Introduction to Hippotherapy

By Barbara Heine, PT

Reprinted from NARHA Strides magazine, April 1997 (Vol. 3, No. 2)

By its very nature, therapeutic riding influences the whole person and the effect on all the body's systems can be profound. It was, therefore, a natural progression for therapeutic riding in North America to branch into the medical application of the horse -- hippotherapy. Unfortunately, the use of this overall term has led to many misconceptions among therapeutic riding professionals.

Any riding program using horse related activities for clients with physical, mental, cognitive, social or behavioral problems is a therapeutic riding program. But when does therapeutic riding become hippotherapy or classic hippotherapy, and what exactly is developmental riding therapy? The following common questions illustrate the confusion many people have about these areas:

* A physical therapist (PT) volunteers in a consulting capacity once a month. Does this mean your program offers hippotherapy?

* An occupational therapist (OT) with a solid horse background consults for your program once a week and works one-on-one with selected clients to address specific areas of motor planning and sensory integration. The horse for these clients has been selected carefully for its movement and behavioral qualities. You notice that the therapist uses a vaulting surcingle for these sessions and in each session the client assumes different positions on the horse, such as kneeling and quadruped (on all fours). Is this hippotherapy, developmental riding therapy or therapeutic riding?

* A PT who leases your facility and horses to provide hippotherapy for several clients each week. The therapist bills each client differently. The clients sit astride the horse facing forward and backward, and occasionally are placed prone over the barrel. The therapist directs the treatment by advising the horse handler when changes in tempo and direction are required. Is this classic hippotherapy or hippotherapy?

* Your program has recently acquired a trained vaulting horse, and you plan to select several clients who could benefit from this activity. One of your volunteers has had previous vaulting experience and is willing to work closely with your instructor to develop this group activity. Will this be hippotherapy, developmental riding therapy or therapeutic riding in the area of recreation and leisure?

* Your program would like to expand to include hippotherapy because there are several clients that you believe would benefit from a more specific one-on-one approach. A PT in a local sports medicine practice is very keen to become involved and he has ridden recreationally as a child. What additional qualifications would this therapist need to provide direct hippotherapy treatment for these clients?

Questions like these highlight the often subtle differences between these various applications of the horse in a therapeutic setting. In today's litigious society, it is essential that people involved with therapeutic riding are informed not only about the role that a therapist can play, but also the requirements, qualifications and training necessary if that therapist is providing a direct service. It is the aim of this article to clarify these issues.

To begin with, we must define the word hippotherapy, which literally means treatment with the help of a horse. It originates from the Greek word "hippos" meaning horse. More specifically, it is the 3-dimensional movement of the horse's hips and pelvis as the hind legs move forward at the walk, that provides a movement challenge to the client.

Classic Hippotherapy
Classic hippotherapy reflects the German model of hippotherapy practiced widely throughout Europe since the 1960's. Since it is purely the horse's movement and the client's responses that constitute the treatment, classic hippotherapy should only be carried out by a PT, OT, or a speech language pathologist with a certificate of clinical competence (SLP/CCC), who has focused training in the following areas:

* Development of body systems and interaction with the development of movement.

* Effect of neuromuscular, musculoskeletal and cardiopulmonary dysfunction on growth and development, motor development and function.

In classic hippotherapy, it is purely the horse's movement that influences the client. The client may be positioned astride the horse facing forward, backward, prone or supine. The client passively interacts with, and responds to, the horse's movement. The therapist's responsibility is to constantly analyze the client's movement. The therapist must constantly analyze the client's responses and adjust accordingly the manner in which the horse is moving. This assumes that the therapist has sufficient understanding of the movement of the horse to direct the horse handler/instructor to alter the tempo and direction of the horse as indicated by the client's responses.

