Research

Therapeutic Horseback Riding in Individuals with Disabilities:
Effect on Hip Range of Motion

Maria C. Bergene

Senior Research Project

Marian College of Fond du Lac, WI

Tuesday, May 9, 2006

Developmental disabilities are defined as a group of severe chronic conditions that contribute to impairments in physical, cognitive, speech or language, self-care, or physiological areas (Winchester, 2002). Examples of these conditions in this study include: Cerebral Palsy, Down syndrome, Mental Retardation, Spina Bifida, Autism, Williams Syndrome, Terminal 14q deletion, Epilepsy, Neurofibromitosis, Cerebral Dysgenesis, Developmental Delay and Depression. Providing medical, social, and family support is one of the greatest challenges to caring for children with these disabilities.  According to a 2005 report from the Center from Disease Control and Prevention website, developmental disabilities are estimated to affect about 17% of all school aged children.  Advances and treatment of developmental disabilities have been slow in coming (Benda, 2003).

            Most of the disabilities listed above require lifelong participation in physical therapy (PT) and occupational therapy (OT) (Ionatamishvili, 2004).  In addition to standard PT and OT, most parents will inquire about alternative therapy programs for their children to improve their motor function (Sterba, 2002).  The introduction to an alternative therapy, such as therapeutic horseback riding, may have a significant impact on accelerating the rehabilitation of persons with physical and developmental disabilities (Lessick, 2004).  In order to better understand the effectiveness of therapeutic horseback riding, I performed a study to measure range of motion by using a goniometer, which is an instrument that measures joint angles by degrees.          

Range of motion (ROM) is noted as one of the many physical benefits therapeutic riding offers. It can be further increased through activities such as mounting, dismounting, saddling, unsaddling and grooming (Bliss, 1997).   It is a measure of musculoskeletal flexibility or the amount of movement a person has at each joint (Benda, 2003).  ROM is the amount of motion available at a specific joint.  The ROM of an articulation depends on the shape of the articulated parts of the bone and the tightness of the ligaments and muscles surrounding it (Kreighbaum, 1996).  It is important to assess joint ROM because if one segment of the kinetic chain is not operating properly throughout its entire range of motion, then adjacent joints and tissues must compensate to accommodate the dysfunctional segment (Clark & Russell, 2005). 

            Passive ROM is the amount of motion obtained by the examiner without any participation by the client.  Passive ROM provides information regarding joint play motion and physiologic end-feel of the movement.  This helps create an objective look at the articular surfaces of the joint.  Active ROM refers to the amount of motion obtained solely though voluntary contraction by the client.  Information provided here includes muscular strength, neuromuscular control, painful arcs, and overall functional abilities (Kreighbaum, 1996).

Horseback riding as a therapy has focused on the concept that riding provides the person with a disability a normal sensorimotor experience that contributes to the maintenance, development, rehabilitation, and enhancement of physical skills (All & Loving, 1999).  Traditionally, therapeutic exercises for children with disabilities are performed indoors in a therapy room.  Children may become bored after a period of time and as a result, many adjunctive therapeutic activities, including swimming and therapeutic horseback riding, have been developed and proposed for children with disabilities (Cherng, 2004).    While traditional therapies often reach a plateau where a patient may lose motivation to keep trying, the excitement of riding stimulates the rider and encourages many patients to work through discomfort and increasing challenges in seeking to improve their abilities and skills (Lessick, 2004).

Therapeutic Horseback Riding (THR) is a riding program in which the primary objective is therapy rather than recreation of learning the skill of riding (Cherng, 2004).  One type of THR is rehabilitative riding, which is a type of treatment that uses movements of the rider to maintain control of the horse (MacKinnon, 1995).  The other type is hippotherapy, which is a treatment strategy in which the primary goal is to improve the individual’s posture, balance, mobility and function via the rhythmic, dynamic movement of the horse (All & Loving, 1999).  This slow, rhythmic movement combined with a gentle stretch of stiff leg muscles appears to reduce abnormally high muscle tone and promote relaxation, while at the same time promoting bilateral symmetrical postural responses that increase tone in hypoactive muscles (Benda, 2003).  The movement of the horse imparts a movement of the rider’s pelvis that resembles walking.  These movements also stimulate the nervous and muscular systems of the rider (Potter, 1994).

A critical aspect of THR is that the gait of the horse provides a precise, rhythmic, and repetitive pattern of movement similar to the mechanics of natural human gait (Engel, 1997).  This may explain why some disabled children, after a series of hippotherapy sessions, walk with greater ease and demonstrate improved posture and range of motion (Benda, 2003).  The horse’s gait moves the rider forward and backward, causing anterior and posterior tilting of the pelvis.  This process is thought to stimulate the rider to develop control of the trunk via flexors and extensors.  Likewise, the horse’s movement side to side causes reciprocal activation of the rider’s lateral flexors of the trunk and may develop further trunk stability. (Sterba, 2002)

The movement of the horse at walk does facilitate pelvic movement, which may be the result of a distinct similarity in pelvic displacements found between the horse and the human (Young, 2005).  The movement angle of the horses’ pelvis at walk is very similar to that of a human pelvis during walking.  The horse’s pelvis moves an average of 3.9 degrees in the sagittal plane, 6.98 in the frontal plane and 9.1 degrees in the transverse plane.  Similarly, children’s gait involved about 2-3 degrees of pelvic motion in the sagittal plane, 10 degrees in the frontal plane and approximately 10 in the transverse plane (Cherng, 2004).

