Introduction:
Horses have been used as treatment tools by physical therapists with the goals of improving a child's balance, strength and coordination. This specialty area is called Hippotherapy which is a multiprofile rehabilitation method that not only helps treat sickness of organ movement, by inhibiting sustained pathological reflexes and facilitating the physiological ones, or correcting muscle tension, but also enhances psychological health by increasing social integration of sick children18. The therapist may place the patient in a variety of positions on the horse such as prone across horse, prone lengthwise with hips abducted and knees flexed, side sitting, or sitting. It is believed that the rhythmic, swinging movement of the horse enhances balance, co-ordination, and motor development. However, Patients who participate in therapeutic riding include children with CP, arthritis, multiple sclerosis, head injury, and stroke2. Unlike many other treatment tools, children find horses exciting and motivating, tapping into their social-emotional needs to connect. Children who typically have difficulty focusing to sit are unable to run away from fine-motor demands while on the horse. At the same time, the vestibular stimulation provided by the horse's movement and proprioceptive stimulation to muscles and joints as the child bounces promotes sensory integration and attention to tasks3. All of these factors contribute to making the hippotherapy farm an ideal setting for teaching children who have cerebral palsy or other developmental disabilities.
Definition:
Hippotherapy is "a term that refers to the use of the multidimensional movement of the horse as a strategy by physical therapists, occupational therapists, and speech-language pathologists to address impairments, functional limitations, and disabilities in patients with neuromusculoskeletal dysfunction. This strategy is used as part of an integrated treatment program to achieve functional outcomes. The term is from the Greek word "hippo," which means horse " 7
History:
While there is evidence that horses have been valued for their therapeutic effects throughout history, their systematic use to benefit human health only started in the 20th century. Germany has the longest tradition, world-wide, of the systematic and specialist profession-led therapeutic use of horses. Hippotherapy has been taught and practiced there by specialist clinicians since the early seventies. It is widely available to children and adults with neuro-motor impairments, but is mainly used to treat children with cerebral palsy. In Autumn 2008, 850 physiotherapists actively practiced hippotherapy (out of some 1500 physiotherapists who qualified to practice since
specialist training began in Germany in the 1970s). By the late 1980s, American and Canadian therapists had developed a national standardized curriculum for hippotherapy. In 1994, the American hippotherapy association (AHA) which was formed in 1992 began registering therapists and setting standards of practice for hippotherapy 7, 13, 4.
Researches:
In a study done by Zurek et al on Dec 2008 to determine the influence of exercise in a mechanical saddle, imitating horse's walk, on the skin temperature responses in lower limbs in children with cerebral palsy. Sixteen children, aged 14-16, were enrolled into
the study. Skin surface temperature was assessed with thermography, using an
infrared thermo vision camera, AGEMA 550, before and directly after 20 +/-5 min of
exercise. The findings demonstrate that mechanical hippotherapy provides an
exercise stimulus that is capable of inducing a visible change in skin
temperature of paralyzed limbs.20
Exemplary thermo graphic recordings. Front view f lower limbs in a child with left-sided spastic palsy. Skin surface temperature distribution: A-before and B-after exercises in mechanical saddle.
Difference in skin temperature at the dorsal foot area in healthy and paralyzed legs before (A) and after (B) mechanical hippo-exercises in children with unilateral spastic palsy.
One qualitative study was done by Debuse et al ( July 2005) on seventeen users aged from 4 to 63, with or without their parents, participated in focus groups or individual interviews in six centers in Britain and in Germany. The main effects of hippotherapy, as identified by users and parents, are normalization of muscle tone, improved trunk control, improved walking ability, carryover effects of hippotherapy to activities of daily living, and increased self-efficacy, confidence, and self-esteem. This study
provided unique and new insights into the context in which hippotherapy happens, as well as its effects on impairment, activity, participation, and quality of life in people with cerebral palsy.3
On other study done by Murphy et al (2008), on 4 children aged 5 to 9 years with physical impairments and/or documented motor delays. Individual measurable objectives were developed using the GAS for each child. Data were collected on each child every other week throughout the baseline and intervention phase over 1 year using a multiple single case experimental A-B design. The researchers reported that children had a significant improvement in functional outcomes based on a standardized T-score formula from the GAS. Two of the 4 children had statistically significant results on the nonparametric binomial test following 6 months of intervention.12
Effect:
Hippotherapy is a multi-dimensional therapy using horse movement that allows therapists to address numerous developmental issues at the same time. A child riding the horse receives constant sensory input including vestibular, proprioceptive, tactile, auditory, olfactory and visual. The vestibular system, which is located in the inner ears and controls balance and equilibrium, is stimulated because the child is on a dynamic surface and the child is facing backward while the horse is moving forward. The therapist enhances this input by having the child change the position of his/her head. Changing positions causes movement in the semicircular canals inside the ears, the part of the body that affects balance. By stimulating this area, the child's ability to process vestibular input can improve. Proprioception is the body's ability to process
heaviness, location and resistance of objects in relation to the body. It affects posture,
movement and the ability to process changes in equilibrium. The body receives proprioceptive input when the nerve endings in the muscles are stimulated, which happens when a part of the body is touched or moved, even by gravity. When a child
rides a horse, the lower extremities receive proprioceptive input from touching the horse. When movement is added, the entire body receives this input. The therapist can also enhance this input by having the child change positions on the horse, having more or less of the body touching the horse. Both vestibular and proprioceptive systems, along with the tactile system, work closely together and are all stimulated when a child is simply trying to maintain balance on the horse.
