www.nature.

com/ijo International Journal of Obesity

REVIEW ARTICLE OPEN

Clinical Research

The usefulness of Integrative Neuromuscular Training to

counteract obesity: a narrative review
1✉
Luca Cavaggioni , Luisa Gilardini1, Marina Croci1, Damiano Formenti 2
, Giampiero Merati2,3 and Simona Bertoli1,4

© The Author(s) 2023

BACKGROUND AND OBJECTIVE: The association between physical activity and diet has a valuable impact in weight status
management to counteract obesity. In this context, within different training strategies (i.e., endurance, resistance training,
concurrent training, agility training) the Integrative Neuromuscular Training (INT) represents a structured training mode focused on
global human movement pattern development with the aim to enhance motor control, mobility and stability. In this narrative
review we aimed to discuss the feasibility of INT interventions on physical fitness and body composition outcomes in individuals
with obesity.
SUBJECTS: Medline/PubMed, EMBASE, Web of Science, Google Scholar including were searched before 1st February 2023 without
1234567890();,:

restrictions on publication year.

METHODS: Two researchers extracted data from published trials. Randomized controlled trials or clinical trials, Body Mass Index of
children and adolescents at the 95% percentile or greater, and for adults to be above 30 kg/m2, detailed intervention description,
randomization process and allocation into an experimental or a control group, trials must have been written in English, were
included.
RESULTS: We included a total of 19 studies complying with the inclusion criteria for the review process. There is evidence that INT
promotes positive adaptations in fitness levels in both younger and older participants with concomitant ameliorations during a
shorter, medium and longer time period. Moreover, cardiorespiratory fitness, muscular strength, balance, postural control and body
composition reached significant remarkable improvements following a specific intervention based on INT principles compared to
other training mode. However, Body Mass Index, fat mass percentage and waist circumference showed similar changes overtime.
CONCLUSIONS: Taken together, these findings support the effectiveness of INT in ameliorating physical fitness (i.e., health-related
and skill related components) without negative changes in body composition. Nevertheless, fitness coaches and therapists may
consider this training modality a feasible option when prescribing physical exercise in outpatients with obesity.
International Journal of Obesity (2024) 48:22–32; https://doi.org/10.1038/s41366-023-01392-4

INTRODUCTION different components, including “health-related” factors, such as

Obesity represents a remarkable health metabolic disease cardiorespiratory fitness, muscular strength and endurance,
characterized by an increased body fat that could lead to an flexibility, and “skill-related” variables as agility, motor coordina-
augmented risk of cardiovascular disease, diabetes mellitus, tion, balance, power, reaction time and speed [7, 8].
hypertension and mortality [1, 2]. An adequate nutrition strategy, Cardiorespiratory fitness can be improved through various form
psychological-behavioral support as well as physical activity of continuous or intermittent exercises with the aim to improve
represent key factors in weight status management [3, 4]. Several cardiorespiratory function [6, 9]. For people with obesity, it is
international guidelines, such as the World Health Organization particularly suggested to observe an exercise intensity between
(WHO) and the American College of Sports Medicine (ACSM) 49% and 85% of peak aerobic capacity to induce several
recommend to respect an amount of 150–250 min per week of modifications in visceral adipose tissue [10] and body fat
moderate-intensity physical activity to obtain a significant weight reduction [11].
loss [5–7]. For what concern muscular strength, the purpose is to increase
In this context, physical fitness refers to the body’s ability to skeletal muscle mass involving major muscle groups [7]. Strength
perform daily-life activities efficiently, which is determined by training for obesity might be helpful to improve myogenesis, lean

1
Obesity Unit - Laboratory of Nutrition and Obesity Research, Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20145 Milan, Italy.
2
Department of Biotechnology and Life Sciences, University of Insubria, 21100 Varese, Italy. 3IRCCS Fondazione don Carlo Gnocchi, 20148 Milan, Italy. 4International Center for the
Assessment of Nutritional Status (ICANS), Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, 20133 Milan, Italy.
✉email: [email protected]

