International Journal of Nursing Sciences 9 (2022) 542e552

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International Journal of Nursing Sciences

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nursing-sciences/2352-0132

Review

Effects of equine-assisted interventions on older adults’ health: A

systematic review
Le


a Badin*, Emilie Alibran, Kristell Pothier, Nathalie Bailly
University of Tours, EA 2114 PAVEA Laboratory, Tours, France

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Equine-assisted interventions (EAI) can improve a variety of health problems in older adults
Received 15 June 2022 and thus promote their well-being. This systematic review aimed to synthesize studies on EAI to un-
Received in revised form derstand better their effects on the health of older adults.
30 August 2022
Method: A systematic search guided by the PRISMA 2020 approach was performed on specific databases:
Accepted 14 September 2022
Available online 20 September 2022
Medline (PubMed), EMBASE, PsycINFO, and Cochrane Library. Peer-reviewed articles published in the
English language from inception to June 2022 were retrieved. Methodological quality was established
using the modified version of the Downs and Black checklist.
Keywords:
Animal assisted therapy
Results: A total of 244 studies were retrieved, and 13 eligible studies were finally included. Three health
Aged domains were investigated: physical (balance, gait, and muscular strength), psychological (quality of life
Equine assisted therapy and cognitive assessment), and physiological (hormonal measures, cerebral and muscular activity).
Health promotion Among the eight studies investigating the physical dimension, four studies highlighted a positive effect
of EAI on balance, four for gait, and three for strength. Regarding the three studies investigating the
psychological dimension, two studies showed a positive effect of EAI on quality of life. Lastly, the four
studies investigating the physiological dimensions all demonstrated a positive effect of EAI on hormonal
measures and cerebral and muscular activity.
Conclusion: Nevertheless, this systematic review provides promising findings regarding the positive
effects of EAI on physical, psychological, and physiological health in older adults. Research on EAI should
therefore be pursued rigorously to promote this non-pharmacological intervention in an older adult
population.
© 2022 The authors. Published by Elsevier B.V. on behalf of the Chinese Nursing Association. This is an
open access article under the CC BY-NC-ND license ([Link]

What is known? What is new?

Today, equine-assisted interventions (EAI) have been proven to
This study proposes a synthesis of EAI with older adults
benefit several populations, including youth and especially regarding the physical, physiological, and also psychological
children with autism. Studies have also shown beneficial out- domains.
comes of equine intervention with individuals with psychiatric
Results contribute to a better understanding of the benefits of
disorders such as post-traumatic stress disorder. EAI on the physical and psychological health of older adults.

Studies conducted on older adults specifically address the
The findings of this systematic review highlight the need for
physical and physiological domains. more rigorous studies to promote this type of innovative inter-

Currently, non-pharmacological interventions are recom- vention for older adults to contribute to improving their quality
mended to maintain or improve the quality of life of older of life.
adults.

1. Introduction

* Corresponding author.
Animal-assisted interventions (AAI) are defined as goal-oriented
E-mail address: [Link]@[Link] (L. Badin). and structured interventions based on human-animal interaction.
Peer review under responsibility of Chinese Nursing Association. According to the International Association of Human-Animal

[Link]
2352-0132/© 2022 The authors. Published by Elsevier B.V. on behalf of the Chinese Nursing Association. This is an open access article under the CC BY-NC-ND license (http://
[Link]/licenses/by-nc-nd/4.0/).

Alibran, K. Pothier et al.
L. Badin, E. International Journal of Nursing Sciences 9 (2022) 542e552

