R E S E A R C H R E P O R T S : S Y S T E M A T I C R E V I E W

Effects of Hippotherapy on Postural Control in Children With Cerebral Palsy: A

Systematic Review
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Fernanda Peia, PT; Nathalie Caroline Veiga, PT; Ana Paula Gomes, PT; Bruna Neves dos Santos, PT;
Nívia Maria Silva Marques, PT; Igor Phillip dos Santos Glória, PhD; Juliana Barbosa Goulardins, PhD
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Universidade Cruzeiro do Sul, São Paulo, Brazil.

Purpose: To summarize and update the current knowledge on the effectiveness of hippotherapy on postural control in
children with cerebral palsy.
Methods: Using a systematic review methodology, the electronic databases PubMed, Virtual Health Library, PEDro, Scielo,
Embase, and Web of Science were searched for eligible articles from 2011 up to September 2021. Quality assessment of
eligible studies was performed using the PEDro scale.
Results: There were 239 identified studies. Eight clinical trials were selected. The total sample consisted of 264 individuals,
with 134 allocated to the experimental group (hippotherapy) and 130 individuals to the control group (conventional
therapy). Most studies had moderate to high methodological quality.
Conclusions: Hippotherapy can be an effective intervention to improve several aspects related to postural control, such as
static balance (especially in the sitting posture), dynamic balance, and alignment (body posture) in children aged 3 to 16
years, particularly with spastic hemiplegia or diplegia.
What This Adds to the Evidence: This review summarizes studies that explore potential effects of hippotherapy on postural
control in children with cerebral palsy. (Pediatr Phys Ther 2023;35:202–210)
Key words: adolescents, cerebral palsy, children, hippotherapy

INTRODUCTION and severity of impairments; therefore, it is described using

Cerebral palsy (CP) is one of the most common physical
and developmental disabilities in childhood.1,2 CP is based on a
combination of clinical signs, neurologic symptoms, limitations
in motor activity, and participation restrictions.3 It is a heteroge-
neous condition in terms of etiology, type of motor impairment,
0898-5669/110/3502-0202
Pediatric Physical Therapy
Copyright © 2023 Academy of Pediatric Physical Therapy of the American
Physical Therapy Association
Correspondence: Juliana Barbosa Goulardins, PhD, Av. Dr. Ussiel Cirílo,
225 Vila Jacuí, São Paulo, SP 08060-070, Brazil (juligoulardins@
gmail.com).
At the time this article was written, Ana Paula Gomes, Bruna Neves dos
Santos, Fernanda Peia, Nathalie Caroline Veiga, and Nívia Maria Silva
Marques were undergraduate students at Universidade Cruzeiro do Sul, São
Paulo, Brazil.
The affiliation for Juliana Barbosa Goulardins has been updated to Postdoc-
toral fellow, Health Technologies Program, Escola Bahiana de Medicina e
Saúde Pública (EBMSP), Bahia, Brazil.
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.pedpt.com).
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000999
different classifications. As for the types of motor impair-
ment, the spastic (70%-80%), dyskinetic (12%-14%) (which
includes dystonia and choreoathetosis), and ataxic (4%) forms
are described.4,5 As for topography, the spastic form is classified
as unilateral, also known as hemiplegia (40%-60%), affecting
one side of the body; or bilateral, affecting both sides of the
body and including diplegia (10%-36%), with lower limbs more
affected than upper limbs, and quadriplegia (24%-31%), with
trunk and all 4 limbs affected.5,6
The child’s level of gross motor function and mobility
and motor development curves is established using the Gross
Motor Function Classification System (GMFCS), which predicts
motor severity of CP in children older than 2 years.7,8 The
GMFCS describes the performance of children aged 2 to 18
years, stratifying function into 5 levels of motor independence,
ranging from I, which includes the presence of minimal or no
dysfunction with respect to community mobility, to V, when
there is total dependence requiring mobility assistance. Motor
functions involve lying down and rolling, sitting, crawling
and kneeling, standing and walking, running, and jumping,
playing a significant role in decisions about interventions to be
performed.9
Functional outcome in CP depends on a few factors in addi-
tion to motor function, including intelligence, physical function,
communication skills, personality attributes, social, environ-
mental factors, and specialized medical care2,6 In addition,

