Duchenne muscular dystrophy (DMD) is the most common inherited neuromuscular disorder, affecting approximately one in 3500–5000 live male births [1]. It is an X-linked recessive and ultimately fatal disease caused by mutations in the DMD gene, which encodes dystrophin [2]. Dystrophin is a structural protein essential for muscle fiber stability, linking actin microfilaments to the extracellular matrix and stabilizing the sarcolemma during muscle contraction and relaxation [3]. Because dystrophin is expressed in striated, smooth, and cardiac muscle, its deficiency primarily affects the musculoskeletal and cardiovascular systems [4].

Until recently, treatment options for individuals with DMD were largely limited to corticosteroid therapy and cardiopulmonary support. However, advances in medical genetics, improvements in quality of care, expanded rehabilitation opportunities, and technological developments have significantly increased life expectancy in this population [4]. Individuals with DMD, who were previously expected to die before adulthood, are now living into their fourth decade [5,6]. As a result, health problems that were previously overlooked due to the shorter life span of individuals with DMD have gained increasing importance, including bladder and bowel health [7]. Although dystrophin deficiency primarily affects striated muscle, it can also impair smooth muscle function [8]. Consequently, destructive effects on the detrusor muscle and urethral smooth muscle contribute to the high prevalence of lower urinary tract symptoms (LUTS) and lower urinary tract dysfunction (LUTD) in children with DMD [9]. Disease-related factors such as decreased muscle strength during functional movements and reduced functional levels of the upper and lower extremities have also been associated with an increased incidence of LUTS and LUTD. Recent studies have reported that approximately 85–87 % of children with DMD experience at least one LUTS, while nearly 44 % are present with LUTD, highlighting the substantial burden of bladder and bowel dysfunction in this population [7,10].

Urotherapy is the first-line treatment for children with LUTS. It consists of non-invasive interventions and does not involve surgical or pharmacological treatments, making it suitable for use in primary care settings [11]. Lumbopelvic stabilization exercise training aims to improve strength in the lumbopelvic musculature, maintain postural control, enhance pelvic floor muscle function, and reduce urinary symptoms through coordinated muscle co-contraction [12]. No studies have been found in the literature on the use of urotherapy and lumbopelvic stabilization exercises in individuals with DMD. Furthermore, the number of studies on treatment for individuals with DMD and LUTD is insufficient [7,9]. Therefore, this study aimed to examine the effectiveness of supervised lumbopelvic stabilization, which addresses factors associated with LUTS in children with DMD and LUTD.

The primary outcome of the study was the severity of LUTD, assessed using the DVISS, to evaluate the effect of lumbopelvic stabilization exercises combined with urotherapy. Secondary outcomes included the effects of a supervised lumbopelvic stabilization exercise program, in addition to urotherapy, on lower urinary tract symptoms, bowel symptoms, physical performance, muscle strength, and participation in activities of daily living.

Participants

The study included ambulatory children aged > 5 years with a diagnosis of DMD who were recruited between November 2024 and July 2025. Children with DMD who scored ≥ 8.5 on the Dysfunctional Voiding and Incontinence Symptom Scale (DVISS) and were classified within the first four stages of the Vignos Scale were eligible for inclusion. Exclusion criteria included the presence of comorbid conditions (e.g., Becker muscular dystrophy or autism spectrum disorder), cooperation difficulties, and lack of adequate internet infrastructure. Of the 71 patients admitted to the Muscular and Nerve Diseases Application and Research Center in XXX University, 39 were excluded. The treatment and active control groups were 16 and 16, respectively. Consequently, the study was completed with 32 children diagnosed with DMD and their families (Figure 1).

Fig. 1.

CONSORT flow diagram of the study.

Sample size estimation was based on right hip flexor strength data reported by Kenis-Coskun et al. (2022). Assuming 95 % power and a two-sided α of 0.05, a minimum of 15 participants per group was required [14]. A post-hoc power analysis for the ANCOVA of dominant hip flexor strength yielded an observed power of 81.17 % (effect size F = 0.520, α = 0.05, total sample size = 32).

Intervention

Before initiating the treatment programs, both groups received an individualized, face-to-face urotherapy session lasting approximately 90 min, tailored to each child’s symptoms. The topic headings addressed in the urotherapy education are summarized in Table 1. The recommendations of the ICCS guidelines were followed during all stages of the urotherapy. All participants were asked to implement the lifestyle modifications learned during this training over the course of eight weeks [11].

Table 1.

Content of the urotherapy education program.

