stroke , caused by ischemia or hemorrhage , results from the interruption of blood supply to 
 the brain that induces constant deficiency of oxygen and causes brain damage1 .
though fatality after stroke has been 
 greatly reduced by the development of medical technology , stroke presents physical and 
 mental obstacles that impair quality of life1 , 2 .
once a stroke has occurred , various motor 
 skills deteriorate , and therefore stroke rehabilitation focuses greatly on exercises 
 designed to recover motor skills2 .
balance is the ability to sustain the center of gravity , and it is a complex process of 
 controlling posture when conducting a voluntary movement and responding to external 
 perturbations3 .
stroke patients often 
 experience hemiplegia , weakness of one side of the body that induces unbalanced posture , 
 loss of proprioception , and abnormal muscle tone , thereby reducing balance ability4 , 5 . 

due to balance instability , stroke patients develop an abnormal gait with a short weight 
 support duration on the affected side , and differences between the strides of the normal 
 side and affected side cause the gait speed to decrease , affecting physical ability and 
 impairing independent daily activities5 , 6 . in order to solve problems concerning balance , walking , and daily activities related to 
 stroke , various treatment methods such as neurological development treatment ( ndt ) , 
 proprioceptive neuromuscular facilitation ( pnf ) , the brunnstrm approach , and motor 
 relearning programs have been developed7 . 

ideal treatment programs are yet to be discovered , and various approaches are being 
 developed for more effective treatment7 , 8 .
many approaches to physical therapy are being developed , and horse - riding exercise is one 
 method being tested for rehabilitation .
horse - riding exercise is a complex and scientific 
 therapeutic method resembling movements from riding a horse9 .
horse riding strongly stimulates proprioceptive sensation by 
 providing the rhythmical and repetitive movements of a horse .
these movements stimulate the 
 upper motor neuron system and input information similar to movement patterns of the pelvis 
 when walking10 , 11 .
such movements control abnormal muscle tone and movement patterns 
 while enhancing balance and walking11 . 

positive effects that can be induced from horse - riding exercise include recovery of 
 disability in patients with cerebral palsy , multiple sclerosis , and spinal cord damage10 , 12 , 13 .
recently , research related to horse - riding exercise is being conducted , but studies 
 investigating the effect of horse - riding exercise on balance , gait , and activities of daily 
 living ( adls ) in stroke patients are still lacking .
therefore , the purpose of this study was 
 to investigate the effect of simulated horse - riding exercise on balance , gait , and adls in 
 stroke patients .
this study included 20 patients diagnosed with stroke on mri at least 6 months prior to the 
 study .
participants were randomly assigned to a control group ( 5 males , 5 females ) and an 
 experimental group ( 5 males , 5 females ) , who participated in a horse - riding exercise 
 program .
the inclusion criteria were a mini - mental state examination ( mmse ) score greater 
 than 24 points , ability to walk more than 10 meters independently , and brunnstrm approach 
 stage of four or greater .
participants were excluded if they suffered from a visual 
 disability or orthopedic disease of the lower extremities . before the experiment , all 

participants were notified of the purpose and method of this study and provided written 
 consent in advance .
this protocol was approved by the institutional review board of nambu 
 university and was conducted in accordance with the ethical standards of the declaration of 
 helsinki .
the general characteristics of the participants are listed in table 1table 1.general characteristics of the participantsexperimental group ( n=10)control group ( n=10)gender ( male / female)5/55/5age ( years)71.1  3.069.2  3.4height ( cm)170.5  7.3167.9  6.5weight ( kg)71.2  7.467.0  6.5paretic side ( right / left)5/55/5onset ( months)10.6  1.110.8  1.1meansd
. the mean age of the experimental group was 71.1  3.0  years , mean height was 
 170.5  7.3  cm , mean weight was 71.2  7.4  kg , and mean time from stroke onset was 10.6  
 1.1 months .
the mean age of the control group was 69.2  3.4  years , mean height was 167.9  
 6.5  cm , mean weight was 67.0  6.5  kg , and mean time from stroke onset was 10.8  1.1 
 months .
both groups were treated using an ndt approach for 30 minutes per day , 5 days a week for 6 
 weeks .
horse - riding exercise utilized mechanical equipment that effectively resembles the 
 movement of an actual horse ( joba eu7800 , panasonic corporation , osaka , japan ) .
the 
 equipment generates three - dimensional movements including twisting , up - down slide , 
 back - forth slide , up - down roll , and back - forth roll . in this study
, a whole body course and 
 partial body course were alternately conducted , and the difficulty was increased from level 
 1 to 4 , according to the adaptability of the participants .
participants were allowed to 
 freely control their posture and were instructed to grab the handle to ensure correct 
 posture while riding .
the bbs is composed of a total 14 
 items and covers sitting , standing , and posture changes .
the total score is 56 points , and a 
 higher score corresponds to better balancing skill .
the 10mwt measures time spent while walking a total of 14 meters , 
 excluding the first and last 2 meters .
the mbi has a total score of 100 points and contains a total of 10 items including 
 personal sanitation , independent bathing , eating , using the bathroom , dressing , controlling 
 bowel movements , controlling urination , walking or using a wheel chair , and moving towards a 
 bed or chair .
scores of 0 to 24 indicate total dependency , scores of 25 to 49 indicate 
 mostly dependent , 50 to 74 indicate moderate dependency , score of 75 to 90 indicate minor 
 dependency , and score of 91 to 99 indicate minimal dependency .
data were analyzed using spss 12.0 ( spss , chicago , il , usa ) .
general features of the 
 participants were detailed as means and standard deviations using descriptive statistics . 

