Hippotherapy Explained

California – The Riverside Press-Enterprise carried a story on August 8, 2000 by Mike Schwartz about a therapeutic riding program for physically disabled children:

Saara Duncan stands up in the stirrups as a handler leads her horse, Traveler, in slow circles around the corral of the Kern Therapeutic Riding Centre in Colton.

The bright, bespectacled 3-year-old rises up and down seven times at the prompting of Danelle Kern, the center's resident physical therapist.

Saara's derring-do is hardly what you'd expect from a child born three months premature with breathing problems, a malformed knee and hip, and severely crossed eyes.

"Look at me," the Yucaipa youngster shouts from atop the gentle Appaloosa, obviously having a ball and showing off.

All the while Saara is watched carefully by Kern, two volunteer assistants and Saara Uhl, the child's her grandmother and legal guardian. They stroll along at the front and sides of Traveler to encourage and protect his tiny rider. Everyone is laughing, cheering Saara on. and having a great time.

But this is no frivolous pony ride.

Rather, it is a specialized, unconventional and controversial form of physical therapy called hippotherapy, in which a horse is used as a treatment tool. The term derives from the Greek "hippos," which means horse.

Physical, emotional benefits

Specially trained, licensed physical therapists, occupational therapists and speech language pathologists use the "three-dimensional" motion of a walking horse to stimulate the rider and help enhance balance, posture, mobility, coordination and strength.

Often other benefits occur in the process. Mental functioning, mood and self-confidence may improve.

Logan Dunn, 4, was born with a severe and rare type of delayed development called Angelman Syndrome. Not long ago, the Loma Linda boy couldn't stand upright without a walker or grabbing a table for balance, says his mother DeAnna. After four months of hippotherapy Logan is showing more self-confidence in standing unassisted.

"Previously he held on with both hands. But now he'll let go with one hand to play with a toy," she says.

Tucked deep within rural Reche Canyon, Kern's 7-acre spread is one of a handful of therapeutic riding centers in the Inland Empire, and the only one dedicated to hippotherapy, says Penni Kern, the executive director and Danelle's mom.

According to Danelle Kern, hippotherapy can be used to treat a wide variety of neurological, skeletal, muscular and emotional disorders, including autism, cerebral palsy, multiple sclerosis, Down syndrome, traumatic brain or spinal cord injuries, stroke, attention deficit disorders, learning or language disabilities and visual or hearing impairments.

"Hippotherapy is totally special and unique," says Kern, who is on the physical therapy staff at Loma Linda University Medical Center and Children's Hospital. "No machine has ever been invented to take the place of a horse's muscle groups moving from side to side, forward and back and up and down. These closely mimic the human gait."

By trying to maintain balance in response to a horse's motion, riders tone, stretch and strengthen the same muscle groups they would use in walking, sitting and reaching on their own.

The warmth, smell, sound, sight and feel of a moving horse flood a rider's senses, says occupational therapist Bethany Lee, executive director of the National Center for Equine Facilitated Therapy, a hippotherapy facility in Woodside, north of San Jose.

"All this sensory information assists the body in normalizing itself," Lee says.

No less crucial is the bond between rider and horse. Like other forms of pet therapy, connecting emotionally with an animal seems to increase attention span, memory, concentration and speech in impaired children and adults, says Kern.

"Treatment is much more effective when you're having fun, especially for kids," she says. "You don't get anywhere with them unless they're having a good time."

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Little acceptance, reimbursement

Nevertheless, relatively few physicians know much about hippotherapy, and many agencies that coordinate rehabilitative services for disabled children and adults don't endorse it.

Critics dismiss it as an alternative treatment backed by little scientific proof that it works.

"There's not enough well-researched evidence that hippotherapy will make a difference versus more established forms of physical therapy," says Dr. Eliana Lois, chief of medical services for the Inland Regional Center in San Bernardino, one of 21 private agencies under the California Department of Developmental Services that provide disabled persons with services fostering an independent lifestyle.

"You can do it as effectively without a horse . . . although it wouldn't be as much fun. I love horses," Lois says. "But I probably wouldn't refer."

Unlike the Inland Regional Center, the San Gabriel/Pomona Regional Center in Los Angeles approves some hippotherapy programs.

"It's up to the discretion of individual regional centers," says center spokeswoman Carmen Roman. "We even (approve) music and swimming therapy and summer camps offering services that aren't really mainstream as long as they fall within state law."

The San Gabriel/Pomona Regional Center tries to consider the needs and desires of clients and their families, says Letha Sellars, the director of children and family services. "Some children are very physically challenged and can't participate in a lot of stuff available to other kids. Hippotherapy for them may be a socialization experience. And families enjoy doing it with them."

Regional centers also consider whether clients have access to other well-proven therapy options, explains Deborah Millot, Inland's assistant chief of community services.

"Some communities may be rich in resources others don't have. We try to help consumers and families pick the option we think works best and that will enhance the quality of their lives."

In regions like the Inland Empire, where insurance and state agency support for hippotherapy is spotty, clients or family caregivers often must pay cash. Therapy sessions at Kern, which last up to one hour, cost $50-$120. Typically clients come once or twice a week for therapy that may last indefinitely, given their chronic problems.

The Denver-based North American Riding for the Handicapped Association, whose 1,200 members offer a variety of recreational and therapeutic riding programs, is confident hippotherapy will become widely accepted -- like acupuncture, chiropractic and other therapies once outside the mainstream.

