Horseback riding in children with cerebral palsy: effect on gross motor function

We define sports therapy as the enjoyment of any sport whichresults in improvements in gross motor function for individ- uals having neurological disorders or developmental disabil-ities. The introduction of sports therapy in the early formativeyears may have a significant impact on accelerating the reha- bilitation of children with neurological disorders or develop-mental disabilities, such as cerebral palsy (CP).
CP is a chronic condition often requiring lifelong participa- tion in physical and occupational therapy (PT, OT). In additionto standard PT and OT to improve motor function, it has beenour clinical experience that parents often inquire about sports John A Sterba* MD PhD, Center for Sports Therapy therapy programs for their children. Recommendations for sports therapy should consider safety, enjoyment, and results of published evidence-based research on its effectiveness.
Unfortunately, there are very few published studies measuring Deborah A Vokes OTR, Robert Warner Rehabilitation Center, the effects of sports therapy programs, such as horseback rid- Children’s Hospital of Buffalo, Buffalo, NY, USA.
ing, on improving gross motor function in children with neuro-logical disorders or developmental disabilities. *Correspondence to first author at Center for Sports In adults with mental retardation,* horseback riding has Therapy Research, Inc., 226 Center Road, East Aurora, been demonstrated to result in improvements in standing and quadruped balance (Biery et al. 1989). In adults with various disabilities, including CP, horseback riding has also beenshown to produce improvements in arm and leg coordination(Brock 1988). Bertoti (1988), using a self-designed, posturalassessment scale, documented improvement in posture ineight of 11 children with CP following a horseback riding peri- The effects of recreational horseback riding therapy (HBRT) od of 10 weeks, with riding conducted in twice-weekly one on gross motor function in children with cerebral palsy (CP: hour sessions. Bertoti recommended further studies to inves- spastic diplegia, spastic quadriplegia, and spastic hemiplegia) tigate the effect of horseback riding on range of motion, bal- were determined in a blinded study using the Gross Motor ance, weight shift, and strength in children with CP. Function Measure (GMFM). Seventeen participants (nine The purpose of our study was to measure the effect of females, eight males; mean age 9 years 10 months, SE 10 horseback riding on gross motor function in children with months) served as their own control. Their mean Gross Motor CP using an accepted and validated outcome measure: the Function Classification System score was 2.7 (SD 0.4; range 1 Gross Motor Function Measure (GMFM; Russell et al. 1989, to 5). HBRT was 1 hour per week for three riding sessions of 6 weeks per session (18 weeks). GMFM was determined every 6 weeks: pre-riding control period, onset of HBRT, every 6 weeks during HBRT for 18 weeks, and 6 weeks following HBRT. GMFM did not change during pre-riding control Seventeen children diagnosed with CP who were aged 4 years period. GMFM Total Score (Dimensions A–E) increased 7.6% or older were identified as candidates for horseback riding (p<0.04) after 18 weeks, returning to control level 6 weeks
therapy (HBRT) through the Center for Sports Therapy following HBRT. GMFM Dimension E (Walking, Running, Research, in conjunction with two local therapeutic horse- and Jumping) increased 8.7% after 12 weeks (p<0.02), 8.5%
back riding centers in western New York State, USA. Four years after 18 weeks (p<0.03), and remained elevated at 1.8% 6
was determined as the ideal age to begin horseback riding by a weeks following HBRT (p<0.03). This suggests that HBRT
multidisciplinary group of administrators in both health and may improve gross motor function in children with CP, which education and therapeutic horseback riding instructors with may reduce the degree of motor disability. Larger studies are the North American Riding for the Handicapped Association needed to investigate this further, especially in children.
(NARHA 1998). Seventeen was the maximum number of chil- with more severe disabilities. Horseback riding should be dren with CP that the two horseback riding centers could considered for sports therapy in children with CP.
Participants comprised nine females and eight males, mean age 9 years 10 months, SE 10 months with a diagnosis of spas-tic diplegic (n=12), spastic quadriplegic (n=3), or spastichemiplegic (n=2) CP. Mean GMFCS score was 2.7 (SE 0.4)range 1 (higher function) to 5 (lower function). The numberof children for each GMFCS Level was: Level I (n=3); Level II(n=7); Level III (n=2); Level IV (n=2); and Level V (n=3). Amajority of riders (n=12) were ambulatory (GMFCS Levels I toIII) and five were non-ambulatory (GMFCS Levels IV and V).
Demographic and clinical data are summarized in Table I.
*North American usage. UK usage: learning disability.
Developmental Medicine & Child Neurology 2002, 44: 301–308 Families of the participants were advised about the study, for 18 weeks, and 6 weeks following the completion of horse- including risks and benefits, before giving written consent.
back riding. Individual riders served as their own control par- Approval for this study was obtained from the Institutional ticipants in this study. After the age of 6 years, children with CP Review Board of the Children’s Hospital of Buffalo, USA. In do not usually make substantial changes in their gross motor conjunction with the Children’s Hospital of Buffalo and the abilities as measured by the GMFM (Palisano et al. 2000), Robert Warner Rehabilitation Center of Buffalo, the children therefore, our study attempted to determine if horseback rid- were screened and examined by a developmental pediatrician ing over a relatively brief period of time (18 weeks) would who performed a health history and physical examination.
The degree of disability for all riders was determined by the Treatment was conducted at two local therapeutic horse- Gross Motor Function Classification System (GMFCS; Palisano back riding centers in western New York State. Therapeutic et al. 1997). The GMFCS was reported to be quick and easy to riding instruction was conducted by trained individuals, use, valid, and reliable among 48 physical and occupational accredited by NARHA, based on their knowledge of the rid- therapists and developmental pediatricians, all with expertize ers’ disabilities and in the methods for safely using trained, therapeutic riding horses. Both riding centers followed the The Children’s Functional Independence Measure (WeeFIM; same comprehensive therapeutic riding lesson plans set forth Braun et al. 1991) was used to determine the riders’ level by the NARHA Curriculum for Riding Therapy and therapeutic of independence in self-care, sphincter control, transfer ability riding procedures, precautions, and contraindications by (e.g. to and from a wheelchair), locomotion, communication, the NARHA Operating Center Standards and Accreditation and social cognition (Braun et al. 1991). When compared with (NARHA 1999). (NARHA resource information available at: the Vineland Adaptive Behavior Scale (Sparrow et al. 1984), the WeeFIM has high sensitivity and specificity (Dittmar et al.
In this study, both therapeutic riding centers conducted 1997) and is both valid and reliable (McCabe et al. 1990).
only recreational, therapeutic horseback riding, not hip- To study the effect of horseback riding on gross motor potherapy. The term hippotherapy, derived from the Greek function in children with CP required a systematic assess- word ‘hippos’ meaning horse, is defined by the NARHA Special ment of each child in a standardized manner to evaluate Interest Section, the American Hippotherapy Association as a functional activities and gross motor milestones. The GMFM form of treatment performed by health professionals, such has been demonstrated to have high levels of validity, reliabil- as physical and occupational therapists and others, in which ity, and responsiveness in assessing motor function and the the horse is used as a therapeutic intervention (NARHA effects of physical therapy in children with CP (Russell et al.
1989, Bjornson et al 1998). Therefore, the GMFM was cho- Horseback riding therapy was conducted at both horseback sen as the tool to measure any clinical changes in the partici- riding centers for 1 hour per week, 6 weeks per session for three consecutive riding sessions: totaling 18 weeks of riding.
Specifically, the GMFM consists of 88 items organized into All 17 riders achieved 18 riding sessions with replacement ses- five Dimensions: (A) Lying and Rolling; (B) Sitting; (C) Crawling sions being attended if there was any absence. In each riding and Kneeling; (D) Standing; and (E) Walking, Running, and class, the instructor followed target objectives for developing Jumping. The levels of each item are explicitly defined and sensory–motor and perceptual–motor skills. These objectives scored on a scale of 0 to 3. Item scores are summed to yield were used by the instructors to select various tasks and activi- scores for each Dimension that reflect the percent of the total ties during each riding class, following the Developmental possible score for that Dimension achieved by each child. The Riding Therapy methods of Spink (1993): riders sit directly on Total GMFM score is derived by averaging the percent scores a horse blanket or a saddle, while the instructors select various for all five Dimensions (A through E), in accordance with the tasks that are based on the child’s individual needs (see below).
GMFM training manual (Russell et al. 1993).
Riders were seated on the horse and directed by the The GMFM measurements were conducted at the Children’s instructor to touch various parts of the horse’s body, such as Hospital of Buffalo by physical and occupational therapists the horses’ mane, or flank, or reach behind to touch the hors- trained and clinically experienced in the GMFM. All thera- es’ back with either hand. The riders could also lie prone pists in our study surpassed the interrater reliability testing over the horse’s back, comfortably positioned on a horse criterion (0.80), achieving a score of 0.95. All therapists also blanket with a handhold by use of a vaulting surcingle. The maintained clinical competency using the GMFM before test- horse initially remained still and then began walking slowly.
ing any of the children in our study. To eliminate bias, these While seated on a horse blanket or saddle, the riders reached therapists were not involved in HBRT. Furthermore, none of for an object or patted the horse on either side of the its mid- the authors of this paper were present during the GMFM line. Riders reached for an object, such as a ring, across their evaluations. All therapists were kept blinded to the horse- midline and the horse’s body using one or both hands back riding conditions and regimen for the children as well together. Riders imitated movements first made by the instruc- tor such as arms abducted or bilateral arm circles, forward orbackward (Fig. 1). Riders were directed to hold a stick hori- zontally with both hands, raising and lowering the stick with The independent variable was the introduction of horseback proper postural alignment. While the rider held two sticks in riding as an additional therapy, beyond traditional PT and OT.
both hands, the instructor transferred rings between the The 17 riders were evaluated by GMFM 6 weeks before riding, sticks. Road construction cones were placed in the riding at the onset of riding, every 6 weeks during the riding period area and while the horse was led, the rider attempted to hit Developmental Medicine & Child Neurology 2002, 44: 301–308 the cones by tossing beanbags or place large rings around ers for assistance and support. Instructors determined that the five non-ambulatory children required back-riders or double All riders’ safety was always ensured: they wore fitted side-walkers for assistance in postural, truncal support, and helmets and used chinstraps. One or two side walkers used hand-over-hand encouragement when reaching, grasping, various side-helping techniques. If the rider was more physi- twisting, or performing other maneuvers during the therapeu- cally challenged, a back-rider was used to sit directly behind tic riding session. The five non-ambulatory riders performed the child, helping to maintain upright posture. The instruc- all the same tasks as the other participants with less disability tor stood nearby and directed the therapy, always monitor- (GMFCS Levels I to III), none of whom used a back-rider. ing the movement and behavior of the horse. A waist straparound the rider was occasionally used by side-walkers or the back-rider to provide a comfortable handgrip . One-way ANOVA with repeated measures using actual scores The horse was led at a controlled walk by a trained assis- for each child and the post-hoc Bonferroni test was used to tant directing the horse with a lead line attached to its halter.
determine statistical significance which was set at p<0.05. As therapy progressed, less support was needed from theside-walkers or the back-rider. While the rider was most often lying or sitting directly on the warm horse blanket or Analysis of the relation between GMFCS Level and changes in occasionally using a saddle, the instructor directed various GMFM could not be performed due to the small numbers of exercises of stretching, balance, and posture as detailed above. These exercises were performed as the horse was led For all riders, PT frequency was consistently 2.5 (SD 0.2) in a slow, steady walk, with the rider responding to the three- times per week and OT frequency was 2.2 (SD 0.2) times per week throughout the entire study. Of 17 riders, a majority The five riders who were non-ambulatory (GMFCS Levels (n=13) had previous horseback riding experience. Five riders IV and V) were positioned on the horse in the straddle posi- had previous orthopedic surgeries, many with multiple ortho- tion using a horse blanket and a surcingle, not a saddle. pedic surgeries: three riders with hamstring lengthening, two Two of these five riders (both GMFCS Level V) needed a back riders with Achilles tendon lengthening, two riders with hip rider, whereas the other three riders (two riders GMFCS Level osteotomies, and one rider with femoral hip resection and IV and one rider GMFCS Level V) only required two side-walk- adductor release. Four of the children had neurological surg- Figure 1: Rider performs arm exercises during horseback riding therapy, assisted by two side-walkers and a lead walker.