An inhibition of spasticity is achieved through the saddle position in hip flexion-abduction-external rotation as well as through rhythmical and 3-D equine movement communicated to the patients’ pelvis and trunk (Lechner, 2003).  A horse’s movement can be short, medium, or long, and can be measured by how smooth or choppy it feels to a rider.  Of central importance is that the 3-D rhythmic movement of the horse stimulates a human walk; a horse’s stride moves the rider’s pelvis with the same rotation side to side movement that occurs while walking (Lessick, 2004).  The horse’s rhythmic gaits, its ability to sense and respond to the rider and the interactive relationship formed between horse and rider contribute to a variety of significant therapeutic gains (Kaiser, 2006). 

Beneficial exercises include stretching, strengthen, relaxing, and developing skills in balance and coordination.  The warmth and motion of the horse’s body can also reduce spasticity, especially in the adductors of the legs, and enhance coordination in other muscle groups (Bertoti, 1988).  The warmth of the horse through the blanket plus the rhythmical movements of the horse have been speculated to improve circulation, reduce abnormally high muscle tone, and promote relaxation in children (Sterba, 2002).

Among the reported physical benefits of riding are improved sitting and standing balance, walking coordination, posture, muscle strength and control, increased ROM (All and Loving, 1999).  For example, standing in the stirrups can be used to strengthen knee, hip, and trunk extensor muscles and improve balance (Lessick, 2004).  The qualitative results of a study showed weekly progress in the children’s sitting posture and improvement in posture, trunk control, pelvic mobility, hand control, flexibility, strength and attention span (Young, 2005).  All parents of children in the moderate group of the above study observed improvement in their children’s physical skills of flexibility, balance, relaxation, and posture (MacKinnon, 1995). 

The primary objective of programs is physical rehabilitation, but they also try to provide mental, physical, and social stimulation (Bliss, 1997).  Young (2005) argues that horse activities improve social interaction and communication.  Individuals who do not communicate before engaging in hippotherapy are found to develop skills in communication as a result of contact with the horse.  The excitement of riding stimulates the riders, encouraging him/her to talk about it and therefore increases one’s interest in life (All & Loving, 1999).   

Among the psychosocial benefits reported with riding are improvements in self-esteem, self-image, and interpersonal skills (Lessick, 2004).  Many riders will also become more outgoing, learn emotional control, self-discipline, develop more patience and feel a sense of normality (Meregillano, 2004).  Perhaps one of the most profound psychosocial benefits of horseback riding is the confidence and increase in self-esteem that comes from being able to maneuver and control an animal that may weigh in the excess of 1000 pounds.  Other individuals have reported increased perception in quality of life and life satisfaction because they have proven to themselves and others; they are more than their disability (All & Loving, 1999). 

In one study parents observed positive changes in functional skills such as gait and activities of daily living, as well as improvements in social skills and general behavior were reported in motivation, willingness to try other new activities, self-confidence, self-esteem, cooperation and enthusiasm (MacKinnon, 1995).  This combination of benefits brings to light a therapeutic strategy that may fill an existing void in the care of a child with a lifelong, chronic disability and offers the parent, therapist, and pediatrician a valuable treatment option (Benda, 2003).

Most centers use an integrated approach involving the two above methods.  Therapeutic riding refers to the use of the horse and equine-orientated activities to achieve therapeutic goals, including physical, emotional, social, cognitive, behavior and educational (Lessick, 2004).  Free S.P.I.R.I.T. Riders in Fond du Lac, where this study was performed, incorporates the two methods.

In the therapeutic riding program, children ride on a moving horse and participate in various activities.  This allows the children to have the opportunity to practice postural and balance strategies under changing environmental conditions, which may promote anticipatory and feedback postural control (Cherng, 2004).  Therapeutic riding with the rhythmic, three-dimensional, movement of a walking horse may provide the child with the opportunity to practice balance function needed in various motor skills in an erect posture.  Variations in the horse’s stride, velocity, and direction stimulate equilibrium responses in the child by facilitating dynamic postural stabilization and recovery (Cantu, 2005).  As the therapeutic riding program progresses, more dynamic and challenging tasks are added, including touching parts of the horse’s body, bending and rotating the trunk with the arms raised, throwing and accuracy activities are performed while seated on the horse.  Changes in the pace of the horse walk and the walking course are also incorporated into the THR program (Cherng, 2004).

