Analysis Of Hippotherapy Outcome Measures

Analysis of Hippotherapy Outcome Measures 1

Analysis of Hippotherapy Outcome Measures

OTD-E Capstone

Lacy Lee Gardner

University of St. Augustine for Health Sciences

November 25, 2009


Abstract

This paper describes the use of hippotherapy with children who have autism spectrum

disorders (ASD). It details the rationale, frames of references and a review of the literature.

Furthermore, descriptions of a capstone project are provided on the investigation of

hippotherapy outcome measures being used by current occupational therapists. Five

hippotherapy sites were visited and at least one full day of sessions was observed at each.

Occupational therapists were also interviewed about current practices. Findings support the

use of non-standardized testing for measuring outcomes of children with ASD. Also noted are

the various methods for delivering hippotherapy services.

Keywords: Hippotherapy, Autism Spectrum Disorders, Outcome Measures


Introduction

Autism Spectrum Disorders (ASD) are estimated to affect approximately 1 in 150

children in the United States yet it is still unclear as to what causes ASD. This developmental

disorder affects numerous aspects of a child’s daily functioning, including communication,

social interaction, cognitive functioning, motor functioning and sensory integration (CDC, 2009).

A wide variety of treatments are available, including behavior and communication approaches,

dietary approaches, medication, and complementary and alternative approaches (CDC, 2009);

however there is currently no consensus as to which treatment strategies are most effective

(Bass, Duchowny, & Llabre, 2009). Some families have participated in traditional therapies

without much success and are seeking complementary and alternative approaches to trial.

“Current research shows that as many as one third of parents of children with an ASD may have

tried complementary or alternative medicine treatments” (CDC, 2009). Therefore, it is not

surprising that hippotherapy is in demand and on the rise (AHA, 2009).

Hippotherapy originates from the Greek word hippos meaning horse and literally

translates to treatment with the help of a horse. “Hippotherapy is a physical, occupational, and

speech-language therapy treatment strategy that utilizes equine movement as part of an

integrated intervention program to achieve functional outcomes” (AHA, 2009). The horse’s

movement provides a multi-sensory environment that facilitates active responses in the client.

Movements are directed and graded by the therapist, allowing the client to participate in

motivating activities to develop transferable skills (Byam & Simmons, 2005). The American

Hippotherapy Association (2009) states that this method of treatment delivery is appropriate

for any child or adult with “mild to severe neuromusculoskeletal dysfunction.” Specific medical


conditions include autism spectrum disorders (ASD), cerebral palsy (CP), developmental delay,

genetic syndromes, learning disabilities, sensory integration disorders, speech-language

disorders, traumatic brain injury, and stroke (AHA, 2009).

“Occupational therapists can use the technique of hippotherapy as part of their

intervention to deign functional and occupation-based treatment plans to meet specific client

goals” (Byam & Simmons, 2005, p.14). They use hippotherapy to address physical impairments,

social participation, behavior modification, psychosocial issues, and cognition. Benefits can

include improved posture, muscle tone, flexibility, endurance, sensory processing, motor

planning skills, body awareness, motivation, self-confidence and problem-solving skills. (See

Appendix A for examples of hippotherapy benefits, intervention techniques, and

generalizations to other skills).

These benefits can be explained through the Person-Environment-Occupation (PEO)

Model, which was designed to reveal the complex relationships among these three factors.

“Occupational performance results from an individual’s engagement in purposeful tasks and

activities within an environment” (Byam & Simmons, 2005, p. 14). With hippotherapy, clients

can achieve their goals through interaction with the unique horse environment and activities

performed while on horseback. People are generally attracted to horses; therefore, this unique

relationship and interaction often motivates clients to engage in intervention activities (Byam &

Simmons, 2005).

Hippotherapy for children with ASD is also represented in the Sensory Integration

model. The Sensory Integration model was developed by Ayers with a central principle of

providing planned and controlled sensory input in order to facilitate a related adaptive


response and enhance the brain’s organization. Occupational therapists can use the horse to

deliver this controlled sensory input, including proprioceptive, vestibular, and tactile. The

therapist can manipulate the horse’s movement, direction, speed and gait or even change the

horse itself, as each moves differently, in order to control the sensory input (Bracher, 2000).

“Each time the equine takes a step there is a concussive force transmitted to the patient giving

them proprioceptive input (the sense of where the body is in relation to other body parts). By

moving through space the patient receives vestibular input (the sense of movement or

orientation in space)” (NARHA, 2008, p.44). And tactile input is received just through touching

the horse. These systems play a key role in the patient’s arousal level, which impacts the ability

to attend to a given task and follow directions (NARHA, 2008). “It has been noted from teachers

and parents that autistic children have improved in most areas of sensory processing and their

reaction to the world around them much more completely after riding” (Stoner, 2004).

Countless testimonials support the outlined benefits of hippotherapy, however

anecdotal evidence is not enough. Insurance companies still consider hippotherapy to be

“experimental and investigational” due to insufficient scientific data in the peer reviewed

medical literature to support its efficacy (Aetna, 2009). Furthermore, the minimal amount of

research available is focused on changes in motor control with diagnoses such as cerebral palsy,

spinal cord injuries and multiple sclerosis. Studies involving children with ASD are extremely

rare.

Upon further analysis, it is hypothesized that outcome measures might be one cause for

the scarcity of evidence available. “Because children with autism have difficulties with

interaction and communication, they rarely comply with standardized administration of test


items. Most of the measures used in autism research have been scales completed by teachers

and parents based on observation of behaviors or structured observations of children in natural

settings from videotapes” (Miller-Kuhaneck, 2004, p.406-7). This limits the possible

measurement tools to be used, eliminating several of the more sensitive tests. Another issue

affecting the quality of available studies is the lack of randomized clinical trials. It is difficult to

obtain randomized samples that are comparable, because children with ASD present with

varied levels of disability and characteristics. Likewise, interventions are individualized to meet

each unique child’s needs and goals. This makes standardization and replication of

interventions very difficult, again presenting a limitation of research (Miller-Kuhaneck, 2004).

From this it was determined that a need exists for investigation of commonly used

assessments among therapists currently practicing in hippotherapy settings. “Measurement of

behavior and performance is not the only issue in regard to children with autism; identifying

which variables to measure is also important to consider. The behaviors of children with autism

relate in complex ways, and multiple behaviors should be measured and correlated to evaluate

intervention effects” (Miller-Kuhaneck, 2004, p. 407).

Differences between Hippotherapy and Therapeutic Horseback Riding

Hippotherapy and therapeutic horseback riding are commonly interchanged terms

however there is a definite distinction between the two. “Hippotherapy establishes a

foundation for neurological function and sensory processing based on a therapeutic model as

where therapeutic riding concentrates on teaching specific riding skills for recreational

purposes based on a recreational/leisure model. In so doing, therapeutic riding gains more

flexibility, balance, strength and improves posture during the sport of riding specifically rather


than establishing the foundations of occupational performance therapeutically” (Cantu, 2005,

p. 52). Both require therapists or instructors to be certified, which is controlled by their

respective national associations. Carriage Barn Equestrian Center’s website offers an excellent

comparison chart outlining the differences between hippotherapy and therapeutic horseback

riding (See Appendix C). Often times a client may begin with hippotherapy treatment and when

significant progress is observed to plateau, he/she may then transfer to a therapeutic riding

program. This allows for underlying functional skills, such as sensory processing, muscle

strength and endurance, to be established initially through hippotherapy and then maintained

through therapeutic riding.

Literature Review

Literature supporting the use of hippotherapy with children who have ASD was

reviewed extensively. Criteria for each of the following areas were established in order to

centralize focus while searching the literature. Intervention criteria included hippotherapy,

therapeutic horseback riding, equine assisted therapy, and animal assisted therapy. Participants

were limited to children ages 18 and under presenting with ASD or related symptoms (delayed

social skills or language disabilities). Outcomes of interest included sensory processing skills,

social functioning, motivation and occupational performance.

Two studies investigated the effects of hippotherapy services on children with autism or

related symptoms. Taylor and colleagues (2000) examined the changes in motivation and

volition of three children with autism after receiving 16 weeks of hippotherapy sessions. Each

45 minute session included donning a helmet and mounting/dismounting the horse, with 20-30

minutes actually spent riding atop the horse. The children were observed after 8 sessions and


again after the conclusion of 16 sessions, using the Pediatric Volitional Questionnaire (PVQ). All

three children demonstrated increased volition from baseline at differing rates. Researchers

concluded that motivation is positively impacted by hippotherapy.

