I Saw a Child
I saw a child who could not walk,
Sit on a horse, laugh and talk.
Then ride it through a field of daisies
And yet he could not walk unaided.
I saw a child, no legs below,
Sit on a horse, and make it go
Through woods of green
And places he had never been
To sit and stare,
Except from a chair.
I saw a child who could only crawl
Mount a horse and sit up tall
Put it through degrees of paces
And laugh at the wonder in our faces.
I saw a child born into strife,
Take up and hold the reins of life
And that same child was heard to say,
Thank God for showing me the way.
By John Anthony Davies
In all aspects of the health professions there are medications, techniques, surgeries, and therapies that are overlooked or seldom heard about by the general public. Knowledge of such treatments would provide a broader base from which to choose an appropriate plan of care, while also establishing a better understanding of health care in general. Although attempting to heal all generations is, at times overwhelming, it is primarily the pediatrics population that proves to be the most challenging. While normal practice calls for the medical professional to deal with an adult patient's pain and discomfort, willingness to get better, and tendency to follow the appropriate precautions; when caring for a pediatric patient, their level of cognitive and physical development, ability to comprehend and follow directions and the incorporation of fun and interesting activities into the therapy program so as to keep the child interested in his/her healing process must be considered. One treatment that is used primarily in pediatrics that has proven to be both psychologically and physically beneficial, yet still remains quite unrecognized, poorly addressed and unexamined, is hippotherapy.
This paper will inform the community on various aspects of hippotherapy, including: an in depth description of the dimensions and intentions of the therapy, a listing and explanation of the populations that will benefit from the treatment and the realm of their possible level of improvement, justification for its uninvestigated status, and possible ways to promote its use.
The use of horses as therapeutic tools began as early as 460 B.C. in ancient Rome and Greece. While documentation is very limited some historians claim that Aesculapius, the Roman God of medicine and healing, instructed the ill and disabled to go horseback riding to raise their spirits and help them to generally feel better.3 The first written evidence of horseback riding being prescribed for its physical and emotional benefits comes from the early 1600s.
Hippotherapy was first studied by a team of young doctors in 1875 outside of Paris, France. The research was considered extremely controversial and no attention was given to the potentially "new" treatment. No one believed that a horse could give such therapeutic benefits to an individual with certain deficits. This new therapy didnot follow the norms of the time period, which consisted of mainly manual therapy. Therefore, it was very rarely, if at all, practiced by licensed therapists of the time.
It was not until 1952 when Liz Hartel of Denmark won the Olympic silver medal for dressage, despite being paralyzed from the trunk down from polio, that both medical and equine professionals worldwide began to show some interest in using the horse as a therapeutic tool for healing.4 By 1957, therapeutic horseback riding was being formally practiced throughout Europe. Patients of all ages were participating in riding programs first in England and then throughout the continent. Shortly thereafter, the appearance of physically and cognitively challenged equestrians became a normal occurrence at riding stables and competition events everywhere. In the early 1960s the enthusiasm surrounding therapeutic horseback riding spread through the Americas from Canada to
Brazil. When the centers were erected across North America, they were used solely as therapeutic riding clinics.