Methods

PARTICIPANTS

            Twenty-four children with a variety of disabilities were identified as candidates for the study through Free S.P.I.R.I.T. riders, Fond du Lac, WI.  24 out of a possible 35 children recruited for this study was eligible.   Participants consisted of five males and 19 females, ranging in age from 5 – 32 years old with a variety of disabilities (Table 1).  Participant criteria in this study were (a) a medical diagnosis, (b) age 4 years or older, (c) able to follow directions, (d) previous participation in THR (e) parental commitment to allow participation without changing current therapy or activity.  All of the participants had previous horseback riding experience. Most of the children received either physical or occupational therapy or both.   Parents of the children were advised about the study, including risks, benefits and assessment measures.   Consent forms were signed prior to beginning (Appendix 1).  Four of the children had to drop out of the program before the end of the study due to conflicts with school, gastric surgery, or the inability to follow instructions, leaving only 20 children to complete the entire 24-week program (Table 1). 

HORSEBACK RIDING PROGRAM

           At Free S.P.I.R.I.T. Riders, each rider wears a protective, fitted helmet with chin straps to ensure safety.  Trained side walkers use various side-helping techniques to help stabilize and assist riders in carrying out the prescribed exercised.  The horse is led at a controlled walk by a trained leader, such as a horse handler, directing the horse with a lead rope attached to its halter.

           If no saddle is used, then there is more contact with horse, resulting in increased stimulation and the need to work harder to maintain balance and equilibrium.  A horse is tacked with a fleece pad and a belt to secure the pad. The children are mounted on the horse sitting forward and a secure mounting ramp is used for all riders.  In this study only two riders did not use a saddle instead only using a fleece pad.

           While seated on a horse blanket or saddle, the riders do simple stretches, pat the horse on either side of the midline.  Riders reach for objects, such as rings, across their midline and the horse’s body using one or both hands together.  Road construction cones are placed in the riding area and while the horse is led, the rider attempts to hit or steer around the cones.  They also toss beanbags or place large rings around the top of the cones.

MEASUREMENTS AND ASSESSMENTS

            Goniometry generates objective information for use by measuring the angles of different body joints. A standard clear universal plastic goniometer with 12-inch arms marked in one-degree increments was used to measure the ROM in degrees in four different positions of hip movement.  The National Academy of Sports Medicine Guide  to Goniometric Assessment was used (Clark & Russell, 2004). 

            Four ROM measurements were taken at all angles of the hip joints on each subject.  One person, the tester, performed all ROM measurements.  Each rider was tested four times, once before the first session, after the second session, after the third session, and finally after the fourth session, which was also the last day of THR for the season.  All sessions were six weeks apart and participants were measured on their prospective-riding day, at the same time.  Participants were taken to a semi-private room to avoid interruptions or disturbances and parents or guardians were encouraged to attend.  The riders were then instructed to lie on an exercise mat, while I explained and demonstrated what I was going to be testing as I measured with the goniometer. 

           All subjects were placed supine on a mat with the hip as near as possible to 0 of flexion and extension with the knee extended.  The trunk and pelvis were stabilized to prevent rotation and lateral tilting.  The protocol for all measurements was followed as described below. 

FLEXION

            Subject was positioned supine with the knee fully flexed, and the hip was at 0.  The knee is then flexed to shorten the hamstrings which have a limiting effect on hip flexion if the muscles are tight.  The hip was flexed to the point of first restriction.  The position was held and measurement was recorded by the researcher.  The goniometer was aligned with the axis of the goniometer centered at the lateral thigh using the greater trochanter as a reference. The stabilizing arm and movement arm are placed at the lateral midline of pelvis

EXTENSION

            Subject was positioned prone with the foot unsupported.  The hip was placed at 0.  The knee was fully extended to shorten the rectus femoris and the hip was passively extended to the point of first restriction. This position was held and measurement was recorded by the researcher.  The goniometer was aligned with the axis of the goniometer centered at the greater trochanter.  The stabilizing arm is at the mid-axillary line of the trunk and the movements are at the lateral midline of the femur, referencing the lateral condyle.

ABDUCTION

            Subject was positioned supine with the knee extended and the hip is at 0. Subject’s legs were straightened and relaxed and the goniometer was aligned at the starting position, which should read 90 and will act as 0.  The leg was passively adducted until the first resistance barrier is noted. This position was held and measurement was recorded by the researcher. The goniometer is aligned with the center at the ASIS (anterior superior iliac spine) of the extremity being measured.  The stabilizing arm is at an imaginary line connecting one ASIS to the other ASIS.  The movement arm is at the anterior midline of the femur, referencing the patellar midline.

ADDUCTION

            Subject was positioned supine with the knee extended and hip is at 0.  The opposite extremity was adducted to allow for adduction of the extremity to be measured. Subject’s legs were straightened and relaxed.  The goniometer was aligned at the starting position, which should read 90 and this will act as 0.  The leg was adducted until the first resistance barrier is noted. This position was held and measurement was recorded by the researcher.  The goniometer center is aligned at the ASIS of the extremity being measured.  The stabilizing arm is lined up with imaginary line connecting one ASIS to the other ASIS.  The movement arm is at the anterior midline of the femur, referencing the patellar midline.  

DATA ANALYSIS

            Paired, two-tailed T-test was used with p=0.05 statistical significance to determine the significance of change from the onset of testing to post-intervention testing for the right and left hip range of motion measurements. 

