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Evaluating the effects of hippotherapy with children who have cerebral palsy

Anna Lundgren & Stacie Bryant

University of Utah

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Introduction

According to the Centers for Disease Control and Prevention (CDC, 2015), cerebral palsy

(CP) is classified as a neurological disorder that can affect peoples body movements, posture

and balance. Cerebral palsy is a non-curable and chronic disorder but people live varying

lengths with CP. Cerebral palsy is considered the leading motor disability in children (CDC,

2015). The CDC states that one in 323 children will have some form of CP ranging from mild

forms to severe multi-limb deficits (2015). While the degree of CP varies, the underlying cause

of CP is damage or abnormal development of the brain. The majority of CP cases are

congenital, which means the damage to brain either occurred before or during birth. A small

percentage of children acquire CP post birth. In addition, the most common form of CP is

spastic CP, which can be described as an increase in muscle tone that affects smooth

coordinated muscle movement (CDC, 2015), which can impact a childs life and ability to

function in everyday activities.

All activities of daily living can be challenging for children who have CP. Children with CP

might have difficulty walking or need adaptive equipment to walk on their own. Cerebral palsy

can also affect the upper extremities, which can make it hard for children to feed themselves,

learn to write properly and learn fine motor and coordinated hand movements. In severe

cases, children can experience developmental delays, intellectual and learning disabilities, and

vision and/or hearing issues. Cerebral palsy is not genetic or hereditary, rather an unforeseen

complication due to birth or infections before birth. In other words, most often mothers are

doing everything in their power to have a safe and healthy pregnancy and one small

complication during birth can result in a child having CP.

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The most common intervention strategy for children with CP is early intervention

through state funding at public schools that is covered under the Individuals with Disabilities

Education Act (IDEA). This act provides supports for children from birth all the way through

school and until the child is 21 years old. It is widely believed among experts that the earlier

the interventions are started, the greater chance a child has at adapting (Rigby & Grandjean,

2015). Other common interventions include medication, surgery, speech therapy, physical

therapy and occupational therapy (CDC, 2015).

Hippotherapy emerged in the late 1980s as a viable alternative approach to working

with children who have CP (Rigby & Grandjean, 2016). Hippotherapy utilizes the natural

rhythm and gait of a horse to provide sensory input and initiate movement control and postural

balance when sitting on a horse (Shurtleff & Engsberg, 2010). This sensory input from the horse

forces the rider to use core strength and balance in order to not fall off the horse. Children also

have an opportunity to work with horses and develop self-confidence by engaging in

hippotherapy. This alternative approach to therapy has become more mainstream in recent

years and is being utilized more as a primary form of intervention (Rigby & Grandjean, 2016).

The purpose of this review is to evaluate the effectiveness of hippotherapy for improving motor

function in children with CP.

Methods
Through accessing the search engines online, two scientific databases were used:

CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed. The date

ranges on the searches were set within the last ten years, from 2005 to 2015. Searches were
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not limited to articles in English; translations of the study were reviewed when the article was

published in a different language.

The subsequent key terms were used to conduct the searches, with the number of initial

articles returned:

Search 1 on PubMed: Hippotherapy, children, cerebral palsy. This search resulted in 34 articles.

Search 2 on PubMed: Hippotherapy, children, cerebral palsy, motor. This resulted in 24 articles.

Search 3 on PubMed: Hippotherapy, children, cerebral palsy, motor function. This resulted in 21

articles.

Search 4 on PubMed: Hippotherapy, children, cerebral palsy, motor function (within last 5

years). This search resulted in 13 articles.

Search 1 on CINAHL: Hippotherapy, children, cerebral palsy. This resulted in 10 articles.

The two researchers conducted these searches together and reached mutual consensus

after reviewing relevant titles and abstracts. Studies were selected based on the following

inclusion criteria: children diagnosed with CP, ages 18 years and younger. Hippotherapy was the

primary intervention, with relevant motor function outcome measures. Only articles that were

published in a peer-reviewed journal were considered. Exclusion criteria were methods

including case study designs and therapeutic horseback riding or simulated hippotherapy as the

primary intervention. Adults and people with a diagnosis other than CP were also excluded

from our literature search.