Received: 30 May 2023 Revised: 19 September 2023 Accepted: 22 September 2023

Published online: 30 September 2023
 L. Cavaggioni et al.
23
mass and protein synthesis, characteristics particularly suited to “balance exercise” OR “proprioception training” OR “propriocep-
counteract sarcopenic obesity [12]. Additionally, the combination tion exercise” OR “postural control” OR “postural stability” OR
between aerobic and strength training modalities (known as “cognitive training” OR “functional training” OR “functional move-
Concurrent Training) seems to be effective in improving body ment” OR “quality of movement” OR “movement quality” AND
composition, cardiorespiratory fitness and muscular strength “obes*“.
[11, 13] with little interference on muscle size growth [14].
Individual with obesity may also obtain other positive effects by Study selection
following a dietary restriction program [11, 15]. In order to exclude duplicate studies, two authors (L.C. and D.F.)
For flexibility, obesity may impair joint range of motion because reviewed the abstracts of each study respecting the following
the adipose tissue interposed around each joint may limit inclusion criteria: a) randomized controlled trials or clinical trials, b)
segmental body rotation, causing mechanical interference [16], Body Mass Index (BMI) of children and adolescents at the 95%
especially in elbow, hip and knee segments [17]. percentile or greater, and for adults to be above 30 kg/m2, c)
Lastly, when dealing with skill-related components of physical detailed intervention description (an health-related component
fitness, especially balance and motor coordination, individuals associated with, at least, one skill-related outcome), d) randomiza-
with obesity exhibit a reduced medio-lateral or sagittal stability tion process and allocation into an experimental or a control
and motor coordination with a concomitant center of pressure group, e) trials must have been written in English and published in
anteriorly shifted, due to compensatory motions counteracting a peer-reviewed journal. Studies with participants with severe
body weight accumulation [18, 19]. cardiovascular, neurological or physical comorbidities, co-
Traditionally, all of these physical fitness’ components can be intervention (psychological or medical support) or duration less
improved through specific movements or exercises targeting a than 3 weeks were excluded.
single specific outcome (i.e., aerobic, strength, balance, flexibility)
in an isolated mode during an entire training session. Data extraction
An innovative training regimen that embraces the interaction Two authors (L.C., D.F.) independently screened the articles by
between all of each component is called Integrative Neuromuscular using title and abstracts. Abstracts were excluded based on the
Training (INT) [20]. This modality can be a suitable option to target exclusion criteria. Next, from the initial list, the full text of the
the overall physical fitness (health and skill-related variables) in an selected articles was screened by those two authors to verify
integrated manner. INT is a training approach targeted on global whether they met the inclusion criteria excluding duplicate
human movement pattern development (e.g., fundamental move- studies. Finally, they compiled a list of all eligible articles for this
ment skills) and specific strength and conditioning exercises (e.g., review. It is worth emphasizing that the participants’ ages, gender,
motor control, mobility, strength, proprioception, cardiorespira- race/ethnicity, etc., were not restricted in order to obtain a more
tory fitness), with the aim to restore a correct movement complete understanding of this topic. The studies were consid-
mechanics by stressing an efficient quality of movement and ered when a consensus was reached by two authors (L.C., D.F.) for
physical fitness [21, 22]. a later presentation and discussion. If in presence of a disagree-
Following INT principles, improvements in muscular strength, ment between these two authors, a third researcher (L.G.) made
power, motor skill performance, dynamic stability and balance the definitive decision.
[21, 23] were observed in children and adolescents [24–26].
Additionally there is an enhancement in motor competence and
proficiency [27], as well as a reduction in movement asymmetries RESULTS
and “motor awkwardness”[28]. Moreover, a recent systematic The review procedure generated 147 papers from three electronic
review reported that INT is an effective training mode to improve databases and after an initial removal before screening (e.g.,
motor performance and injury prevention especially in young duplicate articles), a total of 19 studies complying with the
athletes [29]. Taken together, these findings provide evidence inclusion criteria were considered eligible for the review process.
supporting INT as a training mode to target the overall physical The overall number of participants was 828, with an age range
fitness by focusing on the quality of movement. from 7 to 70 years with a comprehensive intervention’s duration
To the best of the Authors’ knowledge, the existing literature that ranges from three weeks up to twelve months (Table 1).
regarding the effectiveness of INT on individuals with a The main finding of this narrative review was that INT
noteworthy health condition (i.e., obesity) is scarce. However, intervention is effective to improve both health-related and skill-
from a theoretical point of view, INT could be helpful for related fitness components in individuals with obesity, indepen-
ameliorating fitness levels in people with obesity thanks to a dently from training duration and participants’ age. On one hand,
mixture of stimuli within the same training session. balance, postural control, and movement competence appear to
Therefore, the aim of this narrative review was to identify and be better improved by INT than a traditional training regimen. On
synthesize the feasibility of INT intervention on health-related, the other hand, body composition and cardiorespiratory fitness
skill-related and body composition outcomes in individuals with exhibited similar enhancements compared to a common inter-
obesity. vention. In addition, it seems that motor adaptations obtained by
INT were slightly preserved during a subsequent detraining
period.
METHODS
Data sources and searches
This narrative review was structured with a computerized search DISCUSSION
of four electronic databases (Medline/PubMed, EMBASE, Web of Study population: younger versus older individuals
Science, Google Scholar) including articles published before 1st INT appears to be effective in ameliorating postural control in
February 2023 without restrictions on publication year. Articles children and adolescents with obesity ranging from seven to
were limited to human experiments. The search used a combina- sixteen years old (N = 5 studies). In this regards, seven-year-old
tion of the following terms “integrative neuromuscular training” children demonstrated significant changes in Center of Pressure
OR “integrative neuromuscular exercise” OR “integrative neuro- variables (i.e., sway area, mean velocity, antero-posterior velocity,
motor training” OR “integrative neuromotor exercise” OR “neuro- medio-lateral velocity) and dynamic balance score measured with
motor training” OR “neuromotor exercise” OR “neuromuscular the Star Excursion Balance Test following a training program
training” OR “neuromuscular exercise” OR “balance training” OR focused on INT approach (e.g., mini hurdle jumping, agility cone

