Journal — test-1

МІСЦЕ ІНФОРМАЦІЙНИХ ТЕХНОЛОГІЙ У РЕАБІЛІТАЦІЇ ПАЦІЄНТІВ З АМПУТАЦІЯМИ НИЖНІХ КІНЦІВОК (2)

2026-07-08T11:19:35+03:00

Ключові слова: фізична реабілітація, ампутація нижніх кінцівок, інформаційні технології, телереабілітація, фантомний біль, протезування, біологічний зворотний зв'язок

Key words: physical rehabilitation, lower limb amputation, information technologies, telerehabilitation, phantom limb pain, prosthetics, biofeedback

Реферат

Мета роботи – узагальнити наявні дані про застосування інформаційних технологій для покращення якості, ефективності та доступності реабілітаційної допомоги пацієнтам після ампутацій нижніх кінцівок. Систематичний огляд літератури виконано згідно з протоколом PRISMA 2020. Пошук проводився в базах даних PubMed, Scopus, Web of Science та Google Scholar за період 2011-2025 років з використанням ключових слів: lower limb amputation, rehabilitation technology, virtual reality, biofeedback, telerehabilitation, phantom limb pain. Із 847 знайдених публікацій після відбору за критеріями включення до фінального аналізу увійшло 75 робіт: 28 систематичних оглядів і метааналізів, 31 рандомізоване контрольоване дослідження та 16 когортних та обсерваційних досліджень. Показано, що віртуальна та доповнена реальність зменшують вираженість фантомного болю на 32-47% за візуальною аналоговою шкалою. Телереабілітація дає функціональні результати, зіставні з очними візитами, при економії витрат на 34%. Біофідбек-системи поліпшують симетрію ходьби на 18-25%. Мікропроцесорні колінні вузли знижують частоту падінь на 64% порівняно з механічними протезами. Ігрові елементи в реабілітаційних програмах підвищують дотримання пацієнтами призначень на 28%. Інформаційні технології є дієвим засобом відновлювального лікування після ампутацій нижніх кінцівок, що дозволяє персоналізувати терапію, об’єктивно контролювати прогрес та розширити доступ до спеціалізованої допомоги для пацієнтів з віддалених регіонів.

Abstract

The role of information technologies in rehabilitation of patients with lower limb amputations. Bandura O.V., Antonova-Rafi Yu.V. Aim – to summarize available evidence on the use of information technologies for improving the quality, effectiveness, and accessibility of rehabilitation care for patients after lower limb amputations. A systematic literature review was performed following the PRISMA 2020 protocol. Searches were conducted in PubMed, Scopus, Web of Science, and Google Scholar databases for the period 2011-2025 using the keywords: lower limb amputation, rehabilitation technology, virtual reality, biofeedback, telerehabilitation, phantom limb pain. From 847 retrieved publications, after screening 75 studies met the inclusion criteria: 28 systematic reviews and meta-analyses, 31 randomized controlled trials, and 16 cohort and observational studies. Virtual and augmented reality were shown to decrease phantom pain severity by 32-47% on the visual analog scale. Telerehabilitation yields functional outcomes comparable to face-to-face visits while saving costs by 34%. Biofeedback systems enhance gait symmetry by 18-25%. Microprocessor knee joints reduce fall rates by 64% compared to mechanical prostheses. Gaming elements in rehabilitation programs increase patient adherence by 28%. Information technologies serve as an effective means for post-amputation recovery, enabling therapy personalization, objective progress monitoring, and broader access to specialized care for patients in remote regions.

Реабілітація пацієнтів після ампутацій нижніх кінцівок в умовах сучасних викликів в Україні вимагає впровадження високотехнологічних рішень. Масштаби травматизації потребують нових стандартів біомедичної інженерії, основи яких закладені у працях вітчизняних дослідників [1, 2, 3]. Використання інформаційних технологій (ІТ) дозволяє об'єктивізувати процес відновлення та забезпечити дистанційний супровід пацієнтів [4].

Зростання кількості пацієнтів з травматичними та хронічними захворюваннями, що призводять до ампутацій, посилює потребу у впровадженні більш ефективних, доступних та персоналізованих реабілітаційних рішень. За глобальними оцінками, поширеність травматичних нефатальних ампутацій кінцівок залишається значною проблемою охорони здоров'я [5], а цукровий діабет є провідною причиною нетравматичних ампутацій [6]. Епідеміологічні дослідження підкреслюють важливість пацієнт-орієнтованого підходу та стратегій профілактики ампутацій [69]. Інформаційні технології відкривають можливості для підвищення якості реабілітаційних послуг, розширення доступу до спеціалістів, оптимізації протезування та контролю відновлення в режимі реального часу [7, 8].

Сучасні умови воєнного часу актуалізували дослідження бойової травми, зокрема безпрецедентного зростання кількості ампутацій в Україні. У цьому контексті особливої ваги набувають роботи, присвячені специфіці лікувальної тактики при вогнепальних пораненнях [9] та динаміці відновлення ортопедичного статусу поранених [10]. Міжнародний досвід реабілітації військовослужбовців з бойовими травмами підкреслює необхідність мультидисциплінарного підходу [70]. Важливим елементом комплексного підходу є врахування психологічного стану постраждалих, зокрема особливостей психологічної адаптації до втрати кінцівки [11]. Фантомний біль залишається однією з найскладніших проблем, що виникає у 50-80% пацієнтів після ампутації [12, 13].

Незважаючи на значну кількість досліджень щодо окремих технологій реабілітації, систематизований аналіз усього спектра інформаційних технологій у контексті ампутацій нижніх кінцівок залишається недостатнім, особливо з урахуванням потреб українських пацієнтів та ветеранів.

Мета дослідження – систематизувати та проаналізувати роль інформаційних технологій у підвищенні якості, результативності та доступності реабілітації пацієнтів з ампутаціями нижніх кінцівок на основі даних сучасної наукової літератури.

МАТЕРІАЛИ ТА МЕТОДИ ДОСЛІДЖЕНЬ

Систематичний огляд літератури проведено відповідно до рекомендацій PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [14]. Протокол дослідження не був попередньо зареєстрований.

Стратегія пошуку. Пошук здійснювався в міжнародних наукометричних базах даних PubMed, Scopus, Web of Science та Google Scholar за період з 1 січня 2011 року до 31 грудня 2025 року. Використано такі ключові слова та їх комбінації: "lower limb amputation" AND ("rehabilitation technology" OR "virtual reality" OR "augmented reality" OR "biofeedback" OR "telerehabilitation" OR "phantom limb pain" OR "prosthetics" OR "microprocessor knee").

Критерії включення: оригінальні дослідження (рандомізовані контрольовані дослідження, когортні, обсерваційні), систематичні огляди та метааналізи англійською та українською мовами, що описують застосування інформаційних технологій у реабілітації пацієнтів з ампутаціями нижніх кінцівок, опубліковані в рецензованих журналах. Критерії виключення: тези конференцій, редакційні статті, листи до редакції, публікації без повного тексту, дослідження, що стосуються виключно ампутацій верхніх кінцівок, роботи з неповними даними про результати.

Процес відбору. Первинний пошук ідентифікував 847 публікацій. Після видалення дублікатів (n=156) залишився 691 запис для скринінгу за назвами та анотаціями. На етапі скринінгу виключено 498 публікацій, що не відповідали темі дослідження. Повнотекстовий аналіз проведено для 193 статей, з яких 118 виключено через невідповідність критеріям включення (n=67), відсутність кількісних даних (n=31) та низьку методологічну якість (n=20). До фінального аналізу включено 75 джерел (рис.).

{slider title="Блок-схема PRISMA відбору публікацій для систематичного огляду ↓" class="tbl-articles my-figure" open="false"}

Етап	Кількість	Дія
Ідентифікація	n=847	Публікації, ідентифіковані через бази даних
	n=156	Видалено дублікатів
Скринінг	n=691	Записів для скринінгу за назвами та анотаціями
	n=498	Виключено (не відповідали темі)
Відповідність	n=193	Повнотекстових статей для оцінювання
	n=118	Виключено: невідповідність критеріям (67), відсутність даних (31), низька якість (20)
Включено	n=75	Досліджень включено до систематичного огляду

{/sliders}

Для оцінювання якості рандомізованих контрольованих досліджень використано шкалу Jadad [15], для нерандомізованих досліджень – шкалу Newcastle-Ottawa [16]. Систематичні огляди оцінювались за критеріями AMSTAR 2.

Дослідження є систематичним оглядом літератури без залучення пацієнтів та використання первинних клінічних даних, тому не потребувало схвалення біоетичного комітету.

РЕЗУЛЬТАТИ ТА ЇХ ОБГОВОРЕННЯ

Характеристика включених досліджень. До аналізу включено 75 джерел: 28 систематичних оглядів та метааналізів (37,3%), 31 рандомізоване контрольоване дослідження (41,3%), 16 когортних та обсерваційних досліджень (21,3%). Географічний розподіл: Північна Америка – 29 досліджень (38,7%), Європа – 26 (34,7%), Азія – 15 (20,0%), інші регіони – 5 (6,7%). Детальна характеристика включених досліджень за напрямками подана в таблиці.

Телереабілітація. Аналіз 12 досліджень (загальна вибірка n=1847 пацієнтів) продемонстрував, що телереабілітаційні програми забезпечують функціональні результати, порівняні з традиційними очними візитами [17-22]. Систематичний огляд Jansson et al. [20] встановив, що телереабілітація після ендопротезування суглобів є безпечною та ефективною альтернативою. Економічний аналіз показав зниження витрат на 34% при збереженні якості послуг [21]. Задоволеність пацієнтів телереабілітацією становила 87-94% [22].

{slider title="Таблиця. Характеристика включених досліджень за напрямками інформаційних технологій ↓" class="tbl-articles my-figure" open="false"}

Напрямок технологій	Кількість досліджень	Загальна вибірка (n)	Тип досліджень	Основні результати
Телереабілітація	12	1847	5 СО, 4 РКД, 3 КД	Зниження витрат на 34%, задоволеність 87-94%
VR/AR	22	612	8 СО, 10 РКД, 4 КД	Зниження болю на 32-47% за ВАШ
Біологічний зворотний зв'язок	11	423	4 СО, 5 РКД, 2 КД	Покращення симетрії ходи на 18-25%
Сенсорні системи	8	312	2 СО, 4 РКД, 2 КД	Точність детекції фаз ходи 94-98%
Мікропроцесорні протези	18	1256	7 СО, 8 РКД, 3 КД	Зниження ризику падінь на 64%
AI/ML	4	189	2 СО, 1 РКД, 1 КД	Точність розпізнавання намірів 85-92%

Примітки: СО – систематичний огляд; РКД – рандомізоване контрольоване дослідження; КД – когортне дослідження; ВАШ – візуальна аналогова шкала. {/sliders}

Віртуальна та доповнена реальність. Проаналізовано 22 дослідження (n=612 пацієнтів) щодо застосування технологій віртуальної (VR) та доповненої реальності (AR) у реабілітації після ампутацій [23-38, 74]. Метааналіз Cheung et al. [24] (8 РКД, n=198) встановив зниження інтенсивності фантомного болю на 32-47% за візуальною аналоговою шкалою (ВАШ) при застосуванні VR-терапії (стандартизована різниця середніх SMD=-1.12, 95% ДІ: -1.58 до -0.66, p<0.001). Піонерське дослідження Ortiz-Catalan et al. [35] підтвердило нейрофізіологічні механізми VR-терапії: візуалізація рухів відсутньої кінцівки сприяє нейропластичній реорганізації кори головного мозку. Рандомізоване контрольоване дослідження Lendaro et al. [31] (n=124) продемонструвало стійке зниження болю протягом 6 місяців спостереження. Aternali A. et al. [74] у РКД підтвердили ефективність VR-інтервенцій для зменшення фантомного болю.

Системи біологічного зворотного зв'язку. Аналіз 11 досліджень (n=423 пацієнти) показав ефективність біофідбек-систем у навчанні ходьбі на протезі [39-45]. Систематичний огляд Bowman et al. [39] (15 досліджень) встановив покращення симетрії ходи на 18-25% при використанні носимих пристроїв з біологічним зворотним зв'язком. Escamilla-Nunez et al. [41] повідомили про скорочення часу навчання ходьбі на протезі на 21% при застосуванні візуального біофідбеку порівняно зі стандартною терапією.

Сенсорні системи та моніторинг. Застосування інтелектуальних датчиків у системі «кукса – приймальна гільза» дозволяє моніторити стан пацієнта в реальному часі [46-49]. IMU-сенсори (інерційні вимірювальні модулі) забезпечують детекцію фаз ходи з точністю 94-98% [46]. Chen et al. [46] продемонстрували можливість адаптації параметрів протеза в режимі реального часу на основі даних сенсорів. Мобільні додатки для моніторингу стану шкіри культі дозволяють виявляти ранні ознаки ушкоджень з чутливістю 89% [48].

Інтелектуальні протези. Проаналізовано 18 досліджень (n=1256 пацієнтів) щодо мікропроцесорних протезів нижніх кінцівок [50-62, 73]. Систематичний огляд та метааналіз Hahn et al. [52] (12 досліджень, n=687) встановив, що мікропроцесорні колінні модулі (MPK) зменшують ризик падінь на 64% (ВР=0.36, 95% ДІ: 0.24-0.54, p<0.001) та покращують швидкість ходи на 14% порівняно з механічними аналогами. Thibaut et al. [60] у систематичному огляді підтвердили покращення якості життя за шкалою SF-36 на 12-18 балів при переході на MPK. Дослідження споживчих пріоритетів користувачів протезів [72] підкреслюють важливість врахування індивідуальних потреб при виборі протезних компонентів.

Штучний інтелект та машинне навчання. Алгоритми машинного навчання застосовуються для персоналізації реабілітаційних програм та оптимізації параметрів протезів [62-64]. AlQahtani et al. [62] у систематичному огляді продемонстрували можливість керування інтелектуальними протезами на основі електроенцефалографії (ЕЕГ) та функціональної спектроскопії ближнього інфрачервоного випромінювання (fNIRS) з точністю розпізнавання намірів руху 85-92%.

Гейміфікація. Аналіз 6 досліджень (n=287 пацієнтів) показав, що інтеграція ігрових елементів у реабілітаційні програми підвищує комплаєнс на 28% (95% ДІ: 19-37%) порівняно зі стандартними програмами [65, 66]. Gailey et al. [65] у рандомізованому контрольованому дослідженні (n=82) встановили покращення функціональних показників за шкалою Amputee Mobility Predictor на 15% при застосуванні гейміфікованих програм.

Результати проведеного систематичного огляду підтверджують ефективність інформаційних технологій у комплексній реабілітації пацієнтів з ампутаціями нижніх кінцівок. Отримані дані узгоджуються з іншими систематичними оглядами щодо ефективності VR-технологій для терапії фантомного болю [24, 26, 28, 30, 67] та переваг мікропроцесорних протезів [52, 54, 60].

Особливої актуальності набуває впровадження телереабілітаційних технологій в Україні в умовах воєнного часу, коли доступ до спеціалізованих реабілітаційних центрів є обмеженим для значної частини пацієнтів. Вітчизняні дослідження підтверджують необхідність розвитку цифрових платформ для супроводу ветеранів [1-4, 10]. Довгострокові дослідження результатів реабілітації ветеранів підкреслюють важливість безперервного моніторингу та підтримки [71].

Перспективним напрямком є застосування адитивних технологій (3D-друку) для виготовлення індивідуалізованих протезних компонентів, що дозволяє скоротити час виробництва та знизити вартість [73]. Упровадження інформаційних технологій супроводжується низкою організаційних та етичних питань. Збирання великої кількості персональних і біометричних даних вимагає застосування стандартів шифрування, контролю доступу і чіткої інформованої згоди пацієнта [68]. Важливо забезпечити інтеграцію технологічних рішень у наявні робочі процеси медичних закладів та підготувати персонал до їх використання.

Обмеження дослідження. До обмежень систематичного огляду належать: методологічна гетерогенність включених публікацій, що ускладнює проведення метааналізу для всіх категорій технологій; переважання досліджень з країн з високим рівнем доходу, що обмежує екстраполяцію результатів на український контекст; відносно невеликі вибірки в багатьох рандомізованих контрольованих дослідженнях; потенційний ризик публікаційного зміщення.

ВИСНОВКИ

1. Інформаційні технології є ефективним інструментом комплексної реабілітації пацієнтів після ампутацій нижніх кінцівок. Технології віртуальної та доповненої реальності знижують інтенсивність фантомного болю на 32-47%, системи біологічного зворотного зв'язку покращують симетрію ходи на 18-25%, а мікропроцесорні протези зменшують ризик падінь на 64%.

2. Телереабілітація забезпечує функціональні результати, порівняні з очними візитами, при зниженні витрат на 34%, що є особливо актуальним для пацієнтів у віддалених регіонах та в умовах обмеженого доступу до спеціалізованих центрів.

3. Упровадження цифрових технологій у реабілітаційну практику потребує розробки стандартизованих протоколів, навчання персоналу та забезпечення захисту персональних даних пацієнтів.

4. Перспективними напрямками подальших досліджень є розробка систем прямого нейроінтерфейсу для керування протезами, впровадження тактильного зворотного зв'язку та створення національних платформ для дистанційного супроводу ветеранів в Україні.

Внески авторів:

Бандура О.В. – концептуалізація, дослідження, формальний аналіз, написання – початковий проєкт;

Антонова-Рафі Ю.В. – методологія, написання – рецензування та редагування, ведення, адміністрування проєкту.

Фінансування. Дослідження не має зовнішніх джерел фінансування.

Конфлікт інтересів. Автори заявляють про відсутність конфлікту інтересів.

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THE ROLE OF AEROBIC EXERCISE IN IMPROVING COGNITIVE FUNCTION THROUGH BRAIN-DERIVED NEUROTROPHIC FACTOR EXPRESSION: A SYSTEMATIC REVIEW (2)

2026-07-08T11:50:09+03:00

Key words: health, aerobic training, dementia, physical exercise

Ключові слова: здоров'я, аеробні тренування, деменція, фізичні вправи

Abstract

Aging is a major risk factor that progressively contributes to the decline of brain function and increases susceptibility to various neurodegenerative disorders, including dementia. One biological factor that plays a central role in maintaining cognitive health and function is Brain-Derived Neurotrophic Factor (BDNF). The decline in BDNF levels that occurs during aging has been linked to a weakening of the brain's ability to form and maintain new synaptic connections, thereby increasing the risk of cognitive impairment. Furthermore, low BDNF levels are also associated with increased susceptibility to neurodegenerative diseases, such as Alzheimer's, due to the brain's reduced capacity to maintain healthy neuronal function. Therefore, understanding the role of BDNF in the context of aging is crucial for developing effective prevention and intervention strategies to maintain cognitive function in the elderly population. Exercise, particularly aerobic exercise, is a non-pharmacological strategy proven to increase BDNF levels. Several studies have shown that aerobic exercise can improve memory and cognition by increasing BDNF. However, the underlying mechanisms are still limited. Therefore, further research is needed to understand the mechanisms and benefits of aerobic exercise in improving brain health and preventing cognitive decline. This study aimed to determine the effect of aerobic exercise on increasing BDNF levels in humans. We searched several literature databases, such as Scopus, PubMed, Web of Science, and Science Direct, for our systematic review. We searched for articles published between 2015 and 2025 that discussed aerobic exercise and BDNF. Using Scopus, Web of Science, PubMed, and Science Direct, 563 publications were identified. For this systematic review, ten papers that met the inclusion criteria were selected and reviewed. In this study, standard operating procedures were evaluated using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The results of this systematic review indicate that aerobic exercise has been shown to increase BDNF levels in humans. By increasing BDNF levels, aerobic exercise may be a therapeutic strategy for dementia. However, more rigorous clinical trials are needed to validate this.