(Photo from Equistar Therapeutic Riding Center, Appleton, NY. Reproduced with permission.) Horseback Riding and Gross Motor Function John A Sterba et al. eries, including three with selective rhizotomies and one with a WeeFIM (Braun et al. 1991) Motor, Cognitive, and Total ventricular peritoneal shunt. Ten of the riders wore ankle–foot scores did not change before, during, or following HBRT.
orthoses. Only two of the children were on medication: one Absolute values for pre-riding WeeFIM Scores for all 17 riders rider was taking sodium valproate and valproic acid, acetazo- were: WeeFIM Motor, 58.1 (SD 7.4); WeeFIM Cognitive, 22.4 lamide, sodium cromoglycate, and albuterol; the other rider (SD 3.2); WeeFIM Total Score, 80.5 (SD 22.4).
was taking phenobarbital, baclofen, and ranitidine.
From 6 weeks before riding to the onset of riding therapy, Table I: Participant characteristics (n=17)
O, orthopedic; bilat, bilateral; N, neurological; VP, ventricular peritoneal; AFO, ankle–foot orthosis; sd valp/valp ac, sodium valproate andvalproic acid; sd cromogly, sodium cromoglycate.
Developmental Medicine & Child Neurology 2002, 44: 301–308 there were no differences in any of the five GMFM Dimension control the horse but is directly influenced by, and responds to scores or the GMFM Total Score, averaged as control data. After movements by the horse (Potter et al. 1994). The warmth of one session (6 weeks), there was no difference, but after two the horse through the blanket plus the rhythmical movements sessions (12 weeks) of HBRT, GMFM Dimension E (Walking, of the horse have been speculated to improve circulation, Running, and Jumping) increased significantly (8.7%; p<0.02) reduce abnormally high muscle tone, and promote relaxation and remained elevated (8.5%; p<0.03) after three sessions (18 in children with spastic CP (DePauw 1986, Bertoti 1988). In weeks). Six weeks following the HBRT post-riding period, addition, the sensation of rhythmic movement along with GMFM Dimension E remained elevated (1.8%; p<0.03; see Fig other therapy techniques on the horse can be used to facilitate 2). The power of the performed test with alpha=0.05 was and improve co-contraction, joint stability, weight shift, and 0.803, which was above the desired power of 0.8.
postural and equilibrium responses in children with CP After 3 sessions (18 weeks) of HBRT, GMFM Total Score (Bertoti 1988). In our study, GMFM Dimension B (Sitting), (Dimensions A–E) increased (7.6%; p<0.04) but returned to which is related to posture, showed only a 4.1%, non-signifi- pre-riding levels 6 weeks following HBRT in the post-riding cant (p<0.1) improvement. We speculate that evaluating a period (pre-riding: 62.4% [SD 7.8]; post-riding: 60.5% [SD9.3] ns; see Fig 3). The power of the performed test withalpha=0.05 was 0.759, which was just below the desiredpower of 0.8. Table II summarizes the results of GMFM Dimension E There were no significant changes in GMFM Dimension A (Lying and Rolling), Dimension B (Sitting), Dimension C (Crawling and Kneeling), or Dimension D (Standing). Closeinspection of the data revealed that GMFM Dimension B appeared to steadily increase from pre-riding levels (75.2%, SD8.2) to the end of 18 weeks of HBRT (79.3%, SD 8.4). This 4.1% increase, however, did not quite reach statistical significance (p=0.1). Six weeks following HBRT, GMFM Dimension B was observed to decrease (74.2%, SD 8.7), but was not significantly different from pre-riding levels (75.2%, SD 8.2).
Historically, horseback riding has been subjectively described by physicians and therapists in medical literature dating backto the second century (e.g. Galen c129 to c200, Oribasius 1555, Figure 2: GMFM Dimension E (Walking, Running, and Fuller 1705, Quellmaltz 1735, van Swienten 1776, Chassaigne Jumping). After two, 6-week long riding sessions, GMFM 1870: see Baine 1965) as a beneficial form of therapy for Dimension E increased 8.7% (*p<0.02) and after three patients with various neurological disabilities. Without a sensi- sessions increased 8.5% (**p<0.03). Six weeks post-riding, tive tool such as the GMFM, none of these authors were able to Dimension E remained elevated at 1.8% (***p<0.03). measure the clinical efficacy of horseback riding as therapy. There are no further references in the literature to the use of horseback riding as a form of therapy until two serious epi-demics of paralytic poliomyelitis in Scandinavia in 1946.
