# Exercise as it relates to Disease/The effects of hippotherapy on cerebral palsy
### Cerebral Palsy

Cerebral Palsy encompasses a group of disorders that cause motor impairment. It is caused by injury to the central nervous system due to trauma or disease. This occurs during early development, at any time from when a child is in utero until the age of 24 months. Cerebral palsy may include a combination of the following depending on the type of CNS injury and severity:
* Muscle spasticity – due to poor neuromuscular activation
* Trunk and head instability
* Pathological gait
* Poor joint proprioception
* Joint displacement
* Involuntary movement
* Incontinence
* Mental impairment
* Speech impairment
* Impaired vision and or hearing
* Sleep disorders
* Learning and behavioural disability
The condition has a significant impact on quality of life, causing difficulty performing daily tasks and integrating successfully in society. Individuals with cerebral palsy often display low self-esteem and low self-confidence. They are also more likely to experience depression and/or anxiety disorders.

### Classification

Classifications of Cerebral Palsy are based on the location of the CNS injury and the anatomical location/s affected.
| Classification | Location of CNS Injury | Movement Characteristics |
| Spastic | Motor Cortex | Muscle stiffness and constant flexion of affected joints. Spasticity in the facial muscles and tongue can cause slow and slurred speech |
| Dyskinetic | Basal Ganglia | Involuntary movements such as shaking, grimacing and twisting triggered by an attempt at voluntary movement |
| Ataxic | Cerebellum | Lack of coordination and balance during voluntary movements such as walking. Movements appear clumsy and jerky |
| Mixed | Combination of the above | Combination of the above |
| Classification | Anatomical Location Affected |
| Quadriplegia | Both arms and legs with trunk, face and mouth also commonly affected |
| Diplegia | Both legs and may include arms to a lesser extent |
| Hemiplegia | Ipsilateral (same side) arm and leg |

### Prevalence

Spastic cerebral palsy makes up 70-80% of all cases.Cerebral Palsy affects 34,000 Australians and approximately 17 million people globally. The incidence of cerebral palsy is increasing due to the advancements in neonatal care and greater survival rates of premature and low-birth weight children.

## Hippotherapy
### What is Hippotherapy?

The term hippotherapy, derived from Greek ἵππος (híppos) and θεραπεία (therapeía), literally means "treatment with the horse". With the supervision and advice of qualified equine professionals, occupational therapists and physiotherapists, individuals are placed on the horse in various positions and subjected to the movement of the horse. It is important to note that in most cases the individual is not acting on the horse and actively riding, but allowing the horse’s movement to act upon them.

### Impact on Cerebral Palsy

The multidirectional movement of the pelvis whilst riding a horse, mirrors that of the pelvis during normal walking gait. The forward and back, side to side and rotational aspects of the horse’s motion causes the rider to activate trunk stabilisers. The rider can also be placed in a number of positions during treatment forcing joint movement. Relaxation of the joints and muscles is promoted through the rhythmical movement and warmth of the horse. Physiological benefits include:
* Reduced spasticity
* Increased mobilisation of the pelvis, lumbar spine and hip joint
* Increased head and trunk stability
* Improve adductor symmetry
* Increased range of motion
* Improved gait
* Improved balance
* Improved motor function
* Reduced degree of motor disability
* Enhanced joint stability
It is shown that these improvements have been maintained for extensive periods even after cessation of treatment. There is also evidence showing the carry-over of motor skills learnt through hippotherapy into other tasks. Due to the involvement of the horse in the delivery of hippotherapy, treatment also addresses psychological issues. Participants feel more competent, confident and motivated to participate in hippotherapy as it occurs away from the clinical setting and provides the opportunity to bond with the horse. They are subsequently more confident to move in their everyday life due to the physical improvement in their condition from the therapy.

## Further Information

The Cerebral Palsy Alliance
Riding for the Disabled Australia
The American Hippotherapy Association
Hippotherapy and Cerebral Palsy Study - video

## References

* 1 2 3 Koman, A., Smith, B.P., Shilt J.S. (2004) ‘Cerebral Palsy’, The Lancet, vol.363, pp. 1619-1631
* 1 2 3 4 5 Cerebral Palsy Alliance. (2014) ‘What is Cerebral Palsy?’ https://www.cerebralpalsy.org.au/what-is-cerebral-palsy
* 1 2 3 4 5 6 Debuse, D., Gibb, C., Chandler, C. (2009) ‘Effects of hippotherapy on people with cerebral palsy from the users’ perspective: A qualitative study’, Physiotherapy and Practice’, vol. 25, no. 3, pp. 174-192
* 1 2 3 4 5 6 7 Bertoti, D.B. (1998) "Effect of Therapeutic Horseback Riding on Posture in Children with Cerebral Palsy", Physical Therapy, vol. 68, pp. 1505-1512
* 1 2 Lechner, H.E., Kakebeeke, T.H., Hegeman, D., Baumberger, M. (2007) ‘The Effect of Hippotherapy on Spasticity and Mental Well-Being of Persons with Spinal Cord Injury’, Arch Phys Med Rehabil, vol. 88, pp. 1241-1247
* ↑ Sterba, J.A., Rodger, B.T., France, A.P., Vokes, D.A. (2002) ‘Horseback riding in children with cerebral palsy: effect on gross motor function', Developmental Medicine & Child Neurology, vol. 44, pp. 301–308
* 1 2 3 4 5 McGee, M.C., Reese, N.B. (2009) ‘Immediate Effects of a Hippotherapy Session on Gait Parameters in Children with Spastic Cerebral Palsy’, Pediatric Physical Therapy, vol. 21, no. 2, pp. 212-218
* 1 2 3 4 5 Sterba, J.A. (2007) ‘Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy?’ Developmental Medicine & Child Neurology, vol. 49, pp. 68–73
* 1 2 Surtleff, T.L., Standeven, J.W., Engsberg, J.R. (2009) ‘Changes in Dynamic Trunk/Head Stability and Functional Reach After Hippotherapy’, Arch Phys Med Rehabil, vol. 90, pp. 1185-1195
* 1 2 McGibbon, N.H., Benda, W., Duncan, B.R., Silkwood-Sherer, D. (2009) ‘Immediate and Long-Term Effects of Hippotherapy on Symmetry of Adductor Muscle Activity and Functional Ability in Children With Spastic Cerebral Palsy’, Arch Phys Med Rehabil, vol. 90, pp. 966-974
* 1 2 Drnach, M., O’Brien, P.A., Kreger, A. (2010) ‘The Effects of a 5-Week Therapeutic Horseback Riding Program on Gross Motor Function in a Child with Cerebral Palsy: A Case Study’, The Journal of Alternative and Complementary Medicine Vol. 16, No. 9, pp. 1003–1006