This research was conducted via participant-report; thus, the actual classification of equine-intervention that the child underwent was not verified. For the purposes of this research, the participants’ equine-interventions are referred to as EAAT, which encompass HT and AR experiences.
Benefits of Participating in EAAT
The perceived benefits of EAAT were the most frequent occurring code in the data analysis. The benefits discussed by the children were summarized into 2 main categories: psychological and physical. The psychological benefits of participating in EAAT included improved mood, confidence, self-esteem, pride, independence, and sense of achievement. Some quotes demonstrated psychosocial benefits: “When I got up on the horse I could do everything once I got up. I think it gave me independence.” (a 15-year-old girl); “I'm always in a good mood when riding the horse.” (an 11-year-old boy). The EAAT experience also provided the participants with a sense of accomplishment and normalcy, which was something that they often shared in common with their peers: “It was really fun. And it was cool to go back the next day at school and be like, ‘Hey, guys, I just rode a horse.’” and “It gave me something to talk about with my friends.” (a 13-year-old girl).
All of the children described EAAT in a positive light. The differing gaits (ie, trotting, walking) were perceived as enjoyable and fun. One 5-year-old boy adamantly stated, “[I continue to ride horses] because I like it.” Several of the older children who were nonambulatory compared the equine movement to what walking might feel like, and all of the children indicated that they would continue participating in EAAT if given the opportunity. One 13-year-old girl, who is nonambulatory, described her experience as follows: “I felt the beat of the horse, because I don't weight-bear at all, so it was different. It was a very awesome feeling. I really enjoyed it. It was good. I mean, it is a lot of work...but it was good.”
The children perceived a range of physical benefits including increased flexibility, muscle laxity, muscle function, core strength, balance, and a feeling that they were exercising. The children described increased muscle function in the core muscles and muscles and joints of the upper and lower extremities. Some quotes in this category included “I have tight muscles and so it helps me.” (a 7-year-old girl); and “During the trotting, I had to really keep my tummy muscles [tight]... It helps make my muscles more active.” (an 11-year-old boy). The children reported that these physical effects carried over into daily activities off the horse, including walking (in some cases), lifting objects, and general positioning, such as “It makes my muscles stronger so I can put my chair up [at school] when we're going home.” (an 11-year-old boy); and “It helps me spread my hips out when I'm on my bed.” (a 12-year-old boy). A few of the older children were also able to conceptualize a perceived cost/benefit physiological relationship between initial negatives of participating in EAAT corresponding to long-term physical benefits, as a 13-year-old girl explained: “Well when I'd get off, I felt that my hips especially would be really sore and stuff, but that's what you get when you get a good stretch.”
The parents also perceived benefits for their participating children that were both psychological and physical. They reported increased confidence, independence, and a sense of achievement and/or overall well-being. One parent of a 5-year-old boy proudly stated: “For a kid that's in a wheelchair all the time, it gives them this wonderful feeling of being up high. I think it gives them a little bit of confidence.” Furthermore, parents perceived these effects as extending beyond the EAAT experience into daily functioning. They described improved social interactions, a sense of accomplishment and pride, and increased self-esteem when off the horse. A quote demonstrating this is from a mother of a 9-year-old boy:
I mean these kids spend so much of their time in hospitals and in a clinical setting, to actually be able to be outside or be in a corral, be doing something that is so different, I just think it helps them emotionally and to give them that little bit of normalcy something that other kids possibly would be doing, like horseback riding. I think it's highly beneficial for them.
The parents also reported that AR seemed to help their children develop a sense of sportsmanship. One parent of an 11-year-old boy explained, “He does 3 competitions a year. That's another benefit of it; it is a sport for him. He can't run, but when the horse trots, he feels like he's running, like he loves that part.” One parent humorously explained the sportsmanship lesson learned by her 11-year-old son: “They started bumping him up to the higher class [in competition], and he stopped getting the blue ribbons. He wouldn't even take the ribbon the first time that he went. They taught [him] manners and sportsmanship.” Another parent explained the experience for her teenaged girls: “I know that it was a fun time for them to be able to do it and feel very in control; they felt very empowered. With definitely the physical things, but I think it was more the mental, feeling really strong and it felt good for them.”
