An experienced horse handler led the horse, specifically trained for hippotherapy. The horse handler was verbally directed by the therapist to lead the horse in a specific manner or direction, on the basis of John's needs and therapy objectives. The therapist alternated between observing from a few feet away and walking alongside, providing cues. Trained volunteers walked along each side of John and the horse, as a safety measure and to assist as directed by the therapist. All sessions occurred in an enclosed indoor riding arena and included the use of industry standard safety procedures.24
To maximize John's comfort and ability to focus on the therapy rather than a change in personnel, the same therapist, horse, horse handler, and side walkers worked with John each session. Behavioral strategies maximized safety. The behavioral approaches included rewards for compliance, timed activities, “barn rules,” predictable routines, and the use of motivators for positive behavior. “Barn rules,” such as no quick movements or loud voices, were safety rules that applied to all people in the barn area, and were readily accepted by John. His social needs were addressed by the use of age-appropriate conversation, and letting him have a part in the decision-making process. John appeared to enjoy his sessions; arriving early, interacting with his team, and attempting all tasks requested. During 2 sessions, he was less focused, less agreeable, and more sarcastic with his communications. To maximize the safety of all, on these days John was provided with more choices, and the movement of the horse was used as the primary therapeutic tool while he was mounted, versus extra demands of John. He participated in more unmounted horse-related activities to work toward his goals, such as brushing or feeding the horse during these 2 sessions. Four weeks into the hippotherapy sessions, the family reported that aquatic therapy services were discontinued.
Although John and his family reported satisfaction with the therapy and observed improvements in John's mobility, they elected to discontinue therapy services after 12 sessions. The family stated there were transportation issues since John's return to school, as well as a time factor, as the commute to the therapy site was 75 minutes in each direction.
Description of Outcomes
At completion of the program, John demonstrated improvements in his overall balance, functional strength, functional mobility, gross motor skills, and activity level. He had returned to school fulltime and reported increased social experiences with his brother and family, and decreased use of the wheelchair. His scores improved in all physical outcome measures. Please refer to Table 2.
Of interest, were the improvements in speech noted by his family, friends, and medical team. These included increased volume, affect and intonation, descriptive language, and decreased language-processing speed with increased response time. John also demonstrated an increased vocabulary and sense of humor.
One year after discharge, a follow-up call with his family revealed that John was walking independently with a single-point cane in the community for distances up to 150 ft. The family reported that John no longer received PT, but continued to use the ankle foot orthosis and wheeled walker at school inconsistently, to avoid fatigue. John continued to receive psychology services.
This case study describes the use of hippotherapy with a 13-year-old boy, 6 months after sustaining a TBI. Improvements are documented in the body structure/impairment domain with observed changes in functional muscular strength and static and dynamic standing balance. Positive changes in functional mobility, gross motor skills, and participation in home, school, and community activities are also described.
John demonstrated improvements in his PBS and DGI scores, as well as his gait speed. Reported minimally detectable changes for the Berg Balance Scale, from which the PBS was developed, range from 3.3 to 6.3 for adults who have sustained a cerebral vascular accident.25 John's change in score on the PBS exceeded this range of detectable change, with specific improvements noted on the test items requiring a narrow base of support or a weight shift.
Activities that provide mechanical perturbation of the base of support, promote the use of coordinated muscle recruitment, and increase context-related muscular strength may lead to more effective balance.6 In adults, increased core strength through nonresistive exercise in multiple planes has been linked to improved gait parameters and Timed Up and Go scores.26,27 Hippotherapy, by nature of its direct movement perturbations to the trunk, provides targeted nonresistive training of core muscles in a coordinated pattern mimicking human gait,3,4 so it is logical to believe that hippotherapy may have contributed to John's ability to maintain his balance in a manner that specifically led to improved gait and transfers. In this case, improvements in strength may also be attributed to the exercises in the home exercise program.
In addition to the imparted movement perturbations, hippotherapy provides movement through space. This combination of movements promotes adaptive responses, as well as processing of visual, somatosensory, and vestibular information. It is feasible that John was able to generalize these responses to walking and balance activities. In older adults, a minimal detectable change in DGI score of 2.9 is reported.28 John's postintervention DGI score exceeded this range. John's self-selected walking speed also increased. Improvements in gait speed and the DGI score may be linked to an increased ability to accommodate to varied movement through space.