These events led to the founding of the first two centers oftherapeutic horseback riding in Copenhagen, Denmark and Oslo, Norway for the treatment of children with neuromus- cular disorders, especially poliomyelitis and CP (Baine 1965).
From 1953 onward, therapeutic horseback riding was actively promoted by the International Polio Fellowship in England (Baine 1965). This international momentum for HBRT led to the development of the first therapeutic riding program in North America established in Toronto, Canada in1965 as the Community Association for Riding for the Disabled (CARD; Brock 1988, Mackay-Lyons et al. 1988). The North American Riding for the Handicapped Association (NARHA) was founded in 1969 to support riders from both Horseback riding therapy is directed towards improving the rider’s ability to receive and process body-wide sensoryinformation from the smooth, rhythmical movements madeby the horse (Spink 1993). By placing the rider on the horse Figure 3: GMFM Total Score (Dimensions A–E) after three, 6- using a soft blanket in various body positions (e.g. prone, week long riding sessions. GMFM Total Score increased 7.6% supine, side lying, side sitting, or sitting) the rider does not (*p<0.04), returning to pre-riding 6 weeks post-riding (ns). Horseback Riding and Gross Motor Function John A Sterba et al. larger number of children in future HBRT may reveal signifi- the trunk of the rider, likely activating lateral flexors (Spink cant improvement in GMFM Dimension B.
1993). According to Spink (1993), the four functional stages Although similar to the use of therapeutic devices used in of motor control detailed by Bobath and Bobath (1975), the clinic, such as the bolster swing or Swiss ball, horseback namely uncontrolled mobility, proximal mobility on distal riding offers more sensory–motor stimulation and a bond stability, distal mobility on proximal stability, and locomotion, between rider and horse that cannot be simulated artificially may all be stimulated with therapeutic horseback riding. in the clinic or with an inanimate horse. As suggested by Following our study, we inquired with each family which MacKinnon and colleagues (1995), horseback riding pro- factors, such as program costs or time, influenced or limited vides the rider who has a disability with a sensory–motor further participation in HBRT. All riders and their families experience that contributes to the development, mainte- thoroughly enjoyed the horseback riding experience. Our nance, rehabilitation, and enhancement of various sensory informal survey revealed the most important limiting factor was available time, not registration fees, transportation costs, Those who have supported therapeutic horseback riding or accessibility issues. Families uniformly complained about have collectively suggested these possible therapeutic benefits: not having enough time for daily care issues with consider- (1) mobilization of the pelvis, lumbar spine, and hip joints, (2) able time being lost driving their children to and from various normalization of muscle tone, (3) development of head and therapy and physician appointments. Lack of medical insur- trunk postural control, and (4) development of equilibrium ance reimbursement for HBRT was not an issue in our study.
reactions in the trunk (Chassaigne 1870, Baine 1965; Harpoth Our research grant paid for GMFM evaluations and reimbursed 1970; Haskin et al. 1974; Freeman 1984; Bertoti 1988, 1991).
parents for the horseback riding registration fees. All parents, Our results using the GMFM now demonstrate that horseback however, inquired whether medical insurance would ever pay riding as therapy is associated with improvements in total gross for this form of sports therapy. They also agreed that they would pay privately for HBRT, despite the lack of medical insur- In the 17 children with CP, HBRT was associated with ance reimbursement, due to observable improvements that improvements in gross motor function, not only in the were seen not only in gross motor function, but in speech, self- GMFM Total Score but with improvements in the GMFM esteem, and emotional well-being as well as a perceived high Dimension E (Walking, Running, and Jumping), which per- degree of enjoyment by all the children in our study. These sisted 6 weeks after the completion of horseback riding. other benefits of horseback riding are very important and have It is hypothesized that the complex movement of the been previously described in children and adults (Brock 1988, horse influences the rider by passive and active stretching Spink 1993, MacKinnon 1995). All families suggested that once and stimulation of the rider’s balance and postural control.
