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Cerebral Palsy and Therapeutic Riding
Reprinted from NARHA Strides magazine, October 1995 (Vol. 1, No. 1)
Cerebral palsy is a condition caused by damage to the brain, usually
occurring before, during or shortly following birth. "Cerebral" refers
to the brain and "palsy" refers to a disorder of movement or posture.
Cerebral palsy is neither progressive or communicable. It is also not curable,
although education, therapy and applied technology can help people with cerebral
palsy lead productive lives.
The causes of cerebral palsy include illness during pregnancy, premature
delivery or lack of oxygen to the baby. Head injuries can also lead to the less
common acquired cerebral palsy. Between 500,000 and 700,000 Americans have some
degree of cerebral palsy. There are three main types of cerebral palsy:
spastic-stiff and difficult movement, athetoid-involuntary and uncontrolled
movement, and ataxic-disturbed sense of balance and depth perception.
Cerebral palsy is characterized by an inability to fully control motor function.
Depending on which part of the brain has been damaged and the degree of
involvement of the central nervous system, one or more of the following may
occur: spasms; tonal problems; involuntary movement; disturbance in gait and
mobility; seizures; abnormal sensation and perception; impairment of sight,
hearing or speech; and mental retardation.
From Fact Sheet No. 2, National Information Center for Children and Youth
with Disabilities, Washington, DC, 1-800-695-0285.
Medical Considerations for Therapeutic Riding
People with cerebral palsy have difficulty coordinating and producing
purposeful, functional movements. Some people have too much muscle tone, such as
those with spasticity. Their muscles hold their limbs in rather stiff postures
and it is difficult to relax these muscles. Thus, the rider cannot move his
limbs easily except in the direction the spastic muscles pull. Other types of
tone abnormalities include fluctuating tone, as seen in athetoid cerebral palsy
and hypotonia, or too little tone.
Tone is an elusive thing to quantify. Using treatment techniques to temporarily
make tone more normal does not suddenly result in normal, coordinated movement
patterns. In fact, increased tone may be the result of pathologic weaknesses in
other muscle groups coupled with the normal human desire to move. Muscle fibers
are known to change over time, resulting in increasing, age-related difficulty
in maintaining posture. It may be true that abnormal tone, especially spasticity,
is an abnormal response to normal sensation, such as touch and movement
sensation.
Orthopedic problems occur in people with cerebral palsy, perhaps partly because
of the interaction of the abnormal neurologic system with the muscles, joints
and soft tissues. The abnormal, usually asymmetrical pull of spastic muscles
coupled with lack of normal movement and weightbearing can result in progressive
scoliosis and dislocating hips. Other joints, such as wrists, elbows, knees and
ankles, can lose flexibility and range of motion.
Despite these factors, the rhythmic motion, shape, warmth and inherently
motivating quality of the horse can be helpful to people with cerebral palsy
throughout their lives. Therapeutic riding can facilitate cognitive and
sensorimotor development in childhood, help develop a sense of responsibility,
self-confidence and fair play in adolescence and provide life-long recreation
and sport. It can do all this while stimulating the good posture, balance and
flexibility needed for functional independence off the horse.
Riding works best for maintaining range of motion and joint flexibility if a
well-aligned, correct posture on the horse is always a goal. There is no
substitute for a horse with good, symmetric movement. Many riders with cerebral
palsy can achieve normal balance, posture and movement on a horse if the
instructor takes a long, slow approach, focusing on posture and alignment. These
are not "therapy" goals. Good posture, hands-free balance and a
"following seat" are prerequisites to riding with ease and comfort for
the rider and the horse.
Riding sessions for people with cerebral palsy should never result in increased
tone and discomfort. Ask the rider (family member or personal care assistant)
how he feels after the session, when he's at home. Are the muscles relaxed or
tight? If spasticity is worse after the session, decrease the amount of
stimulation. Focus on less impulsion, more stretching and relaxation, more
straight-line work and fewer circles. Use a horse with a wider base and a
smoother walk. Offer an opportunity to sit and rest after dismounting. Try a
saddle with a suede or synthetic cover so the rider's seat and legs will stick
to the saddle better, which will increase his stability and decrease stress.
Recent articles by Ruth DismukeBlakely, SLP/CCC, in AHA News and NARHA
News, indicate that the movement of the horse in hippotherapy sessions can
increase the quantity, quality and volume of vocalization in the rider. For
children with cerebral palsy, the horse is a wonderful motivation for speech,
while the horse's movement can improve the coordination of breathing, swallowing
and sound production. The horse naturally motivates children with cerebral palsy
to move, explore and touch. Using the horse as a large, gentle, rhytiunic and
predictably moving gross-motor platform, where the child is invited and assisted
to explore, can be even more useful than learning to ride. Instructors can
encourage movement and hopefully "disconnect" it from the fear of
failure. The result is self-confidence and courage on and off the horse.
The rider with cerebral palsy benefits from advance preparation in many areas.
Stretching before getting on the horse, as recommended by a physical therapist,
can reduce the warm-up time on the horse. When practicing walk-halt transitions,
the instructor or therapist can use: "Prepare to walk", "Prepare
to halt", "Get ready to whoa." These preparatory phrases allow
the rider to prepare or "set" the posture needed to accomplish the
task.