Therapeutic Horseback Riding
Therapeutic riding varies greatly from hippotherapy. While the therapeutic riding client's goal is to accomplish independent maneuvering of the horse, that is, to steer, control and guide the horse through its paces; the hippotherapy patient's goal is to gain movement and control of his/her own body as a result of learning to counteract the horse's actions. Therapeutic riding while somewhat physically beneficial to the patient, primarily serves a psychological and emotional purpose. It allows a patient that is otherwise at a physical disadvantage with his/her peers to become equal, if not better, at an extremely challenging activity. The patients who undergo this form of therapy are much more mobile and cognitively proficient, however still lacking both mentally and physically, than those who partake in hippotherapy. While medical professionals are readily welcomed and are usually present, the therapeutic riding program is usually run by equine professionals who teach the disabled to ride, and possess a good basis of medical knowledge, as well as a thorough understanding of the horse's movement. The specialist is assisted by numerous aides, volunteers, and oftentimes therapists. In addition various breeds, sizes, and ages of horses are also part of a therapeutic riding program.1, 4
Neither therapeutic horseback riding nor hippotherapy is restricted to the pediatric population, but it is within the pediatric population's plan of care where such treatments
are most utilized. Therapeutic horseback riding serves a wide range of clientele with various conditions, which include but are not limited to:
AmputeesHearing ImpairmentsLearning DisabilitiesAutism
Cerebral PalsyMental RetardationDown SyndromeVisual ImpairmentsEmotional Disabilities
The practice of using horses as therapy in this way has dramatically increased so as to require the construction of 550 centers across North America, as well as the creation
of a continent wide organization, known as the North American Riding for the Handicapped Association (NARHA). 1,3,4 This organization raises funds to keep programs going, as well as providing the much needed information to friends and loved ones of patients who have been told they would benefit from engaging in such an activity.
As NARHA grew and developed it began to also provide a form of therapy for the less able clientele that were being turned away from the therapeutic riding centers. Previously, hippotherapy had only been talked about in North America, while it had already been instituted as a valid form of therapy in Europe. As a result of Europe's health care system, new treatments such as this one were more easily accessible and readily available, before being approved for practice in the United States. Hippotherapy programs were first begun in the United States in the mid-1980s, at which time the American Hippotherapy Association (AHA) was created as a subdivision of NARHA.
The AHA, while organizing centers to provide care nationwide, also oversees the accreditation of hippotherapy programs and instructors.5
The term hippotherapy originates from the Greek word "hippos " meaning horse. It translates literally to "treatment with the help of a horse." Hippotherapy can be explained as a broad category reaching into every realm of treatment and therapy imaginable. In practice it includes one subdivision known as classic hippotherapy. While extremely similar to one another in foundation and analysis, hippotherapy and classic hippotherapy are as different as night and day in application. 1
Classic hippotherapy is directly linked to the German method of treatment practiced throughout Europe since the early 1960s. This technique focuses strictly on the
horse's movement and the client's response to those actions. The client can be astride the horse facing forward, backward, prone, or supine. While the horse is moved through various transitions in pace and direction the client passively interacts with and responds to the movements. There is no active exercising taking place in these programs, rather the focus is on relaxation and stretching. This can be quite challenging for someone who is fearful of heights and/or large animals. Here the therapist is constantly required to analyze the appropriateness of the client's responses. The therapist must then adjust the horse's pace or direction of movement accordingly. Although various types of therapists may be involved in this therapy (i.e. occupational therapists, physical therapists, speech language pathologists), he/she must have adequate knowledge of the horse as an animal and a treatment tool. The primary focus of classical hippotherapy is the client's posture
and response to movement. It may even cause changes in respiration, psychosocial skills, and cognition as well as benefiting motor function, to some extent.1 Classical
hippotherapy has not been well researched, therefore many questions remain unanswered, however enough evidence has been found to make the treatment beneficial in some way. The extent of the benefits and the specific ailments for which it supplies relief have not yet been pinpointed.5
Hippotherapy, in its evolved form, challenges the client to counteract the three dimensional movement of the horse's pelvis and hind legs as it moves forward through various paces. This therapy, while providing extremely beneficial physical supplements
to traditional therapy also attempts to improve neurological function and sensory processing. The improvements made during this therapy can then be generalized to a wide variety of daily living activities.
