Effects of Progressive Neuromuscular Stabilization Exercises Versus Aerobic Exercises on Body Composition and Postural Balance in Children With Obesity

Effects of Progressive Neuromuscular Stabilization Exercises Versus Aerobic Exercises on Body Composition and Postural Balance in Children With Obesity: A Randomized Controlled Trial

Introduction: Childhood obesity can impair postural control, balance, and motor skills, thereby limiting participation in physical activity. Aerobic exercise is widely used to improve cardiovascular fitness and support weight management in children with obesity. In recent years, however, Progressive Neuromuscular Stabilization (PNS) exercises, which aim to retrain the neuromuscular system, have been suggested to have beneficial effects on core stability, balance, and postural control. Technology-assisted exercise interventions may increase children's participation and enhance motivation throughout the rehabilitation process. This study aims to compare the effectiveness of technology-assisted PNS exercises with conventional aerobic exercise in children with obesity.

Methods: This study will be conducted among children attending the Department of Pediatrics, Istanbul University-Cerrahpaşa who meet the eligibility criteria. Children aged 12-18 years with obesity will be recruited. Participants will be randomly allocated into three groups: the Aerobic Exercise (AE) group, the Progressive Neuromuscular Stabilization (PNS) group, and the Control group.

Participants in the exercise groups will receive supervised exercise sessions twice weekly for 12 weeks in a clinical setting and will be instructed to perform home-based exercises on the remaining days. Home exercise programs will be delivered through the BeCure® mobile application, where exercise videos will be uploaded, and participants will be asked to perform progressively advancing exercises on a weekly basis. The control group will receive a single session of exercise counseling. Outcome assessments will be performed before and after the intervention.

Sample Size: The sample size was calculated using G*Power version 3.1. Based on moderate effect sizes reported in the literature (Lengkana et al., 2019), the effect size was set at f = 0.30, with a significance level of α = 0.05 and statistical power of 1 - β = 0.95. Power analysis for a repeated-measures design with three groups and two measurement time points (baseline and post-intervention) indicated a minimum total sample size of 48 participants. To account for potential dropouts, a total of 54 participants will be recruited. Participants will be assigned to the study groups using block randomization stratified by age and sex.

Primary Outcome Measure:

Balance and postural control will be assessed using the Biodex Balance System.

Secondary Outcome Measures:

Body composition will be evaluated using Body Mass Index (BMI), triceps and subscapular skinfold thickness, waist circumference, and Bioelectrical Impedance Analysis (BIA) to determine body fat percentage. Core muscle endurance will be assessed using the Prone Plank Test and the Side Plank Test. Functional performance will be evaluated using the 6-Minute Walk Test (6MWT), the 30-Second Sit-to-Stand Test (30-s STS), and the 20-Meter Shuttle Run Test.

Physical activity level will be assessed using the Physical Activity Questionnaire for Children (PAQ-C). Self-perception and body image will be evaluated using the Self-Perception Profile for Children (SPPC). Health-related quality of life will be assessed using the Pediatric Quality of Life Inventory (PedsQL), while fatigue will be evaluated using the PedsQL Multidimensional Fatigue Scale. Posture will be assessed using the New York Posture Rating Scale.

Study Plan:

Each exercise session will last approximately 40 minutes, consisting of a 5-minute warm-up, 30 minutes of the main exercise program, and a 5-minute cool-down.

Study Overview

• Status: Recruiting
• Conditions: Exercise; Childhood Obesity; Aerobic Exercise
• Intervention / Treatment: Other: Progressive Neuromuscular Stabilization Exercise; Other: Aerobic Exercise

Detailed Description

Detailed Study Description Background

Childhood obesity is a major global public health concern associated with numerous adverse health outcomes, including metabolic, cardiovascular, and musculoskeletal disorders. Beyond these well-recognized complications, obesity negatively affects postural control, balance, motor performance, and functional movement capacity. Excess body weight alters biomechanical alignment, shifts the center of gravity, and impairs neuromuscular coordination, thereby increasing postural instability and reducing participation in physical activity. Consequently, children with obesity often develop a sedentary lifestyle, which further exacerbates obesity and its associated health risks.