International Journal of Obesity (2024) 48:22 – 32

 24
Table 1. Characteristics of included studies.
Reference Study Sample size Number of Exercise intervention based on INT Outcome measurements Results INT components’
duration and age groups principles adherence
Guzmán- 4 weeks 32 children 2 2 times/week of exercises focused on Static postural control detecting (+) in COP mean velocity, sway Partial
Muñoz (7–9 years) EG § lower limbs muscular strength and center of pressure COP variables area (Strength, motor
et al. (2019) CG coordination: (i) mini hurdle jumping, (ii) (sway area, mean velocity, Antero- (+) in SEBT anterior reach, postero- coordination,
agility cone drills, and (iii) agility ladder Posterior velocity, Medio-Lateral lateral reach, postero-medial reach agility, balance)
drills. Then, exercises to improve balance: velocity)
(i) single-leg balance, (ii) marching in Dynamic postural control with Star
place, (iii) tandem walk, and (iv) single-leg Excursion Balance Test SEBT (anterior
squat progressing from stable surface reach, postero-lateral reach, postero-
with eyes open to an unstable surface medial reach)
with eyes closed
Batrakoulis 40 49 adult 3 3 times/week of high-intensity circuit-type Muscular strength (one repetition (+) in muscular strength Complete
et al. (2018) weeks women EG § neuromuscular exercise training with the maximum leg press) (+) in cardiorespiratory fitness (strength, stability,
(36.4 ± 4.4 EG with use of asynchronous music incorporating Cardiorespiratory fitness (VO2max on (+) in daily energy expenditure agility, motor
years) detraining fundamental movement patterns using treadmill) (+) in body composition coordination,
§ bodyweight exercises using portable Daily energy expenditure (portable cardiorespiratory
CG modalities (suspension, belts, balance indirect calorimetry) fitness, agility,
balls, kettlebells, medicine balls, battle Body composition (body mass, body mobility)
ropes, stability balls, speed ladders, foam mass index, lean body mass, waist
rollers, elastic bands) circumference, resting metabolic
rate)
Batrakoulis 10 49 inactive 3 3 times/week of progressive loaded Total body bone mineral density (+) in BMD Complete
et al. (2021) months adult EG § fundamental movement patterns circuit (BMD) and total bone mineral (+) in BMC (strength, stability,
women EG with training (squat, hinge, lunge, push, pull, content (BMC) with dual-energy X- (+) in muscular strength and local agility, motor
(36.4 ± 4.4 detraining carry, rotation, plank) using portable ray absorptiometry muscular endurance, coordination,
L. Cavaggioni et al.

years) § modalities (suspension, belts, balance Flexibility (passive joint range of (+) in flexibility cardiorespiratory
CG balls, kettlebells, medicine balls, battle motion in ankle dorsiflexion, knee (+) in static balance fitness, agility,
ropes, stability balls, speed ladders, foam extension, hip extension, shoulder mobility)
rollers, elastic bands) with bodyweight extension, glenohumeral internal
exercises rotation)
Static balance (Romberg test)
Functional performance (Functional
Movement Screen)
Muscular strength (one repetition
maximum vertical chest press,
supinated closed-grip lat pull-down,
leg extension, lying leg curl
Local muscular endurance
(maximum number of repetitions in
60 s in partial curl-up, kneeling push
up, chair squat)
Batrakoulis 10 49 inactive 3 3 times/week of supervised protocol Psychosocial distress (General Health (+) in psychological distress Complete
et al. (2020) months adult EG § characterized by a hybrid format including Questionnaire, GHQ-12) (+) in subjective vitality (strength, stability,
women EG with a mix of endurance training, core Subjective vitality (subjective vitality (+) in exercise behavioral agility, motor
(36.4 ± 4.4 detraining strengthening and resistance training scale, SVS) regulation coordination,
years) § elements with the use of asynchronous Exercise behavioral regulation cardiorespiratory
CG music incorporating fundamental (Behavioral Regulation in Exercise fitness, agility,
movement patterns using bodyweight Questionnaire–2, BREQ-2) mobility)
exercises using portable modalities

International Journal of Obesity (2024) 48:22 – 32

 Table 1. continued
Reference Study Sample size Number of Exercise intervention based on INT Outcome measurements Results INT components’
duration and age groups principles adherence
Batrakoulis 12 97 adult 4 Progressive loaded fundamental Flexibility (passive joint range of (+) in muscular strength and local Complete
et al. (2022) months women EG 1day/ movement patterns circuit training motion in modified sit&reach, ankle muscular endurance especially in (strength, stability,
(44.8 ± 5.2 week § regimen integrating low-to-moderate dorsiflexion, knee flexion, hip EG 3days/week agility, motor
years) EG 2days/ impact cardiovascular bodyweight drills flexion, shoulder flexion) (+) in flexibility especially in EG coordination,
wee§ and compound resistance training Static balance (Romberg test) 3days/week cardiorespiratory
EG exercises performed intermittently. Each Functional performance (Functional (+) in static balance especially in fitness, agility,
3days/ session used 6–12 whole-body exercises Movement Screen) EG 3days/week mobility)
wee§ and work-to-rest ratios ranging from 1:3 to Muscular strength (one repetition (+) in functional performance
CG 2:1 with a duration of 15–45 seconds maximum vertical chest press, especially in EG 3days/week
supinated closed-grip lat pull-down,
leg extension, lying leg curl
Local muscular endurance
(maximum number of repetitions in
60 s in partial curl-up, kneeling push
up, chair squat)

International Journal of Obesity (2024) 48:22 – 32

Molina- 13 70 children 2 3 times/week of movement-quality Plantar pressure during walking for (=) in plantar pressure surface area Complete
Garcia weeks (10.8 ± 1.2 EG § exercise training composed by self- 10 times along a 10 m-long corridor (=) in plantar force time integrals (strength, stability,
et al. (2019) years) CG awareness of analytical movement on a pressure platform (plantar (+) in plantar maximum force agility, motor
patterns (e.g., anterior and posterior pelvic surface area, plantar maximum force, coordination,
tilt), body posture (e.g., optimal spine force-time integrals) cardiorespiratory
position), mobility (e.g., hip flexion fitness, agility,
mobility), stability (e.g., core stability), mobility)
strength (e.g., bilateral lower limb push
strength, (e.g., squat pattern) combined
with “multi-games” aerobic exercise from
moderate-to-vigorous intensity
Molina- 13 64 children 2 3 times/week of movement-quality Body posture (2-dimensional (+) in lower limb angle and plumb- Complete
Garcia weeks (10.9 ± 1.3 EG § exercise training composed by self- photogrammetry measuring lower tragus distance in sagittal plane (strength, stability,
et al. (2020) years) CG awareness of analytical movement limb angle and plumb-tragus (+) in lower limb angle in frontal agility, motor
patterns (e.g., anterior and posterior pelvic distance in sagittal and frontal plane coordination,
tilt), body posture (e.g., optimal spine plane) (+) in functional performance cardiorespiratory
position), mobility (e.g., hip flexion Functional performance (Functional (+) in one repetition maximum fitness, agility,
mobility), stability (e.g., core stability), Movement Screen) arm press, in handgrip strength mobility)
strength (e.g., bilateral lower limb push Muscular strength (one repetition test, standing long jump
strength, (e.g., squat pattern) combined maximum arm press, leg press, (=) in cardiorespiratory fitness
L. Cavaggioni et al.