Specific riding skills are not taught in hippotherapy (as in therapeutic riding), instead the patient is asked to contract or relax certain muscle groups, or perform a certain activity while on horseback. The entire exercise helps the patient achieve and maintain balance regardless of their position in space. While some patients gain the most beneficial effects from riding astride the horse, others receive their treatment in non-traditional positions such as prone, supine or even backward riding. (See Appendix, Figures 2-6). The treatment approach combines the horse's movement with the treatment principles that apply to the specific therapists' discipline. The therapist chosen to provide
the treatment depends entirely upon the patient's needs. The treatment includes the services provided by a certified physical therapist, occupational therapist, speech
language pathologist, psychologist or psychotherapist, in conjunction with an equine professional, and only with the recommendation of a medical doctor. Hippotherapy is thus a true example of multidisciplinary treatment in its purest form.2
Hippotherapy uses activities on the horses that are significant to the client and appropriately address the individual's needs and goals. The treatment provides an exciting and lively environment that uses graded sensory input designed to generate meaningful responses from the client. (See Appendix, Figure 12) The motion, heat, and texture of the horse not only acts as additional sensory input for the client, but also increases the rider's blood circulation (promoting healing), and reflexes (necessary for normal functioning). Even with a horse merely walking, their gait gently and rhythmically exercises the rider's spinal column, joints, and muscles, all at one time. These movements can not be replicated by any machine, or by completing traditional exercises, both of which tend to concentrate on one muscle or group of muscles at a time. The horse also creates a sensation of moving through space in a rhythmic, natural way that cannot be readily duplicated for those patients who do not ambulate independently.1
Hippotherapy is therefore an all encompassing treatment that affects multiple systems of the body including: sensory integration, proprioceptive (internal sensory) skills, cognition, comprehension, reflex patterns, motor functioning, tactile sensation, psychosocial habits, emotional behavior, and verbal/nonverbal communication.4 For
example, a ten year old patient on horseback might be asked to move from a facing backward position to a face forward position then reach out and touch the horse's ears,
and finally to return to an upright seated position. Before the rider even begins the movement, he must listen carefully to the instructions that were given and figure out how to accomplish the task. When he begins the movement, he must initiate the appropriate actions to eventually carry out the desired activity. Throughout the task the rider is in constant contact with the horse's coat or a saddle pad, providing integrated sensory input at multiple levels of his body. The task calls on the rider's use of his vestibular and proprioceptive systems because while carrying out the activity, he is sometimes positioned in directions different from that which the horse is moving. (See Appendix, Figure 7) This challenges the patient to control his body position in space to an even greater extent. Throughout the task, the rider must interact with the instructor, volunteers, therapist, and the horse, all of which demand a certain level of psychosocial and behavioral control. (See Appendix, Figure 8,10) The exciting and fun loving environment in which the exercise takes place helps to lighten and lift the client's oftentimes disinterest with his routine therapy in the clinic setting.
Hippotherapy even seems to exercise parts of the body that the client did not know they had. Many equestrians will confirm that after a hard ride, they feel tired muscles in areas they did not even know existed.5 Those muscles of the inner thigh (adductor longus, brevis, and magnus), the lower abdominal wall (external, internal and transverse abdominal oblique) and the deep back (erector spinae) that are not readily
exercised with ordinary aerobic activity, oftentimes become sore from the demand placed on them while riding with correct posture and alignment.
