Running head: HIPPOTHERAPY AND CP

Effects of Hippotherapy on Balance, Posture, and Gait in Children with Cerebral Palsy: A Systematic
Review

Nicole E. Rietz, OTS

Jenna L. Euteneier, OTS

University of Utah

HIPPOTHERAPY AND CP 2

Effects of Hippotherapy on Balance, Posture, and Gait in Children with Cerebral Palsy: A

Systematic Review

Cerebral palsy (CP) is the most common cause of physical disability in children, occurring in an

estimated two out of every 1000 births (Reddihough, 2011). This congenital disorder can be accompanied

by a myriad of effects which range in intensity from mild with minimal impairment to complete

dependence. Approximately 70% of children with CP have spastic CP (Reddihough, 2011). Spastic CP is

associated with joint contractures, which can result in atypical balance, postural control, and gait patterns.

During development, children often develop compensations for muscular imbalances and neurological

dysfunction resulting from CP (Morases, Copetti, Angelo, Chiavoloni, & David, 2016). However, these

compensations can produce further muscle imbalances and deformities, impacting a child's functional

ability to engage in activities of daily living (ADL's), instrumental activities of daily living (IADL's) and

meaningful occupations.

Traditionally, occupational and physical therapy have been used to treat CP in children. However,

hippotherapy is an alternative treatment that is rising in popularity in this population. Morases et al. (2016)

postulate that one reason for this effect is that hippotherapy stimulates sensory-motor systems with its

neuromuscular and proprioceptive qualities. Sensory integration is improved because all systems including

visual, vestibular, and proprioceptive are stimulated at once. This then stimulates neurological receptors

and forces the brain to adapt and process the necessary skills to adapt to this type of stimulus (Morases et

al., 2016).

There has been a great deal of research regarding the level of effectiveness of this intervention in

children with CP. However, these studies have shown mixed results as to whether it is an effective

treatment. In this systematic review, our purpose is to ascertain whether hippotherapy is an effective

intervention to improve posture, balance, and gait in children with CP. We look at three categories in tandem

because improvements in balance and posture should, in turn, improve one’s gait ability. Having

improvements in these areas at an early age decreases the need for compensations, which can in turn
HIPPOTHERAPY AND CP 3

decrease muscular imbalances and neurological dysfunction. This then directly impacts the ability in the

future to participate in IADLs, ADLs, and meaningful occupations, outcomes that are of particular interest

in the field of occupational therapy.

Methods

Search Strategy

We conducted a systematic review of relevant research articles within the CINAHL, Google

Scholar, EBSCOhost, and PubMed research databases. All articles were found and analyzed within these

four databases. We used a time limit between 2007 and 2017 in order to find recent and relevant research

articles. Key words used for the search included: cerebral palsy, hippotherapy, equine assisted therapy,

children, gait, posture, postural stability, sitting balance, and balance. A total of 20 articles were found.

Study Selection

Abstracts of each article were reviewed for relevance to the research question. Articles which were

not in English, did not study gait, posture, balance, hippotherapy, cerebral palsy, did not involve children

with cerebral palsy, or were not above level 5 evidence (according to the Levels of Evidence Scale) were

excluded. For example, some articles examined the effects of hippotherapy on adults with CP; however,

these articles were excluded because they were not pertinent to our research question. Another article was

further excluded because it was an additional report of the same study. After eliminating these articles, 11

articles were reviewed. All 11 were found to be relevant to the research question and were included in this

systematic review. Articles utilizing control trials and uncontrolled trials were included, as well as two

meta-analyses. Three articles were the same across reviewers; therefore, eight original articles remained for

the review and analysis.

Study Analysis

Articles used in this systematic review were ranked by level of evidence to help determine the

validity and quality of the results using the Physiotherapy Evidence Database (PEDro) scale scoring system

for randomized control trials and the Level of Evidence scale (1-5) for non-randomized control studies. The
HIPPOTHERAPY AND CP 4

PEDro scale evaluates randomized control trials and assigns them a score from 1-10 with a score of <4

being very poor and a score of 9-10 being excellent (Mehta et al., 2011). The Level of Evidence scale

quantifies articles based on the type of study design, with level 1 considered the highest (randomized control

trials, meta-analyses and systematic reviews) and level 5 the lowest (case studies, expert opinions, and

consensus statements). Levels of Evidence and PEDro scores can be found in Table 1 at the end of this

review.

Results

Effectiveness of Hippotherapy on Postural Control

Hamill, White, and Washington (2007) examined the effects of hippotherapy on postural control

and sitting balance in three children with cerebral palsy using a single subject design. Participants engaged

in weekly 50 minute hippotherapy sessions for 10 weeks, and were assessed for postural control and sitting

balance pre- and post- intervention. Parental questionnaires were also given out pre-and post- intervention

to the parents of the children to examine their perceived effectiveness of the intervention. This study found

no significant difference in postural control or sitting balance in any of the participants after the 10-week

intervention. One of the strengths of the study included assessing postural control pre and post-intervention

as well as including the Parental Questionnaire, which gave additional information about the effects of

hippotherapy on children with CP. However, one of the limitations of this study included a very small

sample size. Therefore, it is very difficult to generalize findings to large populations.

Kang, Jung, and Yu (2012) used a randomized control trial design to examine the effects of

hippotherapy on postural control and sitting balance in children with severe cerebral palsy. The 8-week

hippotherapy intervention was given two times per week with 30 minute sessions, while the comparison

groups received physical therapy or no intervention. A sitting balance test using a force plate was used to

assess participants before and after interventions. The results from the sitting tests demonstrated a

significant decrease in sway pathway and total velocity in the hippotherapy group over both comparison

groups. Sway pathway and total velocity also significantly decreased in the physical therapy intervention

group compared to the control group. The control group had no significant changes in the sway pathways
HIPPOTHERAPY AND CP 5

or total velocity measures. This study was able to overcome some limitations of many previous studies,

such as using a small sample size and only assessing a single CP disorder. However, the study did not look

at all the factors involved in improving sitting balance and posture, which includes improving strength,

endurance and body alignment. Without addressing all of these aspects, it is difficult to fully conclude that

hippotherapy can improve postural stability alone. Nevertheless, the results of this study demonstrate that

hippotherapy has a positive effect on sitting and postural balance in children with CP.

Tseng, Chen, and Tam (2013) performed a meta-analysis that studied the effects of equine therapy

(both hippotherapy and therapeutic horseback riding) on children with CP in 78 articles. Results showed

significant postural improvement after hippotherapy, with the exception of one study which included

participants in the lowest classification of gross motor function. This result shows that hippotherapy may

be effective in higher gross motor function categories, but not in lower classifications. Another article

included in the analysis found maintained postural improvements after 12 weeks. Weaknesses of this study

included small sample sizes and that studies including both hippotherapy and therapeutic horseback riding

were reviewed. Additionally, the types of trials and measurements differed from study to study. The study

did, however, provide a quality ranking of the studies reviewed as well as equalizing the studies as much

as possible.

Zadnikar and Kastrin (2011) similarly performed a meta-analysis on eight articles, reviewing the effect

of both hippotherapy and therapeutic horseback riding on the balance and postural control of children with

cerebral palsy. Their results showed a positive correlation between hippotherapy or therapeutic horseback

riding and improved postural control. All studies reviewed showed a positive effect that – after pooling data

– was shown to be significant. The researchers reviewed many articles, covering a great amount of the

available research. However, there is potential for publication bias in the analysis, as the authors mention

that their funnel plot appeared somewhat skewed. Additionally, the included articles lacked homogeneity

in sample, research methods, measures, and lengths of intervention, making it difficult to accurately draw

conclusions about the general population.

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Effectiveness of Hippotherapy on Balance

Moraes, Copetti, Angelo, Chiavoloni, and David (2016) examined the effects of hippotherapy on

postural balance, dynamic balance, and functional performance in children with CP balance. . The

intervention was given for 30 minutes, twice a week, for 12 weeks. The results showed a significant

improvement in postural stability and balance. There was also a significant difference in Berg Balance Scale

scores, which indicates improvement in functional skills such as self-care, social function, mobility,

caregiver assistance, social function and mobility (Moraes et al., 2016). Overall, an improvement was seen

in sitting position, dynamic balance and functionality in children with CP over 24 total hippotherapy

sessions. This study was able to demonstrate an improvement in postural stability amongst children with

cerebral palsy, which can be viewed as a strength for our purposes. However, this study had several

limitations including a small sample size and not having enough participants in the control group.

Herrero, Gómez-Trullén, Asensio, García, Casas, Monserrat, and Pandyan (2012) examined the

effects of hippotherapy (applied by a simulator, not an actual horse) on sitting balance in children with CP

using a stratified single-blind randomized control trial. The results indicated that sitting balance improved

significantly within the treatment group after the 10 week hippotherapy intervention. However, these results

were not maintained when assessed again after the 12-week follow up period. Therefore, hippotherapy

(simulated) when applied, can help significantly improve sitting balance in children with cerebral palsy

with only short term effects. Hippotherapy intervention must be maintained over time in order to see

improvements in sitting balance (Herrero et al., 2012). This study has many strengths, including testing

hippotherapy effects utilizing a mechanical stimulator. This can possibly provide a safer way of performing

hippotherapy on CP patients who may not be able to ride safely on an actual, physical horse. However, this

study also had many limitations including not having the ability to customize the mechanical simulator to

match the ability of all the children. Matching the ability of the children would have affected the results of

the study as the simulator treatment would not have been comparable between participants.
HIPPOTHERAPY AND CP 7

Kwon et al. (2015) performed a well-executed randomized control trial studying the effectiveness

of hippotherapy on a large sample of children with cerebral palsy. The authors found significant balance

improvements across all gross motor level function classifications studied. This trials strengths included a

large, mostly homogeneous sample of 92 children, in which only one child dropped out from the study.

Treatment group designs allowed better comparison than previous studies as well, as the comparison group

received 30 minutes of aerobic exercise to match the 30 minutes of hippotherapy received by the

intervention group. This helps show that results are more likely due to hippotherapy than simply to the

benefits of extra activity. This aerobic exercise, however, was not completely supervised by therapists, and

the study did not look at long-term effects of hippotherapy, which could be improved upon in future studies.

The meta-analysis mentioned previously by Zadnikar and Kastrin (2011) also addressed balance

using pooled data. In addition to the results found regarding postural control, the researchers similarly found

that hippotherapy and therapeutic horseback riding had a significant positive effect on the balance of

children with CP.

Effectiveness of Hippotherapy on Gait

Kwon et al. (2011) performed a non-randomized control trial of 32 children, looking specifically at

gait. The researchers found that hippotherapy along with conventional physical therapy was associated with

a significantly increased stride length, compared to an increased cadence and walking speed in the control

group who utilized conventional physical therapy alone. This is an interesting finding, as many problems

with gait result in an increased cadence and walking speed to compensate for decreased stride length. The

increase in stride length in the hippotherapy group may then show a different area of improvement due to

hippotherapy than those due to physical therapy. Both groups also saw an increase in walking speed, and

anterior pelvic tilt decreased during gait in the hippotherapy group. Although this study had promising

results, it is important to note that the study consisted of a small sample size and randomization did not

occur, making it difficult to generalize these results to a large population. However, the researchers took

steps to ensure their research was as accurate as possible given these limitations, including blinding all

examiners and including trials in the analysis that best matched each participant’s gait.
HIPPOTHERAPY AND CP 8

In the previously discussed meta-analysis by Tseng, Chen, and Tam (2013), the authors additionally

studied the impact of hippotherapy and therapeutic horseback riding on gait. While they did not find

statistical significance regarding this outcome, there was a large amount of heterogeneity among the

research articles they reviewed, which could affect the level of significance found. Although not significant,

this study did find reduced asymmetrical hip adductor sway during walking, which shows potential

improved gait effects related to the use of hippotherapy.

Discussion

Article Overview

In our search, we found eight articles that related to our research question. Many of these articles

overlapped regarding the three outcomes of balance, gait and postural stability that we were studying. The

effect of hippotherapy on gait was studied by two articles, postural stability by four articles, and balance by

four articles. Three of these articles were randomized control trials and two were meta-analysis, therefore

five of our eight articles were the highest level of evidence available, or level I evidence.

Strengths and Limitations

While one of the limitations of this study was the variability of measures used, the Gross Motor

Function Measurement Scale (GMFMS) and, when measuring balance, the Pediatric Balance Scales were

used across the randomized control trials studied. Another strength of the research is that we searched for

articles across a wide range of health-related research databases. A large limitation of our study was that

most articles were from Korea, making the findings difficult to apply to other populations. Further limiting

generalization, most the studies – including those in the meta-analyses – consisted of small sample sizes.

The articles mostly looked at the short-term effects of hippotherapy. Most studies aside from the

meta-analyses did not look at effects beyond 12 weeks, and the meta-analyses studied a wide variety of

intervention lengths. As a result, we do not have much information about long-term effectiveness of

hippotherapy treatment. We also do not know much about the effectiveness of hippotherapy on children at
HIPPOTHERAPY AND CP 9

GMFM level five. Children in this category have limited movement of extremities and postural stability

and are thought to have greater risk of falling from horses during hippotherapy. The majority also

considered hippotherapy in conjunction with other forms of therapy instead of studying its effectiveness

alone. While looking at effect differences among the groups seems to support the conclusion that

hippotherapy is effective, there is ultimately no way of being sure these results did not come about by

simply having additional treatment time. A final limitation was that only two of the studies had a focus on

gait, which was our primary outcome of interest. While both studies were higher level studies and supported

hippotherapy, increasing the number of articles would increase the validity of these findings.

Clinical Considerations/Conclusion

According to the studies in this systematic review, the effectiveness of hippotherapy in improving

balance, postural stability, and balance is supported in children who have CP and gross motor functioning

above a level five on the GMFMS scale. Despite hippotherapy’s popularity and increased presence as an

alternative intervention in children with CP, there are limited high level studies in the research regarding

its effectiveness. However, each study we reviewed showed positive effects of hippotherapy on our

outcomes of interest, and no negative effects were found in these outcomes. Although there is inherent risk

when working with live animals – even with the most mellow and well-trained horses – this risk is

minimized in hippotherapy through giving the intervention to children with higher GMFMS classifications

and having people to support and walk with the child and horse during treatment. With these risks and

benefits considered, we give this study a Level A class IIa recommendation according to the American

Heart Association Agency for Healthcare Research and Quality (AHRQ, 2012). Another consideration in

recommending this therapy to clients is the cost associated with it. This therapy can be expensive and hard

to come by, and insurance may not cover hippotherapy interventions as well as traditional interventions.

There is a need for further research regarding the cost-effectiveness of hippotherapy as well as increased

higher level research determining its effectiveness on its own.

HIPPOTHERAPY AND CP 10

Understanding the effectiveness of hippotherapy as a supplemental treatment to traditional

occupational therapy methods can enhance the effectiveness of occupational therapy practice and

help facilitate participation in meaningful occupations in children with cerebral palsy.

Occupational therapists who have a knowledge of hippotherapy's effectiveness can refer children

to these services or make steps to become certified in this therapeutic practice.

HIPPOTHERAPY AND CP 11

References

Agency for Healthcare Research and Quality (AHRQ). (2012, March 1). Assessing Cardiovascular Risk: Guideline

Synthesis. Retrieved April 13, 2017, from http://www.medscape.com/viewarticle/759314_9

Hamill, D., Washington, K., & White, O. R. (2007). The effect of hippotherapy on postural

control in sitting for children with cerebral palsy. Physical & Occupational Therapy in

Pediatrics, 27(4), 23-42.

Herrero, P., Gómez-Trullén, E. M., Asensio, Á., García, E., Casas, R., Monserrat, E., & Pandyan, A.

(2012). Study of the therapeutic effects of a hippotherapy simulator in children with

cerebral palsy: a stratified single-blind randomized controlled trial. Clinical

Rehabilitation, 26(12), 1105-1113.

Kang, H., Jung, J., & Yu, J. (2012). Effects of hippotherapy on the sitting balance of children with

cerebral palsy: a randomized control trial. Journal of Physical Therapy Science, 24(9), 833-

836.

Kwon, J. Y., Chang, H. J., Lee, J. Y., Ha, Y., Lee, P. K., & Kim, Y. H. (2011). Effects of hippo therapy

on gait parameters in children with bilateral spastic cerebral palsy. Archives of Physical

Medicine and Rehabilitation, 92(5), 774-779.

Kwon, J. K., Chang, H. J., Yi, S. H., Lee, J. Y., Shin, H., & Kim, Y. (2015). Effect of hippotherapy on

gross motor function in children with cerebral palsy: A randomized control trial. Journal of

Alternative and Complementary Medicine 21(1), 15-21.

Moraes, A. G., Copetti, F., Angelo, V. R., Chiavoloni, L. L., & David, A. C. (2016). The effects of

hippotherapy on postural balance and functional ability in children with cerebral palsy. Journal

of Physical Therapy Science, 28(8), 2220-2226

Mehta, S., Orenczuk, S., Hansen, K. T., Aubut, J. A. L., Hitzig, S. L., Legassic, M., & Teasell, R. W.

(2011). An evidence-based review of the effectiveness of cognitive behavioral therapy

for psychosocial issues post-spinal cord injury. Rehabilitation Psychology 56(1), 15-25.

Reddihough, D. Cerebral Palsy in Childhood [online]. Australian Family Physician, Vol. 40, No. 4,

Apr 2011: 192-196.

Tseng, S. H., Chen, H. C., Tam, K. W. (2013). Systematic review and meta-analysis of the effect of
HIPPOTHERAPY AND CP 12

equine assisted activities and therapies on gross motor outcome in children with cerebral

palsy. Disability and Rehabilitation, 35(2), pp. 89-99. doi: 10.3109/09638288.2012.687033

Zadnikar, M., & Kastrin, A. (2011). Effects of hippotherapy and therapeutic horseback riding on

postural control or balance in children with cerebral palsy: a meta- analysis. Developmental

Medicine & Child Neurology, 53(8), 684-691.

HIPPOTHERAPY AND CP 13

Table 1: Summary of Articles Reviewed

Article Level Sample Design/Variables Measures/Data Collection Findings
Herrero, P., Level 38 children Stratified single-blind Gross Motor Function Measure and Significant
Gómez- I: between the ages study randomized control Sitting Assessment Scale. Measured improvement in sitting
Trullén, E. PEDro of 4-18 years with trial. three times (1. Baseline, 2. 10 weeks balance post 10-week
M., Asensio, 8/10 cerebral palsy 2 groups, intervention and 3. 12 weeks) hippotherapy
Á., García, control intervention. Results
E., Casas, R., were not maintained
Monserrat, after 12-weeks post
E., & intervention.
Pandyan, A.
(2012)
Kwon, Level 92 children with Randomized control trial The GMFM-88 (Gross Motor Positive effects of
Chang, Yi, I: C.P. aged 4-10 Treatment group Function Measure) and Pediatric hippotherapy in
Lee, Shin, & PEDro years from the (conventional physical Balance Scale. Examiner was blinded conjunction with
Kim (2015) 7/10 Republic of therapy and 30 min. to group assignments. traditional physical
Korea. Aerobic exercise vs therapy on both balance
conventional physical and gross motor
therapy and private function at different
hippotherapy. functional levels (I-IV)

