Acute effect of hippotherapy applied on different sitting surfaces in children with special needs

Abstract

Purpose

This study aimed to assess the acute effects of hippotherapy performed on different seating surfaces on sitting balance and walking speed in children with special needs.

Materials and Methods

Children aged 3–18 years with special needs were included. Participants were assigned to three groups: Group 1 (Saddle), Group 2 (No saddle, direct horse contact), and Group 3 (Saddle with additional texture material). Each group received a 30-min hippotherapy session in a riding arena. Sitting balance was measured with the BeCure balance system, and walking speed was assessed using the 10-meter walk test before and immediately after the session.

Results

No significant improvement was found in sitting balance in any group after the intervention. However, Group 3 showed increased walking speed compared to Groups 1 and 2. Intergroup comparisons showed no statistically significant differences in sitting balance or walking speed.

Conclusion

Different texture materials used on saddles may provide more noticeable acute effects in hippotherapy. Future research should involve larger sample sizes and explore subacute and long-term outcomes.

Keywords

hippotherapy sitting balance sitting surface special needs child walking speed

Introduction

A child with special needs is defined as a child who, due to a developmental issue or an acquired condition, experiences physical, sensory, or cognitive limitations and requires special care and education distinct from their peers.¹

Hippotherapy has been used as a therapeutic intervention for individuals with disabilities to improve mental and physical conditions since the 1940s.² It is a therapy method that utilizes the repetitive and rhythmic movements of a horse to enhance motor control, sensory input, and postural stability, while also providing psychological, social, and educational benefits. Hippotherapy affects the musculoskeletal, sensory, limbic, and vestibular systems. It facilitates the transmission of rhythmic impulses. During walking, a horse transmits approximately 90–110 rhythmic impulses or vibrations per minute to the individual's pelvic girdle. These impulses are generated by the alternating elevation of the horse's back and lumbar muscles. This movement creates an oscillatory effect on the patient's pelvis, requiring the patient to adapt and adjust their trunk, thereby improving balance, postural control, and coordination.^3,4

Equine body temperature is approximately 38°C and can rise during exercise. This higher temperature, compared to the human body, may contribute to enhanced sensory perception due to the tactile stimuli generated by the elongation and relaxation of the rider's muscles and ligaments. Furthermore, the warmth of the horse can activate certain muscle reflexes that stimulate the rider's internal organ activity. As a result, hippotherapy serves as a valuable alternative treatment method for various conditions, including gastrointestinal disorders, cardiovascular disease, and post-stroke rehabilitation.⁵

The selection of therapy horses is based on the specific needs and characteristics of the individuals receiving therapy, rather than a particular breed. Ideally, therapy horses should be specially trained, calm, mature (preferably five years or older), and in good health. A smooth gait, such as a trot, is essential for providing a comfortable and therapeutic experience. Additionally, therapy horses should be familiar with therapy environments and equipment, such as balls and mounting ramps, and should remain calm and composed during sessions. Ensuring the horses’ calm demeanor is crucial for the safety and effectiveness of hippotherapy sessions.⁶

The number of clinical studies on hippotherapy in the literature is quite limited. The aim of this study was to investigate the acute effects of hippotherapy applied with different seating surfaces on sitting balance and walking speed in children with special needs. Although the effects of hippotherapy on motor control, postural stability, and walking mechanisms have been extensively discussed in the literature, how different sitting surfaces modulate proprioceptive inputs and short-term effects on motor responses have not been sufficiently explored. In this context, the study comparatively evaluates the effects of different seating surfaces on sitting balance and walking speed. This study examined the clinical effectiveness of hippotherapy and compared it with other application methods. This is the first detailed study on this topic. In addition, guidance is provided on treatment options to achieve rapid healing in this study population. In this respect, the study offers a new perspective on considering different surface properties in hippotherapy. The hypotheses of the study were as follows:

H0: Hippotherapy applied with different seating surfaces has no effect on sitting balance and walking speed in children with special needs.

H1: Hippotherapy applied with different seating surfaces has an effect on sitting balance in children with special needs.

H2: Hippotherapy applied with different seating surfaces has an effect on walking speed in children with special needs.

H3: Hippotherapy applied with a saddle and additional texture material is most effective on sitting balance and walking speed in children with special needs.

