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The Efficacy of Equine-Assisted Activities and Therapies on Improving Physical

Function

Article in Journal of alternative and complementary medicine (New York, N.Y.) · December 2015
DOI: 10.1089/acm.2015.0171

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THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 22, Number 1, 2016, pp. 9–24
ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2015.0171

The Efficacy of Equine-Assisted Activities

and Therapies on Improving Physical Function

B. Rhett Rigby, PhD,1 and Peter W. Grandjean, PhD 2

Abstract

Objective: To summarize the physical benefits of therapeutic horseback riding and hippotherapy and suggest
directions for future research.
Methods: Review of databases for peer-reviewed articles related to equine-assisted activities and therapies.
Databases included MEDLINE via EBSCO, Web of Science, PubMed, Google Scholar, and Academic Search
Complete. Articles were limited to those with full-text access published in English since 1987.
Results: Acute and residual improvements in physical benefits, such as gross motor function (e.g., walking,
running, jumping), spasticity, muscle symmetry, posture, balance, and gait occur in adults and children with
varying disabilities. The benefits appear to be greatest following multiweek interventions with one or more
sessions per week. Modest acute cardiovascular responses are observed during equine-assisted activities and
therapies with little or no evidence for training improvements in heart rate or blood pressure at rest or during
riding.
Conclusion: The present body of literature provides evidence that equine-assisted activities and therapies are an
effective means of improving many measures of physical health. However, more controlled trials are urgently
needed to strengthen the current knowledge base, establish dose-response characteristics of equine-assisted
activities and therapies, and explore the physiologic basis for the promising results suggested from the literature.

Introduction and muscle asymmetry.12,22 EAAT improves pos-

ture4–8,33,36,46 and balance9,10,28,31,34,37–40,45,47 in individuals

E quine-assisted activities and therapies (EAAT) is a

broad term that encompasses therapeutic horseback
riding and hippotherapy (Box 1). Therapeutic horseback
with CP and other disorders. Likewise, balance and lower-
limb strength are improved in healthy, elderly patients.48–50
EAAT may contribute to enhanced physical function as the
riding includes teaching specific riding skills to those with a horse elicits passive and active stretching from the rider, and
variety of disabilities by nonlicensed professionals.1,2 Hip- allows the rider to facilitate righting and equilibrium reac-
potherapy is conducted by physical, occupational, and speech tions while on the horse. The rider, then, reproduces move-
therapists. Hippotherapy interventions use the rhythmic ment patterns that are similar to those of natural human
movement of the horse to include a variety of activities on activities, such as walking.2 More specifically, the pelvic
horseback that are designed to improve functional abilities girdle and torso undergo a similar range of motion in both
and quality of life of individuals with neuromuscular im- activities.51–54
pairments.1,3 Improvements in these factors are thought to be critical for
Horseback riding as a therapeutic tool has been studied in enhancing gait. Walking is crucial for maintaining activities
those with some form of cerebral palsy (CP),2,4–32 Down of daily living (ADLs) and quality of life and gait appears to
syndrome (DS),9,19,33–35 multiple sclerosis (MS),36–40 spina be enhanced following EAAT in adults and children being
bifida,19 spinal cord injury (SCI),41–43 traumatic brain injury treated for neuromuscular disorders.10,18,31,32,35,36,38,45 In
(TBI),10,19,32,44 stroke,10,45 autism spectrum disorder,19,46 addition, decreased energy expenditure while walking has
intellectual disabilities,47 and developmental delay.9,11,19 been reported following EAAT.18,27
EAAT appears clinically useful for improving measures Cardiorespiratory responses have been reported in healthy
of gross motor function,2,6,12–20,28,29,31,33 spasticity,30,38,42,43 participants55–65 and in participants with a chronic condition

1
Department of Kinesiology, Texas Woman’s University, Denton, TX.
2
Baylor Laboratories for Exercise Science & Technology, Department of Health, Human Performance, and Recreation, Baylor University,
Waco, TX.