Horseback riding demands a great deal of posture and balance control. The horse's movements cause the rider's trunk, arms, shoulders, neck, and head to be constantly moving. In order to stay astride the horse, the rider must eliminate unnecessary upper body movement to maintain balance, regardless of the horse's actual transitions in pace or direction. Sustaining such control demands use of multiple muscle groups including the abdominals, the back, and neck extensors, and the scapulothoracic stabilizers.1 Riding a moving horse also increases a client's spatial orientation skills by a significant amount, especially if the client is normally confined to a wheelchair. Such patients very rarely, if ever, have a chance to experience moving through space by way of a rhythmic symmetrical, natural gait pattern. Riding a horse may promote the closest sensation to walking they will ever experience short of actually ambulating independently.5
As the horse moves forward, the rider's pelvis rises on the same side as the stance hind leg of the horse. This alternating rising and falling of each side of the rider's pelvis is equivalent to the motion of the pelvis in the average walker. (See Appendix, Figure 1) The rider also experiences flexion and extension of the hip while riding. Flexion occurs on the side of the horse where the hind leg is in the stance phase. The reciprocal extension takes place at the same time on the opposite side of the horse where the hind leg is in the swing phase of gait. In addition the rider receives an alternating anterior and posterior pelvis tilt while the horse is continually accelerating and decelerating as each hoof lifts off and strikes the ground.11, 30 The anterior tilt is achieved on the stance side of
the horse, when the hoof strikes the ground causing a deceleration and subsequent anterior weight shift. The posterior tilt occurs during the swing phase of the horse's gait when the horse is accelerating, generating a posterior shift in the rider.11, 30 In order to accelerate during the horse's swing phase, its trunk laterally flexes causing rotation in the rider toward the stance side of the horse.30 It is this rotation that primarily inhibits spasticity in the patient. As the horse pushes off with each step its pelvis rotates causing the rider to laterally flex his/her trunk first to one side and then the other.30 No one of these motions occurs at once, but rather all of them intertwine is such a way as to be hidden to the naked viewing eye.
The rider will also have various reactions depending on the changes in pace of the horse's movements. A walking gait allows the rider to relax and stretch his/her body. A trot (faster, two-beat gait) bounces the rider a bit more, which increases proprioceptive input to facilitate co-contraction of the trunk and limbs.30
While straight line walking is necessary for some patients, others benefit more from circle or serpentine patterns. (See Appendix, Figure 13) If the horse is put into either one of these curving patterns, the rider must shift his/her weight to the outside hip causing lateral flexion of the trunk to the inside which stretches the outside of the rider's body.30 The rider's posture must also shift in order to bear the weight symmetrically through their seat in an attempt to maintain their balance.30 Even though most patients begin with straight line walking, a change to either curving patterns or a faster pace serves as the perfect challenge to the more able patients.
All of the benefits mentioned do not merely remain within the riding center; in addition, they carry over into real life situations. Increased posture and limb control can lead to an improved ability to complete functional activities of daily living and may even have a tendency to improve an individual's overall level of independence.5 The goal of all therapies is to better the likelihood of a patient's return to a more normal functioning level. To be a true treatment technique, hippotherapy must assist the therapist in reaching this goal. All indications support the treatment in its initial claim of being a worthwhile and beneficial technique.
Medical Conditions that Benefit from Hippotherapy
As was mentioned earlier, all of these treatments, therapeutic horseback riding, classic hippotherapy, and hippotherapy itself are used for patients of all ages, although they are most commonly used with young children. Specific populations that have been known to show the most beneficial characteristics of the hippotherapy treatments include patients suffering from:
Muscular DystrophySpinal Cord Injuries
Traumatic Brain InjuriesAmputees
Cerebral PalsyMultiple Sclerosis
Spina BifidaPost Polio Syndrome
Muscular dystrophy is another condition in which patients experience deficits that can be improved with the aid of hippotherapy. Muscular dystrophy is a disease of the
muscle tissue that can be caused by an inherited genetic defect, or an abnormality of the immune system. This pathology can develop at any time from development in utero
through adulthood. The characteristics of this pathology can consist of a wide array of signs and related symptoms, that may allow the individual to live an entire lifetime with physical difficulties or it may cause premature death.26 Some common characteristics include: muscle weakness, spasms, loss of limb control, speech and swallowing difficulties.
Most of these patients undergo a multidisciplinary approach to therapy, hippotherapy being one such treatment in their plan of care. The exercises performed on the horse serve as a strengthening tool for these patients. The gentle rocking sensation of the horse's movement helps relax spastic muscle groups throughout the body. The highly sensory environment also helps the patient learn to cope with overwhelming stimulus in his/her everyday encounters.26
During these treatment sessions the patients whole body receives a thorough workout. Therefore it is important not to overwork these patients, and cause more harm than good. The activity also allows the patient to have fun while receiving therapy, thereby diminishing the effect of clinical burnout.