Interaction Organizations (IAHAIO, 2018), AAI includes different an increase in serotonin and a decrease in cortisol levels following 8
types of interventions such as animal-assisted therapies, animal- weeks of EAI among older adults compared to a control group. The
associated activities, or animal-assisted education programs [1]. same results were observed in an autistic population [21]. In
Animal-assisted therapies are generally conducted by a health addition, it has been demonstrated that EAI enhances brain func-
professional (therapists or physicians) with specific therapeutic tion [22,23]. For example, Cho et al. [23] showed that the power of
goals (e.g. improved quality of life), while animal-associated ac- the relatively fast alpha band increased in the equine compared to
tivities and animal-assisted education are more informal and are the horseback riding machine group after 12 weeks of the inter-
often conducted by paraprofessionals, or volunteers. Although vention. These findings suggested that EAI provides psychological
most of the studies on AAI have focused on dog-assisted in- benefits by improving brain function, increasing comfort and con-
terventions [2], equine-assisted interventions (EAI) represent an centration, and reducing stress.
emerging field of AAI aimed at promoting physical and mental Although a growing number of studies support the positive
health. EAI involves horses as co-facilitators in a therapeutic or physical and psychological impact of EAI among young adults, little
recreational environment. EAI encompasses several activities like attention has been paid to EAI for older populations [17]. In addi-
horseback riding, but also activities without classic riding such as tion, their efficacy remains to be proved completely. Thus, the
adapted acrobatics, carriage driving, grooming, and caring for and purpose of this systematic review is to synthesize evidence from
interacting with horses. Previous studies have demonstrated that EAI studies among older adults and to better understand the ben-
EAI seems to alleviate emotional, social, cognitive, and physical efits of EAI on their health.
disorders in various healthcare settings and has been used to treat
neurological disorders [3] and other disabilities such as autism [4] 2. Methods
or psychiatric disorders [5,6].
As people age, individuals have to deal with physical, psycho- 2.1. Search strategy
social, and cognitive changes, and the WHO encourages the
development of early interventions that improve behavioral and The present study was conducted according to the PRISMA [24].
psychological symptoms, while also enhancing social functioning The authors of the study conducted a comprehensive literature
among older adults. search using the following electronic databases: Medline
Most studies on older adults have focused on the physical (PubMed), EMBASE, PsycINFO, and Cochrane Library. The review
benefits of horseback riding. Indeed, regular exercise is an impor- was carried out using the following medical subject heading
tant factor for maintaining health in older age and the unique (MeSH) terms and keywords: [“equine assisted therapy” OR
three-dimensional movement involved in horseback riding stim- “therapeutic horse riding” OR “therapeutic horseback riding” OR
ulates movement to maintain balance and activate core muscles “hippotherapy” OR “equine psychotherapy” OR “equine facilitated
which play an important role in postural control among older therapy” OR “equus” OR “horse therapy” OR “equine assisted
adults. The beneficial effects of EAI have been demonstrated on intervention”] AND [aged “older adult*” OR aged OR elderly]. The
balance, gait, muscle strength, and postural coordination compared final search date was the inception of each database to June 2022.
to conventional walking among older adults [7,9]. The meta- Study eligibility criteria for this systematic review are as
analysis conducted by Hilliere [10] with people with disabilities follow: 1) 60 years old or older. 2) Interventions focused on EAI i.e.,
showed a significant improvement in mobility (e.g. step length, interventions based on IAHAIO guidelines ([Link]
velocity, and walking speed) for the equine group compared to the iahaio-international-guidelines-on-care-training-and-welfare-
control group. In addition, in a randomized controlled trial, White- requirements-for-equines-in-equine-assisted-services). These
Lewis et al. [11] highlighted a significant decrease in physical pain guidelines include EAT-with a therapeutic aim conducted by a
after EAI in older adults with arthritis. These benefits on physical health professional and Equine Assisted Activities (EAA-with rec-
health are important for an aging population because they facilitate reational or educative aims). All these interventions aim to improve
the performance of activities of daily life and may reduce the risk of human health and well-being. 3) Health outcome measures
falling. (physical, psychological, or physiological). 4) Experimental or
EAI can also improve psychological domains such as well-being, quasi-experimental (random controlled trials, non-random
quality of life, and self-rated health, even in people affected by a controlled trials, pre-post test design, etc.). 5) Peer-review articles
variety of diseases [8,12]. In a systematic review conducted on published in English. Articles that were excluded include opinion
adults, White-Lewis et al. [11] highlighted significant improve- papers, editorial reviews, literature reviews, EAI guidelines, or
ments in quality of life/self-efficacy/well-being in 91% of the studies studies with only mechanical horses. Two of the authors of this
(10/11). The same results on quality of life were obtained in a meta- systematic review (N. Bailly and L. Badin) independently extracted
analysis with individuals with disabilities such as cerebral palsy the data and agreed after discussion. The PRISMA flow diagram
and Parkinson’s disease and intellectual disabilities [13]. The ben- (Fig. 1) summarizes the systematic review process.
efits of EAI on psychological and behavioral symptoms have also
been evaluated, especially in an autistic population [14]. For 2.2. Data evaluation
vulnerable older people, for example, those with a neurological
disease such as Alzheimer’s, horseback riding is not always Two of the review authors (N. Bailly and E. Alibran) assessed
appropriate. Nevertheless, it has been reported that EAI without independently the methodological quality of the studies included
riding (e.g. through grooming) also has beneficial behavioral effects using the modified version of the Downs and Black checklist for
[15,16]. For example, it has been demonstrated that activities with assessing randomized controlled trials (RCT) and non-randomized
horses reduce behavioral problems for older adults diagnosed with controlled trials (NRCT) [25]. This is one of the two most useful
dementia [17]. Fewer studies have assessed changes in cognitive tools for quality scoring [26]. It consists of 27 items distributed
functions in EAI. In a population with disabilities, some studies have across five subscales: reporting (10 items), external validity (3
shown no effect of EAI on cognitive function while others have items), internal validity bias (7 items), internal validity confounding
demonstrated an improvement [18,19]. (6 items), and power (1 item). In the modified instrument, answers
Finally, some studies on EAI have focused on physiological are scored 0 or 1, except for one item in the reporting subscale,
changes such as stress hormone levels. Cho et al. [20] highlighted which is scored 0 to 2. The power score was calculated by one of the
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Alibran, K. Pothier et al.
L. Badin, E. International Journal of Nursing Sciences 9 (2022) 542e552

Fig. 1. The PRISMA flow diagram for search strategy.

authors (N. Bailly) and was based on the sample size calculation 3.1. Study and subject characteristics
with the effect size determined for each article. The total maximum
score is 28 with higher scores indicating better study quality. Regarding the 13 studies, five were carried out in Brazil
[7,27,28,30,31], four in Korea [20,22,23,29], three in the USA
2.3. Data analysis [8,12,16], and one in Spain [9]. The total sample included 265 older
adults ranging from 60 to 95 years old. Sample sizes of groups
The description of each study’s aim, characteristics of partici- ranged from 9 to 38 participants. A large majority of studies (n ¼ 10)
pants, organization of equine intervention (frequency, number of were conducted on healthy individuals [7,9,12,20,22,23,27e29,31],
sessions, etc.), contents of interventions, health measures assessed, and two studies were conducted on older adults suffering from
and results were summarized in a review matrix. For each study neurocognitive impairment [16,30] and one study on people with
and according to the health outcome measures (physical, psycho- balance deficit [8].
logical, or physiological), the statistical results before and after EAI
were screened. For studies with control groups (and when data 3.2. Study design
were available), a group by time interaction was screened. Discus-
sions between authors (L. Badin, N. Bailly, and K. Pothier) were held Of the 13 studies: five were RCT [9,23,27e29]; eight were quasi-
to validate the conclusions and clarify any discrepancies to reach a experimental, four of which were non-randomized controlled trials
mutual consensus. The summary tables of evidence are classified [7,12,20,22]; three were single groups with pre-test and post-test
according to research design, as shown in Table 1 (randomized studies [8,30,31]; one study was based on a mixed method
control trial studies), Table 2 (non-randomized control trial including observational quantitative data on a single group but
studies), and Table 3 (single group studies). without pre or post-test [16].

3. Results 3.3. Intervention characteristics

A total of 244 articles were identified from the search. Out of the Among the 13 equine intervention groups, nine were based on
244, 18 were excluded (duplicate records) and 114 were excluded Equine Assisted Therapy (EAT), i.e. conducted by a health profes-
after screening titles and abstracts. The remaining 112 full-text sional with specific health goals [7,8,12,16,27e31] while the other
articles were reviewed, and 99 were excluded based on being four were EAA [9,20,22,23]. A summary of the interventions con-
out-of-scope, reviews on EAI, participants younger than 60 years ducted in each study is presented in Tables 1e3. The duration of
old, or use of mechanical horses only. Finally, 13 articles met the these six different equine assisted interventions was from 1 to 12
inclusion criteria. The authors organized the extracted data in the weeks and they were conducted one to three times per week for
following way: 1) author’s name; 2) purpose of the study; 3) details 15e60 min per session.
of the population; 4) details of the interventions; 5) health outcome Concerning the 10 studies with a control group (CG), in-
measures and 6) major results of outcomes. Studies are summa- terventions were usual daily life activities (i.e. with no interven-
rized in Tables 1e3. tion) for six studies [7,9,12,22,27,28], and one study each for
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Alibran, K. Pothier et al.
L. Badin, E. International Journal of Nursing Sciences 9 (2022) 542e552

Table 1
Summary table of evidence for Randomized Control Trials studies (n ¼ 5).

Study and location Aim of study Population Intervention Measures and Key findings Quality score
Sample Size instruments
(Women)
Age
Group activities

Aranda-Garcia et al., 2015 [9] To evaluate the
Healthy
Sessions
Balance
Balance: ns Total score: 18
Spain separate effect and participants conducted by (Platform)
Maximal gait
Reporting: 9
retention of
N ¼ 38 (26) kinesiologists
Maximal gait speed:
External validity: 1
traditional and
Age: 71.53 (6.7) (specialized in speed (m/s - significant
Internal validity bias: 5
horse exercise years older adults and 16 m walkway) group-by-time
Internal validity: 3
programs on
EAA (n ¼ 10) / 36 in exercise with
Muscle strength: interaction. EAA:
Power: 0
physical function sessions/60 min/ horses. knee extensor w0 < w12
12 weeks
Two types of 90 /60 and
Knee Extensor

Two groups: exercises: 1) Handgrip (%) strength at 90 :

TE (n ¼ 17) / 36 participant on significant
sessions/60 min/ the ground group-by-time
12 weeks (grooming); 2) interaction. TE

CG (n ¼ 11) / participant on (w0 < w12,13) /
Usual daily life the horse EAA (w0 < w1).
activities (without a Knee Extensor
saddle): horse strength at 60 :
walks and trots similar trends
or the participant (but ns)
moves their
Handgrip:
trunk, arms, and significant
head while the group-by-time
horse is interaction.
stationary. TE (w0 < w12 >
w16) / CG: (w0 <
w12 > w16).
Araujo et al., 2013 [27] To assess the effects
Healthy Sessions were held
Balance: BBS
BBS and 30CST: Total score: 13
Brazil of EAT on participants in an equine-
Gait: TUG (s) significant
Reporting: 7
functional mobility,
N ¼ 28 (22) assisted therapy
Muscle strength: group-by-time
External validity: 0
muscle strength,
Age: 65.7 (6.55) center. 30CST (s) interaction:
Internal validity bias: 4
and balance years Sessions with EAT > CG
Internal validity: 2

EAT (n ¼ 12) / 16 progressive levels
TUG: group-by-
Power: 0
sessions/30 min/ of difficulty. 1) time interaction:
8 weeks Familiarization ns

