stroke is a sudden loss of neurological function caused by the disturbance of cerebral 
 blood flow .
clinically , various impairments appear including changes in levels of 
 consciousness , and sensory , motor , cognitive , perceptual , and language impairments1 . aspects of disability due to stroke vary 
 depending on the degree and area of the damage . generally , disorders such as a decrease in 
 muscular strength of hemiplegic patients2 , 
 a slowing of the rate at which power is generated3 , and muscle weakness are seen , along with a possible limitation of 
 the joint range of motion4 .
the 
 aforementioned problems result in decreases in walking speed and walking ability , balance 
 impairment , altered balance confidence , and reduced mobility due to worries about 
 falling5 .
therefore , an important focus 
 of rehabilitation for chronic stroke patients is the development of interventions to promote 
 balance and functional movement6 . 

recently , a trampoline training program was reported to be effective for various target 
 groups , improving postural control , balance and exercise performance .
the trampoline is a 
 balance training device that requires strong integration of the neuromuscular system .
it is 
 frequently used because of its affordability , transportability , ease of use , and simplicity 
 of set up7 .
movements that can be 
 performed on a trampoline can enhance physical factors , such as trunk stability , muscular 
 coordination reactions , range of joint movements , and spatial orientation8 .
the trampoline is a rehabilitation method 
 that can stimulate proprioception and enhance a person s ability to balance9 .
training on a trampoline was shown to 
 improve the ability of elderly patients to recover their balance after falling forward8 , and trampoline training is an effective 
 intervention for promoting balance and other movements in children with intellectual 
 disabilities10 . in particular , 
 predefined mini - trampoline training stroke patients produced a significant increase in their 
 balance .
although the improvements were not statistically significant , trampoline use also 
 improved their mobility and activities of daily living11 .
the stroke patients in that study performed the trampoline 
 training , without holding onto anything while they jumped or , hit a balloon .
it would be 
 difficult to use this method for stroke patients with low physical abilities .
in addition , 
 the effectiveness of trampoline training in preventing falls and improving the walking 
 ability and balance of stroke patients has not been reported .
therefore , this study used a 
 modified trampoline training program for stroke patients and analyzed its effects on 
 balance , gait , and falls efficacy .
the study subjects were 28 adult stroke patients who had been admitted to hospital b , which 
 is in incheon .
the inclusion criteria were single onset of stroke , an mmes - k score of at 
 least 24 points , and the ability to walk minimum of two minutes or more with or without 
 walking aids .
the exclusion criteria were a history of other neurologic or circulatory 
 diseases or disorders , a cardiovascular system abnormality , or a history of visual or 
 auditory sense disorders .
this study used a randomized pre- and post - test , two - group design .
subjects were randomly 
 allocated to a trampoline training group ( tg ; n=14 ) or a control group ( cg ; n=14 ) .
all 24 
 participants completed the intervention . prior to the subjects participation , all the 
 procedures
were explained , and each subject provided his or her written informed consent to 
 participate .
the training group performed modified trampoline training for 30  min three times a week for 
 6 weeks .
trampoline training sessions were performed one - on - one with a physical therapist to 
 instruct the participants on how to use the trampoline ( baleno inc .
, diameter : 45 inch ) with 
 a handle . to increase the difficulty of training
the details of 
 the modified trampoline training programs are described in table 1table 1.content of the modified trampoline trainingstandingin placewith feet in a walking stancewith the right or left foot in front of the other footwith the feet togetherone supporting legweight shiftingto the front , back , right , and left in placeto the front , and back with the feet in a walking 
 stanceto the front , and back with the right or left foot in 
 front of the other footto the front , back , right , and left with the feet 
 togetherlifting the heelhoppingin placewith the feet in a walking stancewith the right or left foot in front of the other 
 footwith the feet togetherwalkingstance , one supporting leg , alternate steps to the 
 front and to the back of the opposite legin placejogging in placejumpingin placeto the front and back , and right and left with the feet in a walking stancewith the right or left foot in front of the other 
 footwith the feet togetherto the front and back , and right and left with the 
 feet togetherto the front and back , and right and left with scissor 
 stepsperforming a tasktossing a balloon between the patient and 
 therapistthrowing a small ball between the patient and 
 therapistthrowing a small ball to pick up on the 
 trampoline .
the control group did not take part in the trampoline training program ; 
 however , both groups received general physiotherapy .
the berg balance scale ( bbs ) and the timed up and go ( tug ) test were used to evaluate 
 patients balance abilities .
the dynamic gait index was used to assess their walking 
 ability , and the falls efficacy scale was used to measure the falls efficacy of the 
 subjects .