Aerobic exercise is widely recommended as a first-line intervention for childhood obesity because of its well-established benefits in improving cardiovascular fitness, energy expenditure, body composition, and overall physical health. However, aerobic exercise alone may not sufficiently address deficits in neuromuscular control, postural stability, and core muscle function, which are common in children with obesity.

Progressive Neuromuscular Stabilization (PNS) exercises are based on the principles of developmental kinesiology and progressive motor control training. These exercises aim to improve postural alignment, enhance core stability, optimize neuromuscular coordination, and restore efficient movement patterns through progressively challenging stabilization tasks. Recent evidence suggests that neuromuscular stabilization exercises may improve balance, postural control, movement quality, and functional performance in pediatric populations. Nevertheless, evidence regarding their effectiveness in children with obesity remains limited.

In addition, adherence to long-term exercise programs represents one of the greatest challenges in pediatric obesity management. Technology-assisted exercise interventions delivered through mobile applications may increase exercise adherence by providing structured guidance, visual demonstrations, progressive exercise progression, and continuous motivation. Therefore, integrating technology-supported home exercise programs with supervised clinical sessions may improve treatment compliance and maximize intervention effectiveness.

This randomized controlled trial aims to compare the effects of technology-assisted Progressive Neuromuscular Stabilization exercises and conventional aerobic exercise on balance, postural control, body composition, functional performance, and quality of life in children with obesity.

Methods

This study will be conducted at the Department of Pediatrics, Istanbul University-Cerrahpaşa, among children referred to the pediatric obesity outpatient clinic. Participants meeting the eligibility criteria will be invited to participate after obtaining written informed consent from their parents or legal guardians and assent from the children.

Children aged 12 to 18 years who are classified as obese according to age- and sex-specific criteria will be enrolled. Eligible participants will be randomly assigned using age- and sex-stratified block randomization into one of three study groups:

Progressive Neuromuscular Stabilization (PNS) Exercise Group Aerobic Exercise (AE) Group Control Group

Both intervention groups will participate in a 12-week exercise program, attending supervised clinical exercise sessions twice weekly. Each session will last approximately 40 minutes, including:

5 minutes of warm-up, 30 minutes of the main exercise program, 5 minutes of cool-down exercises.

In addition to supervised sessions, participants in both intervention groups will perform home-based exercises on the remaining weekdays. Home exercise programs will be delivered through the BeCure® mobile application, where exercise videos prepared specifically for each intervention will be uploaded. Participants will be instructed to complete progressively advancing exercise programs each week. Exercise adherence will be monitored through the mobile application, and participants will receive regular follow-up to encourage compliance.

The PNS intervention will consist of progressively challenging exercises targeting diaphragmatic breathing, trunk stabilization, neuromuscular coordination, developmental movement patterns, proprioception, balance, and postural control. Exercise difficulty will increase throughout the intervention by incorporating unstable surfaces, resistance, dual-task activities, and functional movement progression.

The aerobic exercise program will include age-appropriate rhythmic and functional aerobic activities such as walking, stepping, dynamic movement games, and interval-based exercises. Exercise intensity will be progressively increased according to participants' functional capacity throughout the intervention.

Participants allocated to the control group will receive a single standardized exercise counseling session that includes recommendations regarding healthy lifestyle habits and physical activity but will not participate in the supervised exercise intervention.

Outcome assessments will be performed at baseline and immediately after completion of the 12-week intervention period by assessors blinded to group allocation whenever possible.

