HippotherapyAn Intervention to Habilitate Balance

Deficits in Children With Movement Disorders: A

Clinical Trial
Debbie J. Silkwood-Sherer, Clyde B. Killian, Toby M.
Long and Kathy S. Martin
PHYS THER. 2012; 92:707-717.
Originally published online January 12, 2012
doi: 10.2522/ptj.20110081

The online version of this article, along with updated information and services, can be
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Research Report
HippotherapyAn Intervention to
Habilitate Balance Deficits in Children
With Movement Disorders:
A Clinical Trial
Debbie J. Silkwood-Sherer, Clyde B. Killian, Toby M. Long, Kathy S. Martin

Background. Clinical observations have suggested that hippotherapy may be an

effective strategy for habilitating balance deficits in children with movement disorders. However, there is limited research to support this notion.

Objective. The purposes of this study were to assess the effectiveness of hippotherapy for the management of postural instability in children with mild to moderate
balance problems and to determine whether there is a correlation between balance
and function.

Design. A repeated-measures design for a cohort of children with documented

balance deficits was used.

Methods. Sixteen children (9 boys and 7 girls) who were 5 to 16 years of age and
had documented balance problems participated in this study. Intervention consisted
of 45-minute hippotherapy sessions twice per week for 6 weeks. Two baseline
assessments and 1 postintervention assessment of balance, as measured with the
Pediatric Balance Scale (PBS), and of function, as measured with the Activities Scale
for KidsPerformance (ASKp), were performed.

Results. With the Friedman analysis of variance, the PBS and the ASKp were found
to be statistically significant across all measurements (P.0001 for both measures).
Post hoc analysis revealed a statistical difference between baseline and postintervention measures (P.017). This degree of difference resulted in large effect sizes for PBS
(d1.59) and ASKp (d1.51) scores after hippotherapy. A Spearman rho correlation
of .700 indicated a statistical association between PBS and ASKp postintervention
scores (P.003). There was no correlation between the change in PBS scores and the
change in ASKp scores (rs.13, P.05).

Limitations. Lack of a control group and the short duration between baseline
assessments are study limitations.

D.J. Silkwood-Sherer, PT, DHS,

HPCS, Graduate Program in Physical Therapy, Herbert H. and Grace
A. Dow College of Health Professions, 1202 Health Professions
Bldg, Central Michigan University,
Mt Pleasant, MI 48859 (USA).
Address all correspondence to Dr
Silkwood-Sherer at: silkw1d@
cmich.edu.
C.B. Killian, PT, PhD, Krannert
School of Physical Therapy, University of Indianapolis, Indianapolis, Indiana.
T.M. Long, PT, PhD, FAPTA, Center for Child and Human Development, Georgetown University,
Washington, DC.
K.S. Martin, PT, DHS, Krannert
School of Physical Therapy, University of Indianapolis.
[Silkwood-Sherer DJ, Killian CB,
Long TM, Martin KS. Hippotherapyan intervention to habilitate balance deficits in children
with movement disorders: a clinical trial. Phys Ther. 2012;92:
707717.]
2012 American Physical Therapy
Association
Published Ahead of Print:
January 12, 2012
Accepted: December 28, 2011
Submitted: March 11, 2011

Conclusions. The findings suggest that hippotherapy may be a viable strategy for
reducing balance deficits and improving the performance of daily life skills in
children with mild to moderate balance problems.

Post a Rapid Response to

this article at:
ptjournal.apta.org
May 2012

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Hippotherapy: Habilitating Balance Deficits in Children With Movement Disorders

ostural control is considered to

be an integral part of a persons
ability to interact with the environment and engage in coordinated
movement.1 For children with movement disorders, the lack of postural
control, which correlates with balance deficits, is often the limiting factor in the ability to participate in
activities at home and school and
during play.2 Suggested causes for
this inadequate postural control are
impaired muscle recruitment patterns, with delayed onset, frequent
coactivation of antagonistic muscles,2 and an inability to adequately
integrate intersensory conflict.35
Children with disabilities often rely
too much on vision for intersensory
conflict resolution,25 making them
susceptible to falls in environments
in which somatosensory or visual
information is conflicting, such as
uneven terrain and busy school
hallways.
Westcott and Burtner2 proposed that
habilitation of postural control in
children with balance deficits should
include activities that address the
musculoskeletal, motor, and sensory
processing rate-limiting factors. They
further suggested that these interventions should focus on static and
dynamic equilibrium tasks during
mass and random practice so that
children can actively participate. We
propose that hippotherapy meets
these requirements in a single, functional, meaningful, and motivating
activity accomplished in a noncliniAvailable With
This Article at
ptjournal.apta.org
eTable 1: Raw Pediatric Balance
Scale (PBS) Scores of Participants
in Comparison With Those of
Children Showing Typical
Development
eTable 2: Hippotherapy
Treatment Protocol