Parents also described physical benefits for their child participating in EAAT, including improvements in strength and balance: “I think he's stronger. It helps him with balance and strength,” a mother of an 8-year-old explained; and “I think she's gotten better balance and I think she's able to maintain and gain more strength than she ever had,” a parent of a 7-year-old confidently stated. Other physical benefits perceived by the parents included stabilization or improvement in motor function, postural control, and gait stability. All parents stressed the unique benefits of EAAT, indicating that the type of exercise and range of motion provided by EAAT was quite unique from what is available via other types of therapies. One parent of a 12-year-old boy explained her opinion of EAAT: “The physical benefit you get out of it is something different than you can get out of any medical model therapy. Even swimming, because we swim too. You can't duplicate it. I can't duplicate what the horse did anywhere else.” The parent with teenaged girls, aged 13 and 15 years, explained 1 of the daughters’ experiences:
You could tell that she had ridden because she was a lot more loose, because she has contractures and trying to at least maintain or improve some trunk control and head control. The sensation of what walking feels like, that was important for [younger daughter's name], cause she never really got that feeling except on a horse, and that was something that really felt good to her.
A physical benefit that seemed surprising to some parents was an observed increase in their child's breath and voice control as a result of EAAT participation. One parent of a 5-year-old boy explained what she has noticed in her son: “We've seen a great improvement in [his core strength and breath control]. It definitely works his muscles in a way that we can't repeat through a different process.”
Relationships Formed During Participation in EAAT
Another perceived benefit was the opportunity for the child to form relationships. Children reported relationships with (1) the horse, (2) the instructor/therapist, and (3) other children. The child participants mentioned the relationship with the horse most frequently. The younger children focused on the attractiveness and the emotional connection with the horse. For example, one 7-year-old girl shared the following: “Do you know [horse's name] is very sassy? She gets grumpy. That's the one thing I don't like about her, but I still love her to pieces. Do you know who's the most cooperative and listens always? [Horse's name].” Children perceived the opportunity to build relationships with other children as an important benefit. These included friendships made during the EAAT experience or outside EAAT. One 11-year-old boy stated: “There's a friend of mine who goes to horseback riding.” Finally, children also perceived their relationships with the instructor/therapist or side-walkers in a positive light, and often spoke of past as well as current instructors/therapists by name; “Okay, well, Miss [name] is my teacher. [She] is way nice” (a 7-year-old girl). A 13-year-old girl explained the comfortable feelings she had with her instructor/therapist: “We had the same instructor every time, which was really cool. We had girls and guys that volunteered. They all seemed willing to help us and wanting to be there with us.”
From the parents’ perspective, the child's relationship with the horse was the most influential relationship for their children. One parent explained her child's experience: “They feel so attached to the horses that they ride, just the emotional part of seeing the horse and knowing that after they're done riding, they get to go back into the barn and give the horse the treat, and it's just so much fun for them, they love it” (parent of a 4-year-old girl). Another parent stated: “He had the same horse every time and so he always talked about [horse's name] and when the session was over he would always pet [horse's name]. Yes, definitely a relationship there” (parent of a 5-year-old boy). The parents also stressed the perceived benefit of the child's relationship with the instructor/therapists and side-walkers as a dynamic team. One parent of a 5-year-old boy commented:
He always develops close relationships with some of the college kids that we saw week after week. We would have them for one semester at a time and there would be particular ones that were really drawn to him, they would ask to be with him each time. He likes that a lot and I think they did too.
The parents reported that the continual interactions with the instructor/therapists or side-walkers facilitated communication skills. In addition, a few parents explained that the instructors/therapists and side-walkers changed frequently (as well as the horse, in some instances), which they perceived as a benefit for the child to learn to adapt to new situations and interactions. One parent of a 5-year-old boy explained:
He has a very good relationship with the coach. For him, he always had the same person that's the lead, the hippotherapist [sic], but then there's always a new volunteer. So it's good that it has both consistency in the person that's working with him, but then he also has to adapt to the new volunteer who's walking with him that day.... It's been a good social outlet for him.
Barriers to Obtaining EAAT
The third categorical theme that emerged was composed of barriers encountered by parents and children in obtaining or continuing EAAT. Children were sometimes apprehensive about beginning EAAT, describing an initial feeling of nervousness or intimidation by the horse (“When I first starting riding horses, I was nervous”—an 11-year-old boy). However, all of the children who initially reported apprehension went on to report that they were able to overcome this barrier (“At first I was [scared of the horses], but then I got used to it.”—an 8-year-old boy proudly stated). Most children noted, at least initially, some negative physical consequences of participating in EAAT, such as muscle soreness. A 12-year-old boy stated: “My hips hurt afterwards. They would hurt at first but then they wouldn't” and “Sometimes my legs would get sore because I had to kick my horse for it to go, but besides that it was fine” (a 15-year-old girl).