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The levels of evidence determined the quality of the studies. Levels one and two were

included when possible, with randomized control trial (RCT) studies as the desired design. The

quality of the RCT studies were determined using the PEDro scale and studies that were not

RCTs were analyzed based on factors of research validity. The studies that were published most

recently, or in the last five years, were also highly considered because of the relevance of new

information. In this area of research, studies with 15 or more participants are considered a

decent sample size and were included due to the potential to be representative to the larger

population.

Results

Summaries

Refer to Table 1 for additional details about each study. Kwon et al. (2015) executed the

first known RCT that showed the benefits of hippotherapy in improving gross motor function

and balance in children with CP. The researchers were curious whether there would be

improvement in both motor functioning and balance using the Gross Motor Function Measure

(GMFM) and Pediatric Balance Scale (PBS) as assessment measures. Ultimately the GMFM-88,

GMFM-66 and PBS scores post-study showed significant improvement in the treatment group,

but no significant changes in the control group. Limitations to this study included the

researchers only studying the short-term effects of hippotherapy and did not control for the

variety of other therapeutic activities that the participants were involved with during the time

of the intervention.

Machow et al. (2014) examined how one session of circular hippotherapy can affect the

center of gravity (COG) in children with CP. The research question was rooted in whether or
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not hippotherapy, as a specific intervention for increasing muscle motor development, can help

increase correct posture and improve COG in children with CP who present with asymmetrical

muscle compensations. Findings were significant in terms of improvement in asymmetrical

COG and postural control. Based on these results, one session of hippotherapy can help correct

balance and symmetry of the lower limbs. Limitations to this study include a small sample size,

no control group and lack of randomization of the sample.

McGibbon, Benda, Duncan and Silkwood-Sherer (2009) evaluated the effectiveness of

both immediate and long-term hippotherapy when focusing on increasing the symmetry of the

adductor muscles and improving overall gross motor function in children with CP. This study

differs from the other studies because the researchers focused on a specific muscle group

rather than analyzing overall gross motor function. A smaller portion of this study was

dedicated to analyzing the self-perception of the children in phase 2 of the study. Children with

CP often have asymmetrical and hyperactive adductor muscles, which can cause deficits in hip

range of motion (ROM), hip subluxation and potential for dislocation (McGibbon et al. 2009).

Hippotherapy was used as the intervention in this RCT in both phase 1 and phase 2 of the study.

Overall, phase 1 of this study indicates that 10 minutes of specific hippotherapy significantly

improves symmetry of the adductor muscles. Phase 2 showed that 12 weeks of hippotherapy

also improves symmetry of adductor muscles. Phase 2 was a repeated measures design that

consisted of analyzing six children during a 36-week hippotherapy intervention divided into

three 12-week segments. During the middle 12 weeks, hippotherapy treatment was

administered for 30 minutes and adapted to fit the needs of each child. Activities on the horse

included having the horse walk in circles to challenge core and postural supports, changing
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position while on the horse, and upper-extremity exercises that focused on stretching and

reaching. The outcome measures for phase 2 included the use of surface electromyography

(sEMG) and the Gross Motor Function Measure-66. Results for phase 2 showed that 12 weeks

of hippotherapy in four of the six children showed improvement in adductor symmetry when

participating in functional activities such as walking. According to the data analyzed from the

GMFM-66, all six children improved their motor functioning. Limitations of phase 2 of the study

include a small sample size and not accounting for other therapies or activities that could have

helped with motor functioning. Both short-term and long-term hippotherapy could be an

effective treatment for improving adductor symmetry in children with CP. This study received a

five on the PEDro scale.

