Does Hippotherapy Improve the Functions in Children with Cerebral Palsy? Systematic Review Based on the International Classification of Functioning

Abstract

Objective:

To perform a systematic review of the literature regarding scientific reality of hippotherapy in children with cerebral palsy graded according to France HAS (Haute Autorité de Santé) recommendations and applied to the International Classification of Functioning.

Methods:

The research in MEDLINE and Cochrane Library databases was performed using the keywords: “Equestrian therapy,” “Riding for the disabled,” “Hippotherapy,” “Equine-movement therapy,” and “Therapeutic horse (back) riding.” The methodological quality of the articles was assessed using four levels of proof and three guideline grades (A: strong; B: moderate; C: poor).

Results:

Seven prospective, randomized controlled studies and one systematic review confirm the level of proof of hippotherapy in children with cerebral palsy with grade B. Hippotherapy in children with cerebral palsy contributes to improve motor function, symmetry of muscle contraction, spasticity, posture, and walking. Fifty prospective no randomized studies confirm the level with grade C for balance, motor coordination, lumbopelvic mobility, walking speed, functional development, and social behavior.

Conclusions:

Hippotherapy in children with cerebral palsy can be recommended. Regarding the literature data, the level of proof of hippotherapy in children with cerebral palsy is moderate (grade B).

Introduction

A comprehensive multidisciplinary approach centered on the individual is recommended for the care of individuals with a physical or psychological disability. This process, organized through the International Classification of Functioning (ICF),¹ entails an integrative approach that takes account of the medical, psychological, educational, social, and environmental dimensions. So all activities, which simultaneously address physical, cognitive, emotional, and behavioral aspects, seem to be of particular value in the re-education and rehabilitation of a disabled person.^2,3 Well, equestrian activities with a therapeutic aim can be described as a re-educational activity mediated by the horse, which acts on all these factors.

Cerebral palsy is the leading cause of disability in children. Interruption of oxygen supply to the fetus or brain asphyxia is classically considered the main causal factor explaining later cerebral palsy. It is most often the result of environmental factors, which might interact with genetic vulnerabilities, and could be severe enough to cause the destructive injuries. Cerebral palsy is a group of disorders that affect movement and muscle tone or posture. Signs and symptoms appear during infancy or preschool years.

In general, cerebral palsy causes impaired movement associated with exaggerated reflexes, floppiness or spasticity of the limbs and trunk, unusual posture, involuntary movements, unsteady walking, or some combination of these. It represents a nonprogressive disturbance of motor control, the result of a nonprogressive, permanent cerebral lesion of the developing brain (by agreement before the age of 3).⁴ It is the source of impairments and disabilities of very variable levels, which impact on the neurological and functional development of the child. The main impairment is motor, frequently combined with cognitive, social, and communication disorders.⁴

Hippotherapy designates treatment delivered on horseback by a health professional (physiotherapist, occupational therapist, speech therapist, psychologist, psychomotor therapist, adapted physical activities instructor, etc.). The movement of the horse is used as a therapeutic intervention or a therapeutic tool by the therapist. During hippotherapy treatment, the therapist identifies the impairments and disabilities of patients and sets the objectives to be achieved.⁵ The therapist chooses re-educational methods to stimulate dynamic postural stabilization, recovery following disturbance of balance, and postural control through feedback and anticipation.⁶

This practice aims to bring a real change in re-educational treatment in particular with reference to the practice of a physical activity with a substantial recreational element. These hippotherapy programs must be adapted to the capacities of the children, their symptoms, and their demands. It must be within the framework of a personalized treatment plan. That can be modified to accommodate observations and presumed needs, and in accordance with local, family, and institutional possibilities.

More than a quarter of international scientific publications on hippotherapy deal with the treatment of children with cerebral palsy that is what inspires the production of this literature review.

However, it is necessary to clarify the difference between hippotherapy and other equestrian therapeutic activities. There is therapy with the horse and equitherapy.

First, Renée de Lubersac has developed Therapy with the Horse in the 1980s. This corresponded to a publicized psychological treatment via the horse to improve cognitive, social, emotional even physical potential by psychological and physical means without riding.⁷ This technique, centered on the psychological dimension, would not be deployed intentionally to target the physical and re-educational benefit of equestrian activity.

Then, there is instructor-led recreational equestrian therapy, which is comparable to equitherapy in France. Nontherapist riding instructors and their assistants conduct that. It is based on their equestrian training, on their knowledge of riders' handicaps, and on methods that allow use of proper safety conditions on appropriately trained horses. The horseback riding therapy therapeutic approach as implemented in the United States comprises procedures, precautions, contraindications, and a complete lesson plan that is followed by the instructors and their assistants. The PATH Intl. (Professional Association of Therapeutic Horsemanship International Center Accreditation) must certify it. The instructor chooses target objectives depending on the physical needs of the rider. These exercises are centered on incremental challenges to a rider's ability to stretch and move while maintaining balance and posture in all body positions while the horse walks slowly and evenly.^8

–12

Hippotherapy seems to be the most scientific and reproducible technique. The horse is used as a rehabilitation tool in an established protocol. The therapist uses the movements of the horse for therapeutic purposes on posture and motor function.

Objective

The principal objective of this work was to determine the level of scientific proof of the efficacy of hippotherapy in the re-educational management of children with cerebral palsy. This work come from data in the literature graded according to France HAS (Haute Autorité de Santé) recommendations and applied to the ICF. The secondary objective was to evaluate the hippotherapy protocols offered in the literature enabling an appropriate average duration of treatment to be proposed.

Materials and Methods

A systematic review of the literature was performed by searching the MEDLINE, Cochrane Library, PEDro, and Web of Science databases for the years 1966 to October 2021 (Fig. 1). References listed in the articles retained were considered, and articles matching the inclusion criteria, but not present in the initial search, were selected. A grey literature search was also performed using Google Scholar, Classic Google, and Abes. The keywords used were “Equestrian therapy,” “Riding for the disabled,” “Hippotherapy,” “Equine-movement therapy,” and “Therapeutic horse (back) riding.”

FIG. 1.

Article selection procedure for the literature review PRISMA 2020 flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

An initial selection of articles was made independently by the author because of abstracts to retain articles dealing with hippotherapy and/or equitherapy for children with cerebral palsy. Once these articles were selected, the whole text was recovered for reading. There was then a first reading, which allowed potential articles that did not deal with the subject directly to be ruled out. The following articles were retained: randomized controlled studies, reviews and recommendations, quantitative prospective and retrospective studies, and descriptive studies in French and English containing at least a connection between hippotherapy/equitherapy and children with cerebral palsy. Qualitative studies and case studies were excluded.

The articles were analyzed in two stages: a first stage devoted to the evaluation of methodology following the HAS (French National Health Authority) recommendations,¹³ and then, a second stage devoted to the analysis of writing quality using the Consolidated Standards of Reporting Trials (CONSORT) checklist¹⁴ for the randomized controlled trials and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist¹⁵ for the other nonrandomized controlled trials.

The methodological quality of the articles was therefore evaluated following the good practice recommendations of the HAS of December 2010 in accordance with four levels of proof and three grades (A-B-C).¹³ Studies with very poor quality methodology (inadequate, insufficient number of subjects, imprecise intervention) were, however, retained in view of the small number of clinical trials and randomized controlled studies, literature reviews, and recommendations present in the literature. In the absence of levels of proof, information was collected regarding professional practices. A study of methodology was also performed using the CONSORT criteria,¹⁴ which is an international guidance tool intended to be used to evaluate the writing quality of a randomized controlled trial.

A binary score (0 = absent, 1 = present) was used for all criteria with a maximum score of 37. The scoring was performed solely for the prospective randomized studies.

The PRISMA guide was used to study the methodology of the other nonrandomized articles as the authors suggest.¹⁵ A binary score (0 = absent, 1 = present) was used for all the criteria with a maximum score of 27.

The efficacy of the hippotherapy/equitherapy was then described for each HAS grade using the ICF parameters,¹³ namely the impact on the impairments, activity limitations, and participation restrictions of children with cerebral palsy.

Results

The keyword search identified 296 articles. The empirical search based on the references listed in retained articles identified four additional articles. A total of 296 articles were listed in this way. The first selection exercise ruled out 258 articles, based on abstract reading, which revealed no elements relating to hippotherapy in children with cerebral palsy.

The reading of the whole text of the 38 remaining articles ruled out 13 additional articles:

five dealing with the effect of a horse simulator and not hippotherapy (reason 1, Fig. 1),^16

–20

- one covering global proposals for the treatment of children with cerebral palsy but not specific to hippotherapy (reason 2, Fig. 1),²¹

- two setting out the cardiovascular response of children with cerebral palsy during equitherapy sessions (reason 3, Fig. 1),^22,23

- one qualitative study on the parent's perception of their child with cerebral palsy after a hippotherapy session (reason 4, Fig. 1).²⁴

Four studies were not retained because they did not explore function of child with cerebral palsy (reason 5, Fig. 1).^10,25
–27 Three studies^28
–30 were analyzed but not retained in the literature review, as they were case studies.

Methodological quality

Methodological evaluation according to the HAS criteria

The methodological evaluation of the articles in accordance with France HAS good practice recommendations¹³ did not find any established scientific proof (grade A). However, the study found a scientific presumption (grade B) for 10 articles^{1,6,31

–38} from the 25 articles (level II) including 1 systematic review³⁵ (Table 1).

Table 1.

Level of Proof of Articles According to France HAS Grades

Low-power comparative trials that is level II France HAS recommendations-grade B	Studies containing substantial bias that is level IV France HAS recommendations-grade C
Benda et al. (2003)³¹	Casady and Nichols-Larsen (2004)³⁹
Bertoti (1988)³²	Champagne et al. (2017)⁴⁰
Davis et al. (2009)³³	Cherng et al. (2004)⁸
Deutz et al. (2018)³⁴	Fox et al. (1984)⁴¹
Guindos-Sanchez et al. (2020)³⁵	Haehl et al. (1999)⁴²
Mackinnon et al. (1995)⁹	Hsieh et al. (2017)⁴³
McGibbon et al. (2009)³⁶	Jang et al. (2016)⁴⁴
Mutoh et al. (2019)³⁷	Kuczyński and Słonka (1999)⁴⁵
Silkwood-Sherer and McGibbon (2022)³⁸	MacPhail et al. (1998)⁴⁶
Sterba et al. (2002)¹	Manikowska et al. (2013)⁴⁷
	McGibbon et al. (1998)⁴⁸
	Norrud et al. (2021)⁴⁹
	Quint and Toomey (1998)⁵⁰
	Seung et al. (2019)⁵¹
	Shurtleff et al. (2009)⁵²

HAS, Haute Autorité de Santé.

The remaining 15 articles^{39

–52} are evaluated as being studies containing substantial bias that is level IV with a low level of proof (grade C) (Table 1).

Evaluation of the writing quality analysis

Tables 2 and 3 summarize all items defined in the literature as quality criteria for the writing of a clinical study and verify their presence in the different parts of the article.

Table 2.

Methodological Study of the Randomized Controlled Articles Using the Consolidated Standards of Reporting Trials Checklist

Articles	Total score CONSORT checklist (out of 37)
Davis et al. (2009)³³	24
Deutz et al. (2018)³⁴	26
Manikowska et al. (2013)⁴⁷	17
McGibbon et al. (2009)³⁶	29
Mutoh et al. (2019)³⁷	30
Silkwood-Sherer and McGibbon (2022)³⁸	27
Sterba et al. (2002)¹	22

Binary score (0 = criterion absent, 1 = criterion present after reading/analysis of the article against the 37 items on the CONSORT checklist); good methodological level for scores ≥22.

CONSORT, Consolidated Standards of Reporting Trials.

Source: Schulz et al.¹⁴

Table 3.

Methodological Study of the Nonrandomized Controlled Articles Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist

Articles	Total score PRISMA checklist (out of 27)
Benda et al. (2003)³¹	19
Bertoti (1988)³²	18
Casady and Nichols-Larsen (2004)³⁹	12
Champagne et al. (2017)⁴⁰	18
Cherng et al. (2004)¹⁰	13
Fox et al. (1984)⁴¹	13
Haehl et al. (1999)⁴²	10
Hsieh et al. (2017)⁴³	16
Jang et al. (2016)⁴⁴	18
Kuczyński and Słonka (1999)⁴⁵	17
Mackinnon et al. (1995)⁹	12
MacPhail et al. (1998)⁴⁶	17
McGibbon et al. (1998)⁴⁸	12
Norrud et al. (2021)⁴⁹	10
Quint and Toomey (1998)⁵⁰	10
Seung et al. (2019)⁵¹	18
Shurtleff et al. (2009)⁵²	17

Binary score (0 = criterion absent, 1 = criterion present after reading/analysis of the article against the 27 items of the PRISMA checklist); good methodological level for scores ≥17.

PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Source: Page et al.¹⁵

The CONSORT checklist allowed two levels of methodological evaluation to be distinguished for the prospective randomized studies:

First-level score higher than or equal to 22/37: six level II studies^{1,33,34,36
–38}

Second-level score below 22: one level II study.⁴⁷

The PRISMA checklist allowed two levels of methodological evaluation to be distinguished for the no-randomized studies:

First-level score higher than or equal to 17/27: two level II studies^31,32 and six level IV studies^{40,44
–46,51,52}

Second-level score below 17: one level II study⁶ and eight level IV studies.^{34,39,41
–43,49,50}

Efficacy of hippotherapy and equitherapy

The efficacy of hippotherapy and equitherapy was evaluated in accordance with its impact on the impairments, activity limitations, and participation restrictions of children with cerebral palsy found in the literature (according to the ICF) (Table 4).

Table 4.

Scientific Reality of Hippotherapy in Children with Cerebral Palsy Graded According to France HAS Recommendations and Applied to the International Classification of Functioning

Impairments	Activity limitations	Participation restrictions
Motor function Grade B Five level II studies: Benda et al. (2003),³¹ Deutz et al. (2018),³⁴ Guindos-Sanchez et al. (2020),³⁵ Mutoh et al. (2019),³⁷ Sterba (2007)¹¹ Nine level IV studies: Casady and Nichols-Larsen (2004),³⁹ Champagne et al. (2017),⁴⁰ Cherng et al. (2004),⁸ Hsieh et al. (2017),⁴³ Jang et al. (2016),⁴⁴ McGibbon et al. (1998),⁴⁸ MacKinnon et al. (1995),⁹ Norrud et al. (2021),⁴⁹ Seung et al. (2019)⁵¹	Walking Grade B Three level II studies: Deutz et al. (2018),³⁴ McGibbon et al. (2009),³⁶ Mutoh et al. (2019)³⁷ Speed cadence stride length Grade B One level II study: Mutoh et al. (2019)³⁷ Two level IV studies: Hsieh et al. (2017),⁴³ Manikowska et al. (2013)⁴⁷	Quality of life Grade B Two level II studies: Davis et al. (2009)³³ but with no significant difference, Silkwood-Sherer and McGibbon (2022)³⁸
Symmetry of muscular contraction Grade B Two level II studies: Benda et al. (2003),³¹ McGibbon et al. (2009)³⁶ One level IV study: Norrud et al. (2021)⁴⁹	Posture Grade B Three level II studies: Bertoti (1988),³² McGibbon et al. (2009),³⁶ MacPhail et al. (1998)⁴⁶ Three level IV studies: Haehl et al. (1999),⁴² Kuczyński and Słonka (1999),⁴⁵ Seung et al. (2019)⁵¹	Social behavior Grade C One level IV study: case series Koch (1994)³⁰
Lumbar-pelvic mobility Grade C One level IV study: Quint and Toomey (1998)⁵⁰	Equilibrium and motor control Grade B One level II study: Silkwood- Sherer and McGibbon (2022)³⁸ Two level IV studies: Fox et al. (1984),⁴¹ Haehl et al. (1999)⁴²	Academic results Grade C One level IV study: case series Freeman (1984)²⁹
Spasticity Grade B One level II study: Benda et al. (2003)³¹	Functional developmentGrade C One level IV study: Casady and Nichols-Larsen (2004)³⁹	Concentration Grade C One level IV study: case series Freeman (1984)²⁹
		Communication Grade C One level IV study: Borioni et al. (2012)²⁸

Analysis of the literature suggests a possible efficacy of hippotherapy with respect to the following:

Impairments

Improvement of the motor function of children with cerebral palsy classified as grade B of France HAS recommendations by five level II studies^{1,31,34,35,37} and nine level IV studies.^{5,6,39,40,43,44,48,49,51}

Improvement in the symmetry of the muscular contraction of children with cerebral palsy classified as grade B of France HAS recommendations by two level II studies^31,48 and one level IV study.⁴⁹

Improved lumbar pelvic mobility of children with cerebral palsy classified as grade C of France HAS recommendations by a level IV study.⁵⁰

Improvement in the spasticity of children with cerebral palsy classified as grade B of France HAS recommendations by a level II study.³¹

Activity limitations

Improvement in the walking parameters of children with cerebral palsy classified as grade B of France HAS recommendations by three level II studies,^34,36,37 and improvement in walking speed and cadence stride length classified as grade B of France HAS recommendations by one level II study³⁷ and two level IV studies.^43,47

Improvement of the posture of children with cerebral palsy classified as grade B of France HAS recommendations by three level II studies^32,46,48 and three level IV studies.^42,45,51

Improvement of the balance and motor coordination of children with cerebral palsy classified as grade B of France HAS recommendations by one level II study³⁸ and two level IV studies.^41,42

Improvement of the functional development of children with cerebral palsy classified as grade C of France HAS recommendations by a level IV study.³⁹

Participation restrictions

Trend toward improvement in the quality of life of children with cerebral palsy classified as grade B of France HAS recommendations by two level II studies^33,38 but with no statistically significant difference in one.³³

Three level IV studies^28
–30 were also analyzed but not retained in the literature review because of their very low methodological level (case study). They seem to show a grade C improvement in the social behavior and concentration of children with cerebral palsy,³⁰ an improvement in academic results,²⁹ and finally an improvement in communication.²⁸

Summary of the 25 studies retained dealing with hippotherapy

Table 5 summarizes all the studies in the literature review, with a brief description, and their results classified according to their HAS levels of proof.

Table 5.

Summary of the 25 Studies Retained Dealing Hippotherapy

Studies	Population	Intervention	Measurement	Result (ICF): impairments, activity limitations, participation restrictions, environmental factors	Conclusion of the authors	HAS grade
Benda et al. (2003)³¹	N = 13IntG: 7; 4–12 yearsContG: 6; 4–12 years	One sessionIntG: 8 min hippotherapy +8 min on a stationary barrelContG: 8 min on a stationary barrel	Pre- and post-sessionMuscular symmetry by EMG (10 sec sitting, 10 sec standing, 10 sec walking with symmetrical bilateral electrodes placed on the paraspinal muscles at cervical C4 level, thoracic T12 level, and lumbar L3–4 level)Video	Modification of asymmetry:IntG: 55.5 (SD 82.5)ContG: 11.9 (SD 29.9)Modification in %:IntG: 64.6% (SD 28.3)ContG: 12.8% (SD 88.8)	8 min hippotherapy improves the symmetry of contraction of the paraspinal muscles of children with cerebral palsy, unlike 8 min astride a stationary barrel	B
Bertoti (1988)³²	N = 11IntG: 11; 2–9 yearsContC: 11; 2–9 years	Two 1 h sessions per weekIntG: Hippotherapy for 10 weeksContG: monitored for 10 weeks	Two pre-sessionsOne post-sessionPosture assessment scale: Bertoti test (four grades: zero severe limitation, one moderate limitation, two minimal limitation, three normal symmetrical movement at five postural levels: head/nose, shoulder/scapula, trunk, spine and pelvis)Analysis by Friedman	Pre-session 1: median 20Pre-session 2: median 22Post-session: median 27 Q = 12.86 for p < 0.05Reliability r = 0.82Improvement of 37.5% (p < 0.05) in postural scores before and after the intervention	Two sessions per week of hippotherapy over 10 weeks significantly improve the posture of children with cerebral palsy	B
Davis et al. (2009)³³	N = 99IntG: 50; av. 7.8 yearsContG: 49; av. 8.2 years	Two 40 min sessions per weekIntG: Hippotherapy for 10 weeksContC: monitored for 10 weeks (conventional activity)	Pre- and post-sessionMeasurement made by familyCP QoL-ChildGMFM-66	No significant difference for the GMFM-66No significant difference for the CP QoL-ChildNotable improvement in quality of life without statistically significant difference	Hippotherapy has no influence on the motor function and the quality of life of children with cerebral palsyBut substantial bias: deviations from the protocol variations introduced (lack of control over parallel activities …)	B
Deutz et al. (2018)³⁴	N = 73IntG1: 35; 9.1 ± 3.3 yearsIntG2: 38; 9.1 ± 3.3 yearsGMFCSII 1/4 27; III 1/4 17; IV 1/4 29	Randomized to an early (n 1/4 35) or late (n 1/4 38) treatment groupHippotherapy once or twice weekly during a period of 16–20 weeks (mean: 17 treatments)in a crossover approach	GMFM-66, GMFM dimension E and DQuality of life CHQ 28, KIDSCREEN-27 parental versions	No significant changes were found for total GMFM scores and quality of life parameters, a significant increase in GMFM dimension E was found	Data are in line with previous reports and suggest that hippotherapy shows distinct therapeutic strengths with regard to promoting upright stand and gait in children with cerebral palsy	B
Guindos-Sanchez et al. (2020)³⁵	N = 452 on 10 studies	Systematic review and meta-analysis of randomized controlled clinical trials	GMFM-66, GMFM-88	GMFM-66: SMD = 0.81, 95% CI = 0.47–1.15GMFM-88 dimension A: SMD = 0.64, 95% CI = 0.30–0.97, dimension B SMD = 0.42, 95% CI = 0.09–0.75, and dimension E SMD = 0.40, 95% CI = 0.06–0.73	Potential benefit of HPT intervention in improving gross motor function in children with CP	B
MacKinnon et al. (1995)⁹	N = 19IntG: 10; 5–11 yearsContG: 9; 4–9 years	One 60 min session per weekIntG: hippotherapy for 26 weeksContG: monitored for 26 weeks	Pre- and post-intervention with inclusion in randomized controlled trialBertoti TestGMFMPDMSBOTMPCBCL	Significant improvement in PDMSNo improvement in other measures	Small sample size and variations in ages and impairment levels of the populations may partly explain the absence of significant results. Inconclusive study requiring further scientific research	B
McGibbon et al. (2009)³⁶	Phase 1: N = 47 IntG: 25; 4.1–16.8 yearsContG: 22; 4.0–13.6 yearsPhase 2: N = 6 IntG: 6; 5–12 years	Phase 1: IntG: One single 10 min Hippotherapy session ContG: One single 10 min barrel-sitting sessionPhase 2: IntG: 10 min Hippotherapy once a week for 12 weeks in 6 children chosen from the 25 of the IntG Randomized controlled trial	Phase 1: Pre- and post-session Muscular symmetry by EMG on bilateral adductorsPhase 2: Pre- and post-session then at 12 weeks postintervention Muscular symmetry by EMG on bilateral adductors GMFM-66 PSPPYC SPPC	Phase 1: IntG: Preintervention: asymmetry 111.21 mv (IC 39.97–182.45) Postintervention:asymmetry 65.39 mv (IC 5.21–125.07) Reduction of 45.83 ContG: Preintervention: asymmetry 129.07 mv (IC 65.19–192.95) Postintervention: asymmetry 130.29 mv (IC 33.29–228.70) Increase 1.92Phase 2: Improvement in asymmetry persisting at 12 weeksImprovement in GMFM-66 of the six children included	Efficacy of hippotherapy on the motor function of children with cerebral palsy (improvement in asymmetry of adductors in walking) and their functional capacities	B
Mutoh et al. (2019)³⁷	N = 24IntG: 13; 4–14 yearsContG: 11; 4–14 yearsGMFCS II–III	IntG: 30 min/day, once a week) of hippotherapyContG: day care recreation1-Year intervention and a 3-month follow-up period	Gait parameters for a 5-m walk testGMFM-66,GMFM-EFor caregivers: WHOQOL-BREF self-assessment questionnaire	Better GMFM-66 and GMFM-E scores, increased cadence, step length, and mean acceleration; stabilized horizontal/vertical displacement of patients; better relationship between the psychological status and QOL of the caregivers than those seen in the ContG (p < 0.05)	Children's step length and their caregivers' psychological QOL domain (particularly in the “positive feeling” facet) tended to be preserved up to the 3-month follow-up	B
Silkwood-Sherer and McGibbon (2022)³⁸	N = 26IntG: 13; 3–6 yearsContG: 13; 3–6 years	IntG: 12 weeks of weekly hippotherapy intervention in addition to their usual therapyContG: usual therapy only	PBSActivities Scale for KidsPediatric Quality of LifeAssessments for the treatment group preintervention (P0), postintervention (P1), and 12 weeks after no intervention (P2). ContG assessments in the same time frame: baseline, 12 weeks, and 24 weeks	Treatment group demonstrated significant improvement on the PBS (P0–P1, p = 0.02; P0–P2, p = 0.02) and Activities Scale for Kids (P0–P1, p = 0.02; P0–P2, p = 0.02) with delayed improvement on the 1 Minute Walk Test (P1–P2, p = 0.02) and Pediatric Quality of Life CP Module (P0–P2, p = 0.03)	Improvements in balance in children with CP may promote increased participation and quality of life when hippotherapy is added to their treatment plan	B
Sterba (2007)¹¹	N = 17IntG: 17; 5–16 yearsContG: 17; 5–16 years	One 1 h session of hippotherapyIntG: 18 weeksContG: same population used as their own control	Pre- and post-session then at 6 weeksGMFM-E (walking, running, jumping)GMFM Total Score	Improvement in GMFM-E of 8.5% (p < 0.03) in post-session test and then 1.8% (p < 0.03) at 6 weeksImprovement in the GMFM total score of 7.6% (p < 0.04)	Efficacy of hippotherapy on motor function of children with cerebral palsyRecommendation as an important element in their re-educational treatment	B
Casady and Nichols-Larsen (2004)³⁹	N = 10IntG: 10; 2.3–6.8 yearsNo ContG	One 45 min session per weekIntG: hippotherapy for 10 weeks	Pre- and post-sessionGMFMPEDI	Significant improvement in the GMFM total score and the PEDI total scoreNo percentage reported by the authorSignificant improvement in the GMFM (dimension C), and the PEDI social score	Hippotherapy seems to have a positive effect on the motor and functional performance of children with cerebral palsyBut nonrandomized trial	C
Champagne et al. (2017)⁴⁰	N = 12IntG: 10; 4–12 yearsNo ContGGMFCS I–II	One 30 min per weekIntG: 10 weeks of hippotherapy	BOT2-SF and the GMFM-88 (Dimensions D and E)Twice before the program, immediately after, and 10 weeks following the end of the program	Mean scores for dimensions D and E of the GMFM-88 Dimension scores (p = 0.005) and three of the eight items of the BOT2-SF (fine motor precision (p = 0.013), balance (p = 0.025), and strength (p = 0.012) improved between baseline and immediately after intervention; mean scores immediately after and 10 weeks after intervention did not differ	Hippotherapy provided by a trained therapist who applies an intense and graded session for 10 weeks can improve body functions and performance of gross motor and fine motor activities in children with cerebral palsy	C
Cherng et al. (2004)⁸	N = 14IntG: 14No ContG	Two 40 min sessions per weekIntG: hippotherapy for 16 weeks	Pre- and post-sessionGMFM-E (walking, running, jumping)GMFM Total Score	Improvement in GMFM-E of 10% (p < 0.01)Improvement in GMFM total score of 5% (p < 0.01)	Hippotherapy seems beneficial for the motor function of children with cerebral palsyBut nonrandomized trial	C
Fox et al. (1984)⁴¹	N = 19IntG: 19No ContG	One session per week of 90–120 minIntG: hippotherapy for 6 weeks	Pre- and post-sessionNonvalidated personal scale	Improvement in balance and coordination of hands, arms, and legs: 7.2%Arm strength: 8.1%Leg strength: 13.8%, sitting posture: 19%	Efficacy of hippotherapy on balance, motor function coordination of children with cerebral palsyBut nonvalidated “in-house” scale	C
Haehl et al. (1999)⁴²	N = 4IntG: 2; 4–9 yearsContC: 2; 7–9 years	One intervention per week of two 20 and 40 min sessionsIntG: hippotherapy for 12 weeksContG: a recreational horse-riding session	Pre- and post-sessionVideo with measurements of kinematic measurementTest of posture and of coordinationPEDI	Improvement in posture and coordination testPEDI significantly positiveNo statistical data	Improvement in the posture and coordination of the trunk and upper limbsBut very small number of subjects, imprecise method and nonrandomized trial	C
Hsieh et al. (2017)⁴³	N = 14IntG: 14; 3–8 yearsNo ContG	One 30 min once weekly for 12 consecutive weeks36-week study composed of baseline, intervention, and withdrawal phases (12 weeks for each phase, [phase A baseline Phase B Intervention and retour to phase A] ABA design)	Body Functions (b) and Activities and Participation (d) components of the ICF-CY checklist were used as outcome measures at the initial interview and at the end of each phase	Over the 12 weeks of hippotherapy, significant improvements in ICF-CY qualifiers were found in neuromusculoskeletal and movement-related functions (b7), mobility (d4), and major life areas (d8) and, in particular, mobility of joint functions (b710), muscle tone functions (b735), involuntary movement reaction functions (b755), involuntary movement functions (b765), and play (d811; all p < 0.05) when compared with baseline	Beneficial effects of hippotherapy on body functions, activities, and participation in children with CP	C
Jang et al. (2016)⁴⁴	N = 8IntG: 8No ContG	One 30 min session per weekIntG: hippotherapy for 10 weeksEffect experienced by caregivers	Pre- and post-sessionEvaluation of the children:GMFM, PBS, and Korean version of the Modified Barthel IndexChildren's Depression Inventory, Trait Anxiety Inventory for Children, State Anxiety Inventory for Children, Rosenberg Self Esteem Scale, and the Korean-Satisfaction with Life ScaleEvaluation of caregivers:Beck Depression InventoryBeck Anxiety InventoryKorean-Satisfaction with Life Scale	Significant improvement in the GMFM, in dimension E of the GMFM and the PBS (p < 0.05)No significant improvement in the other scales including evaluation of caregivers	Hippotherapy effectively improved the areas of global motor function and balance. However, no improvement was observed in the psychosocial and emotional parameters.	C
Kuczyński and Słonka (1999)⁴⁵	N = 58IntG: 25; 3–10 yearsContC: 33; 3–10 years	Two 20 min sessions per weekIntG: hippotherapy for 12 weeksContC: a single session	Pre- and post-interventionStabilography: measurement of variation in movement of the center of gravity in relation to the support polygon	Improvement in postural controlPreintervention: Sagittal: 11.2–5.7, frontal: 11.5–6.4Postintervention: Sagittal: 9.0–4.1, frontal: 8.1–4.0 p > 0.07	Efficacy of hippotherapy for the improvement of postural control in children with cerebral palsyBut “dosage” study and nonrandomized trial	C
MacPhail et al. (1998)⁴⁶	N = 13IntG: 6; 5–12 yearsContG: 7; 6–11 years	One 60 min session per weekIntG: hippotherapy for 10 weeks in diplegic and quadriplegic subjectsContG: hippotherapy for 10 weeks in healthy subjects	Pre- and post-interventionVideo in the frontal plane: measurement of the lateral trunk displacement of the child and the pelvic movement of the horse	Lateral displacement of the trunk:Smaller lateral displacement of the trunk in the ContG vs. the IntGIntG: CP = 10.2° (SD 2.2°)ContG: CP = 5.8° (SD 0.5°)Subgroup: better for diplegia (67%–75%) than quadriplegia (8%–36% of the time)	Hippotherapy improves the postural balance of children with cerebral palsy with a better result in a diplegic than in a quadriplegic populationBut small number of subjects and nonrandomized trial	C
Manikowska et al. (2013)⁴⁷	N = 16IntG: 16 5.7–17.5 yearsNo ContG	IntG: One single session of hippotherapy	Pre- and post-sessionSpatiotemporal gait parameters: walking speed, cadence, step length, left/right symmetry collected using a three-dimensional accelerometer device (DynaPort MiniMod)Wilcoxon test	Significant improvement in walking speedNo improvement in step lengthOther spatiotemporal parameters improved but with no significant difference	Efficacy of a single session of hippotherapy on the walking speed of children with cerebral palsyBut low number of subjects and nonrandomized trial	C
McGibbon et al. (1998)⁴⁸	N = 5IntG: 5No ContG	Two 30 min sessions per weekIntG: hippotherapy for 8 weeks	Pre- and post-interventionGMFM-E (walking, running, jumping)	Improvement in GMFM-E of 6.4% (p < 0.05)	Hippotherapy improves motor function. But small number of subjects and nonrandomized trial	C
Norrud et al. (2021)⁴⁹	N = 2IntG: Two children (5 and 6 years) with CP, GMFCS grade 1No ContG	One 45 min session of hippotherapy per week during a period of 6 months	Using video and tested with TrunkImpairment Scale modified Norwegian Version. Skilled physiotherapists analyzed the videos qualitatively, and triangulated recurring changes in movement with the results from the test	Riding bareback, improvements in trunk control were observed and measured. However, riding in a saddle led to reduced trunk controlOther observable movement changes were: from asymmetry to symmetry, adaptation to rhythm, mastery of riding skills, and reduced loss of postural control	Balance and symmetry can be stimulated in a body characterized by imbalance and asymmetryDuring EAPT the children gained the possibility to explore new movement qualitiesEquipment and feedback influenced movement qualities	C
Quint and Toomey (1998)⁵⁰	N = 26IntG: 13; 9–16 yearsContG: 13; 9–16 years	Two to three 10 min sessions of hippotherapyIntG: 10 × 10 min hippotherapy over 4 weeksContG: 10 × 10 min sitting on a static saddle	Pre- and post-sessionPhotography and passive pelvic anteroposterior tilt t Test	Improvement in passive pelvic anteroposterior tiltIntG: improvement of 20.8°ContG: improvement of 8.85° t Test: 2.654	Efficacy of hippotherapy in the treatment of lumbar pelvic mobility of children with cerebral palsyNonrandomized trial	C
Seung et al. (2019)⁵¹	N = 147IntG: 147; 5.78 ± 1.72 years, male: 56.2% GMFCS levels I–IVNo ContG	One 30 min of hippotherapy twice a week for 8 weeks	GMFM-88, GMFM-66, and PBS score were collected retrospectivelyGMFM-66 score increased by 2.0 = good responders to hippotherapy	GMFCS levels I and II compared with level IV (OR 1/4 6.83) and level III compared with level IV (OR 1/4 4.45) were significantly associated with a good response to hippotherapyHigher baseline GMFM E (OR 1/4 1.05) and lower baseline GMFM B (OR 1/4 0.93) were also significantly associated with a good response to hippotherapy	Children with CP, GMFCS levels I–III, with relatively poor postural control in sitting might have a greater chance to improve their GMFM-66 scores through hippotherapyTherapy to improve postural control in sitting	C
Shurtleff et al. (2009)⁵²	N = 18IntG: 10; 5–13 yearsContC: 8; 5–13 years	One 45 min session of hippotherapy per weekIntG: hippotherapyContG: one 45 min session of barrel-sitting	Pre- and post-session then post-session at between 12 and 14 weeksVideoBarrel test: head/trunk dynamic stabilityFunctional test	Significant improvement in post-session barrel test maintained at 12 weeks for N p < 0.05Reliability r = 0.95 post-session and r = 0.94 at 12 weeks	Efficacy of hippotherapy for the improvement of dynamic stability in the head–trunk axis of children with cerebral palsyNonrandomized trial	C