9
10 RIGBY AND GRANDJEAN

century BC, when Greek and Roman soldiers injured in battle

Box 1. Definitions of Key Terms
were placed back on their mounts to facilitate recovery.22 The
Term Definition first complete reference to the value of equine movement as
an effective method to promote and conserve health was
Equine-assisted A broad term that includes any made by Mercurialis (1569) in the book De Arte Gymnasti-
activities activities or therapies that incorporate ca.68 In 1782, J.C. Tissot was the first to describe three forms
and therapies equines. The term includes any of movement: active, passive, and a combination of active
specific riding center activity and passive movement, which is typical of equitation.68
(e.g., therapeutic horseback riding)
In their review, Sterba et al.2 stated that horseback riding
and any rehabilitative treatment
(e.g., hippotherapy).1 as a form of therapy gained more recent acceptance after
Hippotherapy A physical, occupational, or speech two serious epidemics of paralytic poliomyelitis that oc-
therapy treatment modality that curred in Scandinavia in 1946. These events led to the
is conducted by licensed therapists founding of the first two centers of therapeutic horseback
and uses equine movement.1,2 riding in Copenhagen, Denmark, and Oslo, Norway, for the
Therapeutic A treatment modality that uses equine treatment of children with neuromuscular disorders, most
horseback movement and aims to improve notably children with poliomyelitis and CP. From 1953
riding physical and psychosocial attributes onward, therapeutic horseback riding has been actively
of the rider in addition to teaching promoted by the International Polio Fellowship in England.
specific riding skills. This equine-
The first book published on the use of the horse for thera-
assisted activity does not involve
licensed therapists.1,3 peutic means appeared in Germany in 1961. In 1965, the
development of the first therapeutic riding program in North
America was established in Toronto, Ontario, Canada. The
North American Riding for the Handicapped Association,
riding a horse.18,25–27 Although cardiovascular responses to now a part of the Professional Association of Therapeutic
horseback riding are difficult to measure, the stresses of Horsemanship International, was founded in 1969 to support
horseback riding appear to be less than that of low-intensity riders from both the United States and Canada.2
walking.66,67 The purpose of this review is to provide a
historical context of EAAT, summarize the physical bene- Physical effects of EAAT
fits, identify gaps in current understanding, and suggest di-
Once placed on the horse, the rider is in a position that
rections for future research.
inhibits extension spasticity of the legs and applies a long-
lasting stretching of the hip adductors.38 This mechanism
Materials and Methods alone can be useful in reducing abnormally high muscle
This review of the literature included searches of several tone.5 Balance can be improved if neuromuscular and ves-
databases (MEDLINE via EBSCO host, Web of Science, tibular mechanisms are affected. As the horse walks, its
PubMed, Google Scholar, and Academic Search Complete) center of gravity is displaced three-dimensionally with a
for related articles published in English since 1988. The rhythmic movement very similar to that of the human pelvis
search terms included: horseback riding, equine therapy, during walking.38 The horse’s smooth and rhythmic gait
hippotherapy, therapeutic horseback riding, and combina- elicits motor responses in the rider that are essential for
tions of these terms with gross motor function, spasticity, movement patterns of a human pelvis while walking.3 The
posture, balance, gait, cardiovascular, and simulator. One rider’s center of gravity shifts with the moving horse, fa-
hundred and three articles that were related to horseback cilitating righting and equilibrium reactions that improve
riding and EAAT were identified. Because of the scope of trunk stability and posture.3 In addition to musculoskeletal
the paper, we excluded papers that did not include physical, function and motor control, these reactions are thought to
cardiovascular, or metabolic outcomes. Articles were lim- generate improvement in respiratory, circulatory, and di-
ited to peer-reviewed full text, published since 1987. Re- gestive health.3 A wide variety of measurement tools are
maining were 77 articles that directly related to this review. available to assess physical function. The most common
This review is intended foremost for therapists and instruments are listed in Box 2.
healthcare providers who conduct EAAT to improve phys-
ical function in their patients. It is intended for those who Gross motor function
are considering the use of EAAT and would like a broad Gross motor skills are activities that use large muscle
overview of its purported benefits. This review will also be groups to perform complex movement patterns that incor-
useful for researchers and healthcare providers interested in porate trunk balance, coordination, strength, and mobility.13
determining how to overcome the limitations in our current Table 1 summarizes the effects of EAAT on the gross motor
understanding of EAAT. function measure (GMFM) in children with various dis-
abilities. Table 1 shows that dimension E (i.e., walking,
Results running, and jumping) of the GMFM is improved more than
dimensions A through D. Dimension E improved by 8.5% in
History
children with CP after 18 weeks of therapeutic horseback
Hippocrates was the first to describe the ‘‘health-giving’’ riding2 and by 10% in children with CP after 16 weeks of
rhythm of the horse.68 Documentation of the benefits of therapeutic horseback riding in another.15 Similar im-
horses to health and well-being has existed since the fifth provements in total GMFM scores have been reported in
 Box 2. Evaluative Tools to Assess Functional Outcomes
Method Acronym Unique features Reference
Gross Motor Function
12
Calculated gross motor GMFM-66 A calculated version of the GMFM-88, it has been developed
function measure and validated with similar reliability as the GMFM-88
14
Gross motor function measure GMFM-h 16-item measure that includes dimensions A and B from the
assessed on horseback GMFM-88 while riding a horse
19
Gross motor function measure GMFM-88 88-item evaluative measure that is designed to quantify changes
in gross motor skills without regard to quality of performance
in individuals with various disorders
It includes 5 dimensions: (A) lying and rolling; (B) sitting;
(C) crawling and kneeling; (D) standing; (E) walking,
running, jumping
Spasticity
42
Ashworth Scale values ASV A scale, ranging 1–5, that is used to quantify spasticity
in the hip, knee, and ankle while lying supine
Grade 1: no increase in tone; grade 2: slight increase
in tone when the limb is flexed or extended; grade 3:
a greater increase in tone but the limb is easily flexed; grade
4: considerable increase in tone, passive movement is
difficult; grade 5: limb rigid in flexion and extension
Muscle asymmetry
12
Electromyography EMG Measurement of electrical activity of skeletal muscles using
surface electrodes
Posture
5
Assessment scale – A scale, ranging from 0 to 3, or severe to normal; assessed at
the head, neck, shoulder, trunk, spine, and pelvis
33
Accelerometry – Sensors strategically placed on body landmarks that
can measure acceleration in all three dimensions
46
Motion capture – Measurement of the three-dimensional position
of reflective markers using video analysis
46
Force plates and center – Center of pressure calculated using a measurement
of pressure of ground reaction forces in all three dimensions
Balance
9
Pediatric balance scale PBS 14-item standardized assessment including timed single-leg
stance, tandem stance, alternating stool touch and forward
reach; children’s version of BBS
34
Quadruped balance test QBT While on hands and knees with eyes facing forward,
a combination of raising both arms and legs
34
Standing balance test SBT Include standing on one leg with arms at sides, arms across
chest, both blindfolded and without a blindfold
37
Berg balance scale BBS Originally designed for elderly, assess balance and fall risk in
individuals with neuromuscular dysfunction; provides
information on position changes and postural control while
performing ADLs
37
Tinetti performance oriented POMA Same as BBS, but provides an additional assessment of gait
mobility assessment
38
Timed up and go test TUG Measures physical mobility and balance; involves standing
from a chair, walking 3 m, turning and walking back to the
chair, and sitting back down
40
Stabilometry – Analyzes static postural balance by measuring magnitude of
postural sway along A-P and M-L axes with respect to center
of pressure
41
Interactive balance scale IBS Assesses static standing balance by measuring changes in the
vertical pressure of the heels and toes
49
Fullerton advanced FABS Validated test of static and dynamic balance, appropriate for
balance scale higher functioning individuals
Gait
10
Free walking – Velocity assessed using at one’s own volition
23
Walkway with pressure – A portable, carpeted walkway embedded with pressure sensors
sensors that can measure gait speed
36
Walkway with – Can measure gait speed, stride time, and stride length at any
microprocessors given speed
38
10-m walking test – Velocity and cadence assessed in 1 direction at maximum
walking speed over 10 m
46
Motion capture – Measurement of the 3-dimensional position of reflective
markers using video analysis
ADL, activity of daily living; A-P, antero-posterior; M-L, medial-lateral.