Traumatic Brain Injury
A patient who sustains a traumatic brain injury can illustrate the effectiveness of hippotherapy. Traumatic brain injury (TBI) is defined as an impact caused by an external force which damages the communication fibers of the nervous system. This damage
emanates as multiple impairments in cognitive and/or physical functioning.24 Cognitive effects that may appear include, but are not limited to: poor judgment, decreased planning, initiating and monitoring behavior, memory deficits, slow information processing, attention disorders, and poor complex problem solving. Physical (musculoskeletal) effects may involve: seizures, muscle spasticity, vision, hearing, smell, and taste loss, speech impairments, headaches, reduced endurance, loss of limb control, lack of response to proprioception and sensation stimulus, difficulty with balance and coordination, and lack of spontaneous movement.20, 24
As a result of these patients possessing such deficits, hippotherapy becomes a wonderful therapy, and is an appropriate asset to this patient's plan of care. The most common mal-alignment position that these patients experience is a sacral sitting posture, with the pelvis tilted back and the legs extended. When the patient with a TBI is astride a horse, the legs are pulled into a more neutral position by relaxing the hip flexors. While the horse is moving, its natural propulsion attempts to roll the pelvis into a more normal alignment. Such adjustments do take time, however once adjusted, the patient is
encouraged to hold the position throughout the riding session, as well as after the session when the patient returns to normal activities of daily living.20
The moving animal provides consistent multisensory input to the patient with a TBI who may have difficulty organizing such sensory stimulation. These patients also benefit from the multiple texture integration, and proprioceptive exercises that the horse provides throughout the treatment session.
As the patient improves, the therapy sessions can become more challenging in an attempt to re-teach the brain to process complex, multi-step motor movements while still experiencing the sensory "overload" from the environment and the horse itself.20
As a result of the typical symptoms and complications associated with cerebral palsy, patients diagnosed with this pathology also make excellent candidates for hippotherapy. Cerebral palsy is a condition in which the developing brain is damaged before, during or shortly after birth. The disease is nonprogressive, noncommunicable, and permanent, although with the help of the appropriate therapy and applied technology these patients can lead productive, meaningful and many times independent lives.17, 24 The brain experiences the deficit due to a diminished supply of either blood or oxygen for a prolonged period of time. Multiple levels of this condition exist, each with its own problematic symptoms, however all are similar and will be discussed inclusively. The most common forms of cerebral palsy include: spastic, athetoid, and ataxic.24
Cerebral palsy is a movement and postural disorder. Depending on which part of the brain is damaged and to what extent the damage manifests, the patient may present
with any combination of the following characteristics: muscle spasms, muscular tonal problems, involuntary (twitching) movements, inability to execute normal gait patterns,
mobility disturbances, seizures, mental retardation, impairments of sight, hearing, and speech, and abnormal sensation and perception.17
Those individuals with increased muscle tone and spasticity will benefit a great deal from a hippotherapy session on a wide barreled, smooth gaited horse. When
relaxing, the patient receives a nice, long stretch with his/her legs wrapped around the horse, and the smooth gait allows the patient to experience a normal rocking movement against which they must learn to achieve and maintain good posture and balance.15 Incorporating various motor tasks into the treatment encourages muscle strengthening and concentration skills as well. (See Appendix, Figure 9)
Those patients with too little muscle tone should be encouraged to change position while riding. Moving the horse through circles and arcs helps this patient contract and relax different supporting muscle groups in an effort to keep balanced, rather than following straight lines and only asking the patient to contract and hold a few muscle groups at a time to maintain the good posture.13,15
The horse naturally motivates the patient of any age to explore and touch the horse itself, once again giving the patient multiple sensory stimuli to which they must then organize, understand and respond . The warmth of the animal is also a great benefit to the patient, stimulating healing; something a cold, metal, machine can not do.14
Moving through space independently with only the help of the horse, also provides the patient with altering perceptions both visual and auditory (depending on the
footing). 17 Practice with organizing and making appropriate responses to these stimuli also helps the patient be better equipped to participate in activities of daily living.
