Hippotherapy & Therapeutic Riding

Hippotherapy and therapeutic horseback riding share many similar characteristics, beginning with the horse, or more specifically, the pelvic movement of the animal which mimics that of a human walking for riders.

The rocking and side to side motion of the horse helps develop strength and coordination and self-confidence in riders with physical and/or psychological impairments – all while having the time of their lives in many cases.

But there are some subtle differences between the therapies.

Hippotherapy can be considered as physical therapy on horseback, according to the American Hippotherapy Association., which defines it as a “physical, occupational or speech therapy treatment that utilizes equine movement.”1

The movement of a horse is used as a treatment strategy for functional limitations and impairments in people with neuromotor and sensory dysfunction. Hippotherapy also has a positive effect on bowel and respiratory function.

Therapeutic horseback riding is considered recreational riding adapted to people with both physical and psychological impairments. Improvement from therapeutic horseback riding is seen in cognitive, physical and emotional well-being. Lessons are led by a professional riding instructor and conducted with help from volunteers.

Patients and their families and physicians can tell you the great improvements hippotherapy and therapeutic horseback riding brings about. As can I. As a volunteer with Freedom Ride, a therapeutic riding facility in Orlando, Fla., I see wondrous things happen every week.

Complementary Therapies

Hippotherapy and therapeutic riding are often used in addition to conventional therapies. The rider is positioned on a horse, often with bareback pads and surcingles, or handles, for stability. The rider can be sitting on the horse in the usual front-facing position, or may be sitting or lying sideways or backwards.

The movement of the horse gently, rhythmically forces the rider to respond physically. In hippotherapy, the rider does not control the horse. The horse handler leads the horse as directed by the instructor/therapist. The therapist has the rider stand in the stirrups, stretch, reach and play games such as tossing a ball into a basket, placing rings over poles and placing objects in buckets.

Using hippotherapy, physical therapists address skill areas of gross motor ability such as sitting, standing and walking. Occupational therapists work on fine motor control, sensory integration, feeding skills, attention skills and functional daily living skills. Speech-language pathologists remediate communication disorders and promote functional communication.

Hippotherapy for children with cerebral palsy have shown improvement in muscle stiffness, bladder and bowel function, sleep, mood, language and self-esteem.

The benefits of therapeutic riding are virtually unlimited. In addition to physical, cognitive, emotional and behavioral improvements, riders with physical impairments show improvement in flexibility, balance and muscle strength.

The rocking and side to side movements of the riders’ body while on horseback gently relaxes taut muscles, increasing range of motion. The movement encourages riders to work harder to maintain balance of their bodies. The motion simulates human walking for people who use a wheelchair full time, while related activities develop hand-eye coordination, sequencing, short-term memory and social skills in people that have difficulty with these skills. Confidence and self-esteem build as patients are able to do more.

Studies Show Improvements

Clinical studies show riders with the following impairments have benefit from therapeutic horseback riding: amputations, autism, Down syndrome, cerebral palsy, spina bifida, spinal cord injuries, traumatic brain injuries, cardiovascular accident/stroke, chemical abuse, developmental delays, muscular dystrophy, speech, hearing and visual impairments, emotional impairments, and learning impairments.2

In a study led by Bill Benda, MD, associate research scientist at the University of Arizona, Tucson, the effect of eight minutes of hippotherapy on 15 children with spastic CP was studied.Truncal and upper leg muscle activity was measured during sitting, standing and walking using remote surface electromyography. Subjects were randomized to hippotherapy or sitting astride a stationary barrel. Muscle activity was recorded from electrodes placed on bilateral thoracic, lumbar abductor and adductor muscles.

The difference between pretest and posttest asymmetry was calculated and converted to a percentage score. The mean change toward symmetry was 65% after eight minutes of hippotherapy and no change after eight minutes astride a barrel. “The difference was statistically significant,” Benda says. “The next step is to replicate the study with a larger sample size, followed by a multicenter study of 12 weeks.” Benda has also indicated that horse-assisted therapy appears to improve balance in people with multiple sclerosis.

A study done at R.O.C.K., Ride On Center for Kids, showed that hippotherapy can increase respiratory capacity and breath support. Speech Language Pathologist and NARHA Registered Therapist Shannon Middleton looked at 12 children receiving speech therapy. Using hippotherapy once a week for 24 weeks and using incentive spirometer measurements, 67% of the participants were able to increase their flow rate while exhaling. There was a 75% increase in the length of time each participant was able to exhale into the spirometer. Respiratory capacity and breath support are needed for speech.4

Throughout Time

The term hippotherapy is derived from “hippos” the Greek Word for horse. In the 5th century A.D., the Greeks used therapeutic riding to rehabilitate wounded soldiers, although the benefits of therapeutic riding are believed to have been first documented around 600 B.C. The first modern, widely accepted study of the value and benefits of therapeutic riding was done in 1875. During World War I, wounded soldiers were treated in England’s Oxford Hospital using therapeutic riding.

In 1946, there were two polio outbreaks in Scandinavia. Horsewoman, Liz Hartel, contracted polio. She walked with crutches, but started riding to improve muscle strength and coordination. She won a silver medal for dressage in the 1952 Olympics in Helsinki. This brought attention to riding as a therapy for people with physical impairments.5

By the 1950’s, British physicians were looking at the possibilities of this therapy with all types of impairments. In 1969 the British Riding for the Disabled Association (RDA) was founded with the support of the Royal Family. In 1960 the community Association of Riding of the Disabled was formed in the U.S. and Canada.

In 1969 the Cheff Center for the Impaired opened in Michigan and is the oldest center of disabled people in the U.S. That same year, the North American Riding for the Impaired Association (NARHA) was begun to act as an advisory board to horseback riding groups for the disabled.

