Effectiveness of Mechanical Horse-Riding Simulators on Postural Balance in Neurological Rehabilitation: Systematic Review and Meta-Analysis

Effects of Hippotherapy and Horse-Riding Simulators on Gross Motor Function in Children with Cerebral Palsy: A Systematic Review

Background/Objectives: Cerebral palsy (CP) can have a negative impact on gross motor function. Conventional hippotherapy and horse-riding simulators (HRS) have shown promising results on gross motor function in populations with neurological disorders. This review aims to update the knowledge on the effectiveness of hippotherapy on gross motor function in children with CP. Methods: A search was conducted in Academic Search Ultimate, CINAHL, Medline complete, and PEDro covering publications between 2012 and 2022. Two authors identified studies that met the inclusion criteria; a third author resolved discrepancies. Studies were included if they analyzed the effects of hippotherapy on the gross motor function of children with CP. The quality of the methodology was assessed according to the PEDro scale. Results: Of the 150 studies initially identified, 9 were included in this review. The studies showed fair (N = 3) and good (N = 6) methodological quality on the PEDro scale. The majority used conventional hippotherapy (N = 7), while a minority used HRS (N = 2). The most commonly used protocol for conventional hippotherapy was 1-2 sessions of 30-45 min per week for 8 weeks (N = 4), whereas for HRS, these protocols were varied. Seven studies on conventional hippotherapy and one study on HRS showed improvements in gross motor function. However, the hippotherapy protocols were not very standardized and the samples were neither homogeneous nor representative. Conclusions: Conventional hippotherapy and HRS appear to have evidence to support their benefits on gross motor function in children with CP. However, more clinical trials with standardized protocols and more representative samples are needed to confirm these effects.

Efficacy of hippotherapy simulator exercise program in patients with stroke: a randomized single-blind clinical trial

OBJECTIVES

The aim of this study was to investigate the effect of hippotherapy simulator on balance, postural control, mobility, functional capacity and independence level in people with stroke.

METHODS

This study involved 26 people with stroke aged 18-65, who were randomly assigned to a Hippotherapy Simulator Group (HSG; n = 13) and a Conventional Exercise Group (CEG; n = 13). Patients underwent assessments using the Berg Balance Scale (BBS), Postural Assessment Scale for Stroke (PAS-S), Timed Up and Go Test (TUG), Rivermead Mobility Index (RMI), 2-Minute Walking Test (2-MWT), and Barthel Daily Living Activity Index (BI) to evaluate balance, postural control, mobility, functional capacity, and independence before and after treatment. In the HSG, participants received 30 sessions of conventional exercises and hippotherapy simulator - a mechanical and robotic equipment with a dynamic saddle simulating horse movement - exercises over 6 weeks. Meanwhile, the CEG underwent 30 sessions of conventional exercises alone for 6 weeks.

RESULTS

In the post-therapy evaluation between groups, BBS (p = 0.004) and 2-MWT (p < 0.001) scores were higher in HSG compared to CEG. However, no statistically significant difference was found between the two groups in terms of PAS-S, RMI, TUG and BI scores (p > 0.05). Statistically significant differences were found between BBS, PAS-S, RMI, TUG, BI and 2-MWT scores before and after treatment in both groups (p < 0.05).

CONCLUSIONS

Hippotherapy simulator can be added to conventional exercises to improve balance and functional capacity in people with stroke.

The effects of mechanical hippotherapy riding on postural control, balance, and quality of life (QoL) in patients with stroke

PURPOSED

This study aimed to investigate the effects of exercises by mechanical hippotherapy devices on postural control, balance, mobility, and Quality of Life in patients with stroke.

MATERIAL AND METHODS

This was a randomized controlled clinical trial with a total of 30 which were randomly divided into two groups. The participants in the mechanical hippotherapy group (MHG) (n = 15) were given exercises with a mechanical hippotherapy device for 15 min in addition to intensive conventional treatments (45 min), while the control group (CG) (n = 15) received additional 15 min of postural control and balance exercises for five days per week for four consecutive weeks. The primary outcome was The Berg Balance Scale (BBS). Secondary outcomes were the Fugl-Meyer (FM) Rating Scale, Biodex Balance Measurement (BBM), Trunk Impairment Scale (TIS), the Timed Up and Go Test (TUG) and quality of Life Short Form (SF-36).

RESULTS

In the MHG, FM-Lower extremity score (-6.4, p = 0.024), FM-Upper extremity score (-12.87, p = 0.013), TIS (-5.87, p = 0.04) and TUG (5.73, p = 0.027) improved statistically significant compared to CG.