Sample Size

Sample size was calculated using G*Power version 3.1 based on previously published findings (Lengkana et al., 2019). Assuming a medium effect size (f = 0.30), a significance level of α = 0.05, and a statistical power of 95% (1-β = 0.95), repeated-measures ANOVA with three groups and two assessment time points required a minimum total sample size of 48 participants. Considering potential dropouts during the intervention, the final planned sample size is 54 participants.

Primary Outcome

The primary outcome of the study is balance and postural control, which will be assessed using the Biodex Balance System. Static and dynamic postural stability indices, including the Overall Stability Index (OSI), Anterior-Posterior Stability Index (APSI), and Medial-Lateral Stability Index (MLSI), will be recorded.

Secondary Outcomes

Secondary outcome measures include:

Body composition Body Mass Index (BMI) Waist circumference Triceps skinfold thickness Subscapular skinfold thickness Body fat percentage measured by Bioelectrical Impedance Analysis (BIA) Core muscle endurance Prone Plank Test Side Plank Test Functional performance 6-Minute Walk Test (6MWT) 30-Second Sit-to-Stand Test 20-Meter Shuttle Run Test Physical activity level Physical Activity Questionnaire for Children (PAQ-C) Self-perception and body image Self-Perception Profile for Children (SPPC) Health-related quality of life Pediatric Quality of Life Inventory (PedsQL) Fatigue Pediatric Quality of Life Inventory Multidimensional Fatigue Scale Postural assessment New York Posture Rating Scale Expected Significance

This study will provide evidence regarding the comparative effectiveness of technology-assisted Progressive Neuromuscular Stabilization exercises and conventional aerobic exercise in children with obesity. The findings may contribute to the development of more comprehensive rehabilitation strategies that not only improve body composition but also enhance balance, postural control, neuromuscular function, functional capacity, and exercise adherence. Furthermore, integrating mobile application-based home exercise programs into pediatric obesity rehabilitation may offer a practical and sustainable approach for increasing long-term participation in physical activity and improving treatment outcomes.

• Study Type: Interventional
• Enrollment (Estimated): 54
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Emine Dilek Kurbaloğlu, PhD Student; Phone Number: +905416258918; Email: fzt.edilek@gmail.com
• Study Contact Backup: Name: Ela Tarakcı, Professor; Phone Number: +905422175730; Email: etarakci@iuc.edu.tr

Study Locations

• Turkey (Türkiye)
  • Istanbul, Turkey (Türkiye)
    • Recruiting
    • Istanbul University- Cerrahpasa
    • Contact: Emine Dilek Kurbaloğlu, PhD Student; Phone Number: +905416258918; Email: fzt.edilek@gmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Aged 12 to 18 years
• Classified as having Class I obesity (Body Mass Index [BMI] ≥95th percentile and <120% of the 95th percentile for age and sex) or Class II obesity (BMI ≥120% and <140% of the 95th percentile for age and sex), according to the Centers for Disease Control and Prevention (CDC) age- and sex-specific growth charts.
• Able to maintain a single-leg stance on the non-dominant leg with eyes closed for less than 30 seconds.
• Written informed consent provided by a parent or legal guardian, and assent obtained from the participant.
• Willing and able to participate in the study.

Exclusion Criteria:

• Classified as having Class III obesity (Body Mass Index [BMI] ≥140% of the 95th percentile for age and sex).
• Presence of an orthopedic condition that would prevent participation in the exercise program.
• History of any injury or surgery within the previous 6 months.
• Presence of a chronic neurological disorder.
• Presence of a psychiatric disorder.
• Presence of a severe cognitive impairment.
• Presence of cardiovascular disease.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Progressive Neuromuscular Stabilization (PNS) Exercise Group; Participants assigned to the Progressive Neuromuscular Stabilization (PNS) group will participate in a 12-week exercise program consisting of supervised clinical sessions twice weekly and technology-assisted home-based exercises on the remaining weekdays. The exercise program will progressively target diaphragmatic breathing, core stabilization, neuromuscular coordination, balance, postural control, proprioception, and functional movement patterns. Exercise difficulty will gradually increase by incorporating unstable surfaces, resistance exercises, dual-task activities, and dynamic functional tasks. Home exercises will be delivered through the BeCure® mobile application using progressively updated instructional videos. Intervention Behavioral: Progressive Neuromuscular Stabilization Exercise A progressive neuromuscular exercise program designed to improve core stability, postural control, balance, proprioception, and neuromuscular coordination through supervised and home-based exerc	Other: Progressive Neuromuscular Stabilization Exercise; Progressive Neuromuscular Stabilization Exercise Participants will complete a 12-week Progressive Neuromuscular Stabilization (PNS) exercise program consisting of supervised clinical sessions twice weekly and home-based exercises delivered through the BeCure® mobile application. The program is designed to improve core stability, balance, postural control, and neuromuscular coordination through progressively challenging exercises.
Experimental: Aerobic Exercise Group; Participants assigned to the aerobic exercise group will complete a 12-week exercise program consisting of supervised clinical sessions twice weekly and home-based aerobic exercise on the remaining weekdays. The intervention will include age-appropriate aerobic activities such as walking, stepping exercises, dynamic movement games, rhythmic exercises, and interval training. Exercise intensity will be progressively increased according to participants' functional capacity. Home exercise sessions will be delivered through the BeCure® mobile application using weekly exercise videos. Intervention Aerobic Exercise A progressive aerobic exercise program designed to improve cardiovascular fitness, physical activity level, functional capacity, and body composition through supervised and home-based exercise over a 12-week period.	Other: Aerobic Exercise; Aerobic Exercise Participants will complete a 12-week aerobic exercise program consisting of supervised clinical sessions twice weekly and home-based exercises delivered through the BeCure® mobile application. The program includes progressive aerobic activities aimed at improving cardiovascular fitness, physical activity level, and body composition.
No Intervention: Control Group; Participants assigned to the control group will receive a single standardized exercise counseling session at baseline regarding healthy lifestyle behaviors and physical activity recommendations. No supervised exercise intervention or structured home exercise program will be provided during the 12-week study period. Participants will continue their usual daily activities. Intervention Control Group Participants will receive a one-time standardized counseling session including education on healthy lifestyle behaviors, physical activity recommendations, and obesity management.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Overall Stability Index (OSI)	Overall postural stability will be assessed using the Biodex Balance System. Lower scores indicate better postural stability.	Baseline and post-intervention (Week 12)
Change in Anterior-Posterior Stability Index (APSI)	Anterior-posterior postural stability will be assessed using the Biodex Balance System. Lower scores indicate better stability.	Baseline and post-intervention (Week 12)
Change in Medial-Lateral Stability Index (MLSI)	Medial-lateral postural stability will be assessed using the Biodex Balance System. Lower scores indicate better stability.	Baseline and post-intervention (Week 12)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Body Mass Index	Body mass index will be calculated by dividing body weight in kilograms by height in meters squared.	Baseline and post-intervention (Week 12)
Change in Waist Circumference	Waist circumference will be measured in centimeters using a non-elastic measuring tape.	Baseline and post-intervention (Week 12)
Change in Skinfold Thickness	Triceps and subscapular skinfold thickness will be measured in millimeters using a skinfold caliper.	Baseline and post-intervention (Week 12)
Change in Body Fat Percentage	Body fat percentage will be assessed using bioelectrical impedance analysis.	Baseline and post-intervention (Week 12)
Change in Prone Plank Duration	Core muscle endurance will be assessed by recording the maximum time, in seconds, that the participant can maintain the prone plank position with correct alignment.	Baseline and post-intervention (Week 12)
Change in Side Plank Duration	Lateral core muscle endurance will be assessed by recording the maximum time, in seconds, that the participant can maintain the side plank position.	Baseline and post-intervention (Week 12)
Change in 6-Minute Walk Test Distance	Functional exercise capacity will be assessed by measuring the total distance, in meters, walked during the 6-Minute Walk Test.	Baseline and post-intervention (Week 12)
Change in 30-Second Sit-to-Stand Test	Lower-extremity functional performance will be assessed by recording the number of correctly completed sit-to-stand repetitions within 30 seconds.	Baseline and post-intervention (Week 12)
Change in 20-Meter Shuttle Run Performance	Cardiorespiratory fitness will be assessed using the 20-Meter Shuttle Run Test. Performance will be recorded according to the number of completed stages, laps, or total distance.	Baseline and post-intervention (Week 12)
Change in Physical Activity Level	Physical activity level will be assessed using the Physical Activity Questionnaire for Children. Higher scores indicate a higher level of physical activity.	Baseline and post-intervention (Week 12)
Change in Self-Perception	Self-perception will be assessed using the Self-Perception Profile for Children. Higher scores indicate more positive self-perception.	Baseline and post-intervention (Week 12)
Change in Health-Related Quality of Life	Health-related quality of life will be assessed using the Pediatric Quality of Life Inventory. Higher scores indicate better health-related quality of life.	Baseline and post-intervention (Week 12)
Change in Fatigue	Fatigue will be assessed using the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale. Higher scores indicate fewer fatigue-related problems.	Baseline and post-intervention (Week 12)
Change in Posture	Posture will be assessed using the New York Posture Rating Scale. Higher scores indicate better postural alignment.	Baseline and post-intervention (Week 12)