Results

            The overall results indicate that there was an increase in ROM measurements for each of the hip angles measured over 18 weeks.  There was a slight decline in range of motion for all hip angles measured over the last 6 week period (Table 2).  Both dominant and non-dominant sides for flexion and abduction measurements were significant at p=0.042 and p=0.048, respectively over 18 weeks (Figure 1 & 3).   While, extension and adduction were not significant at p=0.61 and p=0.12, respectively (Figure 2 & 4).

Discussion

            There is currently little objective data available about hip joint ROM and functional improvement following THR treatments.  One purpose of this study was to was to provide objective data regarding hip ROM in flexion, extension, abduction and adduction following 18 weeks of 45 minutes per week treatment sessions.  Range of Motion can be used to assess joint tightness, muscle strength and neuromuscular control.  Goniometric measurements are important because they allow objective data for the person measuring changes in joint ROM and there for is able to effectively assess the benefits of the treatment. 

            Increases in hip ROM over all angles measured were observed over the first 12 weeks; however the ROM in all angles measures decreased over the last six weeks.  This I believe is due to the extremely cold weather.  These measurements were taken in mid-November and the barn is not heated.  From this, it may be concluded that THR is effective in improving hip ROM, but it may not be as effective when temperature drop.  As see in table 2, the change of the right and left mean hip range of motion decreased in both the left and the right in all dimensions measured compared to increasing the previous two sessions. 

            One of the concerns for this study was the variety of subjects.  It is hard to determine how effect therapeutic horseback riding is for a specific disorder, age group, or sex.  Of the 20 subjects I measured, I saw 11 different disorders, an age range of 5-32 years old and only 5 males with 15 females.  Even though I had 8 subjects with cerebral palsy, each had a different type and different level of severity.  Therefore even within the same disorder, it is unclear to what extent therapeutic horseback riding helps each subject.  Overall, it is concluded that therapeutic horseback riding does improve hip range of motion and further studies should be conducted. 

Acknowledgements

            I thank the riders at Free S.P.I.R.I.T. Riders for participating in this study and Mary Narges, executive director at Free S.P.I.R.I.T.  for allowing me to conduct this study at the therapeutic horseback riding facility and for her constant support.

Resources Cited

All, A. & Loving, G. (1999).  Animals, Horseback Riding, and Implications for Rehabilitation Therapy. Journal of Rehabilitation, 10, 49-57.

Benda, W., M.D.  (2003). Improvements in Muscle Symmetry in Children with Cerebral Palsy after Equine-Assisted Therapy.  The Journal of Alternative and Complementary Medicine, 9, 817-825.

Bertoti, D.B.  (1988). Effect of therapeutic horseback riding on posture in children with cerebral palsy. Physical Therapy, 68, 1505-1512.

Bliss, B. RN.  (1997). Therapeutic Horseback Riding. RN, 60, 69-70.

Cantu, C. (2005).  Hippotherapy: Facilitating Occupational Performance. Parent Magazine, 51-53.

Cherng, R.  (2004). The effectiveness of Therapeutic Horseback Riding in Children with Spastic Cerebral Palsy. Adapted Physical Activity Quarterly, 21, 103-121.

Clark, M. & Russell, A. (2005). National Academy of Sports Medicine guide to Goniometric Assessment.

Centers for Disease Control and Prevention (2005). Developmental Disabilities.  Retrieved December 18, 2005, from http://www.cdc.gov/ncbddd/dd/default.htm

Engel, B. (1997).  Rehabilitation with the Aid of the Horse:  A collection of studies.  1^st ed.  Durango, CO: Barbara Engel Therapy Services.

Ionatamishvili, N.I.  (2004). Riding Therapy as a Method of Rehabilitation of Children with Cerebral Palsy.  Human Physiology, 30, 561-565.

Kaiser, L. (2006).  Effects of a Therapeutic Riding Program on at risk & special education children.  JAVMA, 228, 46-51.

Kreighbaum, E.  (1996). Biomechanics:  A Qualitative Approach for Studying Human Movement.  4^th ed.  Needham Heights, MA:  Pearson Education Co.

Lechner, H. (2003).  The Short-Term Effect of Hippotherapy of Spasticity in Patients with Spinal Cord Injury.  Spinal Cord, 41, 502-505.

Lessick, M.  (2004). Therapeutic Horseback Riding:  Exploring this alternative therapy for women.  AWHONN Lifelines, 8, 46-52.

MacKinnon, J.  (1995). A study of Therapeutic Effects of Horseback riding for children with Cerebral Palsy.  Physical and Occupational therapy in Pediatrics, 15,17-33.

Meregillano, G.  (2004). Hippotherapy.  Physical Medicine and Rehabilitation Clinic North America, 15, 843-854.

Potter, J.T.  (1994). Therapeutic horseback riding.  Journal of the American Veterinary Medical Association, 204, 131-133.

Sterba, J.  (2002).  Horseback riding in children with cerebral palsy: effect on gross motor function.  Developmental Medicine and Child Neurology, 44, 301-308.

Winchester, P.  (2002). The effect of Therapeutic Horseback Riding on Gross Motor Function and Gait Speed in Children who are Developmentally Delayed.  Physical and Occupational Therapy in Pediatrics,22 , 37-48.