CG (n ¼ 16) / facing the
Usual daily life practitioner to
activities adapt to the
rhythmic
movements of the
horse, with
activities
emphasizing
awareness of
postural aspects
(alignment of the
lower limbs and
spine) needed to
practice riding.
2) Individuals were
stimulated in
different riding
positions (front,
right, and left
lateral; inverted), in
which exercises of
flexion and
abduction across
the breadth of the
shoulders,
bilaterally and
alternately were
performed. 3)
Activities
progressed to
riding facing
forward in the
saddle on sandy,
sloping and uneven
terrains, associated
with movements of
(continued on next page)

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L. Badin, E. International Journal of Nursing Sciences 9 (2022) 542e552

Table 1 (continued )

Study and location Aim of study Population Intervention Measures and Key findings Quality score
Sample Size instruments
(Women)
Age
Group activities

trunk rotation.
With the saddle,
extension bilateral
movements of the
knees were
performed during
sharp curves or
serpentine
movements, also
performed with
eyes closed. The
exercises were
always ended with
5 min of stretching
on a stationary
horse.
Cho, 2017 [23] To identify the
Healthy Sessions conducted Relative alpha
Relative slow Total score: 12
Korea effects of horseback participants by an instructor power (EEG) alpha power: no
Reporting: 6
riding and
N ¼ 31 (24) and assistant (no significant
External validity: 0
mechanical
Age: 67.74 (2.36) more information). group-by-time
Internal validity bias: 4
horseback riding years Program developed interaction.
Internal validity: 2
exercise on the
EAA (n ¼ 15) / 24 by the American
Relative fast
Power: 0
relative a-power sessions/25 min/ Hippotherapy alpha power:
spectrum 12 weeks Association with significant

CG: MH (n ¼ 16) / three phases: group-by-time
24 sessions/ warm-up, interaction for
25 min/12 weeks horseback riding, F3, T3, and P3:
and cool-down. 1) Group effect
Warm-up exercises EAA > MH
(walking speed:
110 m/min): leg
circle and point, sit
on leg march and
neck, shoulder,
wrist circle. 2)
Horseback riding
(walking speed;
110 m/min, trotting
speed; 220 m/min,
and cantering
speed; 320 m/min).
3) Cool-down:
stretching and deep
breathing.
Instructor led the
horse by the bridle
and an assistant
held the
participant’s leg on
the right side of the
horse.
Diniz et al., 2020 [28] To examine the
Healthy
Sessions were
Balance: BBS and
TUG: pretest- Total score: 16
Brazil effects of EAT on participants conducted by FRT (cm) posttest: EAT ()
Reporting: 8
balance and
N ¼ 30 (24) trained
Gait: TUG (s) / CG (ns)
External validity: 0
flexibility
Age: 67.27 (5.82) professionals
Strength: the Sit-
FRT: pretest-
Internal validity bias: 4
years (equine therapy and-Reach Test posttest: EAT (þ)
Internal validity: 4

EAT (n ¼ 15) / 10 center). (cm) / CG (ns)
Power: 0
sessions/30 min/
Program:
BBS: pretest-
10 weeks standard equine posttest: EAT

CG (n ¼ 15) / protocol (Brazil). (ns) / CG (ns)
Usual daily life
Sessions: the
The Sit-and-
activities person sat in the Reach Test
saddle with his pretest-posttest:
or her feet in the EAT (þ) / CG (ns)
stirrups (first
No estimation of
15 min) and his group-by-time
or her feet out of interaction
the stirrups (last
15 min). Covered
area.

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Alibran, K. Pothier et al.
L. Badin, E. International Journal of Nursing Sciences 9 (2022) 542e552

Table 1 (continued )

Study and location Aim of study Population Intervention Measures and Key findings Quality score
Sample Size instruments
(Women)
Age
Group activities

Kim et al., 2014 [29] To examine the
Healthy
No information
Balance: sway
Sway path Total score: 9
Korea effects of EAT on participants on who path length lengths: pretest-
Reporting: 5
static balance and
N ¼ 22 (10) conducted the
Gait: step length posttest EAT () /
External validity: 0
gait
Age: 69.4 (3.3) sessions. (cm) and step TR () Significant
Internal validity bias: 2
years
Sessions: horse time (s) group-by-time
Internal validity: 2

EAT (n ¼ 11) / 36 walked around a interaction:
Power: 0
sessions/20 min/ 30 m diameter EAT > TR
12 weeks circle 20 times to
Step length:

CG: TR (n ¼ 11) / the right and 20 pretest-posttest
36 sessions/ times to the left EAT (þ) / TR (þ).
20 min/12 weeks in the 20 min. No significant
group-by-time
interaction

Step time:
pretest-posttest
EAT () / TR ()
No significant
group-by-time
interaction

Note: BBS ¼ Berg Balance Scale. CG ¼ control group. EAA ¼ equine assisted activities. EAT ¼ equine-assisted therapy. EEG ¼ electroencephalogram. FRT ¼ Functional Reach
Test. MH ¼ mechanical horseback riding. ns ¼ not significant. TE ¼ traditional exercise. TR ¼ Treadmil. TUG ¼ times up & go. 30CST ¼ 30-s Chair Stand Test. (þ) : significant
difference (post-test > pre-test). () : significant difference (post-test < pre-test). Quality of studies (Downs and Black checklist): total score/28 (reporting/11, external validity/
3, internal validity bias/7, internal validity/6, power/1).

traditional physical exercise (i.e. cardiovascular exercise involving Serotonin and cortisol levels were considered in one study as a
different movements of the whole body [9]), a mechanical horse measure of emotional state [20]. Moreover, the Alpha power
[23] and a treadmill [29]. One study did not include information spectrum was measured in two studies using EEG [22,23]. Finally,
about the control group [20]. In one study, Field et al. [16] compared masseter and temporalis muscle activity was assessed using EMG in
the effect of different types of activity in a single group (EAT versus one study [31].
eight care activities: downtime, television, meals/snacks, games,
jokes and riddles, music group, bus time, and physical therapy).
3.5. Effects of interventions on outcome measures

3.4. Measurements 3.5.1. Physical effect of EAI

Eight studies investigated the effects of the equine intervention
In these 13 studies, the authors investigated three main do- on balance in older adults [7e9,12,27e30]. Among them, four
mains: physical, psychological, and physiological. studies demonstrated that there was a significant positive effect of
EAI on balance [7,27,29,30], two studies showed mixed results
3.4.1. Physical measures [8,28] and two studies demonstrated no effect [9,12]. Concerning
Eight articles studied the effect of the equine intervention on the positive effects of EAI on balance, it should be noted that two
physical outcomes [7e9,12,27e30]. Three main domains were controlled studies highlighted a significant group by time interac-
investigated: balance, gait, and strength. Balance was assessed in all tion [27,29], while Araujo et al. (2011) [7] highlighted no significant
these studies. Instruments were: Berg Balance Scale [12,27,28], group by time interaction, but only a positive pre-post EAI effect on
Fullerton Advanced Balance scale [8,12], the Functional Reach Test balance. Two studies conducted on a single group with vulnerable
[28], sway path length [29] or platform utilization for estimation of participants (Alzheimer’s dementia and balance deficit) indicated a
balance [7,30]. Gait was measured in six studies [7,9,27e30]. The positive pre-post test effect on balance. Diniz et al. [28] obtained
Timed Up & Go test was the most frequently used [7,27,28,30]. In mixed results with a significant effect on the Balance Berg Scale but
addition, Aranda-Garcia et al. [9] used maximal gait speed (m/s) on no effect on the Functional Reach test. Finally, Homnick et al. [8]
a marked 16-m walkway, and Kim et al. (2014) [29] measured step reported no significant change in the observation period (weeks:
length and step time using a gait analyzer. Four studies focused on 0e8) and the follow-up period (weeks: 16e24) but highlighted a
muscle strength [8,27,28,30]. The Chair-Stand-Test (30s-CST) was significant improvement in balance score from the beginning to the
reported in two studies [27,30] and the Sit and Reach Test in one end of the EAI intervention (weeks: 8e16).
study [28]. Aranda-Garcia et al. [9] assessed muscle strength of Gait was considered in six studies [7,9,27e30]. Among them,
arms and legs using handgrip and knee extensor. two studies indicated no effect of EAI on gait [27,29]. Only one study
showed a significant group by time interaction [9]. The other
3.4.2. Psychological measures studies indicated a positive effect of EAI on gait only on pre-post
One study focused on cognitive measurements (measures of tests [7,28,30].
global cognition with the mini mental state examination (MMSE) Four studies looked at muscle strength [8,27,28,30]. Among
and semantic fluency test [30] and two studies focused on quality of them, three demonstrated a significant positive effect of EAI
life [8,16]. [27,28,30] with the group by time interaction for Araujo et al. (2013)
[27] or positive pre-post test effects [28,30]. According to Aranda-
3.4.3. Physiological measures Garcia et al. [9], significant positive results were observed in the
Physiological measurements were evaluated in four studies. horse exercise group and the traditional exercise group in knee
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Alibran, K. Pothier et al.
L. Badin, E. International Journal of Nursing Sciences 9 (2022) 542e552

Table 2
Summary table of evidence for Non-Randomized Control Trials studies (n ¼ 4).

Study Aim of study Population Intervention Measures and Key findings Quality score
and Sample Size instruments
location (Women)
Age
Group
activities

Araujo To determine whether EAT
Healthy Sessions were held in an EAT center.
Gait: TUG (s)
TUG: pretest- Total score:
et al., produces changes in balance participants Sessions consisted of different horse gaits (walk and
Balance: CoP posttest: EAT 11
2011
N ¼ 17 (15) trot), ground surfaces (sand, asphalt, and turf), terrains (cm) ()/CG (ns).
Reporting:
[7]
Age range: (flat, hilly, and steep), movement combinations, and
Balance: pretest- 6
Brazil 60e84 years changes of direction. posttest: EAT
External

EAT (n ¼ 7) / (þ)/CG (ns). validity: 0
16 sessions/
No estimation of the
Internal
30 min/8 group by time validity
weeks interaction. bias: 4