Spina bifida is yet another condition for which hippotherapy is beneficial.19 However, like multiple sclerosis, spina bifida can also be a contraindication for hippotherapy treatment sessions.
Spina bifida is a developmental defect in which the neural tube (premature nervous system in utero) fails to close properly. In some cases the defect is simply a bony protrusion that did not form correctly. However, in more severe cases the vertebrae does not close at all and the meninges (coverings of the spinal cord) or perhaps even the spinal cord may protrude through the malformation. Surgery is usually performed shortly after birth to close the defect to prevent further injury and possible infection in the spinal cord.24
Common characteristics include: some amount of paralysis and sensory loss depending on the location of the defect, some degree of hydrocephalus (fluid in the
brain), possible lack of bowel and bladder control.19 Cognition, language, and memory skills often remain unaffected. Additional problems that may result from spina bifida
include: Arnald Chiari II malformation (elongation of the brain stem into the vertebral canal), hydromyelia (a dilation of the spinal cord canal caused by an increase in fluid),
and tethered cord syndrome (the spinal cord becomes anchored after surgery due to progressive scarring). Any of these abnormalities (Arnold Chiari II, hydromyelia, and tethered cord syndrome) can progress to become life threatening if the proper care is not taken.24
Hippotherapy becomes contraindicated for the patient when any one or more of these additional problems appear in the patient's symptoms. Signs of these manifestations include: worsening gait, back or leg pain, newly appeared spasticity, respiratory distress, apnea (breathing stops), increased difficulty swallowing, persistent severe headaches, rapidly increasing scoliosis, and progressive loss of muscle strength. If
any of these symptoms appear hippotherapy should be discontinued and the patient should consult a physician.
If none of the before mentioned conditions exists, hippotherapy is extremely beneficial for these patients. The individuals gain muscle strengthening and endurance, as well as complex sensory stimulation.19
Many patients with spina bifida are paralyzed to some degree, in their lower limbs. Therefore riding a horse allows them to move through space, in a rhythmical, more normal gait. The horse's movement allows them to understand what normal ambulation patterns feel like throughout the trunk and pelvis. Independent sitting balance
may be a problem for these patients. The motion of the horse and the exercises prescribed to the patient while riding will both increase the patient's ability to achieve
independent sitting, and aid the patient in developing the skills necessary to complete functional activities of daily living (walking/sitting).19
**All of the diagnoses discussed thus far, are primarily found in the pediatrics population. The remaining conditions may be found in pediatrics (i.e. spinal cord injuries, and amputees), but they are all more common in the adult community.
Spinal Cord Injuries
Individuals that have sustained a spinal cord injury can be prospective patients for hippotherapy, depending on their specific level of injury and resultant degree of functioning. Most spinal cord injuries are a result of an exterior traumatic event to the posterior region of the body.24 However, some spinal cord deficits are caused by malformation during development or contraction of a harmful virus. The area of injury
usually results in a loss of function at that level and below which may include any combination of the following: paralysis of the skeletal muscles, loss of sensation (touch, pain, temperature, position, and vibration), changes in breathing patterns and capacity, abnormal functioning of the autonomic nervous system that may affect pulse, blood pressure, body temperature perspiration and bowl and bladder function.28
If the patient has the ability to sit in a somewhat controlled and balanced manner, they are a candidate for hippotherapy. While astride the horse the patient can gain strength in the muscles that are still able to function by attempting to constantly counteract and rebalance themselves after being repeatedly moved out of position by the horse's change of pace and direction. These patients undergo various sensory stimulus throughout the ride including texture integration, temperature variances and
proprioception changes, all of which aid the patient in the recovery process, by allowing them to experience natural occurrences that they may have never had since their injury.
Many patients with spinal cord injuries never recover to a level of functioning similar to their premorbid state. Therefore while hippotherapy is a beneficial treatment to maintain an optimal level of functioning for each specific individual, it is in no way a cure, and therapists involved in this plan of care should not become discouraged if they do not see drastic improvements in these individuals’ states of being.24,28
Amputee patients have been known to benefit from various forms of therapy, one of which is hippotherapy. Any patient that has lost a part and/or one or more limbs can
be described as an amputee. While hippotherapy, as a whole body treatment is beneficial for upper limb amputees, its major focus is on lower limb amputee patients. These
individuals must re-educate their limb(s) to function in a normal capacity by first consciously pushing on the various walls of the socket of the artificial limb. With time, practice, and muscle strengthening these movements will hopefully become automatic, and unconsciously controlled.25
While a patient is astride the horse either forward, backward, or turned to one side or the other, various leg exercises can be incorporated into the treatment session. The patient may be asked to squeeze the horse, focusing on the lower extremity adductors (adductor magnus, longus, and brevis), or they may be asked to touch the horse as lightly as possible with their legs strengthening the abductors (gluteus medius). The patient may also be asked to lift and lower their legs, exercising the hip and knee flexors and extensors (quadriceps, iliopsoas and hamstrings, gluteus maximus). While performing all of these activities to strengthen the lower limb musculature necessary for normal ambulation, the pelvis and trunk are also being moved by the horse's motion. The trunk and neck musculature is being called on to keep the patient aligned astride the horse. Not only is the patient strengthening these muscles, but he/she is doing so in a manner similar to what they will need to carry out activities of daily living.25
While hippotherapy patients benefit greatly from the physical aspects of this therapy, they also receive emotional encouragement and aid. Riding enables them to feel equal to their peers and back in control of their lives. Hippotherapy can serve as an
enormous self-esteem builder, which is extremely important for patient's to return to their normal functioning lifestyle.
Multiple sclerosis (MS) is yet another pathology that can be an indicator for hippotherapy but, unlike the other conditions, it can also be a precaution.18
Multiple sclerosis, still remains a somewhat mysterious illness . The disease is displayed by more than one area of inflammation and resultant scarring of myelin (the covering/protection of nerve fibers) in the central nervous system. The scarring causes a lack of communication within the brain and spinal cord. The location and extent of the scaring will determine the specific physical and cognitive deficits experienced by the patient. MS is usually signified by periods of exacerbation and remission. Many patients progress in their disease. Some rely on a wheelchair or other means of assistive device to ambulate in the later years of their life. Some common symptoms of MS include: fatigue, loss of coordination, muscle weakness, tremors, spasticity, numbness, slurred speech, visual difficulties (double vision or blurred vision), possible paralysis, muscle cramps, mood swings, irritability, depression, and bowel and bladder dysfunction.18,24
While most MS patients are good candidates for hippotherapy, those that have no ability to sit without support or those whose symptoms worsen from therapy should discontinue the hippotherapy sessions. Also those patients who are experiencing an acute exacerbation should postpone their riding treatment until they are once again in a period of remission.18
For those patients able to stand and/or walk or have some ability to maintain sitting balance, hippotherapy is a very appropriate treatment. The rhythmic motion of the
horse helps maintain trunk, pelvis, and hip motion and flexibility that may become hindered due to spasticity, inactivity, and decreased muscle strength. This motion also encourages correct sitting balance regardless of position in space.
The treatment session should focus on relaxing the patient, so as to decrease the spasticity. As the patient progresses, muscle strengthening exercises should be included in the treatment session. Developing a good base, (that is neutral posture, relaxation and sitting balance), will ensure a good level of functioning off the horse as well.
Due to the extreme lack of sensation that these patients experience careful attention and examinations must be given in the uncovered skin areas that come into contact with the saddle or other riding equipment. The poor circulation in such areas added to the rubbing of the equipment may cause painless, but extremely harmful skin irritations on the patient.