with “multi-games” aerobic exercise from handgrip strength test, standing

moderate-to-vigorous intensity long jump)
Cardiorespiratory fitness (20 meters
shuttle run test and agility 4×10
shuttle run test)
Molina- 13 50 children 2 3 times/week of movement-quality Biomechanics during walking 7 gait (+) in stance time Complete
Garcia weeks (10.7 ± 1.2 EG § exercise training composed by self- cycles with motion capture analysis (+) in foot abduction (strength, stability,
et al. (2022) years) CG awareness of analytical movement (cadence, stance/support times, step (+) in pelvic tilt agility, motor
patterns (e.g., anterior and posterior pelvic length, stride width pelvis/hip/knee/ (=) in cadence, step length, stride coordination,
tilt), body posture (e.g., optimal spine ankle kinematics in three planes) width, knee/hip/ankle kinematics cardiorespiratory
position), mobility (e.g., hip flexion Muscoskeletal pain (Pediatric Pain (=) in muscoskeletal pain fitness, agility,
mobility), stability (e.g., core stability), Questionnaire) mobility)
strength (e.g., bilateral lower limb push
strength, (e.g., squat pattern) combined
with “multi-games” aerobic exercise from
moderate-to-vigorous intensity
25
 26
Table 1. continued
Reference Study Sample size Number of Exercise intervention based on INT Outcome measurements Results INT components’
duration and age groups principles adherence
Cavaggioni 6 weeks 64 adults 2 3 times/week of movement-quality Functional performance (Functional (+) in functional performance Partial
et al. (2019) (50.5 ± 10.4 EG § exercise training emphasizing mobility, Movement Screen) (+) in static balance (stability, mobility,
years) CG stability and neuromuscular training. t was Static balance (Modified Balance (=) in muscular strength strength,
based on self-awareness about the Error Scoring System) (+) in breathing pattern cardiorespiratory
movement execution while performing Muscular strength (handgrip (=) in body composition fitness)
multi-joint strength exercises, strength test, five repetition sit-to-
diaphragmatic breathing and corrective stand test)
postures to emphasize motor control in a Breathing pattern (total faulty
circuit training mode breathing scale)
Body composition (fat mass %, waist
circumference, body mass index)
Alizadeh 8 weeks 25 adult 3 3 times/week of integrated resistance Cognitive-psychological (+) Brain-derived neurotrophic Partial
et al. (2022) women EG active training including upper and lower limbs performance, brain-derived factor (strength, balance,
(26.3 ± 4.7 individuals multi-joint movements, core stability, neurotrophic factor (BDNF) (+) Executive function motor
years) § motor coordination and balance exercise Cognitive-psychological coordination,
EG inactive in a circuit training mode performance, executive function stability)
individuals (number of errors, number of true
§ responses, reaction time)
CG
Santanasto 12 36 adults 2 3 times/week of physical activity Functional performance (Short (+) in short physical performance Partial
et al. (2015) months (70.6 ± 6.1 EG § combined with weight loss program Physical Performance Battery) battery (cardiorespiratory
years) CG composed by treadmill walking, strength Body composition (visceral fat, (+) body composition (in visceral fitness, strength,
training with ankle weight (standing leg percent body fat, intermuscular fat, percent body fat, intermuscular balance)
curl, knee extension, side hip raise and a adipose tissue, subcutaneous tight, adipose tissue, subcutaneous tight,
L. Cavaggioni et al.

toe stand) and balance exercises muscle density, waist circumference, body weight, body mass index)
body weight, body mass index (=) muscle density, waist
circumference
Bezzoli 3 weeks 20 adults 2 5 times/week of 30-min conditioning Pulmonary function with spirometry (+) in pulmonary function, Paartial
et al. (2018) (52.7 ± 9 EG § session on a bicycle ergometer at an (Forced Vital Capacity, Forced respiratory muscles strength, (balance, stability,
years) CG intensity of 60–70% of heart rate Expiratory Volume 1 second, thoracic excursion cardiorespiratory
maximum combined with resistance Maximum Voluntary Ventilation) (=) in cardiorespiratory fitness, fitness)
training exercises in a circuit mode with Respiratory muscles strength body composition and quality of
the addition of motor control exercises to (maximal inspiratory pressure, life
improve postural alignment, intra- maximal expiratory pressure
abdominal pressure, rib cage mobility, and Thoracic excursion using a 200-cm
the perception of correct muscle tape
activation of transversus abdominis, Cardiorespiratory fitness (6 minute
diaphragm, internal oblique, and pelvic walking test)
floor muscles Quality of life (Short Form Health
Survey questionnaire, SF36)
Body composition (fat mass, fat free
mass, body mass index)
Bonney 14 52 EG § 1 time/week in task-orientated training Cardiorespiratory fitness (20 meters (=) in cardiorespiratory fitness, Partial
et al. (2019) weeks adolescents CG protocol consisting 3 components shuttle run test) muscular strength, motor (cardiorespiratory
(13-16 years) including dance with music, goal-directed Motor coordination (Movement coordination and anaerobic fitness fitness, motor
activities (e.g., throwing at targets, Assessment Battery for Children test (−) cognitive performance coordination,
emptying boxes, walking, and running), 2nd edition) balance, agility)
and team-based games (e.g., tag, relays, Muscular strength (lower extremity
hide-and-seek). hand-held dynamometer, standing
long jump, sit to stand, lateral step-
up, stair climbing)
Anaerobic fitness (10 × 5 meters
sprint test)
Cognitive-psychological
performance (self-efficacy
questionnaire, Children’s Self-
perceptions of Adequacy in and