CG (n ¼ 10) /
Internal
Usual daily validity: 1
life activities
Power: 0
Cho et al., To investigate the effect of
Healthy Sessions conducted by an instructor and assistant (no Serotonin and
Serotonin: Total score: 8
2015 riding exercise on hormone participants more information). cortisol levels significant group-
Reporting:
[20] levels
N ¼ 20 Participants sat on the horses and performed 5-min (Ug/L) by-time interaction 4
Korea
Age: 69.63 exercises at a walk (110 m/min). Instructor led the (EAA > CG)
External
(3.36) years horse by the bridle and an assistant held participant’s
Cortisol: significant validity: 0

EAA (n ¼ 10) leg on the right side of the horse. group-by-time
Internal
/ 8 sessions/ interaction validity
15 min/8 (EAA < CG) bias: 4
weeks
Internal

CG: NI / validity: 0
(n ¼ 10)
Power: 0
Homnick To investigate the practicality,
Healthy Sessions were conducted by volunteers (Cheff Balance: BBS
Balance (BBS, Total score:
et al., safety, and potential participants Therapeutic Riding center). and Fullerton Fullerton): pretest- 11
2015 improvements of EAT
N ¼ 15 (10) Sessions: grooming and tacking, mounting, warmup Advanced posttest: EAT (ns) /
Reporting:
[12]
Mean age: exercises on the horse, riding skills, and dismounting. Balance scale CG (ns) 6
USA 70 years Walking and/or trotting, depending on the skill of the
No estimation of
External

EAT (n ¼ 9) / rider. group-by-time validity: 0
10 sessions/ interaction.
Internal
60 min/10 validity
weeks bias: 4

CG (n ¼ 6) /
Internal
Usual daily validity: 1
life activities
Power: 0
Kim et al., To investigate the effect of
NI Sessions conducted by an instructor (no more Relative alpha
Relative slow alpha Total score: 6
2015 horseback riding exercise on
N ¼ 20 information). power (EEG) power: group-by-
Reporting:
[22] background electroen-
Age: 69.6 Sessions: 1) Warm-up exercises (slowest speed: 110 m/ time interaction 3
Korea cephalograms (3.4) years min); 2) Horseback riding. Instructor led the horse by (ns)
External

EAA (n ¼ 10) the bridle and an assistant held the participant’s leg on
Relative fast alpha validity: 0
/ 24 the right side of the horse power: group-by-
Internal
sessions/ time interaction F3 validity
15 min/8 (EAT > CG) bias: 3
weeks
Internal

CG (n ¼ 10) / validity: 0
Usual daily
Power: 0
life activities

Note: BBS ¼ Berg Balance Scale. CoP ¼ center of pressure. CG ¼ control group. EAA ¼ equine assisted activities. EAT ¼ equine-assisted therapy. EEG ¼ electroencephalogram.
NI ¼ no information. ns ¼ not significant. TUG ¼ Times Up & Go. (þ) : significant difference(post-test > pre-test). () : significant difference (post-test < pre-test). Quality of
studies (Downs and Black checklist): total score/28 (reporting/11, external validity/3, internal validity bias/7, Internal validity/6, power/1).

extensor strength, but only the horse exercise group had signifi- on cortical electrical activity effects (with EEG frequency bands
cantly faster gait speed. However, the traditional exercise group [22,23]). They investigated the relative alpha power index which
showed greater improvements in handgrip than the horse exercise indicates concentration and relaxation. Kim et al. [22] showed that
group. EAI activated faster relative alpha power in all brain domains
analyzed. Furthermore, there was a positive significant difference
3.5.2. Psychological effect of EAI between the horseback riding group and the control group in the
The only study which measured a cognitive dimension with prefrontal activity. Similar results were obtained in Cho’s study [23]
Alzheimer’s disease showed no effect of EAI [30]. Concerning the which compared horseback riding exercises with mechanical
assessment of the quality of life, Homnick et al. [8], indicated the horseback riding exercises. Repeated measures analysis of variance
improved quality of life and Fields et al. [16] showed an increase in showed that the horseback riding group increased the power of fast
conversational social interaction and pleasure. relative alpha power compared to the mechanical horseback riding
group after 12 weeks of intervention. One study analyzed the
3.5.3. Physiological effect of EAI hormonal effects (serotonin and cortisol levels in blood samples) of
Two studies investigated the effects of the equine intervention horseback riding in older adults [20]. The horseback riding group

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Table 3
Summary table of evidence for single group (pre/post-test) studies (n ¼ 4).

Study Aim of study Population Intervention Measures and Key findings Quality score
and Sample Size (Women) instruments
location Age
Group activities

Araujo To describe the effects
Mild to moderate Sessions conducted by a leader and
Balance: CoP (cm)
Gait and Muscle strength: pretest- Total score:
et al., of EAT on balance, Alzheimer two trained EAT providers.
Gait: TUG (s) posttest (þ) 13
2019 functional capacity, and dementia Sessions with progressive levels of
Muscle
Anterior-posterior balance:
Reporting:
[30] cognition
N ¼ 9 (3) difficulty (indoor and outdoor strength:30 CST pretest-posttest (þ) 9
Brazil
Age: 78.6 (7.4) exercises). (s)
Cognition pretest-posttest: ns
External
years Cognitive exercises: memorizing the
Cognition: verbal validity: 0