Barriers described by parents included (1) negative psychological and physical events; (2) physical changes in the child that contraindicated EAAT participation; and extenuating circumstances, such as (3) lack of EAAT knowledge by providers; and (4) issues regarding cost or lack of insurance coverage. Parents worried about the safety of their children and relayed their concerns about potential physical injury or discomfort. One parent of a 12-year-old boy explained her concerns, “For [him], it got where he was just so big, to get off and on the horse, I felt like it wasn't safe for me to do with him.” A parent of an 11-year-old boy explained her concerns with some added humor, “He has fallen off a couple of times, he's never been injured, and when he fell, it's been kind of kooky when it's happened. You know, you need to learn how to deal with pain.” The parents were also concerned about upsetting the children if/when they were no longer able to participate because of medical contraindications. The contraindications most commonly reported for discontinued participation in EAAT were surgeries, scoliosis related surgery, or declining physical ability (such as progressive muscle weakness resulting in diminished head and trunk control). The contraindications were described by parents: “Well, [he] had the rods placed, and so it's contraindicated once you have any kind of rods placed.” (parent of a 12-year-old boy), and “There were times, especially after surgeries that they just weren't able to ride and I really don't know if [she] will ever be able to get back on again because of her fusion” (parent of teenaged girls aged 13 and 15 years).
The majority of the parents reported searching out EAAT on their own, without a referral from a medical professional. The parents and children strongly advocated that providers become more aware of EAAT as a potential therapy intervention and mention it to families with children with neuromuscular manifestations. One parent of an 11-year-old boy stated with a frustrated tone, “Actually, I'm the one that brought it up to my physical therapist. They didn't know this was in our area. I don't think you can really rely on the doctors because they don't seem to even know anything about SMA.” Another parent of a 4-year-old girl advocated for the benefits of the horse and awareness of EAAT: “I think if people were more aware of it and the benefits of it, they would do more of it. I don't think a lot of people understand just the depth that horseback riding can do for a child.”
Another barrier discussed by the parents was the expense of EAAT due to the lack of insurance coverage. The majority of parents reported that they did not have insurance coverage for EAAT. Those who were successful at obtaining insurance coverage either coded EAAT as a subtype of physical therapy or received only partial coverage. A parent of a 4-year-old girl explained their experience with the cost of EAAT: “We pay for it out of pocket. Insurance doesn't pay for recreational therapies, so they will not pay for hippotherapies [sic].”
This study is unique in that it investigates a novel study population (SMA) within the HT/AR field using qualitative methods, as opposed to quantitative (case-control) designs. The study participants supported the use of EAAT through their rich and personal stories conveying their perceived benefits of the EAAT experience. Our findings parallel previous research conclusions that HT/AR provides physical and psychological benefits to its participants.5–17
Results from this study support the premise from previous research that HT/AR participation for individuals with muscle or balance deficits may facilitate improvements in muscle function, core strength, coordination, balance, flexibility, motor learning, and carryover of motor activity off the horse.1,5,6,8,9,13–15,17 The participants’ perceptions also support the AHA statement that HT is a complex intervention program offering unique movements, dynamic support, and increased respiratory/voice control.1
The study participants’ perceived psychological benefits from EAAT participation are both consistent with, and expand upon, previous observations in different study populations that also reported increased self-confidence, efficacy, esteem, and sportsmanship.15–17 The children with SMA perceived EAAT as an enjoyable and fun therapy that provided a rich social outlet.35 The special relationship reported between the children and their horses is another major benefit reported previously.15–17
As with any research investigation, this study has limitations. Inherent to qualitative research, the threats to validity include response biases. Participants self-enrolled in this study. The study did not include participants who indicated EAAT participation, but ultimately discontinued because of negative experiences (despite repetitive attempts to engage them as study participants). Those who participate in EAAT may have an inherent bias that EAAT is of benefit for the child. Many who discontinued EAAT likely did so because of medical contraindications related to disease progression. Another potential response bias is the parental influence on the children's responses during the interviews, especially the younger children.
Our study did not verify the different types of equine interventions in which the participants engaged, meaning that some participants were involved with established HT, while others participated in AR programs. This may be a limitation due to the different interventions performed in HT versus AR programs. Finally, our research investigated only 1 population, those with SMA; thus, our findings extend previous research but may not be generalizable to other populations.