Materials and methods

Study design

This study was designed as an experimental, randomized study involving children with special needs aged 3–18 years who were referred to the Gebze Equestrian Training Center. Ethical approval for the study was obtained from the Istanbul Gedik University Ethics Committee on 17/01/2023 with approval number E-56365223-050.01.04-2023.137548.27-432. Written informed consent was obtained from the parents of children who met the inclusion criteria. In this study, participants were assigned to three different groups through simple random allocation. The group assignment for each participant was determined using sealed envelopes that were randomly arranged, containing only the group numbers (Group 1, Group 2, Group 3). These envelopes were pre-prepared and shuffled by the researchers. Participants, under the supervision of their parents, randomly selected an envelope to determine their group assignment. This approach ensured that researchers had no influence over group allocation, thereby guaranteeing an unbiased and impartial randomization process. Additionally, after randomization, statistical analyses (one-way ANOVA) were conducted to assess whether the groups were homogeneous at baseline.

Additionally, if children with cerebral palsy (CP) were included among the participants, their motor levels were determined before the assessment using the Gross Motor Function Classification System (GMFCS). Children with GMFCS levels III–V were not included in the study.

Inclusion criteria

The inclusion criteria for the study were as follows:

A child with special needs aged between three and 18 years

For individuals diagnosed with CP, a GMFCS classification of level I or level II

Ability to understand simple commands

Ability to sit unaided for at least 10 s

A hip abduction angle of at least 20 degrees.

Exclusion criteria

Presence of clinical conditions that could hinder participation in the study

Inability of the child to cooperate with the research process

Simultaneous participation in another study

Lack of parental consent.

Intervention

Horses and equipment: The horses were pre-screened for suitability for hippotherapy (calm temperament, responsiveness to commands, ≥5 years of age). Sessions were conducted at a trot, and the intervention was applied under three conditions: Group 1 rode with a saddle; Group 2 rode without a saddle, in direct contact with the horse's back; and Group 3 rode on a bubble-wrap (textured) layer placed on the horse's back. The insert measured approximately 60 × 40 cm and was centered on the horse's midline; its cranial edge was aligned with the caudal border of the withers so that the rider's ischial region rested over the textured area. The insert was secured with a non-slip underlay to prevent slippage.

Rationale (materials and placement): The three surfaces were selected to systematically modify somatosensory input and friction/compliance at the horse–rider interface: 1) smooth saddle (lower cutaneous input, higher stability), 2) direct contact (increased proprioceptive/thermal input from the horse), and 3) textured interface (additional cutaneous mechanoreceptor stimulation and micro-perturbations). The hypothesis was that this configuration would enhance postural engagement and trunk adjustments.

Standardization and individualization: All participants within each group received the same surface condition. Only pre-specified minor positional adjustments (±2–3 cm) were permitted to center the pelvis on the midline and accommodate pelvic width; the material, thickness, or texture pattern was not altered.

Hygiene and safety: The textured inserts were covered, disinfected between riders, and replaced when worn. Helmet use was mandatory; a side-walker accompanied each child. Inclusion criteria included hip range of motion (abduction ≥20°) and the ability to sit unsupported for at least 10 s.

The horses used in the program were selected in accordance with hippotherapy principles, and their detailed characteristics are presented in Table 1.

Table 1.

Horses used in hippotherapy and their characteristics.

Name	Age	Type	Gender	Character Traits
ALACA	8	PEARL PONY	MARE	CALM
APAÇİ<	11	PEARL PONY	STALLION	CALM
KARACA	8	PEARL PONY	MARE	CALM
ASYA	9	PONY	MARE	CALM

Outcome measures

A demographic data form was administered to all participants by the researcher. This form included questions about the participant's name, age, medical history, previous surgeries, medications, comorbidities, and history of falls, including the frequency of falls if applicable.

GMFCS

The GMFCS was used to assess the motor functions of children diagnosed with CP. Developed by Palisano et al. in 1997, the GMFCS is a standardized classification system designed to categorize the gross motor functions of children with CP. It was later expanded in 2007. This system classifies motor function differences, particularly in sitting and walking, into five levels:

Level I: Walks without limitations

Level II: Walks with limitations

Level III: Walks using a handheld mobility device

Level IV: Independent self-mobility is severely limited; may use powered mobility

Level V: Transported in a wheelchair pushed by another person.⁷

BeCure balance assessment system

The BeCure Balance Assessment System, developed through the collaboration of physiotherapists and engineers as part of a Scientific and Technological Research Council of Türkiye project, was used to measure the sitting balance of children. This system is fundamentally adapted from the balance platform of the Nintendo Wii Fit system.

The BeCure Balance Assessment System device collects data on center of balance displacement, center of balance position, body weight, and pressure distribution at the four corner points of the device. It includes measurement parameters such as imagery/non-imagery, eyes open/closed, and interval measurement. To initiate a measurement, the “Start” button (green) located below the parameter selection area is pressed. Once the “Start” button is activated, the measurement screen appears. When all measurements based on the selected parameters are completed, a BalanceSystem Sample PDF Report can be generated.⁸

In this study, the BeCure Balance Assessment System protocol was applied under the following conditions: –

Eyes open

–

With imagery

–

30 s of seated balance maintenance on the board.

The displacement of the participant's center of mass along the X and Y axes, and the distance from this displacement to the origin, gives the location of the Body Weight Center. The location of the Body Weight Center was recorded during the assessment.

10-Meter walk test (seconds)

This test was used to assess walking speed. Participants were instructed to walk at their normal pace along a pre-measured 10-meter course (using a walking aide if required). The timer started when the participant's foot was at the starting line and stopped once they crossed the finish line. Two measurements were taken, and the best time (in seconds) was recorded.⁹

Outcome measures were assessed both before and immediately after the intervention. Sitting balance and walking speed parameters were recorded immediately following the hippotherapy session to assess the intervention's effect. This approach is critical for providing the most accurate representation of the effects of hippotherapy.

Study protocol

Following the initial assessment of the children participating in the study, each child participated in a 30-min hippotherapy session in the riding arena. During the session, the children sat on the horse, aiming to maintain their postural balance while adapting to the rhythmic oscillations created by the horse's movement on the sand surface. Following the intervention, all baseline assessments were repeated to examine the acute effects of hippotherapy delivered on different seating surfaces on sitting balance and walking speed. The results were compared.

Sample size

In order to assess the adequacy of the determined sample size in the study, a statistical power analysis was conducted using the G*Power 3.1 software. The analysis was performed using one-factor repeated measures ANOVA (repeated measures, within factors). The effect size (effect size f) was set at 0.40, the probability of α error (α) at 0.05, and power (1-β) at 0.95. Based on the analysis, which included three groups and two measurement points, it was calculated that at least 24 participants were required to achieve sufficient statistical power. With 27 participants included in the study, the required minimum sample size was met, and the obtained results were considered statistically reliable.

Statistical analysis

The data analysis of the study was conducted using the Statistical Package for Social Sciences (SPSS) version 25.0 (SPSS Inc., Chicago, IL, USA). The one-sample Kolmogorov-Smirnov test was used to assess whether the variables followed a normal distribution. Demographic characteristics were expressed as frequency, percentage, mean, and standard deviation.

For within-group analyses, the Wilcoxon signed-rank test was applied to numerical variables that did not follow a normal distribution, while the Student's paired t-test was used for those that did. For between-group comparisons, one-way ANOVA was applied to numerical assessment results that followed a normal distribution, whereas the Kruskal-Wallis test was used for those that did not.

Results

Thirty children with special needs were initially included in the study. However, three participants were excluded because they failed to complete the hippotherapy course according to the study protocol. The final analyses were completed with 27 children and their demographic data are given in Table 2. In the homogeneity analysis of the groups, there were no statistically significant between-group differences in age, height, weight, or sex distribution at baseline (one-way ANOVA for continuous variables; Fisher's exact test for sex; all p > 0.05), indicating that the groups were demographically comparable. This comparability reduces the likelihood that demographic factors confounded the acute outcomes; accordingly, primary analyses were conducted without demographic adjustment, with sensitivity analyses controlling for age, height, weight, and sex yielding similar results.

Table 2.

Demographic characteristics of the groups.

Demographic characteristics	Group 1 (n = 10)Mean ± sd	Group 2 (n = 9)Mean ± sd	Group 3 (n = 8)Mean ± sd
Age (years)	8.8 ± 2.92	9.33 ± 2.62	9.62 ± 3.04
Height (cm)	134.3 ± 17.97	136 ± 20.48	131.75 ± 13.82
Weight (kg)	35.8 ± 18.6	33.3 ± 11.44	35.25 ± 10.10
Gender (F/M)	(3/7)	(4/5)	(3/5)

cm: centimeter; kg: kilogram; F: female; M: male; n: number of persons; sd: standard deviation; Group 1: hippotherapy with saddle; Group 2: hippotherapy without saddle; Group 3: hippotherapy with saddle and additional texture material.

The distances of the body center of mass from the origin, measured using the BeCure system in the X and Y coordinate planes, were calculated for pre- and post-hippotherapy sitting balance and walking assessments of the groups (Table 3). Within-group analyses revealed no significant improvement in sitting balance (p ≥ 0.05), but a significant improvement in Group 3 only in walking speed (p < 0.05).

Table 3.

Sitting balance and walking speed assessment results.

Assesments	Group 1 (n = 10)			Group 2 (n = 9)			Group 3 (n = 8)
Assesments	BHMean ± sd	AHMean ± sd	p	BHMean ± sd	AHMean ± sd	p	BHMean ± sd	AHMean ± sd	p
BWC (cm)	3.6 ± 2.50	2.73 ± 2.62	0.093	3.17 ± 2.01	2.32 ± 2.68	0.260	3.69 ± 1.61	3.29 ± 2.06	0.695
10 Meter Walking Test (sec)	11.01 ± 7.75	10.21 ± 3.54	0.209	13.93 ± 7.30	10.89 ± 3.34	0.150	13.15 ± 3.9	10.95 ± 3.57	0.006*

BWC: Body Weight Center; BH: before hippotherapy, AH: after hippotherapy, sd: standard deviation; n: number of persons; sec: second; Group 1: hippotherapy with saddle; Group 2: hippotherapy without saddle; Group 3: hippotherapy with saddle and additional texture material

*(p ≤ 0.05).

The intra-group differences of the post-hippotherapy BeCure balance analysis results and walking assessment before and after hippotherapy and the comparisons of these inter-group differences are presented in Table 4. No significant difference was found between the groups in terms of sitting balance and walking speed (p ≥ 0.05).

Table 4.

Within-Group differences and intergroup comparisons of sitting balance and walking speed after hippotherapy.

Assessments	Group 1 (n = 10)	Group 2 (n = 9)	Group 3 (n = 8)	p
Assessments	Mean ± sd	Mean ± sd	Mean ± sd	p
BWC (cm)	−0.87 ± 1.52	−0.85 ± 2.02	−0.40 ± 2.79	0.877
10 Meter Walking Test (sec)	−0.8 ± 1.87	−3.04 ± 5.74	−2.21 ± 1.58	0.404

BWC: Body Weight Center; sd: standard deviation; cm: centimeter; n: number of persons; sec: second; Group 1: hippotherapy with saddle; Group 2: hippotherapy without saddle; Group 3: hippotherapy with saddle and additional texture material.

Discussion

Hippotherapy is a rehabilitation method that can create positive effects on postural control, balance, and gait parameters by providing dynamic and multidimensional sensory-motor inputs. The rhythmic, repetitive, and multidirectional movements of the horse stimulate the individual's vestibular, proprioceptive, and somatosensory systems, thereby supporting postural stability and gait mechanisms. In the literature, hippotherapy has been reported to enhance neuromuscular activation and improve motor responses in terms of balance and gait.^10,11 This study is one of the first investigations examining the acute effects of different seating surfaces used during hippotherapy on postural balance and gait speed, making a significant contribution to the literature. Although the general effects of hippotherapy on motor control, postural stability, and gait mechanisms have been extensively addressed, the way the seating surface modulates proprioceptive inputs and its short-term effects on motor responses have not been systematically examined. In this context, this study takes an innovative approach by analyzing the role of altering the seating surface during hippotherapy on sensory feedback and postural stabilization. In particular, the findings suggesting that adding a different textured material (such as bubble wrap) to the saddle may enhance proprioceptive inputs and improve gait speed increase the study's originality. Furthermore, while the acute effects of hippotherapy are generally evaluated based on overall motor functions, this research specifically addressed clinically important parameters such as seating balance and gait speed, providing a unique perspective to the literature. In conclusion, this study offers a novel perspective on optimizing the equipment used in hippotherapy applications and provides valuable insights into how rehabilitation programs can be modified according to individual needs. Additionally, it contributes to the scientific literature by laying the foundation for new research areas aimed at better understanding the sensory and motor effects of hippotherapy.

The findings of this study indicate that there was no statistically significant difference between the groups in terms of seating balance and gait speed. However, a significant improvement in gait speed was observed in children in Group 3, for whom a different textured material was placed on the saddle. This suggests that surface texture may indirectly support postural control and walking performance by stimulating sensorimotor feedback mechanisms. Furthermore, this finding suggests that the physical properties of the seating surface used during hippotherapy should be considered for their effects on balance and movement coordination.

The effects of hippotherapy on balance and gait parameters have been extensively explored in the literature. A study by Matusiak-Wieczorek et al. reported that 12 weeks of weekly 30-min hippotherapy sessions improved postural alignment in the sitting position in children with CP.¹² However, since the current study focused on the acute effects of hippotherapy, no significant improvement in sitting balance was observed. In another study, Moraes et al. demonstrated that an increased number of hippotherapy sessions led to a gradual improvement in postural balance while sitting.¹³ These findings suggest that the effects of hippotherapy on sitting balance may emerge over time and become more pronounced with longer intervention durations.

Regarding gait, Portaro et al. reported that after six months of hippotherapy, individuals with Down syndrome showed functional improvements in walking speed, stride width, bilateral symmetry, and balance.¹⁴ Although the current study involved only a short-term intervention, the significant improvement in walking speed in Group 3 suggests that modifications to the sitting surface may influence proprioceptive inputs.

Additionally, a study by Flores et al. found that horse's walking on sand rather than on asphalt led to greater mediolateral displacement of the center of pressure in children with CP. Moreover, as the horse's walking speed increased, the displacement amplitude and velocity of the center of pressure also increased.¹⁵ This finding indicates that surface type and horse gait speed may affect postural adaptation processes during hippotherapy. In the current study, the improvement in walking speed in Group 3 may be attributed to the additional texture material on the saddle, which likely enhanced sensory feedback, enabling more effective postural stabilization mechanisms.

Furthermore, a case study reported that hippotherapy had positive effects on gross motor function and balance in a child with CP.¹⁶ This suggests that hippotherapy can support motor function at an individual level and strengthen postural control mechanisms.

Additionally, a systematic review by Peia et al. examined the effects of hippotherapy on postural control from a broad perspective. The researchers screened 239 identified studies and noted that most had moderate to high methodological quality. The findings indicate that hippotherapy can support postural control in children aged three to 16 years with spastic hemiplegia or diplegia. Specifically, it was found to improve static balance, dynamic balance, and body alignment in the sitting position.¹⁷ These results are generally consistent with the current study, supporting the potential for positive effects of hippotherapy on postural control. However, the acute measurement of effects of the current study may have resulted in a more limited effect compared to longer-term protocols reported in the literature.

The development of postural control is strengthened over time through the cumulative effects of repeated motor learning processes and neuromuscular adaptations. Therefore, the lack of a statistically significant difference following single-session or short-term interventions suggests that the acute effects of hippotherapy may be limited, but more significant results may emerge with longer-term interventions.

Therefore, future studies should be designed to include longer session protocols, different frequency levels, and age groups to more comprehensively demonstrate the effects of hippotherapy on postural balance.

In conclusion, this study presents preliminary findings on the effects of different sitting surfaces on walking speed in acute hippotherapy interventions. It offers a new perspective on considering different surface properties in hippotherapy. The findings demonstrate that selecting the appropriate seating surface in rehabilitation practices can have significant effects on balance control. These results offer practical recommendations applicable both in clinical rehabilitation settings and in saddle ergonomic design processes. However, considering that long-term hippotherapy interventions have been reported in the literature to lead to greater improvements in postural control, balance, and gait parameters, future studies should focus on longer follow-ups and a detailed analysis of the neuromuscular effects of different sitting surfaces.