av., average age; BOT2-SF, Bruininks–Oseretski Motor Proficiency short form; BOTMP, Bruininks–Oseretsky Test of Motor Proficiency; CBCL, Child Behaviors Checklist; CHQ, Child Health Questionnaire; CI, confidence interval; ContG, control group; CP, Cérébral Palsy; CP QoL-Child, The Cerebral Palsy Quality-of-Life Questionnaire for Children; EAPT, Equine Assisted Physiotherapy; EMG, electromyogram; Gait, Gait ride system of walking analysis; GMFCS, Gross Motor Function Classification System; GMFM, Gross Motor Function Measure; GMFM-E, GMFM dimension-E; HPT, Hippotherapy; ICF, International Classification of Functioning; ICF-CY, The International Classification of Functioning, Disability and Health for Children and Youth; IntG, intervention group; mv, millivolt; N, number of children; OR, odds ratio; PBS, Pediatric Balance Scale; PDMS, Peabody Developmental Motor Scale; PEDI, Pediatric Evaluation of Disability Inventory; PSPPYC, Pictorial Self Perception for Young Children; SD, standard deviation; SMD, standardized mean difference; SPPC, Self-Perception Profile for Children; WHOQOL-BREF, World Health Organization Quality of Life.

Protocol and average duration of treatment

The 25 studies included evaluated the efficacy of hippotherapy and equitherapy in 695 children with cerebral palsy. The average duration was 9.65 weeks (between 1 day and 26 weeks) with a follow-up of the children and a delayed evaluation in three studies: at 6 weeks postintervention,⁸ at 12 weeks postintervention,³⁶ and between 12 and 14 weeks postintervention.⁵²

Few rigorous studies containing a detailed hippotherapy or equitherapy program applied to children with cerebral palsy were found in the literature. They were rather descriptions of tools associated with another therapeutic intervention. The only studies to explain the equitherapy sessions describe the child in a sitting position on the horse walking clockwise in a circle for 4 min and then for 4 min in the anticlockwise direction, with activities of touching different parts of horse's body or objects placed along the route. No detailed protocol of exercises to strengthen specific muscles or to develop proprioceptive function was found in the literature.^31,36

Quality evaluation of studies

Only seven randomized controlled studies^{1,33,34,37,38,47,48} were found in this literature review testifying to the overall low scientific level of trials dealing with hippotherapy in children with cerebral palsy.

The numbers studied were also too small to allow results to be generalized. Sixteen studies^{5,11,18,31,32,39

–44,46

–49,52} involved a population of <20 patients and therefore have low statistical power.

Finally, the level of the results analysis methodology and study design is unsatisfactory: substantial bias was demonstrated,^18,33 and the use of a nonvalidated “in-house” scale^2,32 does not allow actual effectiveness to be determined. Furthermore, some protocols displayed imprecise methods²⁸ or the use of a dose effect, which distorts the results.

