stroke results in impaired blood flow that hinders blood supply to the brain tissue , and 
 this can cause brain damage1 . although 
 stroke patients survive with appropriate emergency measures and early treatment , they may 
 have defects in cognition , perception , language , sensibility , and exercise ability2 . additionally , they may have difficulty in 
 independently performing daily activities owing to physical and mental damage3 . stroke patients exhibit hemiplegia 
 paralysis on either the left or the right side of the body caused by weakening of muscles , 
 and abnormal muscle contractions and movement patterns3 , 4 . weakening of muscles and 
 asymmetric posture due to hemiplegia increase posture disturbances and degrade balancing 
 ability , leading to walking difficulties in stroke patients3 , 5 . functional approaches , neurodevelopment treatments controlling motion , proprioceptive 
 neuromuscular facilitation ( pnf ) using a diagonal movement pattern , and dual - task training 
 are being used for improving the balance and gait of stroke patients5 , 6 . recent studies 
 reported that aquatic exercises have a positive effect on the neurological functions of 
 stroke patients7 . the resistance from 
 water while performing underwater exercises promotes balancing ability by enhancing the 
 muscles of the lower limb and stimulating deep muscle proprioceptors8 , 9 . additionally , 
 buoyancy effectively supports body weight and mitigates any shock on the joints10 . coordination movement using the pnf pattern is devised by patterning the upper and lower 
 limbs for exercise11 , 12 . movements of the human body occurring in three dimensions through 
 gait and induced motion of the body are analyzed11 . coordination movement using the pnf pattern integrates the 
 patterns of each segment and standardizes them into a coordinated system12 . this effectively promotes appropriate 
 posture maintenance , as bilateral exercises involve both sides of the body13 . coordination movement using the pnf 
 pattern has been shown to have a positive effect on the balance and gait of stroke patients , 
 and many studies on coordination movement using the pnf pattern have been reported11,12,13 . however , studies on the effect of 
 coordination movement using the pnf pattern under water on balance and gait in stroke 
 patients are limited14,15,16 . the purpose of this study was to investigate the effect of coordination movement using the 
 pnf pattern under water on balance and gait in stroke patients . the study included 20 individuals diagnosed with stroke by using computed tomography and 
 magnetic resonance imaging more than 6 months previously . they were randomly assigned to an 
 experimental group that performed coordination movement using the pnf pattern under water ( n 
 = 10 ; five male and five female patients ) and a control group ( n = 10 ; five male and five 
 female patients ) . the study included stroke patients who had 24 points on the mini mental 
 state examination ( mmse ) , could independently walk 10 meters , and did not have any visual 
 impairment , visual field defect , and orthopedic disease in the upper and lower limbs . this 
 study complied with the ethical standards of the declaration of helsinki , and written 
 informed consent was received from each participant . the general characteristics of the participants are 
 presented in table 1table 1.general characteristics of subjectseg ( n=10)cg ( n=10)gender ( male / female)5/55/5age ( years)65.96.264.13.6weight ( kg)66.85.0266.47.5height ( cm)165.97.6165.35.3paretic side ( right / left)5/55/5onset ( months)11.31.112.31.3meansd . the mean age , height , weight , and onset time were 65.96.2 y , 165.97.6  cm , 
 66.85.0  kg , and 11.31.1 months in the experimental group and 64.13.6 y , 165.35.3  cm , 
 66.47.5  kg , and 12.31.3 months in the control group , respectively . eg : experimental group , cg : control group both the groups received neurodevelopment treatment ( mat exercise , resistance exercise , 
 postural control exercise , and functional activity exercise ) for 30 minutes a day five times 
 a week for 6 weeks . the experimental group additionally performed coordination movement 
 using the pnf pattern underwater at a temperature of 3234  c and depth of 100  cm . the 
 coordination movement using the pnf pattern involved the sprinter and skate patterns . in the 
 sprinter pattern , the right upper limb and the left lower limb are in flexion , adduction , 
 and external rotation , and simultaneously , the left upper limb and the right lower limb are 
 in extension , abduction , and internal rotation . in the skate pattern , the right upper limb 
 is in extension , adduction , and internal rotation and the left lower limb is in extension , 
 adduction , and external rotation , and simultaneously , the left upper limb and right lower 
 limb are in flexion , abduction , and internal rotation . the sprinter and skate patterns were 
 required to be maintained for 10  s each from a standing posture in left and right 
 alternation . prior 
 to the experimental intervention , the participants were acquainted with the sprinter and 
 skate patterns through training . balance was measured using the berg balance scale ( bbs ) and functional reach test ( frt ) . the bbs is divided into three sections ( sitting , standing , and changing posture ) and 
 includes 14 items . the total score is 56 points and a higher score indicates good balancing 
 ability . the frt measures the distance between the start and end positions while standing 
 comfortably , raising an arm 90 from the torso , and reaching out without losing balance . gait was measured using the 10-meter walk test ( 10mwt ) and timed up and go test ( tugt ) . the participants walked 14 m , and the time taken to walk 10  m 
 was measured , excluding the first 2  m and last 2  m. the tugt assesses functional motility . 