Young, R.  (March 2005).  Horsemastership Part 2: Physical, Psychological, Education and Social Benefits.  International Journal of Therapy and Rehabilitation, 12, 120-125.

Young, R.  (April 2005).  Horsemastership Part 3: International Perspective of its Therapeutic Value.  International Journal of Therapy and Rehabilitation, 12, 171-176

 

Table1 Participant Characteristics (Excel File)

 

Table2 Means and Percentages (Excel File)

 

My Project! (PowerPoint File)

 

THE EFFECTS OF THERAPEUTIC HORSEBACK
RIDING ON BALANCE IN INDIVIDUALS
WITH DISABILITIES

Senior Research Project
Jody L. Margelowsky
Marian College of Fond du Lac, WI
Friday, December 12, 1997

ABSTRACT
Therapeutic horseback riding has been in practice since the early 1600s. The program claims to be beneficial to all people, especially those who have emotional, cognitive, and physical disabilities. In the following dissertation, I will assess the validity of the claim that therapeutic horseback riding is beneficial with respect to balance in individuals with disabilities.

INTRODUCTION
Therapeutic horseback riding is increasing in popularity throughout the world. The North American Riding for the Handicapped Association has published many claims of the program being very beneficial to handicapped individuals by improving balance, self-esteem, coordination, and even socialization skills (www.instanet.com/-sert/benefits) The following study focuses on the effects of therapeutic horseback riding on balance.

The North American Riding for the Handicapped Association (NARHA) was founded in 1969 to promote therapeutic horseback riding in the United States and Canada. The program shares the beliefs of the Greeks in the 1600’s in which horses offer many physical and emotional benefits to their riders. NARHA, a non-profit organization, began as a group of four centers located in the United States, and has grown to over 500 centers nationwide. The primary goal of the program is to provide the appropriate therapeutic exercise as well as to teach proper horsemanship. The horsemanship component helps the participants to have fun and take their focus off of the therapeutic component portion of the program.

The program includes instructors, volunteers, horses, and the participants. Instructors are trained to work with the horses, as well as the students. They must be able to evaluate and monitor equine behavior, screen and select the proper horses for the students, monitor the fit of the tack and equipment for each horse and student, and make up lesson plans that are appropriate for the particular participants and horses.

Volunteers must attend a training session before participating in the program in order to learn how to work with the horses and students properly. Duties of the volunteers include grooming and preparing the horses for class, assisting the instructor in mounting the students on the horses, and assisting the riders during class either as a side walker or a leader.

The horses are all donated by outside sponsors. Because of the nature of the program and the disabilities of the participants, all horses must undergo special training in gentleness and patience with their riders.

The agenda for a particular class in any given session greatly depends upon the abilities of the class as a whole and the goals that the instructor feels need to be met for that particular group. If necessary, the instructor may take time to work one-on-one with the students while the rest of the class performs other activities. Class activities may include, but are not limited to walking gently, off setting the balance of the rider, forcing him/her to maintain a position most appropriate for maintaining his/her balance while weaving poles or barrels, forcing the riders to maintain control of their own bodies as well as the horses and to maintain their balance.

Taking a ring off of a pole and placing it on another, causing the riders to stretch their muscles, which is beneficial especially to those with spastic muscles, and to maintain their balance.

Taking a bean bag off of a barrel and tossing it into a bucket, encouraging hand - eye coordination, stretching, muscular control, and again, balance.

Trotting, resulting in better balance and control of the rider’s own body.

Learning to control the horse (forward, backward, turning), simply making therapy more fun, while still learning control of their own bodies as well as the horse.

Weaving poles, encouraging the rider to maintain control and balance.

All exercises and activities performed are based on proprioceptive neuromuscular facilitation, which maintains that motor activity is organized into patterns of flexion-extension, abduction-adduction, and rotation.

Therapeutic Horseback Riding has several variations in practice. Hippotherapy is one such variation in which a physical therapist and his/her staff acts as the instructor of the program for various participants. Hippotherapy concentrates on using the horse to produce natural movements in the patient rather than the therapist performing these various tasks. The therapeutic movements of the horse and the participant’s response result in the therapeutic benefits of the program.

Therapeutic horseback riding involves a wider variety of professional participation, more diverse client participation, and equine skills more related to the participants horse-handling abilities. There are no physical, occupational, or speech therapists directly associated with the program.

The NARHA has many claims for improving client health. Claims include the following:

Improved balance
As the horse moves, the rider is constantly thrown off-balance, requiring that the rider’s muscles contract and relax in an attempt to re-balance. This exercise reaches deep muscles not accessible in conventional physical therapy. The three dimensional rhythmic movement of the horse is similar to the motion of walking, teaching rhythmical patterns to the muscles of the legs and trunk. Stopping and starting the horse, changing the speed and direction increase the benefits.

Strengthened muscles
Muscles are strengthened by the increased use involved in riding. Even though riding is exercise, it is perceived as enjoyment, and therefore the rider has increased tolerance and motivation to lengthen the period of exercise.

