Efficacy of Therapeutic Horseback Riding in Children with Autism Spectrum Disorder

Dr. Ashleigh Darnell

According to the American Hippotherapy Association, or AHA, the concept of using horses as a therapeutic modality has been around for hundreds of years. As early as 460 B.C., Hippocrates explained the perceived benefits of riding horses as a form of exercise. This first mention of riding as a form of therapy was followed up in 1780 by Tissot in “Medical and Surgical Gymnastics”. He is believed to be the first to make suggestions as to the most beneficial dosage of riding, including speed and desired length of the session (‘American Hippotherapy Association’, 2014). More recently, Danish Olympic dressage rider Liz Hartel is credited for being a public example of the benefits of horseback riding for individuals with disabilities. Hartel won a silver medal in 1952 in dressage after using horseback riding to overcome the impairments she acquired from contracting polio. After such public success, horseback riding gained popularity as a form of therapy in Europe, and eventually spread to North America (‘PATH International’, 2014).

In 1969, a small group of equestrian enthusiasts in North America formed the North American Riding for the Handicapped Association, or NARHA. The purpose of NARHA was to govern the practice of “therapeutic horseback riding”, act as a “clearinghouse of information about therapeutic riding”, and determine best practices(‘PATH International’, 2014). Over the course of a few decades, the organization has grown to over 7,000 current members and over 850 affiliated centers worldwide(‘PATH International’, 2014). In order to keep up with the evolving needs of its members, and to reflect the more global presence of the organization, NARHA changed its name to the Professional Association of Therapeutic Horsemanship, International, or PATH Intl (‘PATH International’, 2014).

From the initial idea to use the horse as a therapeutic modality, several different specific types of therapy have emerged. PATH Intl. classifies these into two main branches, Equine Assisted Activities, often abbreviated to EAA, and Equine Assisted Therapy, or EAT. The two terms are often combined to Equine Assisted Activities and Therapy, or EAAT, as an umbrella term to refer to the field as a whole. EAA includes therapeutic horseback riding, interactive vaulting, developmental vaulting, equine facilitated learning and therapeutic driving. EAT includes Equine Facilitated Psychotherapy and Hippotherapy(‘PATH International’, 2014).

In 1992, the American Hippotherapy Association was formed to standardize the use of horses byphysical therapists, occupational therapists and speech-language pathologists for treating clients with specific neuromuscular impairments. Hippotherapy, the use of the horse’s natural motion to address neuromusculoskeletal impairments, is always provided directly by a licensed therapist (‘American Hippotherapy Association’, 2014). This in in contrast to therapeutic horseback riding, which is provided by an unlicensed professional. However, PATH Intl. provides three different levels of certification for therapeutic horseback riding instructors, in an attempt to standardize the practice and ensure quality (‘PATH International’, 2014). While both hippotherapy and therapeutic horseback riding involve participants riding horses, they have different goals and operate under different treatment principles.

Hippotherapy, in its most basic form, is the utilization of the horse’s unique movement to move the rider’s pelvis in a way that mimics the normal human gait pattern (‘American Hippotherapy Association’, 2014). This rhythmic movement is used to promote trunk stability, strength and endurance, while addressing motor planning and modulation. Therapists may manipulate the horse’s movement, or the patient’s position on the horse, to create the greatest therapeutic impact in order to achieve functional outcomes (Meregillano, 2004), however the rider does not influence the horse (Debuse et al., 2009). Sessions are typically brief and used in conjunction with other treatment strategies (Benjamin, 2000).

Studies have been conducted for decades supporting the use of hippotherapy in a wide range of client populations, including people with intellectual disabilities (Giagazoglou, 2013), older adults (de Araujo), individuals with multiple sclerosis (Bronson et al., 2010; Silkwood-Sherer and Warmbier, 2007; Hammer et al. 2005), children with balance problems (Silkwood-Sherer et al., 2012), individuals with spinal cord injuries (Lechner et al. 2003), and most predominantly, children with cerebral palsy (Bertotti, 1988; McGibbon et al., 1998; Haehl et al., 1999; Casady and Nichols-Larson, 2005; Debuse et al., 2005; Herrero et al., 2012; Sokolov et al., 2002; McGee, 2009; Benda et al., 2003; Zadnikar and Kastrin, 2011; Hamill et al., 2007; Shurtleff and Engsburg, 2010 and 2012).

