ON PEGASUS' WINGS
EQUINE ASSISTED THERAPY IN AUSTIN
USE OF HIPPOTHERAPY
WITH CHILDREN WHO HAVE CEREBRAL PALSY
By
“Even though the sessions are hard for her, Rebecca
smiles every time she gets on the horse.
When she’s done she feels so flexible.
After the first session, her dad noticed she was holding her head up
better. I wouldn’t drive so far for the
sessions if I didn’t think it was worthwhile.”
Rebecca’s mom, 2005
What is Hippotherapy?
Hippotherapy is a strategy
for improving strength, balance and posture used by physical and occupational
therapists that utilizes the movement of a horse. Used in
During hippotherapy, which
is prescribed by a physician, children typically sit on a pad rather than a
saddle to better feel the horse’s movement.
The surface of the horse moves three dimensionally. During hippotherapy, the child learns to
anticipate and make the postural adjustments necessary to remain upright. The warmth of the horse coupled with this
rhythmic movement is thought to be useful in reducing high muscle tone and
promoting relaxation in the rider who has spasticity. During hippotherapy, the movement of the
horse is controlled by the therapist.
This differs from therapeutic horseback riding where the child uses a
saddle and the goal is for that child to learn to ride independently and
experience the physical and social benefits of riding.
What is the research evidence that supports the use
of hippotherapy with children who have cerebral palsy?
Bertoti (1988) provided the
first objective data on the benefits of hippotherapy. Evaluations of posture in 11 children, aged
28-114 months, with spastic cerebral palsy were conducted before and after
participation in hippotherapy provided two times/week for 10 weeks. Each riding session stressed reduction of
spasticity with subsequent facilitation of normal movement skills such as trunk
control and weight shifting. Results of
the postural assessment scores showed that posture was significantly improved
in 8 of the 11 children. The children
with spastic diplegia demonstrated overall improvement while children with
spastic quadriplegia demonstrated more improvement in head and shoulder
alignment. Improvements such as reduced
spasticity and improved balance were reported by all of the parents and
referring therapists.
McGibbon, Andrade, Widener
and Cintas (1998) evaluated the effects of an eight-week program of
hippotherapy on performance on the Gross Motor Function Measure (GMFM), energy
expenditure during walking, and gait parameters in five children with spastic
cerebral palsy. All five children
demonstrated a significant decrease in energy expenditure during walking and a
significant increase in GMFM walk/run/jump subtest after hippotherapy. A trend towards increased stride length and
decreased cadence during walking was noted.
Benda, McGibbon and Grant (2003)
studied 15 children with spastic cerebral palsy, aged 4-12 years. The children were randomly assigned to either
a group that received hippotherapy (seven children) or a group that sat astride
a stationary barrel (eight children).
Surface EMG was used to measure muscle activity of the trunk and upper
legs during sitting, standing and walking tasks before and after
treatment. There was a significant
improvement after hippotherapy in symmetry of muscle activity. There was no significant change after sitting
astride a barrel.
Sterba,
Casady and Nichols-Larsen
(2004) studied 11 children with cerebral palsy, aged 2.3-6.8 years. The Pediatric Evaluation of Disability
Inventory (PEDI) was used in addition to the GMFM. The PEDI measures the child’s functional
performance in the home and community in the areas of self-care skills,
mobility and social function. The improvements
in PEDI total score, PEDI social score, GMFM total score and GMFM
crawling/kneeling subtest demonstrate a significant treatment effect after the
hippotherapy phase and no change in function during the no-treatment phase of
the study.
The results of studies done
to date suggest hippotherapy could be an effective therapy strategy for
improving functional outcomes for children with cerebral palsy. The researchers cited above recommend that
future research be conducted that looks more specifically at how range of
motion, strength, balance and posture is affected by hippotherapy as well as
the specific areas of function most affected.
Future research that compares the effect of hippotherapy with other
treatment procedures that do not involve a horse is also needed.
References
Benda, W.,
Bertoti, D.B. (1988). Effect
of therapeutic horseback riding on posture in children with cerebral palsy. Physical
therapy, 68(10), 1505-1512.