Improved coordination, faster reflexes, and better motor planning
Riding a horse requires a great deal of coordination in order to get the desired response from the horse. Since the horse provides instant feedback to every action by the rider, it is easy to know when you have given the correct cue. Repetition of patterned movements required in controlling a horse quickens the reflexes and aids in motor planning.

Stretching of tight or spastic muscles
Sitting on a horse requires stretching of the adductor muscles of the thighs. This is accomplished by pre-stretching prior to mounting the horse, and starting the rider off on a narrow horse, gradually working to wider horses. Gravity helps to stretch the calf muscles as the rider sits on the horse without stirrups. Riding with stirrups helps to stretch the heel cords. Stomach and back muscles are stretched as the rider is encouraged to maintain an upright posture against the movement of the horse. Arm and hand muscles are stretched as part of routine exercises on the horse and by the act of holding and using the reins.

Decreases spasticity
Spasticity is reduced by the rhythmic motion of the horse. The warmth of the horse may aid in relaxation, especially of the legs. Sitting astride a horse helps to break up extensor spasms of the lower limbs. Holding the reins helps to break flexor spasm patterns of the upper limbs. Fatigue also helps to decrease spasticity by producing relaxation.

Increases range of motion of the joints
As spasticity is reduced, range of motion increases. Range of motion is also improved by the act of mounting and dismounting, and exercises during the lesson.

Reduction of abnormal movement patterns
If spasticity is reduced and range of motion increased, it follows that abnormal movements will be inhibited.

Improved respiration and circulation
Although riding itself is not considered a cardiovascular exercise, trotting and cantering do increase both respiration and circulation.

Improved appetite and digestion
Like all forms of exercise, riding stimulates the appetite. The digestive tract is also stimulated, increasing the efficiency of digestion.

Sensory integration
Riding stimulates the tactile senses both through touch and environmental stimuli. The vestibular system is also stimulated by the movement of the horse, changes in direction and speed. The olfactory system responds to the many smells involved in a stable and ranch environment. Vision is used in control of the horse. The many sounds of the ranch help to involve the auditory system. All of these senses work together and are integrated in the act of riding. In addition, proprioceptors are activated, resulting in improved proprioception (SERT, 3)

In order to have a better understanding of how effective therapeutic horseback riding is, I performed a study in order to test the claim the program improving balance. I hypothesized that those who had been in the program for two years or less would yield more positive and noticeable results than those who had participated longer.

MATERIALS AND METHODS
In order to better understand the benefits of therapeutic horseback riding on balance, a study was performed in cooperation with Marian College and Free S.P.I.R.I.T. Riders. The riding program held by Free S.P.I.R.I.T. Riders was held from April 29, 1997 to October 23, 1997. These six months were broken down into four sessions, each four to six weeks in length. Each class is held once a week and runs for about 45 minutes in length. There is an average of 5 riders per class. In all, for the six month period, there were about forty riders participating in the program. In the forty who participated in the program, 19 participated in the study, and 16 actually finished the program.

Recruitment of the subjects began with the second session. All parents and guardians of the riders were presented with a packet of information explaining what the study involved and what would be expected of their riding student, along with a consent form that would need to be signed in order for the rider to participate in the study as well as access to their medical history (See Appendix A). Ages of the subjects ranged in ages from two to 38 years old.

Disorders of the participants of the study included one or more of the following:

Down Syndrome
Mitochondrial Myopathy
Ataxia
Epilepsy
Developmental Delays
Attention Deficit Disorder
Cerebral Palsy
Ecoli Meningitis
Hearing Loss
Scoliosis
Fetal Alcohol Syndrome
Mental Retardation
Head Injury resulting in Brain Damage
Cognitive Delays/Disabilities
Tourette’s Syndrome
Depressive Disorder

Balance was affected in individuals in various ways. Those who were affected by Mitochondrial Myopathy have generalized muscle weakness, external ophthalmyoplegia, peripheral neuropathy, and symptoms involving the central nervous system and therefore have a decreased ability to maintain their balance (Sato,1991). Cerebral Palsy patients exhibit decreased muscle tone in those areas affected by the disease (Bertoti, 1988). Tourette’s Syndrome is a neurological condition resulting in vocal and motor tics, and also has a high comorbidity rate (Kerbeshian, 1992). Participants with Fetal Alcohol Effects exhibit limb and joint abnormalities including clubfoot, hip dislocation, hypotonia, poor hand-eye coordination, and limited joint movement (Abel, 1984). Down Syndrome often shows its effects in balance as decreased muscle tone and in coordination (Nevid, 1997). It should be noted that many of the participants were diagnosed with more than one disorder.

The objective of the study was to test the hypothesis that riders would show an improvement in balance after participating in the program for 12 weeks. In order to test the balance of the participants, the Tinetti Balance Assessment was used (See Appendix A). It is an assessment tool based on the components of balance most commonly used for the geriatric population in order to detect reasons for frequent falls; but, the test can be used with any ambulatory subject. This quick and simple test, used by many health care professionals, especially physical therapists, consists of a series of tests in which the subject stands and performs various activities. The subject is then rated on a scale of 0-1 or 0-2, depending upon the test.

