# Exercise as it relates to Disease/Could hippotherapy have beneficial effects on walking ability in children with cerebral palsy?

This is an analysis of “Effect of an equine-movement therapy program on gait, energy expenditure, and motor function in children with spastic Cerebral Palsy: a pilot study” by McGibbon et al, 1998.

## The background to the research

The term “Cerebral Palsy” (CP) encompasses a wide range of movement disorders, ranging from slight weakness in one limb, to a complete inability to move voluntarily. There are currently around 34,000 people living in Australia with CP, with 1 in 3 of these being unable to walk.

### Spastic CP

People with spastic CP commonly experience difficulties with movements and skills, including gross motor skills, fine motor skills and postural control. Spasticity is a type of movement disorder causing hypertonia (increased muscle tone), and is characterized by extremely stiff muscles which become stiffer with rapid movement. This means opposite muscle groups need to work harder and expend more energy when walking, standing or trying to maintain postural or trunk control than in a person without spasticity.

### Hippotherapy

Hippotherapy is a type of treatment carried out on a horse by a specially trained therapist, utilizing “the rhythmic, three-dimensional movement” of a walking horse. This movement is thought to mimic the pelvic movements required for normal walking; consequently improving postural control, balance and walking ability, and generalized gross motor function. Hippotherapy has also proven beneficial in the normal functional gross motor development of young children (aged 2-6yrs) with CP.

## Origin of the research

This study was completed as a study for a Master of Science degree majoring in Physical Therapy at the Samuel Merritt College in California, USA. Data was collected from “Therapeutic Riding of Tucson” in Arizona. Nancy McGibbon has an interest in this field, and has since published several further articles on hippotherapy.

## Type of research

This study is a pilot study, and is an example of quantitative research; whereby the authors used a small sample size, with a repeated-measures approach. Pilot studies are used to assess the feasibility of a novel research idea on a small scale, to identify barriers and modifications before potentially leading to conducting a similar study on a larger scale.

## What did the research involve?

Five children with CP were assessed. All children could walk independently, however four required gait aids. The children took part in hippotherapy twice per week for 30 minutes, with each session comprising exercises focusing on three key components: muscle relaxation, postural alignment/independent sitting, and active exercises for strengthening, stretching and dynamic postural control.
The study measured several variables; the amount of energy expended during walking; stride length, velocity and cadence during gait; and the Gross Motor Function Measure (GMFM) item E – walking, running and jumping.
Parents of the children were required to keep a weekly diary of any noticeable changes in motor function.

### Tests for each measure

| Measure | Assessment | Description of Assessment |
| Energy Expenditure | Energy Expenditure Index (EEI) | A specifically designed measure for children with CP which is based on the child's heart rate during walking. |
| Velocity, Cadence and Stride Length | 10m walk test (self-selected and fast paces) | A 16m track in a straight line was marked out, with the middle 10m being the testing zone. The children first walked the track at a self-selected "comfortable" pace, then at a fast pace. The time taken to complete 10m was noted, and the number of steps taken were counted. From this, the child's average walking speed, step length and cadence were calculated. |
| Gross Motor Function Measure | GMFM item E (walking, running, jumping) | 24 items and activities were assessed on a scale of 0-3, compared to a 5yr old child without a disability. A score of 0 represents "cannot initiate", with 3 representing "completes independently". |

## Basic results
### Energy expenditure

All children demonstrated a statistically significant (P<0.05) decrease in energy expenditure during walking following treatment. Parents also reported in their weekly diaries that the children seemed more willing to walk, and walked further.

### Gait

There were no significant changes noted in stride length, cadence or velocity; two children improved their stride length and decreased their cadence, therefore also improving their velocity, compared to baseline whereas the other three children only improved slightly, and not enough to be statistically significant.

### GMFM (item E)

All children showed statistically significant (P<0.05) increases in their GMFM scores after the intervention. Some children improved their abilities to walk without gait aids, and four of the children showed improvements in their ability to ascend and descend stairs.

## Conclusions drawn from the research

Hippotherapy appears to have the potential to be beneficial in decreasing energy expenditure, improving walking efficiency and gross motor function, thereby increasing motivation and participation in children with CP. Children might be more likely to participate in activities with other children if they find the activity less physically exhausting.
Due to the small sample size of this pilot study, and the inconclusive nature of the results of the gait parameters, there is indication and a need for further research in this area. Should further studies be carried out, with a larger sample size of children be assessed under similar conditions and with a similar treatment protocol, the quality of this evidence would be much stronger.

## Practical advice

* Discuss with your GP, paediatrician or physiotherapist if you have any concerns regarding your child.
* Get in touch with the Riding for the Disabled Association if you wish to find out more about horse riding and hippotherapy in your area.

## Further information/resources

* What is Cerebral Palsy?
* Further information on services available for people with Cerebral Palsy
* Riding for the Disabled Association

## References

* 1 2 3 McGibbon NH, Andrade CK, Widener G, Cintas HL. Effect of an equine‐movement therapy program on gait, energy expenditure, and motor function in children with spastic CP: A pilot study. Dev Med & Child Neur. 1998;40(11):754-62
* 1 2 Alliance CP. Facts about CP 2015 [Available from: https://www.cerebralpalsy.org.au/what-is-cerebral-palsy/facts-about-cerebral-palsy/
* ↑ Alliance CP. Spastic CP 2015 [updated 18/11/2015. Available from: https://www.cerebralpalsy.org.au/what-is-cerebral-palsy/types-of-cerebral-palsy/spastic-cerebral-palsy/
* ↑ Riding for the Disabled Association of Australia Ltd. Hippotherapy 2017 [Available from: https://www.rda.org.au/hippotherapy.aspx
* ↑ RJ Cherng, HF Liao, H.W.C. Leung, AW Hwang. The Effectiveness of Therapeutic Horseback Riding in Children with Spastic CP. Adapted Physical Activity Quarterly. 2004;21:101-19
* ↑ Park ES, Rha DW, Shin JS, Kim S, Jung S. Effects of hippotherapy on gross motor function and functional performance of children with CP. Yonsei med jour. 2014 Nov 1;55(6):1736-42
* 1 2 Casady RL, Nichols-Larsen DS. The effect of hippotherapy on ten children with CP. Ped Phys Ther. 2004 Oct 1;16(3):165-72
* ↑ McGibbon NH, Benda W, Duncan BR, Silkwood-Sherer D. Immediate and long-term effects of hippotherapy on symmetry of adductor muscle activity and functional ability in children with spastic cerebral palsy. Archives of physical medicine and rehabilitation. 2009 Jun 30;90(6):966-74.
* ↑ Benda W, McGibbon NH, Grant KL. Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy). The Journal of Alternative & Complementary Medicine. 2003 Dec 1;9(6):817-25.
* ↑ Leon AC, Davis LL, Kraemer HC. The role and interpretation of pilot studies in clinical research. Journ psych res. 2011 May 31;45(5):626-9