Casady, R.L., &
Nichols-Larsen, D.S. (2004). The effect of hippotherapy on ten children with
cerebral palsy. Pediatric Physical Therapy, 16(3),
165-172.
Sterba, J.A., Rogers, B.T.,
France, A.P., & Vokes, D.A. (2002). Horseback riding in children with
cerebral palsy: Effect on gross motor function.
Developmental Medicine & Child
Neurology, 44(5), 301-308.
Journal of Undergraduate Research
Volume 7, Issue 2 - November/December 2005
The use of animals to facilitate treatment, especially with children, has become an increasingly common approach among providers of various types of therapy. In fact, a recent issue of the American Behavioral Scientist devoted an entire issue to research on the therapeutic use of animals. Equine facilitated therapy (EFT), or therapy involving the use of horses to treat people, has recently become particularly popular. The three facets of EFT are (1) physical therapy, which includes hippotherapy and therapeutic riding, (2) mental therapy, which includes equine assisted/facilitated psychotherapy, and (3) social intervention, which includes equine assisted growth and learning programs. There are currently over 650 EFT centers nationwide with more than 30,000 clients, and 25 major universities offer EFT programs (Mission 2005). Yet despite its growing popularity, there is little evidence-based assessment of the effectiveness of using horses in conjunction with physical, mental, or social therapy. The lack of a best practices model creates great variability in practices of EFT and among providers who offer this type of therapy.
<<MORE>>| 4/13/2009 Therapeutic Riding and Hippotherapy: What Is It and How Does It Work? Bettie B. Borton, Au.D., & Amy C. Ogburn, Ph.D., CCC-SLP |
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| Note: This article will be peer-reviewed for ASHA CEUs. If you are interested in receiving ASHA CEUs, be sure to check back. Offering clients with mild-to-severe physical, developmental, cognitive, or emotional disabilities a unique and innovative clinical experience is often challenging. Consider the possibility of equine-assisted activities as a meaningful alternative or addition to your existing treatment regimen. The need to communicate effectively transcends disability, and the consequence of communicative limitations for the child with disabilities frequently compounds a host of other problems. According to the 2000 US Census (as cited by The Center for an Accessible Society, n.d.), 49.7 million Americans have a certified disability and children, age 5 to 20, account for 8% of this number, which is indicative of the serious need for effective treatment. Speech-language pathologists providing services within the context of the conventional clinical setting for children with a wide range of disabilities often struggle to provide effective motivational and naturalistic interventional strategies that translate into life skills and communicative enhancement and incorporate multimodal outcomes. Therapeutic riding/hippotherapy may offer a unique solution for clients who might otherwise languish in the conventional clinical setting due to limitations imposed by their disabilities or the therapy environment itself. Literary references to the physical and emotional benefits of horseback riding date back to writings from the 1600s. However, when Liz Hartel of Denmark won the silver medal for dressage at the 1952 Helsinki Olympic Games, despite having paralysis from polio, medical and equine professionals took active notice (Adams, 2009). Soon afterwards, therapeutic riding was used for rehabilitation in Norway and then in England. The first centers for therapeutic riding in North America began operation in the 1960s. Today, there are more than 1,000 NARHA-affiliated centers in the U.S. and Canada. NARHA, formerly known as the North American Riding for the Handicapped Association, certifies both centers and individuals in therapeutic riding and the American Hippotherapy Association certifies individuals in hippotherapy. Children with physical, cognitive, and developmental disabilities can be very effectively served through equine-facilitated activities resulting in improved balance, range of motion, and muscle control; more efficient motor planning while strengthening muscles, joints, and tendons; and improvements in respiration, circulation, appetite and digestion, concentration, patience, self-discipline, motivation, interpersonal skills, self-esteem, and self-confidence (Johnson, 2009). Equine-assisted activities also help to provide a stronger foundation upon which traditional therapies can be more effectively implemented. Currently, there is a growing trend in speech and language intervention literature toward developing naturalistic approaches to add to or replace the traditional, more drill-like clinician-directed methods for pediatric speech-language pathology (Duchan & Weitzner-Lin, 1987; Fey, 1986; Owens, 2003; Fey et al., 2006; Mancil, Conroy, & Haydon, 2008). Referred to as naturalistic or milieu types of instruction, these therapeutic methods comprise the pragmatics approach to language intervention. This pragmatic or naturalistic emphasis encourages using everyday