per week would be the maximum time their child would be The movement of the rider’s pelvis in response to the horse’s able to participate in future HBRT, due to personal time con- gait has been described to resemble the movement of the straints. This is also the usual regimen for recreational HBRT in pelvis during normal human gait (Bertoti 1988, Spink 1993, Potter et al. 1994, MacPhail et al. 1998). It is hypothesized Our results extend a recently reported finding in a pilot that these movements enhance the rider’s function during study of hippotherapy in five children with CP by McGibbon gait and gait-related activity. The primary horse movements and coworkers (1998). They demonstrated that after 8 have been found to be correlated with the automatic physical weeks of hippotherapy (conducted twice weekly, one hour reaction of the rider in the three components of movement per session), there was a significant improvement in GMFM of the human body, i.e. static/dynamic, weight-shift, and rota- Dimension E. However, there was no improvement seen in tional components (Spink 1993). During the horse’s slow the GMFM Total Score and no documented percent change walk, all three components occur within the rider’s trunk was reported for GMFM Dimension E. No follow-up study and pelvis simultaneously (Spink 1993). The horse’s gait was conducted to determine any carry-over effects following moves the rider forward and backward, causing anterior and hippotherapy. This pilot study may also have been limited by posterior tilt of the pelvis. This process is thought to stimu- a small sample size (n=5) and biased with the the physical late the rider to develop control of the trunk via flexors and therapist conducting both the hippotherapy and the GMFM extensors. Likewise, the horse’s movement side-to-side causes reciprocal activation of the rider’s lateral flexors of the trunk Confounding variables may have also influenced our and may develop further trunk stability. The rotational compo- results. We questioned whether the novelty of the horseback nent of the horse’s movement are believed to cause rotation in riding experience might have contributed to the measurable Developmental Medicine & Child Neurology 2002, 44: 301–308 improvements in total gross motor function and persistent changes in walking, running, and jumping. However, a Sports therapy is the enjoyment of a sport, such as horseback majority of the children in our study (13 of 17) had previous riding, which results in significant improvements in gross horseback riding experience. It is possible that children not motor function. In a heterogeneous group of children with yet exposed to horseback riding may demonstrate an even mild to severe CP, horseback riding clinically improved over- greater improvement in gross motor function.
all gross motor function, especially walking, running, and Our data cannot be explained as a therapeutic effect from jumping, which persisted following HBRT. These significant ongoing PT or OT. Horseback riding was introduced as an results, which should be confirmed in further research, have independent variable, in addition to PT and OT which were provided clinical evidence of a possible reduction in gross consistently conducted throughout the entire study. In addi- motor disability in children with CP. Horseback riding should tion, repetitive GMFM measurements would not produce any be considered for sports therapy for the medical rehabilita- training effect to increase GMFM scores systematically over the 6-week intervals used in our 30-week study (Rosenbaum,personal communication, 2000).
Accepted for publication 14th November 2001. We considered a criticism of whether this observed thera- peutic effect from recreational horseback riding might be due to ‘fun only’ and not the therapeutic effect of movement on the This research was supported by a medical rehabilitation research horse. When we inquired whether these and other families grant from the Children’s Guild, Inc., Buffalo, NY. We would like toextend our appreciation to Mrs Gloria A Favero, Administrative would consider allowing their children to participate in a Secretary of the Department of Occupational and Physical Therapy, future experiment with simulated horse movements, using a Children’s Hospital of Buffalo, for assisting families and scheduling wooden horse with ropes and pulleys, all families declined. If it all the GMFM appointments. We would also like to thank Mary Lane isn’t ‘fun’, children will not participate in therapy, which most Dip P & OT, for GMFM training and Peter L Rosenbaum MD for pediatric physical and occupational therapist know. reviewing our manuscript. This research was presented at the 54thAnnual Meeting of the American Academy for Cerebral Palsy and Initially, we questioned whether lack of a control group of Developmental Medicine, Toronto, Ontario, Canada, 20–23 non-riders might have limited our study design. All of the rid- ers in this study served as their own control. This is a verysensitive way to determine even small therapeutic changes, such as the observed improvement in GMFM Dimension E Baine A. (1965) Pony riding for the disabled. Physiotherapy51: 263–5.
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