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Physical Therapy

cal environment. Hippotherapy is a

treatment strategy provided by rehabilitation professionals (physical
therapists, occupational therapists,
and speech-language pathologists) to
meet functional goals developed as
part of a comprehensive rehabilitation plan.6 Hippotherapy differs
from other forms of horseback riding. Adaptive or therapeutic riding is
provided by riding instructors whose
primary goal is to teach a person
with a disability riding skills as a leisure activity.
Observations have shown that the
3-dimensional movement of a walking horse passively moves a childs
pelvis with motions that are the
same as those required for walking,
thus producing perturbations to the
childs center of gravity in the sagittal, frontal, and transverse planes.7
Not only is the child required to
react to the pelvic perturbations, but
also the simultaneous forward movement through space provides an
opportunity to respond to a variety
of somatosensory, vestibular, and
visual stimuli.7,8 Hippotherapy is a
task-oriented strategy that allows
children to discover their own solutions for improving postural control.8,9 As the therapist alters the
horses speed and direction and client activities, randomization of the
necessary anticipatory and reactive
adjustments is provided, allowing
practice of equilibrium and righting
reactions.9 Thus, hippotherapy provides the benefits of mass practice in
an activity that forces a client to
develop and refine motor patterns
with concurrent practice in integrating sensory information in a controlled environment as a whole-task
activity.8,9
Although balance improvements
have been reported in adults with
multiple sclerosis,9,10 no hippotherapy studies have directly focused
on balance deficits in children. Several studies have shown evidence of

improvements in factors related to

balance in children with cerebral
palsy and Down syndrome, including: improvements in standing posture,11 symmetry of the trunk and
upper-leg muscles during standing
and walking,12,13 dynamic head and
trunk stability,8,14,15 and reaching
skills15; decreased energy expenditure during walking16; and improved
function.16,17 No hippotherapy studies have assessed changes in childrens performance of daily life activities after intervention.18 Therefore,
the purposes of this study were:
(1) to determine the effects of hippotherapy on balance and function,
as measured by the performance of
daily life activities in children with
mild to moderate balance problems,
and (2) to determine whether there
is a correlation between changes in
balance and changes in function.

Method
This repeated-measures design study
consisted of 2 baseline assessments
performed 1 week apart, 6 weeks of
hippotherapy intervention (2 times
per week), and an assessment after
the intervention. Before any testing
took place, all children provided
assent, and informed parent or
guardian consent also was obtained.
Participants
A convenience sample of 16 children
who were 5 to 16 years of age (X10
years 4 months, SD3.32) and had
documented balance problems were
recruited to participate in the study.
For inclusion, children had to be able
to stand for 4 seconds without an
assistive device and to follow testing
instructions to comply with the balance test protocol.19 Participant
demographics are shown in Table 1.
All participants had balance deficits
below the 95% confidence interval
for age and sex on the Pediatric Balance Scale (PBS).20 Additionally,
mean baseline scores of 13 of the 16
participants were more than 3 standard deviations below the mean for

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Hippotherapy: Habilitating Balance Deficits in Children With Movement Disorders

age and sex (eTab. 1, available at
ptjournal.apta.org). Children were
excluded if they had an orthopedic
or medical condition not related to
the primary diagnosis, had begun a
new treatment in the preceding
month, had prior hippotherapy or
adaptive riding experience, or had
allergies or an aversion to horses.
Diagnoses varied, with the most common diagnoses being cerebral palsy
(n5) and Down syndrome (n3).
Intervention
Treatment sessions (40 45 minutes)
were given twice weekly for 6 weeks
between May and August. An appropriately trained hippotherapy horse
was selected for each child. Equipment included bareback pads, American Society for Testing and Materials
certified horse riding helmets, a
halter, and a lead rope. Stirrups were
added as the children progressed.
Horses were led by experienced
horse handlers, and a second person
walking alongside the horse was
used as needed; the primary investigator provided treatment and
functioned as the primary person
walking alongside the horse. The
hippotherapy treatment protocol is
shown in eTable 2 (available at
ptjournal.apta.org). Although sessions were individualized, all participants experienced similar activities. The primary modifications were
changes in the duration and frequency of activities and were based
on the responses and fatigue levels
of the participants.
Outcome Measures
Balance was measured with the standardized 14-item PBS,19,20 a childrens version of the adult Berg Balance Scale.21 The PBS has high total
score test-retest reliability, with an
intraclass correlation coefficient
(ICC [3,1]) of .998, and good interrater reliability, with an ICC (3,1) of
.997.19 The PBS was chosen because
it is easy to administer in any environment and can distinguish
May 2012