202 Peia et al Pediatric Physical Therapy

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 compromised posture and movement lead to mechanical and
structural changes in body alignment, and consequently, to com-
pensatory mechanisms to overcome gravity and recruit muscle
groups, maintaining stability. However, these long-term com-
pensations lead to a muscle imbalance that leads to a deficit
in postural control, which is essential for the development of
functional activities.10-12
Postural control requires controlling the body’s position in
space for the dual purposes of stability and orientation, which
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vary with the task and environment.13 Postural stability or bal-
ance is the ability to control the center of mass in relation to
the base of support or within stability limits, maintaining body
stability both in static and dynamic conditions, through the
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relationship of the various forces acting on the body, including
gravity, muscular, and inertial forces.13 Postural orientation is
defined as the ability to maintain the appropriate relationship
between body segments and between the body and the environ-
ment, and depends on controlling postural alignment and tone
in relation to gravity, the supporting surface, internal references,
and sensory input.13-15
Impairments on postural control have been documented
in children with CP during static (ie, maintaining a posture)
and dynamic (ie, changing positions and moving through the
environment) activities as a result of sensory deficits, muscular
weakness, and biomechanical misalignment, adversely affecting
their performance of daily activities, whose therapeutic manage-
ment requires strategies that simultaneously focus on balance
and motor skills, such as hippotherapy.16-18
Hippotherapy refers to the intentional manipulation of
horse movement as a therapeutic tool for professionals in
occupational therapy, physical therapy, and speech therapy, to
stimulate the sensory, neuromotor, and cognitive systems to
promote functional results.17 The horse and its movements
have been used as a dynamic tool in the rehabilitation of
people with neurologic disorders to improve their biopsy-
chosocial development.18,19 Through the smooth, rhythmic,
3-dimensional, and repetitive movement of the horse, the child
may experience different stimuli and start to control their
movements, and learn to produce movements that reduce
the displacement of the center of gravity while the horse
moves.11,18,20,21
The benefits of hippotherapy in children with CP include
physical, social, cognitive, and emotional functions.11,22 Horse
movement provides sensory input to a precise and repetitive pat-
tern of movement similar to the movement of the pelvis during
walking. This 3-dimensional movement can stimulate balance
reactions, improve balance, and straighten the trunk.22-24 In
addition, hippotherapy goals are to reduce spasticity, increase
strength, endurance, symmetry, and body awareness.21,25
The experience and practice of hippotherapy may lead to
changes and reorganization of the central nervous system, as
it influences several systems simultaneously, such as vestibular,
proprioceptive, tactile, motor, limbic, and visual. In this way,
hippotherapy provides several sensorimotor inputs, which favor
neurologic maturation and basic neuromotor reactions.18
Current evidence suggests that the practice of real-life tasks
and activities, through self-generated active movements, where
the practice is directly aimed at achieving a specific goal, has
Pediatric Physical Therapy
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better results in different motor outcomes in individuals with
CP. In this context, hippotherapy is identified as an effective
strategy for managing symmetry and balance, and probably
effective for manual and gross motor function.26 However, there
are still uncertainties regarding the effects on postural con-
trol in children with CP. The last systematic review on this
topic involved 8 studies, publications until 2010 and included
searches with the adult and pediatric population.21 Therefore,
understanding the current evidence for effective hippotherapy
interventions is critically important to analyze possible changes
in the dosing/delivery method. This systematic review aims to
summarize and update the current knowledge on the effec-
tiveness of hippotherapy on postural control in children and
adolescents with CP.
Therefore, the PICO approach of the study was elabo-
rated as follows: P (Population)—children with CP aged 2 to
18 years; I (Intervention)—Hippotherapy; C (Comparison)—
control group; O (Outcome)—Improvement on postural control
and/or balance. This approach guides the question of the study
“Does hippotherapy have effects on postural control and/or
balance in children with CP?”.
METHODS