International Journal of Obesity (2024) 48:22 – 32

Predilection for Physical Activity)
 Table 1. continued
Reference Study Sample size Number of Exercise intervention based on INT Outcome measurements Results INT components’
duration and age groups principles adherence
Rojhani- 4 weeks 32 adults 2 4 times/week of physical activity Dynamic postural control with Star (+) in static and dynamic postural Partial
Shirazi (36.1 ± 6 EG § combined with balance training exercises, Excursion Balance Test SEBT (anterior control (balance, stability)
et al. (2016) years) CG standing on one leg, standing in tandem reach, postero-lateral reach, postero- (+) in quickness and agility
mode, standing on one leg with closed, medial reach)
walking in a tandem mode, walking on Static postural control with Single
toes and heels, side walk, standing while Leg Stance (SLS)
one upper extremity and the opposite Quickness and agility with Get up
lower extremity were up, rotating the and Go (GUG)
head from side to side, walking backwards
for four steps, and shifting weight from
one foot to the other
Rodrigues- 8 weeks 59 adults 2 3 times/week of functional training (half Cardiorespiratory fitness (6 minute (+) in muscular strength test Partial
Cambiriba (40-59 years) EG § squat with fitball between thigths, walking test) (maximum isometric lumbar (cardiorespiratory
et al. (2021) CG standing hip, squatting laterally with bend Muscular strength (handgrip test, traction) fitness, strength,

International Journal of Obesity (2024) 48:22 – 32

performing leg abduction, walking and maximum isometric lumbar traction) (−) cardiorespiratory fitness, motor
jogging, TRX row, pull rope, push up with Local muscular endurance muscular strength (handgrip coordination)
knees, lumberjack movement) combined (60 second abdominal test) strength), local muscular
with dietary education Flexibility (Wells bench test) endurance, flexibility, quality of
Physical activity level (International life, knee pain, physical activity
Physical Activity Questionnaire) level, body composition
Quality of life (Medical Outcomes
Study 12)
Knee pain (WOMAC)
Body composition (body fat, body
fat percentage, skeletal mass, body
mass index)
Maffiuletti 3 weeks 39 adults 3 5 times/week of 30-min conditioning Static postural control (time of (+) in static postural control Partial
et al. (2005) (20-40 years) EG § session on a bicycle ergometer at an balance maintenance in single leg (balance, stability,
EG intensity of 60–70% of heart rate stance, mean errors on medial-lateral cardiorespiratory
CG maximum combined with resistance direction, mean errors of trunk fitness)
training exercises (40-70% of one motion)
repetition maximum load on lower and
upper-body machines) with the addition
of proprioceptive exercises using a
movable platform (Delos system) in a
L. Cavaggioni et al.

single leg stance

La Scala 30 44 adults 3 3 times/week of aerobic exercises Cardiorespiratory fitness (VO2max (+) in cardiorespiratory fitness Partial
Teixeira weeks (39.7 ± 5 EG § performed on an ergometer combined on treadmill) (−) in physical activity level and (cardiorespiratory
et al. (2020) years) EG with resistance training performed in a Physical activity level (International body composition fitness, strength,
CG circuit mode (squat thruster, hip flexion Physical Activity Questionnaire) stability)
with elbow flexion, ball crunch, side lateral Body composition (fat mass
raise with lunge, horizontal row, stiff leg percentage, lean muscle mass, waist
deadlift, bench press, single leg balance circumference, body mass index)
eyes closed)
Feito 8 weeks 18 adults 2 3 times/week of aerobic (running, rope Total training session duration (+) in total training session Partial
et al. (2019) (25-27 years) EG § jumping), body weight strength exercises Body composition (arm lean mass, duration (strength,
CG (pull-ups, squat), and weightlifting arm fat mass, trunk lean mass, trunk (−) in body composition and in cardiorespiratory
exercises (jerk, kettlebell swing) fat mass, leg lean mass, leg fat mass, glucose control fitness, agility)
waist circumference, body mass
index
Glucose control (Fasting Plasma
Glucose)
27
 L. Cavaggioni et al.
28
drills, single-leg balance, marching in place, single-leg squat) [30].

Note: (+) = significant positive changes of INT group compared to other training interventions; (=) = similar significant changes of INT group respect to other training interventions; (−) = no significant changes
INT components’

cardiorespiratory
Similarly, Molina-Garcia and colleagues demonstrated that 10-

fitness, agility)
adherence year-old participants who followed a movement-quality exercise
(strength,
Partial intervention composed of exercise to improve awareness of
movement pattern, mobility, stability and strength combined with
multi-games exercises, significantly improved their posture in
various body segments (e.g., lower limb angle and plumb-tragus
distance), functional performance in the deep squat and active leg
raise patterns, as well as maximum forefoot force support, while
maintaining their foot and pelvic alignment during the walking
pattern when compared to a conventional lifestyle intervention
(−) in body composition
(+) exercise enjoyment

[31–33]. Conversely, in adolescents (age range from 13 to 16

years), an INT intervention composed of a goal-directed activity
(e.g., throwing at targets, emptying boxes, walking, running) and
team-based games compared to a video games program using
Nintendo Wii gaming system induced similar ameliorations in
muscular strength and in both aerobic and anaerobic fitness
Results

profile without between-groups differences [34].

