Download Equine Movement for Cerebral Palsy: Impact on Gait, Balance

Equine Movement for Cerebral Palsy: Impact on Gait, Balance,
Function, and Quality of Life.
Claire Shores, SPT
University of New Mexico Physical Therapy Program:
Class of 2014
Advisor: Kathy Dieruf PT, PhD, NCS
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Abstract:
Background/Purpose:
This is a case study and evidence-based analysis that is aimed to determine if
equine movement therapy along with traditional physical therapy and gait training is an
effective treatment for children with cerebral palsy.
Case Description:
The patient selected for this case study is five year old male who has ataxic
cerebral palsy and who is receiving physical therapy from Skyline. The physical therapy
included but is not limited to balance training, lower extremity strengthening, gait
training, and equine movement.
A data base review of PubMed, CINAHL plus with full text, and PEDro was
conducted using combination of the following key words: Ataxic cerebral palsy, Cerebral
palsy, Equine therapy, Hippotherapy, Gait training.
Outcomes/Discussion:
A review of the current literature reveled that equine movement (hippotherapy
and/or therapeutic horseback riding) has a beneficial effect for children with cerebral
palsy. Equine therapy can help equalize muscle symmetry in the legs by decreasing
the asymmetry in hip adductors. Hippotherapy has been shown to improve postural
control, balance, pelvic kinematics, walking speed and stride length. It has also shown
to have a positive effect on a child’s gross motor function and functional activities shown
by an increase in their GMFM score with a significant improvement in dimension E.
Equine movement is an appropriate treatment for a five year with cerebral palsy. It may
potentially improve his gait and balance.
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SECTION 1:
Background and Purpose:
Cerebral Palsy is a lifelong, non-progressive disorder that most often occurs
before birth but it can be acquired during delivery or up to three years of age while the
brain is still developing. It involves the brain and nervous system function but is widely
heterogeneous in terms of etiology, types and severity. Prominent features of cerebral
palsy may include abnormal movement patterns, decreased coordination of
movements, irregular muscle tone and/or cognitive deficits that are caused by injury to a
developing brain. (Whalen, 2012) However, it can also affect how the body and brain
develops and change how the brain learns. The symptoms can range from mild to
severe, it may affect the entire body or just a particular limb. Common types of cerebral
palsy include but are not limited to spastic, dyskinetic, ataxic, hypotonic or a mixture.
Cerebral palsy will impact an individual’s health, life span, functional abilities, cognition,
mobility and quality of life. There is no cure for cerebral palsy, however there are known
benefits from therapy intervention, education, and the use of assistive devices that can
increase functional independence and participation for a child with cerebral palsy as
they develop and grow (Snider, 2007).
The therapists at Skyline treat many children with cerebral palsy with a wide
range of symptoms and incorporate equine movement into all of the physical therapy
treatment sessions. The families and therapists of these children say they see a positive
change in these children’s gait, balance, function, and their overall quality of life. They
report they can see a significant difference in the children and that hippotherapy is
helping them with their impairments that are caused by their cerebral palsy.
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Equine movement is thought to provide a multidimensional movement which is
variable, rhythmic and repetitive for the rider/patient. The horse provides a dynamic
base of support making it an excellent tool for increasing trunk strength, balance, and
building overall postural control. It is theorized that the horse may facilitate endurance,
strengthening, postural control, weight bearing, and motor planning for the rider/patient.
Equine movement may offer well-modulated sensory input to vestibular proprioceptive,
tactile, and visual channels. During equine movement while the horse is walking, the
rider/patient must perform subtle adjustments in their trunk to maintain balance and a
stable position. When a patient is sitting forward astride the horse, the horse’s walking
gait is remarkably similar to normal human gait pattern. It will move the rider/patient
pelvis in the frontal, sagittal and transverse plane, much like a pelvis would move during
normal human gait pattern. The effects of equine movement on postural control,
sensory systems, and motor planning can be used to facilitate coordination and timing,
strengthening, grading of responses, respiratory control, and sensory integration skills
have and are currently being researched.
SECTION 2:
Case Description:
On October 26, 2008 Jack was born and suffered a hypoxic episode 2 hours
after his birth and acquired cerebral palsy (ICD-9 code 349.3). Jack has been receiving
physical therapy and equine movement therapy at Skyline since May of 2012. On
November 18th 2013 he received a re-evaluation. Jack presented with difficultly walking
and maintaining balance. He presents with an ataxic gait pattern in his lower
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extremities. Jack’s main complaint is that he has difficulty’s walking straight and talking
clearly enough so that people can understand him. He has had no major surgery or
significant past medical history.
EXAMINAION
History/Medical History
Jack is a five year old boy who suffers from severe ataxia and spastic diplegia
from cerebral palsy. He suffered from a hypoxic episode two hours after a normal birth
with an APGAR score of 8. He required hospitalization in the NICU for two weeks. He
has been receiving physical therapy and speech-language services, along with Equine
movement therapy at Skyline since May of 2012. Jack doesn’t demonstrate any mental
or cognitive deficits for his age, however he does present with some physical
impairments. His functional impairments include difficulty with walking with an ataxic
gait pattern, maintain balance without upper extremity support, and controlling his gross
motor movements due to his cerebral palsy.
Social History
Jack lives at home with mother, father and two dogs. He started attending
elementary school in August of 2013. Jack is a bright and alert boy who demonstrates
cognitive skills within normal limits of his age group. He is a highly active five year old.
Patient’s goals
Jack stated he would like to “talk and walk better”. Jack would like to participate
in a soccer program at school and compete in a vaulting competition next summer.
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Systems review.
-
Cardiovascular: WFL
-
Respiratory: WFL
-
Gastrointestinal: Active bowel sounds, no problems reported, WFL.
-
Musculoskeletal: Spasticity in lower extremities
-
Integumentary: Intact, warm and no rashes.
-
Neurologic: All WNL except patellar reflex is 3
Test and Measures
Jack is a pleasant child who actively participates in a gross motor evaluation
using clinical observation, the Gross Motor Function Measure (GMFM), and the
Peabody Motor Skills-2.
The Gross Motor Function Measure (GMFM) is a clinical tool designed to
evaluate change in gross motor function in children with severe motor deficits. The
GMFM samples motor skills that are typical of normal developmental milestones. While
the measure was designed and validated for children with cerebral palsy (CP), it is
useful for children with other diagnoses such as spina bifida and children whose motor
skills are at or below those of a 5 year old.
GMFM
05/3/12
A. Lying and Rolling
100.00%
B. Sitting
98.30%
C. Crawling & Kneeling
85.70%
D. Standing
25.60%
E. Walking, Running, & Jumping
15.30%
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Total Score (A+B+C+D+E) /5
65.00%
Category
IV
Children who are in level IV of the GMFCS will require adaptive equipment for mobility
and may require assistance. Jack demonstrates the most difficulty with standing
balance activities, walking, running and jumping and coordinating gross motor
movements.
The Peabody Development Motor Skills-2 (PDMS-2) is an early childhood motor
development program that provides in-depth assessment of gross and /or fine motor
skills. The assessment is composed of six subtests that measure interrelated motor
abilities that develop early in life. It is designed to assess that motor skills of children
from birth through 5 years of age.
Gross Motor Evaluation
Peabody Developmental
5/3/12Motor
42-months
Stationary
Raw/%ile /Std/Age
Equivalency
37 / 5% Scores
/ 5 / 14 months
11/18/13 60-months
Raw/%ile /Std/Age
Equivalency
39 / 5% Scores
/ 5 / 18 months
Locomotion
74/ <1% / 2 / 14 months
94 /1% / 3 / 16 months
Object manipulation
11 / 1% / 3 / 17 months
32 / 16% / 7 / 30 months
Sum of standard scores
10
15
Gross Motor Quotient
57
68
<1%
1%
Gross Motor Percentile
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Evaluation
Diagnosis:
Abnormality of gait (ICD-9 Code 781.9) Lack of coordination (ICD-9 code 781.3) ataxic
gait (ICD-9 code 781.2) infantile cerebral palsy, unspecific (ICD-9 code 343.9)
4C Impaired muscle performance, 5A Primary prevention/risk reduction for loss of
balance and falling. 5B Impaired neuromotor development. 5C Impaired motor function
and sensory integrity associated with non-progressive disorders of the central nervous
system - congenital origin or acquired in infancy or childhood
Narrative Assessment:
Jack is a five year old male who is referred to physical therapy for imparted balance and
gait. He suffered from a hypoxic event two hours after birth and is diagnosed with ataxic
cerebral palsy. He is currently a happy healthy boy living at home with his parents and
attends kindergarten in Albuquerque. He demonstrates an ataxic gait pattern, impaired
balance, impaired coordination, lack of core stabilization and uses a rear walker for
mobility assistance. He has been receiving physical therapy and speech and language
therapy services at Skyline since May of 2012 and would continue to benefit from
physical therapy to address the above gross motor impairments and improve his quality
of life.
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Clinical Judgments and Problem List.
-
Ataxic gait
-
Decreased gait speed
-
Poor balance
-
Increased risk of falls
Prognosis and Goals
-
At this time prognosis for this patient is good
-
Short term goals
o Jack will demonstrate walking 50 feet independently with no loss of
balance shown by no falls in 2 weeks.
o Jack will stand unsupported for 20 sec and maintain balance shown by
less than a 20 degree sway in 2 weeks.
o Jack will stand on one foot unsupported for 5 seconds and maintain
balance shown by not falling in 4 weeks.
o Jack will demonstrate picking up an object from the floor with no UE
support and with no loss of balance one time in 4 weeks.
-
Long term goals
o Jack will demonstrated walking 100 feet on a level surface with no loss of
balance in 3 months.
o Jack will stand unsupported for 1 min with no loss of balance and less
than a 20 degree sway in 3 months.
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o Jack will stand on one foot unsupported for 10-15 seconds and maintain
balance shown by not falling in 4 months
o Jack will demonstrate picking up an object from the floor with no UE
support and with no loss of balance 5 times in 4 months.
Intervention:
-
Patient related instruction and education:
o Slow walking speed
o Focus on task at hand
o Practice balancing with no UE support
o Stretch and strengthen LE
o Postural control
-
Direct interventions
o Gait training
o Therapeutic actives and Therapeutic exercises
o Balance and proprioceptive activities
o Equine movement therapy.
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SECTION 3:
Evidenced Based Analysis:
Methodologies of search
The purpose of this analysis is to answer the following PICO question: “In a 5
year old boy with ataxic spastic diplegia cerebral palsy, is equine therapy combined with
gait training an effective treatment to improve balance and gait?” In order to identify
relevant articles the major computerized databases where search: PubMed,
Physiotherapy Evidence Database (PEDro) and Cumulative Index to Nursing and Allied
Heath Literature (CINAHL). The search terms included, Ataxic cerebral palsy, Cerebral
palsy, Equine therapy, Hippotherapy, Gait training.
The first search preformed was in PubMed with the key terms of “Ataxic Cerebral
Palsy”, “Gait Training” which yielded seventeen articles. There were fifteen articles that
were eliminated from title review due to irrelevant content to the PICO question and for
being published more the ten years ago. There were two articles that an abstract
review was preformed, however both were eliminated due to irrelevant content. The
next PubMed search yielded a total of fifty-three articles with the terms “Cerebral palsy”
and “Equine therapy”. There were thirty-seven articles that were excluded by title
review, as the title did not pertain to the subject being analyzed. Four articles were
excluded due to age and being published greater than ten years ago. This left twelve
articles for abstract review, two were excluded due to low level of research and three
were excluded due to irrelevant content. This left seven articles that were found
appropriate for in depth analysis. There were two articles that were not available in full
text English so they were eliminated, leaving five articles. PubMed yielded forty-two
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articles with the terms “Cerebral palsy” and “Hippotherapy”. There were thirty-one
articles that were excluded by title review as the title did not pertain to the subject being
analyzed, two were exclude due to being published over ten years ago. There were
seven articles that were exclude because they were found in the previous search. This
left two article for the abstract review. Which one was excluded to irrelevant content a
leaving one for in depth analysis.
In CINAHL the key terms used were ”Cerebral Palsy”, “Hippotherapy”, “Gait
training” with only one hit which was eliminated after title review due to irrelevant
content. Another CINAHL search was performed with the key terms “Cerebral Palsy”,
“Hippotherapy” with a total of forty-one hits. There was eight articles that were
eliminated due to not being in English, four articles that were eliminated due to being
published more than ten years ago, seven articles that were repeated and found in the
PubMed search and two articles were eliminated due to poor level of evidence, and
fifteen articles were eliminated due to irrelevant material. This left five articles for
abstract review, three of the five were eliminated due to irrelevant material, leaving two
for in depth analysis. The next search performed used the key terms “Cerebral Palsy”,
“Equine therapy” in CINAHL which yielded five articles. One article was excluded due to
not being in English, another article was a repeat from the PubMED search, one article
was excluded due to population, age, and content. And another article was eliminated
because it was published over ten years ago. This left one article for abstract review
which was excluded due to content and irrelevance to the PICO question. The last
CINAHL search preformed was “Ataxic Cerebral Palsy”, there were eight articles only
which of one was related to the PICO question and was kept for in depth analysis.
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In PEDro the terms “Cerebral Palsy”, “Equine therapy”, “Hippotherapy”, “Gait
Training” for the key terms all which yielded zero articles. As well the key terms
“Cerebral Palsy”, “Gait Training” were used all which produced articles that were all
irrelevant to the PICO question.
Data
Base
PubMed
CINAHL
PEDro
Key Terms
Hits After Title
Review
After Abstract After Article
Review
Review
Ataxic Cerebral Palsy,
Gait Training
17
2
0
Cerebral Palsy,
Equine Therapy
53
16
7
5
Cerebral Palsy,
Hippotherapy
42
11
1
1
Cerebral Palsy,
Hippotherapy, Gait
training
Cerebral Palsy,
Hippotherapy
1
1
0
41
5
2
Cerebral Palsy,
Equine therapy
5
1
0
Ataxic Cerebral Palsy
8
1
1
Cerebral Palsy,
Equine therapy,
Hippotherapy, Gait
Training
Cerebral Palsy, Gait
Training
0
7
0
13
2
1
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Outcome/Discussion
The evidence available to answer this specific PICO question, “In a five year old
boy with ataxic spastic diplegia cerebral palsy, is equine therapy combined with gait
training an effective treatment to improve balance and gait?” looks at all types of equine
movement. The evidenced included both hippotherapy, which requires a licensed
therapist to be present during the session and therapeutic horseback riding that does
not, it just requires a trained riding instructor to be present and does not usually provide
therapeutic benefits. The goal in this paper was to use only research that used
hippotherapy and had a licensed therapist guiding the equine therapy session, however
the research is limited so both hippotherapy and therapeutic horseback riding were
included.
Two articles were found that looked at the effects of equine movement on gait
parameters. The first article looked at the temporal-spatial parameters on hip/pelvic
kinematics of gait on children with bilateral spastic cerebral palsy. (Kwon, 2011) They
found that a 30 min session of hippotherapy twice a week for eight weeks would
improve the walking speed and stride length as well as decrease the average pelvic
anterior tilt during gait. It also showed an improvement in the participants GMFM score
particularly in dimension E, which focuses on walking, running and jumping ability, as
shown in this current patient. This would answer the PICO question in the fact that
hippotherapy can have beneficial effects on improving balance and gait on this patient
with cerebral palsy. The other article looked at the immediate effects of hippotherapy on
temporal-spatial parameters on children with spastic cerebral palsy. (McGee, 2009) The
authors of this article concluded that there are no immediate effects on these gait
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parameters immediately after a hippotherapy session. However they did not know the
long term effects or the carryover. Both of these studies were looking at gait parameters
but carried out their study in a very different manner and found different results on their
participants. Therefore there is a need for more studies to be conducted on how
hippotherapy and equine movement will effect a child with cerebral palsy gait
parameters.
One study looked at how therapeutic horse riding effects physical function, health
and quality of life for children with cerebral palsy. (Davis, 2009) This article was not
particularly helpful in answering this PICO question. The authors were more interested
in how it affected the health and quality of life rather than their gross motor function and
gait, and it was just looking at therapeutic horseback riding instead of hippotherapy.
This article was still used and analyzed since it discussed effects that were found on
functional status. The authors found that there was no difference in the GMFM scores
after the ten week study period.
There were also four systematic reviews were used and analyzed. These four
SR’s looked at the effects of hippotherapy on children with cerebral palsy. The first
systematic review looked at the therapeutic effects horseback riding therapy on gross
motor function in children with spastic cerebral palsy. (Whalen, 2012) This systematic
review looked at nine articles and concluded that the current literature on hippotherapy
is limited and there needs to be more research done. However they did state the there
is an overall positive effect on gross motor function in children ages four and above with
cerebral palsy who participate in hippotherapy. The next systematic review metaanalysis that was used looked at effects of both hippotherapy and therapeutic
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horseback riding on postural control or balance in children with all types of cerebral
palsy. (Zadnikar, 2011) The authors looked at eight articles and concluded that postural
control and balance can improve during hippotherapy and therapeutic horseback riding.
This meta-analyses helped answer part of the PICO question in that hippotherapy can
improve overall balance in children with cerebral palsy.
Another systematic review looked at how effective the evidence is on
hippotherapy and therapeutic horseback riding that is available. (Snider, 2007). This
was a well done study, the authors concluded that there is a level 2a evidence that
hippotherapy and therapeutic horseback riding can have positive effects, however there
is a need for higher quality research to be conducted. The last systematic review and
meta-analysis that was used, analyzed the effect of equine assisted activities and
therapies on gross motor outcome in child with cerebral palsy. (Tseng, 2012) This
article useful because the authors separated hippotherapy from therapeutic horseback
riding. The authors found nine studies that looked at hippotherapy and concluded that
hippotherapy can reduce asymmetrical activity of the hip adductors, improve muscle
symmetry during gait and improve GMFM scores. The authors also found five studies
that used therapeutic horseback riding and found that both interventions can be
beneficial to children with spastic cerebral palsy. However there is still insufficient
evidence out there to claim that hippotherapy or therapeutic horseback riding has long
term effects on children with spastic cerebral palsy and more research should be
conducted on this subject.
There was a limited amount of evidence that looked at ataxic cerebral palsy with
hippotherapy. Most of the research that’s been conducted looked at the effects of
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hippotherapy or therapeutic horseback riding (THR) on children who have spastic
cerebral palsy. There was only one study that was found that looked at a six year old
girl who had ataxic cerebral palsy. This was a case report looking at how hippotherapy
affected her self-competence. (Frank, 2011) However this article was included to see
what the positive effects were on ataxic cerebral palsy and to see if they has any
negative or adverse effects. Therefore this was thought to be beneficial to the PICO
question to include this study even though it was at a low level of evidence.
