2. Analysis Of Hippotherapy Outcome Measures
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Analysis Of Hippotherapy Outcome Measures - Document Transcript
1. 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
2. Analysis of Hippotherapy Outcome Measures 2 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
3. Analysis of Hippotherapy Outcome Measures 3 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
4. Analysis of Hippotherapy Outcome Measures 4 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
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3. Analysis Of Hippotherapy Outcome Measures
input in order to facilitate a related adaptive
5. Analysis of Hippotherapy Outcome Measures 5 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
6. Analysis of Hippotherapy Outcome Measures 6 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
7. Analysis of Hippotherapy Outcome Measures 7 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
8. Analysis of Hippotherapy Outcome Measures 8 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
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(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.
9. Analysis of Hippotherapy Outcome Measures 9 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
10. Analysis of Hippotherapy Outcome Measures 10 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:
11. Analysis of Hippotherapy Outcome Measures 11 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
12. Analysis of Hippotherapy Outcome Measures 12 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,
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5. Analysis Of Hippotherapy Outcome Measures
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
13. Analysis of Hippotherapy Outcome Measures 13 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
14. Analysis of Hippotherapy Outcome Measures 14 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
15. Analysis of Hippotherapy Outcome Measures 15 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.
16. Analysis of Hippotherapy Outcome Measures 16 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,
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6. Analysis Of Hippotherapy Outcome Measures
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.
17. Analysis of Hippotherapy Outcome Measures 17 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.
18. Analysis of Hippotherapy Outcome Measures 18 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)
19. Analysis of Hippotherapy Outcome Measures 19 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
20. Analysis of Hippotherapy Outcome Measures 20 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
21. Analysis of Hippotherapy Outcome Measures 21 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 One-
Group Pretest-Posttest 2004 Macauley3 Design IV 6 wks 3 0 O1 X O2 Pretest-Posttest Control Group Design
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2004 Stoner4 II 10 wks 6 6 R O1 X O2 O1 O2 One-Group Pretest-Posttest 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
22. Analysis of Hippotherapy Outcome Measures 22 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
23. Analysis of Hippotherapy Outcome Measures 23 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.
24. Analysis of Hippotherapy Outcome Measures 24 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
25. Analysis of Hippotherapy Outcome Measures 25 Appendix E: Meta-analysis of Hippotherapy Sites
26. Analysis of Hippotherapy Outcome Measures 26 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
27. Analysis of Hippotherapy Outcome Measures 27 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
28. Analysis of Hippotherapy Outcome Measures 28 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
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Analysis Of Hippotherapy Outcome Measures - Document Transcript
1. 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
2. Analysis of Hippotherapy Outcome Measures 2 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
3. Analysis of Hippotherapy Outcome Measures 3 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
4. Analysis of Hippotherapy Outcome Measures 4 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
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