11
 Table 1. Effects of Equine-Assisted Activities and Therapies on Gross Motor Function
Duration/mode/frequency of
Study Participants and groups therapy Measures and methods Outcomes
Case studies
Drnach et al.13 1 child with CP, 5 wk, 1 time/wk, 60 min/ GMFM given before, On average, significant improvements in dimensions D
age 10.0 y session immediately after, 5 wk and E 5 wk after intervention versus baseline; no
after intervention change in dimensions
A, B, or C
Hsieh et al.14 1 child with CP, 12 mo, 2 times/wk, 15 min/ GMFM-88 (dimensions A, B) At 3 mo, GMFM scores increased in dimension A from
age 6.0 y session; backward position administered before and at 21.6% to 31.4% and dimension B was unchanged; at
during first 3 mo; propped months 3, 6, 9 and 12 of 12 mo, scores increased in dimension A from 31.4% to
prone position during last intervention; GMFM-h 82.4% and increased in dimension B from 0% to 25%;
9 mo measured 1 time/month GMFM-h score increased 29.2% to 81.3% from 3 to
12 mo of intervention
Champagne et al.33 2 children with DS, 11 wk, 1 time/wk, 30 min/ GMFM-88 assessed before Improvements in scores in dimensions A–E for 1 child
age 28.0 and 37.0 mo session and after intervention and in dimensions B–-E for second child after
intervention; largest improvements observed in
dimension E for both children
Therapeutic horseback riding
Sterba et al.2 17 children with CP, 18 wk, 1 time/wk, 60 min/ GMFM-88 given 6 wk before, On average, total score significantly increased

12
age ‡5 y session immediately before, every at 18wk but returned to baseline levels
6 wk during, 6 wk after 6 wk after intervention; dimension E score significantly
intervention increased at 12 wk and remained elevated at 18 wk and
6 wk after intervention
Mackinnon et al.6 19 children with CP, 6 mo, 1 time/wk, 60 min/ GMFM, with a focus on Total scores and dimension E score improved in both
age ‡4 y; 10 in session dimension E, administered groups, but improvement was not significant
experimental group, before and after
9 in control group intervention
Cherng et al.15 14 children with CP, 16 wk of riding and 16 wk of GMFM-88 administered No difference in score of dimensions A–D after riding;
age ‡3 y conventional therapy, 2 before, 16 wk after riding, on average, significant improvement in dimension E
times/wk, 40 min/session 16 wk after conventional score and total GMFM score after riding
therapy
Davis et al.16 99 children with CP, 10 wk, 1 time/wk, GMFM-66 given before No significant difference in total score
age ‡4 y; 50 in 30–40 min/session and after intervention
experimental group,
49 in control group
Winchester et al.19 7 children, age ‡4 y; 2 7 wk, 1 time/wk, 60 min/ GMFM-88 given 2 times On average, significant improvements in total score
with CP, others session before (scores were between baseline and immediately after intervention
with various disorders averaged), immediately and between baseline and 7 wk after intervention
after, 7 wk after
intervention
(continued)
 Table 1. (Continued)
Duration/mode/frequency of
Study Participants and groups therapy Measures and methods Outcomes
Hippotherapy
McGibbon et al.12 6 children with CP, 12 wk, 1 time/wk, 30 min/ GMFM-66 given 12 wk All children improved total scores from 12 wk before to
age ‡5 y session before, immediately before, 12 wk after intervention
immediately after, 12 wk
after intervention
Casady et al.17 10 children with CP, 10 wk, 1 time/wk, 45 min/ GMFM-88 given 10 wk 7 children had significantly greater total scores and a
age ‡2 y session before, immediately before, significantly greater score in dimension C from
immediately after, 10 wk immediately before to immediately after intervention
after intervention
McGibbon et al.18 5 children with CP, 8 wk, 2 times/wk, 30 min/ GMFM with a focus on All children showed significant improvement
age ‡9 y session dimension E, given 8 wk in dimension E score after intervention compared with
before, immediately before, either baseline scores; no change in two baseline scores
immediately after
intervention
Hamill et al.20 3 children with CP, 10 wk, 1 time/wk, 50 min/ GMFM with a focus on No changes in dimension B score; parental perception
age ‡27 mo session dimension B, given every included improvements in ROM and head control
2 wk during intervention
Kwon et al.28 92 children with CP, 8 wk, 2 times/wk, 30 min/ GMFM-88 scores with No difference in scores between groups at baseline;
age ‡4 years; 45 in session; aerobic exercise of additional calculation of significant increase in GMFM-88, GMFM-66,

13
experimental group, same frequency/duration in GMFM-66 assessed before dimension B–E scores in experimental group after
46 in control group control group; 3 h/wk of and after intervention intervention; with respect to GMFM level, significant
outside physiotherapy in improvement observed in experimental group after the
both groups intervention in dimension E for level I, dimensions D
and E for level II, dimensions C and D for level III, and
dimensions B and C for level IV
Park et al.29 55 children with CP, 8 wk, 2 times/wk, 45 min/ GMFM-88 and GMFM-66 No difference observed at baseline between groups;
age ‡3 y; 34 in session assessed before and after significant improvement observed with GMFM-88 and
experimental group, intervention GMFM-66 scores in both groups after intervention;
21 in control group significantly greater GMFM-66 score and dimension E
score observed with experimental group after
intervention
Kwon et al.31 32 children with CP, 8 wk of hippotherapy GMFM-88 scores with No difference in scores between groups at baseline;
age ‡ y; 16 in (2 times/wk, 30 min/session) additional calculation of significant interaction effect between groups was
experimental group, and conventional therapy GMFM-66 assessed before observed with
16 in control group (2 times/wk, 30 min/session) and after intervention GMFM-66 and dimension E
in experimental group; 8 wk
of conventional therapy
only (2 times/wk, 30 min/
session) in control group
GMFM dimensions: A, lying and rolling; B, sitting; C, crawling and kneeling; D, standing; E, walking, running and jumping.
CP, cerebral palsy; GMFM, gross motor function measure; GMFM-88, 88-item gross motor function measure; GMFM-h , gross motor function measure assessed on horseback; DS, Down syndrome;
GMFM-66, 66-item gross motor function measure; ROM, range of motion.
14 RIGBY AND GRANDJEAN