Although this type of training has been developed especially for
a younger population with the aim to minimize the injury risk
during sport activities, thanks to a better movement symmetry and
“motor awkwardness” [23, 28, 35], there is a plethora of studies that
performance (exercise enjoyment
percentage, body mass index)

demonstrated the effectiveness of INT also in adulthood by

Body composition (body fat

enhancing both health and skill-related physical fitness compo-

Outcome measurements

nents. Moreover, INT improved also cognitive and psychological

Cognitive-psychological

performance (e.g., selective attention, cognitive flexibility, motiva-

tion, self-efficacy, vitality, enjoyment) with contrasting results on
body weight change or fat mass reduction [36–49].

Duration of intervention: short and long-time training effects

outcomes
scale)

INT training mode induced significant adaptation responses

overtime ranging from a short, to a mid-long-time period people
with obesity. In two studies, a 3-week training duration was
2 times/week of aerobic exercises (rowing
ergometer) combined with nine resistance
training exercises (air squat, front squat,

sufficient to improve cardiorespiratory fitness, respiratory muscles

overhead squat, press, push press, push
jerk, deadlift, sumo deadlift, high pull,

strength, quality of life and postural stability [41, 46]. In this regard,
Exercise intervention based on INT

Bezzoli et al., tested the efficacy of a 3-weeks multidisciplinary

rehabilitation program composed by one daily 30-min condition-
ing session on a bike ergometer (intensity of 60–70% heart rate
maximum) combined with motor control exercises and rib cage
mobility. The Authors demonstrated significant improvements in
medicine ball clean)

pulmonary function (Forced Vital Capacity, Maximal Voluntary

Ventilation, Maximal Expiratory Pressure), quality of life (Patient
Specific Function Scale) and cardiorespiratory fitness (6 minute
principles

walking test) [41]. On the same line of evidence, also Maffiuletti

and colleagues showed that a short-time intervention period
(3 weeks) targeting body weight reduction strategies as energy
between interventions, § = Intervention based on INT approach.

restricted diet, psychological counseling and physical activity

combined with balance and proprioceptive exercises improved
Number of

trunk postural sway and time of balance maintenance in

groups

individuals with obesity [46]. Similarly, Guzmán-Muñoz et al.

EG §

showed that a 4-week training program based on neuromuscular

CG
2

stimuli (e.g., mini hurdle jumping, agility drills, single-leg balance,

marching in place, tandem walk, and single-leg squat) enhanced
EG Experimental Group, CG Control Group
Sample size

static (e.g., mean velocity and sway area center of pressure) and
(26.8 ± 5.9
23 adults
and age

dynamic postural variables (e.g., maximal anterior, postero-lateral

years)

and postero-medial reach distances during a monopodalic stance)

[30]. A period with the same duration appeared to be effective in
ameliorating body balance detected through the single leg test
duration

and the Star Excursion Balance Test following a specific training

8 weeks
Study

protocol (4 week/sessions for 45 min) conducted with adult

continued

individuals who were treated with a sleeve gastrectomy [47].

For what concern mid-time effects ranging from six to fourteen
weeks of intervention duration, there is evidence promoting
et al. (2014)
Reference

positive effects on physical fitness outcomes (i.e., muscular

Heinrich

strength, body balance, flexibility, cardiorespiratory fitness) and

Table 1.

negligeable changes in anthropometry and body composition

both in adults [42, 44] and adolescents [31–34].