Because these patients becoming easily fatigued, a warm-up and resting period should begin and end every treatment session so as to ensure the patient does not overexert him/herself. Throughout the therapy the patient should also gain some degree of muscular endurance which will assist them in maintaining an optimal level of independence while carrying out activities of daily living.
Post Polio Syndrome
Much debate has risen around the issue of post polio patients and exercise. Many scientists and medical professionals believe activity will increase the onset of symptoms. However, as many, if not more, follow the belief that keeping the body healthy and in shape will help to prolong the progression of symptoms.27
Post polio syndrome (PPS) is a condition that may occur in survivors of the poliomyelitis virus, from 10-40 years after contracting the initial illness. Those patients
that experienced severe symptoms when they first had the virus are more likely to have severe symptoms with PPS than those that only had mild complications during their bout with the polio virus. PPS is characterized by: fatigue, progressive muscle weakness, muscle and joint pain, and muscular atrophy. 27
It is believed the recurrence of these symptoms is a result of the body tiring itself out. When these patients experienced the polio virus, various nerve endings in the muscles throughout the body were attacked and destroyed. In an attempt to restore function, the nerve endings that remained sprouted numerous growths to take the place of those that were attacked. For years, these new sprouts allow the body to function normally. However, it is believed that they contribute additional stress to the body and over time they too begin to break down, causing the symptoms that had been absent for quite some time to reappear.27
In order to keep the body tissues at peak performance it is believed by many that a full body exercise is essential. Hippotherapy is then incorporated into these patient's treatment in an effort to keep the body strong and active.24
While these patients do gain emotional, sensory and proprioceptive benefits from the therapy, the primary focus for these patients is full body strengthening. Instead of simply working to hold a normal posture on curves, circles, propulsions, and halts, these patients are usually practicing squeezing and releasing with their legs, reaching forward
and back and up and down with their upper body, and changing position while the horse is moving.
The PPS patients that do undergo exercise treatments are encouraged to use individual tolerance as their limit. Because extreme fatigue is a serious threat, it is important for them to recognize the point at which they begin experiencing discomfort, and/or weakness. Once these symptoms appear, the patient should stop the exercise therapy for that session and be sure to rest before engaging in any other exhausting behavior.27
Medical Insurance Coverage
Most hippotherapy patients depend on some form of insurance or another to cover the costs of treatment. While such coverage is not unheard of, proper regulations must be followed to ensure the insurance companies’ cooperation. In most sates, hippotherapy must be prescribed by a physician before a therapist can legally attend to any individual desiring the treatment.31 As with all therapeutic techniques and tools, careful documentation must be completed in order for the therapist to be reimbursed by a third party payer.29 Medical insurance companies, while reluctant to pay for any kind of "new" and "unknown" treatment, are willing to cover this type of therapy as long as the proper documentation exists, proving patient progression toward individual goals. It is suggested that in addition to careful documentation, therapists practicing in these riding centers should, obtain liability and malpractice insurance, and follow all state regulations and statues within their specialty, while providing treatment to ensure medical insurance coverage.31
Suggestions for the Future of Hippotherapy
While hippotherapy has come a long way in the past fifty years, it still has a way to go before it is utilized to its full potential. Even though all the research studies completed to date show improvements in patient goals, such research has been extremely limited, primarily focusing on cerebral palsy patients and various measurable values such as, kinematics and functional performance, gait, energy expenditure, motor function, and posture.13,14,15 Hippotherapy is known to benefit all the medical conditions discussed earlier, however much more research is needed on other diagnoses, before these beliefs can be known as scientific facts. In addition to a broader scope of research, more medical professionals (especially physicians) need to be made aware that the therapy exists and its wide range of therapeutic benefits. Without medical doctors believing the therapy is helpful to specific patients, they will not prescribe it as a treatment. In the absence of such prescriptions hippotherapy cannot be practiced in most states. The appropriate knowledge of hippotherapy is therefore, the key to its success.