children with varying disorders, such as CP, DS, autism, therefore be considerable; at the same time, EEAT may not
spina bifida, and TBI.19 Evidence also suggests that residual be as cumbersome as other treatment options.
improvements in GMFM scores are maintained 4–16 weeks Although the mechanisms for these improvements are not
after therapeutic horseback riding.2,15,19 clear, it appears that the repeated, small postural adjustments
Hippotherapy may improve GMFM scores by 1%–14% in made through the rhythmic, symmetric movement of the horse
children with CP,17,18 and improvements in GMFM scores are thought to help the rider achieve symmetric weight bear-
can be maintained 12 weeks after hippotherapy ends.12 ing.24 Only 8 minutes of hippotherapy can transiently improve
However, there is evidence that improvements in GMFM postural muscle asymmetry up to 64.6%,22 and reduce ad-
score can also return to baseline 10 weeks after hippother- ductor muscle asymmetry after 10 minutes by 41.2%, in chil-
apy.17 Although little evidence supports that hippotherapy dren with CP.12 The reduced asymmetry of adductor muscles
can improve dimension B (i.e., sitting) of the GMFM, anec- reported after 12 weeks of hippotherapy can be sustained by as
dotal evidence has included improvements in the participant’s much as 48.2% after a 12-week detraining period.12 These
head control and range of motion (ROM) of the torso and results suggest that adductor muscle asymmetry is reduced
head.20 From the evidence presented in Table 1, it appears after single episodes of hippotherapy and that this effect, re-
that children with CP exhibit a predominant acute response peated with hippotherapy training, produces an adaptive im-
and typically improve most in dimension E after EAAT. provement that can be sustained for several weeks. Although
the interaction between acute and training effects has not been
directly studied, hippotherapy appears to be an effective tool
Spasticity
for reducing muscle asymmetry in children with CP. Indeed,
Spasticity is an accompanying phenomenon of SCIs and the magnitude of effects is as strong as or stronger than what
disorders and is defined as a ‘‘velocity-dependent increase in has been reported for passive stretching.22
muscle tone elicited by passive stretching.’’42 In EAAT, the
rhythmic movement of the rider’s trunk (flexion/extension) Posture
combined with trunk torsion has a beneficial effect on
The repetitive, rhythmic movement of the horse during
spasticity.42 Spasticity is inhibited during riding because of
therapeutic horseback riding and hippotherapy allows the
a combination of flexion, extension, and external rotation at
rider to learn to anticipate the correct response in order to
the hip joint.43
remain on the horse.4 Proper postural control, defined as the
Table 2 shows the effects of therapeutic horseback riding
average position of the back and trunk relative to the pelvis,
and hippotherapy on the spasticity of participants with MS or
is necessary in this learning process.4 During hippotherapy,
SCI. The results provide evidence that EAAT can acutely
the rider has numerous opportunities to respond to the
reduce spasticity in patients who have SCI. In adults with SCI,
movement of the horse while performing functional tasks,
improvement after 11 weeks of hippotherapy was greatest
such as reaching and stretching.20 The therapy forces the
in individuals with the highest spasticity after 11 weeks.42
rider to produce compensatory movements in order to
However, there was no significant lasting effect (i.e., 4 days)
maintain postural control on a dynamic surface, thus leading
in the spasticity of adults with SCI following 4 weeks of
to a reduction in the changes of the rider’s center of gravity.4
hippotherapy, suggesting that the results are not maintained in
The effects of therapeutic horseback riding and hip-
this population.43 In children with CP, spasticity levels did not
potherapy on posture are reported in Table 3. During one
differ between a group that performed 12 weeks of therapeutic
session of therapeutic horseback riding, lateral trunk dis-
horseback riding and a group that performed outside thera-
placement can change up to 10.2 degrees in children with
py.30 At present, there is insufficient quantifiable evidence to
CP compared with 5.8 degrees in healthy controls.8 Ten
show that spasticity improves after EAAT in individuals with
weeks of therapeutic horseback riding can significantly
neurologic dysfunction other than SCI.
improve posture in children with CP, as evidenced by im-
proved trunk displacement, head stability, and pelvic
Muscle asymmetry alignment and decreased neck hyperextension.5 Despite
these singular findings, there is insufficient evidence to
Physical growth accompanied by muscle asymmetry and
conclude that posture is improved. The variety of postural
long-term sensory and motor impairments leads to increas-
assessments and subjective nature of evaluate measures
ingly severe disability.22 Muscle asymmetry can be char-
make it difficult to determine the influence of therapeutic
acterized by an uneven distribution of spasticity on one side
horseback riding and hippotherapy. More well-controlled
of the body and can contribute to abnormal posture, balance,
studies that include standardized tests of posture and motion
and gait.12 This muscle imbalance may lead to uneven bone
capture technology before and after EAAT are needed to
growth, contractures, spinal deformities, scoliosis, imbal-
assess acute and chronic responses. If posture is indeed
ances in weight bearing, hip dislocation, chronic pain, and
improved, the residual effect of EAAT is also unknown.
increasing difficulty with performance of basic motor skills
defined in the GMFM.22 Conventional medical procedures
Balance
to correct muscle asymmetry are often invasive and can
include selective dorsal rhizotomy, botulinum toxin injec- According to Hammer et al.,38 the improvement in a
tions, or tendon-release surgical procedures. These treat- participant’s balance can be expected after completion of
ments are invasive and expensive and can require multiple EAAT because riding a horse is a balance-demanding task.
repeated interventions. The benefits are often minimal and The movements of the horse are thought to constantly
may not be worth the time, cost, and pain to the participant. change vestibular sensory information, requiring the rider to
The potential for EAAT to reduce muscle asymmetry may adjust in order to stay upright. Changes in the speed and
 Table 2. Effects of Equine-Assisted Activities and Therapies on Spasticity
Duration/mode/ frequency
Study Participants and groups of therapy Measures and methods Outcomes
Therapeutic horseback riding
Baik et al.30 16 children with CP; 8 in 12 wk, 2 times/wk, 60 min/ Knee joint muscle tone assessed Significant improvement in modified
experimental group (age session before and after intervention ASVs observed after intervention in
12.1 + 3.6 y), 8 in control experimental group; no differences
group (age 8.1 + 2.6 y) observed between groups after
intervention
Hammer et al.38 11 adults with MS, age ‡35 y 10 wk, 1 time/wk, 30 min/ Palmar and plantar flexors, elbow One participant had decreased, but not
session and knee flexors/extensors in a significant, overall spasticity after
sitting position assessed before intervention
and after intervention
Hippotherapy