events, interactions, and conversation as a context for language learning. Several investigations have found that incidental or milieu instruction with children diagnosed with language delay was as effective as direct language instruction (Cole & Dale, 1986), and Fey et al. (2006) found significant increases in the amount of communication in children, aged 24 to 33 months, with 10 or less expressive words or signs. Furthermore, the research indicated that in addition to the speech-language professional, parents, as well as support personnel, have been shown to make effective use of the naturalistic approach (Girolametto, Weitzman, & Greenberg, 2003). Therapeutic riding/hippotherapy is worth considering as an alternative setting for the provision of speech-language remediation. A number of studies and anecdotal reports now support the role of equine-assisted therapy as an effective form of treatment for physical, cognitive, and emotional deficits (Murphy, Kahn-D’Angelo, & Gleason, 2008). Intrinsic to the therapeutic and recreational components of the program, improved mental health, confidence, and self-esteem are natural by-products of the loving relationships fostered between horses and humans. Additionally, equine-assisted therapy centers commonly strive to include family, caregivers, and therapists in goal setting and activities (Johnson, 2009). Therapeutic riding is a term that has been used for many years to encompass a variety of equine activities in which people with disabilities participate whereby a therapist or therapeutic riding instructor uses the movement of the horse as a treatment strategy to improve neuromuscular function, cognitive or developmental delay, or as a recreational avenue with significant benefit to the enhancement of life skill development (NARHA, 2009). Therapeutic riding sessions are commonly provided by NARHA certified instructors. NARHA functions as an industry regulator to insure quality therapeutic horseback riding through instructor certification, site accreditation, and program monitoring. Since 1969, NARHA has provided equine-assisted activity and therapy (EAAT) programs in the United States and Canada via its designated member centers. Each year, “more than 38,000 individuals with disabilities benefit from activities which include therapeutic riding, hippotherapy, equine-assisted psychotherapy, driving, interactive vaulting, and competition” (NARHA, 2009). NARHA also fosters therapeutic equine-assisted activities through continuing education, communication, and research. Hippotherapy is a physical or occupational therapy, or speech and language treatment strategy that uses equine movement as a tool. The term hippotherapy stems from the Greek word, hippos meaning horse and literally means treatment with the help of the horse. People conducting hippotherapy sessions are certified and licensed physical or occupational therapists or speech-language pathologists, but can also be certified by the American Hippotherapy Association (AHA; 2007) at various levels. Hippotherapy in the United States has evolved over the past 30 years. AHA promotes the use of the movement of the horse as a treatment strategy in physical and occupational therapy and speech-language intervention sessions for people with disabilities by having the horse influence the client to enhance outcomes. The client is positioned on the horse and actively responds to the animal’s movement. Unless certified as an instructor through NARHA themselves, therapists/clinicians work in tandem with certified instructors. While the certified instructor directs the horse’s movement to facilitate predetermined lesson objectives and goals, the OT, PT, or SLP functions collaboratively in the riding session to analyze responses from the client and treatment is adjusted accordingly. This strategy is used as part of an integrated treatment program to achieve functional outcomes to improve performances in activities of daily living. According to AHA (2007), there is currently widespread acceptance of hippotherapy within the medical/professional and educational communities. The American Physical Therapy Association (APTA), American Occupational Therapy Association (AOTA) and the American Speech-Language-Hearing Association (ASHA) recognize hippotherapy. Many university training programs offer placements for students in affiliations that include hippotherapy. Some school districts now reimburse for school-based therapy that includes hippotherapy in a treatment plan because it produces educationally relevant functional outcomes. Increasing numbers of major third party payers throughout the country now reimburse for treatment that includes the movement of the horse as a treatment strategy. Articles on the use of the horse in treatment have been published in peer-reviewed journals such as Hippotherapy, Physical Therapy, Physical and Occupational Therapy in Pediatrics, Developmental Medicine and Child Neurology, in addition to numerous articles in clinical publications. Individuals with the following disabilities commonly participate and benefit from equine-facilitated therapy and activities (NARHA, 2009):
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