Before the first class in the second session, each subject was taken to a firm, level area in the stables where there would not be any disturbances. Parents and guardians were encouraged to attend, and the evaluation was performed in the same manner for each subject. The riders participated in the riding program as scheduled, performing the activities as directed by the instructor for the following 12 weeks. The gear and horses the riders were assigned to were specifically chosen for each rider to optimize safety as well as to allow each participant get the most out of his/her riding experience in terms of enjoyment and therapy. The number of volunteers depended upon the rider’s abilities. Those who could handle themselves and their horses with confidence while maintaining their balance and coordination did not require side walkers, while others did. Activities increased in difficulty as the sessions progressed. The Tinetti Balance Assessment was performed again at the end of the last class at the end of the 12 weeks in the same manner as the first evaluation.

RESULTS
The results of the study are as follows: the data is listed for each individual who participated. For those who did not finish the study, the appropriate areas were left blank. The results were broken down into the individual categories and a t-test was performed for the results. The overall assessment for the entire group is listed first. There is also an evaluation of the participants who have been in the program for two years or less and is listed at the end of the results section.

CONCLUSIONS
There are several aspects of the study that should be considered when analyzing the results of the study. Not all participants were new-comers to the program and changes would not be noted as easily in those individuals as in others; therefore, they could have affected the outcome of the data. Like all individuals, the riders who participate in the program all have good days and bad days. Some days the effects of their diagnosis is more prevalent than others and that could easily have affected the outcome of the results.

Medications may have played a role in the outcomes of the tests. Some participants were on medication and others were in the process of changing medications during the study. Some participants were easily distracted by other people and activities during the testing period by other activities and people within the area. Even though the attempt was made to eliminate this factor, it did not always work out as planned. Several of the subjects, whether it be because they were having a bad day, or because of some other factor were not very cooperative during the testing periods and therefore it was difficult obtaining true data. Also, some participants had been seeking additional treatment or therapy during the study.

Some suggested changes or improvements for additional study on the same subject may be to use a video camera during the evaluation period of the study to ensure consistency in the rating of the participants. It would also be interesting if the same or significantly different results would be attained using all new participants for the study.

The Tinetti Balance Assessment was not a very sensitive test; it did not allow for much flexibility when assessing the subjects. A longer testing period and several testings in between would perhaps yield different results as well as highlight specific areas that are being greatly affected by the program. More participants would also have been helpful. If given a second chance, it would be nice to group the participants into groups according to their diagnoses and experience in order to find out what effects the program has on a specific disorder and at what point the program actually begins to have its most profound effects on balance.

 The overall results of the program were positive and it would be interesting to continue this project and implement the changes previously mentioned in order to note any changes in the data.

DISCUSSION
The overall results of the study suggest that therapeutic horseback riding does improve balance in individuals with disabilities. The specific areas most affected by the program appear to be the continuous and discontinuous steps in turning, and balance after the first five seconds after arising from the chair. The differences in these two areas alone is significant enough to suggest the program had a positive effect on the entire group.

When the results were compared for the subjects who had been in the program for two years or less, there were no significant changes within the group. The hypothesis that subjects who participated in the program for two years or less would yield greater results was proven to be incorrect suggesting that there may be a period of time the riders must participate in the program before any significant results can be noticed.

APPENDIX A

Letter given to parents regarding information about the project:

June 6, 1997

Dear Parents and Guardians:

My name is Jody Margelowsky and I am a Senior Biology major at Marian College. I hope to attend graduate school next year for Physical Therapy. I need to do a research project in order to graduate from Marian, so I decided to study the effects of therapeutic horseback riding on balance in individuals with disabilities. In order to perform the study, I need to be able to work with the participants in the program.

I have enclosed a consent form along with a form titled "Form A" and a "Tinetti Balance Assessment" sheet. All of these forms are to inform you of what I would be doing in the study, provided the consent form is signed. You are encouraged to be present during the evaluation of the participants (which will be held before the first class of session 2 and the last class of session 3).

By signing the consent forms, I will be given a copy of the participant’s past medical history that Mary Narges has. The history will not be seen by anyone and the name of the subject will not be used; instead, I will be assigning each participant a number so as to maintain confidentiality during the study.

If there are any questions about the study, please, feel free to call me (414-349-3589) and I will try to clarify anything that is not clear about the study. If I am not home at that time, please leave a message and I will call you back as soon as possible. All signed consent forms can be returned to Mary Narges, Department of Social Services, P.O. Box 1196, Fond du Lac, WI 54936. Please do not feel obligated to enter your participant of the program into this study. It is entirely up to you, I do not want you to feel uncomfortable about what your student will be doing.

Thank you very much for your time and consideration.

Sincerely,

Jody Margelowsky
W3610 Hwy 60
Neosho, WI 53059

JM

Enclosure

IRRB Form : Explanation to parents of the Project Implications and Procedure.

Form A

1. The study I will be performing will involve 20-25 disabled individuals ranging from 2 to 40 years of age. They are all currently enrolled in a therapeutic horseback riding program one hour per week, and all have some type of mental or physical disability.

I will be choosing the participants according to their ability to stand on their own, past medical history (i.e. amount and type of therapy they have been exposed to in the past, severity of the disability, and at what age they were diagnosed), and how long they have been in the therapeutic horseback riding program. I will be able to determine according to the past medical history of each candidate whether or not he/she will be able to participate in the study and to what extent.

The participants will be evaluated before the Session begins and again after the session ends. (Each session consists of 6 class periods, one hour in length.) I will be evaluating students who participate in two sessions (i.e. 12 class periods)

I have attached a copy of the assessment form I will be using to evaluate the participants (Tinetti Balance Assessment). It is a standardized test used in physical therapy clinics and is widely accepted by physical therapists.

* Please note: If participants are not able to perform at any level, they will not be asked to move on to the next level or even used.

* Parents are encouraged to attend the class periods in which the evaluations are taking place (The first and last class of Sessions 2 & 3). The students will participate in the therapeutic riding program as scheduled, and I will be participating as a side walker when necessary. The riding program consists of class periods 45 - 60 minutes in length in which the students ride horses and learn to maintain posture, give commands, and learn control of both their own bodies and of the horses they are riding.  

2. The study poses extremely minimal risks. The participants may lose their balance during the evaluation portion of the study; however, this has been minimized by having an adult present who will supervise, and closely and carefully prevent the participant from falling. All participants and parents of each participant will be informed of any risks. I will have the medical history of each participant so that I will also know the limitations of each individual so as to not push him/her beyond his/her limitations.

3. The participants will benefit from the study through the therapeutic riding sessions, and I will benefit from the information obtained from the participants. I am a student who hopes to become a physical therapist, and this study will help me to better understand the effects of therapeutic uses of horses. It will also help me to learn about yet another means of treatment for many disabilities that people can have. In addition, the medical community will gain documented evidence regarding the potential value of horseback riding therapy on balance.

4. I will have access to the medical histories of the participants. As soon as I obtain those, I will be blacking out their names and assigning each participant a number. Their name will be kept with the assigned number in a separate file and only be used while working with the participant directly. No other people will have access to the file and the names will not be used in any way when reporting the results of the study.

5. The participants will be told what will be done during the study. I will tell them what I would like them to do and that I am not expecting them to do anything they are unable to do. They will be informed about the fact that I will have their medical histories in my possession, and I will be the only person who will see the information during the study. There will be no use of names in the study except for when the participants are being evaluated and worked with; and then there will be no link to their medical history. Once the study is over, the medical histories of the participants will be disposed of properly. Results will be available to all participants and their families at the end of the study and can be mailed directly to them

Balance Assessment Tool Used to Evaluate the Participants:

TINETTI BALANCE ASSESSMENT

 Patient Name (No.):__________________________ Date:_________________

Instructions: Subject is to be seated in hard armless chair; the following maneuvers are tested.

1. Sitting balance leans or slides in chair 0
Steady, safe 1

2. Arise Unable without help 0
Able but uses arm to help 1
Able without use of arms 2

3. Attempts to arise Unstable without help 0
Able but requires more thanone attempt 1
Able to arise with one attempt 2

4. Immediate standing balance Unsteady )staggers, moves feet in first 5 seconds, marked trunk sway) 0
Steady but uses walker or cane or grabs for support 1
Steady without support 2

5. Standing balance Unsteady 0
Steady but wide stance (medial heels > 4 inches apart) or uses cane, walker, or other support) 1
Narrow stance without support 2

6. Balance with eyes closed Unsteady or needs to hold onto object 0
Steady with feet apart 1
Steady, narrow stance without support 2

7. Turning Balance Discontinuous steps 0
Continuous steps 1
Unsteady (grabs, staggers) 0
Steady 1

8. Nudge on sternum (Subject stands begins to fall 0
with feet as close together as Needs to move feet but possible, examiner pushes with maintains balance 1
light even pressure 3 times) Steady, able to withstand pressure 2

9. Neck turn (Patient asked to turn head Unsteady, or symptoms to side and look up while standing with maneuver 0
with feet as close together as able) Decreased ability to do maneuver, but no symptoms or staggering 1
Able to turn head at least halfway to side and able to bend head back to look at ceiling, no staggering, symptoms, or pain. 2

10. One leg standing balance Unable to stand for 5 without support 0
Able 1

Right leg standing balance time: __________
Left leg: __________

11. Back extension (Patient asked to Will not attempt, no lean back as far as possible extension, or unsteady 0
without holding onto object) Decreased ROM or needs to hold object 1
Good extension, steady, no support 2

12. Reaching up (patient attempts to Unstable or unsteady 0
reach object high enough to able, but needs to hold require stretching or standing something for support 1
on toes) Able, steady without support 2

13. Bending down (patient asked to pick Unable to bend down or up small object from floor) get back up; requires multiple attempts 0
Able to get object and get up in single attempt but needs to use arms to pull up or hold onto something for support 1
Able to do maneuver, no support, steady 2

14. Sitting down Unsafe, falls into chair, misjudges distance 0
Uses arms or not a smooth motion 1
Safe, smooth motion 2

Balance score _________/26

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