15
Lechner et al.42 32 participants with SCI, On average, 11 sessions Bilateral hip and knee flexion/ ASVs significantly lower after
age ‡16 y lasting 25–30 min/ extension, hip abduction/ intervention; greatest improvement
session adduction, ankle dorsiflexion/ observed in participants with high
plantar flexion while in a supine spasticity (ASV >38)
position assessed before and after
intervention
Lechner et al.43 12 adults with SCI, age ‡27 y Interventions were control, Hip and knee flexion/extension and Significant decrease in ASVs observed in
hippotherapy, sitting hip abduction while in a supine experimental group compared with
astride a Bobath roll, position assessed before, control; ASV scores were decreased
and sitting on a stool immediately after, and 3–4 d after (not significant) in Bobath roll group
with a rocking seat; each intervention and rocking seat group compared with
lasted 4 wk, 2 times/wk, control group; no significant long-term
25 min/session effects were observed due to
hippotherapy in any group
ASV, Ashworth scale value; MS, multiple sclerosis; SCI, spinal cord injury.
 Table 3. Effects of Equine-Assisted Activities and Therapies on Posture
Duration/mode/frequency
Study Participants and groups of therapy Measures and methods Outcomes
Case studies
Haehl et al.4 2 children with CP, age 4.0 12 wk, 1 time/wk; 20 min/ Postural control and stability Postural stability was greater after
and 9.0 y session for 9-year-old, measured before and after intervention for both children
40 min/session for intervention using video
4-year-old motion capture
Shurtleff et al.7 1 child with CP, age 6.0 y 12 wk, 1 time/wk, Head/trunk control measured Significant improvements in head/trunk
45 min/session using motion capture before, control from before to immediately
immediately after, 24 wk after, after intervention; no change from
9 mo after intervention immediately after to 24 wk after
intervention; improvement in postural
sway 9 mo after intervention
Champagne et al.33 2 children with DS, age 11 wk, 1 time/wk, Accelerometry of head/trunk in Along M-L axis, stability of head was
28.0 and 37.0 mo 30 min/session vertical, A-P and M-L increased at wk 4 for first child, and
directions, measured during stability of trunk was increased at wk 4
wk 1 and 4 of intervention for second child
Therapeutic horseback riding
Bertoti5 11 children with CP, 10 wk, 2 times/wk, Posture assessment scale (scored 8 of 11 children significantly improved
age ‡2 y 60 min/session 0–3, severe–normal) at head/ posture after intervention, evidenced by

16
neck, shoulder, trunk, spine, trunk elongation and more erect
pelvis, assessed before and posture; improvements observed in all 5
after intervention areas measured
Mackinnon et al.6 19 children with CP, age 6 mo, 1 time/wk, Similar to Bertoti5 No difference observed between
‡4 y; 10 in experimental 60 min/session experimental and control groups; in
group, 9 in control group experimental group, those moderately
affected showed gains, those mildly
affected showed slight decreases in
posture
MacPhail et al.8 6 children with CP, 1 session Lateral trunk displacement Mean displacement of trunk was
age ‡5 y; 7 able-bodied measured 3 times during significantly greater in the group with CP
children, age ‡6 y riding using video motion
capture
MacKay-Lyons et al.36 10 adults with MS, 9 wk, 2 times/wk, Postural sway measured using a No significant changes from before to
age ‡25 y 30–45 min/session force platform and center of after intervention; trend toward a
pressure before and after deviation in center-of-pressure
intervention displacement after intervention
Hippotherapy
Ajzenman et al.46 6 children with ASD, 12 wk, 1 time/wk, Postural sway measured using Significant decrease observed in postural
age ‡5 y 45 min/session motion capture before and sway after intervention
after intervention
ASD, autism spectrum disorder.
PHYSICAL BENEFITS OF EQUINE-ASSISTED THERAPIES 17