differences before and after the experiment within the two groups were compared using paired 
 t - test analysis . to compare between - group differences before and after the horse - exercise 
 therapy experiment , independent t - tests were used .
the changes in the scores of the in bbs , 10mwt , and mbi are listed in table 2table 2.comparison of bbs , 10mwt , and mbi measures between the experimental and control 
 groupsgroupprepostbbs ( bug balance scale)experimental group42.4  1.344.1  1.2control group41.6  1.342.2  1.610mwt ( 10-meter walk test)experimental group19.9  0.818.5  1.0control group20.0  0.919.7  0.6mbi ( modified barthel index)experimental group88.0  1.491.5  2.1control group87.3  2.088.2  1.8meansd .
the experimental group exhibited significant differences for all pre- and 
 post - experiment variables ( p < 0.05 ) .
the control group demonstrated no significant 
 different for all pre- and post - experiment variables ( p > 0.05 ) . in the between - group 
 comparison , the outcomes of the experimental group were significantly difference from those 
 of the control group ( p < 0.05 ) . meansd .
the purpose of this study was to investigate the effects of horse - riding exercise on 
 balance , gait , and adls in stroke patients .
significant improvements in balance were as 
 observed in the experimental group ( p < 0.05 ) but not in the control group .
balance , 
 gait , and adls were significantly different between the two groups ( p < 0.05 ) .
research 
 by han et al.14 and lee et al.15 found the bbs to be more significantly 
 improved among those participating in horse - riding therapy than in control subjects . 

horse - riding exercise simulates the natural walking rhythm of a horse , which is similar to 
 that of the human trunk during motion .
while a constant movement pattern is being applied , 
 the trunk muscles act to counteract gravity14,15,16 . 

reduction of the instability of trunk muscles and enhancement of proprioception and 
 vestibular function are considered to improve balance ability16 , 17 .
such results mean that 
 the horse - riding exercise used in this study has positive effects on balance in stroke 
 patients .
patients with hemiplegia from stroke exert a great deal of energy and have difficulty 
 walking independently18 .
changes in gait 
 were observed to be significant in the experimental group but not in the control group ( p 
 < 0.05 ) . in the between - group comparison ,
the outcomes of the experimental group were 
 significantly different from those of the control group ( p < 0.05 ) .
mcgibbon et al.19 used horse - riding exercise in children with cerebral palsy for 12 
 weeks , and it enhanced gait skill by activating adductor muscles .
rhythmical and repetitive movements of 
 the mechanical horse simulate movements during gait and provide a positive effect on gait 
 skill20 . constant pelvis movement and 
 enhancement of trunks
stroke patients need to set goals to improve balance and gait skills that can enable 
 independent daily activities21 . 

significant changes in adls were observed in the experimental group ( p < 0.05 ) but not in 
 the control group . in the between - group comparison ,
the outcomes of the experimental group 
 were significantly different from those of the control group ( p < 0.05 ) .
jung et al.22 showed improvement in movements related to 
 daily activities in children with cerebral palsy following a horse - riding exercise program . 

kim23 used horse - riding exercises in 
 autistic children , and their movements of daily activities significantly improved , 
 coinciding with this study s results .
horse - riding exercise uses various movements in a 
 horse that can naturally provide physical effects to stimulate and activate shortened 
 muscles in order to improve movements in daily activities .
one limitation of this study is the small number of participants , which precludes 
 generalization .
follow - up studies will need to confirm the durability of these effects , and 
 further research should verify the benefits of horse - riding exercise .
 [ purpose ] this study aimed to investigate the effects of horse - riding exercise on 
 balance , gait , and activities of daily living ( adls ) in stroke patients . 
 [ subjects ] among 
 20 participants with stroke , 10 were randomly assigned to the experimental group , and 10 
 were randomly assigned to the control group . 
 the experimental group participated in 
 horse - riding exercise for 30 minutes per day , 5 days a week for 6 weeks . 
 balance was 
 tested with the berg balance scale ( bbs ) . 
 gait was measured using the 10-meter walk test 
 ( 10mwt ) . 
 adls were tested with the modified barthel index ( mbi ) . 
 differences between pre- 
 and post - experiment values within the two groups were compared using paired t - tests . 
 
 between - group differences were compared using independent t - tests . [ results ] the 
 experimental group showed significant improvements in balance , gait , and adls following 
 horse - riding exercise . 
 additionally , the experimental group showed significant differences 
 in balance , gait , and adls compared with in the control group . [ conclusion ] these results 
 support that horse - riding exercise enhances balance , gait , and adls in stroke patients . 
 
 this study supports the need for further research on horse - riding exercise programs . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION