Australian Journal of Psychology

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An umbrella review of the evidence for

equine‐assisted interventions

Cindy Stern & Anna Chur‐hansen

To cite this article: Cindy Stern & Anna Chur‐hansen (2019) An umbrella review of the evidence
for equine‐assisted interventions, Australian Journal of Psychology, 71:4, 361-374, DOI: 10.1111/
ajpy.12246

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Received: 23 December 2018 Revised: 24 January 2019
DOI: 10.1111/ajpy.12246
SPECIAL ISSUE
An umbrella review of the evidence for equine-assisted
interventions
Cindy Stern1 | Anna Chur-Hansen2
1
The Joanna Briggs Institute, Faculty of Health
and Medical Sciences, University of Adelaide,
Adelaide, South Australia, Australia
2
School of Psychology, Faculty of Health and
Medical Sciences, University of Adelaide,
Adelaide, South Australia, Australia
Correspondence
Anna Chur-Hansen, School of Psychology,
Faculty of Health and Medical Sciences,
University of Adelaide, Adelaide, SA 5005,
Australia.
Email: anna.churhansen@adelaide.edu.au
1 | INTRODUCTION
The establishment of the term “human–animal bond” in the
late 1970s signified the recognition of the importance of the
potential therapeutic role animals may play in human health
and well-being (Hines, 2003). Since then interventions with
Aust J Psychol. 2019;71:361–374.
Accepted: 29 January 2019
Objective: To establish the evidence base for animal-assisted interventions, and
specifically, hippotherapy and other interventions involving horses, in the context
of improving biological, physical, psychological and social functioning, and out-
comes in humans.
Method: A review of systematic reviews (an umbrella review) was carried out
using a modified Joanna Briggs Institute methodology and following PRISMA
guidelines. Inclusion criteria were any interventions that included a live horse, for
humans of any age and for any therapeutic purpose. Service and assistance horses
and people who were incarcerated were excluded. Systematic reviews with a
clearly articulated and comprehensive search strategy, with evidence of critical
appraisal, both qualitative and quantitative and mixed methods, and in English
were considered.
Results: Of 19 systematic reviews considered eligible for inclusion, 13 were
included in this umbrella review. These 13 systematic reviews covered 79 individ-
ual studies of equine-assisted interventions, including primarily hippotherapy and
therapeutic horse riding. Participants included children with cerebral palsy, children
and adolescents with autism spectrum disorder, adults with multiple sclerosis,
elderly people, adults post-stroke, people with spinal cord injury, adults with seri-
ous mental illness, adults with balance problems, people with brain disorders,
breast cancer survivors, and obese women.
Conclusions: The evidence for equine-assisted interventions for adults and chil-
dren across a range of conditions and presentations is equivocal. The current evi-
dence base is marred by multiple methodological weaknesses and thus, therapeutic
interventions that include a horse cannot be asserted as best practice at this time.
Rigorous research is indicated to determine the utility of equine-assisted
interventions.
KEYWORDS
animal-assisted interventions, equine-assisted interventions, hippotherapy,
systematic reviews, umbrella review
animals in the context of health and social care have become
common practice in many countries (Fine, 2015). The term
“animal-assisted interventions” (AAIs) is now an accepted
industry term, and a focus of human–animal research in the
field known as “anthrozoology,” with 2017 marking the 30th
anniversary of “Anthrozoös,” the Journal of the International
wileyonlinelibrary.com/journal/ajpy © 2019 The Australian Psychological Society 361
362
Society for Anthrozoology (http://www.isaz.net/isaz/anth
rozoos/). AAIs are defined as: … goal-oriented and struc-
tured interventions that intentionally incorporate animals in
health, education, and human service for the purpose of ther-
apeutic gains and improved health and wellness. Animal-
assisted therapy (AAT), animal-assisted education (AAE)
and animal-assisted activities (AAAs) are all forms of
animal-assisted interventions. In all these interventions, the
animal may be part of a volunteer therapy animal team work-
ing under the direction of a professional or an animal that
belongs to the professional himself. (https://petpartners.
org/learn/terminology/)
Due to increase in both the popularity and general aware-
ness of AAIs, a number of studies have been conducted across
a range of settings and populations and including a variety of
different animals, including horses. In line with the biopsycho-
social model (Engel, 1980), AAI's have been assessed in rela-
tion to biological, psychological, and social outcome variables
(see e.g., Friedmann & Son, 2009). The majority of empirical
studies are quantitative in nature although numerous qualitative
studies have also been undertaken (see e.g., Shen, Xiong,
Chou, & Hall, 2018). Subsequently, there has been some
attempt at synthesising this evidence, with a number of system-
atic reviews conducted over the last 10–15 years. Results are
mixed with most suggested limited beneficial effects as well as
an acknowledgement in the literature of the methodological
weaknesses common in this field of research (Chur-Hansen,
Stern, & Winefield, 2010; Herzog, 2015; Stern & Chur-Han-
sen, 2013). Since there are a number of systematic reviews that
have been conducted in the area that either focus on specific
patient populations and settings or across them, an umbrella
review is warranted to bring together and compare the results
of these systematic reviews to determine whether AAIs which
involve horses are effective across different populations and
settings. To date, no such umbrella review for AAIs with a
focus on horses exists. Two umbrella reviews have considered
the best available intervention evidence for children with cere-
bral palsy in which hippotherapy was but one of a range of
diverse interventions considered (Anttila, Suoranta, Malmi-
vaara, Mäkelä, & Autti-Rämö, 2008; Novak et al., 2013). Simi-
larly, Abraha et al. (2017) conducted an umbrella review
investigating non-pharmacological interventions to treat beha-
vioural disturbances in older patients with dementia which
included one systematic review on AAIs, however, this
included dogs, cats, and fish as well as robotic and toy animals,
but not horses. This study aims to address a gap in the litera-
ture, by reviewing the reviews of equine-assisted interventions
(EAIs) to ascertain the levels of evidence for this AAI on the
biological, psychological and social health and well-being of
children, adults and older people.
1.1 | Equine-assisted interventions
The popularity of and interest in EAIs and hippotherapy is per-
haps best illustrated by an examination of the Table of Contents
STERN AND CHUR-HANSEN
WHAT IS ALREADY KNOWN ABOUT THIS
TOPIC
• Animal-assisted interventions have grown in popularity over
the last decade.
• There are numerous claims that animal-assisted therapies are
beneficial for human physical, psychological, and social
health.
• Equine-assisted interventions, which involve a horse, are one
particular type of animal therapy that is growing in
recognition.
WHAT THIS TOPIC ADDS
• There are a number of studies that evaluate equine-assisted
interventions for human health: all of them have methodolog-
ical flaws.
• This is the first umbrella review on equine-assisted interven-
tions which demonstrates that these methodological flaws
compromise the evidence.
• Based on the current evidence, equine-assisted interventions
cannot be advocated as best practice.
of a key text in the field, “Handbook on Animal-Assisted Ther-
apy. Theoretical Foundations and Guidelines for Practice”, edi-
ted by Fine, and now in its 4th edition (2015). In the 1st
edition, published in 2000, “horses,” “hippotherapy,” “riding
therapy,” and “vaulting” were covered in pages 93–94 and
217–218. By Edition 4, an entire 23-page chapter was devoted
to the role of the equine in AAT (Latella & Abrams, 2015).
A study of the literature shows diverse terminology for the
use of horses interacting with humans for therapeutic purposes
(Latella & Abrams, 2015). Granger and Kogan (2006)
explained that horses in a therapeutic setting can be divided
into the categories of hippotherapy, riding therapy, riding for
rehabilitation and vaulting. Equine-assisted psychotherapy is a
further category of therapy, which by definition must include a
credentialed mental health-care professional and involve activi-
ties with a horse such as riding, grooming, or handling, or other
related actions (Kruger & Serpell, 2006). Equine-facilitated
psychotherapy similarly involves a mental health practitioner
and an equine specialist (Lee, Dakin, & McLure, 2016).
Hippotherapy is often utilised for physical therapy, for
instance to improve balance, posture and gait. Such treat-
ment is delivered by health-care professionals including
occupational, physical, or speech therapists (Latella &
Abrams, 2015). Hippotherapy requires the horse to lead,
while in riding therapy, the rider can be more active and take
control, in order to improve flexibility or gross motor con-
trol, for example. In riding for rehabilitation, the rider simi-
larly takes more control, but in addition, treatment aims to
address psychological and social problems as well as
STERN AND CHUR-HANSEN
physical ones. Vaulting is a variation of riding therapy,
which requires the rider to perform gymnastic exercises on
horseback, with an aim to improve muscle strength, mobility
and self-esteem as well as a number of other physical and
psychological outcomes. Latella and Abrams (2015)
describe a further category of equine therapy, “therapeutic
carriage driving,” which allows people to connect with a
horse or pony as an alternative to riding, which may be par-
ticularly suitable for children and people who require a
wheelchair. Furthermore, not all interventions include an
actual horse, with simulated horseback riding and robotic
horses also incorporated into therapeutic interventions (Lee,
So, Lee, & Moon, 2018).
1.2 | Biopsychosocial applications
A number of studies have been conducted to assess the effi-
cacy of hippotherapy and therapeutic horse riding on biolog-
ical and physical parameters, for example, for improving
muscle symmetry and tone for children with cerebral palsy
(Sterba, 2007). At the other end of the lifespan, a systematic
review focused on the benefits of hippotherapy and horse-
riding simulation for healthy older adults for outcomes
including improved balance, mobility, gait, muscle strength,
and physical fitness (Hilliere, Collado-Mateo, Villafaina,
Duque-Fonseca, & Parraça, 2018). A recent Australian
review and meta-analysis considered hippotherapy for adults
with acquired brain injury to improve motor function
(Marquez, Weerasekara, & Chambers, 2018).
With a focus on psychological health Lee et al. (2016)
note that the incorporation of horses to treat mental illness is
an innovative and novel approach, with limited but promis-
ing evidence for the treatment of adolescents. Selby and
Smith-Osborne (2013) adopted a biopsychosocial approach
in their review of the effectiveness of complementary and
adjunct therapies and interventions involving equines for
chronic illness and health challenges. Research on social
functioning and hippotherapy tends to focus on children with
autism spectrum disorder (ASD), for example, a recent sys-
tematic review considered the effectiveness of equine-based
therapy in the treatment of social and behavioural aspects of
children with ASD (Wiese, Simpson, & Kumar, 2016).
1.3 | Focus of this review
This umbrella review examines the use of AAI's involving
horses, “equine-assisted interventions” or EAIs, on the
health and well-being of children, adults and older people by
synthesising the results of previous systematic reviews. The
review questions are: “What is the effectiveness of EAIs on
the health and well-being outcomes of children, adults and
older people?” and “What are the experiences of children,
adults and older people receiving EAIs?” This umbrella
review aims to establish the current evidence base, highlight
strengths and weaknesses of the methods used for gathering
363
data to evaluate claims regarding EAIs, and offer sugges-
tions regarding future research and practice in the field.
2 | METHODS
This review followed the Joanna Briggs Institute (JBI) meth-
odology for conducting umbrella reviews (Aromataris et al.,
2017), however to accommodate the diversity of interven-
tions, outcomes and populations included in this review, a
modified approach to how the data are presented has been
utilised (i.e., a narrative synthesis is provided instead of the
prescribed tabulated findings and summary of evidence stop-
light indicator system). The protocol was registered with the
International Prospective Register of Systematic Reviews
(PROSPERO) on July 19, 2018 (registration number
CRD42018100796). It follows the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) guid-
ance for the conduct and reporting of systematic reviews
(Moher, Liberati, Tetzlaff, & Altman, 2009).
2.1 | Inclusion criteria
2.1.1 | Participants
This umbrella review considered any reviews that included
people of all ages receiving AAIs which involved a live
horse (i.e., EAIs). For the purpose of the review children
were defined as those up to 17 years of age, adults aged
18–59 years, and older people as 60 years and over. Partici-
pants were receiving EAIs for any specific health condition
or diagnosis (e.g., Dementia, ASD) or for no specific health
condition or diagnosis (e.g., for loneliness, mood).
2.1.2 | Intervention(s)
Reviews were considered that evaluated AAIs as defined
above and including both AAT and AAA. For this review
AAT was defined as: “a goal-oriented, planned, structured
and documented therapeutic intervention directed by health
and human service providers as part of their profession.”
(https://petpartners.org/learn/terminology/) AAA was
defined as activities that “provide opportunities for motiva-
tional, educational, and/or recreational benefits to enhance
quality of life. While more informal in nature, these activi-
ties are delivered by a specially trained professional, para-
professional, and/or volunteer, in partnership with an animal
that meets specific criteria for suitability.” (https://
petpartners.org/learn/terminology/)
While the initial search included interventions involving
any animal or combination of animals delivered by trainers
and handlers, only horses are the subject of this review.
There was no limit in frequency or duration of AAIs and
they could be delivered in a group format or individually.
Animal-assisted education (as defined by Pet Partners, see
https://petpartners.org/learn/terminology/) was not included.
Interventions could be compared with other combinations of
364 STERN AND CHUR-HANSEN

AAIs, alternative therapies (e.g., art therapy, robotic animals, TABLE 1 Search strategy. CINAHL: search ran August 31, 2018
simulators), or no treatment. Reviews focusing on people Search ID Search terms
with service/assistance animals or people who were incarcer- S1 (MH “Pet Therapy”)
ated were excluded. S2 TI Pet Therap* OR AB Pet Therap*
S3 TI Pet assisted OR AB Pet assisted
2.1.3 | Phenomena of interest S4 TI Pet facilitated OR AB Pet facilitated
The phenomenon of interest was the experiences (both posi- S5 (MH “Animal Assisted Therapy (Iowa NIC)”)
tive and negative) of those receiving AAIs involving horses S6 TI animal assisted OR AB animal assisted
for any purpose. S7 (MH “Equine-Assisted Therapy”)
S8 TI Equine Assisted OR AB Equine Assisted
2.1.4 | Outcomes S9 TI equine facilitated OR AB equine facilitated
The outcomes of interest were any outcome related to health S10 TI hippotherap* OR AB hippotherap*
and well-being. For the purpose of this review outcomes are S11 TI horseback n3 therap* OR AB horseback n3 therap*
grouped under the biopsychosocial model (Engel, 1980): S12 TI dog assisted OR AB dog assisted
biological (e.g., blood pressure, heart rate, mobility), psy- S13 TI canine assisted OR AB canine assisted
chological (e.g., depression, anxiety, quality of life, cogni- S14 TI animal facilitated OR AB animal facilitated
tive status), and social (e.g., social functioning, social S15 (MH “Systematic Review”)
interaction). Outcomes could be measured using any vali- S16 TI Systematic Review OR AB Systematic Review
dated instrument, via observation or by self-report, and mea- S17 (MH “Meta Analysis”)
sured during or immediately after the intervention or at a S18 TI Meta Analysis OR AB Meta Analysis
follow-up period. S19 TI metaanalysis OR AB metaanalysis
S20 TI meta synthesis OR AB meta synthesis
2.1.5 | Context S21 (MH “Meta Synthesis”)
There were no limits to the geographical or care setting of S22 TI metasynthesis OR AB metasynthesis
the intervention and could include (but were not limited to): S23 TI qualitative n5 synthesis OR AB qualitative n5 synthesis
acute care hospitals, residential care facilities, rehabilitation S24 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9
OR S10 OR S11 OR S12 OR S13 OR S14
facilities, and schools and mental health facilities.
S25 S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR
S22 OR S23
2.1.6 | Study types
S26 S24 AND S25
This umbrella review included systematic reviews with or S27 S24 AND S25 Limiters—Published Date:
without meta-analysis. Systematic reviews that met the fol- 19900101-20180731
lowing criteria were considered for inclusion: containing a
clearly articulated and comprehensive search strategy using and Web of Science. The registers searched were: PROS-
multiple databases and having evidence of critical appraisa- PERO and the Centre for Reviews and Dissemination. The
l/assessment of risk of bias. Reviews could be quantitative search for unpublished reviews included: Proquest Disserta-
or qualitative in nature or both (in the case of comprehensive tions and Theses Global; MedNar; and Google Scholar. The
or mixed methods reviews) as long as the quantitative or search was conducted between July and August 2018.
qualitative component could be extracted separately.
Only reviews published in English were included. A
2.3 | Study selection
lower date limit of 1990 was set as per the guidance pro-
vided by JBI since there were very few systematic reviews Following the search, all identified citations were collated
published prior to that time (Aromataris et al., 2017). and uploaded into Endnote X8 and duplicates were removed.
Titles and abstracts were screened independently by the two
2.2 | Search strategy authors for assessment against the inclusion criteria for the
review. Reviews that met the inclusion criteria were retrieved
The search strategy aimed to locate both published and
in full and assessed in detail against the inclusion criteria.
unpublished systematic reviews. The search strategy was
Full-text articles that did not meet the inclusion criteria were
developed in consultation with a librarian and consisted of a
excluded and reasons for exclusion are provided in Support-
combination of keywords and index terms which were custo-
ing Information Table S1. Any disagreements that arose
mised for each database/resource (Table 1). The databases
between the reviewers were resolved through discussion.
searched were: The JBI Database of Systematic Reviews and
Implementation Reviews; The Cochrane Database of System-
atic Reviews; The Campbell Collaboration Online Library; 2.4 | Assessment of methodological quality
MEDLINE (via OVID); CINAHL with full text (via EBSCO- Selected reviews were critically appraised by the two authors
host); PsycINFO (via OVID); EMBASE (via ELSEVIER); for methodological quality using the standardised critical
STERN AND CHUR-HANSEN
appraisal instrument from JBI (Aromataris et al., 2017). The
decision was made a priori to only include articles that
scored “yes” for the following questions: Q1 (Is the review
question clearly and explicitly stated?), Q2 (Were the inclu-
sion criteria appropriate for the review question?), Q4 (Were
the sources and resources used to search for studies ade-
quate?), Q5 (Were the criteria for appraising studies appro-
priate?), and Q8 (Were the methods used to combine studies
appropriate?) (Stern & Chur-Hansen, 2018). Any disagree-
ments that arose were resolved through discussion.
2.5 | Data extraction
Data were extracted from articles included in the review
using the standardised data extraction tool from the JBI
(Aromataris et al., 2017). The data extracted included spe-
cific details about the interventions, phenomena of interest,
populations, study methods, and outcomes of significance to
the review questions.
2.6 | Data synthesis
For quantitative reviews extracted findings are presented
narratively and in tabular format for each intervention, popu-
lation, and outcome. Due to extensive variation across each
of these elements, results are not presented using the traffic
light approach as recommend by JBI and as outlined in the
protocol (Stern & Chur-Hansen, 2018).
Similarly, for qualitative systematic reviews the findings
are presented narratively and in tabular format instead of the
traffic light approach due to the inclusion of only one review
containing qualitative evidence and the way in which the
results were presented. Any overlap of original research
studies in each of the included review is also presented.
3 | RE SUL TS
3.1 | Study inclusion
Due to a larger body of work being undertaken by the review
team the search was broad and encompassed interventions
involving any animal or combination of animals delivered by
trainers and handlers. The search identified a total of
644 potentially relevant citations. Following the removal of
duplicates (n = 158) 486 were assessed by title and abstract
for relevance. There were 337 records excluded, of those
10 full-text articles could not be located or obtained and
27 authors were contacted to determine whether their review
had been completed and published; seven did not respond and
the remaining authors advised that their review was either
incomplete or at varying stages of the publication process.
The full-text of 149 articles was examined and 130 did not
meet inclusion criteria leaving 19 articles that were appraised
for methodological quality. The majority of articles excluded
at full-text did not meet our definition of a systematic review,
365
largely because no critical appraisal took place but also due to
the search only including one database, the article indicating
the study was a primary study or a protocol or the description
of the methods signifying the article was a literature review or
discussion piece. The PRISMA flowchart provided in
Figure 1 outlines the search and inclusion process.
3.2 | Methodological quality of included studies
Nineteen reviews were assessed by two independent
reviewers for methodological quality. The total number of
“yes” responses varied from 5 to 10 out of a possible 11, with
14 of the 19 articles scoring at least 8. Nearly all of the studies
scored poorly in regard to publication bias not being assessed
(Q9) while just under half reported on methods to minimise
errors in data extraction (Q7). Under half of the reviews did
not clearly mention if appraisal had been conducted by at least
two reviewers independently (Q6), however, all but one out-
lined appropriate research recommendations (Q11). All arti-
cles appraised included adequate sources and resources for
searching (Q4), however, only 75% of reviews had appropri-
ate search strategies outlined (Q3). Recommendations for pol-
icy and/or practice were supported by data in just over three-
quarters of the reviews assessed.
Since five of the questions on the checklist were deemed
essential for inclusion, six reviews were subsequently
excluded, leaving a total of 13 reviews included in this
umbrella review (see Table 2 for appraisal results).
3.3 | Characteristics of included studies
Thirteen reviews comprising 128 studies relevant to this
review were included in the umbrella review. Of those
128 studies, 79 were unique with 30 of these duplicated at
least once across reviews. The most frequently included
studies were Casady and Nichols-Larsen (2004), Kwon et al.
(2011), and MacKinnon, Noh, Laliberte, Allan, and Lari-
viere (1995), each appearing in four reviews. Nine studies
were included in three reviews, 18 studies appeared in two
reviews and 51 studies appeared only once. Please refer to
Table S2 for the complete listing of duplicate studies. Stud-
ies included in the reviews were undertaken between the
years of 1988 and 2016. One review (Martín-Valero et al.,
2018) also included two systematic reviews—one which is
already included in this review (Tseng et al., 2013) and the
other which was excluded following critical appraisal
(Zadnikar & Kastrin, 2011) and as such is not reported on.
All reviews were quantitative in nature with Jormfeldt
and Carlsson (2018) also including a qualitative component.
The quantitative study designs varied from randomised con-
trolled trials to single case designs while the qualitative stud-
ies consisted of a case study, an evaluation study, an
exploratory study, and a longitudinal study.
The number of participants included in each review (that
were relevant to this review) ranged from 36 (Bronson et al.,
366 STERN AND CHUR-HANSEN

Records identified through database Additional records identified through other

Identification
searching sources
(n = 644) (n = 0)

Records after duplicates removed

(n = 486)
Screening

Records excluded at title and

Records screened abstract
(n = 486) (n = 337)

Full-text studies excluded, with

Full-text studies assessed for reasons
eligibility (n = 130)
(n = 149 ) Ineligible intervention (n = 38)
Eligibility

Ineligible study design (n = 77)

Ineligible outcome (n = 1)
Ineligible language (n = 4)
Studies assessed for Papers containing duplicate data
methodological quality (n= 10)
(n = 19)

Studies excluded following

assessment of methodological
quality
Included

Studies included in the (n = 6)

systematic review
(n = 13)

FIGURE 1 PRISMA flowchart of the study selection and inclusion process (Moher et al., 2009)

2010) to 601 (White-Lewis et al., 2017), however, duplica-
tion of studies needs to be considered. Participants ranged in
age from 2 to 85 years. Six studies focused exclusively on
children/adolescents (mainly those with cerebral palsy), five
were focused exclusively on adults and two reviews con-
tained mixed populations. Most focused on a health condi-
tion/impairment such as cerebral palsy, serious mental
illness (SMI), multiple sclerosis, ASD, stroke, and motor
function impairment while two had no specific pre-defined
criteria.
Four of the included reviews were not specific to EAIs
and examined broader interventions such as exercise, physi-
cal therapy and non-pharmacological interventions of which
EAIs were one of multiple interventions included. The way
EAIs were described, the terminology used, and the person
delivering them varied, however, most reviews distinguished
between hippotherapy (considered an equine-assisted ther-
apy for this review) and therapeutic horseback riding (THR;
considered an equine-assisted activity). Most sessions were
provided once or twice per week lasting between 30–60 min
and lasted anywhere from 4 to 33 weeks.
Much like the interventions, the outcomes measured
were diverse with many outcome tools/methods used on an
individual basis. The most frequently measured outcome
was the Gross Motor Function Measure (GMFM) which
measures gross motor activities. Other outcomes were pre-
dominately biological, largely due to many of the reviews
focusing on conditions such as cerebral palsy, multiple scle-
rosis, stroke and motor function impairment where move-
ment and/or function are diminished. The reviews focusing
on ASD tended to measure outcomes that can be considered
as psychosocial in nature.
The majority of reviews presented results as a narrative
summary with some providing effect sizes. Only Tseng et al.
(2013) and Stergiou et al. (2017) undertook meta-analysis.
The review including qualitative studies described findings
narratively and made no attempt to pool the results in any
type of qualitative synthesis. Refer to Table 3 for a table out-
lining the characteristics of the included reviews.
3.4 | Findings of the review
The findings of the review are presented narratively and all
relevant data (as provided in the individual reviews) are out-
lined in Table S3. Findings are grouped by population and/or
condition in order of the amount of reviews/trials located.
The qualitative findings are presented after the quantitative
findings.
3.4.1 | Children with cerebral palsy
Six reviews representing 39 unique studies examined the use
of hippotherapy and/or THR in children with cerebral palsy.
Over one-third of those primary studies were included in at
least two reviews. All of the studies included in Dewar et al.
STERN AND CHUR-HANSEN 367

TABLE 2 Results of the critical appraisal of eligible studies using the JBI checklist for systematic reviews and research syntheses

Review Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11

Bremer, Crozier, and Lloyd (2016) Y Y N Y Y Y Y Y N Y Y
Bronson, Brewerton, Ong, Palanca, and Sullivan (2010) Y Y Y Y Y Y U Y N N Y
Dewar, Love, and Johnston (2014) Y Y Y Y Y U U Y N Y Y
Francis (2007) Y Y Y Y Y Y U Y N U Y
Hilliere et al. (2018) N U Y Y Y U Y U N Y Y
Jormfeldt and Carlsson (2018) Y Y Y Y Y U U Y N Y Y
Marquez et al. (2018) Y Y Y Y Y Y Y N N Y Y
Martín-Valero, Vega-Ballón, and Perez-Cabezas (2018) Y Y U Y Y U U Y U U U
Rampling et al. (2016) Y Y Y Y Y N Y Y N Y Y
Selby and Smith-Osborne (2013) Y U N Y Y U Y N Y Y Y
Snider, Korner-Bitensky, Kammann, Warner, and Saleh (2007) Y Y Y Y Y Y U N N Y Y
Srinivasan, Cavagnino, and Bhat (2018) Y Y Y Y Y Y Y Y N Y Y
Sterba (2007) Y U Y Y N U U U N Y Y
Stergiou et al. (2017) Y Y Y Y Y Y Y Y N Y Y
Tseng, Chen, and Tam (2013) Y Y Y Y Y Y U Y N Y Y
Whalen and Case-Smith (2012) Y Y U Y Y Y U Y N Y Y
White-Lewis, Russell, Johnson, Cheng, and McClain (2017) Y Y Y Y Y Y U Y N Y Y
Wonsetler and Bowden (2017) Y Y Y Y Y U Y Y N Y Y
Zadnikar and Kastrin (2011) Y U Y Y N Y Y U Y N Y

Note. Y: Yes; N: No; U: Unclear.

Q1. Is the review question clearly and explicitly stated?
Q2. Were the inclusion criteria appropriate for the review question?
Q3. Was the search strategy appropriate?
Q4. Were the sources and resources used to search for studies adequate?
Q5. Were the criteria for appraising studies appropriate?
Q6. Was critical appraisal conducted by two or more reviewers independently?
Q7. Were there methods to minimise errors in data extraction?
Q8. Were the methods used to combine studies appropriate?
Q9. Was the likelihood of publication bias assessed?
Q10. Were recommendations for policy and/or practice supported by the reported data?
Q11. Were the specific directives for new research appropriate?

(2014) were reported on in other reviews, and all but one
study in both Whalen and Case-Smith (2012) and Tseng
et al. (2013) were included in other reviews. A wide variety
of outcomes were measured with over 25 different tools
used; many of which were only measured once: therefore,
the most frequently reported outcomes and tools are sum-
marised here. All reviews used the GMFM-88 and/or the
GMFM-66 to measure gross motor activities. Results were
mixed with some showing a significant improvement and
others showing no difference. In those that showed improve-
ment it was rare that this was maintained following conclu-
sion of the intervention. Stergiou et al. (2017) conducted a
meta-analysis of four studies (three involving hippotherapy
and one using THR) which demonstrated no significant dif-
ference (mean difference, MD: 1.61, 95% CI: −1.92 to 5.14,
p = 0.37). This was also supported by Tseng et al. (2013)
who pooled studies separately for the GMFM-88 and
GMFM-66 and demonstrated no significant differences (not-
ing that some of the same studies were included in analyses
across reviews). The Pediatric Evaluation of Disability-
Inventory (PEDI) which measures functional skills and level
of independence was evaluated in four reviews (Francis,
2007; Martín-Valero et al., 2018; Stergiou et al., 2017;
Whalen & Case-Smith, 2012) and showed mixed results as
did the Sitting Assessment Scale which measures postural
control (three reviews: Dewar et al., 2014; Martín-Valero
et al., 2018; Tseng et al., 2013). Balance was measured
using the Pediatric Balance Scale in three reviews (Martín-
Valero et al., 2018; Stergiou et al., 2017; Tseng et al., 2013)
indicating significant improvements following the interven-
tion. However, Stergiou et al. (2017) undertook a pooled
analyses of two studies (both involving hippotherapy) which
did not result in a significant difference between groups
(MD: 3.21, 95% CI: ‑1.82 to 8.24, p = 0.21). A significant
reduction in muscle activity post-hippotherapy was demon-
strated in two studies in Tseng et al. (2013) (pooled result,
WMD: −32.20, 95% CI: −61.38 to −3.01) while stride
length showed no significant improvement following hip-
potherapy (pooled result of two studies, Weighted Mean Dif-
ference (WMD): 3.37, 95% CI: ‑13.21 to 19.94).
For other outcomes measured please refer to Table S3.
3.4.2 | Children and adolescents with autism spectrum
disorder
Two reviews (Srinivasan et al., 2018; Bremer et al., 2016)
made up of 14 unique studies included children and adoles-
cents with ASD who received hippotherapy or THR as an
368
TABLE 3 Characteristics of the included reviews
Author (year)
Bremer et al. (2016)
Bronson et al. (2010)
Dewar et al. (2014)
Francis (2007)
Jormfeldt and Carlsson (2018)
Martín-Valero et al. (2018)
Objectives of systematic review
To examine and synthesise the
literature with regard to the impact of
exercise interventions on the overall
behaviour of individuals with ASD
from birth to 16 years of age
To examine the evidence for
hippotherapy as an intervention to
improve balance in persons with MS
To evaluate the efficacy and
effectiveness of exercise
interventions that may improve
postural control in children with CP
To determine the effects of
hippotherapy THR as alternative
treatment modalities for children
with CP, DD, and ND
To review studies concerning
equine-assisted interventions among
adult individuals diagnosed with
schizophrenia.
(1) What types of equine-assisted
therapeutic interventions
characteristics have been evaluated?
(2) What types of study designs have
been used to evaluate equine-assisted
therapeutic interventions?
(3) Which outcomes, effects and
possible benefits of equine assisted
therapeutic interventions have been
proven?
To summarise the grades of
recommendation regarding the
benefits of hippotherapy in children
with CP
Review inclusion criteria
Participants: individuals aged 0–16 years
with a diagnosis of ASD, including
diagnoses of PDD made under the
Diagnostic and Statistical Manual of
Mental Disorders
Interventions: exercise interventions
(physical activity that is planned,
structured, repetitive, and purposeful)
compared to no intervention or a
different intervention
Outcomes: measure of stereotypic
behaviours; measure of cognition or
attention; measure of social–emotional
behaviours; measure of additional
behavioural outcomes
Participants: people with MS
Interventions: hippotherapy
Outcomes: balance
Participants: children diagnosed with CP,
0–18 years
Interventions: land-based exercise
intervention that required active
participation by the child
Outcomes: postural control
Participants: children diagnosed with CP
(hemiplegic, diplegic, and quadriplegic),
DD or ND between 2 and 16 years
Interventions: hippotherapy or THR
Outcomes: posture; trunk postural reactions;
gross motor function; muscle tone; gait
speed; functional development;
kinematics; functional performance
Participants: people aged 18–65 years with
schizophrenia or schizophrenia-like
diagnoses
Interventions: EAIs such as EAT, EAP, and
THR
Outcomes: none pre-specified
Participants: infantile CP
Interventions: therapy with a real horse, a
simulator and comparative studies of the
two
Outcomes: gross motor function; stability,
mobility, functionality and balance of the
trunk, head or upper limbs; the
electromyographic activity of the
adductor muscle; sitting independently
and self-perception; psychological
factors; walking speed or length of
STERN AND CHUR-HANSEN
Characteristics of included studies
Included studies: 13
Year range: 2009–2013
All included studies in review applicable
to this review: no, 4 relevant
Study designs: 3 controlled trials
(1 randomised); 1 cohort
Country/setting: not stated
Number of participants (relevant to this
review): 121
Included studies: 3
Year range: 1998–2007
All included studies in review applicable
to this review: yes
Study designs: pilot case–control study;
single study experimental design; pilot
case-series study
Country: not stated
Number of participants: 36
Included studies: 25 primary studies and
3 SRs
Year range: 2007–2013
All included studies in review applicable
to this review: no, 3 primary studies and
2 SRs relevant, however, SRs not
included in results/analysis
Study designs: single subject studies;
group design
Country/setting: not stated
Number of participants (relevant to this
review): 80
Included studies: 8
Year range: 1988–2004
All included studies in review applicable
to this review: yes
Study designs: 3 repeated measures
within-subject design; 1 case study;
1 repeated measures, 1 cohort study,
1 single case design and 1 case series
Country/setting: not stated
Number of participants: 85
Included studies: 6
Year range: 2000–2016
All included studies in review applicable
to this review: yes
Study designs: qualitative case study
design; qualitative evaluation design;
quantitative longitudinal design;
qualitative exploratory design;
longitudinal qualitative design;
comparative quantitative design
Country: Italy; USA; Canada; UK
Number of participants: 137
Included studies: 18; 6 systematic reviews
were located and appraised but not
included in analysis
Year range: 2004–2016
All included studies in review applicable
to this review: no, 17 relevant
Study designs: RCT; non-RCT; case–
control; quasi-experimental; feasibility
study; pilot study; prospective study;
case report
Country/setting: not stated
STERN AND CHUR-HANSEN
TABLE 3 (Continued)
Author (year) Objectives of systematic review
Rampling et al. (2016) To aggregate the evidence base for
non-pharmacological interventions in
reducing violence among adults with
SMI and PD, and to assess the
efficacy of these interventions
Srinivasan et al. (2018) To examine the effects of equine
therapy on specific domains
including social, communication,
behavioural, and sensorimotor skills
as well as broader functional
outcomes including overall adaptive
functioning and quality of life
Stergiou et al. (2017) To determine whether THR and
hippotherapy improve balance,
motor function, gait, muscle
symmetry, pelvic movement,
psychosocial parameters, & the
patients' overall quality of life
Tseng et al. (2013) To evaluate the literature on the
efficacy of equine-assisted activities
and therapies on gross motor
outcomes representing the ICF
component of body functions and
activity in children with CP
Whalen and Case-Smith (2012) To determine the efficacy of
hippotherapy or THR on motor
outcomes in children with CP
White-Lewis et al. (2017) What are outcomes of equine-assisted
therapy interventions studies in
adults?
What is the significance of these
outcomes?
What are various interventions, controls
and comparisons that are identified?
What is the quality, including
internal/external validity, bias, power
and reporting?
What research designs are reported?
What are study strengths and
limitations?
What theoretical/conceptual
frameworks have been used to guide
this research?
What doses, frequency and duration of
equine-assisted interventions have
been used?
Review inclusion criteria
stride; evaluation of the quality of life;
various daily life activities, for example,
jumping, balance in jumping, resistance
and ascending and descending stairs
Participants: adults (18 and over) with a
primary diagnosis of SMI and/or PD
with a history of violence or aggression
(not sexual)
Interventions: any form of specific
non-pharmacological intervention
Outcomes: violence outcomes
Participants: no predefined criteria
Interventions: equine therapy
Outcomes: social, communication,
behavioural, and sensorimotor skills as
well as broader functional outcomes
including overall adaptive functioning
and quality of life
Participants: children, adults & the elderly
with diagnoses associated with
impairments in motor function
Interventions: hippotherapy or THR
Outcomes: postural control, balance, gait,
and spasticity as well as overall quality
of life indicators
Participants: children with spastic CP
under 18 years
Interventions: hippotherapy or THR
Outcomes: postural control; gait; gross
motor activity; muscle activity and tone
Participants: a diagnosis of CP (all types),
under 18 years
Interventions: hippotherapy or THR; a
physical therapist, occupational therapist,
or an accredited therapeutic riding
instructor implemented the intervention
Outcomes: gross motor outcomes
Participants: age 16 years of age or older
Interventions: intervention involving a
living horse or horses
Outcomes: physical symptoms
369
Characteristics of included studies
Number of participants (relevant to this
review): 558
Included studies: 23
Year range: 2003–2015
All included studies in review applicable
to this review: no, 1 relevant
Study designs: RCT
Country/setting: US
Number of participants (relevant to this
review): 90
Included studies: 15
Year range: 2009–2016
All included studies in review applicable
to this review: no, 14 relevant
Study designs: 3 RCTs; 4 controlled
clinical trials; 1 crossover; 5 single
group pre-test post-test studies/multiple
time points; 2 single subject design
Country/setting: US; Spain; Canada; UK;
Italy; Slovakia
Number of participants: 368
Included studies: 16
Year range: 1995–2015
All included studies in review applicable
to this review: yes
Study designs: studies with a
control/comparison group or
self-controlled
Country/setting: not stated
Number of participants: 505
Included studies: 15
Year range: 1988–2011
All included studies in review applicable
to this review: yes
Study designs: RCTs; observational
studies
Country/setting: not stated
Number of participants: 277
Included studies: 9
Year range: 1988–2009
All included studies in review applicable
to this review: yes
Study designs: 2 RCTs; 2 one-group
pre-test–post-test designs;
5 repeated-measures within-subject
designs
Country/setting: not stated
Number of participants: 157
Included studies: 31
Year range: 1988–2015
All included studies in review applicable
to this review: yes
Study designs: 12 RCTs;
19 quasi-experimental
Country/setting: Korea (n = 8); US
(n = 7); Brazil (n = 4); Germany
(n = 3); Italy (n = 3); Switzerland
(n = 2); Canada (n = 1); Portugal
(n = 1); Spain; (n = 1); Sweden
(n = 1)
Number of participants: 601
370 STERN AND CHUR-HANSEN

TABLE 3 (Continued)

Author (year)
Wonsetler and Bowden (2017)
Objectives of systematic review
To examine changes in spatiotemporal
variables and asymmetry measures in
intervention studies associated with
significant changes in SSWS
To differentiate between spatiotemporal
raw variables and measures of
asymmetry in their potential
relationship with motor recovery
Review inclusion criteria
Participants: adult participants; >18 years
of age; clinically diagnosed with stroke,
regardless of time since diagnosis and
lesion site
Interventions: any clinical physical therapy
intervention to effect gait
Outcomes: spatiotemporal variables and
asymmetry measures associated with
SSWS
Characteristics of included studies
Included studies: 46
Year range: 1995–2015
All included studies in review applicable
to this review: no, 1 relevant
Study designs: quasi-experimental
Country/setting: not stated
Number of participants (relevant to this
review): 15

Note. ASD: autism spectrum disorder; CP: cerebral palsy; DD: developmental delay; EAI: equine-assisted intervention; EAP: equine-assisted psychotherapy; EAT:
equine-assisted therapy; ICF: international classification of functioning, disability and health; MS: multiple sclerosis; ND: neurological disorders; PD: personality disor-
der; PDD: pervasive developmental disorder; RCT: randomised controlled trial; SMI: serious mental illness; SR: systematic review; SSWS: self-selected walking speed;
THR: therapeutic horseback riding.

intervention. The studies included in Bremer et al. (2016)
were all included in Srinivasan et al. (2018) so the results of
this review will be reported. Outcomes were grouped into
domains with the most commonly measured outcomes being
social communication, behavioural, and motor. Of the
11 studies measuring social communication outcomes, nine
showed significant improvements, for behavioural outcomes,
five of seven studies showed significant improvement and
for motor outcomes, four of seven studies showed significant
improvement. Three out of four studies measuring sensory
outcomes showed significant results while for quality of life
outcomes, two out of three studies demonstrated improve-
ments. Physiological, functional participation, and executive
functioning domains only comprised of one study each and
all showed significant effects following the intervention. The
authors of this review went on to calculate effect sizes across
domains and from those in which confidence intervals did
not include zero concluded that the intervention only pro-
duced positive effects in the behavioural domain.
3.4.3 | Adults with multiple sclerosis
Three systematic reviews (Bronson et al., 2010; Stergiou
et al., 2017; White-Lewis et al., 2017) constituting eight
unique studies examined the role of hippotherapy and/or
THR in people with multiple sclerosis. The majority of out-
comes measured related to balance and gait. All but one
study that measured balance showed improvement following
the intervention. This was also the same for gait. Other out-
comes measured in individual studies that showed improve-
ments included global severity, health status, depression,
speed/stride, postural stability/control, spasticity, mobility,
muscle tension, ground reaction force, and fatigue, while
activities of daily living, pain, disability, somatisation, qual-
ity of life, sway, and function did not show improvements.
3.4.4 | Elderly
Stergiou et al. (2017) and White-Lewis et al. (2017) (consti-
tuting a total of nine unique studies) included elderly partici-
pants and looked at elements of mobility and balance.
Pooled results of two studies (one hippotherapy and one
THR) showed no significant improvement in balance
between intervention and control groups (MD: 0.94, 95%
CI: −0.04 to 1.92, p = 0.06). Results were mixed with the
timed up and go test (two studies) and muscle strength (two
studies) while improvements in step length and sway length,
gait, brain activity, body composition, quality of life and
hormone levels were noted (all measured in single studies).
3.4.5 | Adults post-stroke
Three systematic reviews (Stergiou et al., 2017; White-
Lewis et al., 2017; Wonsetler & Bowden, 2017) examined
the effect of hippotherapy or THR on adults following
stroke, however, this constituted only three unique studies.
Motor impairment in the lower limbs (Stergiou et al., 2017;
White-Lewis et al., 2017), gait velocity (White-Lewis et al.,
2017), step length asymmetry (White-Lewis et al., 2017;
Wonsetler & Bowden, 2017), and quality of life (White-
Lewis et al., 2017) demonstrated statistically significant
improvements while balance (White-Lewis et al., 2017),
ambulation (White-Lewis et al., 2017), and cadence did not
(White-Lewis et al., 2017).
3.4.6 | Spinal cord injuries
One review undertaken by White-Lewis et al. (2017)
included three studies of participants with spinal cord inju-
ries. Out of the outcomes measured (spasticity, pain, and
well-being), only spasticity improved significantly following
hippotherapy compared to the control. There was no differ-
ence in pain between the intervention and control groups
and results were mixed for well-being. One study included
multiple morbidities and data regarding spinal cord injuries
could not be extracted individually and thus is not
reported here.
3.4.7 | Adults with serious mental illness
Two reviews representing two studies focused on adults with
SMI, one with schizophrenia/like diagnoses (Jormfeldt &
Carlsson, 2018) and the other on people with SMI who had
a history of aggression (Rampling et al., 2016). An improve-
ment in negative psychiatric symptoms and a reduction in
hospitalisations were noted in the first study using THR (sta-
tistical data not provided) while a statistically significant
STERN AND CHUR-HANSEN
reduction in violent incidences and aggression was reported
in the other study utilising hippotherapy.
3.4.8 | Adults
White-Lewis et al. (2017) included two studies measuring
balance in adults and both reported improvements. The
review also included two studies (published in the same arti-
cle) looking at strength-disabled adults and reported
improvements in self-concept and strength/coordination.
3.4.9 | Brain disorders
Significant improvements post-hippotherapy in balance, gait
and walking were seen in White-Lewis et al., 2017 (one
study) in people with brain disorders. No changes in depres-
sion and functional ambulation were demonstrated.
3.4.10 | Breast cancer survivors
The effect of THR on breast cancer survivors was measured
in White-Lewis et al. (2017) (one primary study). Significant
improvement in cardiac fitness, body composition, strength,
and quality of life were reported.
3.4.11 | Obese women
White-Lewis et al. (2017) also included a study looking at
the weight and gait of obese women. Statistically significant
improvement in BMI and gait were reported.
3.4.12 | Other
White-Lewis also included one study containing people with
“physical/psychosocial-intellectual disability,” however,
details on the dosage of the intervention, measurement tools
and outcome comparisons were not provided therefore
results are not reported.
3.5 | Qualitative findings
3.5.1 | Adults with serious mental illness
The review by Jormfeldt and Carlsson (2018) included four
qualitative studies. Only a narrative summary of each study
was provided with no participant illustrations provided.
Overall, all studies reported positive experiences of partici-
pants involved in the program with no negative experiences
or issues mentioned. Positive elements reported related to
the relationship between the horse and the participant; the
experience being a “stepping stone” for participants; the
acquirement of transferrable skills; and psychosocial benefits
including improved confidence, self-esteem, self-concept,
and self-efficacy.
4 | DISCUSSION
Based on the 79 unique studies that were considered in our
umbrella review of 13 separate systematic reviews of the lit-
erature on EAIs, largely comprising of hippotherapy and
371
THR, the conclusion from this present study is that the evi-
dence that such interventions are beneficial across biologi-
cal, social and psychological domains, across the lifespan, is
equivocal. While some studies report improvements, and
others do not, the current evidence base is flawed and com-
promised by serious methodological weaknesses in study
design. At this point in time, therefore, while it may be that
therapeutic interventions that include a horse have benefits,
such interventions cannot be confidently advocated as best
practice, based on current research evidence.
All of the review articles included in this study noted
similar methodological challenges in their included articles,
particularly around risk of bias (Wonsetler & Bowden,
2017). For example, Whalen and Case-Smith (2012) noted
that the research design of all studies in their review was a
limitation, with the majority of studies using repeated mea-
sures, within-subject or one group pre-test–post-test designs.
Small sample sizes, no control group or comparison groups,
no randomisation, and lack of detail about the intervention
were further methodological weaknesses. Despite this,
although, Whalen and Case-Smith concluded that there is
evidence that hippotherapy and THR may have positive
effects on gross motor function in children with cerebral
palsy. Bronson et al. (2010) identified small sample sizes,
lack of standardised outcome measures, lack of randomisa-
tion, and case–control and case series designs as methodo-
logical challenges in their review, yet also concluded that
hippotherapy has a positive effect on balance in persons with
multiple sclerosis and enhances quality of life.
One challenge of reviewing and combining the evidence
in the area of EAIs is the diversity of methods of interven-
tion (e.g., frequency, duration, content, and personnel
involved), terminologies used, outcome measures and tools
employed, as well as the presenting issue or condition for
treatment. This dilemma has been noted by other reviewers
(Lee et al., 2016). The interdisciplinarity of EAIs also poses
a challenge, insofar as the approaches taken in the design of
studies and the outcome measures of interest are not com-
mon across studies. This review highlights the focus on bio-
logical or physical aspects of health, such as balance and
gait and a corresponding dearth of research into psychologi-
cal health: for example, there were no studies identified on
EAIs for depression. Anestis, Anestis, Zawilinski, Hopkins,
and Lilienfeld (2014), in their review of equine-related treat-
ments for “mental disorders,” concluded that existing studies
are so flawed, and the evidence base so weak, that these
interventions should not be offered to the public. This strong
stance is noteworthy in the context that many authors sup-
port the use of EAIs and argue for its benefits, even in light
of the lack of evidence. Jormfeldt and Carlsson (2018) state
that even though further research is necessary for a solid evi-
dence base, people with severe mental illnesses such as
schizophrenia may benefit from EAIs. However, Anestis
et al. are not alone in their position that advocating for
372
equine therapies is unwarranted. Tseng et al. (2013) simi-
larly drew the conclusion, based on their meta-analysis, that
there is no evidence that THR or hippotherapy improves
gross motor function for children with cerebral palsy.
The limited number of studies that exist is also notewor-
thy, given the seeming popularity of interventions that
include horses. Stergiou et al. (2017), in their meta-analysis,
decried that they could only identify eight studies for inclu-
sion. These eight studies, on hippotherapy and THR,
included participants from children through to the elderly,
and with a range of physical health problems. Consistent
with other reviews, the need for further, better designed
research was the conclusion made, though the authors con-
cluded that these interventions appear to be viable options
for balance, gait, and psychomotor disorders. The limited
number of high-quality studies on which to base systematic
reviews and meta-analyses and the heterogeneity of partici-
pants, compromise the evidence base for EAIs.
There are some limitations to this umbrella review. Man-
uscripts that were not in English that may have been eligible
were excluded (Mansfeld, 2002; Moraes, da Silva, Copetti,
Abreu, & de David, 2015; Prieto, Silva, Silva, Santos, &
Gutierres Filho, 2018). The majority of eligible studies were
quantitative. While this is not a limitation to our study, it is
interesting that given the number of qualitative studies in the
area of AAT and AAI, there was only one located involving
EAIs that was subsequently included. Future research is
indicated that is based on well-designed qualitative methods.
Although the search of databases and resources consid-
ered unpublished and/or grey literature and the review subse-
quently included one thesis, publication bias is also
acknowledged. During study screening a few theses were
identified that may have met the inclusion criteria but could
either not be located or due to budget constraints the full-text
was not obtained. Unpublished and/or grey literature plays
an important role in reducing publication bias by producing
a more balanced picture of available evidence and should
thus be included in reviews wherever feasible.
As alluded to previously, the heterogeneity of the
included articles in terms of populations, interventions and
comparators, outcomes and study design precluded pooling
of studies across the majority of reviews. The relatively
small number of studies and the large amount of duplication
across reviews suggests more primary studies may be needed
in the area as well as indicating potentially unnecessary or
redundant synthesis has been undertaken. While some inde-
pendent replication can be worthwhile, it has also been criti-
cised (see Konstantinos, Siontis, Hernandez-Boussard, &
Ioannidis, 2013) and deliberation on approaches to efficient
synthesis of evidence and the reduction of “research waste”
should be considered.
Although the assessment of methodological quality of
the 13 systematic reviews that were included in this umbrella
review indicated that the majority of included articles were
STERN AND CHUR-HANSEN
of good quality and specific assessment criteria deemed
essential were established a priori, some methodological lim-
itations were noted. In particular, Q8 of the appraisal tool
around methods to combine studies; although most (if not
all) of the articles acknowledged the heterogeneity across
studies many did not explicitly outline their approach to data
synthesis and made no mention of the intention to statisti-
cally combine studies but simply provided a narrative sum-
mary. Important statistical data were not provided in some
articles (in one review supplementary data was not accessi-
ble) and in one article systematic reviews were included and
appraised but subsequently not included in the results. Addi-
tionally, for Q2 regarding appropriate inclusion criteria,
many articles were broad in defining inclusion criteria in
terms of outcomes, associated tools and interventions.
Assessment of publication bias was rarely undertaken and
some of the appraisal tools used were general and not spe-
cific to study design. The short-term nature of outcome mea-
surement was common with very few measuring long-term
follow-up. In terms of data, some discrepancies in figures
presented in the narrative and the tabular format were evi-
dent and in one article the authors reanalysed the primary
data and reported variations in results between their calcula-
tions and that of the primary study authors. Finally, it was
unclear why some studies calculated effect sizes but did not
go on to pool studies. Based on these issues a modified
approach to how to present data was warranted in this
umbrella review; however, the authors acknowledge this as a
deviation from the JBI methodology.
The need for well-designed (and well-reported), rigorous
quantitative and qualitative methodologies to assess the
impact of EAIs is clear. This call for better methods is not
new. Indeed, researchers in the field of anthrozoology have
been calling for higher level standards in research for a num-
ber of years (Chur-Hansen et al., 2010). With regards to
quantitative approaches, including experimental designs,
Kazdin (2015) lists randomisation to conditions, clear inclu-
sion and exclusion criteria for participants, strong control
and comparison groups, the use of treatment manuals and
protocols, assessment of treatment integrity, the use of multi-
ple (reliable and valid) outcome measures, the evaluation of
both clinical significance as well as statistically significant
change, and follow-up or longitudinal data collection. There
are some promising signs that some progress is being made:
for example, Srinivasan et al. (2018) in their systematic
review of equine therapy for people with ASD were the first
to report of the size of treatment effects by calculating effect
size estimates and their 95% confidence intervals. Tseng
et al.'s (2013) meta-analysis is noteworthy, with a second
meta-analysis published in 2017 by Stergiou et al. (2017).
Herzog (2015) has called for an AAT Clinical Trial Registry,
which to date, does not exist. Qualitative research similarly
needs to follow trustworthy and rigorous methods, with clear
research questions articulated (Stern & Chur-Hansen, 2013),
STERN AND CHUR-HANSEN
and well-designed methods of data collection, analysis and
reporting adhered to (Braun & Clarke, 2006, 2013). One
contribution of the current umbrella review is the evidence
that standardised approaches to the implementation and eval-
uation of interventions is a fundamental requirement for this
field to produce credible and convincing data to support the
claim that EAIs are effective. Without this, health profes-
sionals cannot reasonably or ethically assert that interven-
tions with horses are beneficial to humans. Similarly, the
community cannot be confident that the treatments they are
receiving have demonstrated efficacy. It is noteworthy that
Serpell, McCune, Gee, and Griffin (2017) have highlighted
public and media pressure to report positive findings related
to AAIs. Consequently, findings that show no effects, or
where human or animal welfare might be compromised, are
likely underreported, in both the academic and wider com-
munity literature. As scientist-practitioners, psychologists
are well placed to make meaningful contributions to knowl-
edge in this area, and we call upon scholars to conduct high
quality research to provide an evidence base from which to
advocate for EAIs, or not, from a position of theoretical and
methodological strength.
ORCID
Cindy Stern https://orcid.org/0000-0002-0924-5042
Anna Chur-Hansen https://orcid.org/0000-0002-2935-
2689
REFERENC ES
Abraha, I., Rimland, J. M., Trotta, F. M., Dell'Aquila, G., Cruz-Jentoft, A.,
Petrovic, M., … Cherubini, A. (2017). Systematic review of systematic
reviews of non-pharmacological interventions to treat behavioural distur-
bances in older patients with dementia. The SENATOR-OnTop series. Brit-
ish Medical Journal Open, 7(3), e012759. https://doi.org/10.1136/bmjopen-
2016-2759
Anestis, M. D., Anestis, J. C., Zawilinski, L. L., Hopkins, T. A., &
Lilienfeld, S. O. (2014). Equine-related treatments for mental disorders lack
empirical support: A systematic review of empirical investigations. Journal
of Clinical Psychology, 70(12), 1115–1132. https://doi.org/10.1002/jclp.
22113
Anttila, H., Suoranta, J., Malmivaara, A., Mäkelä, M., & Autti-Rämö, I. (2008).
Effectiveness of physiotherapy and conductive education interventions in
children with cerebral palsy: A focused review. American Journal of Physi-
cal Medicine & Rehabilitation, 87(6), 478–501. https://doi.org/10.1097/
PHM.0b013e318174ebed
Aromataris, E., Fernandez, R., Godfrey, C., Holly, C., Khalil, H., &
Tungpunkom, P. (2017). Umbrella reviews. Joanna Briggs Institute
Reviewer's Manual. Adelaide, Australia: The Joanna Briggs Institute.
Retrieved from https://reviewersmanual.joannabriggs.org/
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualita-
tive Research in Psychology, 3(2), 77–101. https://doi.org/10.
1191/1478088706qp063oa
Braun, V., & Clarke, V. (2013). Successful qualitative research: A practical
guide for beginners. London, England: Sage.
Bremer, E., Crozier, M., & Lloyd, M. (2016). A systematic review of the beha-
vioural outcomes following exercise interventions for children and youth
with autism spectrum disorder. Autism, 20(8), 899–915. https://doi.org/10.
1177/1362361315616002
Bronson, C., Brewerton, K., Ong, J., Palanca, C., & Sullivan, S. J. (2010). Does
hippotherapy improve balance in persons with multiple sclerosis: A
373
systematic review. European Journal of Physical and Rehabilitation Medi-
cine, 46(3), 347–353.
Casady, R. L., & Nichols-Larsen, D. S. (2004). The effect of hippotherapy on
ten children with cerebral palsy. Pediatric Physical Therapy, 16(3),
165–172. https://doi.org/10.1097/01.PEP.0000136003.15233.0C
Chur-Hansen, A., Stern, C., & Winefield, H. (2010). Gaps in the evidence about
companion animals and human health: Some suggestions for progress. Inter-
national Journal of Evidence-Based Healthcare, 8(3), 140–146. https://doi.
org/10.1111/j.1744-1609.2010.00176.x
Dewar, R., Love, S., & Johnston, L. M. (2014). Exercise interventions improve
postural control in children with cerebral palsy: A systematic review. Devel-
opmental Medicine and Child Neurology, 57(6), 504–520. https://doi.org/10.
1111/dmcn.12660
Engel, G. (1980). The clinical application of the biopsychosocial model. Ameri-
can Journal of Psychiatry, 137, 535–544.