Реферат

Роль аеробних вправ у покращенні когнітивної функції через експресію нейротрофічного фактора мозкового походження: систематичний огляд. Пріамбодо А., Аюбі Н., Вібава Дж.К., Курназ М. Старіння є основним фактором ризику, який поступово сприяє зниженню функцій мозку та підвищує сприйнятливість до різних нейродегенеративних розладів, зокрема деменції. Одним з біологічних факторів, що відіграє центральну роль у підтриманні когнітивного здоров’я та функцій, є нейротрофічний фактор мозкового походження (Brain-Derived Neurotrophic Factor, BDNF). Зниження рівня BDNF, яке відбувається під час старіння, пов’язане зі зменшенням здатності мозку формувати та підтримувати нові синаптичні зв’язки, що підвищує ризик когнітивних порушень. Крім того, низькі рівні BDNF також асоціюються з підвищеною сприйнятливістю до нейродегенеративних захворювань, таких як хвороба Альцгеймера, через знижену здатність мозку підтримувати здорову нейрональну функцію. Тому розуміння ролі BDNF у контексті старіння є важливим для розробки ефективних стратегій профілактики та втручання з метою збереження когнітивних функцій у населення літнього віку. Фізичні вправи, особливо аеробні, є немедикаментозною стратегією, що доведено підвищує рівень BDNF. Декілька досліджень показали, що аеробні вправи можуть покращувати пам’ять і когнітивні функції шляхом підвищення рівня BDNF. Однак механізми, що лежать в основі цього процесу, залишаються недостатньо вивченими. Тому необхідні подальші дослідження для розуміння механізмів і переваг аеробних вправ у покращенні здоров’я мозку та запобіганні когнітивному зниженню. Метою цього дослідження було визначити вплив аеробних вправ на підвищення рівня BDNF у людей. Для проведення систематичного огляду було здійснено пошук у кількох наукових базах даних, таких як Scopus, PubMed, Web of Science та ScienceDirect. Були відібрані статті, опубліковані в період з 2015 до 2025 року, що стосувалися аеробних вправ і BDNF. У результаті пошуку в Scopus, Web of Science, PubMed та ScienceDirect було виявлено 563 публікації. Для цього систематичного огляду було відібрано та проаналізовано десять робіт, що відповідали критеріям включення. У дослідженні стандартні операційні процедури оцінювалися відповідно до критеріїв Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Результати цього систематичного огляду свідчать, що аеробні вправи здатні підвищувати рівень BDNF у людей. Підвищення рівня BDNF завдяки аеробним вправам може розглядатися як терапевтична стратегія при деменції. Однак для підтвердження цих висновків необхідні більш ретельні клінічні дослідження.

A major global health concern is Alzheimer's disease and associated dementias, especially for those 65 and older [1]. Alzheimer's has been more common during the last three decades [2], reflecting changes in the population's demographics, such as aging and rising life expectancy. Despite advancements in medical research, the precise etiology of Alzheimer's disease is still unknown, which makes it more difficult to create efficient therapies and preventative measures [3]. By 2050, 152 million individuals will have Alzheimer's due to the rising frequency of dementia [4], Therefore, a plan is required for handling, diagnosis, and prevention [3]. People, their families, and health care systems around the world are all impacted by the significant social and economic effects [5]. The need for dementia care is expected to rise as the population ages, making a thorough grasp of the condition's epidemiological trends and risk factors essential [6].

The most prevalent and well-researched neurotrophin in the mammalian brain is BDNF [7]. These elements promote neurogenesis, neuronal development, and neuronal differentiation while shielding neurons from stress and neurotoxicity [8]. Moreover, neurophysiological processes like long-term potentiation are linked to BDNF synthesis and signaling [9]. Partial antioxidant protection is provided by BDNF, which rises with age in reaction to oxidative damage [10]. In the central nervous system (CNS), a specialized protein known as BDNF plays a role in neurogenesis, synaptic plasticity, neuronal development and differentiation, and synaptogenesis [11]. CNS regions like the thalamus, hippocampus, and limbic system are the main sites for BDNF synthesis [12]. Furthermore, platelets, skeletal muscles, vascular endothelium, and immune cells all peripherally produce BDNF [13]. The blood-brain barrier, however, is inaccessible to peripheral BDNF [14]. The main locations of central BDNF expression are the midbrain, striatum, hippocampus, frontal cortex, and hypothalamus [15]. BDNF levels in blood serum are substantially lower in people with Alzheimer's disease and other neurodegenerative diseases, than in healthy people [16]. Therefore, if prophylactic measures are not taken, cognitive function will be impaired.

In Alzheimer's disease, physical activity can enhance cognitive performance, modify neuroinflammatory pathways, and support brain health as a non-pharmacological therapy [17]. In particular, aerobic exercise has become an essential part of stroke patients' rehabilitation, especially when it comes to addressing cognitive deficiencies and enhancing recovery results [18]. Walking, cycling, and swimming are examples of aerobic exercise as any physical activity causes the heart rate to increase and enhances cardiovascular fitness [19]. Aerobic exercise has emerged as a possible treatment for moderate cognitive impairment through molecular processes such as controlling microglia and astrocytes and triggering neuroprotective proteins. Additionally, it enhances cognitive performance, stimulates neurogenesis, and boosts cerebral blood flow [20]. Frequent aerobic exercise is a promising way to improve cognitive recovery and functional independence in individuals who have experienced an ischemic stroke since it reduces the cognitive decline associated with the condition [21]. However, the molecular processes that lead to increased BDNF levels due to aerobic exercise are currently poorly understood and studied. Therefore, based on this gap, the aim of this study was to determine the effect of aerobic exercise and its mechanisms on increasing BDNF levels.

MATERIALS AND METHODS OF RESEARCH

This study design is a systematic review, analyzing previous experimental studies conducted in humans. This study analyzed the effect of aerobic exercise on BDNF levels in humans by reviewing the scientific literature. The following search tools were used to locate scientific literature: Web of Science, Pubmed, Science Direct, and Scopus. The search terms used were: aerobic exercise, BDNF, and cognitive function. Publications were selected based on the following inclusion criteria: year of publication, experimental study, and articles related to humans (Table 1).

{slider title="Table 1. Inclusion criteria ↓" class="tbl-articles my-figure" open="false"}

Web search engines	Pubmed, Science Direct, Scopus, and Web of Science
Publishing period	2015 – 2025
Keyword	Cognitive function, BDNF, and aerobic exercise
Language Type of article	English Original research article
Full Text	Articles matched the purpose and/or topic of the research

{/sliders}

The study's inclusion criteria were established by looking through pre-established databases for material published in the previous 10 years. Additionally, experimental studies on the rise in BDNF levels following aerobic exercise were included in the publications. Among the search terms used were: BDNF levels. Furthermore, our research excluded papers that did not meet the standards for scientific validity or those were not included in reputable search indexes such as Scopus, Web of Science, PubMed, or Science Direct. Therefore, we screened the chosen papers using our pre-established inclusion criteria.

Each publication's complete text, abstract, and title were added to the Mendeley database following review and confirmation. Using Scopus, Science Direct, Pubmed, and Web of Science, 563 publications were found during the initial screening stage. 195 qualified papers were chosen for the second screening stage following the identification of duplicate articles and the reasons behind title irregularities. In the next phase, 107 papers were identified based on the concordance of the reviewed titles, abstracts, and keywords. After reviewing each paper, we decided that the study should be experimental, the parameter should be a BDNF biomarker, the intervention should be aerobic exercise, and the sample should be human. We examined these publications to identify those that satisfied our predefined inclusion criteria. Following a rigorous review and observation process, ten papers that satisfied the inclusion criteria were chosen for analysis. This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Figure). This study reviews previous literature that meets bioethical and ethical standards. The studies we analyzed from the literature have undergone an ethical screening process based on the Helsinki Declaration.

