What AMA has to say
Horse power: When riding turns into treatment
Hippotherapy has begun to attract attention from the medical community. One physician even owns a program.
By Greg Borzo, AMNews correspondent. June 17, 2002.
Whoever put up the old sign in a corner of the stable probably had no idea how it would apply so poignantly. "Time spent in the saddle is never wasted," it reads. And some say this adage sums up hippotherapy -- including the program run by the physician-owned EquiTherapy Center from the back arena of an elegant stable in suburban Chicago.
But many of the patients with developmental disorders, neuromuscular disabilities or skeletal impairments who receive hippotherapy here don't need to look to the sign for motivation. They're already fired up.
More likely, it's the therapists, volunteers and staff who take the message to heart. They are part of a growing, national effort to show hippotherapy makes a difference, at least for some patients some times.
Despite facing initial and widespread skepticism, hpot supporters are increasingly having success demonstrating its value.
Awareness and acceptance are growing," says Norman White, MD, medical director at Presbyterian Health Plan in Albuquerque, N.M., which recently began reimbursing for HPOT on a case-by-case basis.
"It may appear to have a recreational flavor, but hippotherapy holds immense promise of therapeutic benefit for a variety of conditions, when used in concert with other therapies," says Stephen T. Glass, MD, child neurologist in Woodinville, Wash. He refers patients for hippotherapy so frequently that it's printed on his prescription pad.
Why a horse?
Hippotherapy uses the multidimensional movements of a horse to achieve specific therapeutic functional outcomes. Specially trained physical therapists, occupational therapists and speech-language pathologists use selected horses as mobile therapeutic treatment tools.
A horse's rhythmic, repetitive movements work to improve muscle tone, balance, posture, coordination, strength, flexibility and cognitive skills. The movements also generate responses in the patient that are similar to and essential for walking. In addition, adjusting to and accommodating for the horse's movements increases sensorimotor integration.
Therapists address various therapeutic goals by having patients ride in different positions: sitting or laying forwards, backwards or sideways; standing in the stirrups; and riding without holding. In addition, therapists have patients stretch, reach or play games ~ such as catch ~ while on the horse.
Used widely in Europe for more than 50 years, hpot was introduced in the United States in the 1970s' Today the North American Riding for the Handicapped Assn. has accredited some 790 therapeutic riding centers. About 150 offer HPOT, according to the American Hippotherapy Assn. ~ a section of the riding association formed in 1992. AHA has registered almost 400 therapists to provide HPOT and certified about 35 hippotherapy clinical specialists.
The difference between therapeutic riding and HPOT is important. Therapeutic riding is supervised recreational riding for people with disabilities. HPOT, on the other hand, is a medical therapy provided under a physician's prescription. Patients who are successful with HPOT often progress to therapeutic riding.
In most cases, sessions are weekly and last 30 minutes. Horses must be gentle, patient and trained. The horses are often small to accommodate the most typical HPOT patients: children, even as young as 18 months.
Supporters maintain a horse can provide better results than conventional methods for some outcomes. "In some cases HPOT is the only way I can achieve certain treatment goals," says Joann Benjamin, a physical therapist certified in hippotherapy who is also secretary of AHA.
"We're not talking about pony rides," says Don Vichick, MD, an Albuquerque orthopedic surgeon. "Hippotherapy can be an effective component of a total therapy package."
Able-bodied people don't realize how hard it is on kids with disabilities and their families, says emergency physician Jeff Lee, MD, the owner of EquiTherapy in Morton Grove, IL. "Their disabilities are forever, but hippotherapy can make a difference, medically and functionally."
Motivation plays a big part. Many children with disabilities have spent a lot of time hospitalized, sometimes tethered to machines, says Bethany Lee, executive director of the National Center for Equine Facilitated Therapy in Woodside, Calif., the nation's largest hpot program. "Many of them come to dislike their therapist, at least in a traditional setting."
Put kids on a horse, though, and they light up, says Ellen In, a physical therapist at EquiTherapy. "Sometimes they don't even realize they're working, because just sitting on a horse is comparable to working on a ball. Riding a horse presents constant yet engaging balance and postural challenges."
HPOT gets results because kids love the experience, Lee says. "Some have a picture of their horse on the wall. For countless kids, their first word was not 'mama' but 'giddy up' or the name of their horse!"
Limited but mounting evidence
Still, HPOT faces a certain degree of skepticism, mainly because there continues to be a lack of hard research supporting such heart-warming sentiments. "The lack of evidence-based research is hindering further acceptance," Dr. White says.
AHA calls promoting research one of its main challenges. Still, a growing body of scientific study is building a case.
A 1998 study in Developmental Medicine & Child Neurology investigated the effects of an eight-week course of twice-weekly HPOT on five children with spastic cerebral palsy. After HPOT, all children showed a significant decrease in energy expenditure during walking and a significant increase in scores on walking, running and jumping of the gross motor function measure. In addition, a trend toward increased stride length and decreased cadence was observed.
"The strong results warrant further investigation," says lead author Nancy McGibbon, a therapist at Therapeutic Riding of Tucson, Ariz. "Unfortunately, physical therapists are not, by nature, researchers."