They last article that was used also looked at the effects of hippotherapy on the
motor function of children with spastic cerebral palsy. (Chang, 2012) This study
concluded that hippotherapy for 30 minutes twice a week for eight weeks can improve
gross motor function and balance in children with cerebral palsy with a significant
improvement in dimension D and E of the GMFM and the Pediatric Balance Score. This
study was similar to the study that Kwon conducted in 2011 and repeated similar
results.
Overall it has been concluded that there are no negative or adverse effects for
children with cerebral palsy when they participate in a hippotherapy or therapeutic riding
program. Most studies state that there is an overall positive effect for these children,
whether it is on their gait, muscle symmetry and tone, balance and posture, or selfconfidence and quality of life.
Therefore it has been concluded that equine therapy is an appropriate treatment
for this patient. The evidence that is available states that the patient should participate
in at least 30 min of equine movement therapy one to two times a week for a minimum
of eight weeks. There is no improvement after a single session of hippotherapy however
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the longer the child participates in an equine program the more benefits they will receive
it from it. To answer the PICO question “In a five year old boy with ataxic spastic
diplegia cerebral palsy, is equine therapy combined with gait training and effective
treatment to improve balance and gait?” It has been concluded that the answer is yes.
Equine movement therapy has the possibility to benefiting or improving gait parameters,
hip/pelvic kinematics, stride length, muscle symmetry, postural control and balance, as
well as self-confidence and quality of life a child with cerebral palsy. However there is
still a need for further research to understand the exact effects that equine movement
has on a child with ataxic cerebral palsy.
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References
1. Kwon. J., Chang, H.J., Young Lee, J., Ha, Y. Lee., P., Kim, Y., (2011). Effects of
Hippotherapy on Gait parameters in Children With Bilateral Spastic Cerebral
Palsy. Arch Phys Med Rehabil, (92), 774-779.
2. Davis, E., Davis, B., Wolfe, R., Raadsveld, R., Heine, B., Thomason, P., Dobson,
F., Graham H.K., (2009). A randomized controlled trail of the impact of
therapeutic horse riding on the quality of life, health, and function of children with
cerebral palsy. Developmental Medicine and Child Neurology, (51), 111-119.
3. Whalen, C., Case-Smith, J. (2011) Therapeutic Effects of Horseback Riding
Therapy on Gross Motor Function in Children with Cerebral Palsy: A Systematic
Review. Physical & Occupational Therapy in Pediatrics, (32), 229-242.
4. Zadnikar, M., Kastrin, A., (2011) Effects of hippotherapy and therapeutic
horseback riding on postural control or balance in children with cerebral palsy: a
meta-analysis Developmental Medicine and Child Neurology. (53) 684-691.
5. Snider, L., Korner-Bitensky, N., Kammann, C., Warner, S., Snalch, M. (2007)
Horseback Riding as Therapy for Children with Cerebral Palsy: Is There
Evidence of Its Effectiveness? Physical & Occupational Therapy in Pediatrics,
27(2), 5-23.
6. McGee, M.C., Reese, N. B., (2009), Immediate Effects of a Hippotherapy session
on Gait Parameters in Children with Spastic Cerebral Palsy. Pediatric Physical
Therapy. (21), 212-228.
7. Frank, A., McCloskey, S., Dole R. (2011), Perceived self-competence and
Participation in a Child with Cerebral Palsy. Pediatric Physical Therapy. (23) 301308.
8. Chang, H.J., Kwon, J.Y., Lee, J.Y., Kim, Y.H. (2012). The Effects of
Hippotherapy on the motor function of children with Spastic Bilateral Cerebral
Palsy. J Phys Ther Sci, (24), 1277-1280.
9. Tseng, S., Chen, H., Tam, K., (2013), Systematic review and meta-analysis of
the effect of equine assisted activities and therapies on gross motor outcome in
children with cerebral palsy. Disability and Rehabilitation, 35(2), 89-99.
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APPENDIX A – ANALYSIS WORKSHEETS
Intervention – Evidence Appraisal Worksheet
Article 1
Citation (use AMA or APA format):
Kwon. J., Chang, H.J., Young Lee, J., Ha, Y,. Lee, P., Kim, Y., (2011). Effects of Hippotherapy on
Gait parameters in Children With Bilateral Spastic Cerebral Palsy. Arch Phys Med Rehabil, (92),
774-779
Level of Evidence (Oxford scale):
2c
Is the purpose and background information sufficient?
Appraisal Criterion
Study Purpose
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a
question or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you.
Consider how the study can be applied to PT
and/or your own situation. What is the purpose
of this study?
Literature
Relevant background presented?
A review of the literature should provide
background for the study by synthesizing
relevant information such as previous research
and gaps in current knowledge, along with the
clinical importance of the topic.
Describe the justification of the need for this
study
Reader’s Comments
Yes, it is to evaluate the effects of hippotherapy
on temporospatial parameters and pelvic/hip
kinematics of gait in children with bilateral
spastic cerebral palsy.
This study gives a brief background on what
hippotherapy and equine movement is trying to
achieve. It also talked about two previous studies
that have looked at the effects of hippotherapy
on gait parameters in children with cerebral palsy
and a need to continue the research in this area.
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Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
Assignment – After meeting baseline
measurements and meeting the study’s criteria,
participated were enrolled in separate categories
according to the GMFCS level. The participants
were then allocated to of two groups. The
treatment group that received conventional
physiotherapy and hippotherapy or the control
group with received only conventional
physiotherapy. All examiners were blinded. This
was a nonrandomized prospective controlled
trial.
Attrition – This study does not mention the
attrition or if there were participants that were
lost. They include their exclusion criteria for
what candidates are not eligible for this study,
but fail to mention if they had any lost or drop
out candidates during the duration of this study.
History – This study does not state any external
events that happen during the duration of this
study they may have effected their results.
Instrumentation – This study used the Gross
motor Function Classification System, Gross
Motor Function Measure, and Pediatric Balance
Scale to measure the gross motor level, function
and balance of the participants. They also used
the Vicon 612 Motion Analysis system to
measure the participant’s temporospatial and
kinematics of their gait.
Maturation – This study took place from October
2008 to June 2010, however the treatment time
was only 10 weeks for a single participate
including the pre and post measurements and
the 8 weeks of intervention. They did not state
any other changes in the participants over the
time they participated in the study. However
they did include a control group to decrease the
threat of maturation.
Testing – This study did not go into detail about
their testing process, just that there was a pretest before the intervention and a post-test after
the intervention. They stated that to measure
the temporospatial and kinematic analysis of gait
was performed using the Vicon 612 motion
analysis system. Reflection infrared light markers
were attached to lower extremities landmarks
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
 Instrumentation
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
22
and the child was asked to walk barefoot on a
6m walkway.
Compensatory Equalization of treatments – This
study only states that the examiners and the
Physician are blinded it does not state whether
or not the physiotherapist that are providing the
treatment or blinded. Therefore this is a risk of
have compensatory equalization of the
treatments.
Statistical Regression – It states that participates
in the hippotherapy and the control group were
similar in terms of age, sex, GMFCS level, body
weight, height and history.
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
1. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this assignment
process for the study’s results?
No, this is a nonrandomized prospective
controlled trial. They do not state how the
participants were assigned to each group. The
potential consequences for this are a potential
bias, and that the control group and the
hippotherapy group are not similar enough.
2. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
Yes, it states that the patients were allocated to
one of the following groups, the conventional
physiotherapy group (control) or the
hippotherapy plus conventional physiotherapy
group (hippotherapy group). All the examiners
including the physician performing the gait
analysis were blinded to the interventions.
3. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
4. Did the subjects know to which
treatment group they were assign?
23
Yes, This study states that the hippotherapy and
the control groups were similar in terms of age,
sex, GMFCS level, body weight, height, and
history of surgery. They include a table of the
demographics of the participants.
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
This study did not state whether the participants
knew if they were in the intervention or the
control group.
5. Did the investigators know to which
treatment group subjects were assigned
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
No, the investigators were blinded.
6. Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Yes, both groups received conventional
physiotherapy, the only difference between the
control group and the intervention group is that
the intervention group received hippotherapy
twice a week for 30 minutes for 8 weeks.
7. Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
There was no follow up in this study, just a pretest and a post-test. Therefore we do not know
if the beneficial effects that the participants
received had any carry over time.
8. Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the
authors do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
This is not stated. We do not know if there were
any subjects lost during the duration of the
study. It can be assumed that there were no
participants lost.
9. Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Yes, the data for the primary and secondary
outcomes were analyzed according to the
intention-to-treat principle with the baseline
observation carried forward in cases where data
were missing.
24
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
10. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
11. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
12. Do these findings exceed a minimally
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will
you still use this evidence?
In the intervention group (hippotherapy) the
stride length increased significantly with no
change in cadence. In the control group there
was an increase in cadence. No statistically
significant difference was noted in the pelvic and
hip kinematic parameters in the sagittal plane
between the two groups. There was a statistically
significant interaction was noted between the
interventions with respect to 3 parameters,
average pelvic anterior tilt, at initial contact, and
pelvic anterior tilt at terminal stance. There was
statistically significant interaction between the
groups for scores in dimension E (running,
walking , jumping) of the GMFM and PBS
a. n/a
b. P set at < .05 for all tests.
c-f. n/a
It indicates that hippotherapy would be a
potential treatment that may benefit my patient
to improve his temporospatial parameters and
pelvic kinematics parameters. According to this
study I should use this treatment in my practice
There is no MCID stated in this study, however I
believe the results of this study are clinically
significant.
Can you apply this valid, important evidence about an intervention
in caring for your patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
13. Does this intervention sound
appropriate for use (available,
affordable) in your clinical setting? Do
you have the facilities, skill set, time, 3rd
party coverage to provide this
treatment?
14. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
This intervention is appropriate for Skyline
because they have the available resources,
facilities and skill set to provide hippotherapy.
However this is not practical for all pediatric
clinical settings.
Yes, they are similar in the fact that they are all
children with cerebral palsy. However they have
bilateral spastic cerebral palsy and my patient
has ataxic cerebral palsy. I believe I can still use
this intervention despite the difference.
25
15. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
16. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes
17. Are there any threats to external validity
in this study?
No
Yes
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
4
Summarize your findings and relate this back to
clinical significance
This article found that an 30 min, twice a week,
for 8 weeks hippotherapy program in
conjunction with standard physical therapy is
beneficial for children with bilateral spastic
cerebral palsy for their pelvic kinematics and
temporospatial parameters in gait. This article
has clinical significance for my patient and me at
Skyline. There needs to be further randomized
controlled trials to assess the effect of
hippotherapy and the changes in kinematics for
children with cerebral palsy and specifically
ataxic cerebral palsy.
26
Pedro Scoring System:
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones
and Bartlett Publishers, Sudbury, MA 2008
27
Intervention – Evidence Appraisal Worksheet
ARTICLE 2
Citation (use AMA or APA format):
Davis E, Davis B, Wolfe R, Raadsveld R, Heine B, Thomason P, Dobson F, Graham HK (2009). A
randomized controlled trail of the impact of therapeutic horse riding on the quality of life,
health, and function of children with cerebral palsy. Developmental Medicine and Child
Neurology, (51), 111-119
Level of Evidence (Oxford scale):
1b
Is the purpose and background information sufficient?
Appraisal Criterion
Study Purpose
Reader’s Comments
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a
question or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you.
Consider how the study can be applied to PT
and/or your own situation. What is the purpose
of this study?
Yes it states, “This Randomized controlled trial
examined whether therapeutic horse riding has a
clinically significant impact on the physical
function, health and quality of life of children
with CP”
Literature
Yes, they provided background review on
previous studies that have been performed such
as another systemic review from Sterba. This
study states that there were 5 out of the 6
studies that showed improvements in gross
motor function after a therapeutic horse riding
programs. However the measures were not
consistent or reliable. These studies also have
small sample sizes and don’t include a control
group. They also state that there have been no
studies done that have examined whether
therapeutic horse riding impacts psychosocial
outcomes of children with CP and their quality of
life. Therefore there is a need for a study to exam
the effects of therapeutic riding on physical
function, quality of life and health that also has a
larger sample size and a control group.
Relevant background presented?
A review of the literature should provide
background for the study by synthesizing
relevant information such as previous research
and gaps in current knowledge, along with the
clinical importance of the topic.
Describe the justification of the need for this
study
28
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
Assignment- The allocation was constructed
randomly to avoid the risk of any major
imbalance in numbers of participants allocated to
intervention or control groups. The project
officers, participants and their primary caregivers
were blinded as to whether they were in the
intervention group or the control group.
Attrition – There were 5 children who had a
GMFCS Level of IV and were excluded from
further participation in the study. Three children
were not able to be assessed reliably on
functional measures because of intellectual
impairments and one child was unable to have
the follow-up assessment due to a emergency
surgery and could no longer participate in the
study. There were three children who
participated in the initial assessment but
withdrew from the study for unknown reasons.
One child had to withdraw from the study
because the riding aggravated an existing hip
condition.
History – the only outside adverse event that
they reported was the there was an outbreak of
equine influence that occurred that prevented
the horses from being transported. Therefore
some of the participants had to ride a different
horse then the one that they were matched with
at the start of the study. There was a total of 16
participants that had to use more then one horse
throughout the 10 weeks
Instrumentation – The Gross Motor Function
Classification System was used to assess what
level the participants were at and if they
qualified. The GMFM-66 was used to assess gross
motor at their baseline and at the follow up
assessments and was administered by a single
blinded physiotherapist. There was the Cerebral
Palsy Quality of Life Questionnaire for Children
(CP QoL-Child) form that was uses to assess the
participants quality of life and function. The
Child Health Questionnaire was also another
generic instrument used to measure functional
health status, well-being and health outcome of
children.
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
 Instrumentation
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
29
Maturation – There was not much change
reported with the participates. The intervention
started in June/July 2007 and the postintervention was in September/October 2007.
They participants had 6 weeks prior to
intervention to complete the forms and
assessment and had 6 weeks after the 10 week
intervention to complete the post forms and
assessment. They were all children from the
ages of 4-12 so the growth of the children
between this time frame was not reported.
Testing - The testing was preformed within a 6
week period before the intervention started, this
included the Cebreal Palsy Quality of Life
Questionnaire for Children and the GMFM-66.
There was then a control group that did not
change their lifestyle or treatment/intervention
for 10 weeks and then there was intervention
group that participated in a 10 week therapeutic
riding program. Then the GMFM and CP-Qolchild was performed again in a 6 week period
after the 10 week time period.
Compensatory Equalization of the Treatments –
The participants and their primary care givers
were blinded as to whether they were placed in
the intervention or the control group. The
children in the control group were asked to
continue with their normal daily/weekly routines,
even if this included other forms of treatment
and was not monitored. They then participated
in an identical 10 week therapeutic horse riding
program after the study was completed,
although there was no further assessment after
the control group completed the riding program.
The physiotherapist were blinded to the
randomization and participants and were asked
not to mention when they were completing the
horse riding intervention. The Physiotherapist
that was administering the GMFM-66 was
unaware or blinded to who was part of the
control group and who was part of the
intervention group. The data analyst and the
senior statistician were not blinded to the
treatment groups.
Compensatory Rivalry – Participates were
blinded to whether they were in the control
group or the intervention group. They were
30
separated and did not receive treatment
together.
Statistical regression to the mean – Participants
who were outliers or not within 1 standard
deviation of the mean were not eligible to
participate in this study. The eligibility criteria
was that the children had to be within the age of
4-12 with cerebral palsy and had to have a
GMFCD level of I to III and who had not
previously 36 children participated in a
therapeutic horse riding program.
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
18. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this assignment
process for the study’s results?
19. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
20. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
21. Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
31
Yes, the participants were randomly assigned to
the treatment and control groups. It is a
randomized controlled trial
No they did not know who was going to be in
which group prior to allocation, it was done
randomly by a pre-generated sequence that was
concealed from the project officers.
Yes, the groups were similar at the start of the
trial. They stated that the randomization was
stratified by age and by the GMFCS level to avoid
the risk of any major imbalance in numbers of
participants allocated to intervention or control
group.
They reported the demographics of each group. I
do not consider the small differences between
the groups a threat to the research validity, I
believe the groups were similar enough.
No the subjects were blinded to whether they
were in the treatment or control group.
22. Did the investigators know to which
treatment group subjects were assigned
?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
23. Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
24. Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
25. Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the
authors do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
Yes, they stated that the data analyst and the
senior statistician were not blinded to the
treatment groups. Only the project officers,
participants and caregivers were blind and did
not know whether they were in the treatment or
control group. Since the primary investigators
were not blinded it could possibly skew the
results by favoring one group.
No, the participants in the control group were
just asked to continue with their normal
daily/weekly routines, even if this included other
forms of treatment such as other physiotherapy.
Since there was no regulation of the control
group treatment the results could be skewed
within that group since they were receiving
different forms of therapy that could affect the
results for their Quality of Life Questionnaire and
the GMFM.
They did not state if there was a follow-up after
the post test and assessment. Therefore we do
not know if there is a carryover or a long term
effect from this treatment.
No, there were five children who had a GMFCS
Level of IV and were excluded from further
participation in the study. Three children were
not able to be assessed reliably on functional
measures because of intellectual impairments
and one child was unable to have the follow-up
assessment due to an emergency surgery and
could no longer participate in the study. There
were three children who participated in the
initial assessment but withdrew from the study
for unknown reasons. One child had to withdraw
from the study because the riding aggravated an
existing hip condition.
This gave them a smaller sample size then what
they wanted because the excluded those
participates from the results
26. Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
Yes, the patients were analyzed in the groups to
which they were randomly assigned.
32
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
27. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
The results of the study demonstrate that a 10week therapeutic horse riding program did not
increase the gross motor function (GMFM-66)
health or quality of life of children with cerebral
palsy.
a. n/a
b. GMFM-66; p=45; 95% CI (-1, 2)
c-f. n/a
28. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
According to this study there is no increase for
the GMFM-66, health, or Quality of Life for
children with cerebral palsy for receiving
hippotherapy treatment. This does not directly
apply to my practice because I am looking more
at balance and gait. However it is still important
to take into consideration.
The MCID is not stated. I would still take this
evidence into consideration.
29. Do these findings exceed a minimally
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will
you still use this evidence?
Can you apply this valid, important evidence about an intervention
in caring for your patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
30. Does this intervention sound
appropriate for use (available,
affordable) in your clinical setting? Do
you have the facilities, skill set, time, 3rd
party coverage to provide this
treatment?
31. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
This intervention is appropriate for Skyline
because they have the available resources,
facilities and skill set and coverage to provide
hippotherapy. However this is not practical for
all pediatric clinical settings.
Yes, they are similar in the fact that they are all
children with cerebral palsy. However my patient
is specifically ataxic cerebral palsy. I believe I can
still use this intervention and evidence despite
the difference.