direction of the horse are thought to increase the control of Table 5 summarizes the effect of EAAT on gait. Overall,
muscle fibers, thus improving balance through neuromus- no significant difference in the temporal-spatial gait param-
cular coordination.38 eters has been reported following an acute exposure to the
The effects of therapeutic horseback riding and hip- therapies. However, training programs have yielded signifi-
potherapy on balance of participants with various disorders cant improvements in stride length by 17%36 and by 29%.31
and healthy elderly individuals can be found in Table 4. In Changes in gait velocity and cadence are mixed. Statistically
adults with MS, 20 weeks of therapeutic horseback riding significant differences are seen in ankle kinematics (i.e.,
can improve balance, assessed by the Tinetti performance improved ROM, improved gait cycle parameters), but not
oriented mobility assessment, by an average of 25%.39 knee kinematics, after 13 weeks of hippotherapy in children
Additional anecdotal reports provide evidence for balance with DS.35
improvements after 10 weeks of therapeutic horseback rid- ROM, body segment displacement, and muscle forces
ing.38 Twenty-four weeks of therapeutic horseback riding need to be characterized at the ankle, knee, and pelvis in
can improve standing and quadruped balance by an average individuals with neuromuscular disorders following EAAT.
of 58% and 75%, respectively, in adolescents and young These variables should be investigated concurrently with
adults with DS.34 Hippotherapy training can improve bal- temporal-spatial gait measures to help describe why these
ance by 8%–11% in adults with CP and TBI after 8 weeks10; measures may improve.
by 20%–23% in adults with MS after 4 months40; by 6% in
adults following a stroke after 16 weeks45; by 3%–24%
Cardiovascular and metabolic benefits of EAAT
in healthy elderly individuals after 8 weeks48,50; and by 25%
in children with intellectual disabilities after 10 weeks.47 The cardiorespiratory and metabolic responses to thera-
In summary, short-term EAAT of as little as 8 weeks can peutic horseback riding25,27 and hippotherapy18,26 have been
acutely improve balance in adults of varying age and dis- investigated in children with CP. Heart rate has been mea-
ability. At present, there is insufficient evidence to conclude sured before, during, and immediately after the hippother-
that balance is improved after EAAT in children with apy sessions.26 These responses can be highly variable, in
varying neuromuscular disorders. It is not clear whether part because of anticipation felt by the participant, which
training duration is a critical factor, when balance may be may influence the measurement of change in the responses
influenced most, or how long balance improvements last from rest to exercise, and the time at which the measure-
after EAAT interventions. More research is needed, partic- ments are made during the therapy session. For example,
ularly with acute and chronic responses in children after an mean systolic blood pressure (-5% change) and diastolic
EAAT intervention. blood pressure (-2% change), heart rate (-8% change), and
blood oxygen saturation (-1% change) were lower 5 min-
utes into hippotherapy compared with resting conditions
Effects of EAAT on the pelvis and gait
before the session in 22 children with spastic CP.26 In
The position of the pelvis is important in that it affects the contrast, heart rate (14% change), oxygen consumption
alignment of the spine, head, and limbs.69 The movement of (41% change) and ventilation (45% change) were elevated
the pelvis is involved in many ADLs, such as walking. In- after 20 minutes of therapeutic horseback riding in children
dividuals who are diagnosed with some neuromuscular with varying severity of CP.27
dysfunction likely experience hindered gait and abnormal Heart rate has been used to calculate energy expenditure
pelvic kinematics, leading to increased resistance to move- while walking before and during hippotherapy training.18 In
ment throughout the ROM of the pelvis and trunk.69 children with spastic CP, the energy expenditure index
The effects of a hippotherapy program on pelvic kine- (EEI) while walking was assessed before and after an 8-
matics (i.e., pelvic displacement, ROM) in children with week hippotherapy intervention in children with spastic
spastic CP have been investigated.31,32 In one study, the CP.18 The walking EEI is defined as (walking heart rate –
authors evaluated the effects of hippotherapy on gait in resting heart rate)/walking velocity.70 All five participants
children diagnosed with bilateral spastic CP.31 An analysis showed significantly decreased EEI (mean, 39%) after the
of pelvic kinematics revealed a decrease in average pelvic hippotherapy compared with before the therapy.18 Among
tilt during gait after hippotherapy.31 The authors hypothe- children with varying severity of CP, 10 weeks of thera-
sized that the decrease in pelvic tilt may be related to an peutic horseback riding elicits a higher average resting heart
improvement observed in the balance of the participants.31 rate and a higher median and peak heart rate during exercise
Trunk, pelvis, and hip motion were also observed during the in wheelchair-dependent participants compared with those
stance phase (i.e., the contact of a limb on the ground) of gait who are more ambulatory.25 The lower walking energy
in 11 children with CP and other neurologic disorders after 10 expenditure may reflect the fact that those who participate in
weeks of hippotherapy.32 Hip flexion decreased to match the EAAT are more comfortable with walking or can perform
values observed in controls after hippotherapy.32 The inves- ADLs more easily or a combination of both. The limited
tigators reported qualitative improvements; however, no sig- results are promising, and further investigation is critically
nificant change in trunk and pelvic positioning were needed to determine whether the therapies have a sustaining
observed. The authors concluded that the observed increase in effect with regard to energy expenditure while walking.
postural control was likely influenced by improvements in Cardiovascular responses to EAAT remain poorly defined.
trunk and hip alignments during gait.32 These studies provide Heart rate and blood pressure responses may be influenced by
evidence that hippotherapy can improve some aspects of gait anticipation of the riding because heart rate increases as a
through an increase in postural control, balance, or a com- result of the anticipation or excitement of an unfamiliar
bination of the two. event.71 At present, there is insufficient evidence to suggest
 Table 4. Effects of Equine-Assisted Activities and Therapies on Balance
Duration/mode/frequency
Study Participants and groups of therapy Measures and methods Outcomes
Therapeutic horseback riding
Biery and 8 participants, age 24 wk, 1 time/wk, 20 min/session SBT and QBT assessed 6 mo Significant improvement in standing and
Kaufmann34 ‡12 y; 7 with DS, 1 before, immediately before, and quadruped balance from immediately
with ID immediately after intervention before to immediately after intervention
Hammer et al.38 11 adults with MS, age 10 wk, 1 time/wk, 30 min/session BBS and TUG measured 4 times 4 participants significantly improved
‡35 y before, 5 times during, 4 times balance throughout intervention; 5
after intervention; walking a participants significantly improved
figure 8 3 times before, 4 times balance from before to after
after intervention intervention; 8 participants anecdotally
improved from before to after
intervention
Muñoz-Lasa et al.39 27 adults with MS, age 2 series of 10 weekly therapy POMA assessed before and after Significant improvement observed in
‡34 y; 12 in sessions, separated by 4 wk; 24 wk protocol experimental group after intervention;
experimental group, intervention lasted 30–40 min no change in control group after
15 in control group intervention
Homnick et al.49 15 healthy adults, age 10 wk, 1 time/wk, 60 min/session BBS and FABS assessed before and Small, nonsignificant increase in balance
‡65 y; 9 in after intervention; same tests before and after intervention in both
experimental group, 6 were assessed in controls groups
in control group
Hippotherapy

18
Silkwood- 16 children, age ‡5 y; 5 6 wk, 2 times/wk, 45 min/session PBS administered 2 times before, 1 Significant improvement in all 4 measures
Sherer et al.9 with CP, others with time after intervention of the PBS after hippotherapy when
various disorders compared with baseline for all
participants
Sunwoo et al.10 8 adults with chronic 8 wk, 2 times/wk, 30 min/session BBS and POMA assessed 8 wk No change from 8 wk before to
brain disorders (e.g., before, immediately before, immediately before intervention;
CP, TBI), age ‡25 y immediately after, and 8 wk after significant improvement immediately
intervention after intervention from baseline
measures; significant improvement still
evident 8 wk after intervention when
compared to baseline measures
Kwon et al.28 92 children with CP, 8 wk, 2 times/wk, 30 min/session; PBS assessed before and after No difference in scores between groups at
age ‡4 y; 45 in aerobic exercise of same intervention baseline; significant improvement in
experimental group, frequency/duration in control PBS score in experimental group after
46 in control group group; 3 hours/wk of outside intervention; significant difference
physiotherapy in both groups between groups after intervention
Kwon et al.31 32 children with CP, 8 wk of hippotherapy (2 times/wk, PBS assessed before and after No difference in scores between groups at
age ‡4 y; 16 in 30 min/session) and conventional intervention baseline; significant interaction effect
experimental group, therapy (2 times/wk, 30 min/ between groups was observed
16 in control group session) in experimental group;
8 wk of conventional therapy (2
times/wk, 30 min/session) in
control group
(continued)
 Table 4. (Continued)
Duration/mode/frequency
Study Participants and groups of therapy Measures and methods Outcomes
Silkwood- 15 adults with MS, age 14 wk, 1 time/wk, 30 min/session BBS and POMA administered Experimental group significantly
Sherer et al.37 ‡24 y; 9 in before, 7 wk into, and after improved after intervention from
experimental group, 6 intervention baseline; no change in experimental
in control group group after intervention from 7 wk into
intervention; control group did not
change after intervention from baseline;
significant difference observed between
groups after intervention
Menezes et al.40 11 adults with MS, age 4 mo, 2 times/wk, 50 min/session Balance and stability measured Experimental group significantly
‡32 y; 7 in using stabilometry before and improved in postural balance after
experimental group after intervention intervention with greatest reduction of
and 4 in control oscillations occurring in A-P direction
group
Choi et al.41 10 adults with Similar to Lechner et al.42 Static standing balance assessed No significant difference after
incomplete cervical using IBS before and after intervention compared to baseline
SCI, age ‡27 y intervention
Giagazoglou et al.47 19 children with ID, age 10 wk, 2 times/wk, 30 min/session Double-leg stance with eyes open Significant improvement observed with
15.3 + 2.1 y; 10 in and eyes closed, 1-leg stance with 1-leg stance and eyes open condition in

