The Effects of a 5-Week Therapeutic Horseback Riding Program on Gross Motor Function in a Child with Cerebral Palsy: A Case Study

Introduction

T he ability to make a positive and sustainable impact is a goal that physical therapists strive for when treating children with cerebral palsy (CP). In order to achieve such a goal, the physical therapist often uses a variety of community-based resources to incorporate efficient and cost-effective interventions with the goal of achieving optimal functioning and to facilitate participation within the home, school, and community.

Therapeutic horseback riding (THR) has become increasingly popular as an effective community-based intervention. THR can be used to achieve a variety of objectives including cognitive, social, physical, educational, and behavioral goals. ¹ The basis for THR is the use of a horse and the ability it has to provide a smooth, rhythmical pattern of movement to the rider. As the horse walks, its center of gravity is displaced three dimensionally with a pattern very similar to the action of the human pelvis during gait. Riders may be placed in various positions atop the horse in order to achieve specific postural responses such as prone, side lying, side sitting, or sitting. ² The movement of the horse is used to promote the recruitment and strengthening of key muscles used in the rider. The rider continually responds to a changing environment, encouraging adaptive behaviors and postural strategies to maintain postural control on a dynamic surface. ³ Available studies cite THR as the major contributing factor in decreasing spasticity, improving weight-shifting ability, balance, rotational skills, and increasing postural control. ^2,4

There are two basic types of horseback riding interventions that are commonly cited in the literature: Hippotherapy and THR. THR, which was used in this study, is typically provided by a riding instructor who teaches the rider basic riding skills. These can include certain movements that promote better posture and balance. Hippotherapy, on the other hand, is provided by a rehabilitation professional who is educated on the movements of the horse and the variety of techniques that can be used to promote postural control and motor skills in the rider. ¹ There are specific standards and training for both hippotherapy and THR. ^5,6

According to the North American Riding for the Handicapped Association, there are now over 782 member riding centers in the United States today providing services to over 40,000 people each year. ⁷ The largest percentage (33%) of health professionals working at the centers are physical therapists. In the current health care environment, knowledge of alternative, effective, and cost-efficient treatment is crucial. Physical therapists would benefit their patients by being aware of the availability of therapeutic riding programs, the positive effects of THR, and the appropriate length of time in which positive outcomes may be expected.

Several studies show the benefits of THR when provided for 6 weeks or longer. The evidence suggests that programs of this duration provide physical benefits to children with disabilities and may facilitate community participation. ^1,4,8

Bertoti completed the first objective clinical study analyzing the effects of THR in 1988. ² In this study, the children rode in 1-hour sessions twice weekly for 10 weeks (20 riding sessions). The outcome showed that in 8 of the 11 participants, there were significant improvements in the areas of posture, decreased muscle spasticity, improved weight-shifting ability, improved balance and rotational skills, improved postural control, and an overall improvement in functional skills.

McGibbon evaluated the effects of an 8-week THR program on 5 children with spastic CP. ⁹ A total of 16 riding sessions were performed over 8 weeks. The results suggested that the THR program greatly benefited the walking energy expenditure and gross motor function (Gross Motor Function Measure [GMFM] Dimension E: Walking, Running, and Jumping) in these children.

The Center for Sports Therapy considered the effects of THR on gross motor function in children with CP. ¹⁰ THR sessions were conducted in 6-week cycles for three consecutive sessions totaling 18 weeks (18 riding sessions). The results showed overall improvements in activities such as walking, running, and jumping (GMFM Dimension E) with overall better scores in gross motor function.

In this current case study, the authors sought to explore the effect of a shorter duration of THR (one time per week for 5 weeks or five riding sessions) on the gross motor function of a child with CP. Current literature supports the use of THR as an effective treatment tool, but with durations of treatment typically 6–18 weeks or more.

Materials and Methods

This case study compares the scores of the GMFM before, after, and again 5 weeks post THR. A subject for this case study was recruited from a local outpatient facility. The pool of participants included children who were already enrolled and had agreed to participate in the facility's established 5-week THR program. The pool consisted of a heterogeneous group of children with disabilities, many who were receiving outpatient services or medication regimens in addition to THR. Approval for this study was obtained from the participating institutions and from the parents and the participating child.

The study and procedure were reviewed with the medical director of the facility who had identified an appropriate individual who met the inclusion criteria to participate in the study. Inclusion criteria included (1) enrolled in the facility's riding program, (2) has a medical diagnosis of cerebral palsy, (3) is affected by no other medical complications such as uncontrolled seizures, (4) has the functional ability to sit and stand alone or with support, (5) has the consent from parents or guardians, (6) the child is able to follow simple one-step directions, and (7) is between the ages of 3 and 16 years of age.

Exclusion criteria were as follows: (1) severe uncontrollable behavioral problems, (2) child has had orthopedic or neurologic surgery in the previous 6 months, or (3) has a fever or infection at the time of the initial evaluation.

The child chosen for this study was a 10-year-old, left-handed white boy with a diagnosis of CP, spastic diplegic presentation. He attended the local public school where he participated in a regular education program. He has a history of bilateral adductor muscle, hamstring, and Achilles tendon releases several years prior to the study. His gross motor function was at Level II according to the Gross Motor Function Classification System. ¹¹ During this study, he had neither significant health conditions nor took any medications. The child was ambulatory, required no assistive devices, and was not participating in any other forms of therapy or sports during the study. He was chosen to due to the limited external factors that could affect the outcome such as concurrent physical therapy interventions or changes in medications.

A single subject with repeated-measures design was utilized for evaluation of the collected data. The schedule of testing using the GMFM consisted of testing before the THR session began, after the 5-week program was completed, and 5 weeks postintervention. Measurements were performed by a physical therapist who was trained in the application of the GMFM.

The GMFM was chosen as the tool for measuring outcomes in this case study based on the following factors: (1) the clinical relevance and sensitivity of the test to change in motor function; (2) the element of time required to complete the test; (3) reliability of the GMFM, providing consistent scores when used repeatedly with the same subjects; and (4) the validity of the measure. ¹²

The child was accompanied by his parents on each occasion and participated in all five sessions. The riding took place in an indoor riding arena. The same horse was used for each session and was provided by the facility. The horse had been used in THR on previous occasions. The subject wore a helmet and was accompanied by two side walkers and a leader. Riding was carried out with the use of a lightweight saddle with handles to maximize independence with handling and to promote a closer connection between horse and rider. The horse was led around the arena by an experienced handler at a walking pace while the child followed the commands of the instructor. The child was encouraged to utilize the reins and to provide verbal cues to the horse such as “whoa” and “move on.”

The hour-long session began with the horse and rider completing several large circles around the arena and changing directions at least once. The children in the riding group, usually 4 or 5 others, would listen for the riding instructor's next command with the anticipation of the child fulfilling each task to the best of his or her ability. The rider was encouraged to focus on sitting upright in the saddle while maintaining symmetrical postural alignment and to sit as independently as possible with only minimal assistance and contact from the side walkers.

The horses were led through orange cones in a serpentine pattern and over rails that were laid on the ground approximately 15 feet apart. Riders alternated upper extremity movements while leaning and stretching their bodies to coordinate the tossing of a ball into a bucket positioned on the ground below them. Other motions and activities were dispersed throughout the session integrating balance exercises, strengthening, postural control, and flexibility.

Results

The three sets of GMFM scores were analyzed and compared to identify any changes in gross motor function. Each dimension was scored and the differences between the three tests were recorded as positive change, negative change, or no change in motor function.

The pretest was conducted on the day prior to the initiation of the first scheduled riding session; the post-test was conducted upon the completion of the THR, and the post post-test was administered 5 weeks postintervention. The results of the post-test demonstrated significant improvements in two of the five dimensions of the GMFM. These categories were (D) standing and (E) walking, running, and jumping. The scores progressed from an original score of two to a three, the maximum score. The scores on dimension A, B, and C remained unchanged throughout the testing.

The GMFM scores reflect the child's performance of complex patterns of movement that incorporate trunk balance and coordination as well as strength and mobility. ¹² These increases in lower extremity strength, upright postural ability, and overall balance contributed to the child's ability to exhibit increases in scores on the GMFM. The improvements were seen in the tasks of stepping over a stick, walking forward with consecutive steps on straight lines and walking down stairs with alternating steps. It can be concluded that these skills were enhanced as a direct resulting of the subject's participation in THR.

The post-post test was administered to evaluate the maintenance of the results. The scores were consistent in dimensions D and E with seven of the eight items unchanged. One item from dimension D, the ability to walk on a straight line 3/4;″ wide, returned to the baseline score.

Discussion

This study chronicled the changes demonstrated by a 10-year-old boy with CP and the direct effects of short-term, 5-week THR on his gross motor skills. Following the intervention, improvements were noted in the categories of standing, and walking, running, and jumping, areas that require the use of multiple postural muscles, balance and coordination, and weight-shifting ability.

Postural control and muscle strengthening are two direct benefits that can be attributed to THR. The primary implication is the relationship between improved posture control and the ability to enable the child to walk more efficiently and effectively. Large muscle groups in the lower extremities and trunk are recruited during THR, thus adding strength gains to the flexibility improvements.

In addition to the objective findings in this clinical case analysis, there were subjective improvements noted by the author and the child's parents. The subject not only expressed excitement with riding, but the child's level of self-assurance and confidence appeared to increase with each passing week of THR, resulting in a decreased fear of overall movement.

Conclusions

The results of this case study show a beneficial outcome of a short term THR program (1 time per week for 5 weeks or five sessions). In today's economic climate, especially in health care, it is essential to be aware of therapeutic interventions that are effective and efficient. A 5-week program consisting of 1 hour of riding per week appears to have positive effects on the gross motor function in a child with CP. Further research to help solidify more standard protocol for THR with children with CP and length of episodes of care to help maximize potential and utilize services most effectively would be helpful. Additional information and research proving effectiveness of this treatment would possibly help lead to better reimbursement options with insurance companies.