between children showing typical

development and those with mild,
moderate, and severe balance deficits across diagnoses.19,20
Functional performance of daily life
skills was assessed with the selfadministered 30-item Activities Scale
for KidsPerformance (ASKp).22 The
ASKp assesses 6 domains of performance of daily life skills: personal
care (eg, bathing, toileting), dressing, locomotion, standing skills,
transfer skills, and basic self-care

(eg, making a snack, performing

chores at home). This questionnaire
measures the impact of childrens
disability on overall function and participation within relevant environments. It correlates with parent
reports on the Childhood Health
Assessment Questionnaire (r.81,
P.000) and clinician observations
of childrens function (intraclass
correlation coefficient [ICC].92,
P.000) across diagnoses,22 making
it useful for this study. Like the PBS,
the ASKp has high test-retest reli-

The Bottom Line

What do we already know about this topic?
Although the use of hippotherapy as a treatment strategy is growing
among specially trained therapists, evidence is limited regarding how this
strategy has an impact on functional skills of children with motor disabilities. Research published within the past 5 years suggests that hippotherapy improves factors related to functional skills of children, including
standing posture, symmetry of the trunk and upper-leg muscles during
standing and walking, dynamic head and trunk stability, and reaching
skills as well as decreased energy expenditure during walking. Some
evidence also suggests that adults with multiple sclerosis improve their
balance skills following hippotherapy.

What new information does this study offer?

This study found that hippotherapy improved postural control and balance (as measured by the Pediatric Balance Scale) and functional performance of activities of daily living (as measured by the Activities Scale for
KidsParticipation) in children with mild to moderate balance deficits
regardless of their diagnosis. It further demonstrated there is some correlation between balance skills and the ability to perform functional
activities. The improvements in balance and performance following hippotherapy were not only statistically significant, but also appear to be
clinically significant.

If youre a patient, what might these findings mean to

you?
The use of hippotherapy is a viable treatment option for improving
balance problems in children with a variety of diagnoses, including cerebral palsy, Down syndrome, developmental coordination disorders, and
autism spectrum disorders. Hippotherapy is an intervention strategy provided by rehabilitation professionals and has goals and purposes different
from adaptive (therapeutic) horseback riding.

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Hippotherapy: Habilitating Balance Deficits in Children With Movement Disorders

Table 1.

scores from the DVDs were used for

analysis.

Participant Demographicsa

Age
(y)

Sex

Primary Diagnosis

GMFCS
Levelb

Balance
Deficit
Category
Before
Intervention

Disability
Severityc
Before
Intervention

PDD

Moderate

Moderate

16

Autism

Moderate

Moderate

11

VI with CP (diplegia)

Moderate

Mild

10

PDD

Mild

Mild

11

CP (diplegia)

Moderate

Moderate

13

DS

Mild

Mild

VI

Mild

Mild

15

DS

Mild

Mild

12

DS

Moderate

Mild

DCD

Mild

Mild

12

CP (quadriparesis)

Severe

Moderate

CP (quadriparesis)

Severe

Moderate

DCD

Mild

Mild

14

Cerebellar hyperplasia

Moderate

Mild

Autism (Asperger)

Mild

Moderate

10

CP (hemiplegia)

Mild

Mild

GMFCSGross Motor Function Classification System,30 Ffemale, Mmale, PDDpervasive

developmental delay, VIvisual impairment, CPcerebral palsy, DSDown syndrome,
DCDdevelopmental coordination disorder.
b
Used only for children with CP.
c
Based on classification categories and baseline Activities Scale for Kids scores of Plint et al.31

ability (ICC.97), making it a good

choice for repeat assessments.23
Scores on the ASKp are reported as
percentages, with 100% representing complete participation.
Data Collection
Baseline
measurements
were
obtained 7 days apart at approximately the same time of day for each
child. The 2 sets of baseline measurements (baseline 1 and baseline 2)
were obtained to assess the stability
of the measurements. After the second baseline assessment, the first
treatment session was provided.
Postintervention assessments were
completed within 24 to 48 hours
after the final treatment session.
The PBS was administered first and
videotaped, and then the ASKp was
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Physical Therapy

completed. Children completed the

ASKp if they were cognitively able;
otherwise, parent reports were used
because the tool is valid with either
method of reporting (ICC.94).24
The same individual (child or parent)
completed the ASKp for all of the
assessments. Once all of the data had
been collected, the videotaped PBS
examinations were randomized with
regard to testing order, copied to
DVDs, and sent to 3 pediatric physical therapists for scoring. The randomization of testing order ensured
that the therapists were unaware of
the baseline and postintervention
assessments. All of the therapists
scored 3 assessments from the same
3 children, for a total of 9 PBS examinations, to establish interrater reliability for the DVD scoring. The PBS

Data Analysis
On the basis of earlier hippotherapy
research,10 12,16,17,25 a sample size of
20 participants was determined with
a repeated-measures design and a
power-level analysis, calculated at
0.8 power under the assumptions of
mean differences of 2 and a pooled
standard error of 2.45. As a control
for alpha inflation, the power analysis included a Bonferroni post hoc
pair-wise correction (0.0167).
SPSS 16.0 (SPSS Inc, Chicago, Illinois) and the Shapiro-Wilk test
revealed that the data did not meet
the assumptions of a normal distribution; therefore, nonparametric analysis was performed.26 Within-group
differences were calculated with the
Friedman analysis of variance, followed by post hoc analysis with the
Wilcoxon signed rank test for pairwise comparisons with a Bonferroni
correction of 0.0167. The Spearman
rho was used for bivariate 2-tailed
correlation analysis.26 Finally, the
effect size was calculated.

Results
Recruitment was discontinued at 16
children so that all participants could
complete hippotherapy before the
start of the new school year. This
schedule prevented the addition of
new activities that might confound
the effects of the hippotherapy intervention (Fig. 1).
PBS
The values for interrater reliability
(ICC [2,1]) of the PBS scores for
the 3 therapists were .88 (95%
confidence interval1.0 1.0) and
.94 (95% confidence interval
.08 1.0) for the baseline and postintervention measurements, respectively. Statistically significant differences were found among the 3 PBS
scores (226, P.001) (Fig. 2).
Post hoc analysis revealed no differ-

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Hippotherapy: Habilitating Balance Deficits in Children With Movement Disorders

ences among the baseline scores (T
[Wilcoxon test]4.62, P.05), but
there was a statistically significant
difference between the preintervention assessment and the postintervention assessment (Tab. 2). Scores
on the PBS showed median increases
of 5.5 and 4.0 points from the baseline 1 and baseline 2 assessments,
respectively, to the postintervention
assessment. To further assess which
items of the PBS might have led to
this overall change, we conducted
an analysis of correlations between
the total PBS score and individual
item scores. Most participants (14/
16) achieved the ceiling limit for all
of the items, with the exception of
single-leg stance, tandem stance,
alternating stool touch, and forward
reach. The single-leg stance score
showed the highest correlation with
the total PBS score (r.87, P.01
[2-tailed]), followed by scores for
tandem stance (r.76, P.01
[2-tailed]), alternating stool touch
(rs.69, P.01 [2-tailed]), and
forward reach (rs.52, P.01
[2-tailed]).
Because of the significance of the
correlation of the scores for these
test items with the total PBS score,
they were further analyzed to determine significance before and after
the intervention. For analysis of
single-leg stance, the times that
each child spent in single-leg stance
were averaged for the right and left
lower extremities. As a group, the
children showed a median increase
in time spent in single-leg stance
of 2.5 to 2.7 seconds, which was
a statistically significant increase
from the baseline assessments
to the postintervention assessment
(213.24, df2, P.01) (Tab. 3).
Analysis of tandem stance revealed
that the children, as a group, showed
median increases in standing time
of 8.5 and 2.5 seconds from the
baseline 1 and baseline 2 assessments, respectively, to the postintervention assessment (220.31,
May 2012

Screened
via phone interview
(n=21)
Excluded
(n=3)
Did not meet age criteria
(n=1)
By parent report did not
have balance deficits
(n=1)
No follow-up by parent
after study explained
(n=1)
Assessed
for eligibility via
baseline PBS
(n=18)
Excluded
(n=2)
Maximum PBS score
(n=1)
No show at second baseline
(n=1)
Enrollment
(n=16)

Intervention
Attended 12 sessions
(n=15)
Attended 11 sessions
(n=1, due to illness)

Analysis
Analyzed
(n=16)
Excluded from
analysis
(n=0)

Figure 1.
Flowchart of recruitment and participation. PBSPediatric Balance Scale.

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Hippotherapy: Habilitating Balance Deficits in Children With Movement Disorders

100

50
ASKp Total Score

Pediatric Balance Scale Score

60

40
30
20
*
12

10

12

12
*

80

60
12

40

0
Baseline Test 1

Baseline Test 2

Postintervention

Baseline Test 1

Postintervention

Baseline Test 2

Figure 2.
Box plots of Pediatric Balance Scale and Activities Scale for KidsPerformance (ASKp) scores. The variance of interquartile scores was
smaller in the postintervention assessment than in the preintervention assessments for both measures.

Table 2.
Within-Group Comparisons of Pediatric Balance Scale (PBS) and Activities Scale for KidsPerformance (ASKp) Total Scores for the
16 Participantsa
Assessment
Tool
PBS

Test

Median
Score

Interquartile
Range

Exact
Significance
(2-Tailed)

Effect Size
(Cohen d)

1.91 (4.62)

.065c

0.34

4.118.13

3.52 (0.0)

.000d

1.59e

3.967.41

3.53 (0.0)

.000

1.59e

1.26 (6.88)

.223c

0.46

6.2914.41

3.34 (3.50)

.000d

1.46e

5.0412.82

3.41 (0.0)

1.51e

Baseline 1 (B1)

47.5

10

38.5649.94

Baseline 2 (B2)

49.0

39.6351.12

Change from B1 to B2
Postintervention (PI)

0.551.43
53.0

Change from B1 to PI
Change from B2 to PI
ASKp

z Score
(Wilcoxon T)b

95%
Confidence
Interval

45.4655.67

Baseline 1 (B1)

80.0

28.4

66.9684.74

Baseline 2 (B2)

81.7

22.1

68.8385.86

Change from B1 to B2
Postintervention (PI)
Change from B1 to PI
Change from B2 to PI

0.084.4
92.1

15.8

79.6292.88

.000

PBS scores range from 0 to 56; ASKp scores are percentages, with 100% representing complete performance of activities.
Wilcoxon T transformed to z score.
No significant difference in PBS and ASKp baseline scores (P.05).
d
Statistically significant increases in PBS and ASKp scores after hippotherapy (P.01 with Bonferroni correction of 0.0167).
e
Large effect size.
b
c

df2, P.001) (Tab. 3). As a group,

the children showed a median
decrease of 3.0 seconds in the time it
took to alternately touch the stool
8 times (Tab. 3). Statistically significant differences among the 3 forward reach measurements were also
found (216.38, df2, P.000);
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Physical Therapy

these translated to a median increase

in reach of about 5 to 6.3 cm (2.0
2.5 in) after hippotherapy (Tab. 3).
ASKp
Significant differences in ASKp
scores were found among the 3
testing sessions (221.70, df2,

P.001) (Fig. 2). These data translated to a difference between the

baseline and postintervention assessments but not between the baseline assessments (Tab. 2). The children had postintervention scores
(median92.1) that were statistically higher than their baseline 1

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Hippotherapy: Habilitating Balance Deficits in Children With Movement Disorders

Table 3.
Within-Group Comparisons of Timed Pediatric Balance Scale Items for the 16 Participantsa

Assessment
Single-leg stance

.928

0.05

0.773.30

2.95 (1.50)

.001c

1.22d

0.663.28

2.70 (7.0)

.004

1.08d

2.10 (1.50)

.039

6.1914.75

3.20 (0.0)

.000c

1.37d

3.3212.31

2.94 (0.0)

.001

1.22d

0.63 (5.88)

.110

Baseline 1 (B1)

2.5

1.8

1.634.44

Baseline 2 (B2)

2.3

3.5

Test

5.0

5.5

Change from B2 to PI
Baseline 1 (B1)

1.5

9.2

Baseline 2 (B2)

7.5

10.0

Change from B1 to B2
Postintervention (PI)

10

16.2

Change from B2 to PI
Baseline 1 (B1)

12.5

11.0

Baseline 2 (B2)

12.5

16.0

0.698.99
3.2711.48

9.5

10.0

0.37

10.3120.32

10.522.37
10.8421.91
2.152.03

Change from B1 to B2
Postintervention (PI)

3.166.96

0.165.15

Change from B1 to PI

z Score
(Wilcoxon T)b

1.674.52
0.760.89

Change from B1 to PI

Forward reach

1.34 (5.75)

95%
Confidence
Interval

Postintervention (PI)

Alternating stool touch

Effect
Size

Interquartile
Range

Change from B1 to B2

Tandem stance

Exact
Significance
(2-Tailed)

Median
Score

0.22

8.5218.73

Change from B1 to PI

4.111.02

3.18 (0.0)

.000c

1.36d

Change from B2 to PI

4.650.85

2.95 (0.0)

.001

1.22d

0.58 (5.30)

.603

3.8911.05

3.04 (3.25)

.001c

1.28d

5.7210.80

3.43 (2.00)

1.52d

Baseline 1 (B1)

22.9

20.3

Baseline 2 (B2)

21.6

33.0

Change from B1 to PI
Change from B2 to PI

12.8024.03
3.862.26

Change from B1 to B2
Postintervention (PI)

12.9325.48

27.9

10.2

0.21

21.7231.47

.000

Single-leg stance, tandem stance, and alternating stool touch are reported in seconds; forward reach is reported in centimeters.
Wilcoxon T transformed to z score.
Statistically significant increase in time spent in single-leg stance and tandem stance, decreased time for alternating stool touch, and increased distance for
forward reach after hippotherapy (P.01 with Bonferroni correction of 0.0167).
d
Large effect size.
b
c

scores (median80.0, T3.5, P

.01) or baseline 2 scores (median
81.7, T0, P.01). Data for subsections of the ASKp also were analyzed
to determine where specific functional improvements occurred.
Although the Friedman analysis of
variance revealed statistically significant increases in scores for each
subsection, post hoc analysis only
showed changes between baseline 1
and postintervention scores for the
personal care and dressing sections.
Because of the limited number of
questions in each section, the sigMay 2012

nificance of these changes may be

questionable and, therefore, is not
reported.
Correlation Analysis
Two-tailed correlation (rs values)
between the PBS baseline scores and
the ASKp baseline scores ranged
from .78 (P.001) (baseline 1) to .69
(P.001) (baseline 2), and the correlation between the postintervention scores (.70) was significant
(P.01). There was no correlation
between the change in PBS scores
and the change in ASKp scores

from the baseline assessments to

the postintervention assessment
(rs.13, P.64). Specific PBS items
that correlated with ASKp scores
were the alternating stool touch
(rs.62, P.01) and tandem stance
(rs.58, P.01); there was no correlation for single-leg stance or forward reach.

Discussion
After the hippotherapy intervention,
statistically significant improvements
in balance and function were
observed for the children who par-

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Hippotherapy: Habilitating Balance Deficits in Children With Movement Disorders

ticipated in the present study.
Research observations of large effect
sizes and statistical significance are
useful analytical tools; however, if
changes are not clinically significant,
treatment strategies still are not viable options for children with movement disorders. In an effort to understand whether clinically significant
improvements occurred, we categorized the children as having mild,
moderate, or severe balance deficits.
We used this method instead of comparison with children showing typical development because the childrens PBS scores, even after
hippotherapy, were so far below
those of their age-matched peers that
comparison with cutoff scores was
not a meaningful interpretation of
clinically significant improvements20
(eTab. 1).
Because we found a correlation
between the PBS and the ASKp, this
information was used in conjunction
with the clinical observations made
by the first author (D.J.S.) to group
the children into balance categories.
Children were categorized as having
mild balance problems if their average baseline PBS scores were greater
than or equal to 49, moderate deficits were classified as scores
between 35 and 48, and scores of
less than or equal to 34 signified
severe balance deficits. These categories are similar to those used with
the Berg Balance Scale to assess
changes in older adults who dwell in
the community.27 On the basis of
this categorization, 8, 6, and 2 children were considered to have mild,
moderate, and severe balance deficits, respectively, at the start of
the study (Tab. 1). All children categorized as having mild balance
deficits showed improvements in
PBS scores after the intervention.
After hippotherapy, children with
moderate balance deficits, with 1
exception, were categorized as
having mild deficits, and 1 of the
2 children with severe balance defi714