Motor learning theory suggests that effective balance training requires opportunities for predictive strategies and reactive responses.6 It is hypothesized that the improvements in balance observed after hippotherapy might relate to the opportunity for both anticipatory and reactive postural control.11 Varied and specific equine movements impart this targeted and repetitive neuromuscular facilitation at a high intensity of practice with the horse stepping at a frequency of 80 to 100 steps per minute for the majority of the session. Altering John's position on the horse provided opportunities for motor planning and a variety of muscular responses. Sit-to-stand and partial stand (“2-point”) activities may have promoted development of hip/ankle balance strategies. Standing and gait activities immediately after the mounted activities promoted generalization of skills.
Minimal clinically important differences have been reported for the GMFM for children with CP, on the basis of the Gross Motor Classification System (GMCS).29 John could be described as GMCS Level III because of his need for an assistive device. John's improvements well exceed the reported minimal clinically important differences for large effect size of 2.4 for Dimension D and 3.0 for Dimension E. Improvements in jumping skills may be related to improved core strength and balance previously discussed, and exercises in the squatting position with the use of stirrups.
Hippotherapy has been linked with improved self-esteem and confidence, with reported carryover into daily life.30 It has been proposed that this feeling of increased self-esteem may in itself promote the recovery process.31 Improved mental health after hippotherapy, compared with traditional PT, has been documented.32 The novel and “nontherapy” atmosphere of the barn environment, coupled with the opportunity for animal engagement, may have positively affected John's motivation for therapy, self-esteem, confidence, and subsequently his participation in nontherapy activities.
Interaction with the horse was encouraged and used advantageously by allowing John to make decisions about the therapy session as well as feed, brush, pet, and care for the horse. For example, John would work on standing balance while holding a feed bowl for the horse. He would make the necessary postural adjustments as the horse pushed the bowl with its muzzle, providing an unexpected external perturbation. Removing equipment from the horse also provided a functional way for John to generalize his skills.
John complied with all safety rules, and initiated more conversation and interactions as the weeks passed. He did not discuss his home or school life during the sessions, and when questioned directly in regard to “how are things going?” would make a humorous comment and deflect the question. One area in which John did not demonstrate improvement was on the Psychological Well-Being Index. According to his family, at the time of the posttest, John was verbalizing more concerns regarding the accident in general and was reportedly more aware of the loss of some friendships, which may have affected his score. The family was seeking additional psychological services to address these concerns.
Hippotherapy has been linked with motor and participation improvements in a variety of neuromuscular disorders.8–13,32–35 Although the described improvements in this case cannot be solely attributed to hippotherapy, the family reported acceleration in John's rate of improvement during the period of this intervention, even with discontinuation of aquatic therapy. Per family report, many of these gains were sustained and improved upon over the following year. The incorporation of hippotherapy may have allowed for intense practice opportunities, specifically focusing on trunk control and promoting improvement in several aspects of John's life. In addition, the novel environment and opportunity to interact with a horse may have positively affected John's behaviors, motivation, and motor outcomes. Further investigation with larger participant groups is needed to explore the effectiveness of hippotherapy with this population. John demonstrated changes 6 months after injury; the effect of this intervention on individuals with more acute injuries as well as chronic residual deficits is needed. Exploration of therapeutic dosage, with measures sensitive to specific aspects of balance, changes in postural control, gait pattern and parameters, and self-esteem/participation may better describe the use of equine movement for motor rehabilitation.
1. American Hippotherapy
Association. Present Use of Equine Movement by PT, OT, SLPs in the United States. Fort Collins, Colorado: American Hippotherapy
3. Riede D. Acceleration and Vibration Measurements on the Horse and Rider. Madison, WI: Omnipress; 1988:71–85.
4. Garner B RB. Human
pelvis motions when walking and when riding a therapeutic horse. Hum Mov Sci. 2015;39:121.
5. Schirm A, Riede D. Elektromyographische messungen am rumpf wa “hrend der hippotherapie. 3rd European Congress in Therapeutic Riding, Munich, Germany; 1998.
6. Horak FB, Henry SM, Shumway-Cook A. Postural perturbations: new insights for treatment of balance disorders. Phys Ther. 1997;77(5):517–533.
7. Riede D. The effects of riding. In: Physiotherapy on the Horse. Madison, WI: Omnipress; 1988:41–42.
8. 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.
9. 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.
10. Casady RL, Nichols-Larsen DS. The effect of hippotherapy
on ten children with cerebral palsy. Pediatr Phys Ther. 2004;16(3):165–172.
11. 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.
12. Frank A, McCloskey S, Dole RL. Effect of hippotherapy
on perceived self-competence and participation in a child with cerebral palsy. Pediatr Phys Ther. 2011;23(3):301–308.