The perceived physical benefits from EAAT may be, in part, a result of multiple confounding variables that influence the children's motor abilities and self-perception, such as medication use, the age of the child, severity/type of SMA, the rate of disease progression, and the children's participation in other therapies. Other extenuating factors that may have influenced the study participant population include the reality that EAAT is expensive and not readily covered by insurance, which may preclude participation for those of lower socioeconomic status. The location of EAAT programs and feasibility of time and transportation are also factors influencing EAAT participation.
Table 3 summarizes the various EAAT experiences for participants in this study through frequency counts of the number of times that general idea was mentioned throughout the interviews. This same information could have been obtained via a survey method. Frequency counts may be helpful to quantify the importance of a variable; however, they are not able to capture the depth of feeling about an issue, which is the essence of qualitative research.
We hope that our observations may encourage additional studies to explore the potential benefits of HT/AR in comparison to other available therapeutic interventions. Additional studies to assess the longitudinal effect on quality of life and gross motor function in children who regularly participate versus those who have never participated in HT/AR may be of value in helping facilitate support for HT/AR programs and facilities, as well as enhance the range of options available to our patients.
We used qualitative research methods to examine parent and child perceptions of EAAT participation in children with SMA. All participants reported significant psychological as well as physical benefits. Overall, their comments highlighted several unique features provided by this therapeutic treatment strategy, emphasizing the rich, complex, and positive emotional, social, and physical experiences not readily available in traditional settings. We demonstrated that EAAT has the capacity to enhance quality of life for those incorporating it as part of a proactive treatment strategy targeted to help maintain strength, postural control, and range of motion in children with SMA.
The authors thank the children with SMA and their parents who so generously donated their time to participate in this study. Appreciation is also extended to the University of Utah Graduate Program in Genetic Counseling for the research funding and Donata Viazzo-Trussell, Kristin Krosschell, and Ben Chism for their assistance and helpful suggestions.
2. Professional Association of Therapeutic Horsemanship (PATH) International. EAAT definitions. http://www.pathintl.org
. Accessed March 26, 2012.
3. Biery MJ. Riding and the handicapped. Vet Clin North Am Small Anim Pract. 1985;15(2):345–354.
4. Hammer A, Nilsagard Y, Forsberg A, Pepa H, Skargren E, Oberg B. Evaluation of therapeutic riding (Sweden)/hippotherapy (United States). A single-subject experimental design study replicated in eleven patients with multiple sclerosis. Physiother Theory Pract. 2005;21(1):51–77. doi:10.1080/09593980590911525.
5. Sterba JA. Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy? Dev Med Child
Neurol. 2007;49(1):68–73. doi:10.1017/S0012162207000175.x.
6. Shurtleff TL, Standeven JW, Engsberg JR. Changes in dynamic trunk/head stability and functional reach after hippotherapy. Arch Phys Med Rehabil. 2009;90(7):1185–1195. doi:10.1016/j.apmr.2009.01.026.
7. McGibbon NH, Benda W, Duncan BR, Silkwood-Sherer D. Immediate and long-term effects of hippotherapy on symmetry of adductor muscle activity and functional ability in children with spastic cerebral palsy. Arch Phys Med Rehabil. 2009;90(6):966–974. doi:10.1016/j.apmr.2009.01.011.
8. Whalen CN, Case-Smith J. Therapeutic effects of horseback riding therapy on gross motor function in children with cerebral palsy: a systematic review. Phys Occup Ther Pediatr. 2011;32(3):229–242. doi: 10.3109/01942638.2011.619251.
9. Zadnikar M, Kastrin A. Effects of hippotherapy and therapeutic horseback riding on postural control or balance in children with cerebral palsy: a meta-analysis. Dev Med Child
Neurol. 2011;53(8):684–691. doi:10.1111/j.1469-8749.2011.03951.x.
10. Benda W, McGibbon NH, Grant KL. Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy
(hippotherapy). J Altern Complement Med. 2003;9(6):817–825. doi:10.1089/107555303771952163.
11. Johnson CC. The benefits of physical activity for youth with developmental disabilities: a systematic review. Am J Health Promot. 2009;23(3):157–167. doi:10.4278/ajhp.070930103.