33
32. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
33. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
No, there were no many benefits to this study,
therefore the risks outweigh the benefits.
34. Are there any threats to external validity
in this study?
No
Yes
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
5
Summarize your findings and relate this back to
clinical significance
The results of this study demonstrated that a
10week hippotherapy program did not improve
the GMFM-66, health, or quality of life for
children with cerebral palsy.
More research needs to be done to establish
whether hippotherapy truly is beneficial to these
areas or not. These study should include a larger
sample size, more control or guidelines for the
control group and having participants adhere
better to the intervention. I think this study is
very clinical significant to this clinical site
however it is not as significant for my patient
who is looking to improve his gait.
34
Pedro Scoring System:
1=yes, 2=yes, 3= yes, 4=yes, 5=yes, 6=no, 7=no, 8=yes
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones
and Bartlett Publishers, Sudbury, MA 2008
35
Systematic Review – Evidence Appraisal Worksheet
ARTICLE 3
Citation (use AMA or APA format):
Whalen, C., Case-Smith, J. (2011) Therapeutic Effects of Horseback Riding Therapy on Gross
Motor Function in Children with Cerebral Palsy: A Systematic Review. Physical & Occupational
Therapy in Pediatrics, (32), 229-242
Level of Evidence (Oxford scale):
2a
Does the design follow the Cochrane method?
Appraisal Criterion
Reader’s Comments
Step 1 – formulating the question
• Do the authors identify the focus of the
review
• A clearly defined question should specify
the types of:
• people (participants),
• interventions or exposures,
• outcomes that are of interest
• studies that are relevant to
answering the question
Step 2 – locating studies
 Should identify ALL relevant literature
 Did they include multiple databases?
 Was the search strategy defined and
include:
o Bibliographic databases used as
well as hand searching
o Terms (key words and index
terms)
o Citation searching: reference lists
o Contact with ‘experts’ to identify
‘grey’ literature (body of
materials that cannot be found
easily through conventional
channels such as publishers)
o Sources for ‘grey literature’
Part 3:Critical Appraisal/Criteria for Inclusion
• Were criteria for selection specified?
Yes, The purpose of this systematic review is to
examine the efficacy of hippotherapy and
therapeutic horse riding in children with cerebral
palsy on motor outcomes through synthesis of
research evidence
They identified and selected all relevant articles
The databases that this SR used were PubMed,
Cochrane Reviews, CINAHL plus with full text,
Ovid Medline and EBSCOhost Medline with full
text.
The following terms were used “cerebral palsy”,
“therapeutic riding”, “therapeutic horseback
riding”, “horse riding”, “horseback riding”,
“hippotherapy”, “equine-assisted therapy”,
“developmental riding therapy”, and “riding for
the disabled”.
‘Grey literature’ was excluded from this SR
Specific inclusion criteria included: Subjects had
to have a diagnosis of CP (all types),
Hippotherapy or THR was the primary
36
•
•
•
Did more than one author assess
the relevance of each report
Were decisions concerning
relevance described; completed
by non-experts, or both?
Did the people assessing the
relevance of studies know the
names of the authors,
institutions, journal of
publication and results when
they apply the inclusion criteria?
Or is it blind?
intervention, mobility and gross motor outcomes
were measured, a PT, OT, or accredited
therapeutic riding instructor implemented the
intervention.
The two authors assessed the relevance of each
article independently and used the same
inclusion and exclusion criteria. There were not
blinded.
Part 3 – Critically appraise for bias:
• Selection –
• Were the groups in the study
selected differently?
• Random? Concealed?
• Performance• Did the groups in the study
receive different treatment?
• Was there blinding?
• Attrition –
• Were the groups similar at the
end of the study?
• Account for drop outs?
• Detection –
• Did the study selectively report
the results?
• Is there missing data?
Selection: Only two studies had randomization,
there other studies were not.
Performance: Only a few of the studies had
blinding or had a control group.
Attrition: Was not reported in this SR
Eight of the nine studies had a small sample size
Detection: Yes
Part 4 – Collection of the data
 Was a collection data form used and is it
included?
 Are the studies coded and is the data
coding easy to follow?
 Were studies identified that were
excluded & did they give reasons why
(i.e., which criteria they failed).
- No, the collection data form was not included
- No, they are not coded.
- Yes there were a total of 63 relevant articles
however 47 of them were excluded since
there were no available in English, or
mobility/gross motor outcomes were not
studied, or barrel sitting was used instead of a
horse.
37
Are the results of this SR valid?
Appraisal Criterion
Reader’s Comments
35. Is this a SR of randomized trials? Did
they limit this to high quality studies at
the top of the hierarchies
a. If not, what types of studies
were included?
b. What are the potential
consequences of including these
studies for this review’s results?
36. Did this study follow the Cochrane
methods selection process and did it
identify all relevant trials?
a. If not, what are the
consequences for this review’s
results?
37. Do the methods describe the processes
and tools used to assess the quality of
individual studies?
a. If not, what are the
consequences for this review’s
results?
38. What was the quality of the individual
studies included? Were the results
consistent from study to study? Did
the investigators provide details about
the research validity or quality of the
studies included in review?
- No, they only included two studies that were
randomized, there rest are not.
a. RCT, repeated measures within-subjects
and one group pretest-posttest.
b. They are not a high level of evidence so
the results need to be taken with
caution.
- Yes
- No, they just included their databases used,
the keywords that were searched, and the
study inclusion and exclusion criteria a validity
assessment using the PEDro scale. There is a
possible risk of bias
The studies included in this SR ranged from a
Pedro score of 3 to 6 out of 10. Most of the
studies had similar types of intervention. Two
studies were RCT’s five were repeated measure
within subject studies, and the last two were one
group pretest-posttest studies.
Six of the seven studies reported positive
outcome from this intervention on gross motor
function. However they were all looking at
different results. So they are not consistent from
study to study. Some studies demonstrated
significant improvement to posture, stride
length, head and trunk stability, or a significant
increase on the GMFM dimension E or the PEDI.
No
39. Did the investigators address publication
bias
Are the valid results of this SR important?
Appraisal Criterion
Reader’s Comments
40. Were the results homogenous from study
to study?
a. If not, what are the
consequences for this review’s
results?
They all had similar types of intervention and
treatment session, however there was not a
single study that used the same treatment
duration and frequency.
