Abstract
Introduction
There are a multitude of effective treatments available that were once, and may still be, underutilized. For example, the utilization of art therapy for mental and physical conditions such as cancer and traumatic brain injury have become increasingly more common (Bitonte et al., 2014). In addition, meditation therapy, once used exclusively for religious purposes, is now a viable tool to relieve health issues such as stress and mood disturbance (Carlson et al., 2001). Hippotherapy is the use of equine movement in physical, occupational, or speech therapy in order to obtain functional improvements in patients. Despite therapeutic benefits being confirmed, hippotherapy is limited in its use (Heine, 1997; Benda et al., 2003;…). Deeper understanding of its application and underuse must be investigated in order to obtain its maximum benefits.
Hippotherapy has been more thoroughly studied in patients with cerebral palsy, multiple sclerosis, spinal cord injury, stroke, and autism spectrum disorder. However, usage of this therapeutic tool is not limited to these disorders (Shover, 2010; Geurino et al., 2015). According to the American Hippotherapy Association, Inc, physical therapists, occupational therapists, and speech therapists use the horse’s movements to improve core control, balance, fine motor skills, visual skills, cognition, and communication skills in patients (Granados et al., 2011). All skills achieved while on the horse are meant to positively impact functional capabilities off the horse. Hippotherapy has been shown to help in multiple areas of deficits such as motor deficiencies, speech deficiencies, and sensory processing dysfunctions.
Motor deficiency
The variability of the horse’s pelvic movement is carefully graded and matched to the needs of the patient in order to provide optimum physical and sensory input. When humans walk, there is a certain amount of pelvic lateral tilt, pelvic rotation, and anterior and posterior pelvic movement all happening simultaneously. These depend on the person’s body type. The ratio of movement that the horse causes in a person’s pelvis when they are sitting on top is similar to the ratio of movement when the person walks (Heine, 1997). At the same time, the horse’s ambulation has been shown to help improve ambulatory muscles throughout the patient’s body due to similar human ambulatory movement (Benda et al., 2003). The patient sitting on top is learning to use his or her muscles reciprocally, learning to be stable and mobile at the same time. Through the constant rhythmic stimulation in the sagittal, coronal, and transverse planes, a patient learns to adjust his or her body to simulate walking. While the horse provides specific movement stimulus, varying the horses’ tempo and direction can alter the degree of stimulus based on the patients’ needs.
Having a stable posture is an automatic response during a child’s development. For patients with neuromuscular disorders, an unstable posture can inhibit fine and gross motor skills. Sitting on the horse’s back requires the use of core muscles, thus strengthening the core muscles and improving postural control and balance. In addition, the therapist can maneuver the horse so that subtle adjustments in trunk control by the patient is needed. Focusing on having an upright body increases a patient’s function in his or her upper extremities (Shurtleff et al., 2009).
Speech deficiency
The position of the patient on the horse influences pelvic and spine movement as well as expansion of the ribcage. Having postural control and thus an improved alignment positions the body to have greater control over respiration, oral motor function, and speech. Control over the hyoid muscles helps gain head, neck, and oral motor control. Control over the pelvic girdle allows greater control of the respiratory and thoracic muscles, allowing deeper breathing movements. The greater facilitation of alignment and motor control improves communication function (Shover, 2010).
Sensory processing dysfunction
Patients experiencing sensory processing disorders may have poor motor skills, appear uncoordinated, and have difficulty adjusting to different situations. Targeting the vestibular, proprioceptive, and visual systems, therapists use the movement of the horse to obtain an adaptive response from the patient (Silkwood-Sherer et al., 2007). Therapeutic activities during a hippotherapy session are used to help patients integrate sensory information and increase spatial dimension and coordination (Casady et al., 2004).
Mental wellbeing
Although hippotherapy is not directly used for mental health purposes, research has shown positive impacts on the patients and their family. Motor skills are connected to social skills, language, and movement. Limitations in movement can hinder interactions in a social setting, creating challenges to acquire developmental social skills (Geurino et al., 2015). Hippotherapy uses the horse to promote coordination and awareness, which increases confidence in one’s abilities. This confidence aids in the recovery of feelings of security, motivation, discipline, and emotional adaptation (Ajzenman et al., 2013; Granados et al., 2011).
Application
In most states in the U.S., a prescription from a physician is required for therapy, including treatment that uses hippotherapy. A physical therapist, occupational therapist, or speech language pathologist should have continuing education and certification to provide safe and effective hippotherapy as a part of a patient’s plan of care. The American Hippotherapy Association, Inc provides several levels of training, and the American Hippotherapy Certification Board oversees certification in the U.S.. A hippotherapy session, at the least, requires a team consisting of the patient, therapist, horse, and a horse handler. The patient is situated on the horse while the therapist walks by the side of the horse and patient. The horse handler directs the gait, speed, and course of the horse at the request of the therapist. Horses are very sensitive to the subtlest touch and require training to be able to perform the movement needed for hippotherapy. Horses are chosen with excellent movement and calm disposition to reduce the chances of injuries that can be inflicted on the patient. The number of sessions varies depending on the aim of treatment. However, movement input usually lasts 30 minutes and improvements can be observed in as short as 4 weeks (Lechner et al., 2007). Hippotherapy differs from therapeutic riding, a recreational activity which focuses on teaching riding skills for individuals with disabilities. Also known as adaptive riding, in therapeutic riding, the rider is learning how to be in control of the horse and its movement (Lessick et al., 2004). In contrast, in hippotherapy the therapist directs the movement of the horse in order to achieve an adaptive response (Casady et al., 2004).
Comparison to a clinical setting
Hippotherapy involves the integration of all body systems, including musculoskeletal, neurologic, cardiac, respiratory and sensory systems, with the vestibular, proprioceptive, and visual systems being primarily targeted. It is possible to stimulate all these systems in a clinical setting. However, sensory and motor input from the horse is multi-modal and highly organized, providing a more meaningful and functional impact on the patient.
Materials and methods
Participants
Southern California consists of ten counties: Los Angeles, San Diego, Orange, Riverside, San Bernardino, Kern, Ventura, Santa Barbara, San Luis Obispo, and Imperial Counties. According to the National Rehabilitation Information Center, a rehabilitation center is defined as having one of the following therapies: physical therapy, occupational therapy, or speech therapy (What is a Rehabilitation Center?). Therapy centers who self identified as rehabilitation centers in these ten counties were contacted and surveyed. The search engine site, Google, and Yellow Pages were used in order to find rehabilitation centers. Internet searches with the words “Rehabilitation Centers,” “Physical Therapy, Occupational Therapy, Speech Therapy,” and the county name were used to find rehabilitation centers. Rehabilitation Center websites were searched to identify whether they offered therapies for developmental disorders, orthopedic disorders, or neurologic conditions. Another criteria for the rehabilitation centers were that they must provide physical therapy, occupational therapy, or speech therapy services. One hundred and fifty two rehabilitation centers were called or emailed, and forty centers filled out and submitted the survey. One center indicated that it did not identify as a rehabilitation center and thus their data was taken out.
Only 9 out of the 10 counties were represented in the data, while one county, Imperial County, was not. 13 centers out of the 33 centers contacted in Los Angeles County responded. 3 centers out of the 28 centers contacted in San Diego County responded. 11 centers out of the 23 centers contacted in Orange County responded. 2 centers out of the 10 centers contacted in Riverside County responded. 3 centers out of the 11 centers contacted in San Bernardino County responded. 1 center out of the 11 centers contacted in Kern County responded. 2 centers out of the 10 centers contacted in Ventura County responded. 3 centers out of the 12 centers contacted in Santa BarbaraCounty responded. 2 centers out of the 11 centers contacted in San Luis Obispo County responded. No centers out of the 3 centers contacted in Imperial County responded. There were more centers contacted in Los Angeles, San Diego, and Orange County as these are the top three most populous counties in Southern California. Imperial County is the least populous, spans the least amount of area in the region, and did not contain many listings for rehabilitation centers.
Survey
A survey with four questions were emailed to one hundred and fifty two rehabilitation centers. Only physical therapists, occupational therapists, speech therapists, program directors, or other site employees were permitted to participate in the survey. The primary emphasis of the questions was to understand if hippotherapy is underutilized, and if so, why. Thus, four questions were carefully constructed to answer this problem. The first question, “Physical Therapists, Occupational Therapists and Speech Language Pathologists may use hippotherapy with their patients to achieve functional movement. Are you familiar with hippotherapy and its therapeutic benefits?,” aimed to identify whether hippotherapy was recognized as a therapeutic tool amongst therapists and rehabilitation center workers. The second question, “Do you offer hippotherapy?,” was used to quantify the number of rehabilitation centers that provided hippotherapy. The third question asks, “It has been shown that hippotherapy has some therapeutic value and we live in a part of the country where it should be available year round because of the favorable year-round weather, so why do you believe it is not utilized more at your rehabilitation center or rehabilitation centers who do not offer hippotherapy? lack of patient insurance who are willing to fund hippotherapy? lack of patient funding to pay for it privately? lack of therapists who have expertise in hip-potherapy? no patient demand/patients are unaware of its value? patient/rehab center remuneration (money) issues? therapists are unaware of hippotherapy? patients believe horses are unsafe? therapists believe horses are unsafe? other reasons?”
The third question was used to identify the major reasons as to why hippotherapy may be underutilized at these centers. This question was presented in checkbox form so that survey participants could mark as many answer choices as they deemed fit. The fourth question, “Since hippotherapy requires facilities that can house horses, many hippotherapy treatments are found on farms and not rehabilitation centers. Would you be willing to refer your patients to a therapist who is certified to provide hippotherapy?” was intended to measure whether therapists valued hippotherapy enough to refer their patients to centers that offered this therapeutic strategy. The survey was emailed to all the rehabilitation centers, with follow up emails for clarifications.
Results
One hundred and fifty two rehabilitation centers in Southern California were contacted in order to understand the pervasiveness of hippotherapy. Forty centers filled out and submitted the survey and results were analyzed. 85% (34/40) of therapists and other rehabilitation center representatives who completed the survey on behalf of their rehabilitation center indicate that they are aware of the therapeutic benefits that hippotherapy offered while 15% (6/40) of therapists and other rehabilitation center representatives are not aware (Fig. 1). Despite this, 82.5% (33/40) of surveyed rehabilitation centers do not provide hippotherapy services to their patients while only 17.5% (7/40) of surveyed rehabilitation centers do provide hippotherapy services (Fig. 2). Remuneration issues are the main reason behind rehabilitation centers’ inability to provide hippotherapy. Lack of patient insurance willing to fund hippotherapy was the primary reason, with lack of private patient funding, and rehabilitation center remuneration issues following (Fig. 3, 62.5% (25/40), 45% (18/40), 37.5% (15/40)). Lack of therapists who have expertise in hippotherapy, no patient demand/patients are unaware of its value, and the inability for rehabilitation centers to obtain lands to house horses followed respectively (Fig. 3, 37.5% (15/40), 27.5% (11/40), 22.5% (9/40)). Three centers believe other therapy treatments are better, and none believe that patients or therapists considered horses to be unsafe (Fig. 3, 7.5% (3/40), 0% (0/40), 0% (0/40)). Obstacles hinder the offering of hippotherapy, however, 64.7% (22/33) of rehabilitation centers who do not offer hippotherapy are willing to refer clients to a therapist certified to provide hippotherapy, while 32.3% (11/33) indicate they are unsure (Fig. 4).
Discussion
Hippotherapy is the use of equine movement in physical, occupational, or speech therapy in order to obtain functional improvements in patients. Studies show improvement in motor function and sensory processing as a result of using hippotherapy (equine movement). Despite the literature being unequivocal that hippotherapy has value in treating patients, our review reveals a paucity of Southern Californiarehabilitation facilities that offer hippotherapy as an available option in therapy at their centers. In order to determine the causes of this, we surveyed one hundred fifty two rehabilitation centers in Southern California. Among the forty respondents, 85% (34/40) of rehabilitation centers are familiar with hippotherapy and its therapeutic benefits, while at the same time, 82.5% (33/40) of rehabilitation centers do not offer hippotherapy (Fig. 1, 2). In addition, 64.7% (22/33) of rehabilitation centers are willing to refer patients to therapists certified to provide hippotherapy while 32.3% (11/33) of rehabilitation centers are unsure if they would refer (Fig. 4). Lastly, results show that lack of insurance coverage, private funding, and rehabilitation center monetary issues play a primary role in the lack of Hippotherapy being utilized at rehabilitation centers (Fig. 3, 62.5% (25/40), 45% (18/40), 37.5% (15/40)).