Review Planning and Execution
All steps of this review were informed by the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) statement.27 The corresponding protocol was regis-
tered on the International Prospective Register of Systematic
Reviews (PROSPERO) platform (CRD42021274678).
Searches
An electronic search for articles was carried out in dif-
ferent databases in the health area: PubMed, Virtual Health
Library (VHL), PEDro, Scielo, Embase, and Web of Science.
The search strategy included the descriptors proposed in the
Medical Subject Headings (MeSH), in the Descriptors in Health
Sciences (DeCs) and keywords found in studies on the subject,
using their combinations in Portuguese and English, refer-
ring to Hippotherapy “Hippotherapy”; Horse Assisted Therapy
“Equine Assisted Therapy”; Cerebral Palsy “Cerebral Palsy”; Pos-
tural Control “Postural Control” and “Postural Balance”. The
resulting search terms were combined as follows: “Equine-
Assisted Therapy” OR “Hippotherapy” AND “Cerebral Palsy”
AND “Postural Control” OR “Balance.” All search strategies
were developed in September 2021. These combinations of
descriptors were used individually to expand the possibilities of
obtaining articles regarding the topic (see Supplemental Digital
Content 1, available at: http://links.lww.com/PPT/A460).
Thus, the search for complete articles included: (a) available
in electronic databases focused on health and related areas; (b)
identified through descriptors widely accepted in the scientific
literature; and (c) met the eligibility criteria.
Screening and Eligibility Criteria
Studies that met the following criteria were selected and
included: (a) clinical trial design; (b) quantitative study design;
Effects of Hippotherapy on Postural Control in Children With Cerebral Palsy 203
 (c) published in the last 10 years; (d) evaluated children and
adolescents with CP aged 2 to 18 years; (e) who evaluated
postural control and/or balance; and (f) used hippotherapy as
a therapeutic resource or hippotherapy simulator. Exclusion
criteria were studies that: (a) were systematic reviews and meta-
analyses, correspondence, editorials, conference abstracts, case
studies, or book chapters; (b) protocol studies; (c) uncontrolled;
and (d) included individuals with another neurologic condition
associated with CP.
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Selection of Studies
The procedures related to the selection of studies, data
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extraction, and evaluation of methodological quality were devel-
oped independently by 2 authors. Reviewers independently
assessed the articles and made their selections according to
preestablished eligibility criteria. The results were compared and
if there were disagreements, they were resolved by consensus
with the help of a third reviewer. Studies were analyzed by titles
and abstracts; abstracts that met the criteria or those that needed
further clarification were selected for full review.
Data Extraction
The selected studies were evaluated in full text and
data extraction was performed by 2 independent reviewers,
extracting data on: (1) publication identification, study location,
Fig. Flowchart representing the selection process of the studies included in the systematic review.
204 Peia et al
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Unauthorized reproduction of this article is prohibited.
and year; (2) study design; (3) sample; (4) experimental and
control interventions; (5) outcome measures related to postural
control and/or balance; (6) outcomes and results of postural
control analysis after interventions; and (7) conclusion.
Quality Assessment
The risk of bias and methodological quality of each included
clinical trial was assessed using the PEDro (Physiotherapy Evi-
dence Database scale). The scale consists of 11 items and scores
only 10. These items are scored as present (1 point) or absent
(zero point) and the final score is obtained by the sum of the
scores of the items; in this way, the maximum score of the PEDro
scale is of 10 points. Studies with a PEDro score of 6 or more
points are classified as high quality and less than 6 points as low
quality.28,29
RESULTS
Of 239 references identified through our search, 220 were
excluded for several reasons. The flow of information through
screening to selection is in the Figure. A thorough and full-text
assessment was performed of 19 studies, in which 11 articles
were excluded, and 8 studies considered potentially relevant
were included (Table). There were 264 children and adolescents
with CP of whom 134 were treated with hippotherapy (exper-
imental group) while 130 received comparison intervention
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TABLE
Characteristics of the Studies

Population
EG/CG: n
Study (Mean Age, Male: Female) Experimental
Country Topographic Distribution/Tone Intervention Control intervention Outcomes

Pediatric Physical Therapy

Design GMFCS n: Level Type (Duration) Type (Duration) Assessment Results

Silva e Borges et al33 40 RS (12 sessions, twice PT (12 sessions, twice a GMFCS Comparison between groups disclosed
Brazil EG: 20 (5.65 ± 2.48 y; 8:12) a week, 40 week, 40 min/session) Assessment of body oscillations statistically significant postintervention
RCT CG: 20 (5.77 ± 2.29 y; 9:11) min/session) AP, ML: improvement both in the AP (P < .0001) as
Spastic diplegic CP F-Scan System in the ML (P < .0069) direction in the RS
GMFCS: 8: II; 16: III; 14: IV; 2: V group
Herrero et al34 38 RS on in workout RS off (10 wk, once a GMFM (dimension B for balance Sitting balance (measured by dimension B)
Spain EG: 19 (9.95 y; 14:5) mode (10 wk, once week, 15 min/session) and the total score), and Sitting improved significantly in the EG and the
RCT GC: 19 (9.05 y; 10:9) a week, Assessment Scale effect size was greater in the severely
? 15 min/session) disabled group. The improvements in sitting
GMFCS: 4: I; 3: II; 5: III; 7: IV; balance were not maintained over the
19: V follow-up period. Changes in the GMFM
total score and the Sitting Assessment Scale
were not significant.
Kang et al31 43 EC = HTG + PTG CG (no treatment) Force plate to measure sitting Sway pathway and velocity significantly
Korea EG: 14 (8.2 ± 1.1 y; 7:7) (hippotherapy, PTG: strengthening and balance (pathway and velocity decreased in HTG compared with PTG and
RCT CG: 14 (7.8 ± 1.5 y; 7:7) 30 min/session + stretching exercises in of center of pressure) CG. Left/right pathway, total pathway,
PTG: 15 (8.2 ± 1.2 y; 8:7) strengthening and 30-min sessions, left/right velocity, and total velocity were
Diplegic and hemiplegic CP stretching exercises semi-weekly, for 8 wk significantly reduced in PTG compared with
GMFCS: ? in 30-min sessions, that in CG.
semi-weekly for
8 wk)
Lee et al32 26 HTG (1 h/d, 3 times a RS (1 h/d, 3 times a BPM (software 5.3, SMS Both groups showed significant improvements
Korea EG: 13 (10.8 ± 1.6 y; 8:5) week, for 12 wk) + week, for 12 wk) + 20 Healthcare Inc, UK) as the in static and dynamic balance but significant
RCT CG: 13 (10.0 ± 2.2 y; 9:4) 20 min of min of conventional center of pressure sway length differences between the 2 groups were not
? conventional physical therapy while standing for 30 s with the found
GMFCS: ? physical therapy before intervention eyes open and looking to the

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before hippotherapy and performed front. Dynamic balance ability
and performed stretching on the was measured using the PBS.
stretching on the horseback riding
horse for 5 min simulator for 5 min
before and after the before and after the
exercise exercise
Silkwood-Sherer and 13 HTG (12 wk of weekly CG (continued with their PBS The only significant difference between the
McGibbon11 EG: 9 (3-6 y; 6:3) hippotherapy usual therapy only) 1-min walk test (1MWT) groups, postintervention, was on the PBS.
United States CG: 4 (3-6 y; 2:2) intervention in The Activities Scale for Kids, Within-group analysis showed no significant

Copyright © 2023 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
RCT Spastic CP addition to their Performance version (ASKp) changes for the CG between any
GMFCS: 6: II; 7: III usual therapy, PreSchool version of the pretest/posttest measures. The treatment
30 min/session) Children’s Assessment of group demonstrated significant
Participation and improvement on the PBS and ASKp delayed

Effects of Hippotherapy on Postural Control in Children With Cerebral Palsy

Enjoyment (APCP) improvement on the 1MWT and PedsQL-CP
Pediatric Quality of Life (PedsQL) Module.
(continues)

205
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TABLE
Characteristics of the Studies (Continued )

206 Peia et al
Population
EG/CG: n
Study (Mean Age, Male: Female) Experimental
Country Topographic Distribution/Tone Intervention Control intervention Outcomes
Design GMFCS n: Level Type (Duration) Type (Duration) Assessment Results

Matusiak-Wieczorek 39 HTG (30 min of CG (continued with their Sitting Assessment Scale (SAS) Statistically significant differences were noted
et al16 EG: 19 (8.42 ± 2.24 y; 10:9) hippotherapy once usual therapy only) GMFCS only in the scores awarded for trunk position
Poland CG: 20 (8.3 ± 2.62 y; 11:9) weekly for 12 control and arm function. In the final
NRCT Diplegic and hemiplegic spastic consecutive wk) assessment, nearly 80% of patients were able
CP to control the head position, more than half
GMFCS: 23: I; 16: II had excellent control of the trunk position
and the same number of participants had
good control of the arms, while the smallest
improvement was observed in foot function
control.
Matusiak- Wieczorek 45 EG I: HTG (30-min CG (continued with their Sitting Assessment Scale (SAS) A comparison of SAS showed an improvement
et al30 EG I: 15 (7.93 ± 2.6 y; 9:6) hippotherapy usual therapy only) in almost all the assessed categories among
Poland EG II: 15 (7.60 ± 1.84 y; 8:7) sessions twice the children who participated in
RCT CG: 15 (8.13 ± 2.56 y; 8:7) weekly for 12 hippotherapy. In study group I, statistically
Diplegic and hemiplegic spastic consecutive wk) significant differences were noted in the
CP EG II: HTG (30-min assessment of head position control, arm
GMFCS: 29: I; 16: II hippotherapy function and trunk control and in study
sessions once group II in the assessment of trunk control.
weekly for 12
consecutive wk)
Şik et al25 20 EG = HTG PTG (2 wk of Gross Motor Function Posttreatment evaluation of both groups
Turkey EG: 10 (7 y; 7:3) (hippotherapy for conventional Measure-88 (GMFM-88) revealed statistically significant
RCT CG: 10 (6 y; 6:4) 30-45 min once a physiotherapy with PBS improvements in weltering, sitting, crawling,
Diplegic, hemiplegic and day for 10 wk) + 1-h sessions every Computed walking analysis standing and walking-running-jumping
quadriplegic spastic CP PTG (2 wk of day) sub-parameters and total scores of

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GMFCS: ? conventional GMFM-88. The improvement in weltering,
physiotherapy with crawling, standing, and total GMFM-88
1-h sessions every scores was significantly higher in the
day) hippotherapy group compared with the
control group. The PBS significantly
increased in both groups and the difference
between the improvement rates of 2 groups
was not significant. While walking speed
and cadence significantly improved, a

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significant improvement was not detected in
the walking parameters of the control group.

Abbreviations: AP, anterior-posterior; CG, control group; CP, cerebral palsy; EG, experimental group; GMFCS, Gross Motor Function Classification System; GMFM, Gross Motor Function Measure; HTG, hippotherapy
group; ML, medium-lateral; NRCT, nonrandomized clinical trial; PBS, Pediatric Balance Scale; PTG, physical therapy group; RCT, randomized clinical trial; RS, riding simulator; ?, uninformed.

Pediatric Physical Therapy

 (control group). Study samples ranged from 13 to 45 partici-
pants. Age ranged from 3 to 16 years, with a predominance of
males (n = 147) in the total sample compared with females (n =
117). For the remainder, data extraction and quality assessment
were based only on information available in the original reports.
Studies Description
Two studies were conducted in Poland16,30 and Korea,31,32
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and 1 study was conducted in Brazil,33 Spain,34 the United
States of America11 and Turkey.25
The instruments most used to assess postural control and/or
balance were the Pediatric Balance Scale and Sitting Assessment
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Scale, in addition to the Gross Motor Function Measure (GMFM)
dimension B, the F-Scan System (assessment of body sway),
among others.
In 5 studies, interventions analyzed included hippotherapy
with real horses,16,24,25,30,31 in 2 using the riding simulator33,34
and 1 study compared whether there were differences between
horse riding and riding simulator.32 All these studies support
the improvement in postural control in children with CP.
Interventions were categorized as experimental (horse hip-
potherapy, horse hippotherapy + conventional physical therapy,
or hippotherapy with riding simulator) and control (conven-
tional physical therapy; no intervention; or riding simulator).
The duration of the experimental intervention varied among
studies. Most hippotherapy sessions lasted between 30 minutes,
with frequency between 1 and 3 times a week in a protocol
between 8 and 12 weeks.
The treatment protocols of the experimental group varied
among studies, but had similar purposes. Kang et al31 applied
a hippotherapy protocol that consisted of sitting and standing
in the saddle, manipulating objects (bar, ball, hoop, and toys),
and maintaining the posture while the horse moved. Silkwood-
Sherer and McGibbon11 used a protocol that was divided into
3 stages, which included relaxation and adaptation of the child,
maintenance of postural alignment, training in the sitting posi-
tion, and active exercises with the child sitting on the horse
while still and in motion. Şik et al25 applied a hippotherapy
protocol through stretching exercises, strengthening, dynamic
balance, and postural control associated with the horse’s step.
Matusiak-Wieczorek et al16,30 performed the same hip-
potherapy protocol; the 2020 study was an update of the 2016
study. In these studies, children were placed sitting on the horse
that was walking, stimulating the child’s body alignment that
was corrected through verbal commands and touches on the
pelvic girdle, in addition to performing active exercises with the
horse in motion.
In the Silva e Borges et al study,33 the experimental group
was placed in a riding simulator (model EU6310), at level 1
and a frequency of 100 Hz, the simulator was covered by a
plush riding pony making it more attractive and fun for children.
Herrero et al34 performed a protocol that consisted of sitting in
the hippotherapy simulator with active trunk extension, while
the simulator was turned on in workout mode.
Furthermore, Lee et al32 performed a protocol that included
conventional physical therapy for 20 minutes before hip-
potherapy, and during hippotherapy, postural control exercises
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were performed in the anterior and lateral sitting position, while
the horse walked at a walking pace at 6 km/h.
Random allocation of experimental and control groups
was performed in 7 studies,11,16,25,31-34 which considerably
increased the methodological quality of these studies. The
sample size ranged from 1324 to 45 participants.30
The studies did not provide an adequate description of
the clinical condition of the individuals included, considering
motor alterations (nature and typology of the motor dis-
order and functional motor skills), associated deficiencies, and
anatomical and neuroimaging findings.6 However, children with
hemiplegia and spastic diplegia were prevalent in the samples.
In the analysis of hippotherapy effects on postural con-
trol, some variations were observed among studies. In the
comparison between groups, the experimental group (hip-
potherapy with equine or riding simulator) had significant
improvements when compared to the comparison group, either
with conventional physical therapy or without intervention
(P < .05).11,16,25,30,31,33,34
Improvement was significantly more frequent (P = .001)
in the study group in younger children aged 6 to 7 years. The
higher the frequency of hippotherapy, the better and greater the
results in relation to the evaluated outcomes.16,30
The study’s quality assessments are in shown in Supple-
mental Digital Content 2 (available at: http://links.lww.com/
PPT/A461). The scores obtained for methodological quality
ranged from 5 to 8 points. Only 1 study received 5 points,16
4 studies received 6 points,11,25,30,32 2 studies received 7
points,31,33 and 1 study received 8 points,34 ranging from fair
to good methodological quality.
DISCUSSION
The aim of this systematic review was to analyze the efficacy
of hippotherapy interventions (with a horse or riding simu-
lator) on postural control in children and adolescents with CP.
A total of 8 studies were analyzed, involving 264 participants.
Based on our results, we suggest that hippotherapy can be an
effective intervention to improve several aspects related to pos-
tural control, such as static balance (especially in the sitting
posture), dynamic balance, and alignment (body posture) in
children aged 3 to 16 years, particularly with spastic hemiplegia
or diplegia.
Postural control includes balance and postural
orientation,13,14 and these are important components for
performing motor tasks. Several sensory alterations associated
with CP, including proprioception, vision problems, skin
perception, and alterations in the vestibular system, may
contribute to the impairment of postural control.21
Hippotherapy acts on several components of postural con-
trol, including anticipatory and reactive postural adjustments,
balance, sensory, and musculoskeletal systems.35 This review
reinforces previous studies21 demonstrating that hippotherapy
is a comprehensive resource to improve postural control in chil-
dren with CP and, consequently, daily activities, independence,
and quality of life.11,16,25,30-34
The improvement in static balance in the sitting posture
was demonstrated by the reduction of the sway and velocity
Effects of Hippotherapy on Postural Control in Children With Cerebral Palsy 207
 path,31 and improvement in the mid-lateral and anteroposterior
displacement of the trunk.33 The stimuli caused by the horse’s
movement generated a postural reflex mechanism, which results
in maximum functionality in the sitting position.34 Individuals
undergoing hippotherapy continually respond to a changing
environment, and this promotes adaptive behaviors, move-
ment strategies, automatic postural reactions, and anticipatory
responses. Therefore, the repetition of these adjustments results
in an increase in the control of body position.16,30
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Interventions and comparison groups varied among studies
in terms of protocols administered, types of activities per-
formed, and temporal characteristics of sessions. However, all
studies had positive effects of hippotherapy, whether on the
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horse 11,16,25,30-32 or riding simulator,33,34 associated31 or
not with conventional physical therapy,11,16,25,30,32-34 on the
improvement of postural control in children with CP, in 111,34
to 5 weekly sessions,25 for 225 to 12 weeks,11,16,30,32,33 from
1534 to 60 minutes.25
Hippotherapy with a horse was compared to the use of a
riding simulator; it was observed that both had positive results
and there were no significant diferences.23,32 The riding simu-
lator reproduces the biomechanical characteristics of the horse
such as walking, trotting, and galloping. It was developed to
overcome the limitations of hippotherapy, such as unavailability
and high cost. This device offers an indoor riding experience
and mimics the animal’s rhythmic movement, thus promoting
muscle strength and improving the sense of balance. It offers
advantages over hippotherapy, as it has no space limitations, has
a low price, is easy to handle, and is not affected by weather
conditions.32
However, benefits of horse-riding simulation can be limited
to physical fitness and muscular activity. Among the preferred
animals for the neurorehabilitation of children with CP, the
horse stands out the most.36 Although the present study has a
focus on physical outcomes, and previous studies agree on these
benefits of horse riding or simulator riding, investigations into
psychological, cognitive, and social changes are needed. The
potential of the animal-human relationship is well documented
in children, providing specific social, emotional, and cognitive
development.37 Therefore, it is expected that the most relevant
differences between horse and simulator hippotherapy reside in
the psychological, emotional, and social variables.
Additionally, the intensity of the interventions varied among
studies because many different types of exercise can be per-
formed as hippotherapy. In most instances, the therapy was
poorly described and not standardized. Studies using simulated
mechanical hippotherapy33,34 were more fully explained and
therefore reproducible in future research and clinical practice.
Moreover, the time riding on the horse could be an essential
factor in intervention effects. Although there is a slight tendency
pointing that more extended interventions may cause fur-
ther improvements, the most adequate protocol characteristics
cannot be defined with the current evidence.
According to therapy programs,38 results may change
according to participants, riding places, or horses. Thus, pos-
tural control training during hippotherapy sessions may be
biased by this uneven ground. For this reason, a conventional
riding place could be a solution to avoid differences among
208 Peia et al
Copyright © 2023 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
studies. Besides that, differences among horses may reflect in
locomotion, personality, breed, health, or body condition scores.
Indeed, horses might react differently according to the environ-
ment and people through emotional cues like voice, posture,
expression, and pheromones.38 It is known that horse-patient
cooperation may change with the horse’s temperament as well
as by its breed. However, current studies do not include horse
conditions, although this topic is quite interesting because
it could help determine the best horse breeds to implement
hippotherapy.
The positive contribution of hippotherapy for children
with CP seems to be unique. However, it is known that each
individual with motor dysfunction has its own profile, which
demonstrates the importance of formulating individualized pro-
grams that take into account the demands of the child at a
certain stage of development. For this, it is essential to know
the characteristics of the sample. The studies did not provide an
adequate description of the clinical condition of the individuals
included, considering motor alterations (nature and typology
of the motor disorder and functional motor skills), associ-
ated deficiencies, and anatomical and neuroimaging findings.6
The most commonly reported motor alteration was spas-
ticity, with topographical impairment including diplegia and
hemiplegia.11,16,25,30,31,33 Only 1 study included children with
quadriplegia.25 Functional motor skills were described based on
the GMFCS in 5 studies, and vary from levels I to V.11,16,30,33,34
Therefore, the better the child’s previous functional level, the
better the response to treatment.16,30
In addition to understanding the clinical manifestations that
make the child more or less responsive to hippotherapy, adjust-
ments in interventions may likely have been made to ensure
safety, especially for quadriplegic children and/or functional
levels IV and V. For example, if the CP is spastic type affecting the
legs and trunk (particularly in quadriplegia), sitting astride may
be difficult and hip alignment may become compromised; also
if head/neck control is problematic, the participant may require
direct treatment by a therapist.39 These descriptions were not
detailed in the studies.
In 1 study,33 the GMFCS was also incorrectly used as an
outcome measure. Many studies used the GMFCS inappropri-
ately, without recognizing (or at least indicating) the risks to
their interpretations. While use of the GMFCS level as a pre-
dictor variable within regression analysis or as an “outcome
indicator” within a discriminant function analysis is acceptable,
the GMFCS should not be used as an outcome variable. The
GMFCS was not developed, and has never been validated, for
this purpose, but other tools have.40,41 For example, the GMFM
is an evaluative measure that has been validated to measure
change over time or in response to an intervention in children
with CP.41 Individuals with CP have different disabilities, at
different ages, and can improve their functionality with inter-
ventions and therapies, but overall, they do not change GMFCS
levels.7,8
Our findings were different from those of other pedi-
atric reviews that included children with CP who received
hippotherapy. A previous meta-analysis demonstrated that
hippotherapy was effective in improving postural control in
children with CP; however, the comparison groups involved
Pediatric Physical Therapy
 more children without motor alterations, considered typical,
than children with CP.21 In our study, comparison groups were
composed only of children with CP, which made the comparison
of results more accurate. Furthermore, samples from both inter-
vention and control groups did not differ in the preintervention
assessment, demonstrating homogeneity.
This study has some limitations. Although the searches
were comprehensive and resulted in a significant number of
identified records, a much smaller number of studies were
Downloaded from http://journals.lww.com/pedpt by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
included in this systematic review. It is important to clarify
that only studies that included hippotherapy as an intervention
strategy were included, thus excluding other approaches within
equine therapy. According to the American Hippotherapy Asso-
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 04/09/2024
ciation Inc, both recreational and medical services involving
equines should be clearly described and labeled. The term
“equine therapy” is frequently misused to describe many ser-
vices and activities involving equines, and is discouraged when
describing therapy services provided to humans as well as
recreational activities for people with disabilities. Related terms
that also do not provide adequate clarity or transparency to
describe the service or activity provided include “horse therapy”
and “riding therapy,” and were therefore not included in this
review.42
The lack of long-term follow-up and heterogeneity of the
protocols suggests the need to unify hippotherapy interven-
tion programs, specifically, in subjects with CP. Moreover,
despite assessing the same outcomes among the different studies
included in the review, the statistical comparison was not always
possible due to studies using different scales and measuring
instruments to assess the clinical differences. Therefore, the
results obtained should be taken with caution since a limited
number of studies were analyzed.
The study provides the basis for future research on the
importance of the implementation and effectiveness of hip-
potherapy in the postural control of children and adolescents
with CP. Additional research using a larger sample size, ran-
domized, with more accurate evaluation protocols and the
evaluation of long-term clinical effects, is necessary to enrich
the information regarding this topic of great and current
importance, since all studies point to for significant results of
hippotherapy. Hippotherapy promotes improvement in postural
control and balance in children with CP, in addition to posi-
tively influencing the improvement of the quality of life of these
individuals.
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