Reference
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;46:347-353.
Design
Systematic review of the literature
Study methodologies: Case control or case series
Background
Multiple sclerosis (MS) is a chronic disease resulting from progressive demyelination of axons within the central nervous system.1 Clinical symptoms include functional impairment of motor function and strength, sensory loss, and interference with coordination and balance. Symptom may vary from patient to patient, and the disease may be relapsing and remitting or progressive. Given the wide variety of clinical presentations, a variety of treatments are available, with the primary goal of improving balance when engaged in daily activities. Exercise training has been shown to be a valid strategy in this regard.2,3
Hippotherapy refers to a systematic program of physical therapy on horseback under the direction of a certified hippotherapy specialist who is also a licensed physical therapist, occupational therapist, or speech and language therapist. It utilizes the movement of the horse to provide continual dynamic changes in the rider’s balance, posture, and proprioceptive input, resulting in moment-by-moment compensatory motor responses that eventually retrain the neuromuscular system.4,5
Hippotherapy has been utilized as a therapeutic intervention for a number of neurologic conditions, including cerebral palsy, spinal cord injury, traumatic brain injury, and MS.
Hippotherapy has been utilized as a therapeutic intervention for a number of neurologic conditions, including cerebral palsy, spinal cord injury, traumatic brain injury, and MS.
Materials and methods
The specific research question for this systematic review was “Does hippotherapy as an intervention improve balance in persons with MS”? The authors searched the databases of MDLIN, AMED, EMBASE, ERIC, Scopus, ISI Web of Science, CINAHL, PsychINFO, Science Direct, and PEDro in 2009 using the terms: hippotherapy, horse, riding, horseback riding, horseback riding therapy, equine movement therapy, equine assisted therapy, therapeutic riding, AND balance, postural balance, equilibrium, posture, postural reactions, postural sway, dynamic balance, AND multiple sclerosis. Only full-length articles written in English or translated into English were included due to limited access to translation facilities.
Results
Out of 13 articles generated related to hippotherapy, balance, and MS, 3 met the inclusion criteria and were assessed. The mean time and duration for the hippotherapy intervention was 7.75 hours (range 5.0–13.5) over 11.2 weeks (range 9–14) respectively, and interventions were completed both outdoors and indoors. Collectively all 3 studies reported improvements in balance, with 1 study suggesting greatest improvement in patients with primary progressive MS when compared to other subtypes of the illness. Study limitations included very small sample sizes, as well as lack of random selection of subjects, which is important due to the variable nature of MS.
Discussion
Published research in the fields of animal-assisted therapy, equine-assisted therapy, and hippotherapy is relatively small but has been growing exponentially over the past decade. Methodologies such as the randomized controlled trial are very difficult to apply, as these interventions depend upon constantly changing therapeutic input from one multifactorial source (the horse) to a recipient with one variation of a multifactorial disability (cerebral palsy, traumatic brain injury, MS).
Despite the broad search strategy utilized, only 3 articles met inclusion criteria.6,7,8 Nonetheless, all 3 suggested improvement in balance after hippotherapy sessions, and it is relevant to this discussion that there is significant observational evidence of the value of hippotherapy from therapists, patients, and family, although more specifically in the realms of cerebral palsy and traumatic brain/spinal cord injury.
The United States has more than 700 therapeutic riding centers, and thousands more exist abroad. North American Riding for the Handicapped Association (NARHA) oversees credentialing of therapeutic riding centers, and the American Hippotherapy Association (AHA) ensures the credentialing of qualified therapist in providing hippotherapy interventions.
Practice Implications
Although therapeutic riding in general, and hippotherapy in particular, do not have the plethora of rigorous research evidence of more conventional therapies, a multitude of centers have been treating tens of thousands of patients for decades with very conclusively positive observational findings. Risk to the patient is very low, and there are no documented side effects of these interventions other than the occasional allergy to horses or other environmental sources such as hay. Given the paucity of beneficial therapies and lack of any known cures, referral to a therapeutic riding center should be made to patients afflicted with these severe neurological disabilities.