19
experimental group, 9 eyes open while standing on experimental group after intervention
in control group pressure pad, assessed before and
after intervention
Beinotti et al.45 20 adults post-stroke, 16 wk (1 time/wk) and conventional BBS measured before and after Greater improvement observed in
age ‡30 y; 10 in therapy (2 times/wk) in intervention experimental group after intervention
experimental group, experimental group; 16 wk of
10 in control group conventional therapy (3 times/
wk) in control group
de Araujo et al.48 17 healthy adults, age 8 wk, 2 times/wk, 30 min/session Stabilometry and TUG test assessed No significant difference observed in
‡60 y; 7 in before and after intervention stabilometry variables in either group
experimental group, after intervention; significant
10 in control group improvement observed with TUG test
performance in experimental group
after intervention
de Araujo et al.50 28 healthy adults, age Similar to de Araujo et al.48 BBS and TUG test assessed before Significant improvement observed with
‡60 y; 12 in and after intervention BBS assessment observed with
experimental group, experimental group after intervention;
16 in control group no change in TUG test performance in
either group after intervention
ID, intellectual disability; SBT, standing balance test; QBT, quadruped balance test; BBS, Berg balance scale; TUG, timed up and go; POMA, performance-oriented mobility assessment; FABS,
Fullerton advanced balance scale; PBS, pediatric balance scale; TBI, traumatic brain injury; IBS, interactive balance system.
 Table 5. Effects of Equine-Assisted Activities and Therapies on Gait
Duration/mode/frequency
Study Participants and groups of therapy Measures and methods Outcomes
Therapeutic horseback riding
Winchester 5 children, age ‡6 y; 7 wk, 1 time/wk, Gait speed assessed 2 times before, No significant differences observed from
et al.19 diagnoses include 60 min/session immediately after, 7 wk after before to immediately after or from
spina bifida, autism, intervention before to 7 wk after intervention
DS, and TBI
MacKay-Lyons 10 adults with MS, 9 wk, 2 times/wk, Gait speed, stride time, stride length at Gait speed, stride length significantly
et al.36 age ‡25 y 30–45 min/session free pace, fast pace assessed before greater at normal pace with no change in
and after intervention stride time in 7 participants after
intervention
Hammer et al.38 11 adults with MS, 10 wk, 1 time/wk, Maximum velocity during 10-m walking One participant significantly increased gait
age ‡35 y 30 min/session test assessed before and after velocity after intervention
intervention
Hippotherapy
Sunwoo et al.10 8 adults with chronic 8 wk, 2 times/wk, 10-m walking test, assessed 8 wk before, No change observed from 8 wk before to
brain disorders (e.g., 30 min/session immediately before, immediately immediately before intervention;
CP, TBI), age ‡25 y after, 8 wk after intervention significant improvement observed from
immediately before to immediately after
intervention; no change observed from
immediately after to 8 wk after
intervention

20
McGibbon 5 children with CP, 8 wk, 2 times/wk, Stride length, cadence, gait velocity, No significant differences were observed at
et al.18 age ‡9 y 30 min/session assessed 8 wk before, immediately any time point; a trend toward increased
before, immediately after intervention stride length, decreased cadence was
observed
McGee et al.23 9 children with CP, 1 session, 30–45 min Time in swing, stance, single and double No significant differences observed after
age ‡7 y support, step length, stride length intervention compared with baseline
assessed before and after intervention
Kwon et al.31 32 children with CP, age 8 wk of hippotherapy Cadence, single-limb support, stride Gait velocity increased in both groups after
‡4 y; 16 in (2 times/wk, 30 min/session) length, gait velocity assessed before intervention; significant increase in stride
experimental group, and conventional therapy (2 and after intervention length with no change in cadence
16 in control group times/wk, 30 min/session) in observed in experimental group after
experimental group; 8 wk of intervention; increase in cadence
conventional therapy (2 observed with control group after
times/wk, 30 min/session) in intervention
control group
Copetti et al.35 3 children with DS, 13 wk, 1 time/wk, 50 min/ Angular kinematics of ankle and knee Significant differences in ankle dorsiflexion
age 7.3 + 2.08 y session measured before and after intervention ROM, observed in balance phase of gait
after intervention
Beinotti et al.45 20 adults post-stroke, age 16 wk of hippotherapy Cadence and gait speed measured before Significant improvement observed in both
‡30 y; 10 in (1 time/wk) and conventional and after intervention groups with cadence after intervention; no
experimental group, therapy (2 times/wk) in differences observed between groups
10 in control group experimental group; 16 wk of before or after intervention
conventional therapy
(3 times/wk) in control group
PHYSICAL BENEFITS OF EQUINE-ASSISTED THERAPIES 21