International Journal of Obesity (2024) 48:22 – 32

 L. Cavaggioni et al.
29
Lastly, when dealing with long-time interventions, Batrakoulis improvements overtime without differences between training
et al. demonstrated that an INT program conducted over interventions (INT protocol versus control) for both upper and
10 months was able to increase daily energy expenditure, reduce lower-body segments. On one hand, it could be speculated that
fat mass, improvement muscular strength and cardiovascular these controversial results might be due to a reduced adherence
performance in forty-nine individuals with obesity [37]. The same to the training program, or to the equipment used (e.g., elastic
research group highlighted that a progressive INT based protocol bands, dumbbells, suspension belts, kettlebells, medicine balls,
(e.g., squat, hinge, lunge, push, pull, carry, rotation, plank battle ropes), but on the other hand the duration of each training
exercises) using portable tools (e.g., suspension, belts, balance program (e.g., from eight weeks to ten months) induced a better
balls, kettlebells, medicine balls, battle ropes, stability balls, speed movement pattern learning and muscle recruitment leading to
ladders, foam rollers, elastic bands) preserved muscular strength, positive changes in muscular strength [50, 51].
aerobic fitness, flexibility, bone mineral density and psychological
regulation (e.g., wellbeing, vitality) in inactive females with obesity Flexibility outcome
[39, 40]. Moreover, positive findings were also detected following In three studies, joint range of motion showed significant changes
eighteen weeks of weight loss combined with an INT program in between groups [38, 40, 48]. In detail, Batrakoulis et al. demon-
obese elderly adults, promoting significant improvements in strated remarkable variations (p < 0.001) in sit and reach test and
physical function tested via Short Physical Performance Battery, in glenohumeral internal rotation in favor to INT group respect to
abdominal visceral (VAT) and thigh intermuscular adipose tissue control group. For what concern ankle dorsi-flexion and shoulder
(IMAT), when compared to individuals who followed a traditional extension test there is trend in reaching a significant difference
physical activity program combined with educational lifestyle (p = 0.057) [40]. Moreover, the same research group demonstrated
workshops [49]. Finally, La Scala Teixeira et al. demonstrated that that an INT program performed with a different frequency (e.g.,
an INT protocol with a duration of 30 weeks improved one day/week, two days/week, or three days/week) was able to
cardiorespiratory fitness, whereas controversial changes in fat induce significant improvements compared to what observed in
mass, body weight and lean mass were found. However, waist the control group (p = 0.025) [38]. Specifically, one day/week was
circumference showed a significant reduction overtime when more effective to ameliorate ankle dorsiflexion and shoulder
compared to other training interventions (e.g., interdisciplinary flexion; two days/week induced significant ameliorations in
therapy and interdisciplinary education) [45]. passive range of motion in ankle dorsiflexion, hip flexion and
shoulder flexion. Finally, three days/week promoted a better
Cardiorespiratory fitness outcome flexibility (p < 0.001) in ankle dorsiflexion, knee flexion, hip flexion
Cardiorespiratory fitness was investigated in six studies and shoulder flexion [38]. Lastly, the study by Cambiriba and
[33, 34, 37, 41, 45, 48] reporting significant improvements colleagues found that the flexibility detected through the Wells
following a specific neuromuscular training protocol. Batrakoulis bench test reached similar changes in the experimental group
and colleagues (2018) showed positive changes in VO2max from who followed a training protocol focused on INT principles when
baseline (26.1 ± 4.4 mL/kg/min) to post-training (33.1 ± 4.8 mL/kg/ compared to control group [48].
min; p < 0.001) following a INT protocol (e.g., high-intensity whole-
body multi-joint movements in a circuit training modality Body balance, postural control, and functional performance
respecting a heart rate maximum major of 65%) with a outcomes
concomitant significant reduction in blood lactate concentration Several studies have reported positive changes in both static
during the entire training phase (i.e., from week one to week forty) [42, 46, 47] and dynamic balance [30, 47], measured in different
[37]. On the same line of evidence also Bezzoli et al., reported stances, after a period of INT, underlying the importance of a
significant improvements in distance covered during the six- neuromuscolar training for stimulating proprio and exteroception
minute walking test (403.4 ± 158.4 m pre-training versus in individuals with obesity. On the same line of evidence, the
464.6 ± 131.6 m post-training) in obese individuals who performed center of pressure sway area and velocity [30], combined the
neuromotor exercises combined with conditioning sessions maximum force sustained by the medio-lateral forefoot, the lower
performed at 60–70% of their maximum heart rate [41]. Notably, limb angle, pelvic tilt and the plumb-tragus alignment significantly
also La Scala Teixeira and colleagues observed a significant main improved (p < 0.05) thanks to neuromotor exercises whose aim
effect of time on VO2max (F = 12.441, p = 0.001) in individuals who was to preserve an optimal spine position, self-awareness of
performed different functional training circuits composed by free movement patterns, core muscles stabilization and muscular
weights, elastic bands and bodyweight movements (e.g., upright strength [31, 33]. Functional performance has also been shown to
row with sumo squat, dumbbell fly with pelvic elevation, elastic improve with INT intervention, with five studies reporting a
trunk rotation, front raise with side lunge, suspended row, knee significant increase in the Functional Movement Screen total score
flexion with elbow flexion, trunk lateral flexion, single leg balance [38, 39, 42] and single scores in the Hurdle Step (p = 0.0036),
with eyes closed) (p = 0.014) [45]. Conversely, three studies did Active Straight Leg Raise (p = 0.0003) and Deep Squat (p = 0.004)
not observe between-group changes in this specific outcome movement patterns [32, 42]. Moreover, also Santanasto and
following a INT program [33, 34, 48]. colleagues demonstrated a significant amelioration in functional
capacity after an INT protocol using the Short Physical Perfor-
Muscular strength outcome mance Battery, with scores increasing from 9.7 at baseline to 10.3
Concerning the effects of INT on muscular strength, five out of arbitrary units at the end of the intervention period in older
seven studies reported significant improvements. Specifically, the people with obesity [49]. Taken together, all these findings
upper and lower-body strength assessed with different proce- provides evidence that individuals with obesity may benefit from
dures (e.g., one repetition maximum in vertical chest press, one an INT protocol focused on motor control, articular stability and
repetition maximum in supinated lat pull-down, one repetition movement competence in ameliorating their body balance and
maximum in arm press, isometric handgrip strength test, one postural control.
repetition maximum in horizontal leg press, one repetition
maximum in seated leg extension, one repetition maximum in Cognitive performance outcome
leg curl, sit to stand test, standing long jump test, isometric knee Regarding the effects of INT on cognition, three studies showed
extensor test, isometric ankle plantar-flexors and dorsi-flexor test) beneficial adaptations on cognitive and psychological perfor-
showed positive changes in individuals with obesity in favor to an mances [36, 39]. In detail, psychological distress scores detected
INT approach [33, 37, 38, 40, 42]. Two studies [34, 48] found similar using a specific questionnaire (i.e., General Health Questionnaire

