By Stanley St.Hilaire
Hippotherapy is a treatment tool incorporating physical, occupational, and speech language therapy by utilizing the rhythmic movement of a horse to bring back neurological functions. It has been used to preserve and promote balance in patients with stroke, cerebral palsy, and spinal cord injury. It helps improve postural control by generating vestibular inputs due to the movement of the horse. The repetitive, rhythmic and sway of the horse stimulates the patient’s postural reflex mechanism, resulting in balance and coordination training.
This paper is a review of the current research in adults with stroke utilizing hippotherapy as an effective system to bring back motor function.
Over 15 articles were evaluated to assess the effectiveness of hippotherapy. Studies from the last decade on hippotherapy in adult stroke patients using either live horses or a simulator were included. Children and patients recovering from other injuries were excluded. In many of the studies, an experimental group that underwent horseback riding therapy was compared to a control group that performed regular conventional therapy over many weeks.
Review has shown hippotherapy to be an effective tool that improves balance and strengthens pelvic, abdominal, and lumbar muscles. Hippotherapy should be considered and is recommended if available for stroke patients. However, its use may be limited in some situations due to financial considerations, allergies, and fear of falling.
Keywords: Hippotherapy, equine-assisted therapy, stroke, horseback riding
Stroke also known as cerebrovascular accident is a leading cause of death and is a significant cause of disability in the United States. Most stroke patients experience symptoms such as trouble walking or speaking, problems with coordination, overactive reflexes, stiff muscles, and loss of motor function and sensation, especially in the limbs and face. In addition to pharmacotherapy and lifestyle changes; to resolve and prevent future strokes, physical/occupational therapy is used to preserve and promote functionality. Hippotherapy is a physical, occupational, and speech therapy that uses the natural gait and movement of a horse to provide motor and sensory input. Its influence on balance, functional capacity, posture, spasticity, and gait ability has led it to be considered in rehabilitation plans for patients recovering from stroke in addition to cerebral palsy, autism, arthritis, multiple sclerosis, head injury, behavioral disorders, psychiatric disorders, and spinal cord injury.
Hippotherapy has been studied minimally, even though some positive effects have been shown. Some of the most definitive studies are explored below.
Tulay Koca et al. explained how horses provide a rhythmic movement which stimulates anterior and posterior swinging during patient ambulation. It encourages the rider to achieve proper balance and posture. The movement of the horse mimics the normal movements of the human pelvis during walks and showed that the rhythm of a horse’s gait affects the bones of a patient's pelvic girdle twice as much as the gait of a patient. The slow and rhythmic movement of the horse’s body has therapeutic value and ensures the development of paraspinal muscles. Hippotherapy is a good tool in the recovery of patients enduring strokes due to its shortening of recovery times, improving balance, mobility, posture, and muscle control of the patient.
Sung et al. investigated 20 stroke patients divided equally in which they compared an experimental group that received conventional rehabilitation for 45 minutes/day followed by hippotherapy simulator versus a control group with conventional rehab alone for 60 minutes per day. A significant difference with the activation of the erector spinae was found in both groups with greater results seen in the experimental group (p<0.001) after 4 weeks. Per Sung et al, the ability to perform sit to stand is closely related to gait performance in stroke patients; those patients who have better sit to stand motor control also have better gait performance.
Beinotti et al. reviewed a study comparing an experimental group with conventional therapy twice a week and hippotherapy once a week versus a control group with conventional therapy three times a week. There were a total of 20 participants. Both groups were observed over 16 weeks for a total of 48 sessions. Many tools were used in order to assess the improvements of the motor functions such as gait and balance. The balance and gait were assessed using Berg Balance scale, Fugl-Meyer of lower limbs and balance, Functional assessment of gait (cadence), and the Functional Ambulation Categories scale. According to the researchers, significant improvements were observed in the experimental group including motor impairment in lower limbs (p=0.004), balance over time (p=0.007) but a significant trend between groups (p=0.056). The gait independence, cadence and speed were not significant in both groups (p=0.93, 0.69 and 0.44). The study showed Hippotherapy with conventional therapy proved to be a good tool in the treatment of gait training for hemiparetic patients after stroke.
Lee et al. reviewed 30 stroke patients divided into 2 equal groups.Hippotherapy and the other used treadmills, with training sessions over 30 minutes 3 days per week over 8 weeks. It showed improvement in Berg Balance score, gait velocity and step length asymmetry in the hippotherapy compared to the treadmill (p<0.05).
