Joann Benjamin, PT, HPCS
PT Advance – Summer 2000

With an ever-increasing number of people seeking treatment in community, non-clinical settings, it comes as no surprise that hippotherapy is as popular as it is effective. Many patients, parents and doctors are requesting hippotherapy as part of a rehabilitation program. Therapists who integrate hippotherapy have found increasing demand for their services. Across the country, more and more therapists are learning about hippotherapy, and are including it in their practice.

Hippotherapy literally means treatment with the help of a horse, from the Greek word hippos meaning horse. The American Hippotherapy Association (AHA) has defined hippotherapy as “a term that refers to the use of the movement of the horse as a strategy by Physical Therapists, Occupational Therapists, and Speech-Language Pathologists to address impairments, functional limitations, and disabilities in patients with neuromusculoskeletal dysfunction. This strategy is used as part of an integrated treatment program to achieve functional outcomes.”(AHA, 2000)

Current concepts of Hippotherapy have developed from earlier principles, developed in Germany and practiced widely throughout Europe since the 1960’s. This model formed the basis of the first curriculum established for Hippotherapy in the U.S. in 1987.

The movement of the horse is the strategy that a therapist uses to improve a patient’s neuromotor function. The patient may be positioned astride the horse facing forward or backward, sitting sideways, lying prone or supine. The patient interacts with, and actively responds to, the horse’s movement. The therapist’s responsibility is to continuously analyze the patient’s responses and adjust accordingly the manner in which the horse is moving. For this reason the therapist must have sufficient understanding of the movement of the horse to direct the experienced horse handler/therapeutic riding instructor to alter the tempo and direction of the horse as indicated by the patient’s responses.

Often, the primary focus of a PT treatment is the patient’s postural and motor responses. Positive effects from the movement of the horse can be seen in motor coordination, muscle tone, postural alignment, stiffness/flexibility and strength. Other effects on body systems can and do occur as well. Changes are often seen in the respiratory, cognitive, sensory processing, balance, affective, arousal and speech/language production functions. These changes may be a consequence of the postural and motor changes. For instance, the patient’s respiration and speech will improve as a result of improvements in trunk alignment and motor coordination. Many times, however, the system changes are a direct result of the horse’s movement. The focus of PT may not be to achieve changes in speech production, but it can often occur. That is the beauty of using the horse’s movement as a treatment strategy and also why the varied disciplines of PT, OT and Speech can use hippotherapy so successfully as a part of their treatment programs.

The therapist will use activities on the horse that are meaningful to the patient and will specifically address the particular functional goals of that patient. Goals are function oriented, and would not include specific skills associated with being on a horse, such as riding. The movement of the horse provides a foundation of improved neuromotor function and sensory processing that can be generalized to a wide variety of activities outside the treatment setting. In other words, the patient’s adaptive responses to the horse’s movement ultimately bring about improvements in function. Because the environment is a natural one, often the challenges associated with being in a non-clinical setting add additional opportunities to make the hippotherapy portion of treatment beneficial for the patient’s community integration.

Hippotherapy is part of a complete treatment program. It can be used as a preparatory activity such as using the movement of the horse to facilitate increased arousal and postural tone for a patient who is hypotonic, prior to gait training. It can be used to mobilize the spine and pelvis to allow for participation in developmental positions on the floor. Hippotherapy can be used as a primary strategy, leading to improved function off of the horse. Just a few examples might be the achievement of midline orientation, reciprocal weight bearing through the pelvis as is needed for gait or unilateral reaching, or improved sequencing/motor planning when asked to do activities on the horse. The movement of the horse may be used as a follow up to other PT procedures done off of the horse, to reinforce the input from the therapist and improve generalizability of a task. The possibilities of using the strategy are endless, as the input from the movement of the horse is so strong, and provides such a variety of sensory-motor experiences.

The Therapist’s Role in Hippotherapy

There are guidelines as to the qualifications, responsibilities and training requirements of therapists wishing to practice Hippotherapy that have been established by the American Hippotherapy Association and approved by the North American Riding for the Handicapped Association (NARHA). Keep in mind, the use of the horse’s movement as a treatment strategy does not mean that a therapist is a ‘hippotherapist’ any more than a physical therapist using the principles of NDT is a neurodevelopmental therapist, or a PT using a pool is an aquatherapist.

Any therapist providing direct treatment services in a Hippotherapy program should meet the following qualifications:

• Is licensed or registered to practice PT, OT, or SLP
• Has received training in the principles of Hippotherapy, equine movement and equine psychology. One way that this can be achieved is through attendance at an AHA approved 3-4 day course “Introduction to Hippotherapy”.
• Is the equivalent of a NARHA registered instructor (minimum level) and, if not, has a NARHA registered instructor assisting with the horse at all treatment sessions, assuring that the horse is handled effectively, humanely and with utmost safety.
• Maintains current professional and general liability insurance.

Because hippotherapy is part of the integrated treatment plan, the initial evaluation, documentation, discharge criteria, and billing will all follow the structure consistent with the profession of the therapist who is using the movement of the horse as a treatment strategy. Long and short term goals are established which are functional, measurable and relevant to the patient’s needs.

Therapists who have completed an introductory hippotherapy course and have basic hippotherapy experience can become registered with the AHA. Registration is required for a therapist who uses hippotherapy at a NARHA accredited program and indicates a basic level of knowledge of hippotherapy. Once a therapist has achieved extensive clinical experience using hippotherapy as part of their professional practice, they are eligible to take the Hippotherapy Clinical Specialist Examination administered by the Professional Testing Corporation (PTC). A therapist who passes this advanced exam is a Hippotherapy Clinical Specialist (HPCS). There are currently fewer than 50 clinical specialists in the US, though this number is growing.

Additional Roles for Therapists

Therapists have much to offer any therapeutic riding program and may become involved in roles other than in hippotherapy or direct patient 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 regarding benefits of the horse in rehabilitation
• Liaison with the medical community
• Recruitment of additional health care professional
• Referral of patients/clients
• Competitive rider classification at the National and International levels

By helping in this way, a therapist has an opportunity to observe the innumerable qualities of the horse. 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.

Hippotherapy offers the therapist a unique opportunity. The input that the movement of the horse provides to the patient is natural, rhythmical, multi-dimensional, and rich in sensory input. The therapist can use the tool in many ways to create a neuromotor experience unequal to any other tool the therapist has. It is no wonder hippotherapy continues to be requested by therapists, doctors and patients – as a part of a treatment program that will help therapists help their patients achieve their goals.