Park, Rha, Shin, Kim and Jung (2014) examined the effects of hippotherapy as an

effective intervention to increase everyday functional performance and motor function of kids

with spastic CP. This study was comprised of one group of 34 children with CP who received 45-

minute hippotherapy sessions two times a week for 8 consecutive weeks, and one control

group of 21 children with CP who were waiting for hippotherapy services. The treatment

encouraged balance, strength and postural control skills by emphasizing forward reaching

movement while on the horse. Each group was assessed before and after the treatment period

with the Gross Motor Function Measure (GMFM-66 and 88) and the Pediatric Evaluation of

Disability Inventory: Functional Skills Scale (PEDI-FSS). The results of this study conclude that

gains were made in both groups in gross motor function (GMFM), but the hippotherapy group

gained significantly more in dimension E, which includes walking, jumping and running. The

intervention group also made significant gains in all three areas of the PEDI test, which include
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mobility, self-care and social functioning. The data of this study suggests that hippotherapy

treatment can increase participation in functional daily activities in children with spastic CP. The

limitations of this study include lack randomization and lack of control for certain factors,

including interventions other than physical and occupational therapy, control for

communication or cognition levels, or socioeconomic status.

Kang, Jung and Yu (2012), examined the evidence that hippotherapy improves balance

while sitting in children with severe CP. This hippotherapy study was a RCT that consisted of

three groups: hippotherapy and physical therapy (HTG), physical therapy (PTG), and the control

group with no intervention (CON). The study comprised of 45 children with severe CP who were

randomly assigned into the three groups and kept blind of the other groups interventions. The

hippotherapy intervention involved the subject riding the horse while manipulating objects and

maintaining correct posture. The physical therapy intervention involved typical stretching and

strengthening activities. The interventions were conducted two times a week for 8 weeks in 30-

minute sessions. A pre- and post-test was administered to every subject before and after the

interventions to test sitting balance. The measure used was the PDM Multifunction Force

Measuring Plate, which assesses the velocity and pathway of the center of pressure of each

child while sitting. The results concluded that the HTG group significantly improved sitting

balance, including decreased center of pressure pathway and velocity, compared to the PTG

and CON groups. These results indicate that hippotherapy is an effective intervention to

improve postural sitting balance in kids with severe CP and can be used effectively in

combination with physical therapy. The limitation of this study was whether hippotherapy
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alone resulted in sitting balance improvements or other interventions such as physical therapy.

This study received a PEDro score of four.

Manikowska, Jozwiak, Idzior, Chen and Tarnowski (2013) examined the evidence for a

one-time hippotherapy session improving components of gait in children with CP. This study

was comprised of 16 children with CP who ambulated without assistance. The design was a pre-

/posttest, one group pilot study, with the subjects acting as their own controls. Walking speed,

stride length, cadence, step length and bilateral symmetry were assessed before and after a 30-

minute hippotherapy session using a three-dimensional accelerometer device (DynaPort Mini

Mod). Results indicated significant increase in walking speed after the intervention, and

increases in other gait parameters, but these changes were not statistically significant. This

study provides evidence that effects from hippotherapy can be achieved after just one session

and can elicit improvement in normalization of gait for children with CP. The limitation for this

study entails a small population due to the pilot study design.

Discussion
Six articles were used to evaluate the effectiveness of hippotherapy as an intervention

for improving motor function in children with CP. Articles ranged from level one RCTs to level

three pre-post design studies. Results from the articles indicate common findings of

improvement in sitting balance, walking speed, muscle symmetry and center of gravity stability.

Positive effects of hippotherapy used in addition to other interventions, such as physical

therapy, was also mentioned across many of the studies. The majority of the studies included

similar justifications of the physiological reasons as to why hippotherapy is considered to

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benefit children with CP. These reasons include improving blood circulation, relaxing spastic

muscles, providing sensory input, and reducing muscle tone.

Strengths across studies include positive outcomes post hippotherapy intervention.

These outcomes suggest that hippotherapy is an effective intervention to improve motor

function for children with CP. Other strengths include the number of children who were willing

to participate in the research studies. It was noted and appreciated how valuable it is to be

able to study children with CP to help not only current populations, but benefit future

generations who have CP. In multiple RCT studies, if children were not chosen for the

intervention group they still received a horseback ride for being willing to be in a study. In

addition, the children in the treatment group received free hippotherapy that ultimately

benefited them. Overall, even though positive outcomes affected the participants on a

spectrum, all saw an improvement in gross motor function.