13. Granados A, Agis I. Why children with special needs feel better with hippotherapy
sessions: a conceptual review. J Altern Complement Med. 2011;17(3):191.
14. Lentini JA, Knox M. A qualitative and quantitative review of equine facilitated psychotherapy (EFP) with children and adolescents. Open Complement Med J. 2009;1:51.
15. Hammer A, Nilsagard Y, Forsberg A, Pepa H, Skargren E, Oberg B. Evaluation of therapeutic riding (Sweden)/hippotherapy
(USA). A single-subject experimental design study replicated in eleven patients with multiple sclerosis. Physiother Theory Pract. 2005;21(1):51.
16. Sunwoo H, Chang WH, Kwon JY, Kim TW, Lee JY, Kim YH. Hippotherapy
in adult patients with chronic brain disorders: a pilot study. Ann Rehabil Med. 2012;36(6):756–761.
17. Hagen C, Malkmus D, Durham P. Levels of cognitive functioning. In: Rehabilitation of the Head Injured Adult: Comprehensive Physical Management. Downey, CA: Professional Staff Assoc; 1979:88–89.
18. Franjoine MR, Gunther JS, Taylor MJ. Pediatric balance scale: a modified version of the berg balance scale for the school-age child with mild to moderate motor impairment. Pediatr Phys Ther. 2003;15(2):114–128.
19. Lubetzky-Vilnai A, Jirikowic TL, McCoy SW. Investigation of the dynamic gait index in children: a pilot study. Pediatr Phys Ther. 2011;23(3):268–273.
20. Marchetti GF, Whitney SL. Construction and validation of the 4-item dynamic gait index. Phys Ther. 2006;86(12):1651–1660.
21. Russell D, Rosenbaum P, Avery L, Lane M. Administrating and scoring guidelines for the GMFM-88 and GMFM-66. In: Gross Motor Function Measure (GMFM-66 and GMFM-88) Users' Manual Second Edition (2013). London, UK: Wiley Blackwell Publishing; 1993.
22. van Brussel M, Helders PJ. The 30-second walk test (30sWT) norms for children. Pediatr Phys Ther. 2009;21(3):244.
23. Chasseny O, Dimenas E, Dubois D, Wu A. The Psychological Well-being Index Users Manual. Lyon, France: MAPI Research Institute; 2004.
25. Donoghue D. Physiotherapy Research and older people (PROP) group, stokes EK. How much change is true change? the minimum detectable change of the berg balance scale in elderly people. J Rehabil Med. 2009;41(5):343–346.
26. Granacher U, Gollhofer A, Hortobágyi T, Kressig R, Muehlbauerb T. The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: a systematic review. Sports Med. 2013;43(7):627.
27. Granacher U, Lacroix A, Muehlbauer T, Roettger K, Gollhofer A. Effects of core instability strength training on trunk muscle strength, spinal mobility, dynamic balance and functional mobility in older adults. Gerontology. 2012;59:105.
28. Romero S, Bishop MD, Velozo CA, Light K. Minimum detectable change of the berg balance scale and dynamic gait index in older persons at risk for falling. J Geriatr Phys Ther. 2011;34(3):131.
29. Oeffinger D, Bagley A, Rogers S, et al. Outcome tools used for ambulatory children with cerebral palsy: responsiveness and minimum clinically important differences. Dev Med Child Neurol. 2008;50(12):918–925.
30. 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.
31. Bizub AL, Joy A, Davidson L. “It's like being in another world”: demonstrating the benefits of therapeutic horseback riding for individuals with psychiatric disability. Psychiatr Rehabil J. 2003;26(4):377.
32. Lechner H, Kakebeeke T, Hegemann D, Baumberger M. The effect of hippotherapy
on spasticity and on mental well-being of persons with spinal cord injury. Arch Phys Med Rehabil. 2007;88:1241.
33. Benda W, McGibbon N, Grant K. Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy
). J Altern Complement Med. 2003;9(6):817–825.
34. Bronson C, Brewerton K, Ong J, Palanca C, Sullivan SJ. Does hippotherapy
improve balance in persons with multiple sclerosis: a systematic review. Eur J Phys Rehabil Med. 2010;46(3):347–353.
35. Haehl V, Giuliani C, Lewis C. Influence of hippotherapy
on the kinematics and functional performance of two children with cerebral palsy. Pediatr Phys Ther. 1999;11:89–101.
Keywords:Copyright © 2016 Academy of Pediatric Physical Therapy of the American Physical Therapy Association
activities of daily living; adolescent; ambulation; community participation; hippotherapy; human; male; postural balance; traumatic brain injury