{slider title="Figure. PRISMA flowchart of the article selection process ↓" class="tbl-articles my-figure" open="false"}

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RESULTS AND DISCUSSION

{slider title="Table 2. Summary of the design and intervention of the studies ↓" class="tbl-articles my-figure" open="false"}

Author	Design	Participants	Participants Age	Intervention	Outcome
[22] (Munoz et al., 2024)	Randomized controlled trials	62 college students	20 years	Exercise Program The nine functional exercises in the single moderate-intensity training session ranged from 70% to 80% intensity and involved moderate cardiovascular demands. The first exercise is an agility ladder exercise in which the participant uses a ladder placed on the ground to do low jumps with his feet while alternating between using his right and left support. The second exercise is jumping rope. In the third exercise, athletes combine step-ups and bodyweight squats.	It has been demonstrated that aerobic exercise dramatically increases BDNF expression
				Moving forward between five cones placed on the ground is the agility difficulty in the fourth exercise. The fifth exercise is the conventional push-up. The foothold lateral sidestep is the sixth exercise. In the seventh exercise, participants execute leaps and squats. Dumbbell step-ups are a part of the eighth exercise, which is comparable to the third. The athlete cross-steps and shuffles laterally in the ninth exercise, which uses carioca
[23] (Roh et al., 2020)	Randomized controlled trials	20 respondents participated in this study	12 years	Exercise Program Taekwondo training 5x a week for 16 weeks	BDNF levels increased significantly after the intervention
[24] (Jeon & Ha, 2015)	Randomized controlled trials	20 junior-high school students	15 years	Exercise Program The exercise group engaged in aerobic exercise under supervision for eight weeks. For eight weeks, the control group was instructed to maintain their regular sedentary routines, while the exercise group worked out three days a week. The intensity of aerobic activity for the intervention was established by measuring the maximal oxygen uptake (VO₂max) of each participant in the exercise group. A treadmill was used for the exercise, and the intensity was adjusted between 40% and 60% of VO₂R using the ACSM-recommended scale	Following aerobic activity, BDNF expression significantly increased
[25] (Jeon & Ha, 2017)	Randomized controlled trials	40 male students	15 years	Exercise Program For 12 weeks, the training sessions were held four times a week at University D in Yongin. Using the American College of Sports Medicine (ACSM) suggested scale, training intensities were set at 40% VO₂R, 55% VO₂R, and 70% VO₂R for each group. Low-, moderate-, and high-intensity training were all conducted on a treadmill	Following 12 weeks of aerobic activity, BDNF at rest was significantly higher in the moderate intensity exercise group (p<0.05) and the high intensity exercise group (p<0.01) than it was before the intervention
[26] (Hakansson et al., 2017)	Randomized controlled trials	19 healthy older adults	65-85 years	Exercise Program For thirty-five minutes, the physical exercise group engaged in moderately intense exercise	BDNF expression significantly increased in the group that engaged in physical exercise
[27] (Morais et al., 2018)	Randomized controlled trials	22 peserta participants	58 years	Exercise Program For two weeks in a row, patients were instructed to walk once a week for 30 minutes in the goal training zone (low intensity, 50-63% of maximum heart rate, and moderate intensity, 64-76% of maximum heart rate)	The study's findings demonstrated that throughout the chronic post-stroke phase, a single 30-minute session of moderate-intensity aerobic exercise increased blood BDNF levels
[28] (Vedovelli & Giacobbo, 2017)	Randomized controlled trials	32 eligible participants	≥75 years	Exercise Program 60 minutes of aerobic physical activity per session. Physical activity performed 3 times a week for 3 months	BDNF levels increased after the intervention
[29] (Sugimoto et al., 2025)	Randomized controlled trials	14 healthy adults	29 years	Exercise Program Electrically stimulated eccentric contractions of antagonist muscles to create a hybrid training system (HTS) that combines voluntary muscle contractions with electrical stimulation of antagonist muscles. Using electrical stimulation, a training technique that combines a traditional bicycle ergometer with HTS (HERG) raises the training intensity of a traditional cycling ergometer. Participants engage in 30 minutes of ergometer training at an intensity suitable for their AT following a 2-minute warm-up at 30 W. Participants were guided and observed to maintain their goal heart rate and a cadence of 60-80 rpm throughout the exercise	Following exercise, HERG and cycle ergometer exercise both markedly raised BDNF and lactate levels
[30] (Silveira Rodrigues et al., 2023)	Randomized controlled trials	11 T2DM subjects	63 years	Exercise Program These 40-minute workouts took place between 2:00 AM and 4:00 PM and were separated by 72 hours. A treadmill was used for the exercises. There was no warm-up before the workouts, and following post-exercise blood collection and cognitive testing, a cool-down consisting of thigh, hip, neck, and back stretching exercises was conducted. The six-minute walk test (6MWT) was used to gauge the AER exercise's intensity. The 6MWT requires participants to walk for six minutes in a 30-meter indoor area at their fastest pace (Rikli and Jones 2013). Walking at 90–95% of the 6MWT speed is required of participants in the AER	There was a significant increase in BDNF expression after physical exercise
[31] (Raharjo et al., 2021)	Randomized controlled trials	A total of 14 obese female adolescents	19-24 years	Exercise Program With a 5-minute warm-up (HRmax 50-60%), 30 minutes of continuous activity (HRmax 60-70%), and a 5-minute cool-down (HRmax 50-60%), the participants engaged in physical exercise for 40 minutes at an intensity of 60-70% of HRmax. From 7:00 to 9:00 western indonesian time, physical activity was conducted on a Richter Treadmill (4.0 HP DC). A Polar Heart Rate Monitor (Polar H10 Heart Rate Sensor, Inc., USA) was used to track heart rate during moderate-intensity physical activity. Every participant in the control group stayed sat and rested until the physical activity was finished	According to the study's findings, obese women's serum BDNF levels rise after a single morning session of moderate-intensity exercise

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The purpose of this study was to carry out a systematic review to look into how aerobic exercise affects human BDNF levels. The findings demonstrated that aerobic exercise raises BDNF levels in people. According to past research, aerobic exercise significantly increases BDNF levels [22]. According to the findings of earlier studies, doing aerobic exercise on a treadmill three times a week for eight weeks significantly increases BDNF levels [24]. According to the American College of Sports Medicine's (ACSM) recommended scale, each group's exercise intensity was set at 40%, 55%, and 70% VO₂R. On a treadmill, exercises at low, moderate, and high intensities were performed. Exercise significantly raises BDNF levels, according to research [25].

Another study's results indicate that the senior physical activity group engaged in moderate-intensity exercise for 35 minutes significantly raised their BDNF levels following exercise [26]. It was demonstrated that walking for 30 minutes once a week for two weeks in a row between 50 and 63% of maximum heart rate for low intensity and 64 and 76% of maximum heart rate for moderate exercise, which is the goal training zone had a substantial effect on elevated BDNF levels [27]. Another study described using an ergometer for 30 minutes at a level of intensity suitable for their skill level. Participants were guided and observed to maintain their goal heart rate and a cadence of 60-80 rpm throughout the activity. Following the intervention, BDNF levels significantly increased, according to the data [29].

Previous studies' findings demonstrated that aerobic exercise on a treadmill significantly raised BDNF levels as well [30]. According to other studies, physical activity that is performed for 40 minutes at an intensity of 60-70% HRmax, with a 5-minute warm-up (50-60% HRmax), 30 minutes of continuous movement (60-70% HRmax), and a 5-minute cool-down (50-60% HRmax) all significantly raise BDNF levels [31]. Thus, based on the systematic review conducted, it is clear that aerobic exercise increases BDNF levels, an indicator of performance and cognitive function. However, the underlying mechanisms still require in-depth discussion of the physiological and molecular mechanisms. Therefore, in the following discussion, we will attempt to provide a discussion related to this.

Molecular mechanisms of aerobic exercise increase BDNF levels

One non-pharmacological method of enhancing public health is aerobic exercise. Additionally, higher rises after an intense workout, in serum BDNF levels in athletes may suggest that the CNS is still sensitive enough to support neurotrophin synthesis, which is triggered by cytokine production after the contraction of skeletal muscles. 'Exercise' is the aggregate term for the release of a range of myokines, cytokines, and peptides [32].

The human body's skeletal muscles, in particular, physically produce more reactive oxygen species (ROS) during physical activity [33]. Frequent stressors like physical exercise cause oxygen depletion, which makes it difficult for the body to satisfy its rapidly increasing oxygen demands. Among the extremely reactive substances are reactive oxygen species and reactive nitrogen species (RNS) produced by several tissues and organs as a result of this [34]. Other signal transduction pathways will be impacted by ROS. Since it is a physiological response to physical activity, the rise in ROS during exercise has long been discussed and is perfectly normal. ROS is the initial step in the signal transduction mechanism that influences the increase in adenosine monophosphate-activated protein kinase (AMPK) and initiates the production of PGC-1α [35]. In muscle cells, adenosine monophosphate-activated protein kinase (AMPK) has a unique role in binding PGC-1α. Remarkably, PGC-1α regulates mitochondrial biogenesis and also has an impact on mitophagy and mitochondrial dynamics [36].

Prior studies have demonstrated that physical activity increases PGC-1α expression (Ayubi et al., 2025). There are various ways that this interaction can take place. To boost AMPK's kinase activity, PGC-1α can first directly bind and activate it [38]. Second, PGC-1α triggers the expression of target genes for AMPK signaling that are involved in the oxidation of fatty acids [38]. It is well known that Sirtuin 1 (SIRT1) deacetylates a number of transcription factors and significant proteins that activate AMPK [39]. The response to elevated PGC-1α expression is influenced by this activated SIRT1 [38]. PGC-1α, expressed in skeletal muscles, is crucial for maintaining metabolic function because it promotes glucose homeostasis, oxidative capacity, mitochondrial biogenesis, insulin sensitivity, suppresses muscles atrophy, and reduces systemic inflammation [40].

PGC-1α controls the skeletal muscle's expression of fibronectin type III domain-containing protein 5 (FNDC5) [41], which is released into the bloodstream after being broken down into irisin [42]. PGC-1 alpha may be a major molecular initiator of BDNF responses in enriched environments and during physical activity [43], was identified as a byproduct of muscular contraction and exercise [44]. An attempt was made to explain the health benefits of physical activity on metabolic status in terms of browning (i.e., conversion) of white adipose tissue (WAT) and its resistance to diet-induced obesity by identifying irisin as a hormonal factor or myokine (a polypeptide of 112 amino acids) that is cleaved under the transcriptional control of PGC1-α from the fibronectin type III transmembrane precursor domain-containing 5 (FNDC5) [45], in reaction to physical activity. Exercise-induced irisin secretion may be influenced by elevated FNDC5 [45].

According to research, irisin, a myokine generated during exercise, can indirectly modify BDNF levels via improving metabolic processes that impact the general effectiveness and function of the central nervous system [46]. In people with risk factors like metabolic syndrome, these interactions establish irisin as a myokine that promotes mental wellness, brain plasticity, and metabolic health [47]. It is also important to note that irisin is one of the few stimuli that is known to cause neurogenesis in this environment [48], it also reduces synapse loss and neuronal damage [49]. Indeed, research conducted both in vitro and in vivo has demonstrated that irisin promotes brain progenitor cell development and upregulates the expression of neurotrophic factors like BDNF [50]. In this instance, irisin-induced elevated BDNF signaling encourages synaptic plasticity, dendritic spine development, and, eventually, enhances cognitive function [51]. A crucial neurotrophic factor involved in neurogenesis, synaptogenesis, differentiation, neuroplasticity, neurotransmission, and neuronal survival, irisin is an upstream modulator of brain-derived neurotrophic factor (BDNF) [9]. It is believed that irisin increases BDNF expression, which mediates exercise-induced neuroprotection [52]. So it is known that irisin secretion after exercise has an impact on increasing BDNF levels which will have an impact on improving cognitive function [52].

Strenght and Limitations

This systematic review has the advantage of focusing only on randomized controlled trials, the most reliable form of scientific evidence, and eliminating the potential for ambiguous causal relationships. Furthermore, the collected samples focused on humans, provided consistent data, and were not mixed with samples from other categories, including animal samples.

One limitation we identified was the lack of information on how exercise, particularly aerobic activity, can increase BDNF levels. Therefore, this study is considered significant for increasing our understanding of how aerobic exercise affects BDNF levels and improves cognitive function. The general population, especially older adults, may benefit from aerobic exercise that prevent cognitive decline. However, this may be related to its effective duration and intensity, which remain unclear. Therefore, further experimental studies are needed to determine the optimal timing and intensity for increasing BDNF levels in humans.

CONCLUSION

1. Brain-Derived Neurotrophic Factor levels, a biomarker and indicator of cognitive function, have been shown to increase in response to aerobic exercise.

2. Therefore, aerobic exercise is an excellent non-pharmacological treatment for slowing age-related cognitive decline, especially in older adults.

3. It can also be applied therapeutically to mitigate additional negative effects associated with aging.

Contributors:

Priambodo A. – data curation, visualization, writing – review & editing;

Ayubi N. – conceptualization, writing – original draft;

Wibawa J.C. – conceptualization, writing – original draft;

Kurnaz M. – methodology, formal analysis.

Acknowledgement

This research is not currently receiving funding from any source. We would like to thank the authors who contributed to this work.

Funding. This research received no external funding.

Conflict of interests. The authors declare no conflict of interest.

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THE EFFECTIVENESS OF MASSAGE THERAPY FOLLOWED BY CORE STABILITY EXERCISES FOR HEALING CHRONIC PELVIC INJURIES (2)

2026-07-08T13:09:51+03:00

Key words: chronic pelvic injury, Tepurak massage, core stability exercise, pain reduction, range of motion, musculoskeletal rehabilitation

Ключові слова: хронічна травма таза, масаж Тепурак, вправи для стабілізації м’язів кора, зменшення болю, діапазон рухів, реабілітація опорно-рухового апарату

Abstract

Chronic pelvic injuries, commonly caused by overuse, poor ergonomics, or physical strain, often lead to limited mobility and decreased quality of life due to pain and reduced joint range of motion (ROM). Non-pharmacological approaches offer a safer alternative to drug-based treatments, with growing interest in manual therapy and targeted exercise interventions. This study aims to evaluate the effectiveness of massage therapy followed by core stability exercises in the healing process of chronic pelvic injuries, particularly in reducing pain and improving ROM, as well as assessing the extent to which this combined intervention enhances musculoskeletal function and accelerates recovery. A pretest-posttest design without a control group was conducted with 20 participants from Yogyakarta and East Java. Pain levels were assessed using the Visual Analogue Scale (VAS), while hip joint ROM was measured with a goniometer across six primary movements. Data normality was tested using the Shapiro-Wilk test, and statistical analysis of pretest and posttest differences was performed with the Wilcoxon signed-rank test. The results showed a highly significant reduction in pain, with a decrease of 92.28% (p<0.05) post-intervention. All measured ROM parameters also showed significant improvement, with the greatest increase observed in hip extension at 21.63%. The average improvement across all movements was 16.24%, indicating that the combined intervention had a positive effect on pelvic joint function. Massage therapy followed by core stability exercises is effective in reducing pain and improving joint ROM in chronic pelvic injury cases. These findings support the application of integrative non-pharmacological therapies as a safe and effective musculoskeletal rehabilitation strategy that enhances function and quality of life for individuals with chronic pelvic disorders.

Реферат

Ефективність масажної терапії з подальшим виконанням вправ для стабілізації м’язів кора у відновленні при хронічних травмах тазової ділянки. Субагіо І., Сабіллах М.І., Окта Йо., Праното Н.В., Сапутра Д.Е.В., Сарі Н.С., Асмаваті П. Хронічні травми тазової ділянки, які зазвичай виникають унаслідок надмірного навантаження, неправильної ергономіки або фізичного перенапруження, часто призводять до обмеження рухливості та зниження якості життя через біль і зменшення обсягу рухів у суглобах. Нефармакологічні підходи пропонують безпечнішу альтернативу медикаментозному лікуванню, при цьому зростає інтерес до мануальної терапії та цілеспрямованих фізичних вправ. Це дослідження має на меті оцінити ефективність масажної терапії з подальшим виконанням вправ для стабілізації м’язів кора в процесі відновлення при хронічних травмах тазової ділянки, зокрема щодо зменшення болю та покращення обсягу рухів, а також визначити, наскільки така комбінована терапія покращує функцію опорно-рухового апарату та прискорює відновлення. Було проведено дослідження за схемою «до–після» без контрольної групи за участю 20 осіб з Джок’якарти та Східної Яви. Рівень болю оцінювали за допомогою візуальної аналогової шкали (VAS), тоді як обсяг рухів у кульшовому суглобі вимірювали гоніометром у шести основних рухах. Нормальність розподілу даних перевіряли за допомогою тесту Шапіро–Вілка, а статистичний аналіз відмінностей між показниками до та після втручання проводили за допомогою критерію знакових рангів Вілкоксона. Результати показали високодостовірне зменшення болю після втручання — на 92,28% (p<0,05). Усі вимірювані показники обсягу рухів також продемонстрували значне покращення, причому найбільше збільшення спостерігалося при розгинанні кульшового суглоба — на 21,63%. Середнє покращення за всіма рухами становило 16,24%, що свідчить про позитивний вплив комбінованого втручання на функцію тазових суглобів. Масажна терапія з подальшим виконанням вправ для стабілізації м’язів кора є ефективною для зменшення болю та покращення обсягу рухів у суглобах при хронічних травмах тазової ділянки. Отримані результати підтверджують доцільність застосування інтегративних нефармакологічних методів терапії як безпечної та ефективної стратегії реабілітації опорно-рухового апарату, що сприяє покращенню функціонального стану та якості життя осіб із хронічними порушеннями тазової ділянки.

In the current millennial era, humans cannot be separated from various daily activities such as work, sports, and other individual interests [1]. These activities can cause a decline in physical condition and disruption in activities, known as musculoskeletal disorders [2]. This illness affects muscles, bones, joints, ligaments, and other tissues, it is characterized by persistent pain and movement limitations [3]. The pelvis is a structure that supports and maintains equilibrium in the body, it joins the upper and lower limbs [4]. Because of its important role, the pelvis is susceptible to irritation and impaired movement function due to injuries such as muscle tension, tears of muscle tissue and ligaments, and shifting of bones and joints. Activities that can trigger pain in the pelvis include walking, sitting for too long, lifting heavy objects in the wrong position, and unergonomic body positions. The pelvis serves as the connection between the upper and lower limbs, playing a crucial role in maintaining balance and supporting the body's weight [5]. The hip joint is created by the articulation of the femoral head with the acetabulum of the os coxae, also known as the synovial ball and socket joint is one type of enarthrosis joint [6]. Because it may move in all planes-flexion, extension, abduction, adduction, and rotation, the hip joint is multiaxial. Numerous anatomical characteristics of the hip joint make it appropriate for supporting weight and providing stability during standing, walking, and sprinting. The constituent parts support and strengthen the pelvis, enabling it to stand erect and develop into a fully functional entity.

The mechanism of injury occurs in soft tissue (muscles, tendons, ligaments) which will result in closed bleeding in the tissue and swelling [7]. This swelling causes increased pressure on the tissue and will result in pain and stiffness. An injury is a physical anomaly brought on by excessive movement or accidents that causes discomfort, heat, redness, swelling, and the incapacity of the muscles, tendons, ligaments, joints, or bones to function normally. Injuries are closely related to the emergence of discomfort in the body [8]. This is a form of the body's natural response that signals that something is not right in a person's body, discomfort can include pain. Pain is an unpleasant emotional and sensory experience connected to prospective or existing tissue damage [9]. This general symptom is also present in the majority of injuries. Over 50, women in Asia have a 20% risk and males a 5.6% chance of hip joint damage. Of the 46 individuals surveyed, 45.5% reported having pelvic pain in a Surabaya hospital in Indonesia. Low back pain has been related to a number of issues, including an excessive physical exertion and an uncomfortable working position [10, 11].

Hip joint disorders require greater therapy right away in an attempt to mend the joint and prevent worsening consequences. The healing process of an injury is influenced by its type and timing, whether it's acute or chronic. Acute injuries typically heal within 4-6 days, while chronic injuries can take from 3 weeks to 12 months to heal, depending on the affected tissue and the severity of the damage [12]. Treatment to cure muscle pain can be done through pharmacological or non-pharmacological therapy, pharmacological therapy uses drugs that are often used to treat joint pain, even though they have side effects that are not good for the body's health. Many techniques, including shiatsu, acupuncture, cold therapy, heat therapy, chiropractic adjustments, and massage, are included under non-pharmacological therapy [13]. Because they wish to avoid the negative effects of medication, people frequently choose non-pharmacological treatment for musculoskeletal diseases, particularly those affecting the hip joint. Therapeutic massage, like Tepurak Massage (Tekan, Tepuk, Gerak), is one type of non-pharmacological treatment that is used.

Massage is manipulation using the hands with various movements to reduce stiffness and muscle tension. Tepurak manipulation presses trigger points to relax muscles, increase joint range of motion, and reduce pain. This movement realigns the joints and loosens tight muscles. The advantages of Tepurak include increasing range of motion (ROM), reducing pain, and actively involving the patient making it safer. Massage techniques are very diverse and have undergone many developments, such as Frirage massage, fitness massage, acupressure, deep tissue massage, Tepurak, and others. Exercises utilizing the capabilities of the trunk, lumbar spine, pelvis, hips, abdominal muscles, and tiny muscles along the spine are referred to as core stability training [14]. Together, these muscles create strength that tries to stabilize the body and preserve the spine through symmetrical alignment. The body can move more effectively and efficiently when the spine is robust and solid. Effective and efficient movement of the body can lower the chance of injury, improve athletic capabilities including strength, speed, and functionality, and support the body during all dynamic motions, while having a strong core improves strength and balance, lowers the risk of back problems, and maximizes movement and balance in the upper and lower limbs. Based on the description above, researchers want to further explore the efficacy of combining massage therapy with Core Stability Exercises in the treatment of chronic pelvic injuries.

MATERIALS AND METHODS OF RESEARCH

In this study, a pretest-posttest design was utilized without a control group to assess the impact of Tepurak manipulation followed by core stability exercises on pain and range of motion in individuals with chronic pelvic injuries. The participants were residents of the Special Region of Yogyakarta (DIY) and East Java, selected using incidental sampling based on specific inclusion and exclusion criteria. The inclusion criteria were individuals who had experienced pelvic injuries for more than three weeks and who were willing to provide informed consent. The exclusion criteria included individuals with severe pain preventing walking, fractures, fever, or urinary issues. The sample size was calculated using the Slovin formula, which resulted in a minimum of 17.65 participants, and a total of 20 participants were included in the study. The exclusion criteria included individuals with severe pain preventing walking, fractures, fever, urinary disorders, structural abnormalities of the hip joint that could affect range of motion and pain syndrome (such as hip osteoarthritis, hip dysplasia, adhesive processes, or other degenerative joint conditions), as well as participants presenting neurological symptoms including radiating pain, numbness, muscle weakness, or impaired motor control. Participants with a history of hip surgery or other musculoskeletal disorders unrelated to chronic pelvic injury were also excluded from the study.

The inclusion criteria were individuals who had experienced chronic pelvic injuries for more than three weeks during January-May 2020, were willing to participate in the study, and were able to provide written informed consent. Eligibility was confirmed through medical records, anamnesis, injury history, and physical examination results, including pain assessment and hip joint ROM evaluation.

Data collection was carried out using two primary instruments: the Visual Analogue Scale (VAS) to measure pain levels and a goniometer to assess ROM in hip movements such as flexion, extension, abduction, adduction, and internal and external rotations. Pain was rated on a scale from 0 to 10, with higher scores indicating greater pain intensity. ROM was measured in degrees using a goniometer before and after the intervention to evaluate the effects of the treatment on the participants’ range of motion. The sampling method employs the Slovin formula with a significance level of 20%, which uses quota sampling to calculate the sample size [15].

Based on calculations, the minimum sample size is 17.6471, but in this study, 20 people were involved. The sample consisted of 20 people who met two inclusion criteria: (1) had experienced a pelvic injury longer than three weeks ago; and (2) were willing to participate in the study and could provide documentation of their informed consent. Broken bones, excruciating pain that prevents you from walking, fever, and issues with urinating are among the exclusion criteria. In this study, researchers used instruments in the form of medical records of anamnesis and examination results. The history includes the duration of the injury, the cause of the injury, and the history of the injury. Meanwhile, the examination includes a pain scale and ROM.

The intervention protocol consisted of two sequential treatment components: Tepurak massage therapy followed by Core Stability exercises. Each participant received the intervention three times per week for four consecutive weeks, with each session lasting approximately 45-60 minutes. The intervention was administered by trained therapists and supervised by the research team.

The first stage involved Tepurak massage therapy (Tekan, Tepuk, Gerak), which was performed for approximately 20-30 minutes. The procedure included trigger point pressure, tapping techniques, passive joint mobilization, and assisted movement targeting the pelvic, lower back, gluteal, and hip muscle regions. The massage intensity was adjusted according to participant tolerance and pain response, with moderate pressure applied to avoid discomfort or tissue irritation.

Following the massage intervention, participants performed Core Stability exercises for approximately 20-30 minutes. The exercise program included pelvic bridge, plank, side plank, bird-dog, and abdominal drawing-in maneuvers. Each exercise was performed in 2-3 sets with 10-15 repetitions or maintained for 20-30 seconds depending on the movement type. Exercise intensity was progressively adjusted based on the participant’s functional capacity and tolerance. A short rest interval of 30-60 seconds was provided between sets.

The intervention sequence was standardized for all participants, where massage therapy was consistently performed before the exercise session to promote muscle relaxation, reduce pain, and improve joint mobility prior to active stabilization training.

For statistical analysis, descriptive statistics was used to calculate the mean, standard deviation, and range for both pain and ROM at pretest and posttest. The normality of the data was tested using the Shapiro-Wilk test, and since the data were not normally distributed, non-parametric methods were applied. The Wilcoxon Signed-Rank Test was used to analyze the differences between pretest and posttest data. A significance level of 0.05 was used, and any p-value less than 0.05 was considered statistically significant, indicating that the treatment had an effect.

The assessment is conducted by gauging pain levels through the utilization of the VAS. This scale assesses the intensity of pain felt by the patient from 0-10. Patients are asked to move the marks on the VAS to measure how much pain they feel. The higher the number on the pain scale, the greater the pain felt by the patient, and vice versa. ROM examination of the hip is carried out by measuring the angle of movement in degrees using a goniometer. This ROM measurement involves several positions, namely flexion, extension, abduction, adduction, internal rotation, external rotation. A goniometer is used to measure the ROM angle to determine the influence between data before and after treatment.

The research was conducted in accordance with the principles of bioethics set out in the WMA Declaration of Helsinki – “Ethical principles for medical research involving human participants” and “Universal Declaration on Bioethics and Human Rights” (UNESCO).

This approach allowed the study to assess the impact of the intervention on both pain and ROM, ensuring the validity of the findings. All statistical analyses were performed using SPSS Version 26.0 (IBM SPSS Statistics, Chicago, IL, USA), and the software was licensed under WHIQVZYWLARL9JEYQEGDUBLH8Z3ZCJAL3FLXMS98V95TSDYI7FOEXUPRR.

RESULTS AND DISCUSSION

Descriptive Analysis of Research Subjects

The subjects in this study were sufferers of chronic pelvic injuries who lived in the Special Region of Yogyakarta and East Java during January-May 2020. The research involves a total of 20 participants, with Figure 1 illustrating that 12 of them were female (60%), while 8 were male (40%) (Fig. 1).

Women are twice as likely to get injured compared to men. This is caused by differences in anatomical structure, where women's pelvis is larger and has a more hyperextended ROM than men’s. Women tend to have a gynecodal pelvic type which has an oval-shaped pelvic cavity, shallower and wider than the male pelvis. The curve of the female sacrum also tends to be wider. The individuals involved in the study ranged from 21 to 32 years old, with an average age of 24.25 and a standard deviation of 3.492. The following histogram displays the age statistics of the research subjects (Fig. 2).

{slider title="Fig. 1. Gender Pie Chart ↓" class="tbl-articles my-figure" open="false"}

{/sliders}

Based on Figure 2, the majority of injuries occur between the ages of 23 and 24. This is because the majority of the research sample consisted of daily exercisers who were also athletes. Regularly training athletes run the risk of overusing themselves to the point of injury, which can result in inflammation and ischemia. On average, eight participants (40% of the total sample) were either students or entrepreneurs.

{slider title="Fig. 2. Subject Age Histogram ↓" class="tbl-articles my-figure" open="false"}

{/sliders}

Based on Figure 3, the majority of research subjects consisted of students and entrepreneurs, each accounting for 8 participants (40%). This is due to high physical activity in these two groups, which can cause ergonomic problems and musculoskeletal disorders.

The typical length of time for the injury to heal falls within the span of 3 to 13 months. Duration of subject’s injury data are presented in the Figure 4.

{slider title="Fig. 3. Subject Job Diagram ↓" class="tbl-articles my-figure" open="false"}{/sliders}

{slider title="Fig. 4. Subject's Injury Duration Diagram ↓" class="tbl-articles my-figure" open="false"}{/sliders}

It can be seen that most research participants had their injuries for three to thirteen months. The fact that the injury is comparatively not felt acutely means that this time is included in the chronic phase. Three categories can be used to categorize injury length:

1. An acute injury lasts between four and six days after it occurs;

2. Sub-acute stage: this phase follows an injury and can extend for 4-21 days or 10-17 days;

3. Chronic stage: this phase might linger anywhere from three weeks to a year, depending on the tissue and degree of injury.

Descriptive Statistics of Research Variables

Painful

The pain scale is measured using a VAS with a number range of 0-10, where the higher the number on the VAS, the higher the level of pain felt. The mean outcomes and the variability represented by the standard deviation on the pain scale examination of 20 research subjects before and after Tepurak manipulation are presented in the Table 1 and the Figure 5.

{slider title="Table 1. Results of Descriptive Analysis of Pretest-Posttest Pain Scale Data ↓" class="tbl-articles my-figure" open="false"}

Variable	Pretest		Posttest		Decline
Variable	mean	std. dev	mean	std. dev	Decline
Painful	7.3	0.801	0.6	0.68	6.7

{/sliders}

Histogram illustrates how the average value of the pretest and posttest pain scales differed during Tepurak manipulation. The decrease in the average pain scale from the pretest to the posttest shows that Tepurak manipulation has the effect of reducing pain in research subjects. The smaller standard deviation at the posttest compared to the pretest may indicate that intersubject pain variability was reduced after treatment, indicating increased uniformity of response to the Tepurak manipulation.

{slider title="Fig. 5. Histogram of the average pretest-posttest pain scale ↓" class="tbl-articles my-figure" open="false"}{/sliders}

ROM

The ROM values for flexion, abduction, extension, internal rotation, external rotation, and adduction from the pretest and posttest were subjected to descriptive statistical analysis, and the findings are shown in the Table 2.

The average ROM values for flexion, abduction, extension, internal rotation, external rotation, and adduction following Tepurak manipulation may be observed based on the data in Table 2. Tepurak manipulation produces physiological effects such as muscular relaxation, which can lead to an increase in range of motion.

Figure 6 shows the difference in average scores between the pretest and posttest ROM on Tepurak manipulation. The table above presents the average value of ROM before (pretest) and after (posttest) Tepurak manipulation on research subjects. From this data, changes in ROM values can be seen for each movement observed. A decrease or increase in ROM values in the posttest compared to the pretest can provide an idea of the effectiveness of Tepurak manipulation in increasing flexibility or reducing stiffness in the movement. The increase in ROM after Tepurak manipulation is the explanation of Ambardini et al. This indicates that Tepurak manipulation is effective in increasing flexibility and reducing stiffness in the observed movements. Thus, the physiological effect of muscle relaxation caused by Tepurak manipulation made a positive contribution to the increase in ROM in the research subjects.

{slider title="Table 2. Results of Descriptive Analysis of Pretest-Posttest ROM Data ↓" class="tbl-articles my-figure" open="false"}

Variable	Pretest		Posttest		Enhancement
Variable	mean	std. dev	mean	std. dev	Enhancement
Flexion	86.05	12.890	99.95	11.307	13.9
Extension	50,1	18.324	59.9	18.660	9.8
Adduction	43,35	12.093	51.65	13.192	8.3
Abduction	51,4	7.549	59.25	8.565	7.85
External rotation	41,3	3.04	47.6	5.365	6.3
Internal rotation	38.65	3.453	44.55	5.443	5.9

{/sliders}

{slider title="Fig. 6. Histogram of average pretest-posttest ROM ↓" class="tbl-articles my-figure" open="false"}

{/sliders}

Tepurak manipulation, which is believed to promote muscle relaxation, was evaluated by measuring the range of motion (ROM) at the hip and shoulder joints, focusing on movements such as flexion, extension, abduction, adduction, internal rotation, and external rotation. These movements are commonly associated with the flexibility and mobility of the joints, and the assessment was conducted both before (pretest) and after (posttest) the manipulation. For instance, flexion and extension were measured at both the hip and shoulder joints, with flexion referring to the forward movement of the limb and extension referring to its backward movement. Similarly, abduction and adduction were assessed as the outward and inward movement of the limb, respectively, at these joints. Internal and external rotation were also evaluated at the shoulder and hip, with internal rotation referring to the inward rotation of the limb and external rotation referring to its outward rotation. The data presented in Table 2 show a marked increase in ROM after Tepurak manipulation, indicating the technique’s effectiveness in enhancing flexibility and reducing stiffness, particularly through its physiological effect of muscle relaxation. This supports the hypothesis that Tepurak manipulation can improve ROM by facilitating greater joint mobility and muscle flexibility.

Normality Test

Based on the results of data processing using SPSS 25.0 software in Table 3.

{slider title="Table 3. Normality test results using the Shapiro-Wilk test ↓" class="tbl-articles my-figure" open="false"}

Variable	P value (<0.05)	Distribution
Flexion pretest	0.000	Abnormal
Flexion posttest	0.034	Abnormal
Extension pretest	0.000	Abnormal
Extension osttest	0.000	Abnormal
Adduction pretest	0.000	Abnormal
Adduction posttest	0.000	Abnormal
Abduction pretest	0.000	Abnormal
Abduction posttest	0.000	Abnormal
Ex. Rot pretest	0.012	Abnormal
Ex. Rot posttest	0.001	Abnormal
In. Pretest rotation	0.019	Abnormal
In. Posttest rotation	0.000	Abnormal
Painful pretest	0.012	Abnormal
Painful posttest	0.000	Abnormal

{/sliders}

The ROM data for flexion, abduction, extension, internal rotation, external rotation, adduction, and pain have an irregular distribution, according to Table 3 test results for the Shapiro-Wilk test. As a result, non-parametric statistical methods, particularly the Wilcoxon signed-rank test, will be utilized for data analysis.

Inferential Statistical Analysis Test

The study's hypothesis is that massage therapy can effectively lower the degree of discomfort associated with long-term pelvic injuries. If the Asymp value is met, this hypothesis will be accepted. Rejected if the Asymp value is less than 0.05 (p<0.05). p>0.05 and sign >0.05. The following are the findings from the examination of the research data:

Non-Parametric Statistical Analysis

The outcomes of hypothesis testing conducted with the Wilcoxon signed rank test on pain scale data are as follows (Table 4).

Pain Scale

Based on Table 4, prior to the intervention, subjects' ratings on the movement pain scale ranged from 6 to 9%, with an average of 7.3 and a standard deviation of 0.801 for pain. Following the intervention, posttest movement discomfort ranged from 0 to 2%, with an average of 0.6 and a standard deviation of 0.681. There was a -0.12 difference in the standardized Z-value between pretest and posttest movement pain data. Utilizing a significance level of 0.05, the cumulative probability value of -0.12 is 0.000 (Asymp. Sig 2-tailed). Since 0.000<0.05, the null hypothesis (H0) is rejected, and the alternative hypothesis (H1) is accepted. The movement pain scale decreased in every patient, according to the data, and the hypothesis was confirmed by significance testing. Therefore, it may be said that a significant contrast was observed in the subject data scales between the initial assessment and the follow-up, suggesting that a combination of core stability exercises and massage manipulation is effective in reducing pain associated with chronic pelvic injuries.

{slider title="Table 4. Results of the Wilcoxon Signed-rank test for pretest and posttest pain scale data ↓" class="tbl-articles my-figure" open="false"}

Pain Variables	N	Mean	Standard Deviation	Minimum Value	Maximum Value	Z-value	Asymp Sig. (2tailed)
Pretest	20	7.3	0.801	6.00	9.00	-4.008^b	0.000
Posttest	20	0.6	0.681	.00	2.00	-4.008^b	0.000

{/sliders}

ROM

Table 5 statistical analysis, which employed the Wilcoxon signed-rank test, reveals that the range of flexion ROM values among individuals during the pretest varied from 45 to 100%, averaging 86.050 with a standard deviation of 12.890. Meanwhile, the range of individuals' flexion ROM values on the posttest varied from 68 to 128%, with an average of 99.950 and a standard deviation of 11.306. The difference between the posttest and pretest flexion ROM data yielded a normalized Z-value of -3.928. The cumulative probability value of -3.928 is 0.000 (Asymp. Sig 2-tailed) with a significance threshold of 0.05. Given that 0.000<0.05, H0 is rejected, and H1 is accepted.

{slider title="Table 5. Wilcoxon signed-rank test results of ROM pretest-posttest data ↓" class="tbl-articles my-figure" open="false"}

ROM	Pain Variables	N	Mean	Standard Deviation	Min Value	Max Value	Z-value	Asymp Sig. (2tailed)
Flexion	Pretest	20	86.050	12.890	45.00	120.00	-3.928	0.000
Flexion	Posttest	20	99.950	11.306	68.00	128.00	-3.928	0.000
Extension	Pretest	20	50.100	18.324	35.00	120.00	-3.929	0.000
Extension	Posttest	20	59.900	18.660	45.00	135.00	-3.929	0.000
Abduction	Pretest	20	51.400	7.549	44.00	80.00	-3.936	0.000
Abduction	Posttest	20	59.250	8.564	48.00	90.00	-3.936	0.000
Adduction	Pretest	20	43.350	12.092	35.00	90.00	-3.833	0.000
Adduction	Posttest	20	51.650	13.192	45.00	105.00	-3.833	0.000
External Rotation	Pretest	20	41.300	3.404	35.00	50.00	-3.840	0.000
External Rotation	Posttest	20	47.600	5.364	40.00	65.00	-3.840	0.000
Internal Rotation	Pretest	20	41.300	3.404	35.00	50.00	-3.018	0.003
Internal Rotation	Posttest	20	4.550	5.443	40.00	65.00	-3.018	0.003

{/sliders}

The ROM extension pretest scores ranged from 35 to 100%, with a 50.100 average and an 18.324 standard deviation. Meanwhile, the post-test abduction range of motion scores varied from 45 to 135%, with an average of 59.900% and a standard deviation of 18.660. The standardized Z-value for the difference in abduction ROM data between the pretest and posttest is -3.929. With a significance threshold of 0.05, the cumulative probability value of -3.929 is 0.000 (Asymp. Sig 2-tailed). As 0.000 is less than 0.05, the null hypothesis (H0) is rejected, and the alternative hypothesis (H1) is accepted.

The initial scores for abduction range of motion (ROM) ranged from 44 to 80%, with an average of 51.400% and a standard deviation of 7.549. Conversely, individuals' scores on the posttest for internal rotation ROM varied from 48 to 90%, with an average of 59.250% and a standard deviation of 8.564. The difference in internal rotation ROM data between the posttest and pretest is indicated by a standardized Z-value of -3.936. The cumulative probability value associated with -3.936 is 0.000 (Asymp. Sig 2-tailed) with a significance threshold of 0.05. Since 0.000<0.05, the null hypothesis (H0) is rejected, and the alternative hypothesis (H1) is accepted.

Similarly, the pretest scores for adduction range from 35 to 90%, averaging at 43.350 with a standard deviation of 12.092. Post-test scores for adduction, on the other hand, vary from 45 to 105%, with an average of 51.650% and a standard deviation of 13.192. The normalized Z-value for the change in adduction ROM data between posttest and pretest is -3.833. Given a significance threshold of 0.05, the cumulative probability value for -3.833 is 0.000 (Asymp. Sig 2-tailed), leading to the rejection of H0 and acceptance of H1 since 0.000<0.05.

Pretest findings for the range of motion in external rotation showed a spread from 35 to 50%, with a standard deviation of 3.404 and an average of 41.300%. Following the post-test, individual results for external rotation ROM ranged from 40% to 65%, averaging at 47.600% with a standard deviation of 5.364. The normalized Z-value representing the difference in external rotation ROM data between the pretest and posttest is -3.840. Given a significance threshold of 0.05, the cumulative probability value of -3.840 is 0.000 (Asymp. Sig 2-tailed). H0 is rejected in favor of H1 since 0.000 < 0.05.

The internal rotation ROM pretest, on the other hand, had a range of 35 to 50%, with an average score of 41.300 and a 3.404 standard deviation. The individuals' posttest internal rotation ROM scores, on average 44.550% with a standard deviation of 5.443, ranged from 40 to 65%. The standardized Z-value indicating the difference in internal rotation range of motion (ROM) between the pretest and posttest is -3.018. Considering a significance threshold of 0.05, the cumulative probability value associated with -3.018 is 0.003 (Asymp. Sig 2-tailed). As 0.003 is less than 0.05, we reject the null hypothesis (H0) and accept the alternative hypothesis (H1).

These findings showed that the subject's range of motion increased, and the hypothesis was validated by substantial testing. Hence, one can infer that there is either a notable distinction in the subject data scales between the pretest and post-test, or that the combination of massage manipulation and Core Stability Exercise is highly proficient in enhancing the ROM for flexion, abduction, extension, internal rotation, external rotation, and adduction, particularly in cases of long-term pelvic traumas.

Effectiveness

Painful

After massage manipulation and followed by core stability exercises, the percentage effectiveness of reducing the pain scale is calculated using the following formula:

By doing this calculation, the difference in score between the posttest and pretest is divided by the pretest score, then the result is multiplied by 100%. From this calculation, the percentage of effectiveness in increasing pain was obtained at 92.28%.

ROM

Based on Table 6 percentage effectiveness of increasing ROM after calculating the effectiveness of mass manipulation as followed by Core Stability exercises is carried out by calculating based on the mean value of the pretest and posttest using the formula:

Effectiveness was determined by taking the difference between the pretest and posttest scores, dividing that number by the pretest score, and then multiplying the result by 100%. The results showed that increasing range of motion in flexion movements was 17.26% effective, in extension movements it was 21.63%, in adduction movements it was 19.99%, in abduction motion it was 15.38%, in external rotation motion it was 15.28%, and in internal rotation motion it was 7.94%. The study's average percentage number for how successful it was to increase ROM was 16.24%.

This study is significant due to the increasing prevalence of chronic pelvic injuries, particularly among individuals who engage in high levels of physical activity, such as athletes, students, and workers with repetitive or strenuous tasks. Chronic pelvic pain, often associated with musculoskeletal dysfunction, can severely impact mobility, productivity, and overall quality of life. Yet, it is frequently neglected or treated symptomatically through pharmacological approaches, which carry potential side effects. Therefore, exploring non-pharmacological treatment methods, such as the combination of Tepurak massage and core stability exercises, provides a safer and potentially more effective alternative for managing and rehabilitating chronic pelvic conditions. The integration of massage techniques targeting muscle tension and joint alignment with exercises aimed at strengthening the pelvic and core muscles may offer synergistic benefits in pain reduction and functional recovery.

{slider title="Table 6. Painful and ROM effectiveness ↓" class="tbl-articles my-figure" open="false"}

Variable	Pretest	Posttest	Effectiveness
Painful	7.3	0.6	92.28%
Flexion	86.05	99.95	17.26%
Extension	50.1	59.9	21.63%
Abduction	51.4	59.25	15.38%
Adduction	43.3	51.65	19.99%
Internal Rotation	41.3	44.55	7.94%
External Rotation	41.3	47.6	15.28%

{/sliders}

The findings of this study are supported by several previous studies. It was found that traditional massage therapy significantly increased joint flexibility and reduced muscle stiffness, aligning with the present study’s results where participants experienced an average ROM improvement and pain reduction [16]. Similarly, it was emphasized that core stability training enhances spinal alignment and pelvic control, reducing the incidence of low back and pelvic injuries – an outcome echoed in this study [17]. Furthermore, research has noted that massage can improve blood circulation and reduce inflammation in soft tissues, which explains the significant post-intervention improvements in both pain and ROM observed in this study [18].

The implications of this research are noteworthy for physical therapists, sports trainers, and healthcare providers. The demonstrated effectiveness of combining Tepurak massage with core stability exercises suggests that this approach could be implemented as a standard non-pharmacological treatment protocol for patients suffering from chronic pelvic injuries. It also encourages the integration of traditional therapeutic techniques with modern rehabilitation exercises, potentially improving patient compliance and outcomes. However, the study has several limitations. The sample size was relatively small (n=20) and obtained through incidental sampling, which may limit the generalizability of the findings. The absence of a control group also restricts the ability to attribute the results solely to the intervention. Furthermore, the study relied on subjective pain scales and basic ROM measurements, which may lack the precision of more advanced diagnostic tools.

Core Stability exercises contributed to pain reduction and ROM improvement by enhancing neuromuscular control, pelvic stability, and activation of the deep trunk muscles that support the lumbopelvic region. Improved stabilization may reduce excessive mechanical stress on the hip and pelvic structures, thereby decreasing pain and facilitating more efficient movement patterns during functional activities. These mechanisms may explain the significant improvements observed in pain intensity and joint ROM following the combined intervention.

For future research, it is recommended to conduct randomized controlled trials with larger sample sizes to validate these findings. Incorporating objective assessments such as electromyography or motion analysis systems could also provide more comprehensive data. Additionally, long-term follow-up studies would help determine the sustainability of the treatment’s effects and its potential role in preventive care for individuals at high risk of pelvic injury.

CONCLUSION

1. This study demonstrated that the combination of Tepurak massage therapy and Core Stability exercises was effective in reducing pain and improving hip joint range of motion in individuals with chronic pelvic injuries.

2. The intervention resulted in a 92.28% reduction in pain intensity and an average range of motion improvement of 16.24% across all measured movements.

3. The combined intervention contributed to improved musculoskeletal function by enhancing joint mobility, reducing muscle stiffness, improving pelvic stability, and supporting functional movement during daily activities.

4. The sequential application of massage therapy followed by core stability exercises facilitated muscular relaxation and neuromuscular activation, which may accelerate the recovery process in chronic pelvic injury rehabilitation.

5. Tepurak massage helps reduce muscle stiffness and improve joint mobility, while core stability exercises support pelvic stability and functional movement control during rehabilitation.

6. This non-pharmacological approach provides a safe and effective rehabilitation strategy that may improve functional recovery and quality of life while minimizing dependence on medication and its potential side effects.

7. Further randomized controlled trials with larger sample sizes and long-term follow-up are recommended to validate the effectiveness and sustainability of this intervention.

Acknowledgment

We thank the participants and the institutions involved in this study, including Universitas Negeri Surabaya, Universitas Teuku Umar, Universitas Negeri Padang, Universitas Negeri Yogyakarta, and Sleman District Health Office, Indonesia. Special thanks to the research team for their contributions in data collection, analysis, and manuscript preparation.

Contributors:

Sabillah M.I. – methodology, conceptualization, formal analysis, resources, writing – original draft, writing – review & editing, funding acquisition;

Subagio I. – methodology, conceptualization, formal analysis, resources;

Ockta Yo. – methodology, conceptualization, formal analysis, resources, writing – original draft;

Pranoto N.W. – formal analysis, resources, writing – original draft, writing – review & editing;

Saputra D.E.W. – visualization, data curation, writing – original draft;

Sari N.S. – formal analysis, writing – original draft, writing – review & editing, funding acquisition;

Asmawati P. – writing – review & editing, funding acquisition.

Funding. This research received no external funding.

Conflict of interests. The authors declare no conflict of interest.

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