^* p<.05,

^** p<.01,

^*** p<.001, Quantitative data (gait parameters) are presented as mean±standard deviation and were analyzed using Wilcoxon signed rank test.

FHP, forward head posture; COG, center of gravity; RT, right; LT, left.

Table 8.

Difference in changes in gait parameters between groups

Variances	Experimental	Control	Z	p
FHP (º)	-4.00±1.61	-2.06±0.94	-3.72	.00^***
Trunk lean angle (º)	-3.72±1.99	-1.44±1.34	-3.47	.00^***
Horizontal movement of COG RT (cm)	-2.17±0.86	-1.89±0.76	-0.95	.39
Horizontal movement of COG LT (cm)	-1.67±0.84	-1.17±0.71	-1.94	.07
Step Width (cm)	-2.17±3.24	-3.56±2.41	-1.26	.23
Stride Length Lt (cm)	2.50±3.20	0.61±1.50	-2.85	.00^**
Stride Length Rt (cm)	1.94±3.61	0.33±2.79	-2.22	.03^*

^* p<.05,

^** p<.01,

^*** p<.001, Quantitative data (gait parameters) are presented as mean±standard deviation and were analyzed using Mann-Whitney U test.

FHP, forward head posture; COG, center of gravity; RT, right; LT, left.

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