20 sessions/30 min/horse’s and therapist’s names/ fluency and
Internal
10 weeks memorizing colors and objects MMSE validity
(weeks 1e2), controlling the horse’s bias: 3
reins (during 10 min and 15 min
Internal
with horse walking). validity: 1
Physical exercises: horse in walk,
Power: 0
sand surface, flat terrain (weeks 1
e2), changes in direction in walk
(weeks 3e4), and in trot (weeks 5
e6). Towards the end of the
program, the participants must ride
the horse while it is in a walk on an
asphalt and grass surface on flat,
rough, and sloping terrain.
De Mello To evaluate the effect of
Healthy Sessions were conducted in an Muscle strength Activity of the masseter and Total score:
et al., EAT on the participants equine therapy center. (Masseter and temporalis muscles: pretest-posttest 14
2020 stomatognathic system
N ¼ 17 (14) Sessions: the person sat in the saddle temporal muscles ()
Reporting:
[31]
Age: 66.5 (7.0) with his or her feet in the stirrups for activities): EMG - 8
Brazil years the first 15 min and his or her feet mV
External

1 session/17 min out of the stirrups for the last 15 min. validity: 0

Internal
validity
bias: 4

Internal
validity: 2

Power: 0
Fields To investigate links
Dementia residents Sessions conducted by two-certified Observation grid
QoL indicators: EAT ¼ all other Total score: 8
et al.,between nine different from in LTC therapeutic riding instructors and (time used with LTC activities
Reporting:
2018 activity situations (one:
N ¼ 9 (4) one volunteer. computer-assisted)
QoL domains: conversation and 4
[16] equine program) and
Mean age: 83.3 Residents were asked individually to
QoL indicators: apparent affect (pleasure):
External
USA QOL in LTC residents years choose between riding, grooming, gaze, position EAT > other activities validity: 0

8 sessions/< 1 h/8 and petting a horse, or sitting back and movement,
Internal
weeks and watching others participate in conversation, and validity

8 other LTC activities. participation in bias: 3
activities the activity
Internal
(downtime,
QoL domains: validity: 1
television, meals/ apparent affect
Power: 0
snacks, games, and agitation
etc.)/16
observations/4 h/8
weeks
Homnick To evaluate the effects
Participants with Sessions were conducted by
Balance: short
Balance: observation period Total score:
et al., of EAT on measures of balance deficits volunteers (Cheff Therapeutic Riding form of the (weeks 0e8): ns / start to the 10
2013 balance and QoL
N ¼ 9 (5) center). Fullerton end of the EAT intervention
Reporting:
[8]
Age range: 71e83 Sessions: grooming and tacking, Advanced Balance (weeks 8e16)(þ) / End of the EAT 5
USA years mounting, warmup exercises on the scale intervention and end of the
External

EAT (n ¼ 9) / 8 horse, riding skills, and dismounting.
QoL (Rand Short follow-up period (week16e24): validity: 0
sessions/60 min/8 Walking and/or trotting, depending Form Health ns
Internal
weeks on the skill of the rider. Survey)
QoL: start to the end of the EAT validity
intervention: Overall perception bias: 4
of general health (þ)
Internal
validity: 1

Power: 0

Note: CoP ¼ center of pressure. EAT ¼ equine-assisted therapy. EMG ¼ electromyography. LTC ¼ long-term care facilities. MMSE ¼ Mini-Mental State Evaluation. ns ¼ not
significant. QoL ¼ quality of life. TUG ¼ Times Up & Go. 30CST ¼ 30-s Chair Stand Test. (þ) : significant difference (post-test > pre-test). () : significant difference(post-
test < pre-test).

showed a significant increase in serotonin and a decrease in cortisol 3.6. Quality of studies
levels between the pre and post-test indicated a better emotional
state. Only one study documented masseter and temporalis muscle The summary of the quality scores is displayed in Tables 1e3.
activity [31]. The intervention involving a horse highlighted a The quality scoring descriptive statistics include a mean of 11.46
significantly lower electromyographic activity for these two ([6,18], ET: 3.4) [9] scored the highest with 18/28 points. Overall, the
muscles. findings indicate that the majority of studies were of low quality,
particularly for the two items: external validity and power.

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4. Discussion 4.2. Study rigor and study quality