 the time taken to sit on an armchair , stand up at the starting signal , walk 3 m , and return 
 to the sitting position is measured . the collected data were analyzed using spss 12.0 ( spss , chicago , il , usa ) . the paired 
 t - test was used to compare in - group data before and after the intervention . moreover , the 
 independent t - test was used to compare the changes in the results of the bbs , frt , 10mwt , 
 and tugt before and after the intervention between the groups . the changes in the results of the bbs , frt , 10mwt , and tugt are presented in table 2table 2.comparison of the results of the bbs , frt , 10mwt , and tugt between the 
 experimental and control groupsgroupprepostd - valuebbseg42.51.145.11.3 * 2.61.1(score)cg40.71.541.61.20.91.2frteg18.31.120.40.8 * 2.11.2(cm)cg18.80.919.41.00.60.910mwteg14.61.112.61.7*2.01.4(sec)cg14.91.114.30.90.61.3tugteg18.41.216.11.6*2.31.6(sec)cg18.51.018.21.00.31.0meansd . d - value : difference value , eg : experimental group , cg : control group , bbs : berg 
 balance scale , frt : functional reach test , 10mwt : 10-meter walk test , tugt : timed up 
 and go test . on comparison between the groups , there were greater improvements 
 in the results of the bbs , frt , 10mwt , and tugt in the experimental group . meansd . d - value : difference value , eg : experimental group , cg : control group , bbs : berg 
 balance scale , frt : functional reach test , 10mwt : 10-meter walk test , tugt : timed up 
 and go test this study investigated the effect of coordination movement using the pnf pattern under 
 water on the balance and gait of stroke patients . there were significant differences in the 
 results of the bbs and frt ( used for balance ) before and after the experimental 
 intervention . on comparison between the groups , there were greater improvements in the 
 results of the bbs and frt in the experimental group . lee et al.14 and jeong et al.15 showed an improvement in balancing ability after applying 
 coordination movement using the pnf pattern in stroke patients . chol et al.17 reported that coordination movement using 
 a tapping and pnf combination pattern enhanced the balance of stroke patients . previous 
 studies differ from the present study in the treatment environment , but the results 
 correspond . coordination movement using the pnf pattern improves function and enhances 
 balancing ability by stimulating a proprioceptive sense of the muscles and tendons7 , 8 . 
 during coordination movement using the pnf pattern underwater , the water provides resistance 
 and helps to strengthen the muscles7,8,9 . in 
 a challenging condition with buoyancy and turbulent currents , muscle fibers are activated to 
 maintain posture and balance , and this is expected to improve balance7,8,9 . gait is the fundamental motion in body movement that requires coordination of the upper and 
 lower limbs and involves continuous and repetitive movements of each segment18 . stroke patients exhibit an 
 inefficient gait condition with high energy consumption , and they have difficulty in walking 
 independently19 . in the present study , the results of the10mwt and tugt ( used for gait ) significantly differed before and after the 
 intervention in the experimental group . on comparison between groups , the results of the 
 10mwt and tugt showed greater improvements in the experimental group . lee et al.14 and jeong et al.16 showed an improvement in gait ability after applying 
 coordination movement using the pnf pattern in stroke patients . previous studies differ from 
 the present study in the treatment environment , but the results correspond . coordination 
 movement using the pnf pattern has been designed by analyzing patterns of inter - related 
 movements of each body segment11 , 12 . it improves posture and balance by 
 efficiently working on the muscles on the paralyzed side and thus improves walking 
 ability11,12,13 . additionally , it supports 75% of the body 
 weight with buoyancy , and this partial weight support positively influences gait 
 function20 , 21 . the findings of this study indicate that coordination movement 
 using the pnf pattern may be an appropriate therapy method for stroke patients who have 
 problems with gait because of declined weight support and balancing ability . the findings may not be generalizable as the participants 
 were selected using specific criteria . additionally , no follow up was conducted ; therefore , 
 the duration of the effect after the experimental intervention is unknown .
[ purpose ] to investigate the effect of coordination movement using the proprioceptive 
 neuromuscular facilitation pattern underwater on the balance and gait of stroke patients . 
 [ subjects and methods ] twenty stroke patients 
 were randomly assigned to an experimental 
 group that performed coordination movement using the proprioceptive neuromuscular 
 facilitation pattern underwater and a control group ( n = 10 each ) . 
 both the groups 
 underwent neurodevelopmental treatment , and the experimental group performed coordination 
 movement using the proprioceptive neuromuscular facilitation pattern underwater . 
 balance 
 was measured using the berg balance scale and functional reach test , and gait was measured 
 using the 10-meter walk test and timed up and go test . to compare in - group data before and 
 after the intervention , paired t - test was used . 
 independent t - test was used to compare 
 differences in the results of the berg balance scale , functional reach test , 10-meter walk 
 test , and timed up and go test before and after the intervention between the groups . 
 [ results ] comparison within the groups showed significant differences in the results of 
 the berg balance scale , functional reach test , 10-meter walk test , and timed up and go 
 test before and after the experimental intervention . on comparison between the groups , 
 there were greater improvements in the scores of the berg balance scale , functional reach 
 test , 10-meter walk test , and timed up and go test in the experimental group . 
 [ conclusion ] 
 the findings demonstrate that coordination movement using the proprioceptive neuromuscular 
 facilitation pattern under water has a significant effect on the balance and gait of 
 stroke patients .