Urotherapy Topics
Urinary system anatomy	Regulation of voiding frequency
Urinary system physiology	Teaching optimal voiding posture
Bowel system physiology	Teaching optimal defecation posture
Pelvic floor anatomy, physiology, and awareness	Behavioral recommendations for bowel health
Definitions of lower urinary tract symptoms	Proper straining techniques
Etiology of lower urinary tract symptoms	Nutritional recommendations (bladder irritants, fiber intake, fluid intake)
Association between lower urinary tract symptoms and Duchenne	Recommendations for communication with the child
Importance of child and family education	Strategies to increase physical activity
Regulation of water intake	Genital hygiene
Teaching abdominal massage	Benefits of breathing exercises
Benefits of trunk exercises	Benefits of stretching exercises
Awareness of nocturnal alarm therapy	Mindfulness and meditation techniques

Regular recording and frequent communication with the physiotherapist are essential for effective urotherapy. Therefore, four strategies were employed to enhance adherence and motivation: signing a compliance contract, a star-reward system, balloon-coloring tracking, and reminder messages [11].

The active control group received only urotherapy training, which is considered the gold standard in the management of pediatric LUTS [11]. The treatment group, in addition to urotherapy, received a lumbopelvic stabilization exercise program. All lumbopelvic stabilization exercises were delivered synchronously via online video conferencing platforms under the real-time supervision of an experienced physiotherapist. Exercise performance was continuously monitored, and incorrect movements were immediately corrected to ensure proper technique and intervention fidelity. The exercise program was designed according to the FITTEA principle and was progressive (Figure 2) [22]. Sessions were conducted three times per week, each lasting approximately 30 min (5 min of warm-up, 20 min of exercise, and 5 min of cool-down; in a way that does not cause fatigue), for a total duration of eight weeks. Consequently, the treatment group performed 24 supervised trunk stabilization exercise sessions in addition to adhering to their urotherapy tasks.

Fig. 2.

Lumbopelvic stabilization-based exercise program of intervention group.

Thirty-two children with DMD, aged 5–12 years, Vignos stages 1–4, and with a DVISS ≥ 8.5, were enrolled. The treatment (n = 16) and active control groups (n = 16) were comparable in demographic and clinical characteristics, including age, anthropometrics, DVISS scores, physiotherapy frequency, Vignos stage, corticosteroid use, scoliosis, and toilet habits (p > 0.05) (Table 2).

Compared with baseline, both the treatment and active control groups showed significant reductions in DVISS total scores and enuresis frequency (p < 0.05). A significant decrease in TUG time was observed only in the treatment group (p < 0.05), whereas no significant changes were detected in Gower’s test duration in either group (p > 0.05). Between-group comparisons revealed no significant differences in DVISS total scores, enuresis frequency, or Gower’s test duration (p > 0.05). However, the treatment group demonstrated a significantly greater improvement in TUG time, indicating a benefit in physical performance outcomes (Table 3).

Within-group analyses demonstrated significant improvements in the treatment group for trunk flexor (p < 0.001) and extensor strength (p = 0.006), dominant (p = 0.010) and non-dominant (p = 0.011) quadriceps femoris strength, as well as dominant and non-dominant hip flexor strength (both p < 0.001). In the active control group, a significant improvement was observed only in non-dominant quadriceps femoris strength (p = 0.046). Both groups showed improvements in Barthel Index scores. Between-group comparisons revealed no significant differences in changes in trunk flexor strength, trunk extensor strength, or non-dominant knee extensor strength (p > 0.05). However, improvements in dominant quadriceps femoris (p = 0.036), dominant hip flexor (p = 0.009), non-dominant hip flexor strength (p = 0.031), and Barthel Index total scores were significantly greater in the treatment group (Table 4).

Analysis of bladder diary data (urination frequency, number of lower urinary tract symptoms, and daily fluid intake) and bowel diary data (defecation frequency and pain intensity during defecation) revealed a statistically significant reduction in the number of symptoms in both groups (p < 0.05). Between-group comparisons showed no significant differences in these variables, except for defecation frequency (p > 0.05) (Table 5).

In this study investigating the effects of a lumbopelvic stabilization-based exercise program combined with urotherapy in children with DMD and LUTD, it was found that urotherapy alone effectively reduced LUTS severity, enuresis frequency, and the number of associated symptoms. Both urotherapy and the combined exercise intervention were effective for these parameters; however, no additional benefits of combining lumbopelvic stabilization exercises were observed. Neither intervention affected Gower’s time nor daytime voiding frequency. In the urotherapy-only group, daily fluid intake and weekly defecation frequency increased, and defecation-related pain decreased.

The supervised lumbopelvic stabilization program led to improvements in functional movements and increased strength in pelvis-related muscle groups, including trunk flexors/extensors, hip flexors, and knee extensors. Incorporating these exercises into rehabilitation, alongside standard urotherapy, appeared to enhance participation in daily life activities.

To enable physical performance testing and address limitations in previous studies with wide age ranges [7,9], only ambulatory children with DMD aged over five years were included, in line with guideline recommendations [16,23]. Participants’ ages and other demographic or disease-related characteristics were similar across intervention and control groups, enhancing internal validity and homogeneity.

Consistent with the study’s primary hypothesis, both groups showed reductions in LUTD severity, but no significant between-group differences were found, indicating that adding lumbopelvic stabilization exercises did not further reduce LUTS or symptom severity. Previous research supports these findings: remote urotherapy at home has demonstrated significant effects on LUTS in children [24], and urotherapy has been shown to improve uroflowmetry parameters and reduce residual urine volume [25]. Borgström et al. (2022) reported significant reductions in weekly enuresis frequency with standard urotherapy in healthy children [26], and Jørgensen et al. (2023) emphasized the need for controlled studies to clarify urotherapy’s role in pediatric enuresis [27]. Thus, the present findings align with existing literature while providing novel data for the DMD population.

Although lumbopelvic stabilization was expected to improve pelvic floor function and further reduce LUTS, no significant additional effect beyond urotherapy was observed. Nevertheless, in a progressive condition such as Duchenne muscular dystrophy, the absence of symptom deterioration remains clinically meaningful. Preserving urinary function while simultaneously improving physical performance and participation in activities of daily living may therefore represent a relevant therapeutic goal in this population. Moreover, in this study, the authors focused on abdominal stabilizer muscles because of their influence on the pelvic floor. Since the authors anticipated that these children might perform pelvic floor exercises incorrectly, it was not included in the program. Instead, the authors focused on the thoracic diaphragm and transversus abdominis muscles to indirectly influence the pelvic floor, which may explain the observed outcomes. Nevertheless, in a progressive condition such as DMD, the implemented core stabilization exercises at least halted the progression of LUTS and did not exacerbate them, indicating that this intervention can be considered safe for children with DMD and LUTD [5].

Daily fluid intake increased significantly only in the urotherapy group, whereas no significant change was observed in the exercise group. This may be explained by the additional weekly exercise sessions in the latter, adding responsibilities beyond the standard urotherapy tasks. Moreover, although bladder diaries are recommended by guidelines, they capture only the assessed week and may not fully reflect the child’s routine [28]. Therefore, conclusions based solely on bladder diaries should be interpreted with caution.

In the present study, urotherapy in children with DMD and LUTD led to increased weekly defecation frequency and reduced pain during defecation. This effect is likely related to softer stool consistency resulting from lifestyle modifications. Shiro et al. reported a significant association between stool consistency, as assessed by the Bristol Stool Scale, and perceived pain, supporting this interpretation [24]. Moreover, behavior changes such as adequate hydration, avoidance of postponement maneuvers, increased pelvic floor awareness, and higher physical activity levels are expected to positively influence bowel health [29]. These findings are consistent with previous research. Bowel outcomes were assessed as secondary measures due to their close association with lower urinary tract dysfunction in pediatric populations. In children with Duchenne muscular dystrophy, bowel dysfunction may contribute to urinary symptoms; therefore, bowel-related findings should be interpreted as clinically relevant complementary outcomes [16].

Improvement in lumbopelvic stabilization enhances proper pelvis and spine alignment during both static and dynamic activities, increases spinal stability through better intra-abdominal pressure control and motor coordination, and reduces strain during physical activity [30]. Shahvarpour et al. [31] reported that an eight-week lumbar stabilization program positively affects movement patterns and motor control, while Jeong et al. [32] demonstrated that good lumbopelvic control improves dynamic stability during gait. Consequently, increased confidence and reduced fear of falling may enhance movement quality [33]. These findings are consistent with the improvements observed in the Timed Up and Go Test in our intervention group.

Lumbopelvic stabilization exercises can enhance spinal stability, improve postural control, and prevent common spinal deformities in children with DMD, although their importance is not yet emphasized in disease management guidelines [23]. While muscle strength increased in all assessed groups, significant differences between-groups were observed only in the dominant quadriceps femoris and bilateral hip flexors, likely due to approximately 1-kg increases in these muscles [34]. Although such exercises cannot reverse genetic damage or fully eliminate disease symptoms, they help preserve muscle function, increase strength, and delay functional decline [35].

As functional levels progressively decline in DMD, dependence on caregivers increases [36], and the presence of LUTS further impairs participation in ADL [37] Both interventions improved independence, with significantly greater gains in the exercise group. These findings suggest that targeting LUTS is important for enhancing participation in ADL in children with DMD and LUTD.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Scientific Research Ethics Committee of Lokman Hekim University (October 31, 2024; approval no 232) and registered at ClinicalTrials.gov (NCT06643923).

The entire data set related to the study is available and archived by the authors. With publication, anonymized participant data can be shared upon reasonable request. Requests should be directed by email to the corresponding author (demett.ozturkk@gmail.com). After signing the data access agreement, the corresponding author will share the data of the article.

Each participant was given detailed information about the study, and each participant was asked to sign an informed consent form.

This work was supported by the TUBITAK (Project ID: 125S108); and the Lokman Hekim University Scientific Research Projects Coordination Unit (Project ID: THIZ-2025–125).

Demet Öztürk: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data curation, Writing – original draft, Writing – review & editing, Visualization, Project administration, Funding acquisition. Aynur Ayşe Karaduman: Methodology, Software, Validation, Investigation, Resources, Data curation, Writing – review & editing. Türkan Akbayrak: Conceptualization, Methodology, Software, Validation, Formal analysis, Writing – review & editing, Supervision.