Physical Therapy

cits improved to having only moderate deficits. Thus, improvements

in balance after hippotherapy were
related to the severity of the baseline
deficits, not to the diagnosis. These
findings may be due to the fact that
children with more severe disabilities have greater room for improvement. They also may be related to a
ceiling effect of the PBS. For children
with milder balance deficits, other
tools, such as sensory organization
testing, may provide more information on changes in their balance
abilities.
Another method of measuring clinical improvement is to use the minimal detectable change. Although
no minimal detectable change values
exist for the PBS, they do exist
for the Berg Balance Scale.20 The
Berg Balance Scale has been used
to assess balance in children with
cerebral palsy,28 so it might be helpful to compare changes found in the
present study with minimal detectable changes in adult populations
with disabilities. Minimal detectable
change values of 2.5 and 3.8 are considered to be clinically significant in
people with balance deficits after
stroke29 and traumatic brain injury,
respectively.30 The fact that the
median increases in PBS scores for
the children in the present study
were 5.5 points (baseline 1 to postintervention) and 4.0 points (baseline 1 to postintervention) could
suggest that the observed balance
improvements after hippotherapy
were clinically relevant.
Plint et al31 found that children without disabilities had a mean score
on the ASKp of 93.12 (SD6.45)
and that the mean scores on the
ASKp were 85.86 (SD13.77) for
children with mild disabilities,
52.66 (SD22.53) for children
with moderate disabilities, and 21.00
(SD10.33) for children with severe
disabilities. With this classification of
disability severity, 11 children in the

present study would have been considered mildly disabled and 5 would
have been considered moderately
disabled before the hippotherapy
intervention (Tab. 1). After 12 hippotherapy sessions, not only did the
children show improvements within
their disability levels (high versus
low end of the range), but also only
2 children still would have been considered moderately disabled and the
remainder of the children would
have moved into the mildly disabled
category (Tab. 4).
These results are not meaningful
unless they also constitute clinically
significant changes. Young et al24
reported an effect size of 1.79 in
34 children who had musculoskeletal disorders and showed either positive or negative clinically important
changes. They further stated that this
change correlated with a clinically
significant change of 1.73 standard
deviations. With the method used by
Young et al24 for calculating a clinically significant change, our effect
size of 1.51 would correlate with a
change of 1.3 standard deviations.
We would argue that an effect size of
1.51 and a change of 1.3 standard
deviations after 6 weeks of intervention are still clinically significant.
Additionally, the adolescents with
cerebral palsy in our study had a
10.1% median increase in their ASKp
scores from the baseline 2 assessment to the postintervention assessment, a finding that is statistically
significant (T0.0, P.05). In contrast, Palisano et al32 found that adolescent children (11.6 17.7 years of
age) with cerebral palsy did not
show changes in their ASKp scores
over a 1-year period. According to
convention, the effect sizes observed
between baseline and postintervention scores for both the PBS and the
ASKp were large enough to suggest
that the degree of separation
between the scores was likely due to
the intervention and that the possi-

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Hippotherapy: Habilitating Balance Deficits in Children With Movement Disorders

Table 4.
Number of Participants Classified by Disability Level Before and After Intervention
Disability Classificationa
Moderate
Parameter
Score range

Mild

Severe

Low

Middle

High

Low

Middle

High

30.13

30.241.4

41.563.8

63.973

73.179

79.192.7

92.899

Classificationb before
hippotherapy
Classification after
hippotherapy

a
Based on Activities Scale for Kids scores of Plint et al.31 Score ranges for the low, middle, and high subcategories were determined by dividing the standard
deviation for each category by 2, adding the resulting number to the low end of the range, and subtracting the resulting number from the high end of the
range.
b
Baseline classification (mean of the 2 Activities Scale for Kids baseline scores before hippotherapy).

bility of a type I or II error was

diminished.26
Correlation of
Balance With Function
We found a correlation between
the PBS and the ASKp. However, no
correlation between the change in
PBS scores and the change in ASKp
scores was observed. There are several possible explanations for this
finding. One possibility is the small
sample. Additionally, the Berg Balance Scale has a nonlinear progression in relation to the severity of
balance deficits.33 It is likely that
the PBS also has this quality which,
in conjunction with its ceiling
effects, may explain this finding.20
Finally, the correlation of .84
between the PBS and the ASKp may
reflect the difference in the constructs of motor activity, the former
being a measure of motor capacity
and the latter being a measure of
motor performance.34

stool touch correlated best with the

ASKp scores, because the increased
ability to alternately touch the stool
suggests improved reaction time and
improved
motor
coordination.
Increased time in tandem stance
demonstrates that a child can handle
a narrower base of support, which
may translate to an improved ability
to negotiate within a classroom. The
correlation with the ASKp scores
may be explained for both of these
items by the fact that many of the
questions inquire about a childs ability to maneuver within the environment. However, there were no correlations between the ASKp scores
and single-leg stance (which showed
the highest correlation with the PBS
scores) or forward reach. The lack of
correlation of these 2 items may be
due to the fact that the ASKp questions were not specific to single-leg
activities or reaching activities in a
standing position, other than putting
on pants.