Outcomes for hippotherapy interventions are typically positive, and it is theorized that the success of the intervention is related to the combined effects of sensory stimulation and motor rehabilitation (Sokolov et al., 2002). So far the evidence shows that hippotherapy may effectively improve motor reaction times and balance (Giagazoglou, 2013), improve trunk stability and ability to reach with upper extremities (Shertleff and Engsburg, 2010), and improve muscle symmetry (McGibbon et al., 1998) in populations with neuromusculoskeletal impairments.

In contrast to hippotherapy, therapeutic horseback riding is more correctly classified as a recreational activity than a therapy (Debuse et al., 2009). All et al. (1999) suggests that therapeutic horseback riding is designed to improve mobility, balance, and posture while developing a therapeutic relationship with the horse. Sessions are typically conducted by a PATH Intl. Certified Instructor, who has sufficient general knowledge of disabilities and horseback riding to deliver safe, progressive riding sessions (‘PATH International’, 2014). There are three levels of instructor certification, with each level requiring more advanced knowledge and skill (‘PATH International’, 2014). Typically, sessions range from 30 minutes to an hour, and focus on learning a skill related to horsemanship. For example, a rider may learn to influence the horse to change gaits by using his or her legs or voice as a cue.

“Because horseback riding rhythmically moves the rider's body in a manner similar to a human gait, riders with physical disabilities often show improvement in flexibility, balance and muscle strength. In addition to the therapeutic benefits, horseback riding also provides recreational opportunities for individuals with disabilities to enjoy the outdoors.” (‘PATH International’, 2014)

Though most evidence is anecdotal, quantitative data is slowly emerging to support the claims. To date, studies have examined the effects of therapeutic horseback riding on various populations, including children with cerebral palsy (Bertoti, 1988; MacKinnon et al., 1995; Dmach et al., 2010; Whalen and Case-Smith, 2012), individuals with multiple sclerosis (Munoz-Lasa et al., 2011), children with scoliosis (Ihara et al. 2012), older adults (Homnick et al., 2013), veterans with spinal cord injuries (Asselin et al., 2012) individuals with schizophrenia (Corring et al., 2013), Freidrich’s ataxia (Gilliland and Knight, 2012), children with dyspraxia (Hession et al., 2014), children with developmental delay (Winchester et al. 2002) and most commonly, children with autism spectrum disorder (Kern et al., 2011;Ward et al., 2013; Gabriels et al., 2012; Holm et al., 2014). Though the sparse evidence suggests that therapeutic horseback riding, and EAAT in general is beneficial in each of these populations, it remains unclear why it is beneficial and how these benefits may be best captured quantitatively.

With the growing prevalence of autism spectrum disorder, and the growing availability of EAAT (‘PATH International’, 2014), it is important to elucidate how EAAT may benefit children with ASD, including which children are most likely to benefit, what results may be expected, and the optimum amount of exposure to EAAT to obtain those results. As the needs and impairments of children with ASD are not purely physical, but psychological, cognitive, and social (Bass et al., 2009), all aspects of EAAT must be investigated in order to determine its value and viability as a therapeutic activity.

Gabrielset. al. conducted a study on 42 children diagnosed with ASD between the ages of 6 and 16, measuring the effect of ten weekly sessions of therapeutic riding. The study measured self-regulation using the Aberrant Behavior Checklist- community, a survey filled out by caregivers that focuses on five areas: Irritability/Agitation, Lethargy/Social Withdrawal, Stereotypic Behavior, Hyperactivity, and Inappropriate Speech. Additional measures included the Vineland Adaptive Scales- Interview Edition and the Bruininks-Oseretsky Test of Motor Proficiency. The study utilized a waitlist control group of 16 subjects for comparison. Participants rode in therapeutic horseback riding sessions for at least 45 minutes per week during the intervention period, and were excluded if they were unable to attend more than two sessions. Compared to the waitlist control group, participants in the intervention group showed significant improvement in ABC-c scores indicating an increase in self-regulation. Caregivers reported improvements in expressive communication and motor skills, though no statistically significant improvement was measured on the secondary outcome measures (Gabriels, et. al., 2012).