The touch, sights, sounds and smells of the horse and the barn contribute to stimulating other sensory systems. During therapy, most of these systems are stimulated on a sub cortical level because the child is focusing on the activity, such as throwing a ball, and not consciously processing the sensory input. Because of this, the positive effects of hippotherapy continue after the session ends.
As a result, the person on horseback experiences a rhythmical and harmonious movement through space while sitting in an upright posture and moving with the horse according to his or her abilities. The repetitive, symmetrical and regular movement of the horse allows the individual on horseback to adopt the horse's
movement, practice it, repeat it, make it automatic, and thus to improve his or her own movement patterns. Hippotherapy also causes regulation of muscle tone, development of symmetry, joint mobilization, stretching of tight muscles, improved respiratory function and movement of the face and mouth, stimulation of digestive function and multi-sensory feedback of movement through space. Importantly, hippotherapy is also generally regarded as a highly enjoyable physical activity by users of all ages. It has important psychological benefits such as increased confidence, a sense of achievement, motivation and self-esteem. To a large extent, the enjoyment and sense of achievement clients experience comes from the horse itself. Horses are large, powerful animals; they are social and seek interaction with humans. Everything about them invites particularly children to explore: their warm bodies, their coats, their manes, and their soft noses. Importantly, our clients participate in a "normal" physical activity which takes place in an equestrian centre, not a hospital or clinic. Both children and adults tend to experience hippotherapy not as a therapeutic intervention, but as riding. Also, hippotherapy has a positive effect on respiration, circulation, bowel and bladder control 20, 4, 1, 17, 15, 3,10,5,8,6 .
Indications:
There is considerable research evidence that Hippotherapy is particularly beneficial for people who have neurological disorders that affect their ability to move (neuro-motor impairments). These may be congenital, such as cerebral palsy, or acquired, such as multiple sclerosis, spinal cord injuries, traumatic head injuries, stroke, autism or Parkinson's disease. Also, hippotherapy is indicated for people with abnormal muscle tone or for patients who have difficulties with coordination of arm and/or leg movements, with balance in sitting, standing and/or walking, in controlling their trunk and/or head in an upright position and difficulty or inability to walk. Hippotherapy is also likely to benefit children with Developmental Delay, Dyspraxia, Spina bifida, convulsive disorders, amputation, muscular dystrophy, learning or language disabilities and Down's syndrome 4, 17, 16, 14, 19.
Precautions:
Hippotherapy may or may not be used with following conditions depending on the patients ability. Some of theses conditions include abnormal fatigue, allergies, Arnold chiari malformation and cardiac condition. Other conditions are diabetes, heterotrophic ossification, dysplasia with significant restriction of hip abduction range and any history of breakdown of grafting over bearing areas. Hip dislocation, subluxation, hydrocephalus, incontinence, obesity, osteoporosis and peripheral vascular disease also considered as possible relative contraindications. Also, any child 2-4 yrs of age may can not receive hippotherapy. Recent surgery, recent dorsal rhizotomy, sensory deficits, shunts, spinal fusion, substance abuse and tethered cord may limit applying hippotherapy 9.
10
Contraindications:
Patients with certain conditions can not receive hippotherapy at all. Some of these conditions are orthopedic such as herniated disc, atlanto-axial instability, coax arthrosis (degeneration of the hip joint), excessive kyphosis or lordosis, hemivertebrae and severe osteoporosis. Pathologic fractures (osteogenesis imperfecta), spondylolisthesis, structural scoliosis greater then 30 degrees and an unstable spine should not be use hippotherapy. Other conditions that impede using of hippotherapy are acute arthritis, acute multiple sclerosis and agitation with severe confusion 19,9.
Hippotherapy in the Middle East:
Horse-riding therapy has not been implemented so far in Kuwait, but has been applied recently in the United Arab Emirates, specifically in Dubai. Said the Ministry of Social Affairs and the police of Dubai on the Convention on a partnership for the implementation of the programme, launched by the Ministry on treatment to ride horses to the children with disability. The Convention on treatment to ride horses with the General Administration of Dubai Police, to provide a joint programme was founded by scientific which proved its effectiveness in many developed countries, of Horse special features not available in others, where it can benefit children with cerebral palsy, and persons with mental disabilities, and delays contribution or behavioral disorders of this programme, which is reflected on their abilities and achieve a lot of remedial objectives, such as the force of muscles and improve the status of the body, skills development and mobility, and assist children to the dynamic growth and the development of proper balance. This program has an impact on the psychological aspects and physical and cognitive when the beneficiaries of disability or where this style therapeutic specialists are qualified, trained in particular on the use of horses for therapeutic purposes commensurate and the nature of the problem of disabled children. Participates Dubai police in the implementation of the treatment programme through the provision of horses, which will be the implementation of the Programme on its way, and the provision of the requirements of co-sponsorship and supervision after rehabilitation and training, and the provision of instructors in the area of horse-riding18.