4.1. Effects of EAI on older adults’ health The quality assessment of the thirteen studies highlights that
the majority of them were of low quality with a minimum total
Three health domains were investigated: physical, psychologi- score of 6 [22]. Only one study [9] was of sufficiently high quality to
cal, and physiological. Concerning the physical domain, the main be able to legitimately claim significant results. The scores were
findings of this review are that EAI is an effective intervention that very low in external validity and statistical power. This indicates
improves physical functioning (including balance, gait, and that all the studies had the insufficient statistical power to detect
strength) of older adults even in older adults with disabilities. Our clinically important effects and none of the findings could be
results are similar to previous systematic reviews conducted on generalized to an older population. Although the studies reported
healthy older adults or people with disabilities [10,11,13]. Nowa- improvement, the current research evidence is compromised by
days, we know that physical activity is beneficial for the health of methodological weaknesses in the study design. Serious risk bias
older adults [32,33], so it is coherent that greater benefits were can be highlighted such as small samples, no comparison or control
found in the older adults participating in EAI, than in those who had group, no systematic randomization, and lack of details regarding
a daily life routine without any activity. However, a more striking the intervention. This low quality of the studies had already been
result is the comparison of EAI versus physical activities. Aranda- highlighted in a previous systematic review [43].
Garcia et al. [9] for gait and Kim et al. [29] for balance found a
greater effect of EAI than for traditional physical activities. Firstly, 4.3. Limitations
this difference could be explained by the fact that more dynamic
and complex movements were performed during the EAI sessions; Although EAI seems to be a beneficial intervention for older
the whole body is more involved during an EAI session than for a adults, there are several limitations to be considered. Firstly, the
simple activity (e.g. stooping, turning, etc.). Secondly, during the high degree of heterogeneity of the studies renders interpreting the
EAI session, other ancillary and body-stimulating activities were results difficult and does not allow them to be generalized. The
taken into consideration; the older adults who performed the ex- heterogeneity of the programs and interventions impacts the re-
ercises with the horse also had to walk much longer distances due sults, making them more difficult to interpret because several
to the size of the equestrian center. They had to walk to the stables variables are taken into account. Indeed, the contents of sessions
to collect the horse, then walk to the training site and return the differed according to the type of intervention (EAT or EAA), some
horse to its stable. Thirdly, the sensory and motor stimuli of the studies had a specific, predefined program with various therapeutic
horse’s movements transmitted to the older adult while riding objectives (EAT), while for others the objectives were only recrea-
could also improve their physical abilities [34]. tional (EAA). In addition, the frequency and the duration of the
Concerning physiological effects, EAI changes hormone levels sessions also varied from one study to another (one session to 36
and brain activity. It increases levels of serotonin and decreases the sessions/15 min to 60 min). Secondly, the physical measures
secretion of cortisol, but it also activates faster relative alpha power assessed refer to different concepts. Regarding balance, some tools
in all brain domains analyzed. These effects are similar to those measured both static and dynamic balance (e.g. Berg Balance Scale
observed during other sports activities. and Fullerton Advanced Balance Scale), while others assessed only
Concerning the effects of EAI on the psychological domain, our static balance (e.g. sway path length test and platform) or the dy-
review highlights an improvement in the quality of life of older namic balance (Functional Reach Test). Concerning gait, some tools
adults, even in people with Alzheimer’s disease. This is in line with evaluated simple walking (e.g. maximal gait speed on straight lines,
results in the literature on people with disabilities [13,35,36]. In the step length, and time) and others complex walking which involves
present review, two studies [16,28] found a beneficial effect of the executive functions (e.g. TUG). Finally, for muscular strength, some
equine intervention on the quality of life of older adults with Alz- tools measured lower limb strength (e.g. 30s-CST, Sit and Reach
heimer’s disease. Several explanations can be advanced. First of all, Test, and knee extensor), while others assessed upper limb strength
equestrian activities are usually performed in groups and group (e.g. handgrip). Moreover, aging is known to be a complex process
activities promote social interaction among seniors, an important resulting in a heterogeneous population. Indeed, with advancing
element of well-being in older adults [37]. Secondly, EAI is an age, people's trajectories vary. Thus, it is complicated to generalize
outside activity, and connection with nature should be taken into the results, particularly since the studies in our systematic review
account. Indeed, most studies indicate that direct contact with were conducted on healthy older adults or older adults with neu-
nature benefits the quality of life of older adults [16,38,39]. In rocognitive and balance disorders.
addition, communication with the horse and the bond with the Finally, it is important to mention that conducting EAI depends
animal, in general, are also elements underestimated in the liter- on several limiting factors: notably the region and more precisely
ature but are linked to the well-being of older adults [40,41]. All the geographical proximity of an equestrian center. In addition, the
these positive results must be interpreted with caution: only two culture of the country is also a factor. Nowadays, this innovative
studies concern the quality of life. Thirdly, links between the activity has been developed more in certain countries such as Ko-
physical domain and quality of life are well-established [32] and rea, Brazil, and the United States [11,43]. This cultural difference can
physical activity adapted to the older adult’s capacities is one of the be illustrated, for example, by the Native American population who
recommendations regarding aging well and tending towards the are likely to have stronger relationships with animals, as they focus
optimum quality of life [42]. Finally, these links can also be on the equality and interdependence of all creatures and perceive
explained by hormonal reasons. EAI has similar effects to sports, it possibilities for health and healing in the human-animal bond.
increases serotonin levels (a hormone responsible for well-being) Regarding the horse, it is a sacred animal that will guide all in-
and decreases the secretion of cortisol (a stress hormone). This dividuals in the right direction [44e46]. Another factor to consider
type of intervention has relaxing effects, decreasing stress. This can when conducting this type of intervention is the personal experi-
certainly explain the improvement in the quality of life of older ence of the beneficiary, such as a potential phobia of horses which
adults who benefited from EAI. would generally exclude that person from attending a session.
Finally, the economic status would also seem to be a variable to be
taken into account, since EAI sessions are quite expensive. Although
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Alibran, K. Pothier et al.
L. Badin, E. International Journal of Nursing Sciences 9 (2022) 542e552

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