INTRODUCTION

Cerebral palsy (CP) is a well-known neurological disorder that affects 2 to 3 per 1000 live births.1 The body system impairments associated with CP are well-defined in the literature.2 The long-term goal for many children with CP is to become active members of society by achieving their maximum capacity.3 Reaching maximum capacity includes gaining functional independence as well as autonomy in social, educational, and recreational skills. Interventions should focus on all areas of function—body structures and functions, activity, and participation—to positively affect the child’s quality of life.

In 2001, the World Health Organization published the International Classification of Functioning, Disability and Health (ICF).4 The ICF comprises a biopsychosocial model, which is an enablement-based integration of the previous disablement models that have shaped and guided physical therapy clinical reasoning in the past.4 Rather than focusing on functional and societal limitations and disability, the enablement model looks at children’s participation in desired activities, because they relate to important life situations. Rather than a focus on deficits, an enablement perspective stresses what the child can and does do in the environments that are most relevant to the child.

Participation, as defined in the ICF, is involvement in any life situation4 and restrictions in participation are any difficulties an individual would experience in those life situations. A key domain of participation that is important to children with CP is the area of mobility.4 Although the literature is replete with reports of investigations of interventions to improve mobility in children with CP, the evidence in support of measuring the effect of these interventions on broader aspects of participation and from the perspective of the child or family is sparse. Several descriptive studies examined how environmental factors can affect participation.5,6 Morris et al7 demonstrated the effectiveness of family assessment of participation and found that the manual, movement, and intellectual abilities of individuals with CP were predictive of an individual’s physical independence and mobility but not of other domains of participation. Other studies have addressed how children with CP have limited out-of-school contacts with friends and restricted participation in organized social activities.8 This case report, which describes the effect of a course of hippotherapy for a child with mild ataxic CP, provides an example of 1 possible intervention strategy that could be directed toward increasing self-competence and participation in this patient population.

As defined by the American Hippotherapy Association, hippotherapy is part of a program integrated with other therapies and uses the unique movement of the horse to assist in achieving particular functional goals.9 Hippotherapy is thought to improve hip and pelvic flexibility, posture, balance, and mobility.10 The horse’s 3-dimensional movements result in responses of the child’s trunk that are considered similar to those used in gait.11 Hippotherapy and the rhythmical movement of the horse also claim a physiological effect on the rider that may facilitate breathing and digestion, promote muscle relaxation, enhance equilibrium and perception, and improve muscle tone.11

Hippotherapy typically occurs in a barn, arena, or outdoor location, with the child frequently responding positively to this unique experience in a natural setting. Another potential factor in the positive effect of hippotherapy could be the human-horse interaction acting as a powerful motivator to engage the child as a willing participant in therapeutic exercise activities. Bartlett and Palisano12 identified motivation as 1 of 4 key constructs perceived by pediatric physical therapists to affect the achievement of motor skills.

Several relevant studies, including 2 systematic reviews, report on the effectiveness of hippotherapy in children with CP. Researchers have found improvements in posture and motor function following hippotherapy as measured by the Gross Motor Function Measure (GMFM)13,14 and the Pediatric Evaluation of Disability Inventory.14,15 The literature also contains evidence of a positive effect on gait, posture, muscle symmetry, and energy expenditure.13,1517

Although the results of these studies demonstrate positive effects of hippotherapy for children with CP and some document statistically significant improvements in function, they do not fully capture the physical, social, and emotional changes that each individual may have experienced. McGibbons and colleagues13 and Casady and Nichols-Larsen14 discuss the subjective improvements that may result from hippotherapy, including increased willingness and motivation to perform motor activities and improved self-perception and confidence, but did not objectively measure these improvements in their studies. The systematic reviews by Snider and colleagues10 and by Sterba18 highlight the absence of evidence addressing participation as an outcome measure and recommended further research in this area.

Since the publication of those reviews, there have been a limited number of investigations of hippotherapy that focus on participation. Debuse et al19 used qualitative methods to investigate the perspectives of individuals with CP of all ages who participated in hippotherapy in Germany. Their findings explored a variety of factors including the actual movement experience of being on the horse and the perceived physical and psychological effects of the intervention.19 To add to the growing evidence in support of hippotherapy, it is the purpose of this case report to describe this child’s improvement in function as well as participation as measured by perceived self-competence and social acceptance.

 

DESCRIPTION OF THE CASE

The child was a 6-year-old girl referred to physical therapy by her orthopedic physician with a specific recommendation for hippotherapy. She has a diagnosis of mild ataxic CP because of a congenital malformation of the cerebellum. Her functional performance was consistent with level I on the Gross Motor Functional Classification System.20 The child’s mother reported a history of ocular motor apraxia, which had resolved over time. Head thrusts and other atypical movements were not evident during examination or intervention. She had no significant medical or surgical history and was not taking any medications at the time of her initial examination. Although she had prior experience with home-based early intervention including physical, occupational, and speech therapies, she was not receiving additional physical therapy during the hippotherapy program, and she did not have prior experience with this type of intervention. Her medical equipment included bilateral foot orthotics.

The child lived in a 2-story house with her parents and 9-year-old sister. She attended a regular preschool in the morning and a school with a language enhancement program in the afternoon. At the time of her initial visit, the child’s mother reported that her child had poor endurance during family activities such as taking walks or playing games in the pool. Her mother’s reasons for seeking hippotherapy included the desire to have her daughter (1) increase strength as it relates to her ability to participate and keep up with her peers; (2) increase body awareness and balance for running in a straight line; and (3) improving sensory processing, because it relates to putting her hands in contact with sand, dirt, and other textures. Although they were not objectively measured, the initial examination confirmed deficits in skills that use muscle strength, endurance, balance, and awareness of body in space. The child had difficulties negotiating steps without a handrail while using a step-over-step pattern. She was unable to hop on her right foot and only able to hop once on her left foot, and she was unable to generate a 2-foot takeoff and landing when jumping. She had limited walking endurance with difficulty keeping up with her family for distances greater than 1 block. She was able to run for a distance of 50 feet in 5 to 6 seconds but had difficulty running in a straight line. She exhibited a posterior pelvic tilt and used her upper extremities to maintain postural alignment on moveable surfaces (eg, therapy ball or the horse). She was able to balance on each foot for a maximum of 5 seconds with increased postural sway. Specific activity limitations, which affected her ability to perform age-appropriate gross motor functional skills, are noted in Table 1. The child and mother participated in the creation of short-term goals, which are listed in Table 2.

DESCRIPTION OF OUTCOME MEASURES

The child’s change in performance was assessed through a variety of outcome measures. The hippotherapy clinic had established procedures to increase the variety of patient data collection tools to capture information on all aspects of functioning and regularly used several types of measures with the children attending hippotherapy. The therapist used 3 specific measures because of their relevance for this child’s needs. These measures were thought to be helpful in demonstrating progress toward the short-term goals set at the initial examination.

 

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