Limitations across the studies include lack of consistency of outcome measures and

severity of CP, along with limited RCTs. Almost every article used a different test to measure

aspects of gross motor function. Some of these testing instruments included an accelerometer

device, the Pediatric Evaluation of Disability Inventory: Functional Skills Scale, a PDM

Multifunction Force Measuring Plate, a surface electromyography, the Gross Motor Function

Measure and Pediatric Balance Scale. These studies also lacked consistency in the severity of CP

that the participants experience. For example, the range of diagnosed CP included spastic,

severe, hemiplegic, diplegic, and ranged from I-IV on the Gross Motor Function Classification

System (GMFCS). Overall, there was a lack of RCTs to choose from in this category; only three

RCT studies were selected out of all the articles that were searched. Other limitations include
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lack of higher levels of evidence in occupational therapy journals and differences in how

hippotherapy was administered varied across studies. Many studies did not control

participants involvement in other therapeutic activities and additionally recruited a limited

number of participants.

In this evidence-based review the effects of hippotherapy were analyzed as a treatment

for children with CP with outcomes measuring motor function. Based on level one RCTs, level

two nonrandomized 2-group comparisons, and level three-pre/post test design, results from

the hippotherapy interventions showed statistically significant motor function improvements in

children with CP. These motor improvements include gross motor functions, gait parameters,

sitting and standing balance, symmetry of adductor muscle and functional ability. Findings from

this review suggest that hippotherapy is an effective rehabilitation intervention for children

with CP. When paired with other physical therapy or occupational therapy interventions,

hippotherapy also demonstrated to provide significant gains in motor function. It should be

noted that along with motor function gains, secondary benefits include increased social skills,

self-confidence, motivation and active participation. The clinical recommendation is that

hippotherapy should be used by itself or in conjunction with other occupational and physical

therapy interventions.

The articles analyzed indicate hippotherapy as an evidence-based practice intervention

recommended by the AHA to be Class IIa; Level B. In other words, hippotherapy can be an

effective treatment for many children with CP. There is potential that hippotherapy might be

not beneficial for all children with CP due to severe limits of motor function, severe cognitive

impairment, limited access, parental concerns or fear of horses. Overall, due to high levels of
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evidence, outcomes suggest that hippotherapy can be an effective and recommended

intervention to increase functional motor outcomes.

Evidence supports that hippotherapy can be used within the scope of occupational

therapy practice. Hippotherapy can benefit all areas of functioning in children with CP such as

activities of daily living, functional mobility, social participation, leisure, play, education, and

self-care. Occupational therapists can become certified hippotherapy specialists that allow an

OT to utilize the unique aspects of a horse to benefit children with CP. This intervention is

client-centered and focuses attention and energy on the specific needs of the child.

Hippotherapy can also take into account a childs personality, context of their environment and

parent or guardian involvement. Hippotherapy is a tool that an OT can use to provide sensory

and motor input to a child and then be able to measure outcomes and analyze growth. This

type of intervention connects with the foundational concepts that occupational therapists are

trained in and can also be seamlessly combined with speech therapy and/or physical therapy.

Hippotherapy is an intervention that can improve functional motor outcomes in children with

CP and aligns with the values of occupational therapy.

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References

Centers for Disease Control and Prevention (CDC). (July 13, 2015). Facts about cerebral palsy.

Retrived from http://www.cdc.gov/ncbddd/cp/facts.html

Herrero, P., Gomez-Trullen, E. M., Asensio, A. Garcia, E., Casas, R., Monserrat, E., & Pandyan, A.