A 2011 study by Kern et al. also suggests that therapeutic horseback riding decreases symptoms of ASD in children. Twenty participants were measured using the Childhood Autism Rating Scale, or CARS, after a three month waitlist period, and again after three and six months of weekly therapeutic horseback riding sessions. Participants showed an overall maintenance of CARS levels during the waitlist period, and a reduction of ASD symptoms, as measured by the CARS, after three and six months of therapeutic horseback riding. In addition, a quality of life measure showed improvement during the waitlist period, and throughout the duration of the study, suggesting that enrollment in therapeutic riding sessions may increase quality of life (Kern et al., 2011).

Though the previous studies suggest that EAAT is an effective treatment for symptoms of ASD, Ward et al. (2013) demonstrate that the effects of EAAT may also generalize to other settings, and may continue after treatment withdrawal. The teachers of 21 elementary school age children with ASD reported improved social interaction and improved sensory processing, as well as a decrease in the severity of symptoms of autism, over the course of several weeks of therapeutic horseback riding. Participants ranging in age from Kindergarten to fifth grade were measured using the Gilliam Autism Rating Scale-2(GARS-2)and the Sensory Profile School Companion (SPSC) before beginning six weeks of therapeutic horseback riding sessions. Improvements in both measures were noted at the conclusion of six weeks, and improvements in the GARS-2 measure were maintained during the first six week withdrawal period. When sessions resumed, improvements in both measures were again observed. This suggests that some effects of EAAT may be maintained during periods of no EAAT in children with ASD, but that some effects require ongoing intervention (Ward et al., 2013).

During the course of the study, teachers were asked to fill out an additional measure in order to capture generalized changes in behavior due to the EAAT intervention. In all, teachers and parents of the participants reported changes in behavior including improved “social communication as well as their attention, tolerance, and reactions to sensory input in the classroom” (Ward et al. 2013). This suggests that the effects of EAAT may be generalizable to other areas of participants’ lives, but will require further investigation to confirm.

The need for further investigation is highlighted by a similar study that observed the effects of nine weekly therapeutic riding sessions on children with ASD (Jenkins and Reed, 2013). Jenkins and Reed utilized the Child Behavior Checklist and Teacher Rating Form, as well as direct observation, to quantify the effects of therapeutic horseback riding on seven children between the ages of 6 and 14 in various settings. The participants were observed for specific problem behaviors at home, and while attending an after-school program. This study showed no clinically significant improvement of the intervention or control groups in either setting. However, parents reported via exit survey that their children exhibited an increase in expressive language and that therapeutic riding increased their child’s motivation (Jenkins and Reed, 2013). Though this study is small, it is one of only a handful that does not rely exclusively on parent report for data. The authors conclude that, though their results suggest that therapeutic riding sessions did not address the behavior of the participants, it may be useful for motivating children with ASD to improve behavior (Jenkins and Reed, 2013).

A study by Bass et al. (2009) supports the idea that EAAT may be most effective as a motivational tool for children with ASD. Thirty four children ages 5-10 years old were measured using the Social Responsiveness scale to rate symptoms of ASD, and the Sensory profile to rate social functioning, before beginning twelve weeks of therapeutic horseback riding sessions. Upon post-testing, improvements were observed in both measures. The authors explain:

“The observed increase in social functioning may be the therapeutic horseback riding argues that this experience may have been a very stimulating event that was directly associated either with the physical presence or natural movement of the horse. The act of riding the horse may have been perceived as a rewarding stimulus that accounted for higher levels of motivation and social engagement. Because horseback riding inherently demands a high level of attention and interaction from participants, it may encourage children to break out of sedentary routines that impede their activity level” (Bass et al., 2009).

Though horseback riding is a physical activity, and though physical improvement has been indicated as a result of EAAT in several populations (Winchester et al., 2002), there is little evidence to support the claim that therapeutic horseback riding impacts the physical fitness level of children with ASD. Several measures of motor skills have failed to capture any sort of physical improvement in children with ASD related to therapeutic horseback riding (Gabriels et al., 2012; Bass et al., 2009). However, caregivers often report improvements in strength, coordination and motor proficiency, even when outcome measures have failed to record change (Holm et al., 2014; Scialli, 2002). Caregivers and teachers have also reported improvements in expressive communication and increased motivation to improve behavior after EAAT intervention, though no statistically significant improvement was quantitatively measured(Gabriels, et. al., 2012; Jenkins, 2013).