The primary focus of classic hippotherapy is the rider's posture and movement responses. However, other effects may occur in respiration, cognition and speech production. For example, if the treating therapist is a PT whose goal is to strengthen the trunk muscles and positively affect the client's posture, respiration and speech will improve due to the increased trunk strength. That is the beauty of the horse as a treatment tool -- these "other" changes occur even though you are not focusing on them.

Hippotherapy
Hippotherapy, on the other hand, is a treatment approach that uses the movement of the horse based on the methodology of classic hippotherapy with the addition of the treatment principles that apply to the particular profession of the therapist providing the service. The unique combination of the horse, the horse's movement and a non-clinical environment produces an extraordinary effort on all the systems of the body. Therefore, although hippotherapy is frequently used to achieve physical goals, it also affects psychological, cognitive, social, behavioral and communication outcomes. Hippotherapy is truly a multidisciplinary form of treatment and can be applied by a PT, OT, SLP/CCC, psychologist or psychotherapist.

It is a treatment approach that uses activities on the horse that are meaningful to the client and specifically address the individual's goals. Hippotherapy provides a controlled environment and graded sensory input designed to elicit appropriate adaptive responses from the client. It does not teach specific skills associated with being on a horse -- rather, it provides a foundation of improved neuromotor function and sensory processing that can be generalized to a wide variety of activities outside treatment. In other words, the client's adaptive responses to the environment and the horse's movement ultimately bring about improvements in function.

An example of a meaningful activity in which multiple systems of the body are affected could be the following: A young client may be asked to move from facing forward to facing backward and then to quadruped (on all fours). In this position, he may be asked to reach one hand down to pat the horse. This activity (the transition, the quadruped position and the reaching activity), is overlaid on the constant rhythmical 3-dimensional movement of the horse. Therefore, in addition to the facilitation of automatic postural responses and stimulation of trunk muscles, there are increases in sensory input to the following systems of the body:

* Vestibular -- because the client is facing backward while the horse is moving forward.

* Proprioceptive -- heavy touch pressure through the hip, knee, wrist, elbow and shoulder joints in the quadruped position.

* Tactile -- touching the soft warm coat of the horse.

* Cognitive -- higher level motor planning skills required to execute the transition.

* Motor (physical) -- stability of hips and pelvis required to maintain position while reaching forward with one hand.

This is a meaningful activity for any client who exhibits trunk weakness, poor pelvic control, decreased gross motor skills, poor motor planning and a diminished ability to process sensory information.

Developmental Riding Therapy
Developmental riding therapy is distinguished from either classic hippotherapy or hippotherapy by its broader professional participation, more diverse client population, and equine skills/training specific to the areas of dressage, horse-handling and vaulting.

Jan Spink, M.A. developed this technique in the late 1980's to address a growing need for a more specific philosophy and methodology that focused on a multidisciplinary approach to therapeutic riding. This approach incorporates the treatment techniques and expertise of six health or education professions: PT, OT, speech therapy, rehabilitation or psychomotricity, special education and psychology. Some fundamental and distinctive elements of developmental riding therapy are:
* Individual sessions with active therapist input, a client-centered focus, and graded control of sensory stimuli during mounted and non-mounted activities.

* Use of developmental positions on the horse that directly correlate with specifically controlled movement challenges from the horse.

* Development of interrelationships among the client, therapist and horse.

* Selected components of riding and vaulting skills.

* Use of a horse that has been carefully screened for movement and behavioral qualities.

* Use of therapists or specialists who are thoroughly trained in horsemanship as well as in the philosophy and methods of equine-assisted therapy and the specific features of the system of developmental riding therapy (Spink 1987, 1990).

Developmental riding therapy can serve as an entry point for riders whose skills are not yet well enough developed for therapeutic group riding or vaulting. For the hippotherapy client who has met all long term goals, developmental riding therapy is an ideal transition to another program. The client is able to continue therapy in the motivating and pleasurable environment of the horse, but is provided with greater challenges through the use of specific riding or vaulting skills.