descriptive statistics were 
 used to describe the patients characteristics after confirming that the data were normally 
 distributed
. comparisons of both groups general characteristics were performed using the 
 independent t - test or  test .
pre- and post - data were analyzed using the paired 
 t - test to test within - group differences and the independent t - test to test differences 
 between the groups .
the subjects general characteristics are presented in table 2table 2.general characteristics of the participantsparameterstg ( n=12)cg ( n=12)gendermale / female ( % ) 8/4 ( 66.7/33.3)6/6 ( 50.0/50.0)affectedsidelt / right ( % ) 6/6 ( 50.0/50.0)6/6 ( 50.0/50.0)disease duration , months14.8 ( 9.6)13.9 ( 6.0)age , years53.2 ( 11.2)55.75 ( 8.8)height , cm165.1 ( 5.2)168.3 ( 8.5)weight , kg62.64 ( 8.2)69.09 ( 9.4)values are n ( % ) or mean ( sd ) .
no significant differences in general characteristics were observed between 
 the tg and the cg ( age : 53.17 and 55.75  years ; height : 165.09 and 168.27  cm ; weight : 62.64 
 and 69.09  kg ; respectively ) .
tg : trampoline training group ; cg : control group differences in pre- and post - test values within groups and between groups are summarized in 
 table 3table 3.comparison of bbs , tug , dgi , fes within groups and between groupsparametersvaluestg ( n=12)cg ( n=12)prepostprepostbalancebbs33.8 ( 8.2)44.3 ( 7.5)34.6 ( 7.1)41.8 ( 6.3)tug31.7 ( 13.2)26.3 ( 11.0)32.8 ( 11.3)30.7 ( 11.2)gaitdgi11.1 ( 3.4)17.7 ( 3.2)12.2 ( 2.5)15.5 ( 3.3)falls efficacy fes51.3 ( 15.4)63.9 ( 13.2)52.8 ( 11.8)57.1 ( 13.0)values are means ( sd ) . * within - group difference ( p<0.05 )
tg : trampoline training group ; cg : control group ; bbs : berg 
 balance scale ; tug : timed up and go test ; dgi : dynamic gait index ; fes : falls efficacy 
 scale .
specifically , tg showed a significant increase in the bbs ( p < 0.05 ) and a 
 significant decrease in the tug test time ( p < 0.05 ) .
in addition , the tg showed a significant increase in the 
 dynamic gait index ( p < 0.05 ) , and this difference was also significantly greater than 
 that of the cg .
the falls efficacy scale was also significantly different between the pre- 
 and post - test in the tg , and the improvement in the tg was significantly greater than that 
 in the cg ( p < 0.05 ) .
values are means ( sd ) . * within - group difference ( p<0.05 ) .
tg : trampoline training group ; cg : control group ; bbs : berg 
 balance scale ; tug : timed up and go test ; dgi : dynamic gait index ; fes : falls efficacy 
 scale
balance is the ability to maintain the gravity line of the body with a minimum degree of 
 deviation within the base of support12 . 

it is important to provide treatment to increase the balance abilities of stroke 
 patients13 .
a previous study found a 
 significant change in postural sway in athletes following balance training on a 
 trampoline7 .
that study reported 
 improvements in muscle endurance , sensorimotor control , and reaction times within the 
 muscles of the ankle complex due to challenges to the neuromuscular system and specific 
 movements of the ankle joint muscle after a trampoline training program . in another previous 
 study , a trampoline intervention resulted in significant improvements in the motor 
 performance and balance of children with intellectual disabilities10 . during trampoline training ,
the participants are forced 
 to continuously respond to changes in gravity , and this provides deep proprioception as well 
 as other sensory inputs .
in addition , performance improvements in balance tasks may be the 
 result of alterations in the complex sensory motor stimulation due to participants efforts 
 to adapt to the trampoline s unstable surface and maintain balance .
an another previous 
 study conducted trampoline training for patients with stroke11 , and reported a significant improvement in the bbs . in that study , 
 participants tried to stabilize their bodies while maintaining their center of gravity on 
 the base of support and responding to different environments and tasks .
the reported 
 improvements were attributed to the participants being forced to keep their balance on the 
 elastic and unstable ground11 . in the present study ,
significant improvements were found in the bbs and the tug test after 
 the intervention .
the participants in our study had to maintain their balance while performing 
 various operations on the unstable ground .
this task likely contributed to improving the 
 patients ability to balance due to the repeated sensory feedback and the continuous 
 experience to postural sway .
in addition , the modified trampoline training consisted of not 
 only static balance training , such as standing and weight shifting , but also dynamic balance 
 training , such as hopping , walking , jumping , and performing a task .
significant improvement 
 was seen in the bbs , a measure of dynamic balance , as well as in the tug test , a measure of 
 static balance . in the study of miklitsch et al .