One reason HPOT is hard to study is that scientists have yet to devise ways to measure its impact objectively. The Institute for Human Performance, Rehabilitation and Biomedical Research at the State University of New York's Upstate Medical University has set out to rectify this, combining clinical and applied research spaces. Two case studies using computerized gait analysis have demonstrated that HPOT improves kinematic parameters of gait in children with CP.
"Given the growing interest in hippotherapy, we'll continue to broaden our search for objective results," says Suchita Kulkarni-Lambore, PhD, an assistant professor at SUNY Upstate and a physical therapist who co-authored the studies.
In a yet-to-be published study, Bill Benda, MD, associate research scientist at the University of Arizona in Tucson, investigated the effect of eight minutes of hippotherapy on 15 children with spastic CP. They measured truncal and upper leg muscle activity during sitting, standing and walking using remote surface electromyography. All subjects were randomized to HPOT or sitting astride a stationary barrel.
Muscle activity in microvolts was recorded from electrodes placed on bilateral thoracic, lumbar, abductor and adductor muscles. The difference between each pretest and posttest asymmetry was calculated and converted to a percentage score.
The mean change toward symmetry was 65% after eight minutes of HPOT and no change after eight minutes astride a barrel. "The difference was statistically significant," Dr. Benda says. "The next step is to replicate the study with a larger sample size, followed by a multicenter study of 12 weeks."
Reimbursement issues, questions
Because scientific findings are limited, HPOT reimbursement policies and practices vary considerably. Although AHA does not track third-party payment, it recently launched a survey to determine which payers have HPOT reimbursement policies and what those policies are.
Typical of those who cover HPOT is Harvard Pilgrim Health Care, which pays only when HPOT is part of a supervised physical or occupational therapy program provided by one of the plan's contracted vendors.
On the other hand, Aetna Inc. does not cover HPOT. Its policy: "There is insufficient scientific data in peer-reviewed medical literature to support the effectiveness of hippotherapy for the treatment of patients with CP or other motor dysfunction."
Meanwhile, many payers do not have a policy or pay for therapy without determining the type of treatment. And in rare situations, this ambiguity has led to difficulties. One Maryland therapist was asked to return $56,000 in reimbursement payments because the payer felt the use of HPOT had been concealed. The therapist filed a complaint with the state insurance commission, maintaining that she had coded her work appropriately. This action first led to a ruling in the therapist's favor, which was later reversed on appeal.
Still, many HPOT programs, including EquiTherapy, accept only out-of-pocket payments. Rates range from $70 to $150 per half-hour session.
Even though billing questions persist, there is considerable agreement that when HPOT is provided it should be done under a physician's order. There are many contraindications for HPOT, and only a physician can determine whether HPOT is safe and appropriate for a given patient.
"In many cases, physicians are not aware of hippotherapy until a patient's family brings it to their attention, but a physician should be the one to evaluate the patient and approve the therapy," McGibbon says.
When they first hear about HPOT, many physicians question the safety of putting a person with disabilities on a horse. Nevertheless, HPOT's safety record is outstanding, according to AHA. Often, the therapist rides with a patient the first few sessions. And sidewalkers on each side of the horse ensure the rider's safety.
"We've had plenty of riders fall or get hurt on the able-bodied side of this stable, but none on the therapy side," says Nicholas Coyne, EquiTherapy manager and owner of the center's 12 horses. Coyne carefully selects suitable horses. Some are former police horses that are "unflappable." Thanks to the number of horses, therapists are able to match patients with the most appropriate horse in terms of gait, pace, size and character.
The quality of horses as well as the training and skills of therapists are crucial. Some programs are not reputable and others are not medically qualified, Dr. Vichick warns. "Hippotherapy can be effective, but check out any program before you make a referral."
"If someone invented a pill that achieved the benefits of hippotherapy, you can be sure it would be prescribed and reimbursed," Dr. Benda says.
Conditions most often treated by hippotherapy
* Cerebral palsy
* Multiple sclerosis
* Down syndrome
* Developmental delay
* Traumatic brain injury
* Spinal cord injury
* Convulsive disorders
* Muscular dystrophy
Riders taught him value of HPOT
When Jeff Lee, MD, bought the Morton Grove Equestrian Stables in 1995, he didn't know anything about hippotherapy. Some of his riders did, however, and he soon became intrigued.
Dr. Lee, an emergency physician, joined the North American Riding for the Handicapped Assn., took HPOT courses and worked as a sidewalker for several months. Then, in 1997, he started the EquiTherapy Center, hiring Nicholas Coyne as manager in 1999. Two therapists now work there part-time, but Coyne wants to hire several more.
The program's 12 horses, together with the automobile traffic they generate, kick up a lot of dust - which sometimes triggers efforts by local residents to try to curtail his activities. "They want us to become invisible," he says.
Instead, Dr. Lee plans to expand. This summer, he hopes to begin operating from a large new stable he built expressly for HPOT. It may even include an area for conventional therapy. Meanwhile, he plans to affiliate with a university to train students and conduct HPOT research.
Dr. Lee understands why many physicians are skeptical about HPOT, in part because of its unconventionality and in part because of stories of nefarious activity surrounding horses.