Fine, A. (Ed.). (2015). Handbook on animal-assisted therapy: Theoretical foun-
dations and guidelines for animal-assisted interventions (4th ed.). London,
England: Elsevier/Academic Press.
Francis, B. A. A. (2007). Effects of therapeutic horseback riding and hippother-
apy for children with cerebral palsy, developmental delay and neurological
disorders: Systematic literature review. (Doctoral dissertation). MGH Insti-
tute of Health Professions.
Friedmann, E., & Son, H. (2009). The human–companion animal bond: How
humans benefit. Veterinary Clinics: Small Animal Practice, 39(2), 293–326.
https://doi.org/10.1016/j.cvsm.2008.10.015
Granger, B. P., & Kogan, L. (2006). Animal-assisted therapy in specialized set-
tings. In A. H. Fine (Ed.), Handbook on animal-assisted therapy: Theoretical
foundations and guidelines for practice (2nd ed., pp. 213–236). San Diego,
CA: Academic Press.
Herzog, H. (2015). The research challenge: Threats to the validity of animal-
assisted therapy studies and suggestions for improvement. In A. H. Fine
(Ed.), Handbook on animal-assisted therapy: Theoretical foundations and
guidelines for animal-assisted interventions (4th ed., pp. 402–407). London,
England: Elsevier/Academic Press.
Hilliere, C., Collado-Mateo, D., Villafaina, S., Duque-Fonseca, P., &
Parraça, J. A. (2018). Benefits of hippotherapy and horse riding simulation
exercise on healthy older adults: A systematic review. Physical Medicine
and Rehabilitation, 10(10), 1062–1072. https://doi.org/10.1016/j.pmrj.2018.
03.019
Hines, L. M. (2003). Historical perspectives on the human–animal bond.
American Behavioral Scientist, 47(1), 7–15. https://doi.org/10.1177/
0002764203255206
Jormfeldt, H., & Carlsson, I. M. (2018). Equine-assisted therapeutic interventions
among individuals diagnosed with schizophrenia. A systematic review.
Issues in Mental Health Nursing, 39(8), 647–656. doi, https://doi.org/10.
1080/01612840.2018.1440450
Kazdin, A. E. (2015). Methodological standards and strategies for establishing
the evidence base of animal-assisted therapies. In A. Fine (Ed.), Handbook
on animal-assisted therapy: Theoretical foundations and guidelines for
animal-assisted interventions (4th ed., pp. 378–389). London, England:
Elsevier/Academic Press.
Konstantinos, C., Siontis, K. C., Hernandez-Boussard, T., & Ioannidis, J. P. A.
(2013). Overlapping meta-analyses on the same topic: Survey of published
studies. British Medical Journal, 347, f4501. https://doi.org/10.1136/bmj.
f4501
Kruger, K. A., & Serpell, J. A. (2006). Animal-assisted interventions in mental
health: Definitions and theoretical foundations. In A. H. Fine (Ed.), Hand-
book on animal-assisted therapy: Theoretical foundations and guidelines for
practice (2nd ed., pp. 21–38). San Diego, CA: Academic Press.
Kwon, J. Y., Chang, H. J., Lee, J. Y., Ha, Y., Lee, P. K., & Kim, Y. H. (2011).
Effects of hippotherapy on gait parameters in children with bilateral spastic
cerebral palsy. Archives of Physical Medicine and Rehabilitation, 92(5),
774–779. https://doi.org/10.1016/j.apmr.2010.11.031
Latella, D., & Abrams, B. N. (2015). The role of the equine in animal-assisted
interactions. In A. Fine (Ed.), Handbook on animal-assisted therapy: Theo-
retical foundations and guidelines for animal-assisted interventions (4th ed.,
pp. 115–137). London, England: Elsevier/Academic Press.
Lee, P. T., Dakin, E., & McLure, M. (2016). Narrative synthesis of equine-
assisted psychotherapy literature: Current knowledge and future research
directions. Health & Social Care in the Community, 24(3), 225–246. https://
doi.org/10.1111/hsc.12201
374
Lee, W., So, B. R., Lee, Y., & Moon, C. (2018). A new robotic horseback-riding
simulator for riding lessons and equine-assisted therapy. International Jour-
nal of Advanced Robotic Systems, 15(4), 1–11. https://doi.org/10.1177/
1729881418784433
MacKinnon, J. R., Noh, S., Laliberte, D., Allan, D. E., & Lariviere, J. (1995).
Therapeutic horseback riding: A review of the literature. Physical & Occupa-
tional Therapy in Pediatrics, 15(1), 1–15. https://doi.org/10.1080/
J006v15n01_01
Mansfeld, K. (2002). Meta-analysis of animal assisted therapy: A literature
review. (Doctoral dissertation). University of Vienna, School of Humanities
and Social Sciences, Institute of Psychology.
Marquez, J., Weerasekara, I., & Chambers, L. (2018). Hippotherapy in adults
with acquired brain injury: A systematic review. Physiotherapy Theory and
Practice, 1–12. https://doi.org/10.1080/09593985.2018.1494233
Martín-Valero, R., Vega-Ballón, J., & Perez-Cabezas, V. (2018). Benefits of hip-
potherapy in children with cerebral palsy: A narrative review. European
Journal of Paediatric Neurology, 22(6), 1150–1160. https://doi.org/10.1016/
j.ejpn.2018.07.002
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G.; The PRISMA Group.
(2009). Preferred reporting items for systematic reviews and meta-analyses:
The PRISMA statement. PLoS Medicine, 6(7), e1000097. https://doi.org/10.
1371/journal.pmed.1000097
Moraes, A. G., da Silva, M. L., Copetti, F., Abreu, A. C., & de David, A. (2015).
Hippotherapy in the postural control and balance in individuals with cerebral
palsy: Systematic review. Revista Neurociências, 23(4), 546–554. https://doi.
org/10.4181/RNC.2015.23.04.1062.09p
Novak, I., Mcintyre, S., Morgan, C., Campbell, L., Dark, L., Morton, N., …
Goldsmith, S. (2013). A systematic review of interventions for children with
cerebral palsy: State of the evidence. Developmental Medicine and Child
Neurology, 55(10), 885–910.
Prieto, A. V., Silva, F. C., Silva, R., Santos, J. A. T., & Gutierres, P. J. B., Filho.
(2018). A equoterapia na reabilitação de indivíduos com paralisia cerebral:
uma revisão sistemática de ensaios clínicos [The hippotherapy in the rehabil-
itation of individuals with cerebral palsy: A systematic review of clinical tri-
als]. Brazilian Journal of Occupational Therapy, 26(1), 207–218. https://doi.
org/10.4322/2526-8910.ctoAR1067
Rampling, J., Furtado, V., Winsper, C., Marwaha, S., Lucca, G., Livanou, M., &
Singh, S. P. (2016). Non-pharmacological interventions for reducing aggres-
sion and violence in serious mental illness: A systematic review and narrative
synthesis. European Psychiatry, 34, 17–28. https://doi.org/10.1016/j.eurpsy.
2016.01.2422
Selby, A., & Smith-Osborne, A. (2013). A systematic review of effectiveness of
complementary and adjunct therapies and interventions involving equines.
Health Psychology, 32(4), 418–432. https://doi.org/10.1037/a0029188
Serpell, J., McCune, S., Gee, N., & Griffin, J. A. (2017). Current challenges to
research on animal-assisted interventions. Applied Developmental Science,
21(3), 223–233. https://doi.org/10.1080/10888691.2016.1262775
Shen, R. Z., Xiong, P., Chou, U. I., & Hall, B. J. (2018). “We need them as much
as they need us”: A systematic review of the qualitative evidence for possible
mechanisms of effectiveness of animal-assisted intervention (AAI). Comple-
mentary Therapies in Medicine, 41, 203–207. https://doi.org/10.1016/j.ctim.
2018.10.001
Snider, L., Korner-Bitensky, N., Kammann, C., Warner, S., & Saleh, M. (2007).
Horseback riding as therapy for children with cerebral palsy: Is there evi-
dence of its effectiveness? Physical & Occupational Therapy in Pediatrics,
27(2), 5–23.
STERN AND CHUR-HANSEN
Srinivasan, S. M., Cavagnino, D. T., & Bhat, A. N. (2018). Effects of equine
therapy on individuals with autism spectrum disorder: A systematic review.
Review Journal of Autism and Developmental Disorders, 5, 1–20. https://
doi.org/10.1007/s40489-018-0130-z
Sterba, J. A. (2007). Does horseback riding therapy or therapist-directed hip-
potherapy rehabilitate children with cerebral palsy? Developmental Medicine
and Child Neurology, 49(1), 68–73.
Stergiou, A., Tzoufi, M., Ntzani, E., Varvarousis, D., Beris, A., & Ploumis, A.
(2017). Therapeutic effects of horseback riding interventions: A systematic
review and meta-analysis. American Journal of Physical Medicine & Reha-
bilitation, 96(10), 717–725. https://doi.org/10.1111/j.1469-8749.2007.
0175a.x
Stern, C., & Chur-Hansen, A. (2013). Methodological considerations in design-
ing and evaluating animal-assisted interventions. Animals, 3(1), 127–141.
https://doi.org/10.3390/ani3010127
Stern, C., & Chur-Hansen, A. (2018). Animal-assisted interventions in health
and social care: An umbrella review protocol. PROSPERO 2018 CRD42018
100796. Retrieved from http://www.crd.york.ac.uk/PROSPERO/display_
record.php?ID=CRD42018100796
Tseng, S. H., Chen, H. C., & Tam, K. W. (2013). Systematic review and meta-
analysis of the effect of equine assisted activities and therapies on gross
motor outcome in children with cerebral palsy. Disability and Rehabilitation,
35(2), 89–99. https://doi.org/10.3109/09638288.2012.687033
Whalen, C. N., & Case-Smith, J. (2012). Therapeutic effects of horseback riding
therapy on gross motor function in children with cerebral palsy: A systematic
review. Physical & Occupational Therapy in Pediatrics, 32(3), 229–242.
White-Lewis, S., Russell, C., Johnson, R., Cheng, A. L., & McClain, N. (2017).
Equine-assisted therapy intervention studies targeting physical symptoms in
adults: A systematic review. Applied Nursing Research, 38, 9–21. https://
doi.org/10.1016/j.apnr.2017.08.002
Wiese, C., Simpson, R., & Kumar, S. (2016). The effectiveness of equine-based
therapy in the treatment of social and behavioural aspects of children with
autism spectrum disorder: A systematic review. Internet Journal of Allied
Health Sciences and Practice, 14(3), 12.
Wonsetler, E. C., & Bowden, M. G. (2017). A systematic review of mechanisms
of gait speed change post-stroke. Part 1: Spatiotemporal parameters and
asymmetry ratios. Topics in Stroke Rehabilitation, 24(6), 435–446. https://
doi.org/10.1080/10749357.2017.1285746
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 and Child Neurology, 53
(8), 684–691. https://doi.org/10.1111/j.1469-8749.2011.03951.x
SUPPORTING I NFORMATION
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How to cite this article: Stern C, Chur-Hansen A.
An umbrella review of the evidence for equine-
assisted interventions. Aust J Psychol. 2019;71:
361–374. https://doi.org/10.1111/ajpy.12246