Although the majority of rehabilitation centers surveyed in Southern California are familiar with hippotherapy in physical therapy, occupational therapy or speech therapy, around the same majority of rehabilitation centers do not provide hippotherapy. The data shows that the root cause in the lack of hippotherapy provision usage is due to the exclusion by insurance carriers that would cover the fees for therapy that includes hippotherapy (Fig. 3, 62.5% (25/40)). Although many research studies have produced positive results, hippotherapy has yet to be seen as valid by the health insurance companies. Thus, many patients are forced to resort to private funding to pay for therapy that includes equine movement. In addition, about 37.5% (15/40) of rehabilitation centers indicate that rehabilitation center monetary issues was a problem in hippotherapy’s utilization, likely due to the housing, upkeep, and training of the horse (Fig. 3). According to a conversation with Joann Benjamin in August, 2015, a Board Certified Hippotherapy Clinical Specialist based in California who previously served on the board for the AmericanHippotherapy Association, hippotherapy is labor intensive, requires the horse and overhead of the stable/surrounding land, and is expensive to provide, yet the actual fees for service in Southern California are aligned with other clinics that provide physical therapy, occupational therapy, or speech therapy treatment. Typical treatment ranges from $80 to $120 per treatment depending on location and therapist experience. The issue of payment can deter a patient from utilizing this therapeutic strategy since most insurance companies do not reimburse for treatment incorporating hippotherapy.
Factors that follow after monetary issues are 37.5% (15/40) of centers believe that there is a lack of therapists who have expertise in hippotherapy and 27.5% (11/40) of centers believe that there is no patient demand/patients are unaware of its value (Fig. 3). The horse being used as a therapeutic tool dates back to ancient times and modern use of hippotherapy has occurred for more than 50 years, now in more than 30 countries worldwide (Heine, 1997; Benda et al., 2003). In addition, the American Hippotherapy Association, Inc has set standards for practice and certification since 1994 (What is Hippotherapy). Yet, hippotherapy is not commonly used as a therapeutic treatment in the U.S., and the scope of its practice is limited. Furthermore, 22.5% (9/40) of centers indicate rehabilitation centers cannot obtain land to house horses, 7.5% (3/40) of centers believe other therapy treatments are more efficient, and 0% (0/40) marked that patients or therapists believe that horses are unsafe (Fig. 3).
In addition, 17.5% (7/40) of rehabilitation centers marked that they believe there are also other reasons as to why hippotherapy is underutilized besides those listed (Fig. 3). Out of the 7 rehabilitation centers who indicated “others,” 5 rehabilitation centers state that they believe distance issues was a problem. There are only about seven accredited facilities that provide hippotherapy in Southern California, a region that spans across 10 counties, 56,503.81 square miles, and a population of 23,587,150 million (California QuickFacts from the US Census Bureau). Due to the limited number of rehabilitation centers that offer hippotherapy, transportation to a facility that offers hippotherapy could be time costly. At least 1 out of the 7 rehabilitation centers indicates that there are long waiting lists and another rehabilitation center indicates that none of the required courses to be certified by the American Hippotherapy Certification Board are offered on the West Coast of the U.S. However, more American Hippotherapy Association Level I and Level II trainings are being provided in the West.
Terminology is key in increasing hippotherapy’s credibility. Hippotherapy is not a separate therapy from physical, occupational, or speech therapy. Its’ aims to stimulate the patient’s sensorimotor and neuromotor system in order to increase mobility and stability are the same as therapeutic strategies used in an indoor setting. Thus, according to the American Physical Therapy Association, the American Occupational Therapy Association and the AmericanSpeech and Hearing Association, hippotherapy is a treatment approach that falls within the scope of physical, occupational, and speech therapy practice (Rehr, 2013). Future research studies can further examine the reasons why insurance carriers exclude inclusion of hippotherapy in treatment programs. In addition, additional analysis into why some insurance carriers cover the expenses and others do not should be evaluated.
Finally, recent California legislation, California Senate Bill 43 (2016), regarding habilitative therapy may impact future reimbursement for hippotherapy (Health Care Coverage: Essential Health Benefits, 2016).
Conclusions
In conclusion, hippotherapy is a known therapeutic tool amongst rehabilitation centers. Despite lack of usage, the majority of rehabilitation centers who do not offer hippotherapy would refer their patients to a center that utilizes hippotherapy. The use of hippotherapy in physical therapy, occupational therapy or speech therapy at treatment centers is inhibited by the lack of remuneration, primarily from insurance carriers. Understanding the reasons why insurance companies fail to cover hippotherapy under its coverage plan may remedy the underutilization of this therapeutic strategy.
Conflict of interest
There are no declarations. No funding, grants or equipment was provided for the project from any source. No financial benefits were provided to the authors. This research was previously presented as a poster at the California Society of Physical Medicine and Rehabilitation’s Annual Meeting on April 25, 2015 in Anaheim, California and at the U.S. Psychiatric and Mental Health Congress on September 11-12, 2015 in San Diego, California.
Footnotes
Acknowledgments
I would like to thank Joann Benjamin and the employees at Therapy Services at Ride On as well as Carrie Jacobs from OT Outdoors for their invaluable support and guidance as research mentors for me.