, the bbs showed a significant improvement , 
 but the tug test did not , despite improvement in the bbs .
however , in our study , 
 participants resolutely performed high difficulty dynamic activities because they used the 
 handle . therefore , both the bbs and the tug test significantly improved .
twenty percent of stroke patients need a wheelchair for tasks in everyday life after 3 
 months , and almost 70% decrease their walking speed or step length when they resume 
 walking14 .
therefore , rehabilitation for the recovery of walking ability is 
 very important for the development of a patient - dependent gait after stroke14 . in a previous study
, stroke patients 
 could jump for the first time in many years due to the availability of assistance , which was 
 the motivation for them to participate in an exercise program16 .
in addition , patients reported increased leg strength on the 
 affected side after jumping training , and all patients felt that they regained control of 
 the affected leg . in another previous study , the mechanical efficiency increased and energy 
 costs reduced when the patients jumped on an elastic surface17 .
it was also reported that subjects could jump from a little 
 crouching stance on a trampoline , therefore the elastic energy loss decreased and the speed 
 of movement was facilitated , allowing the subjects to use maximum leg muscle power during 
 the jump action18 .
the experimental 
 subjects in that study were able to complete these actions , because it is easier to jump on 
 a trampoline than it is to jump on solid surface . in this study ,
the dynamic gait index is the tool used to assess the 
 ability to control the reactions when walking tasks change in response to the external 
 environment .
therefore , training the patients to carry out various movements on the unstable 
 surface of the trampoline , would have improved their postural control and balance abilities , 
 as evidenced by the dynamic gait index , which would also have improved their walking 
 abilities .
most falls are caused by a loss of 
 stability in the forward direction20 . 

after elderly patients completed the trampoline training program of a previous study , they 
 showed an increased ability to regain their balance when suddenly falling forward8 . in the present study ,
in addition , a score of 20 
 points or less on the bbs can be interpreted as a high risk of falls , a score between 21 and 
 40 points as a medium risk of falls , and score of 41 to 56 points suggest a low risk of 
 falls21 . in the present study ,
the 
 trampoline training group had a mean bbs score of 33.83 , indicating a medium risk of falls 
 before the intervention , and a mean bbs score of 44.25 , indicating a lower risk of falls , 
 after the intervention .
balance training using a trampoline is effective at equalizing the 
 muscles and helping them to maintain balance as well as improving the balance of their power 
 and strength9 .
the current study 
 demonstrated that trampoline training improved the falls efficacy by reducing this 
 imbalance , and the result was not ipsilateral to contralateral .
participants performed the 
 various actions on the unstable surface using the handle attached to the trampoline . in 
 addition , performing operations such as hopping or jumping on a trampoline should give 
 patients more experience to help them avoid falls during activities on a solid surface in 
 their homes .
first , there was a temporary increase of spasticity in 
 some patients during trampoline training .
however , no further increase or continuous 
 degradation was observed when the intervention was suspended .
second , the results of this 
 study can not be generalized to other populations because of the small sample size and the 
 small area from which the patients were sampled
. therefore , we suggest that further studies 
 be conducted using larger sample sizes as well as considering the muscle tone of 
 patients .
 [ purpose ] this research was conducted to investigate the effects of modified trampoline 
 training on the balance , gait , and falls efficacy of stroke patients . 
 [ subjects ] 
 twenty - four stroke patients participated in this study . 
 the subjects were randomly 
 allocated to one of two groups : the trampoline group ( n=12 ) or the control group ( n=12 ) . 
 
 [ methods ] both groups participated in conventional physical therapy for thirty minutes per 
 day , three times a week for six weeks . 
 the trampoline group also took part in trampoline 
 training for thirty minutes per day , three times a week for six weeks . 
 we evaluated 
 balance ( berg balance scale , timed up and go test ) , gait ( dynamic gait index ) , and falls 
 efficacy ( falls efficacy scale - k ) to confirm the effects of the intervention . 
 [ results ] 
 both the trampoline and the control group showed significant improvements in balance , 
 gait , and falls efficacy compared to before the intervention , and the improvements were 
 significantly greater in the trampoline group than in the control group . [ conclusion ] 
 modified trampoline training resulted in significantly improved balance , dynamic gait , and 
 falls efficacy of stroke patients compared to the control group . 
 these results suggest 
 that modified trampoline training is feasible and effective at improving balance , dynamic 
 gait , and falls efficacy after stroke . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION