Rebound Therapy – Where is the Evidence?
Ailsa Miller – May 2007
The use of rebound therapy with children with both physical and learning disabilities is expanding. Rebound therapy involves the therapeutic use of a trampoline and can be used across a range of disabilities. This article will explain the concept of Rebound therapy, its many benefits and the considerations to be made in its use. It will discuss the current evidence for Rebound therapy and make suggestions further scientific research needed. Rebound therapy has been found to be a very useful adjunct to therapy for children with profound and multiple learning disabilities, but as its use continues to grow so does the need for scientific research into its therapeutic effects.
What is Rebound Therapy?
Rebound therapy is the use of a trampoline for therapeutic effects (CSP, 2007). Although trampolines have been used within the area of special education since the 1950s (Smith and Cook, 1990), the concept of Rebound therapy was first developed in the early 1980s by Eddy Anderson during his work with children with physical and learning disabilities (Roberts, 2006). Rebound therapy was originally developed and used within the area of children with physical and learning disabilities but is being developed with an increasingly expanding number of client groups. Participants’ disabilities can
range from mild to severe physical disabilities and mild to profound and multiple learning disabilities (Smith and Cook, 2007). Rebound therapy should be used as part of a therapy programme adding to existing therapies and not in isolation (Smith and Cook, 1990).
Effects of Rebound therapy
There are a wide range of benefits reported for Rebound therapy but there has been minimal research conducted into its effectiveness and evidence to confirm these benefits is therefore questionable (CSP, 2002). Most of the benefits described are from anecdotal evidence and have been observed by therapists using Rebound therapy as an intervention.
Rebound therapy has been observed to reduce hypertonia and increase hypotonia with the correct application of bounce (Smith and Cook, 1990). Vigorous bouncing increases tone by stimulating the sensory systems and gentle bouncing can reduce tone by having a shaking effect on the muscle spindles (Smith and Cook, 2007).
The cardio-respiratory system works harder as the demand on the muscles to support the body against the increased gravitational effect causes an increase in both heart and respiratory rate (Smith and Cook, 2007). The increased heart and respiratory rate cause venous return and lymphatic drainage to increase (Tortora and Grabowski, 2003). Forcing the muscles to work constantly to maintain position and balance increases the demand for oxygen (Sherwood, 2004). Increasing the work of the cardio-respiratory system increases exercise tolerance and fitness (Jones and Barker, 1996). Rebound
therapy may therefore provide another good source of cardiovascular exercise for children with profound and multiple learning disabilities who may have limited access to exercise activities.
The use of an unstable surface disturbs balance, provides increased sensory stimulation through the skin and joints and stimulates equilibrium reactions through stimulation of postural mechanisms (Carr and Shepherd, 1998).
Providing an environment which tests balance mechanisms can stimulate anticipation of movement and protective reactions (Jones and Barker, 1996). In this way the use of a trampoline may help to improve balance and develop protective and saving reactions.
Facilitation of movement occurs throughout the bounce, the most active movement takes place in the ‘gravity free’ zone at the top of the bounce when acceleration of the body equals the down thrust of gravity (Smith and Cook, 2007). Movements can be amplified by the recoil ability of the trampoline springs, producing larger movements than on land (Smith and Cook, 2007).
The movement of the trampoline stimulates gaseous movement (Smith and Cook, 1990). Abdominal massage has been shown to improve bowel function (Holey and Lawler, 1995), the bounce of the trampoline has been reported to provide a similar effect to massage and may be particularly useful in stimulating bowel function for non ambulatory patients who can often suffer with constipation (Kozma and Mason, 2003).
The movement of the trampoline can stimulate a cough reflex (Smith and Cook, 2007). Techniques of vibrations and shaking are used in respiratory physiotherapy to assist in the clearance of secretions (Pryor and Webber, 2002) and the trampoline has been reported to produce similar effects. The combination of shaking of the lungs by the trampoline, increased respiratory rate and stimulation of the cough reflex suggests that Rebound therapy may be useful in chest clearance.
Gentle bouncing and good positioning of a patient can induce relaxation (Smith and Cook, 2007). The movement of the bed is similar to that of water which has shown relaxation benefits, relaxation can in turn help to reduce muscle tone (Kesiktas et al, 2004).
Rebound therapy gives the user a sense of freedom and independence. The therapist can initiate movement by providing the bounce of the trampoline, propelling the user into free air (Smith and Cook, 1990). This provides another therapy intervention to facilitate free active movement, which is particularly important for children with 24 hour postural management programmes. The therapy can also be provided in a relatively hands-free manner, as the therapist can provide an effect by transference of weight and altering the
bounce, making it extremely useful for those patients with whom handling is not always tolerated (Roberts, 2006).
Other reported benefits of Rebound therapy include increased vocalisation, increased eye contact and concentration and increased confidence and self esteem (Lawrence, 2004).
The Chartered Society of Physiotherapy (CSP) recently published guidelines for safe practice in Rebound therapy which all therapists should be aware of before using Rebound therapy. Rebound therapy can be used safely with patients with a wide range of physical and learning disabilities and there are very few people for whom it would not be suitable (Smith and Cook, 2007). The three absolute contraindications to the use of Rebound therapy include detaching retina, atlantoaxial instability and pregnancy (CSP, 2007). Each user should be screened for a range of precautions listed by the CSP’s
information publication ‘Safe Practice in Rebound Therapy’ and if any are
found to be present then appropriate modification or precautions should be taken (CSP, 2007).
Rebound therapy should only be carried out by therapists who have received training and gained practical experience by attending a course in Rebound therapy (CSP, 2007). Whilst the physiotherapist remains responsible for the assessment and re-evaluation of the service user and identifying their therapeutic programme, the therapy itself can be carried out by trained assistants and support workers (CSP, 2007). For safety reasons Rebound therapy requires a number of ‘spotters’ around the trampoline responsible for
preventing users getting too close to the edge (Smith and Cook, 1990). The number of spotters required may vary depending on the abilities of the user. It is the responsibility of the physiotherapist to ensure there are adequate numbers and that all have received training from a therapist competent in
Rebound therapy (CSP, 2007). It requires facilities which can accommodate a trampoline safely. A ceiling height of 4.87 metres has been described as the minimum safe height for trampolining (CSP, 2007). The ceiling may be lower for use in Rebound therapy but the operator and service user should not bounce higher than 30 centimetres (CSP, 2007). Rebound therapy is staff intensive and the initial cost of equipment and finding an appropriate environment can be expensive. This requirement for large numbers of staff and expensive equipment could make the implementation of Rebound therapy difficult in some settings.
In 2002 the CSP identified Rebound therapy as one of nine research priorities in the area of Learning disabilities. They stated that there had been ‘no research into the effectiveness of Rebound therapy’ and that it was ‘therefore
being used without any evidence base to inform practice and service provision’. Much of the literature on Rebound therapy provides anecdotal evidence of the benefits as observed by therapists and is often based on single case studies. A study by Jones et al (2006) based an exercise programme around Rebound therapy and applied it to a population with learning disabilities to ascertain whether this improved goal attainment in areas of behaviour, access to community based experiences, health and physical competence. They reported that their sixteen week exercise programme demonstrated significant gains in goal attainment. The intervention, although reportedly based around Rebound therapy, included a variety of other elements including hydrotherapy, team games, walking and active and passive exercise programmes. The inclusion of so many elements makes it difficult to determine whether Rebound therapy played a significant part in the improvements seen. Rebound therapy has, however, been shown to be effective in a small subject sample when combined with other therapies. A small pilot study by Lloyd (2002) into the effects of Rebound therapy on the behaviour of adults with moderate and profound learning disabilities found that Rebound therapy reduced challenging behaviours and caused improvements in positive behaviours.
As highlighted by the CSP (2002), there is a need for well designed research into the effectiveness of Rebound therapy using appropriate outcome measures. This research should aim to investigate all the reported benefits of Rebound therapy and whether these have an impact on patient function. Inclusion criteria should clearly define the population to be included and explain the protocol to be used and duration and frequency of the intervention. The CSP (2002) has listed Rebound therapy as a research priority for learning disabilities. Rebound therapy is used across a variety of patient groups and the transferability of results from research would need to be considered. It may be necessary to carry out investigation into the effectiveness of Rebound therapy in all patient groups including children with physical and learning disabilities, patients with cystic fibrosis, multiple sclerosis and stroke. Comparison between Rebound therapy and other interventions would also be necessary to show whether Rebound therapy is effective and produces more significant improvement than alternative therapies. Evidence based practice involves the use of current best evidence to make decisions about the care of individuals (Sackett et al, 1996). Weaknesses in the current body of research regarding Rebound therapy causes difficulty for therapists practicing evidence based healthcare. The lack of evidence for Rebound therapy’s effectiveness causes difficulties justifying its implementation. This is likely to result in problems with regards to application for funding when trying to initiate a Rebound therapy programme.
Rebound therapy is no longer just used for children with physical and learning disabilities. It has expanded to be used among adults with learning disabilities, patients with cystic fibrosis, multiple sclerosis, developmental co-ordination disorders, dyspraxia and stroke (Era et al, 1991, Roberts, 2006). The use of the trampoline is also being developed with those in a persistent vegetative state. Noda et al (2004) found improvements in the awareness and clinical condition of permanent vegetative state patients following musicokinetic therapy (passive vertical trampoline bouncing to music). They state that
vertical motions of the body stimulate vestibular and somatosensory pathways including propriopception and touch and therefore activate motor pathways. The autonomic pathways related to cardiovascular and respiratory functions are also stimulated (Noda et al, 2004). This suggests that the use of the trampoline in Rebound therapy may also heighten the awareness of neurologically impaired patients, increase cardiovascular and respiratory work and activate movement through stimulation of the sensory system.
Rebound therapy has the potential to be used with an even wider range of client groups. The effects on balance could be applied to patients with balance disturbances and used within a falls prevention programme with the elderly. The effects seen on tone could be beneficial to a variety of patients, for example following stroke and head injuries. Rebound therapy could provide a useful alternative or complementary method in the treatment of those with constipation. The effect of relaxation could be beneficial in many fields with patients experiencing anxiety. The stimulation of the cough reflex combined with an increase in respiratory rate could indicate the use of Rebound therapy as an added intervention to be used with respiratory patients. Rebound therapy could also provide a range of benefits in the management mental health patients including improved communication, concentration confidence and self esteem. The provision of a structured exercise programme may also help to improve social awareness and interaction with others and provide a sense of achievement (Lawrence, 2004), which could be of benefit to mental health patients.
Before Rebound therapy expands into further areas and it use becomes more widespread, there is a need for further research to be carried out to prove its effectiveness. There needs to be comparison between Rebound therapy and other interventions to discover whether the benefits of Rebound therapy are more significant than other more conventional interventions. If there are no significant differences then the high initial costs and large staffing requirements may make implementation unfeasible when alternative effective therapies are already available. Without evidence to prove the effectiveness of Rebound therapy, gaining funding for Rebound therapy may prove difficult
in some areas. This is of particular relevance within the NHS at present, where budgets are stretched and evidence based practice is encouraged (Department of Health, 2004).
In conclusion, the benefits described from Rebound therapy make it a useful additional therapy for use with children with ranging physical and learning disabilities. It offers a similar service to that of hydrotherapy and therapeutic horse riding in providing benefits such as altering muscle tone, relaxation, stimulation of balance reactions and postural mechanisms and the facilitation of movement (Smith and Cook, 1990). Rebound therapy provides an extra intervention which can provide children with a feeling of freedom, giving important independent movement time for those with postural management programmes and an enjoyable method of exercise, whilst still providing therapeutic effects. It has the added benefit of requiring minimal handling for therapeutic effects making it useful for those patients who do not tolerate handling well. Rebound therapy is continually expanding and has the potential to be used regularly with a wide range of patient groups. Although the use of Rebound therapy is widespread, anecdotally reported benefits have yet to be substantiated by scientific research. Further study is indicated in this field before a recommendation regarding further use is possible.
; There are a wide range of anecdotally reported benefits of Rebound
therapy, including alterations of tone, facilitation of movement,
improved balance and posture and an increase in cardiovascular
; Rebound therapy is a useful adjunct to therapy similar to that of
hydrotherapy and therapeutic horse riding, providing an enjoyable
method of exercise with therapeutic effects and some time for
independence and free movement.
; Rebound therapy is already used with a wide variety of patient groups
and may have the potential for further expansion.
; The evidence base for Rebound therapy is currently lacking and further
research into its effectiveness is required. This should include a
comparison to other therapies and assessment within the many patient
; Although Rebound therapy is an expanding intervention, evidence of its
effectiveness will need to be demonstrated before recommendation
concerning further use is possible.
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Chartered Society of Physiotherapy (2007) Safe Practice in Rebound Therapy.
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Department of Health (2004) Standards for Better Health: Health Care
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