It is important to note that, though there are stringent safety guidelines and precautions and contraindications set by PATH Intl., best practice is still being established. Most research has been conducted within the traditional 8-12 week semester, with each participant receiving one hour of therapeutic horseback riding per week. Though positive outcomes have been observed within that frame of time, it is worthwhile to examine different doses of EAAT (Kern et al., 2011; Holm et al.; Shurtleff and Engsburg, 2012).

In order to determine benefits of a lengthier period of therapeutic riding sessions, Kern et al. (2011) used several measures, including the CARS, and the TP-CIS over a six month period of weekly sessions. The results demonstrate decreases in symptoms of ASD after three and six months of treatment compared to a three month waitlist control period, as well as improvement in some areas of parent-child interaction (Kern et al. 2011).

Holm et al. (2014) aimed to measure parent perception of the impact of therapeutic riding on the stereotypical behaviors displayed by autistic children. The study is the first to compare different weekly dosages of therapeutic riding. Though the results were positive, and increased with increased sessions per week, the study does not compare therapeutic riding to other interventions or combinations of interventions that may be as, or more, beneficial. In addition, the results of the study are based on the observation of only three participants and not generalizable to a larger population (Holm et al., 2014).

In summary, evidence in the field of EAAT is slowly emerging to quantitatively capture the positive outcomes that have been qualitatively described for centuries. The current evidence shows that EAAT is a promising form of therapy and/or recreation that has the potential to impact many populations of people; especially those populations, like children with ASD, which require intervention in multiple systems. Further investigation is needed utilizing different outcome measures, various doses, and larger populations. Therapeutic horseback riding may prove to be an effective way to decrease symptoms of ASD, improve quality of life, improve self-efficacy and social functioning, provide a physical outlet and, provide motivation for improved behavior in children with ASD.

References

All, A. C., Loving, G. L., & Crane, L. L. (1999). Animals, horseback riding, and implications for rehabilitation therapy. Journal of Rehabilitation, 65(3), 49-57. Retrieved from

American Hippotherapy Association. (2014). Americanhippotherapyassociation.org. Retrieved 9 April 2014, from

Asselin, G., Penning, J., H., Ramanujam, S., Neri, R., & Ward, C. (2012). Therapeutic horse back riding of a spinal cord injured veteran: A case study. Rehabilitation Nursing, 37(6), 270-276. doi:10.1002/rnj.027

Ball, J., E., Ball, C., G., & Kirkpatrick, A., W. (2013). Equine-assisted therapy: Is it safe for our clients? Occupational Therapy Now, 15(3), 9-11. Retrieved from

Bass, M. M., Duchowny, C. A., & Llabre, M. M. (2009). The effect of therapeutic horseback riding on social functioning in children with autism. Journal of Autism & Developmental Disorders, 39(9), 1261-1267. doi:10.1007/s10803-009-0734-3

Benda, WilliamMcgibbon, Nancy H.Grant,Kathryn L. (2003). Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy). Journal of Alternative & Complementary Medicine, 9(6), 817-825. Retrieved from

Benjamin, J. (2010). Introduction to Hippotherapy « American Hippotherapy Association. Americanhippotherapyassociation.org. Retrieved 9 April 2014, from

Bertoti, D. B. (1988). Effect of therapeutic horseback riding on posture in children with cerebral palsy. Physical Therapy, 68(10), 1505-1512. Retrieved from

Bronson, C., Brewerton, K., Ong, J., Palanca, C., & Sullivan, S. J. (2010). Does hippotherapy improve balance in persons with multiple sclerosis: A systematic review Retrieved from

Button, S., Sue. (2010). The effects of therapeutic horseback riding on classroom attention of special education students. Northern Illinois University). , 177 p. (UMI Order AAI3439609.) Retrieved from (2012128017).

Corring, D., Lundberg, E., & Rudnick, A. (2013). Therapeutic horseback riding for ACT patients with schizophrenia. Community Mental Health Journal, 49(1), 121-126. doi:10.1007/s10597-011-9457-y

Debuse, D., Gibb, C., & Chandler, C. (2009). Effects of hippotherapy on people with cerebral palsy from the users' perspective: A qualitative study. Physiotherapy Theory & Practice, 25(3), 174-192. doi:10.1080/09593980902776662