Bunketorp-Käll et al. confirmed hippotherapy having improvements in gait and functional mobility. It investigated a randomized controlled trial in stroke patients, they compared horse-riding therapy(H-RT) and rhythm and music-based therapy (R-MT) to display its effect in functional mobility. It showed participants in the H-RT demonstrated immediate improvement and continued improvement at a 6-months follow up in short distance walking capacity, at both self-selected and fast speed. R-MT showed improvement only at 6 months follow up when they performed better at self-selected speed. Horse riding therapy showed an improvement in gait and functional mobility while Music-based therapy effectiveness isn’t clear
Hippotherapy has been shown to improve physiological aspects including balance, strength, coordination, muscle tone, joint range of movement, weight bearing, posture, and gait in patients with neurological problems. It aids in recovery of normal function in patients with stroke. Upon my review, I certainly find hippotherapy can help with depression which can often be seen in stroke patients. The ability to spend a couple times a week outside riding a horse is therapy all around. As stated by Marquez et al. hippotherapy may be an enjoyable alternative to routine therapy with potential benefits, such as quality of life and mood. Although hippotherapy is promising and remains to be efficacious, there are limitations in the research available. Of all the research reviewed a larger sample of participants was needed over a longer period to best assess the effectiveness of Hippotherapy.
1. Sung, Yun-Hee et al. “A hippotherapy simulator is effective to shift weight bearing toward the affected side during gait in patients with stroke.” NeuroRehabilitation vol. 33,3 (2013): 407-12. doi:10.3233/NRE-130971
2. Beinotti, Fernanda et al. “Use of hippotherapy in gait training for hemiparetic post-stroke.” Arquivos de neuro-psiquiatria vol. 68,6 (2010): 908-13. doi:10.1590/s0004-282x2010000600015
3. Pohl, Petra et al. “A qualitative exploration of post-acute stroke participants' experiences of a multimodal intervention incorporating horseback riding.” PloS one vol. 13,9 e0203933. 20 Sep. 2018, doi:10.1371/journal.pone.0203933
4. Lee, Chae-Woo et al. “Effects of hippotherapy on recovery of gait and balance ability in patients with stroke.” Journal of physical therapy science vol. 26,2 (2014): 309-11. doi:10.1589/jpts.26.309
5. Koca, Tuba Tulay, and Hilmi Ataseven. “What is hippotherapy? The indications and effectiveness of hippotherapy.” Northern clinics of Istanbul vol. 2,3 247-252. 15 Jan. 2016, doi:10.14744/nci.2016.71601
6. Marquez J., et al. “Hippotherapy in adults with acquired brain injury: A systematic review.” Physiother Theory Pract. 2020 Jul;36(7):779-790. doi: 10.1080/09593985.2018.1494233. Epub 2018 Jul 17. PMID: 30015542.
7. Bunketorp-Käll, Lina et al. “Effects of horse-riding therapy and rhythm and music-based therapy on functional mobility in late phase after stroke.” NeuroRehabilitation vol. 45,4 (2019): 483-492. doi:10.3233/NRE-192905
8. Han, Jun Young et al. “Therapeutic effects of mechanical horseback riding on gait and balance ability in stroke patients.” Annals of rehabilitation medicine vol. 36,6 (2012): 762-9. doi:10.5535/arm.2012.36.6.762
9. Sunwoo, Hyuk et al. “Hippotherapy in adult patients with chronic brain disorders: a pilot study.” Annals of rehabilitation medicine vol. 36,6 (2012): 756-61. doi:10.5535/arm.2012.36.6.756
10. Dominguez-Romero, Juan G et al. “Effectiveness of Mechanical Horse-Riding Simulators on Postural Balance in Neurological Rehabilitation: Systematic Review and Meta-Analysis.” International journal of environmental research and public health vol. 17,1 165. 25 Dec. 2019, doi:10.3390/ijerph17010165
11. Kim, Hyungguen et al. “Effect of horseback riding simulation machine training on trunk balance and gait of chronic stroke patients.” Journal of physical therapy science vol. 26,1 (2014): 29-32. doi:10.1589/jpts.26.29
12. Kang, Kwon-Young. “Effects of mechanical horseback riding on the balance ability of the elderly.” Journal of physical therapy science vol. 27,8 (2015): 2499-500. doi:10.1589/jpts.27.2499
13. Kinney, Adam R et al. “Equine-assisted interventions for veterans with service-related health conditions: a systematic mapping review.” Military Medical Research vol. 6,1 28. 29 Aug. 2019, doi:10.1186/s40779-019-0217-6
14. Park, Jungseo et al. “The effects of horseback riding simulator exercise on postural balance of chronic stroke patients.” Journal of physical therapy science vol. 25,9 (2013): 1169-72. doi:10.1589/jpts.25.1169
15. Lee, Dong-Kyu, and Eun-Kyung Kim. “The influence of horseback riding training on the physical function and psychological problems of stroke patients.” Journal of physical therapy science vol. 27,9 (2015): 2739-41. doi:10.1589/jpts.27.2739