International Journal of Obesity (2024) 48:22 – 32

 L. Cavaggioni et al.
30
-12) significantly decreased by 68%, vitality score increased by these body composition findings suggest the key role that a
53% (p = 0.001) and finally also the introjected regulation, supervised nutritional management may have, in combination
intrinsic regulation and identified regulation significantly with a regular physical activity (preferably based on neuromus-
improved throughout the five-month period (p = 0.001; cular stimuli) to obtain a more pronounced fat loss and weight
p = 0.004, p = 0.001). During the subsequent 5 month- reduction [57–59].
detraining period, these results were attenuated, but not It is interesting to note that training interruption is a recognized
completely lost when compared to baseline scores [39]. As for problem that occurs during weight loss interventions, with a
neurological functions, the brain-derived neurotrophic factor had frequent tendency to regain body mass reaching values similar to
a significant enhancement in both active and inactive obese pre-intervention [60]. Noteworthy, an INT protocol appeared to be
women, as well as the executive function performances following adequate to mitigate the negative effects of training cessation (i.e.,
a specific INT training regimen [36]. Last but not least, a specific five months) showing slower decrements in both health-related
neuromuscular training program presented significant changes (i.e., cardiovascular, strength, flexibility) and skill-related (e.g.,
overtime in exercise enjoyment (p = 0.002) compared to a balance, motor coordination) outcomes [37, 38, 40]. Moreover, as
common exercise protocol [44]. INT was shown to improve enjoyment with respect to a traditional
training program [44], an INT protocol may be suitable to prevent
Body composition and anthropometry outcomes training interruption.
With respect to body composition indicators INT appeared to induce Lastly, it is worth noting that regular physical exercise that
similar changes compared to traditional training. Three evidences incorporates INT principles is a safe and injury-free option for both
reported a remarkable reduction in visceral fat (−15.1%, p = 0.004), children and adults. This is likely due to the multicomponent, high-
percent body fat (−7.2, p = 0.001), intermuscular adipose tissue intensity and intermittent nature of this training, which includes
(−23.6, p = 0.001), subcutaneous tight fat (−12.3%, p = 0.002), body neuromuscular and cognitive tasks enhancing muscular performance
weight (−5.5%, p = 0.002) and BMI (−5.2%, p = 0.002) after and motor coordination, thereby reducing the risk of injury [38].
12 month of INT [49]. On the same line of evidence, Batrakoulis From a practical perspective, this narrative review lays the initial
and colleagues highlighted significant improvements by 1.9% in foundation to promote the usefulness of INT to treat obesity in a
bone mineral density and 1.5% in bone mineral content [40] with population with different age (e.g., younger and older) and
positive changes also in BMI, lean mass and waist circumference anthropometry. These evidence on INT allows fitness coaches,
[37]. Notably, these ameliorations were mitigated following a therapists and practitioners to consider INT principles a feasible
5-month detraining observing a slight weight regain and body alternative to the most common exercise intervention used within
composition profile (body mass, p = 0.003; BMI, p = 0.004; waist obesity. Taking this into account, a customized exercise training
circumference, p = 0.001; hip circumference, p = 0.015; resting and a structured nutritional approach may display an important
metabolic rate, p = 0.001) without reaching baseline levels [37]. By role in supporting individuals with various health conditions,
contrast, non-significant interactions and between-group differences including physical disabilities [61], obesity [62], cancer [63] and
were observed in BMI [41–45], fat mass percentage [41–45], lean diabetes mellitus [64].
mass [43, 45], waist circumference [41–43, 49], body weight [44], Nevertheless, some limitations of the present study should be
muscle density [49] and hip circumference [41] suggesting similar recognized. First, the narrative nature of the review (as compared
changes regardless of the exercise nature (e.g., INT or traditional to systematic approach with meta-analysis) prevents us to depict
exercise resistance training). firm conclusions about the efficacy of prescribing INT protocols for
In summary, these studies analyzed the contribution of the INT individuals with obesity. Second, the limited number of electronic
regimen on physical fitness and body composition to counteract databases considered during the searching process may have
obesity. In fact, it is well documented that a multidimensional contributed to limit the discussion of the results. Third, studies
exercise program targeted on the mixture of various fitness utilizing telemedicine approaches were not considered in the
components are able to achieve whole-body postural improve- present study, although this modality seems to be a new frontier
ments, muscular strength and cardiorespiratory fitness thanks to a gaining even more attention into research and clinical setting in
more efficient neural plasticity underlying a more proficient motor obesity management [65].
skill learning [52] and movement competency [26]. An exercise In conclusion, this review highlights the beneficial role of INT
intervention that incorporates INT principles (i.e., health and skill- programs in improving physical fitness in both younger and older
related variables) focused on dynamic mobility, stability, funda- individuals with obesity, with significant ameliorations over short,
mental movement pattern correction, cardiovascular and cogni- medium and long time period. The most INT outcomes used in the
tive stimuli, may help to develop neural adaptations, new motor analyzed studies were cardiorespiratory fitness, muscular strength,
units recruitment, intermuscular coordination and strength gains balance, postural control and body composition, with significant
[53, 54]. These findings suggest that the improvements due to INT remarkable improvements following a specific training intervention
contribute to better quality of movement and postural control based on INT approach targeting both health-related and skill-
during daily-life activities. This is significant, as increased body related physical fitness components. However, BMI, fat mass
weight in known to lead to balance deficits compared to normal- percentage and waist circumference showed comparable improve-
weight individuals [55]. Moreover, an INT regimen characterized ments with respects to traditional training exercises. Taken together,
by high-intensity body-weight circuit training exercises displayed these findings support the effectiveness of INT protocols in
significant ameliorations in skeletal muscle oxidative capacity, a ameliorating health-related and skill- related physical fitness
delay muscle fatigue perception and a cardiovascular endurance components. Therefore, fitness coaches and therapists may consider
improvements [56]. INT as feasible option when working with outpatients with obesity.
Despite INT exhibits similar results compared to a common
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