Collaborators and Investigators

• Sponsor: Istanbul University - Cerrahpasa
• Investigators: Study Chair: Emine Dilek Kurbaloğlu, PhD Student, Istanbul University - Cerrahpasa

Publications and helpful links

General Publications

• Men J, Wang P, Gao Q, Li Y, Zhu G, Yu Z, Wu S, Zhang Y, An W, Wang J, Wu Y, Li Z, Zhang J. Impact of exercise on anthropometric outcomes in children and adolescents with overweight or obesity: a systematic review and meta-analysis based on 113 randomized controlled trials worldwide. BMC Public Health. 2025 Jul 7;25(1):2400. doi: 10.1186/s12889-025-23413-9.
• Bataweel EA, Ibrahim AI. Balance and musculoskeletal flexibility in children with obesity: a cross-sectional study. Ann Saudi Med. 2020 Mar-Apr;40(2):120-125. doi: 10.5144/0256-4947.2020.120. Epub 2020 Apr 2.
• Kc S, Goyal M, Sharma S, Goyal K. Balance training exercises and postural control in overweight and obese children: A systematic review. J Bodyw Mov Ther. 2025 Jun;42:344-351. doi: 10.1016/j.jbmt.2024.12.036. Epub 2024 Dec 28.

Helpful Links

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Study record dates

Study Major Dates

• Study Start (Actual): July 3, 2026
• Primary Completion (Estimated): January 15, 2027
• Study Completion (Estimated): August 15, 2027

Study Registration Dates

• First Submitted: July 26, 2026
• First Submitted That Met QC Criteria: August 2, 2026
• First Posted (Actual): August 4, 2026

Study Record Updates

• Last Update Posted (Actual): August 4, 2026
• Last Update Submitted That Met QC Criteria: August 2, 2026
• Last Verified: August 1, 2026

More Information

Terms related to this study

• Keywords: childhood obesity
• Additional Relevant MeSH Terms: Nutrition Disorders; Overnutrition; Body Weight; Overweight; Obesity; Pathological Conditions, Signs and Symptoms; Behavior; Nutritional and Metabolic Diseases; Signs and Symptoms; Pediatric Obesity; Motor Activity; Motor Activity; Movement; Musculoskeletal Physiological Phenomena; Musculoskeletal and Neural Physiological Phenomena; Exercise
• Other Study ID Numbers: 25.06.2026-1665933

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data collected during this study will not be made publicly available because the study involves minors and contains sensitive personal and health information.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No