that EAAT has a residual or training effect similar to the pelvis while sitting on a walking horse, the motion of the
effects generally expected from training to improve cardio- rider’s pelvis while ambulating along a level surface, and the
vascular fitness.72 Limited information exists on the cardio- motion of the horse’s pelvis while walking.51,52,77
respiratory responses to horseback riding, particularly in While most studies have focused on the noticeable,
those with physical disabilities, in part because of a host of physical benefits of EAAT, the literature lacks evidence as
factors that confound measurement precision. Movements of to why the benefits occur. Very little evidence exists re-
the rider in response to the horse augment the variability. garding the physiologic responses to EAAT, which need to
Environmental conditions, such as temperature and humid- be investigated concurrently with functional testing. For
ity, and the logistics of collecting respiratory data as the horse example, improvements in an individual’s circulatory sys-
and rider move throughout a large space, add to the diffi- tem could affect exercise performance and thus gross motor
culties in characterizing the physical responses to horseback function. Improvements in an individual’s respiratory sys-
riding. Even if most of these factors are controlled for during tem could affect walking velocity and duration. Improve-
a single measurement session, reproducing the same condi- ments in neuromuscular function could decrease spasticity
tions becomes almost impossible in attempts to obtain pre and lead to a lower energy expenditure and less stress placed
and post-training measurements, which are often separated on the cardiovascular system while performing ADLs.
by many sessions and several weeks. The existing literature have several limitations. Anestis
Nonetheless, because cardiovascular fitness is a central et al. recognized and discussed many of these limitations in
measure of physical fitness and is an independent predictor of their recent systematic review of equine-related treatments
chronic health conditions, more studies are needed to in- for mental disorders.78 Although some assessments exist,
vestigate whether horseback riding at a walking pace stim- more validated, standardized, and quantitative evaluative
ulates the cardiovascular system, including studies that instruments are needed, particularly for balance and posture.
provide data on a dose-dependent response (i.e., different More stringent control over the existing instruments that rely
walking intensities) and more measurements taken through- on subjective measures is also needed (e.g., gross motor
out the therapy. function measure, Ashworth scale). Those performing as-
It may be of tremendous value to clinicians to understand sessments using these instruments should have formal train-
cardiovascular responses to various horseback riding inten- ing or a form of certification before administering the tests.
sities in order to compare to other ADLs and to ascertain Inter- and intratechnician reliability measures should be re-
whether cardiovascular adaptations result from EAAT as ported.
they do from consistently practiced ADLs (e.g., walking, Although electromyography data have been used during
running, and jumping). Careful planning and thoughtful hippotherapy to assess activation,22 more studies must be
control of environmental factors are critical because a va- performed to investigate exactly which muscles are being
riety of factors conspire to prevent reliable cardiovascular activated and to what degree, using electromyography and
measurements during EAAT. motion capture. Experimental protocols and interventions
during EAAT should be described in more detail. In partic-
ular, the activities performed on the horse during therapeutic
Considerations of the horse
interventions must be specified relative to the severity of the
The effect of EAAT on the horses is an often overlooked, participant’s chronic disability. For the studies that analyze
but important, aspect that may affect changes observed in the cardiorespiratory data, a more comprehensive cardiorespira-
rider. Although horses are typically chosen for health, passive tory profile is needed to investigate chronic adaptive changes.
and tractable behavior, or quality of gait, it is important to Cardiorespiratory data need to be integrated with variables
identify horses that are at risk for high levels of stress during related to functional testing in order to improve understanding
the therapy session, leading to health and behavioral prob- of physical changes with EAAT from a dynamic standpoint.
lems.73–75 A horse used for EAAT that should be gentle and Control groups are not included in much of the related
pleasant, a temperament that will have a calming effect on the current literature. Future protocols should include more
rider. However, horses are social animals and respond to within-group crossover designs and more randomization of
external stimuli that may go unnoticed by the riders or han- participant populations with the same chronic condition if
dlers, resulting in increased stress that may lead to the horse separate groups are studied. Control groups might also be
exhibiting noncompliance during EAAT sessions.76 composed of those with similar disorders assigned to stan-
dard or conventional therapy.
Additional studies should provide data on children and
Discussion
adults with varying neuromuscular disorders and varying
EAAT is a broad term that includes hippotherapy and severity of their respective conditions, longer treatment pro-
therapeutic horseback riding. These forms of therapy im- tocols, and follow-up assessments (e.g., at least up to 1 year
prove gross motor function (particularly walking, running, after therapy).
and jumping), spasticity, and muscle asymmetry in individ- A common weakness that exists for most treatment/in-
uals with various disorders, including CP. These physical tervention programs is also true of equine-related pro-
benefits can lead to improvements in posture and balance. grams. The differences in equine-related programs are
EAAT can also elicit modest, acute cardiovascular responses across facilities pose a major obstacle for establishing
and improve components of gait, including walking velocity, generalizable benefits. To promote generalizability in this
stride length, and cadence. The improvements observed in field, practitioners should be aware of and document how
gait of those who regularly engage in EAAT are thought to be their particular programs and the measurements they obtain
related to the similarities between the motion of the rider’s to establish efficacy are modified from those described in
22 RIGBY AND GRANDJEAN

the literature.79 Interested readers are referred to excellent 10. Sunwoo H, Chang WH, Kwon JY, et al. Hippotherapy in
discussions on the topic of program fidelity.78,79 adult patients with chronic brain disorders: a pilot study.
In conclusion, the present body of literature provides ev- Ann Rehabil Med 2012;36:756–761.
idence that EAAT is an effective means of improving many 11. Murphy D, Kahn-D’Angelo L, Gleason J. The effect of
measures of physical health. The benefits of EAAT appear to hippotherapy on functional outcomes for children with dis-
be greatest after a multiweek intervention in which the par- abilities: a pilot study. Pediatr Phys Ther 2008;20:264–270.
ticipant rides one or more times per week. Any improve- 12. McGibbon NH, Benda W, Duncan BR, Silkwood-Sherer,
ments generally begin to decrease and return to preriding D. Immediate and long-term effects of hippotherapy on
levels several weeks after the riding has stopped. At present, symmetry of adductor muscle activity and functional ability
the primary need is the undertaking of controlled trials to in children with spastic cerebral palsy. Arch Phys Med
Rehabil 2009;90:966–974.
firmly establish the efficacy of EAAT in order to continue the
13. Drnach M, O’Brien PA, Kreger A. The effects of a 5-week
promising results suggested from the limited evidence pre-
therapeutic horseback riding program on gross motor
sented herein. Evidence for the efficacy of EAAT might lead function in a child with cerebral palsy: a case study. J
to a more widespread acceptance by healthcare practitioners Altern Complement Med 2010;16:1003–1006.
and therapists. This may lead to a greater demand for EAAT 14. Hsieh YL, Zhan SY, Wu SK, et al. Hippotherapy on gross
to be recognized as beneficial by health insurance providers motor function in a child with hypotonic quadriplegic ce-
and ultimately result in EAAT becoming more affordable rebral palsy: a 1-year follow-up. Tw J Phys Med Rehabil
and accessible. 2008;36:177–185.
15. Cherng RJ, Liao HF, Leung HWC, Hwang AW. The
Acknowledgments effectiveness of therapeutic horseback riding in children
with spastic cerebral palsy. Adapt Phys Activ Q 2004;21:
All work was completed in the Baylor Laboratories for
103–121.
Exercise Science & Technology, Department of Health, 16. Davis E, Davies B, Wolfe R, et al. A randomized controlled
Human Performance, and Recreation, Baylor University, trial of the impact of therapeutic horse riding on the quality
Waco, TX. of life, health, and function of children with cerebral palsy.
Dev Med Child Neurol 2009;51:111–119.
Author Disclosure Statement 17. Casady RL, Nichols-Larsen DS. The effect of hippotherapy
No competing financial interests exist. on ten children with cerebral palsy. Pediatr Phys Ther
2004;16:165–172.
18. McGibbon NH, Andrade CK, Widener G, Cintas HL. Ef-
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