The NARHA, now called The Professional Association of Therapeutic Horsemanship International (PATH Intl.), has established safety guidelines and training, certifies therapy riding instructors, accredits therapeutic riding centers, distributes information and offers inexpensive insurance to member organizations.

Accreditation through PATH Intl. is voluntary, but it shows the center is dedicated to meeting industry standards for quality and safety. Certified instructors are required to have a high level of skills and knowledge about horses, riding and safety.

Hippotherapy, meanwhile, has evolved into a medical field. The American Medical Association’s CPT Code for equestrian/hippotherapy is S8940.5 In addition to hippotherapy, Equine Facilitated Mental Health, Equine Experiential Learning, and more are becoming popular. There are more hippotherapy and therapeutic horseback riding centers opening and thriving across the U.S. Most rely a good deal on trained volunteers, certified instructors and the recommendations of physicians and former riders.

For Safety’s Sake

Many riding centers provide once a week therapy during the warm months of the year. Centers like Freedom Ride in Florida are able to offer therapy year-round. Some centers have indoor facilities and can offer therapy year round, or are located in other warm climates as well, such as Arizona.

Riding centers serve a variety of populations. Some are geared toward children ages 6-15 with orthopedic and neurological problems. Others target patients with developmental challenges, emotional issues, hearing and vision impairments, autism, and more. There are programs tailored for the nation’s military veterans as well.

Of course, there is always a risk of falling off a horse, which makes safety a primary concern for hippotherapy practitioners and therapeutic horseback riding centers.

At Freedom Ride there are three volunteers and an instructor for each lesson. The instructor walks beside or in front of the horse. There is a “horse handler” who leads the horse as directed by the instructor and/or rider. On each side of the rider is a “side walker”. The side walkers will support riders who have trouble controlling legs or torso, and they may be there for emotional support with more independent riders, plus everything in between.

Those riders with extreme fatigue or unable to tolerate heat should not ride in hot, summer conditions. The American Hippotherapy Association suggests using caution with riders with diabetes, obesity, hip joint conditions, mild to moderate osteoporosis, incontinence, recent surgeries or allergies to dust or horses. They also recommend that people with severe osteoporosis, bone fractures, instability of the spine, herniated disk, severe arthritis, heart disease, seizures, sores on weight-bearing surfaces and those using anticoagulants avoid hippotherapy altogether.1

Many hippotherapy programs accept only out-of-pocket payments to avoid insurance issues. Rates can range from $70 to $150 per half-hour session. There is agreement on all sides that hippotherapy should be done under a physician’s order. Some physicians’ first awareness with hippotherapy is when a patient brings up the topic. Some are skeptical or hesitant to put a person with impairments on a horse. They worry about the danger of falling.

Most reputable centers have outstanding safety records. Horses are selected carefully for temperament, gait, and size. At Freedom Ride, most of the horses are on the small side to accommodate the children’s sizes. They are retired from various equestrian pursuits, including jumping, dressage and other competitive disciplines where steadiness and calm are important.

At most centers volunteers are trained to tend to the stable and the horses, and to assist with lessons. They can be seen cleaning stalls, feeding and grooming horses, and general barn maintenance duties. During classes, volunteers are needed as horse handlers and side walkers

Mutually Satisfying

Freedom Ride started in 1988 with two riders, a borrowed horse, a handful of volunteers and rented space at a local barn. In 2001 the organization was given a lease on 10 acres in the City of Orlando adjacent to Trotters Park.

Freedom Ride got its name when a young rider said riding was the one thing that made her feel she had freedom.

Today, Freedom Rides servers over 150 individuals annually and is the only Premier Accredited PATH International facility in Central Florida. We provide therapeutic riding to adults and children four years and older with spina bifida, developmental impairments, autism, Down syndrome, muscular dystrophy, cerebral palsy, learning impairments, brain injury, speech-language disorders, and more.

A program for veterans has been initiated. It operates on donations and riders’ fees, receiving no money from any governmental agency.

When I decided to volunteer at Freedom Ride, it was for several reasons. I am a retired registered nurse, and miss the joy of helping others attain or maintain a healthy, meaningful life. I have always been a fanatic horse lover, so it was an easy decision. Cleaning stalls, grooming and feeding horses was what I expected to do and I actually enjoy them.

I was shocked at the impact the lessons made on me! My first experience was a lesson for a little boy about siks years old, strapped into a wheelchair, unable to speak. The therapist lifted him onto the horse and the other side walker and I supported him. We had to hold him on the horse, and in a sitting position. Volunteers are not typically briefed on the details of a rider’s specific impairment.

As the 15-minute lesson progressed, I could feel the boy working to sit up and maintain his balance, which he didn’t do in his wheelchair. When the lesson ended, his mother asked him how he liked it. He grinned from ear to ear and waved his arms. According to Mom, the boy reacted that way whenever she mentioned Freedom Ride. It was one of the few things he communicated about.

Since then, I’ve been a side walker or horse handler for other lessons and it’s always uplifting. Freedom Ride has seen unresponsive children respond to their horse or to the therapist. There have been children who have clearly shown better balance and improved flexibility of their limbs. A mother I spoke with said that her child had improved lung function after every lesson.

Volunteers have also told me they’ve experienced satisfaction, increased self-esteem and self-worth, as well as increased empathy and understanding of others people with or without physical or psychological impairments while enjoying the benefits of exercise and fresh air, and better health and fitness.

Some volunteers have even said they found mucking out stalls was cathartic, soothing and calming – myself included!

References for this article can be accessed here.

Laurie P. Hiemenz
 has worked as a registered nurse in four states in four very different healthcare settings. She volunteers at Freedom Ride, a therapeutic horseback riding facility in Orlando, Fla.

About The Author