Hippotherapy and Parkinson's Disease
Condition: Quality of Life; Parkinson's Disease
MeSH terms: Parkinson Disease
Study type: Observational [Patient Registry]

Summary: 
      BACKGROUND: Motor symptoms associated with Parkinson's disease may impair one's independence
      and ability to perform daily activities consequently decreases quality of life. Hippotherapy
      has been shown as an effective treatment to improve function in daily activities and quality
      of life in other neurological populations, thus a study was conducted to assess the effects
      of hippotherapy in people with Parkinson's disease.

      METHODS: Nine volunteers formed the treatment group which participated in a ten-week
      hippotherapy program, and nine individuals formed the control group (attended a ten-week
      series of lessons on Parkinson's disease). Outcome measures included 30-second chair stand
      (as a measure of strength-endurance), gait velocity (during 10m walk test) and health-related
      quality of life.
    

Detailed description: 
      Parkinson's disease (PD) is associated with motor symptoms such as bradykinesia, rigidity and
      postural instability 1 which interfere with the patient's independence, and ability to carry
      out activities of daily life 2. In addition, losses in functional may result in a decreased
      health-related quality of life (HRQL) 3. Thus, as PD progresses HRQL gets worse 4.

      Exercise programs are suggested to improve functional capacity and HRQL in people with PD 3.
      However, in the later stages of PD, mobility problems restrict the potential to participate
      in exercise programs, resulting in even greater loss in functional capacity and HRQL.
      Furthermore, a decline in the efficacy of pharmacological treatment and complications due to
      motor fluctuations and medication side effects make the role of complementary treatments such
      as hippotherapy critical to individuals with PD at late stages. Hippotherapy is a therapeutic
      intervention commonly used in populations with mobility deficits, since they do not require
      effort or walking from patients who can no exercise in standing position. When is on the
      horse, the patient exercises as he/she is walking unassisted 5. Neurological conditions are
      improved by horse's movement stimulations. The set formed by the patient and his horse
      performs rhythmic and three-dimensional oscillations which trigger very important
      neuromuscular responses from the rider's postural reflex mechanisms 6. The horse's movements
      are sensed by the participant on the saddle, and when the horse is slowly walking it has been
      argued to be similar to the pelvic movement produced by human gait, thereby strengthening the
      trunk muscles and improving balance 7. The senses are integrated during the act of riding
      performing sensory stimulation 8. Furthermore, hippotherapy has been demonstrated to be an
      effective method to improve functional capacity by increasing gait velocity in people with
      brain disorders 9, functional mobility in elderly 10 and functional strength in people after
      stroke 11 and in people with spinal cord injury 5. In addition, hippotherapy has been shown
      to improve HRQL in children and in adults 6.

      Considering the potential benefits of hippotherapy to anticipatory postural adjustments and
      sensory stimulation 9, 11, it could be hypothesized that hippotherapy may increase functional
      capacity and improve HRQL in individuals with PD. This hypothesis has not been tested yet.
      Therefore, the purpose of this study was to assess the effects of a hippotherapy program on
      functional capacity and on HRQL in people with PD.

      (4) Methods

      Subjects People with confirmed diagnosis of PD by medical report were invited through
      advertisements on radio, on television, public announcements and posters around the hospitals
      to participate in the Physical Activities Program for Persons with Neurodegenerative
      Diseases. Among 81 registered volunteers, 18 participants, six women and twelve men, unable
      to perform usual physical activity because they were in the late stages according to Hoehn
      and Yahr scale (H & Y≥ 3), or because they need to use a wheelchair for severe mobility
      problems were enrolled in the hippotherapy program which formed the sample (n=18). Exclusion
      criteria were uncontrolled hypertension, unstable cardiovascular disease and had practiced
      riding or hippotherapy six months before the intervention period. Among the 18 volunteers
      from the sample, three women and six men were randomized for the intervention group called
      hippotherapy group (HT) (n=9), which performed ten weeks of hippotherapy sessions (2
      familiarization + 8 hippotherapy weeks) twice a week with each session lasting thirty
      minutes. Nine other participants who were waiting to be allocated to the hippotherapy program
      in the following semester attended lectures on PD, twice a week for ten weeks, with each
      session lasting thirty minutes. Demographics and characteristics of the sample can be seen in
      Table 1. This study was approved by the Research Ethics Committee of the University of
      Brasilia on 10/10/2013 by the number CAAE 17329213.7.0000.0030. All participants were
      informed about the procedures and agreed to participate in the study signing the informed
      consent term.

      Instruments Quality of life was measured using the Parkinson's Disease Quality of Life
      Questionnaire (PDQL) Brazilian version 4.

      Functional mobility was evaluated by the Timed Up and Go Test (TUG) according Podsiadlo and
      Richardson 12.

      Strength endurance was measured using the Thirty-second Chair Stand Test (30CST) according
      Gill and McBurney 13.

      Gait velocity was evaluated using the Ten Meter Walk Test (TMW) according Bohannon, Andrews
      and Thomas 14.

      All functional tests had three trials with a 2 minutes interval between each trial, and the
      average of the two last measurements was used for analysis.

      Hippotherapy Procedures Familiarization sessions were initially 15 minutes and gradually
      evolved to 30 minutes in order to allow all participants to adapt to the horse's rhythmic
      movements and to the act of mounting the horse. The sessions were performed at the First
      Regiment of Cavalry Guard of the Brazilian Army. All practitioners used helmet, shirt, pants
      and closed shoes. The team was composed by an auxiliary guide, a physical education teacher
      and two auxiliaries. In order to mount and dismount, all participants used a specific ramp
      for hippotherapy classes. All horses used saddle and riding equipment, the stirrups were
      individually adjusted.

      The sessions began with a 5 minutes warm up that involved stretching and body awareness
      exercises. Then, the training was conducted for 20 minutes with arms and torso exercises,
      changes of direction called serpentine movements; up and down hip movements with feet on
      stirrups, and forced expiration. In the final 5 minutes, exercises for relaxation were
      conducted with the horse which involved moving the hand on the horse's neck, laying forward
      on the head and stroking the horse. The horses walking speed was between 5.8 and 6.4 Km/h.

      In order to assess the effect of the hippotherapy the difference between post and pre-tests
      scores for each dependent measure was calculated (delta (∆)).

      To assess whether data had normal distribution the Shapiro-Wilk test was used, which did not
      indicate a normal distribution for functional capacity variables. Thus, the Mann-Whitney U
      test for independent samples was used in order to compare the changes in functional capacity
      between groups. The Shapiro-Wilk test demonstrated a normal distribution for PDQL variables
      data, and then parametric statistics was performed with a one-way analysis of variance
      (ANOVA). Statistical analysis was performed using the program Statistica 7.0 (StatSoft Inc.,
      Tulsa, Oklahoma, USA), adopting a significance level of p≤0.05.
    

Intervention name(s): Hippotherapy
Intervention type(s): Other
Intervention description(s): The sessions began with a 5 minutes warm up that involved stretching and body awareness exercises. Then, the training was conducted for 20 minutes with arms and torso exercises, changes of direction called serpentine movements; up and down hip movements with feet on stirrups, and forced expiration. In the final 5 minutes, exercises for relaxation were conducted with the horse which involved moving the hand on the horse's neck, laying forward on the head and stroking the horse. The horses walking speed was between 5.8 and 6.4 Km/h.
Other intervention name(s): Equine Therapy
Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        18 volunteers with Parkinson's desease.
      
Keywords: Parkinson's disease; Quality of life; Gait velocity; Capacity