CONCLUSION

Exercises using mechanical hippotherapy devices could improve postural control, functional mobility and balance in patients with stroke. It may also improve the quality of life.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03528993IMPLICATIONS FOR REHABILITATIONNCT03528993It was concluded from our results that mechanical hippotherapy could be included in the treatment programs of stroke patients.

[Hippotherapy versus hippotherapy simulators as a treatment option in children with cerebral palsy: A systematic review]

INTRODUCTION AND OBJECTIVE

Hippotherapy (HPOT) and hippotherapy simulators (SHPOT) are used in children with cerebral palsy to achieve their maximum functionality and independence. The aim is to find out if HPOT and SHPOT produce the same effects on balance, gross motor function, and postural control in children under 18 years old with cerebral palsy.

MATERIALS AND METHODS

The keywords used were: hippotherapy, equine-assisted therapy and cerebral palsy. The databases used were PeDro, Scopus, LILACS, ScienceDirect, Cochrane Library, Web of Science and CINAHL Complete (Ebsco). Studies were included if they were randomized clinical trials that studied the effect of HPOT and/or SHPOT on the variables mentioned in these patients.

RESULTS

Four studies assessed balance, 4 studied gross motor function, and 2 investigated postural control. Both HPOT and SHPOT produced benefits in all of them.

CONCLUSIONS

According to the studied variables both interventions produce similar improvements. Although, they increase with HPOT possibly due to greater sensory stimulation.

Trunk postural reactions to the force perturbation intensity and frequency during sitting astride in children with cerebral palsy

The purpose of this study was to examine kinematic and neuromuscular responses of the head and body to pelvis perturbations with different intensities and frequencies during sitting astride in children with CP. Sixteen children with spastic CP (mean age 7.4 ± 2.4 years old) were recruited in this study. A custom designed cable-driven robotic horse was used to apply controlled force perturbations to the pelvis during sitting astride. Each participant was tested in four force intensity conditions (i.e., 10%, 15%, 20%, and 25% of body weight (BW), frequency = 1 Hz), and six force frequency conditions (i.e., 0.5 Hz, 1 Hz, 1.5 Hz, 2 Hz, 2.5 Hz, and 3 Hz, intensity = 20% of BW). Each testing session lasted for one minute with a one-minute rest break inserted between two sessions. Kinematic data of the head, trunk, and legs were recorded using wearable sensors, and EMG signals of neck, trunk, and leg muscles were recorded. Children with CP showed direction-specific trunk and neck muscle activity in response to the pelvis perturbations during sitting astride. Greater EMG activities of trunk and neck muscles were observed for the greater intensities of force perturbations (P < .05). Participants also showed enhanced activation of antagonistic muscles rather than direction-specific trunk and neck muscle activities for the conditions of higher frequency perturbations (P < .05). Children with CP may modulate trunk and neck muscle activities in response to greater changes in intensity of pelvis perturbation during sitting astride. Perturbations with too high frequency may be less effective in inducing direction-specific trunk and neck muscle activities.

Translation, Adaptation, and Determining the Intra-Rater Reliability of the Balance Evaluation Systems Test (BESTest) for Persian Patients with Chronic Stroke

This study aimed to translate and culturally adapt the BESTest to the Persian language and evaluate its intra-rater reliability in Iranian patients with stroke. A forward-backward translation and expert panel review method was followed. Eighteen patients post-stroke (15 men, 3 female) were included which were assessed by a physiotherapist two times with a one-week interval. The mean total score for the test and retest were 83.66 (SD = 11.98) and 82 (SD = 13.23), respectively. There were no floor and ceiling effects. The intra-rater ICC for the total score was 0.88 (95% CI = 0.73-0.95). The ICC for the BESTest sections ranged from 0.55 (95% CI = 0.12-0.80) to 0.89 (95% CI = 0.55-0.96). The standard error of measurement and the smallest detectable change of the BESTest total score were 8.33 and 22.82, respectively. Our findings confirm the intra-rater reliability of the Persian BESTest for balance assessment of patients with chronic stroke.

Rehabilitation of Gait and Balance in Cerebral Palsy: A Scoping Review on the Use of Robotics with Biomechanical Implications

Cerebral palsy (CP) is a congenital and permanent neurological disorder due to non-progressive brain damage that affects gross motor functions, such as balance, trunk control and gait. CP gross motor impairments yield more challenging right foot placement during gait phases, as well as the correct direction of the whole-body center of mass with a stability reduction and an increase in falling and tripping. For these reasons, robotic devices, thanks to their biomechanical features, can adapt easily to CP children, allowing better motor recovery and enjoyment. In fact, physiotherapists should consider each pathological gait feature to provide the patient with the best possible rehabilitation strategy and reduce extra energy efforts and the risk of falling in children affected by CP.

Efficacy of Robot-Assisted Gait Therapy Compared to Conventional Therapy or Treadmill Training in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis

BACKGROUND

Motor, gait and balance disorders reduce functional capabilities for activities of daily living in children with cerebral palsy (CP). Robot-assisted gait therapy (RAGT) is being used to complement conventional therapy (CT) or treadmill therapy (TT) in CP rehabilitation. The aim of this systematic review is to assess the effect of RAGT on gait, balance and functional independence in CP children, in comparison to CT or TT.

METHODS

We have conducted a systematic review with meta-analysis. A search in PubMed Medline, Web of Science, Scopus, CINAHL, PEDro and SciELO has been conducted for articles published until October 2022. Controlled clinical trials (CCT), in which RAGT was compared to TT or CT and assessed gait speed, step and stride length, width step, walking distance, cadence, standing ability, walking, running and jumping ability, gross motor function and functional independence in children with CP, have been included. Methodological quality was assessed with the PEDro scale and the pooled effect was calculated with Cohen's Standardized Mean Difference (SMD) and its 95% Confidence Interval (95% CI).

RESULTS

A total of 15 CCTs have been included, providing data from 413 participants, with an averaged methodological quality of 5.73 ± 1.1 points in PEDro. The main findings of this review are that RAGT shows better results than CT in the post-intervention assessment for gait speed (SMD 0.56; 95% CI 0.03 to 1.1), walking distance (SMD 2; 95% CI 0.36 to 3.65) and walking, running and jumping ability (SMD 0.63; 95% CI 0.12 to 1.14).

CONCLUSIONS

This study shows that the effect of RAGT is superior to CT on gait speed, walking distance and walking, running and jumping ability in post-intervention, although no differences were found between RAGT and TT or CT for the remaining variables.

Effectiveness of Mechanical Horse-Riding Simulator-Based Interventions in Patients with Cerebral Palsy-A Systematic Review and Meta-Analysis

BACKGROUND

Mechanical horse-riding simulator (HRS) exercises are a type of therapy based on the use of robotic or mechanical devices that produces movement similar to a real horse with the aim of simulating hippotherapy. This review analyses the effectiveness of HRS therapies in patients with cerebral palsy (CP).

METHODS

A systematic review and a meta-analysis were carried out by searching studies in PubMed Medline, SCOPUS, Web of Science, CINAHL, PEDro and SciELO up until October 2022. We selected clinical trials that assessed the effectiveness of HRS therapy, compared to other interventions, in patients with CP. The main variables were gross motor function (its global score and dimensions, such as sitting ability), functional balance, spasticity, hip range of motion (ROM), posturographic balance and satisfaction. The risk of bias was assessed using the Cochrane Risk of Bias Tool. The pooled effect was calculated using Cohen's Standardized Mean Difference (SMD) for a 95% confidence interval (95% CI).

RESULTS

Twelve studies were included in the systematic review, and 10 were included in the meta-analysis, providing data from 343 patients with spastic diplegic CP. Our findings revealed that HRS plus physiotherapy is more effective than physiotherapy in improving the total gross motor function (SMD 0.98; 95% CI 0.35-1.62), sitting ability of the gross motor function (SMD 0.84; 95% CI 0.32-1.36) and functional balance (SMD 0.6; 95% CI 0.1-1.08), and HRS therapy is better than sham to improve pelvic abduction ROM (SMD 0.79; 95% CI 0.21-1.37).

CONCLUSIONS

Horse-riding simulator-based therapy is an effective therapy to improve gross motor function, functional balance and abduction pelvic ROM in children with CP, in comparison to physiotherapy or sham.

Effects of hippotherapy simulation exercise vs. conventional home exercises on muscle strength and balance in people with multiple sclerosis: A randomized controlled trial

OBJECTIVE

To determine the efficacy of hippotherapy simulation exercise on the improvement of muscle strength, balance, spasticity, and quality of life in individuals with multiple sclerosis (MS).

DESIGN

Randomized controlled trial.

SETTING

Outpatient clinic at the rehabilitation clinic of University of Usak, Turkey PARTICIPANTS: Individuals with MS (n = 40) participated in this randomized clinical study.

