Hippotherapy

Original Editor - Asma Alshehri

Top Contributors - Asma Alshehri, Dakota Martin, Kim Jackson, Sukhi Dhaliwal, Leana Louw, Carina Therese Magtibay, Katherine Chandler, Brandon Oates, George Prudden and Chelsea Mclene

Edited April 2023 by Dakota Martin, Katherine Chandler, and Brandon Oates as part of the Arkansas Colleges of Health Education School of Physical Therapy Musculoskeletal 1 Project

Definition 

Hippotherapy comes from the Ancient Greek words meaning "horse" (hippos) and "treatment" (therapy). It is utilized as a treatment tool in therapy and is derived from evidence based practice and sound clinical reasoning skills. Using intentional movements of the horse, sensory, neuromotor, and cognitive systems are influenced to promote functional outcomes in individuals with physical and psychosocial disabilities and impairments.

American Hippotherapy Association. What is Hippotherapy? Available from: https://youtu.be/RzcUTg-VKsM [last accessed 22/22/2021]</ref>

How does it work?

Hippotherapy involves a specially trained therapist who uses the horse as a "live" treatment tool. The movement of the horse is used to achieve long-term and short-term treatment goals that are individualized to each patient.

1. The three-dimensional movement of the horses mimics the normal movements of the human pelvis when walking. The rhythmic, repetitive, and multidirectional movements provided by the horse stimulate the anterior and posterior swinging movements of the patient.
2. The movement of a walking horse produces 100 rhythmic impulses per minute. This encourages the patient to maintain balance and upright posture by repetitively challenging postural reactions and remain sitting on the horse. Thus, improving balance, muscle control, and the development of paraspinal muscles.
3. The patient rider receives large sensory and motor input from not only the horse but from those also around the horse who are assisting with the session.

When used under the direction of a licensed and trained therapist, Hippotherapy can elicit positive changes in children with neurological disorders who present with a combination of cognitive, motor, and psychosocial disabilities. Positive impacts have also been demonstrated in a patient's strength, muscle coordination and tone, and sensory processing used in mobility, talking, and the use of fine motor skills for activities of daily living and general attention to tasks.

TheSheaCenter. Hippotherapy Ride Along:Visualizing How Equine Movement Benefits Clients. Available from: https://youtu.be/J_MvYAvYQkk [Last Accessed 22/22/2021]</ref>

Hippotherapy as a tool in Physiotherapy

According to the American Hippotherapy Association, Hippotherapy is best described as a tool rather than a therapeutic procedure, a strategy in itself, or modality. Therefore, in places like the United States, Hippotherapy does not have its own CPT (Current Procedural Terminology) billing code but can be utilized within a patient’s overall treatment plan. The horse itself is not the tool. Rather, a licensed Physiotherapist leading skilled movement and treatment strategies while utilizing the horse is the tool.

Who can provide Hippotherapy

In most countries, Hippotherapy requires a specialization and can be provided by or supervised by the following healthcare professionals once they have achieved the necessary training and certification.

• Physiotherapists (PT)
• Occupational Therapists (OT)
• Speech-Language Pathologists (SLP)

In North America, The American Hippotherapy Association has a licensing program to become a titled Hippotherapy Clinical Specialist (HPSC).

Safety and qualifications for horses, handlers, and aides to participate in Hippotherapy

Hippotherapy requires a team to ensure the safety of all those involved, especially the patient. The team often consists of a horse, a handler that guides the horse around an arena, a therapist who works with the patient, and a therapy aide or side-walker to assist the therapist. In the event of an emergency, therapists must be trained to safely dismount the patient while the horse handler swiftly and carefully moves the horse away from the patient.

Horses that participate in Hippotherapy are held to a distinct standard by the American Hippotherapy Association. Horses utilized in Hippotherapy have been evaluated and selected based on their body mechanics and gait patterns during ambulation, ability to discern and follow instruction delivered by the handler, rather than the patient mounted on the horse, and their ability to maintain neutrality to any potential distractions such as other people, sounds, sights, and experiences. Handlers are responsible for the safety and well-being of horses and leading the horse in a way that is conducive to the therapist's given instruction and direction during a patient’s treatment session. During therapy a therapy aide or side-walker may also be utilized. These individuals are not licensed and can be volunteers used to assist a therapist in maintaining a patient’s safety while mounted on the horse.

Certification

For therapy professionals to obtain an American Hippotherapy Certification Board (AHCB) certification in the United States, or to become a Hipppotherapy Clinical Specialist® (HPCS), it is recommended that they first hold a PT, OT, or SLP license in the state they are practicing in, with a recommended minimum of one year, or 2,000 hours of experience in their field. If the therapist has been practicing less than one year, it is recommended to have a mentor. The experience should be as a practicing therapist working within their state’s practice act in areas of sensory, neuromotor, and cognitive systems. Currently, AHCB offers two different exams for certification–an option for entry-level certification as well as an option for advanced certification.

Differentiation between Hippotherapy and Therapeutic Riding

Hippotherapy	Therapeutic Riding
Utilized in medical treatment, mainly for children with neuromotor dysfunction	Teaches horsemanship and riding skills to children or adults with special needs
Utilizes specific treatment goals with outcome measures and reassessments	A form of therapy with possible progression toward competitive or independent riding goals
Evidence based treatment tool	Educational, recreational, and therapeutic
Individual sessions	Group or individual sessions
Horse is led or long lined by a handler	Horse is led, lunged, or ridden independently
Utilizes sheepskin, flatbed, or saddle	Usually utilizes a saddle exclusively
Horse is assessed for appropriate gait and conformation	Horse is assessed for height, width, and temperament match with rider
Handler facilitates the movement of the horse who then influences the rider who has no control of the horse	The rider or leader influences the movement of the horse
Utilized by Physio, Occupational or Speech Therapists with training in Hippotherapy through the American Hippotherapy Association Each session requires a therapist, a skilled horse handler, and a sidewalker to provide stability and insure safety of the patient	Led by an instructor and/or therapist

Who can benefit from Hippotherapy

A wide variety of patients of all ages, backgrounds, and medical histories can benefit from the use of Hippotherapy. Patients with Cerebral Palsy have been shown to have increased motor and neuromuscular re-education outcomes with the use of Hippotherapy. This would include greater head and trunk control and stability as well as functional reaching with their upper extremities. Children with autism and developmental delays have shown to have improved motor function in activities requiring balance, strength, and postural control as well as psychosocial improvements in confidence and self-esteem. Patients who often become overstimulated have experienced a calming effect after walking periods on horseback which has allowed for improvements in fine motor skills, gross motor skills, and speech.

The patient population for Hippotherapy typically consists of children with varying psychosocial and physical disabilities. This includes but is not limited to:

• Cerebral Palsy
• Traumatic Brain Injury
• Down Syndrome
• Autism
• Behavioural Disorders
• Muscular Dystrophy
• Amputees
• Cerebrovascular Accidents
• Multiple Sclerosis
• Psychiatric Diseases
• Spinal Cord Injuries
• Rheumatism Joint Diseases
• Developmental Dyspraxia and Delay

Physiotherapy and Hippotherapy

A Physiotherapist with specialized training in Hippotherapy is able to provide treatment plans tailored to patients' physical needs and ability to ride. The therapist will manipulate the horse's movements as well as the riders position to attain functional outcomes in the areas of:

• Gait training
• Balance
• Postural control
• Strengthening
• Range of motion
• Normalization of muscle tone
• Proprioception
• Vestibular input

Common Physiotherapy exercises practiced in conjunction with Hippotherapy

Hippotherapy can be used in conjunction with many multi-targeted Physiotherapy exercises. Common goals set for pediatric populations are throwing a ball to a target to increase hand-eye coordination, reaching in all directions, including across midline, overhead, and beneath the hips, to challenge and increase trunk and postural control and balance, and normalizing muscle tone to elicit functional movement patterns. Physiotherapists commonly utilize equipment such as basketball goals to encourage patients to throw a ball to a target while maintaining balance and upright posture on the horse. At times, the horse can be ambulatory, as well, to further challenge the patient. Other common exercises include fishing games with a rod while mounted on a horse, placing handheld objects in color-coated buckets while the patient reaches outside their base of support, and sitting backwards with both upper extremities propping a patient up to maintain a modified quadruped position while the horse is ambulatory in order to regulate and improve upper extremity muscle tone, endurance, and postural control.

Benefits

Improvements in:

• Muscle tone and strength
• Gross motor skills
• Fine motor skills
• Range of motion
• Coordination
• Endurance
• Symmetry
• Body awareness
• Mobilization of pelvis, lumbar region, and hip joints
• Balance
• Head and trunk control
• Body awareness
• Posture
• Mobility
• Hand-eye coordination
• Limbic system function related to arousal, motivation, and attention span
• Sensorimotor function
• Oral motor ability, voice quality, and vocal communication
• Emotional and cognitive well-being
• Self-esteem
• Confidence
• Didactic and group interaction
• Concentration

Contraindications

The American Hippotherapy Association considers the following to be absolute contraindications for Hippotherapy:

• Active mental health disorders that would be unsafe
• Acute herniated disc with or without nerve root compression
• Chiari II malformation with neurologic symptoms
• Atlantoaxial instability
• Coxarthrosis
• Grand mal seizures – uncontrolled by medications
• Hemophilia with a recent history of bleeding episodes
• Indwelling urethral catheters
• Medical conditions during acute exacerbations (Rheumatoid Arthritis, herniated nucleus pulposis, Multiple Sclerosis, Diabetes, etc.)
• Open wounds over a weight-bearing surface
• Pathologic fractures without successful treatment of the underlying pathology (e.g. severe osteoporosis, osteogenesis imperfecta, bone tumor, etc.)
• Tethered spinal cord with symptoms
• Unstable spine or joints including unstable internal hardware

The North American Riding for the Handicapped Association (NARHA) include the following as contraindications and precautions for Hippotherapy:

• Uncontrollable seizures
• Moderate agitation with severe confusion, disruptive behavior
• Exacerbation of Multiple Sclerosis
• Hemophilia
• Coxarthrosis
• Any spinal fusion, organic or operative
• Spondylolisthesis
• Unstable spine, including subluxation at cervical level
• Acute herniated disc
• Structural scoliosis greater than 30 degrees; excessive kyphosis or lordosis; hemivertebrae
• Atlantoaxial instability
• Pathological fractures
• Cerebrovascular Accident secondary to angioma that was not totally resected
• Cerebrovascular Accident secondary to unclipped aneurysm or presence of other aneurysms
• Open pressure sores or wounds
• Detached retina
• Anticoagulant medications
• Complete quadriplegia
• Acute stage of arthritis
• Severe osteoporosis
• Drug dosages causing physical states inappropriate to riding settings
• Any patient whom the therapist is not completely comfortable/confident in treating

Patient safety equipment

Before a patient is introduced to and mounts a horse, they should be provided proper equipment for riding. A properly fitting helmet is an essential item and various sizes should be available for patients so that the appropriate selection is made. Helmets should fit comfortably over the patient’s head and hit just above the brow line. The chin strap should be snug, avoiding side-to-side motion with a head shake. Patients should also be fitted with a gait belt. Often, gait belts will possess two handles to ensure maximum safety for both the therapist and the patient. Two handles can allow both the Physiotherapist and a side-walker to maintain a safe grasp on the patient. If the Physiotherapist is holding both handles, the side-walker should maintain light contact with the patient’s leg if advisable for the patient.

Care and criteria of horses utilized in Hippotherapy

Horses have basic need requirements that include:

• Nutritious foliage (grass and hay)
• Adequate clean water
• Sufficient free roaming space and housing

• Teeth floating
• Hoof maintenance
• Annual vet visits for vaccinations and Coggins testing
• Some horses may require additional care due to age and health needs

In most cases, a PT will not be responsible for the care of a horse as the horse would be cared for by an outside source (i.e., the owner of the horse or barn management). Although cases can differ, horses can be boarded off-site or on-site. Depending on the given situation, additional costs for off-site or on-site boarding could exist. Another consideration is the transportation of horses if housed off-site.

Criteria of a therapy horse:

• The horse must exhibit a docile demeanor.
• The horse must have no condition that affects temperament or movement (i.e., inadequate balance and symmetry).
• The horse must be desensitized to sudden external movements, noises, and tools or props PT uses.
• The horse must be able to stand quietly for mounting/dismounting as well as grooming and tacking.
• Horses must have exceptional "barn etiquette.” People and other animals should not upset them.
• These are generalized requirements. Facilities may require more in-depth requirements depending on the situation.