The Therapist's Role in Therapeutic Riding
If you currently run a therapeutic riding program and are considering expanding your services to include hippotherapy, here are some guidelines as to the qualifications, responsibilities and training requirements of therapists wishing to practice hippotherapy. Keep in mind, the use of the horse as a treatment tool does not mean that a therapist is a "hippotherapist" any more than an OT who uses sensory integration principles is a sensory integrationist (or a PT using a pool is a hydrotherapist).

Any therapist providing direct treatment services in a classic hippotherapy/hippotherapy program must meet the following qualifications:

* Is licensed or registered to practice a nationally recognized health care profession.

* Maintains current professional liability insurance.

* Has received training in the principles of classic hippotherapy, equine movement and equine psychology through attendance at a minimum of one American Hippotherapy Association (AHA) approved "Introduction to Classic Hippotherapy" course. The completion of this course is a requirement of any therapist wishing to become registered with AHA.

* Is a NARHA certified instructor (any level) and if not, has a NARHA certified instructor assisting with all treatment sessions.

Legally, a therapist must be in direct attendance to the client at all times during a session. If a therapist, operating within the scope of his professional practices act, conducts a group session, he will be actively engaged in the treatment of the whole group and focusing on each client, as and when appropriate. In such a case, treatment progress notes must be kept on each child in the group.

To practice hippotherapy, the treatment principles of a particular health profession are integrated into the hippotherapy setting. The actual treatment on the horse is only one part of a comprehensive treatment program that begins with an initial evaluation. A crucial part of this initial evaluation is the establishment of a treatment plan that incorporates both long and short term goals. Long term goals must be functional and relevant to each client's family/school/work situation. Therefore consultation with the client's family is necessary.

The treatment plan is developed based on the professional training and constraints of the professional practice act of the health professional providing the service. Choosing the horse whose movement best addresses the client's needs, and appropriate equipment to facilitate the desired responses is an integral part of the treatment plan. Regular documentation is provided through progress notes recorded after each treatment.

Re-evaluation of each client should be carried out at three to six month intervals (or less, depending on the reimbursement source) to ensure that the treatment plan and treatment goals remain appropriate for the client. There will be occasions when re-evaluation confirms whether a client has met the long term goals and in the therapist's professional opinion, hippotherapy can no longer address the needs of that client. In this case, the client should be discharged from hippotherapy. It is the responsibility of the treating therapist to write a discharge summary and to communicate directly with the client and/or client's family to recommend further treatment such as PT, OT or speech therapy, or a transition into another program. In the case of a client meeting all long term goals, an ideal opportunity is presented to transition that client to a therapeutic riding program where the learning of "real" riding (or vaulting) skills can add a new and exciting dimension to their lives. If the client's functional abilities and motivation are high it is quite likely that they can make the transition to able-bodied riding or vaulting classes, or competitive equine sports.

Additional Roles for Therapists
Therapists have much to offer any program and may become involved in roles other than direct client service. These can include:

* Consultation

* Staff and volunteer training in body mechanics, physical and cognitive impairments, basic handling/transfer skills, precautions and contraindications

* Community education

* Liaison with the medical community

* Recruitment of additional health care professionals

* Referral of clients

By helping in this way, a therapist has an opportunity to observe the innumerable qualities of the horse as a treatment tool. This can often be such an enlightening experience that the therapist will be motivated to gain the additional skills and training necessary to provide direct service to some of your clients. Instructors should remember that very few therapists come equipped with horse knowledge and riding skills. You can therefore help each other grow and learn.

The hippotherapy team of horse, client, sidewalkers, therapist and instructor is a wonderful example of a symbiotic relationship. No one part can operate without the other and the greater the harmony that exists between all members of the team, the greater the benefit to the client. After all, the client's safety, progress and happiness are the reasons all of us love what we do and continue to strive to be better at it.

Barbara Heine, PT, is the 1998 President of the American Hippotherapy Association. She is the executive director of the National Center for Equine Facilitated Therapy in Woodside, CA.