Stergiou A, Tzoufi M, Ntzani E, Varvarousis D, Beris A, Ploumis A. Therapeutic Effects of Horseback Riding Interventions: A Systematic Review and Meta-analysis. Am J Phys Med Rehabil. 2017 Mar 1 [Epub ahead of print].
OBJECTIVE: Equine-assisted therapies, such as therapeutic riding and hippotherapy, are believed to have positive physical and emotional effects in individuals with neuromotor, developmental, and physical disabilities. The purpose of this review was to determine whether therapeutic riding and hippotherapy improve balance, motor function, gait, muscle symmetry, pelvic movement, psychosocial parameters, and the patients’ overall quality of life. DESIGN: In this study, a literature search was conducted on MEDLINE, CINAHL, MBASE, SportDiscus, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, PEDro, DARE, Google Scholar, and Dissertation Abstracts. Only studies with a control / comparison group or self-controlled studies performing preintervention and postintervention assessment were included. Excluded were (1) studies not providing data on baseline score or end-point outcome, (2) single-subject studies, (3) studies providing only qualitative data, and (4) studies that used a mechanical horse. Sixteen trials were included. The methodologic quality of each study was evaluated using Downs and Black quality assessment tool. RESULTS: Most of the studies showed a trend toward a beneficial effect of therapeutic riding and hippotherapy on balance and gross motor function. The meta-analysis showed improvement in both the Berg Balance Scale and the Gross Motor Function Measure in therapeutic riding and hippotherapy programs. CONCLUSION: Programs such as therapeutic riding and hippotherapy are a viable intervention option for patients with balance, gait, and psychomotor disorders.
Let us begin by defining the two terms used in this study to describe therapeutic horseback riding. The terms used in this article to refer to a therapeutic activity with the help of the horse are therapeutic riding (TR) and hippotherapy (HT). Together, they are sometimes referred to as “equine-assisted activities and therapies.” The term “therapeutic riding” is used to denote the adaptive or modified sport of equitation (riding on horseback), with the purpose of contributing to the cognitive, physical, emotional, and/or social wellbeing of people with disabilities. The term “hippotherapy” is used to describe a hippotherapy health professional’s use of the movement of the horse to address the limitations or disabilities of patients with neuromotor, developmental and physical disabilities. Hippotherapy might be prescribed to address problems with posture, balance, mobility, walking energy expenditure, function, and/or sensory abilities.
Participants in a therapeutic horseback riding program have a wide variety of underlying physical, functional, mental, or emotional disabilities, including central nervous system disease (such as cerebral palsy, stroke, multiple sclerosis, spinal cord injury), lower motor neuron disorders (including spinal muscular atrophy, Charcot-Marie-Tooth disease, myasthenia gravis, muscular dystrophies, sarcopenia), sensory deficits (for example, blindness, deafness) and conditions along the autism spectrum.
It is clear that a wide variety of patients could benefit from equine assisted treatments, if they are effective for the specific deficit of concern. The purpose of this review was to determine whether therapeutic riding and hippotherapy improve balance, motor function, gait, muscle symmetry, pelvic movement, psychosocial parameters, or overall quality of life. The method of addressing this question was a systematic review of well-controlled scientific studies of equine-assisted therapy.
This literature review was designed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement (for details, see: www.prisma-statement.org/). The literature search included the following databases: MEDLINE, CINAHL, MBASE, SportDiscus, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, PEDro, DARE, Google Scholar, Scopus, ISI Web of Science, and Dissertation Abstracts. The following search algorithm was used: “therapeutic riding” OR “therapeutic horse riding” OR “therapeutic horseback riding” OR “horse riding” OR “horseback riding” OR hippotherapy OR “equine-assisted therapy” OR “equineassisted movement therapy” OR “equine therapy” OR “equine movement therapy” OR “developmental riding therapy” OR “riding for the disabled.” Other sources of published papers included hard copies of Pediatric Physical Therapy, Gait and Posture, Developmental Medicine and Child Neurology, American Journal of Physical Medicine & Rehabilitation, Archives of Physical Medicine and Rehabilitation, and Physiotherapy Theory and Practice, and of the Gait and Posture conference and the American Academy of Cerebral Palsy and Developmental Medicine. The reference lists of the included articles were also searched for additional studies.
For inclusion, published articles needed to be in English, and published on or before February 29, 2016. Subjects need to have impairments in motor function and studies needed to be controlled, and focus on the quantitative effects of HT or TR on postural control, balance, gait, and/or spasticity as well as overall quality of life indicators. Studies were excluded if they did not provide data on baseline score or end-point outcome, if they provided only qualitative data, if they did not use a live horse, if they included additional interventions, or if they studied no more than one subject.
The methodologic quality of each study was evaluated using a Downs and Black quality assessment tool (see www.ncbi.nlm.nih.gov/pmc/articles/PMC1756728/pdf/v052p00377.pdf) by two of the coauthors, independently; differences were resolved by a third investigator.
A total of 16 studies were identified and analyzed. Eight studies assessed the effect of HT and TR in children with cerebral palsy, for a total of 343 subjects (170 in the study groups, 158 in the control groups). Four randomized clinical trials assessed the use of equine-assisted therapy for mobility improvement in the elderly, representing a total of 90 participants (43 in the intervention group, 47 in the control group). Three studies focused on subjects with multiple sclerosis, although one of these studies did not include a separate control group. The total number of participants was 52, with 32 in the intervention group and 20 in a separate control group. One randomized clinical trial assessing the effect of HT on post-stroke individuals was identified. That study included 10 subjects in the intervention group and 10 subjects in the control group, for a total of 20 participants. The studies used a variety of measurable and quantified endpoints, but not all studies used the same endpoints. Most commonly used were the Berg Balance Scale, the Pediatric Balance Scale, or the Gross Motor Function Measure.
Of the 16 studies, only 8 included data that could be subjected to further meta-analysis. For all of these studies, subjects in the TR and HT treatment groups demonstrated higher scores on the Berg Balance Scale and the Gross Motor Function Measure than did control subjects; but these differences did not reach statistical significance.
Equine-assisted therapy is increasing in use and popularity. Multiple therapists and facilities can be found throughout the country (see the American Hippotherapy Association, www.americanhippotherapyassociation.org/). Several studies do indeed demonstrate improvements in subjects receiving treatment, compared to those not receiving such treatment. The authors note that “all studies and meta-analysis showed increased scores concerning the impact of HT and TR;” but this difference was not statistically significant. As the authors point out, the number of controlled studies is small, and their endpoints vary greatly. So greatly, in fact, that comparing one study to another (as was done in this meta-analysis) is quite difficult. The effort taken by this research team should be commended, based on their exhaustive search of the literature and their detailed evaluating of each study’s design.
Current indications for therapy are broad, and the goals of therapy are varied and often quite subtle. As a result, the few studies that are done are understandably dissimilar and not easily compared. Perhaps one of the most important messages to come out of this study, then, is that future researchers should carefully consider the subjects and endpoints that they study in order to focus their energy on demonstrating reliable, statistically sound, and comparable studies. In fact, it might be worth the time and effort of organizations like the AHA to work with researchers to propose meaningful and measurable endpoints, as well as research priorities – populations and disabilities to focus current research efforts. Multi-center trials are another way to add power to a study, but they add cost and complexity which the field may not yet be equipped to bear.
-Reviewed by Ronald Sherman, MD