If the rider has decreased or asymmetric range of motion at the hips and knees,
select the horse that accommodates the problem so the rider can sit easily in
good alignment without being pulled to one side. If the hip is partially
dislocated (subluxed), the type of horse is essential. The lack of range of
motion, spasticity, the horse's natural shape and movement can all potentially
worsen the subluxation. In general, the rider with cerebral palsy who has
orthopedic problems at the hips or spine may benefit greatly from consultation
with a physical therapist who can assist the instructor in creating an
appropriate riding program.
-Liz Baker, PT, NARHA Medical Commitfee Chairman
A Review of Relevant Literature
Information on the use of the horse as a treatment modality for patients with
neurological disorders was first published in a 1870 thesis by Chassaine, who
was studying at the University of Paris. It was not until the 1970s that
articles related to therapy for cerebral palsy using therapeutic riding started
to appear in scientific literature on a regular basis. These early publications
(in German) lacked many of the details that are necessary to evaluate the
effects of treatment or they were general reviews of observed effects
(subjective evaluation). Horster et al (1976) gave a general review of
hippotherapy and riding therapy and their use. The study concluded that the
psychological benefit was important because patients maintained their
motivation. Improvements were noted in coordination, muscle tone and reactions.
A similar report was used to report results of an opinion survey on the
possibilities of improving motor functions of children with cerebral palsy with
the help of therapeutic riding (Feldkamp, 1979). The consensus was that some
difficulties could be helped with therapeutic riding but some key problems, such
as spasticity, would not be helped. Again the psychological benefits
(motivation) were reported.
Satter (1978) reported the general observations of children in Austria who were
treated for five years. Contrary to the opinions expressed in Feldkamp's
article, Satter reported the ability to normalize muscle tone and an improvement
in body control, coordination of movements, rotation and orientation in space.
Equilibrium and righting reactions, symmetry, head and postural control and
spasticity of adductor groups could be helped by the three-dimensional movements
of the horse. He also noted the positive effect on motivation.
The report by Tauffkirchen (1977) is more specific in treatment methods. The
various positions and duration of each treatment (maximum 15-20 minutes) were
given. An improvement in posture, tone, inhibition of pathological movement
patterns, facilitation of normal automatic reactions and promotion of sensimotor
perceptions was achieved. Also, the author commented on the positive motivation
factor.
Bertoti's report (1988) is the most complete report reviewed and is objective.
In this study on posture, 27 children (spastic diplegia or quadraplegia) were
followed in a repeated-measures design: pretest, 10-week period of no riding,
pretest 2, 1 0 weeks of riding and post-test. Thus, each child served as his own
control. They rode twice weekly for one-hour sessions. A specific protocol was
followed for each session and for posture evaluation. The sessions resulted in
decreased spasticity, improved weight shift, improved balance and rotational
skills and improved postural control. In addition to the objective measurements,
other subjective improvements were noted, such as improved self-confidence; less
fear of movement and position change; decreased extensor muscle hypertonus and
hip adductor muscle spasticity; improved movements for sitting, walking and
stance; and improved weight-bearing. The study demonstrated that therapeutic
riding can be a valuable treatment modality for children with cerebral palsy.
This report was supported by Campbell's 1990 report. In contrast, Lacey (1993)
reported no beneficial effect on posture for three and four-year-olds receiving
therapy for six weeks.
In summary, additional studies need to be conducted that will address the
interactions of intensity of the physical therapy, the duration of each therapy
session, the frequency of therapy and the duration of the treatment program.
Currently, it appears that twice weekly sessions of at least 30 minutes for a
minimum of 10 weeks might be the best therapy protocol.
References:
Bertoti, D. 1988. "Effect of Therapeutic Horseback Riding on Posture in
Children with Cerebral Palsy," Joumal Physical Therapy, 8 (10),
1505-1512.
Campbell, S. 1990. "Efficacy of Physical Therapy in Improving Postural
Control in Cerebral Palsy." Pediatric Physical Therapy, 90 (203),
135-140.
Feldkamp, M. 1979. "Motor Goals of Therapeutic Horseback Riding For
Cerebral Palsied Children." Rehabilitation, 18 (2),56-61.
Fetterf, Ph.D., PT, L. "Cerebral Palsy: Contemporary Treatment
Concepts" from Contemporary Management of Motor Control Problems:
Proceedings of the II Step Conference, 1991. Foundation for Physical
Therapy, Alexandria, VA.
Horster, R., Van Horde, H. and Riegner, C. 1976. "Hippo-Therapy and
Therapeutic Horseback Riding in the Treatment of Children and Adolescents with
Cerebral Pareses and Dysmelias," Festschrift Fur Allgemeinmedizier,
52 (1), 15-21.
Lacey, S.K. 1993. "The Effects of Therapeutic Horseback Riding on
Posture." Master Abstracts International, 31 (4), 1777.
Rieger, C. 1978. "Scientific Principles of Hippo- and Riding- Therapy-A
Compilation of Study Results." Rehabilitation, 17 (1),15-19.
Rieger, C., Eltze, J., Ofteringer, K., and Hengst, C. 1974. "Therapeutic
Value of Horseback Riding, Comments on Riding. Therapy in the Treatment of
Cerebral Motor Disorders," Offentl Gesundheirsews, 36 (2), 130-132.
Satter, L. 1977. "Horseback Riding Therapy for Children With Movement
Malfunction Considering Especially Cerebral Palsy Patients," Pediatric
and Padologie, 13, 337-334.
Tauffkirchen, E. 1978. "Hippotherapy-A Supplementary Treatment for Motion
Disturbances Caused by Cerebral Palsy," Pediatric and Padologie, 13
(4), 405-1 I.
-J. Warren Evans, Ph.D., NARHA Research Committee Chairman
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