Maccauley and Gutierrez (2004) published a study of the effectiveness of hippotherapy

for children with language-learning disabilities. Hippotherapy was administered in two 60

minute sessions a week for 6 weeks, addressing speech and language goals. Participants and

their parents completed a 21-item client satisfaction questionnaire both prior to and upon

completion of the hippotherapy intervention. Parents reported improvements in speech and

language abilities however the children reported no difference when receiving hippotherapy.

Two additional studies investigated the effects of therapeutic horseback riding on

children with autism spectrum disorders (ASD) 4 to 10 years of age. Stoner (2004) implemented

one 60 minute session weekly for 10 weeks with 20 minutes of pre-mounted activities and 30

minutes of mounted activities. Bass, Duchowny and Llabre (2009) implemented one 60 minute

session weekly for 12 weeks with five minutes for mounting and dismounting, 10 minutes of

warm-up activities, 15 minutes of riding skills, 20 minutes of mounted games, and 10 minutes

of horsemanship and grooming tasks. Both of these studies utilized a pretest-posttest control

group design with participants randomly assigned to either the experimental group or placed

on a wait-list. And again, both studies reported improvements after therapeutic horseback

riding. Stoner (2004) and Bass et al (2009) reported improvements in sensory processing skills

as evidenced by the sensory profile. Bass also reported improvements in social functioning as

evidenced by the social responsiveness scale.


Candler (2003) published a study of therapeutic horseback riding at a one week summer

day camp. The study targeted individualized occupational performance established through the

Canadian Occupational Performance Measure (COPM). Twelve children with identified sensory

modulation disorders ages 5 to 13 years participated in this summer camp. This one group

pretest-posttest design demonstrated an improvement in both satisfaction and performance of

outlined occupations after participating in therapeutic riding sessions and arts and crafts

activities at camp. However, with multiple activities and interventions implemented throughout

each day, Candler (2003) was unable to determine if the positive outcome can be fully

attributed to the equine activities.

Sams, Fortney and Willenbing (2006) reported the effects of occupational therapy

incorporating various animals, including horses, on social interactions and language use in 22

children with autism. Each weekly session, averaging 28.5 minutes in length, facilitated sensory

integration, language use, sensory skills, and motor skills through either traditional or animal-

assisted occupational therapy. The number of behaviors for use of language and social

interaction were counted and compared between the two types of treatment sessions. After 15

weeks, positive behaviors during animal-assisted treatment sessions outnumbered those during

the traditional treatment sessions. This study supports the unique and natural interest children

exhibit towards animals.

The above articles provide support for the use of equine-assisted therapies in promoting

positive occupational and behavioral outcomes in children with ASD. However, further research

is needed to validate these findings. According to Sackett’s levels of evidence, these studies

present evidence limited to Levels III and IV due to lack of control for internal and external


validity. Studies with increased sample size, randomized control groups and use of reliable,

valid standardized assessments are needed to provide Level I evidence. Research outside the

realm of physical benefits is beginning to emerge, focusing on behavioral, cognitive, and

psychosocial benefits. This is merely the beginning of many efforts to close the hippotherapy

literature gap.

(See appendix D for Evidence Table of quantitative research studies discussed above.)

Method

Local hippotherapy sites within a 100 mile radius of St. Augustine Florida were found

through public access, including internet and phone book searches as well as word of mouth.

(See Appendix E for reference listing of local sites). Although many of the sites offered both

hippotherapy and therapeutic horseback riding, this search was limited to those offering

hippotherapy treatment delivered by an occupational therapist. Four hippotherapy sites in this

geographical area were contacted, along with one in Gainesville, Georgia due to a prior Level II

fieldwork placement at this site. Each site was visited for observation of at least one full day of

sessions administered to children with autism spectrum disorders (ASD).

The specific type of treatment delivery was noted at each site, classic hippotherapy vs.

equine-facilitated therapy. Classic hippotherapy focuses solely on the horse’s movement and

the child’s reaction. Whereas, equine-facilitated therapy additionally incorporates traditional

occupational therapy activities while atop the horse. Occupational therapists at each site were

also verbally interviewed about current practices and outcome measures being utilized.

Questions included:


a. What diagnoses are treated at this hippotherapy facility?

b. What age is this population?

c. What is the cost of hippotherapy services? How are these services funded, billed,

or reimbursed?

d. What measurement tools are being used at initial evaluation and follow-ups?

e. What measurement tools are viewed as the most effective in demonstrating

improvements for children with ASD?

f. How is progress monitored?

g. Is there a specific child that “sticks out” as demonstrating significant

improvements as a result of hippotherapy treatment sessions?

Results

Results indicated that therapists currently use a variety of standardized assessments

primarily for billing purposes, as insurance companies request the report of standardized

scores. This includes the Bruininks-Oseretsky Test of Motor Proficiency, Peabody

Developmental Motor Scales, Beery-Buktenica Developmental Test of Visual-Motor Integration,

and Sensory Profile to name a few. However, therapists agree that administering standardized

assessments to children with autism spectrum disorders (ASD) is difficult and not often

accurate. The most valuable information regarding an individual’s progress is obtained through

observations and reports from family and teachers.

Observations also revealed a significant difference in delivery of hippotherapy services

across each site visited. Each therapist administered hippotherapy services with personal

variations; some adhered strictly to classic hippotherapy guidelines, while others added more


traditional therapeutic activities to treatment sessions. While all methods appear to benefit

children with ASD, this capstone project influenced the development of a personal preference

for delivery of hippotherapy services in the form of equine-facilitated therapy sessions;

incorporating traditional activities while on the horse adds depth to each treatment session.

Equine-facilitated therapy still offers children the benefit of classic hippotherapy, improving

trunk control and sensory processing skills, as well as the benefit of improving fine motor or

visual motor skills, for example. This provides children with an opportune learning environment

in which skills can be easily generalized to other environments.

Lastly, it was discovered that information about local hippotherapy sites is not easily

accessible to the community. Conventional search methods utilized by most families were not

successful. Therapists offering hippotherapy services are not advertised or publicized. Families

in the community may not know the many ways in which hippotherapy can benefit a child with

ASD.

(See Appendix E for meta-analysis of hippotherapy sites).

Discussion

These results support the use of hippotherapy to benefit children with autism spectrum

disorders (ASD). Therapists and families alike have reported children making significant gains

after participating in hippotherapy. However, insurance companies continue to disregard these

services as therapeutic, considering them experimental. Therapists are then forced to creatively

document hippotherapy services, using phrases such as “dynamic surface” and “barrel” in order

to avoid the term “horse.” Additionally, therapists are forced to use standardized assessments

in reporting therapeutic gains, despite the known superior value of clinical observations and


reports from parents and teachers. Therapists value non-standardized outcome measures over

standardized testing to demonstrate improvements in children with ASD.

The results also suggest that the community would benefit from a publicized reference

listing of all local therapy sites. Families as well as the health profession need to be informed of

the incredible benefits hippotherapy has to offer. A reference list of all local hippotherapy sites

within a 100 mile radius of Saint Augustine, Florida has been composed and will be submitted

to local autism support groups (See Appendix D).

Additionally, the knowledge gained in this capstone can be used to develop a future

study supporting the use of hippotherapy with this particular population. It is hypothesized that

children participating in hippotherapy will demonstrate improvements in social functioning and

sensory processing skills compared to participants not receiving the treatment. The study will

include at least 50 children diagnosed with ASD between 4 and 18 years of age. Each child will

be randomly assigned to either the control group or experimental group, amounting to

approximately 25 in each group. Children in the control group will wait-listed and will continue

to receive any conventional therapies. Children in the experimental group will participate in 60

minute hippotherapy sessions once a week for 16 weeks.

Outcome measures will include the Sensory Profile (SP), Sensory Responsiveness Scale

(SRS), and the use of video to rate the children’s performances on a categorized likert scale. The

SP and SRS will be completed by the caregivers both before and after the 16 week period. The

caregiver will not be allowed to view previous completed forms when completing the

assessments at the conclusion of treatment in order to prevent bias. Bass, Duchowny and

Llabre (2009) utilized the SP and SRS in their study exploring the effect of therapeutic horseback


riding on social functioning in children with autism. These assessments provide information

about a child’s social functioning, sensory processing skills and characteristic behaviors of

children with ASD. Both the SP and SRS are considered to be highly reliable and valid

standardized assessment tools.

A 15 minute video will be recorded during the children’s first and last hippotherapy

session and then viewed by a blinded therapist to rate the children’s performance on a

categorized likert scale (based on percentage or number of occasions identified behaviors are

observed). This method can be used to prevent bias and establish inter-rater reliability. This

allows the therapists’ highly valued clinical observations to be quantified.

After 16 weeks, the hippotherapy services will be discontinued and can resume

traditional therapeutic interventions. A follow-up will be completed 8 weeks after the

intervention is discontinued in order to measure the continued benefits. It is hypothesized that

children participating in hippotherapy will demonstrate decreased social functioning and

sensory processing skills after services are discontinued. Sometimes effects become evident

when an intervention is removed, as supported by this parent’s testimonial.

“Morgan had started going every other week for therapy and she missed 3 sessions

which amounted to 6 weeks. Well, her teacher called me and wanted to talk about her

behavior and at home I have been having a hard time with her on doing homework. She

would say, ‘Mom, my head is feeling funny,’ so I would make her do some wall pushups,

etc. Well, it finally dawned on me that she had missed hippo and her body was getting

out of sync again! [The therapist] felt the same way so now Morgan is back to weekly


therapy sessions, but it's only been 2 weeks so no major improvement yet, but I know

by the end of this year she will be doing much better.” –Chante McNeal

Therefore, it may be beneficial to include an interrupted time-series withdrawal design in which

the treatment is removed then re-introduced (O1 X1 O2 X0 O3).

The literature supporting the use of hippotherapy with children with ASD is very limited.

However, therapists, parents and families of children with ASD who have participated in this

unique treatment have reported the immense benefits. “More people need to understand that

[hippotherapy] is helpful – I even have a hard time with Morgan’s elementary school teachers

understanding the impact it has on her” (Chante McNeal). Future studies are needed in order to

further assess its therapeutic benefits. After extensive research and investigation through this

capstone project, I feel the above described study would provide Level IV evidence supporting

the many benefits hippotherapy has on children with autism spectrum disorders.


References

Aetna. (2009) Clinical policy bulletin: Hippotherapy. Retrieved on October 31, 2009 from

http://www.aetna.com/cpb/medical/data/100_199/0151.html.

American Hippotherapy Association. (2007). Retrieved on October 31, 2009 from

http://www.americanhippotherapyassociation.org.

Bass, M. M., Duchowny, C. A., & Llabre, M. M. (2009). The effect of therapeutic horseback

riding on social functioning in children with autism. Journal of Autism and

Developmental Disorders, 39, 1261-1267.

Bracher, M. (2000). Therapeutic horse riding: What has this to do with occupational therapists?.

British Journal of Occupational Therapy, 63 (6), 277-282.

Byam, E., & Simmons, D. (2005). Environment and occupation in hippotherapy. OT Practice, 10

(7), 13-18.

Candler, C. (2003). Sensory integration and therapeutic riding at summer camp: Occupational

performance outcomes. Physical & Occupational Therapy in Pediatrics, 23 (3), 51-64.

Cantu, C. O. (2005). Hippotherapy: Facilitating occupational performance. Exceptional

Parent, 35 (3), 51-53.

Latella, D., & Langford, S. (2008). Hippotherapy: An effective approach to occupational therapy

intervention. OT Practice, 13 (2), 16-20.

Macauley, B. L., & Gutierrez, K. M. (2004). The effectiveness of hippotherapy for children with

language-learning disabilities. Communication Disorders Quarterly, 25 (4), 205-217.

Miller-Kuhaneck, H. (2004). Autism: A comprehensive occupational therapy approach (2nd ed.).

Bethesda, Maryland: AOTA Press.


NARHA. (2008). Humans, horses and health: Hippotherapy. Palaestra, 24 (1), 43-44.

Sams, M. J., Fortney, E. V., & Willenbring, S. (2006). Occupational therapy incorporating animals

for children with autism: A pilot investigation. American Journal of Occupational

Therapy, 60 (3), 268-274.

Stoner, J. B. (2004). Riding high. Advance for Occupational Therapy Practitioners, 20 (13), 42.

Taylor, R. R., Kielhofner, G., Smith, C., Butler, S., Cahill, S. M., Ciukaj, M. D., & Gehman, M.

(2000). Volitional change in children with autism: A single-case design study of the

impact of hippotherapy on motivation. Occupational Therapy in Mental Health, 25, 192-

200.


Appendix A: Benefits of Hippotherapy, Intervention Techniques, and Generalization to Everyday

Learning Skills

Intervention Generalization to
Skill Area Sample Goal Example Other Skills
The rider is placed The child will play
backward and side- with siblings at the
Improve dynamic
Motor sitting while the horse playground and with
balance
walks at a moderate peers at school
pace without falling
The rider feels the
The child will be able
rhythm of the horse
Improve awareness of to stand in line at
Sensory at a walk, a trot, and
self in space school without
with transitional
bumping into others
movements
The rider receives
positive, specific
feedback after The child will
Provide a successful achieving a simple demonstrate
Emotional experience to goal such as an increased self-esteem
improve confidence independent half in social and family
seat, holding the situations
reins, or sitting
independently
The child will help
The rider is asked to with simple chores
make the horse go around the house and
Follow two-step
Process/Cognition forward by squeezing demonstrate
commands
his or her legs and increased ability to
saying “walk on” participate in
classroom activities
With each transitional The child will interact
movement, the rider with at least one peer
Increase
Communication/ is asked to verbalize in school or on a play
verbalizations and
Social Participation commands to the date. The child will
social interactions
horse such as “walk verbalize his or her
on,” “whoa,” or “trot” needs at home.
(Latella & Langford, 2008)


Appendix B: Comparison of Therapeutic Horseback Riding and Hippotherapy

A Comparison of Therapeutic Riding and Hippotherapy programs

Both programs require:
Qualified Equines
Safe environment for humans and equines
Qualified equine professionals and horse handlers
Therapeutic Riding/Equine Assisted Activities Hippotherapy/Equine Assisted Therapy
• Recreation/leisure • Hippotherapy (HPOT)
• Sport/Education • Equine Facilitated Psychotherapy (EFP)
• Vocational/Equine • Equine Facilitated Therapy (EFT)
• Improvement in social skills, quality of life • Attainment of therapy based goals as per
and mobility professional designation and functional
• Includes riding, driving, vaulting and outcomes assessed during evaluation.
ground work adapted as needed for • Goals include improved function,
individual participant rehabilitation, not necessarily equine
• Goals include riding ability, acquisition of related.
leisure skill, self accomplishment, • HPOT - mounted use of the horse’s
animal/human interaction. Goals are movement to achieve therapy based goals
equine related • EFP – mounted or unmounted activities,
• Implemented by trained instructor use of equine/human relationships to
• Therapists as consultants achieve therapy based goals.
• EFT – mounted or unmounted activities
using equine skills to achieve functional
goals.
• Implemented by licenced/credentialed
medical human service professional, PT,
OT, SLP, or Phychologist

Chart retrieved from The Carriage Barn Equestrian Center at
http://www.carriage-barn.com/therapeutic_hippo.html#comparison


Appendix C: Evidence Table

Table 1. Summary of studies: Interventions and participants

Study Control Total
Intervention/time Population Ages
Authors Intervention n

Hippotherapy: 45 min/session x
None
1 session/wk x 16 wks
2000 (Each participant Children with 4-6
Session included donning 3
Taylor1 served as his/her autism yrs
helmet, mounting, 20-30 mins on
own control)
horse, dismounting

One week summer day camp: None Children with
2003 Therapeutic horseback riding (Each participant sensory 5-13
12
Candler2 Sensory integration intervention served as his/her modulation yrs
Camp arts and crafts own control) disorder

None Children with
2004 Hippotherapy: 60 min/session x (Each participant language-
3 9-12
Macauley3 2 sessions/wk x 6 wks served as his own learning
control) disabilities

Therapeutic horseback riding: 60
min/wk x 10 wks Children with
2004 4-10
Session included 30 mins pre- Wait-list autism or PDD- 12
Stoner4 yrs
mounted activities and 30 mins NOS
mounted activities

None
OT incorporating animals:
(Each participant Children with 7-13
2006 Sams5 average 28.5 mins/session x 1 22
served as his/her autism yrs
session/wk x 15 wks
own control)

Therapeutic horseback riding: 60
min/wk x 12 wks
Session included 5 mins Children with 4-10
2009 Bass6 Wait-list 34
mounting/dismounting, 10 mins ASD yrs
warm-up, 15 mins riding skills, 20
mins mounted games, 10 mins
horsemanship/grooming


Table 2. Summary of Studies: Research methods

Level of Treatment Control Rx
Study Authors Research Design Rx n
Evidence Duration n

2000 Taylor1 Single subject A-B-B design IV 16 wks 3 0

One-Group Pretest-Posttest
2
2003 Candler Design IV 1 wk 12 0
O1 X O2

2004 Macauley3 Design IV 6 wks 3 0
O1 X O2

Pretest-Posttest Control
Group Design
2004 Stoner4 II 10 wks 6 6
R O1 X O2
O1 O2

5
2006 Sams Design IV 15 wks 22 0
O1 X O2

Pretest-Posttest Control
6 Group Design
2009 Bass III 12 wks 19 15
R O1 X O2
O1 O2


Table 3. Summary of Studies: Outcomes, measures, and results

Study Outcome of Measurement Tool Result Clin Statistics Level of
Authors Interest Signif Evidence
2000
Motivation/Volition PVQ + NR NS IV
Taylor1

COPM (modified for
NR IV
2003 Occupational summer camp setting)
Candler2 performance - Performance + p=.001
- Satisfaction + p=.001

21-item questionnaire NR IV
2004 Speech and
- parents + p<.000
Macauley3 language abilities
- participants - p<.02

SP
2004 +
Sensory processing 1 question with 3 NR NR II
Stoner4 +
possible answers

2006 Social interactions Number of behaviors + large p<.01
IV
Sams5 Language use Number of behaviors + small p<.05

SRS + none p=.017
2009 Bass6 Social functioning III
SP + small p<.01

Legend for Table 3

PVQ Pediatric Volitional Questionnaire + Result favored animal therapy
COPM Canadian Occupational Performance - Result did not favor animal
Measure therapy
SP Sensory Profile NR Not reported
SRS Sensory Responsiveness Scale ND No difference
NS Not significant


List of References:

1. Taylor, R. R., Kielhofner, G., Smith, C., Butler, S., Cahill, S. M., Ciukaj, M. D., & Gehman,

M. (2000). Volitional change in children with autism: A single-case design study of the

impact of hippotherapy on motivation. Occupational Therapy in Mental Health, 25, 192-

200.

2. Candler, C. (2003). Sensory integration and therapeutic riding at summer camp: Occupational

performance outcomes. Physical and Occupational Therapy in Pediatrics, 23 (3), 51-64.

3. Macauley, B. L., & Gutierrez, K. M. (2004). The effectiveness of hippotherapy for children

with language-learning disabilities. Communication Disorders Quarterly, 25 (4), 205-217.

4. Stoner, J. B. (2004). Riding high. Advance for Occupational Therapy Practitioners, 20 (13),

42.

5. Sams, M. J., Fortney, E. V., & Willenbring, S. (2006). Occupational therapy incorporating

animals for children with autism: A pilot investigation. American Journal of Occupational

Therapy, 60 (3), 268-274.

6. Bass, M. M., Duchowny, C. A., & Llabre, M. M. (2009). The effect of therapeutic horseback

riding on social functioning in children with autism. Journal of Autism and

Developmental Disorders, 39, 1261-1267.


Appendix D: Reference List of Local Hippotherapy Sites

Freedom Ride
Sandra Wainman, OTR/L
1905 Lee Road
Orlando, Florida 32810
(407) 293-0411
(497) 629-9455

HOPE: HOrses helping PEople
Cathi Brown, OTR/L
Edi Walker, OTR/L
9814 SW 153rd Avenue
Archer, Florida 32618
(352) 495-0533
(904) 961-9479

Hope Reigns
Children’s Therapy Network
Gina Johnson, OTR/L
3804 Pioneer Trail
New Smyrna Beach, Florida 32168
(386) 428-4805

Hope Therapy
Becky Davenport, OTR/L
1591 Big Branch Road
Middleburg, Florida 32068
(904) 291-6784
(904) 887-8451


Appendix E: Meta-analysis of Hippotherapy Sites


Comparison of Hippotherapy Sites
Children’s Freedom HOPE: HOrses Hope Walker
Name Therapy Ride, Inc. helping PEople Therapy Therapy
Network, Services
Inc.
Gina Johnson, Sandra Wainman, Cathi Brown, OTR/L Rebecca Nicole Walker,
OTR/L OTR/L Edi Walker, OTR/L Davenport, OTR/L
Therapist(s) OTR/L Nolina Varley,
OTR/L
New Smyrna Orlando, FL Archer, FL Middleburg, FL Gainesville, GA
Beach, FL
Location
3+ years 5-6 years 3 years to 2 years to 3 years to
7-9 years 70 years 85 years 18 years
Population 10+ years
autism, autism, autism, PDD, ASD, CP, ASD, CP,
sensory mitochondrial oppositional/defian Down’s Down’s
Diagnoses processing disorder, t behavior disorder, Syndrome, Syndrome,
disorder, sanfilippo disease developmental learning Sensory
cerebral palsy, disorders, sensory disability, processing
multiple spine processing disorder, developmenta disorder,
disorders CP, muscular l delay, ADD/ADHD,
including dystrophy, brachial multiple developmenta
spondylosis plexus injury, brain sclerosis, brain l delay,
tumor, terminal injury, CVA, microcephaly,
brain cancer (war veterans agenesis
– corpus
amputations) callosum,
hemi-
hypertrophy
Classic Classic Classic Equine- Equine-
Hippotherapy Hippotherapy Hippotherapy Facilitated Facilitated
Method of 30 minute 45 minute weekly 60 minute weekly 60 minute 60 minute
Delivery weekly sessions sessions weekly weekly
sessions x 6 sessions sessions
weeks
OT Services: MacKay OT Services: Insurance and OT Services:
Hope Reigns Scholarship (State Insurance and private pay Insurance and
Cost, Billing, sponsoring, Funding), private-pay private-pay
Funding Third-party Medicaid, Third- Barn Fees: Private- Barn Fees:
Insurance, party Insurance, Pay, HOPE non- Private-pay,
Private-pay Private-pay, profit organization Finding Faith
Barn Fees: donations non-profit
Hope Reigns organization
sponsoring,
Private-pay


Sensory Profile, VMI, BOT, SCSIT, PDMS, SP SP, MMT, SP, BOT,
Great Postural clinical Primarily clinical ROM, FM/GM PDMS, VMI,
Outcome Scale, clinical observations observations and skills, clinical clinical
Measures observations (fine/gross motor developmental observations, observations
(posture, trunk skills, imitation of milestones caregiver
support/streng postures, interview
th, cognition, postrotary
ability to follow nystagmus, etc.)
instructions, Track progress
etc.) with worksheets:
 Arousal level
at beginning
and end
 Posture used
on horse
 Balance
(maintaining
center
alignment)
 Changing
positions on
horse
 Oral motor
(Used for
calming/B
awareness,
develop
awareness of
mouth, %
drooling of
session)
 Pelvis (%
Active vs
Passive
movement)
 Trunk/Postur
e (% upright,
slight slouch,
slouch)

Weekly report
sent home to
caregivers


Susie is a 9 Aaron is a 6 year Christopher is a 9 Billy is a 9 year Morgan is a 9
year old girl old boy with year old boy with old boy with year old girl
Mini-Case with autism. autism who was ASD. autism who is with ASD. Her
Study Hippotherapy non-verbal prior His mother non-verbal parents and
has improved to beginning reported carryover and displayed teachers
her trunk hippotherapy. at home after the behaviors such reported
control, After two years, first few visits, with as kicking, improvements
sensory he now talks non- improvements in biting and in behaviors
processing and stop! He has also dressing, grooming, pinching. After and attention
communication improved sensory attention and focus. participating after
skills. She has modulation skills in participating
now plateaued and now hippotherapy, in
after making experiences less his parents hippotherapy.
significant “meltdowns.” and teachers Recently she
progress and report a was unable to
her therapist significant attend
has referred behavior sessions for 6
her to change and weeks and
therapeutic improvements Morgan’s
horseback in attention teacher
riding. and focus. contacted her
mother
regarding her
changes in
behavior in
the classroom.
Her mother
also reported
difficulties
attending to
homework.
Morgan
reported
“Mom, my
head is feeling
funny.”
Therapist Sessions provided Rebecca and
prepares as weekly OT her mother
Additional clients for session through teamed
Information hippotherapy Life Skills together to
sessions in Academy begin HOPE
clinic by Therapy in an
simulating the effort to serve
horse with a those with
saddle placed special needs
on an egg-ball. through their
Therapist love for
reports this has horses.
offered a
smooth
transition.

Analysis Of Hippotherapy Outcome Measures

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