Discussion

Although the use of hippotherapy for the re-education of children with cerebral palsy is relatively common, the authors note that rigorous studies on the subject are scarce. Their methodologies are debatable, difficult to use, and/or to apply to patients. The various hippotherapy modalities and protocols are not always defined sufficiently to allow generalization and implementation during hospitalization or outpatient care. No level 1 study or grade A recommendation was found.

The literature confirms a level of proof of hippotherapy programs in children with cerebral palsy at HAS grade B based on eight clinical studies. The question now raised is that of the mechanism of action of hippotherapy in the improvement of physiological parameters.

The principle of hippotherapy lies in the continuing generation of disequilibrium, where the horse generates rhythmic stimuli and postural changes, resulting in adjustments secondary to the imbalance.^20,53 The postural interactions dimension of equestrian practice acts as a postural stimulator for patients. It varies their speed and position forcing the riders to displace their center of gravity, working simultaneously on stability, dynamic posture, vestibular balance, and somatosensory reflexes.⁴⁸ It is also established that the simple fact of being in the saddle on a walking horse entails the contraction of around 300 muscles.³¹ The horse's pendulum-like motion unbalances the rider's seat imposing more than 2000 postural adjustments every half hour.³¹

Children with cerebral palsy often have postural disorders related to asymmetric muscle contraction, in particular of the adductor muscles and the spinal muscles.^{1,3,36,54
–56} The erector spinae muscles are often active in isolation, which permits the voluntary maintenance of trunk posture by the child. Postural disorders seem to increase during dual task activity that requires particular attention. So postural adjustment, to anticipate the disequilibrium that is induced during the performance of an active movement, does not occur.

The motor impairment of children with cerebral palsy represents an anomaly of the automatic antigravity responses for which these children must compensate by voluntary control, when their neuromuscular potential allows this.⁵⁷ This anomaly is also accentuated by the pronounced lack of axial proprioceptive references in children with cerebral palsy.¹⁹ This prevents them from feeling their position in space and therefore from managing the imbalance.

Pérennou et al.⁵⁸ demonstrated that muscular tone mainly that of the extensor muscles is the main agent in combating gravity. The mechanisms by which it is distributed (spinal cord and brain stem) are the fundamental mechanisms of postural control making the nervous system the main organ of balance. The integrity of the cerebral structures involved in the control of antigravity orientation is necessary for correct postural orientation. It may therefore be supposed that the topography of cerebral damage in children with cerebral palsy may be reproduced in the disordered perception of the vertical that follows strokes. This may be due to damage to the brain stem, cerebral hemispheres or central and peripheral damage to the gravity sensing, and somatosensory and vestibular pathways.⁵⁸

Finally, postural stabilization is the result of a complex physiology requiring the choice of a stabilized frame of reference and involving cerebral control associated with the contribution of sensory afferents.⁵⁸ The brain uses a number of limited, tested, stored motor maneuvers in a repertoire that in principle include the response elements appropriate to usual situations.⁵⁸ There seems to be some plasticity since new strategies may be learnt, perhaps, for example, by means of hippotherapy, in line with the postural stimulation of children with cerebral palsy.

The aim of the re-educational care of children with cerebral palsy is to improve their independence by optimizing their functional and locomotor capacities. Children with cerebral palsy show abnormal antigravity automatic responses. Hippotherapy appears to improve posture in children by improving muscle tone in the extensor muscles.

The hypothesis can then be advanced that hippotherapy will improve the functional independence of children with cerebral palsy by optimizing their walking ability⁶ through an improved representation of the environment with better control of postural stabilization. This may be made possible by restoring the balance between the contraction of agonists and antagonists (extensors/flexors) allowing the extensor muscles to fulfill their role in combating gravity. Furthermore, the symmetrical left–right walking motion of the horse will repeatedly displace the child on either side of the midline causing continuous proprioceptive and vestibular stimulation, which will increase awareness of the body. Thus, these repeated postural adjustments will help the child to create a more “normative” perception of the midline and of the symmetry of loading.³⁶

The choice of horse will also have an impact on the functional result. The principle of hippotherapy is to use equine biomechanics on the biomechanics of the child with cerebral palsy to fight against harmful motor patterns. A precise and objective analysis of the gait of the child and the horse is mandatory to find a pair to improve the functions of children with cerebral palsy.

The performance of high-powered randomized clinical studies is thus necessary to demonstrate the efficacy of hippotherapy in children with cerebral palsy. The objective will be to show the superiority of hippotherapy over conventional treatment in the functional independence of children with cerebral palsy. These studies will perhaps result in hippotherapy being viewed as a real re-educational resource that may lead to treatment being funded by social security, as is already the case in Sweden, Norway, and Switzerland,⁵⁹ allowing it to be used by the majority of patients.

Conclusions

There is no proof of the efficacy of hippotherapy in the re-education of children with cerebral palsy. However, literature on the subject is scarce, and from the data currently available, it is possible to suggest that hippotherapy could form an integral part of the treatment of children with cerebral palsy. Further work is necessary to better specify the content of hippotherapy programs and protocols, alone or associated with other therapies (multisensory stimulation methods …) and their medical–economic impact. In particular, it seems essential to validate the content of sessions supporting this practice and to develop evaluation tools specific to hippotherapy. This is why a survey of good practices and a “state of the art” is necessary to prove the effectiveness of hippotherapy, to standardize practices and programs, and to promote their recognition by health authorities.

Footnotes

Authors' Contributions

E.P.: writing review. P.F. and D.V. proofreading and correction.

Author Disclosure Statement

The authors do not report any potential conflicts of interest.

Funding Information

No funding was received for this article.

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