"This is already happening," says Michael Kaufmann, the association's education and communications director. "Fifteen years ago when you talked about putting disabled patients on horses, most people said it was dangerous. Today health professionals and the general public are much more familiar with how therapeutic riding helps."

Gus LaZear, a program specialist at the Casa Colina Centers for Rehabilitation in Pomona, has referred several patients for hippotherapy.

"I've heard good stories about it," says LaZear, who takes disabled people on outdoor adventure treks. "Being around horses in general, touching them and combing them, is great therapy." Kaufmann acknowledges that better studies are needed. "The problem is that variables, such as different kinds of horses and instructors, complicate setting up a meaningful research design," he says.

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Recognition slowly growing

"I'm confident that the quality of hippotherapy being done and continuing research will show it's a successful form of treatment," says Barbara Heine, president of the American Hippotherapy Association based at the national center in Woodside.

Perhaps the best evidence hippotherapy works was reported early last year by Dr. Daniel Bluestone, then a pediatric neurologist at UC San Francisco, who had been following the progress of children receiving the treatment.

Comparing MRI scans over time, Bluestone found that the repetitive movement of riding prompts physical changes in the brain.

"We think that hippotherapy is effective in helping rework networks within the cerebellum and within the motor system up in the cerebrum," he said in a Discovery Channel documentary. "The pathways within the brain that facilitate a particular movement become reinforced over time.

"The more pathways you reinforce, the better the brain compensates and the better motor function can improve."

Bluestone, who now practices in Fresno, said children do especially well in hippotherapy because the child's brain is constantly developing and changing. The "sensory inputs" children receive during therapy allow them to remodel their neural networks.

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Deep historical roots

The therapeutic value of the horse was recognized by the Greeks as early as 460 B.C. Studies continued in 19th-century France and in the mid-1940s in Scandinavia. So-called classic hippotherapy evolved mainly in Germany during the 1960s before coming to the United States and Canada.

The classic technique can be performed by a licensed physical, occupational or speech therapist who first evaluates a patient, sets goals and selects exercises meeting specific needs, says Lee of the national equine therapy center.

For example, positioning a patient astride the horse facing sideways or backward helps improve balance and pelvis alignment. A prone position extends the trunk and neck, while lying supine stretches chest muscles and elicits a need to pull up into a sitting position, she says.

The therapist monitors responses and instructs a handler to change the horse's direction and tempo accordingly. The health professional keeps careful progress notes and reports regularly to the referring physician "just like in any therapy clinic," Lee says.

Bouncing along on Taco, an Arab gelding, Logan Dunn waves his arms, twists his torso, flashes a cherubic smile and makes happy sounds although he cannot speak. His mother, DeAnna, and father, Rob, tag alongside.

"At the very least he's having an adventure," DeAnna says. "He loves horseback riding. His attitude is, 'Let's go. Let's go."'

Classic approach broadened

The Kern Therapeutic Riding Centre blends classic therapeutic principles with a modern, multidisciplinary form of hippotherapy. Sessions are embellished with imaginative exercises suggested by licensed therapists, physicians, clinical psychologists and students who volunteer at the ranch.

"What's this, Saara?" asks Danelle Kern, holding up a flash card.

"A boat," the child replies.

As Traveler strolls along, Saara, at one point lies flat on her back, and at another point while sitting up, assembles a jigsaw puzzle and strings beads of various shapes on a cord.

While most patients are children, adults also utilize hippotherapy.

John Kimber, 55, of Highland laughs as he leans forward on Dolly to wrap a curler in the quarter horse's mane.

Kimber, a retired attorney and teacher, had a stroke in 1996 that left him with poor balance and a weak, numb left side. A month of exercises on horseback has improved his balance and dexterity, he says.

"I know I'm making progress and doing great," Kimber says. He chuckles and adds, "I feel a little tired right now. Yeah, it's work. They work me here. But I enjoy it."

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Safety measures

Each steed is guided by an experienced handler, with "sidewalkers" ready to steady riders who lose their balance or to assist in exercises and games.

Instead of a saddle, a hippotherapy horse wears a blanket and a surcingle -- a fleece or foam pad with gripping handles strapped around the belly. Part of the healing process is the warmth radiating from the horse's back, Danelle Kern explains.

"I don't know how you can ever simulate that with a machine," she says.

Safety equipment includes equestrian helmets, Devonshire stirrups that are closed in front to properly position feet and prevent them from sliding through, and quick-release "peacock" stirrups that unhook if a rider falls.

The program isn't for everyone, Kern says. She may exclude people who weigh more than 300 pounds or more than 20 percent of a horse's weight; quadriplegics lacking control over trunk muscles; brittle-boned osteoporosis patients and Down's syndrome cases with atlantoaxial instability (poor alignment of their first two neck bones due to loose ligaments).

Other reasons for excluding riders include acute herniated disks, degenerated hip joints, curvature of the spine greater than 30 degrees, acute arthritis and heart trouble requiring anticoagulant medication, says Lee of the National Center.

Although clients usually don't learn to ride on their own, the National Center teaches vaulting, or horseback gymnastics, to those who've met all hippotherapy goals.

"They still have handlers and sidewalkers," Lee says. "But when children flourish and get more mobile, they need something more challenging to do."