(2012). Study of the therapeutic effects of a hippotherapy simulator in children with

cerebral palsy: a stratified single-blind randomized controlled trial. Clinical

Rehabilitation, 26(12), 1105-1113. doi: 10.1177/0269215512444633

Kang, H., Jung, J., & Yu, J. (2012). Effects of hippotherapy on the sitting balance of children with

cerebral palsy: A randomized control trial. Journal of Physical Therapy Science, 24(9),

833-836. doi:10.1589/jpts.24.833

Machow, A., Malachowska-Sobieska, M., Demczuk-Wlodarczyk, E., Sidorowska, M., Szklarska,

A., & Lipowicz, A. (2014). Influence of neurophysiological hippotherapy on the

transference of the centre of gravity among children with cerebral palsy. Ortopedia,

Traumatologia, Rehabilitacja, 16(6), 581-593. doi: 10.5604/15093492.1135048

Manikowska, F., Jwiak, M., Idzior, M., Chen, P. B., & Tarnowski, D. (2013). The effect of a

hippotherapy session on spatiotemporal parameters of gait in children with cerebral

palsy - pilot study. Ortopedia Traumatologia Rehabilitacj, 15(3), 253-257.

doi:10.5604/15093492.1058420

McGibbon N. H., Benda, W., Duncan B. R., & Silkwood-Sherer D. (2009). Immediate and long-

term effects of hippotherapy on symmetry of adductor muscle activity and functional

ability in children with spastic cerebral palsy. Physical Medical Rehabilitation 90(6), 966-

974. doi: 10.1016/j.apmr.2009.01.011

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Park, E. S., Rha, D., Shin, J. S., Kim, S., & Jung, S. (2014). Effects of hippotherapy on gross motor

function and functional performance of children with cerebral palsy. Yonsei Medical

Journal, 55(6), 1736-1742. doi:10.3349/ymj.2014.55.6.1736

Rigby, B. R., & Grandjean, P. W. (2016). The efficacy of equine-assisted activities and therapies

on improving physical function. The Journal of Alternative and Complementary

Medicine, 22(1), 9-24. doi: 10.1089/acm.2015.0171

Shurtleff, T. L., & Engsberg, J. R. (2010). Changes in trunk and head stability in children with

cerebral palsy after hippotherapy: A pilot study. Physical & Occupational Therapy in

Pediatrics, 30(2), 150-163. doi: 10.3109/01942630903517223

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Table 1

Study Participants Age Design Outcomes

Kwon 92 children with Between Level 1 Study concluded that

et al. diagnosis of CP 4-10 years Experimental hippotherapy can improve
(2015) with a GMFCS old. Randomized motor function and have a
Level I-III Control Trial (RCT). positive impact on children
Half the group tx with CP.
(n=46) the other
half control (n=46).

McGibb 58 children with Ages 4-16 Level 1 Pretest / Hippotherapy can improve
on et al. spastic CP Posttest adductor muscle symmetry
(2009). randomized control during walking and other
trial plus clinical motor skills.
follow-up.

Macko 19 children ages Ages 4 - Level 3: One group Study concluded that one 30
w et al with spastic CP 13 pre/post test min session of hippotherapy
(2014) with the GMFCS could have statistically
levels I-III significant effect on the
change in the position of the
center of gravity in children
who have CP who present
with asymmetric model of
compensation.

Park et 55 children with Ages 3-12 Level 2 - 2 group, Study concluded that
al. spastic CP with nonrandomized hippotherapy can produce
(2014) GMFCS levels I-IV study significant gains in gross
1 hippotherapy motor functions, specifically
group (n=34), running, jumping and
1 control group walking, as well as significant
(n=21) improvement in self-care,
mobility and social
functioning.

Kang et 45 children with Average Level 1 - Physical therapy plus

al. severe CP (both age was 8 Randomized hippotherapy resulted in the
(2012) hemiplegic and years old Control Trial (RCT) highest levels of sitting
diplegic) Single-blind study balance, including decreased
3 groups: center of pressure pathway
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HTG, n = 14 and velocity. The study

PTG, n =15 concluded that hippotherapy
CON, n = 14 in addition to physical
therapy is more effective
than physical therapy alone,
and no intervention at all.

Maniko 16 children with Ages 5-17 Level 3 - one group Study reported significant
wska et CP years old pre-post test study difference in higher walking
al. (GMFCS I-III) speed after intervention. The
(2013) study also determined that
hippotherapy positively
affects gait after just one
sessions.