In addition, Association of disabled children in Jedah initiated to apply the hippotherapy which is the first of its kind in Saudi Arabia, through the use of some of the horses trained at one of the stables, the association takes the children with their families once every weekend to complete the treatment.
Egypt was exclusively on presence of treatment unit in the horses and balance and is the only unit in the Middle East can be summed up the idea of a unit hippotherapy as electronic unit similar to the horse real.11
Conclusion:
In, my opinion, hippotherapy has many physical, physiological and psychological benefits documented in people during interactions with animals. In addition, it is help in decreased stress levels, reduced feelings of anger, hostility, tension and anxiety, improved social functioning, and increased feelings of empowerment, trust, patience and self-esteem. Through working with the horse, patients can gain insight into their feelings, behaviors, patterns, congruency, boundaries, and stumbling blocks to recovery. The process can be a very effective adjunct to treatment. So, the time had come to applicant this kind of treatment in Kuwait, Hoping to improve the patient condition and make him an effective member in society.
Referances:
1. Barbara H. Introduction to Hippotherapy. NARHA Strides magazine 1997 Apr. http://www.narha.org/PDFfiles/tr_hippo.pdf. 2010 Apr 3.
2. Clinical Policy Bulletin: Hippotherapy. Aetna 2009 Jul 4. http://www.aetna. com/ cpb/medical/data/100_199/0151.html. 2010 Apr 3.
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4. Dorothee D. hippotherapy. Horse Power for Ability. http://horsepower forability .com/what%20is%20hippotherapy.htm. 2010 Apr 3.
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6. Jan ST. Pediatric physical therapy. Glenside, Pennsylvania: Lippincott Williams & Wilkins; 2008. 680 p.
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8. John A, Brian T, Amy P, Deborah A. Horseback riding in children with cerebral Developmental Medicine & Child Neurology palsy: effect on gross motor function.
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9. Kate V, Mary AW. Hippotherapy: A Therapeutic Treatment Strategy. Gannett Healthcare Group 2009. http://www.todayinpt.com 2010 Apr 3.
10. 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 cerebral palsy: a pilot study. Developmental Medicine & Child Neurology 1998;40(11):754-62.
11. Muhammed A. Hippotherapy. Al-rhama center for intensive physical therapy 2009. http://www.el-rahma.com/ex/index.htm. 2010 Apr 3.
12. Murphy D, Kahn-D'Angelo L, Gleason J. The effect of hippotherapy on functional outcomes for children with disabilities: a pilot study. Pediatric Physical Therapy 2008; 20(3): 264-70.
13. Nicole W. Walking Through the Steps of Hippotherapy. Kids Enabled 2007 Jun 1. http://www.kidsenabled.org/articles/index.php/200706/walking-through-the-steps-of-hippotherapy/. 2010 Apr 3.
14. Renee RT, Gary K, Caitlin S, Sherri B, Susan MC, Monica DC, Melanie G. Volitional Change in Children With Autism: A Single-Case Design Study of the Impact of Hippotherapy on Motivation. Occupational Therapy in Mental Health 2009; 25(2):192 - 200.
15. Unknown. Benefit of hippotherapy and therapeutic horseback riding. Midwest therapeutic riding program. http://www.mtrpinc.org/benefits.html. 2010 Apr 3.
16. Unknown. Healing Horses: Hippotherapy & Health Insurance. Medhealth Insura nce 2008 Oct 28. http://www.medhealthinsurance.com/blog/health-horses-insurance/. 2010 Apr 3.
17. Unknown. Hippotherapy. Adventurous Kids Equestrian Center. http ://www.Ad venturous-kids.com/aquatic_therapy1.htm. 2010 Apr 3.
18. Unknown. Hippotherapy for handicapped children. Dubai police news 2008 feb. http://www.dubaipolice.gov.ae/dp/news/news_show.jsp?Id=857372226&ArticalType=1. 2010 Apr 3.
19. Unknown. Hippotherapy. Three Gaits, Inc 2009. http://www.3gaits.org/hippothe rapy.htm. 2010 Apr 3.
20. Zurek G, Dudek K, Pirogowicz I, Dziuba A, Pokorski M. Influence of mechanical hippotherapy on skin temperature responses in lower limbs in children with cerebral palsy. Journal Physiology and Pharmacology 2008; 59(6): 819-24.