Conclusion

No significant difference was observed in acute improvement in sitting balance following hippotherapy interventions with children with special needs with saddles, without saddles, and with saddles with additional textured materials. However, the most significant increase in walking speed was observed in hippotherapy applied with additional textured materials. There was no acute superiority in the hippotherapy program implemented with different surfaces in terms of sitting balance and walking speed. The findings suggest that different texture materials placed on the saddle may have a more significant effect in acute hippotherapy applications. The importance of considering saddle surface selection, particularly in hippotherapy rehabilitation programs, has been demonstrated. Future studies with larger sample sizes are recommended to examine subacute and long-term effects, thus increasing the generalizability of the findings.

Footnotes

Acknowledgments

The authors have no acknowledgments

ORCID iDs

Gonul Ertunc Gulcelik

Ebru Sever

Burak Atalay

Emirhan Dursun

Irem Memisoglu

Ethical approval

Ethical approval for the study was obtained from the Ethics Committee of Istanbul Gedik University on 17/01/2023, with the approval number E-56365223-050.01.04-2023.137548.27-432.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Clinical trials

NCT05993598

References

Homan

Greenberg

Mailick

. Generativity and well-being of midlife and aging parents with children with developmental or mental health problems. Res Aging 2020 Mar; 42: 95–104.

McGibbon

Benda

Duncan

, et al. Immediate and long-term effects of hippotherapy on symmetry of adductor muscle activity and functional ability in children with spastic cerebral palsy. Arch Phys Med Rehabil 2009 Jun; 90: 966–974.

McKeon

Hertel

. Diminished plantar cutaneous sensation and postural control. Percept Mot Skills 2007; 104: 56–66. Available from: https://journals-sagepub-com-s.web.bisu.edu.cn/doi/abs/10.2466/pms.104.1.56-66?journalCode=pmsb.

Peterka

. Sensorimotor integration in human postural control. J Neurophysiol 2002 Sep; 88: 1097–1118.

Villar Arceredillo

. Efectos de la equinoterapia en niños con parálisis cerebral. Revisión bibliográfica [Internet]. 2017 [cited 2023 Apr 27]. Available from: https://uvadoc.uva.es/handle/10324/23323.

Köseman

Şeker

. Hippotherapy and characteristics of horses used in therapy. Erciyes Univ Vet Fak Derg 2015 Oct 1; 12: 195–201.

Palisano

Rosenbaum

Walter

, et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol 1997; 39: 214–223.

Becure. Virtual rehabilitation [Internet]. [cited 2023 Apr 27]. Available from: https://tr.becureglobal.com/.

Shubert

Schrodt

Mercer

, et al.

Are scores on balance screening tests associated with mobility in older adults?

J Geriatr Phys Ther 2006 Apr; 29: 33.

10.

Yücel Şen

Carman

Yarar

, et al. Evaluation of the effects of hippotherapy on balance and motor function in children with cerebral palsy. Osmangazi Med J 2023; 45: 58–63.

11.

Koç

Altınkaya

İnanç

. The therapeutic benefits of hippotherapy: an occupational therapy perspective. Gümüşhane Univ J Health Sci 2023; 12: 324–333.

12.

Matusiak-Wieczorek

Dziankowska-Zaborszczyk

Synder

, et al. The influence of hippotherapy on the body posture in a sitting position among children with cerebral palsy. Int J Environ Res Public Health 2020 Sep 19; 17: 6846.

13.

Moraes

Ângelo

Chiavoloni

, et al. Hippotherapy on postural balance in the sitting position of children with cerebral palsy–Longitudinal study. Physiother Theory Pract 2020; 36: 259–266.

14.

Portaro

Cacciola

Naro

, et al. Can individuals with down syndrome benefit from hippotherapy? An exploratory study on gait and balance. Dev Neurorehabil 2020 Aug; 23: 337–342.

15.

Flores

Dagnese

Copetti

. Do the type of walking surface and the horse speed during hippotherapy modify the dynamics of sitting postural control in children with cerebral palsy? Clin Biomech 2019 Dec; 70: 46–51.

16.

Ahmed

Al Zubayer

Akter

, et al. Physical effects of hippotherapy on balance and gross motor function of a child with cerebral palsy. Arch Clin Med Case Rep 2023; 7: 181–186.

17.

Peia

Veiga

Gomes

, et al. Effects of hippotherapy on postural control in children with cerebral palsy: a systematic review. Pediatr Phys Ther 2023; 35: 202–210.