Kang, Jung, Level 45 children, aged Randomized control trial Center of pressure pathway and Significant
& Yu (2012) 1: 6-10 (22 females, 3 groups (hippotherapy velocity test given using a force plate. improvement in sitting
PEDro 21 males) with and physical therapy, Center of upper body weight traced balance and postural
5/10 hemiplegic and physical therapy only, or for 30 seconds 3 times. control in hippotherapy
diplegic C.P. control) group over PT group
and control.
Tseng, Chen, Level 78 articles from 7 Meta-analysis Quality evaluated using Critical Significant
& Tam I databases. Inclusion criteria: Review Form-Quantitative Studies improvement of
(2013) Articles ranged children under 18 yrs. Meta-analysis according to PRISMA postural control and
from 1988 to w/CP , peer-reviewed guidelines. non-significant
2011. RCT and observational Studies rejected if standard deviations improvements in hip
studies with objective and errors were either not reported or adductor activity during
outcomes that included could not be extracted. gait with short term
quantitative motor Heterogeneity assessed; data pooled if hippotherapy; no
function. heterogeneity not met. statistical significance
found for long term
hippotherapy
Zadnikar & Level 77 studies from Meta-analysis Articles reviewed by two researchers Statistical significance
Kastrin I 11 databases Inclusion crieteria: Quality evaluated using Critical found regarding the
(2011) ranging from children and adults w/CP, Review Form – Quantitative Studies effectiveness of
October 1988 to quantitative study Treatment effects quantified (odds hippotherapy on
December 2009 designs, investigating the ratio with 95% CI) posture and balance
effect of hippotherapy or Heterogenity quantified
THR on postural control Publication bias potential was
or balance assessed
Kwon, Level 32 children (4-9
Chang, Lee, II yrs) with bilateral
Ha, Lee, & spastic C.P. 21
Kim (2011) boys and 11 girls.
Gross Motor
Function
Classification
System (GMFCS)
level I or II, age
4-10 years.

Experimental, single-blind non-randomized control trial. Participants assigned to hippotherapy plus physical therapy group or physical therapy
only group.

Two groups: intervention and Hippotherapy

controlGMFM-88 and together with
Pediatric Balance Scale. conventional
Measurements before and after physical therapy
treatment. Examiner blinded to showed
group assignments significantly
positive effects on
HIPPOTHERAPY AND CP 14

balance in children
with bilateral CP
Moraes, Level III 15 children with Quantitative study The Berg Balance Scale (BBS) Significant
Copetti, cerebral palsy, aged design, 1 group – pre- and the Pediatric Evaluation of improvement in
Angelo, 5-10 years and post-treatment Disability Inventory (PEDI) postural stability,
Chiavoloni, effects of were used to analyze sitting balance and
David (2016) hippotherapy dynamic position pre and post functional skills in
balance and intervention. hippotherapy
functional COP analyzed using the intervention group.
performance. anteroposterior displacement
(COPap), medio-lateral
(COPml), and velocity
displacement (VelCOP).

Hamill, Level IV 3 children with CP, Single subject Gross Motor Function No significant
Washington, aged 27-54 months, research study- 1 Measure, Sitting Assessment difference in
& White who were unable to group, 3 participants. Scale, and Parental postural control or
(2007) sit alone without Questionnaires were measured sitting balance in
external support. and given out pre-and post- any of the
intervention. participants post
hippotherapy.