Only 2 of 4 PBS tasks that correlated

with increased PBS scores correlated
with the ASKp scores. Decreased
time for alternating stool touch
should translate to improved abilities
to ascend and descend stairs and
change falls into trips or no loss of
balance. This notion may explain
why the improvement in alternating

The lack of correlation between the

change in PBS scores and the change
in ASKp scores does not negate the
fact that all children showed
improvements in both balance and
performance of daily life skills. We
suggest that hippotherapy provided
the children with an opportunity to
improve anticipatory and reactive

May 2012

postural control strategies in

response to complex sensory input.
Moving through space while maintaining postural control gave the
children an opportunity to calibrate
their perceptual skills to a higher
level. This change, in turn, allowed
for further engagement with the
environment, which allowed for
exploration and refinement of new
movement patterns. The new movement patterns allowed for better
functional abilities in daily activities,
as measured by the ASKp. Therefore,
the present study met the challenge
posed by Harris and Roxborough35
to demonstrate that an intervention
(specifically hippotherapy) used to
treat postural control influences childrens ability to function within their
natural environments.
Study Limitations
The lack of a control group without
the hippotherapy intervention is a
study limitation, as is the short duration between baseline measurements. To negate concerns regarding
maturation effects on improvement,
the time between the baseline scores
should have matched the intervention time (6 weeks). However, it can
be argued that children with a mean
age of 10 years 4 months do not
experience
large
maturational

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Hippotherapy: Habilitating Balance Deficits in Children With Movement Disorders

changes within a 7- to 8-week
period.

This study done in partial fulfillment of the

requirements of Dr Silkwood-Sherers doctoral degree program.

Although representative of a typical

hippotherapy practice, the variety of
diagnoses for the children in the
present study is both a strength and
a limitation. The strength is that
improvements in balance and function after hippotherapy did not
appear to be diagnosis dependent.
However, the limitation is that the
small number of participants within
each diagnostic category limited the
ability to generalize the results to a
specific diagnosis.

Institutional review boards at Central Michigan University and University of Indianapolis

approved this study.

Despite the statistically significant

and apparently clinically significant
findings, the small sample requires
the use of some caution in interpreting the results. The findings provide
some encouraging preliminary evidence but need to be replicated with
a larger sample and a control group.

References

Conclusion
Hippotherapy appears to be a viable
treatment strategy for improving balance and functional performance of
daily life skills in children with mild
to moderate balance problems. The
present study strengthens the evidence for using hippotherapy to
treat balance deficits in children
with neuromuscular disorders. Recommendations for future research
include randomized controlled trials
with larger numbers of children with
a specific diagnosis and additional
measures of body/structure and
function as well as measures to
assess changes in participation and
quality of life.
Dr Silkwood-Sherer, Dr Killian, and Dr Martin
provided concept/idea/research design. All
authors provided writing. Dr SilkwoodSherer provided data collection, project
management, participants, facilities/equipment, and institutional liaisons. Dr SilkwoodSherer and Dr Killian provided data analysis.
Dr Killian, Dr Long, and Dr Martin provided
consultation (including review of manuscript
before submission).

716

Physical Therapy

An abstract submission and an oral presentation of portions of this research were given
at the Federation of Riding for the Disabled
International Conference; August 2009;
Munich, Germany; and at the Developmental and Child Neurology Conference; September 2326, 2009; Scottsdale, Arizona.
ClinicalTrials.gov
NCT01313325

registration

number:

DOI: 10.2522/ptj.20110081

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HippotherapyAn Intervention to Habilitate Balance

Deficits in Children With Movement Disorders: A
Clinical Trial
Debbie J. Silkwood-Sherer, Clyde B. Killian, Toby M.
Long and Kathy S. Martin
PHYS THER. 2012; 92:707-717.
Originally published online January 12, 2012
doi: 10.2522/ptj.20110081

References

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