INTERVENTIONS

Patients in both groups received 36 treatment sessions, 3 times per week for 12 consecutive weeks. Subjects in the study group performed hippotherapy simulation exercise via a hippotherapy simulator device. The control group received conventional home exercises.

MAIN OUTCOME MEASURES

The primary outcome measures included the Monitoring My Multiple Sclerosis (MMMS) Scale, the Berg Balance Scale (BBS), and the Timed Up and Go (TUG) test; quadriceps muscle strength was measured with a dynamometer.

RESULTS

At the level of physical activity, post-intervention MMMS measures showed significant differences in both cases. TUG was significantly lower, and muscle strength and BBS were significantly higher in both post-interventions. No outcome measure showed a significant difference between the groups at both post-intervention and follow-up.

CONCLUSIONS

The results of this study in the field of hippotherapy simulation exercise for people with MS indicate a positive effect on health conditions, balance, mobility skills, and muscle strength. Further studies are necessary to confirm these preliminary results.

Equine-Assisted Therapies for Children With Cerebral Palsy: A Meta-analysis

CONTEXT

Equine-assisted therapy in different facets aims to improve the clinical condition of children with cerebral palsy. A more comprehensive overview on the overall effects and on the differences between different treatment modalities seems desirable.

OBJECTIVE

We compared the effectiveness of various equine-assisted treatments on motor capabilities and quality of life of children with cerebral palsy.

DATA SOURCES

We conducted systematic searches of PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials.

STUDY SELECTION

Randomized and nonrandomized controlled parallel-group or crossover studies on equine-assisted therapies in comparison with standard of care were included.

DATA EXTRACTION

Data on motor function assessed by different instruments were considered as the primary outcome. Secondary outcomes included global, social, physical, and emotional scores of quality of life.

RESULTS

Strong evidence for a positive effect of equine-assisted therapies, particularly hippotherapy, on global gross motor function and motor capabilities during walking in children with cerebral palsy was identified (SMD 0.24, 95% CI 0.05 to 0.43, P = .01, t2 = 0.00, I2 = 15%; SMD 2.68, 95% CI 1.02 to 4.34, P = .002, t2 = 0.0, I2 = 0%). No evidence for the improvement in quality of life could be shown in the global assessment, nor in any subscore.

CONCLUSIONS

Equine-assisted therapy, particularly hippotherapy, can be a therapeutic tool for children who are learning to walk.

LIMITATION

The heterogeneity of tools used in different studies and the low number of studies addressing quality of life issues limited the number of studies available for distinct analyses.

The Effect of Contact with a Horse on Positive and Negative Emotions of Polish Physiotherapy Students Within 6 Years from the First Time Hippotherapy Session

Background

Activities with horses cause many emotional reactions in their recipients, the measurement and analysis of which can provide information about positive or negative attitudes toward hippotherapy activities. The purpose of the study was to explore how horse contact affects the emotions of female and male students experiencing horseback riding during a three-day hippotherapy session.

Material and Methods

The study included 252 physiotherapy students from the Medical University of Wrocław who participated in hippotherapy classes during a three-day didactic and scientific course implemented in the years 2014–2019. The Scale of Positive and Negative Experience (SPANE) and the Sanoquell automatic 766 pulse measuring device were used for the study. The SPANE took place at the beginning (study I) and at the end (study II) of the camp. Pulse was measured daily before and after hippotherapy (6 times).

Results

Analysis of variance proved the existence of statistically significant difference between the intensity of positive feelings (SPANE-P, p=0.000) and negative feelings (SPANE-N, p=0.000) and in the outcome of overall satisfaction/happiness balance (SPANE-B, p=0.000) in I and II study in the group of women. No such difference was noted for the men. The pulse in women measured on the third day was statistically significantly higher than in men (p=0.0345).

Conclusion

Hippotherapy classes bring physiotherapy students an increase in positive feelings and a decrease in negative feelings. Personal experience seems to be the best way to understand and consciously use hippotherapy as a therapeutic method.

Benefits of Equine-Assisted Therapies in People with Multiple Sclerosis: A Systematic Review

This systematic review aimed to provide an up-to-date analysis of the effects of equine-assisted therapies (EAT) in people with multiple sclerosis (PwMS). The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were followed to conduct this systematic review. PubMed and Web of Science databases were employed in the search, which ended in February 2022. The risk of bias analysis was performed using the Evidence Project tool. After removing duplicates, thirty-nine studies were identified. However, only ten fulfilled the inclusion criteria and were included in this systematic review. Therefore, a total of 195 PwMS, aged between 40.3 and 51.3, were included in this systematic review. EAT-based interventions had a mean length of 13.6 weeks with a session´s frequency ranging from ten to once a week. All sessions involved real horses and lasted a mean of 34.4 min. Among the included articles, four were randomized controlled trials (RCT), four did not perform randomization, and two employed a prepost design without a control group. RCTs showed positive effects on quality of life, fatigue, balance, spasticity, and gait speed. Furthermore, non-RCT showed improvements in balance, spasticity, and postural control (postural control was not assessed in RCT studies). Importantly, significant effects were only observed when the comparison group was inactive or followed usual care. Therefore, EAT is a promising and effective therapy to improve quality of life, fatigue, balance, spasticity, and gait speed in PwMS. However, since comparison groups are heterogeneous, results could vary depending on the research design. Moreover, the inclusion of noncontrolled studies (in order to have a wide perspective of the state of art) could increase the risk of bias and make the results be taken with caution.

The Effect of a Horse-Riding Simulator with Virtual Reality on Gross Motor Function and Body Composition of Children with Cerebral Palsy: Preliminary Study

This study aimed to evaluate the effect of a horse-riding simulator (HRS) with virtual reality (VR) on gross motor function, balance control, and body composition in children with spastic cerebral palsy (CP). Seventeen preschool and school-aged children with spastic CP were included; 10 children in the intervention group (HRS group) received 30 min of HRS with VR training twice a week for a total of 16 sessions in addition to conventional physiotherapy. Seven children in the control group were instructed to perform home-based aerobic exercises twice a week for 8 weeks in addition to conventional physiotherapy. Gross motor function measure (GMFM) and body composition were evaluated before the first session and after the last session. Before and after the 2-month intervention, Pediatric Balance Scale and Timed Up and Go test were evaluated for the HRS group. GMFM scores and body composition changed significantly in the HRS group (p < 0.05). However, no significant differences were observed in the control group. Changes in the GMFM total scores, GMFM dimension D scores, and skeletal muscle mass significantly differed between the HRS and control groups (p < 0.05). HRS with VR may be an effective adjunctive therapeutic approach for the rehabilitation of children with CP.

Identifying patterns in trunk/head/elbow changes of riders and non-riders: A cluster analysis approach

Correct rider oscillation and position are the basics for a good horseback riding performance. In this paper, we propose a framework for the automatic analysis of athletes behaviour based on cluster analysis. Two groups of athletes (riders vs non-riders) were assigned to a horseback riding simulator exercise. The participants exercised four different incremental horse oscillation frequencies. This paper studies the postural coordination, by computing the different discrete relative phases of head-horse, elbow-horse and trunk-horse oscillations. Two clustering algorithms are then applied to automatically identify the change of rider and non-rider behaviour in terms of postural coordination. The results showed that the postural coordination was influenced by the level of rider expertise. More diverse behaviour was observed for non-riders. At the opposite, riders produced lower postural displacements and deployed more efficient postural control. The postural coordination for both groups was also influenced by the oscillation frequencies.

The Effectiveness of Hippotherapy to Recover Gross Motor Function in Children with Cerebral Palsy: A Systematic Review and Meta-Analysis

Cerebral palsy (CP) is a permanent disorder of the posture and movement, which can result in impairments of gross motor function, among others. Hippotherapy (HPT) is an emerging intervention to promote motor recovery in patients with neurological disorders, providing a smooth, precise, rhythmic, and repetitive pattern of movement to the patient. The main objective of this systematic review and meta-analysis of randomized controlled clinical trials was to analyze the effectiveness of HPT interventions on gross motor function in subjects with CP. The following databases were searched in May 2019: PubMed, Scopus, Embase, and Web of Science. The methodological quality of the randomized controlled trials was assessed using the Physiotherapy Evidence Database (PEDro) scale. A total of 10 studies were analyzed in this review, involving 452 participants. Favorable effects were obtained on the gross motor function (Gross Motor Function Measure-66, standardized mean difference (SMD) = 0.81, 95% confidence interval (CI) = 0.47–1.15, Gross Motor Function Measure-88 dimension A SMD = 0.64, 95% CI = 0.30–0.97, dimension B SMD = 0.42, 95% CI = 0.09–0.75, and dimension E SMD = 0.40, 95% CI = 0.06–0.73). The results obtained in the present review show the potential benefit of HPT intervention in improving gross motor function in children with CP.