12. Snider L, Korner-Bitensky N, Kammann C, Warne S, Saleh M. Horseback riding as therapy for children with cerebral palsy: is there evidence of its effectiveness? Phys Occup Ther Pediatr. 2007;27(2):5–23. doi:10.1300/J006v27n02_02.
13. Champagne D, Dugas C. Improving gross motor function and postural control with hippotherapy in children with Down syndrome: case reports. Physiother Theory Pract. 2010;26(8):564–571. doi:10.3109/09593981003623659.
14. Silkwood-Sherer DJ, Killian CB, Long TM, Martin KS. Hippotherapy—An intervention to habilitate balance deficits in children with movement disorders: a clinical trial. Phys Ther. 2012;92(5):707–717. doi:10.2522/ptj.20110081.
15. Debuse D, Gibb C, Chandler C. Effects of hippotherapy on people with cerebral palsy from the users’ perspective: a qualitative study. Physiother Theory Pract. 2009;25(3):174–192. doi:10.1080/09593980902776662.
16. Glazer HR, Clark MR, Stein DS. The impact of hippotherapy on grieving children. J Hosp Palliat Nurs. 2004;6(3):171–175. doi:10.1097/00129191-200407000-00013.
17. Debuse D, Chandler C, Gibb C. An exploration of German and British physiotherapists’ views on the effects of hippotherapy and their measurement. Physiother Theory Pract. 2005;21(4):219–242. doi:10.1080/09593980500321143.
18. Sproule DM, Kaufmann P. Therapeutic developments in spinal muscular atrophy
. Ther Adv Neurol Disord. 2010;3(3):173–185. doi:10.1177/1756285610369026.
19. Stavarachi M, Apostol P, Toma M, Cimponeriu D, Gavrila L. Spinal muscular atrophy
disease: a literature review for therapeutic strategies. J Med Life. 2010;3(1):3–9.
20. Kaplan JC. Gene table of monogenic neuromuscular disorders (nuclear genome only). Neuromuscul Disord. 2009;19(1):77–98. doi:10.1016/j.nmd.2008.11.001.
21. Munsat TL. Workshop report: international SMA collaboration. Neuromuscul Disord. 1991;1(2):81.
22. Nicole S, Diaz CC, Frugier T, Melki J. Spinal muscular atrophy
: recent advances and future prospects. Muscle Nerve. 2002;26(1):4–13. doi: 10.1002/mus.10110.
23. Melki J, Lefebvre S, Burglen L, et al. De novo and inherited deletions of the 5q13 region in spinal muscular atrophies. Science. 1994;264(5164):1474–1477. doi:10.1126/science.7910982.
24. Mailman MD, Heinz JW, Papp AC, et al. Molecular analysis of spinal muscular atrophy
and modification of the phenotype by SMN2. Genet Med. 2002;4(1):20–26. doi:10.1097/00125817-200201000-00004.
25. Cook LS, White JL, Stuart GC, Magliocco AM. The reliability of telephone interviews compared with in-person interviews using memory aids. Ann Epidemiol. 2003;13(7):495–501.
26. Chwalow AJ, Balkau B, Costagliola D, Deeds SG. Comparison of different data collection methods within a study sample: telephone versus home interviews. Health Educ Res. 1989;4(3):321–328. doi:10.1093/her/4.3.321.
27. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–115. doi:10.1111/j.1365-2648.2007.04569.x.
28. Miles M, Huberman MM. Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed. Thousand Oaks, CA: Sage Publications Ltd; 1994:278–279.
29. Lincoln Y, Guba E. Establishing Trustworthiness. Naturalistic Inquiry. Beverly Hills, CA: Sage Publications Ltd; 1985:289–331.
30. Morrison-Beedy D, Cote-Arsenault D, Feinstein NF. Maximizing results with focus groups: moderator and analysis issues. Appl Nurs Res. 2001;14(1):48–53. doi:10.1053/apnr.2001.21081.
31. Polit D, Becky C. Nursing Research: Principles and Methods. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:570–594.
32. Sandelowski M. The problem of rigor in qualitative research
. ANS Adv Nurs Sci. 1986;8(3):27–37.
34. Mason J. Qualitative Researching. London: Sage Publications Ltd; 2002:5–6.
35. Granados AB, Agis IF. Why children with special needs feel better with hippotherapy sessions: a conceptual review. J Altern Complement Med. 2011;17(3):191–197. doi: 10.1089/acm.2009.0229.
Keywords:© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association.
adolescent; child; equine-assisted therapy; parents; qualitative research; spinal muscular atrophy