38
41. If the paper is a meta-analysis did they
report the statistical results? Did they
include a forest plat? What other
statistics do they include? Are there CIs?
42. From the findings, is it apparent what
the cumulative weight of the evidence
is?
N/A
N/A
Can you apply this valid, important evidence from this SR in caring
for your patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
43. Is your patient different from those in
this SR?
44. Is the treatment feasible in your setting?
Do you have the facilities, skill set, time,
3rd party coverage to provide this
treatment?
No, my patient is very similar to these studies
populations.
Yes, this treatment is very feasible for the Sklyine
setting they have the facilities, recourses, skills
and 3rd party coverage to provide this treatment,
however this is not a practical treatment for all
pediatric clinics.
Yes.
45. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
What is the bottom line?
Appraisal Criterion
Reader’s Comments
Summarize your findings and relate this back to
clinical significance
Based on this SR findings I can concluded that a
child with cerebral palsy age 4 and up can benefit
from hippotherapy or therapeutic horseback
riding. They are likely to see improvements to
their gross motor function and mobility, more
specifically their walking running, jumping and
postural stability. More research is need to find a
consistence of treatment, but I believe that
hippotherapy will be beneficial to my patient.
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones
and Bartlett Publishers, Sudbury, MA 2008
39
Systematic Review – Evidence Appraisal Worksheet
ARTICLE 4
Citation (use AMA or APA format):
Zadnikar, M., Kastrin, A., (2011) Effects of hippotherapy and therapeutic horseback riding on
postural control or balance in children with cerebral palsy: a meta-analysis Developmental
medicine and child Neurology. (53) 684-691
Level of Evidence (Oxford scale):
2a
Does the design follow the Cochrane method?
Appraisal Criterion
Reader’s Comments
Step 1 – formulating the question
• Do the authors identify the focus of the
review
• A clearly defined question should specify
the types of:
• people (participants),
• interventions or exposures,
• outcomes that are of interest
• studies that are relevant to
answering the question
Step 2 – locating studies
 Should identify ALL relevant literature
 Did they include multiple databases?
 Was the search strategy defined and
include:
o Bibliographic databases used as
well as hand searching
o Terms (key words and index
terms)
o Citation searching: reference lists
o Contact with ‘experts’ to identify
‘grey’ literature (body of
materials that cannot be found
easily through conventional
channels such as publishers)
o Sources for ‘grey literature’
40
This aim of this meta-analysis is to summarize
and evaluate critically the evidence for or against
the effectiveness of hippotherapy and
therapeutic horseback riding in people with
cerebral palsy.
People – People diagnosed with Cerebral Palsy
Intervention – Hippotherapy and/or therapeutic
horseback riding.
Outcome – postural control and balance
Studies – 8 studies met the inclusion criteria
Yes, they identified all relevant literature and
used multiple databases. They performed a
systematic literature search of a total of 11
databases to identify all relevant evidence on
hippotherapy or THR. This included Web of
Science, MEDLINE, Pro Quest, Current Contents,
The Cochrane Library, Cochrane Database of
Systematic Reviews, the Cochrane Controlled
Trials Registers, Ovid, Embase, CINHAL, and
Google Scholar. The following key words were
search, “developmental riding therapy”, “equinemovement therapy”, “riding therapy”, “riding for
disabled”, “therapeutic horseback riding”,
“therapeutic riding”, “hippotherapy”, “cerebral
palsy”, “posture control”, “balance”.
They did not talk about contacting ‘experts’ to
identify any ‘grey’ literature.
Part 3:Critical Appraisal/Criteria for Inclusion
• Were criteria for selection specified?
• Did more than one author assess
the relevance of each report
• Were decisions concerning
relevance described; completed
by non-experts, or both?
• Did the people assessing the
relevance of studies know the
names of the authors,
institutions, journal of
publication and results when
they apply the inclusion criteria?
Or is it blind?
Part 3 – Critically appraise for bias:
• Selection –
• Were the groups in the study
selected differently?
• Random? Concealed?
• Performance• Did the groups in the study
receive different treatment?
• Was there blinding?
• Attrition –
• Were the groups similar at the
end of the study?
• Account for drop outs?
• Detection –
• Did the study selectively report
the results?
• Is there missing data?
Inclusion criteria included a quantitative study
design, the investigation of the effect of
hippotherapy or THR on postural control or
balance and the study group comprised of
children or adults with cerebral palsy.
• Yes, all potentially relevant citations were
reviewed independently by two investigators.
• Yes, by two investigators.
• n/a
Due to the variety of outcomes presented in the
8 studies, the overall quality of each article was
examined using a 16 dichotomous items
evaluating internal and external validity of the
study, its findings, and it conclusions. Studies
included Randomized Control trial, Quasiexperimental designs and prospective
experimental designs.
• Yes
• Yes, the treatment effect on postural control
or balance was coded as a dichotomous
outcome and was easy to follow.
• Yes there was 77 potentially relevant studies
that were identified but only 8 studies fulfilled
the inclusion criteria, they provided reasons
for why the others were excluded.
Part 4 – Collection of the data
 Was a collection data form used and is it
included?
 Are the studies coded and is the data
coding easy to follow?
 Were studies identified that were
excluded & did they give reasons why
(i.e., which criteria they failed).
Are the results of this SR valid?
Appraisal Criterion
Reader’s Comments
46. Is this a SR of randomized trials? Did
they limit this to high quality studies at
the top of the hierarchies
They stated that they use quantitative and
included RCT, PED, and QED, they are not all
41
47.
48.
49.
50.
a. If not, what types of studies
were included?
b. What are the potential
consequences of including these
studies for this review’s results?
Did this study follow the Cochrane
methods selection process and did it
identify all relevant trials?
a. If not, what are the
consequences for this review’s
results?
Do the methods describe the processes
and tools used to assess the quality of
individual studies?
a. If not, what are the
consequences for this review’s
results?
What was the quality of the individual
studies included? Were the results
consistent from study to study? Did
the investigators provide details about
the research validity or quality of the
studies included in review?
Did the investigators address publication
bias
randomized. Only 3 out of the 8 studies were
randomized. The potential consequences for this
is there was a lower level evidence analyzed and
there is a potential for bias.
Yes
Yes, they stated their inclusion and exclusion
criteria. The selected articles were rated for
methodological quality. The treatment effect
was coded as a dichotomous outcome and
quantified by odds ratio. They used a randomeffects model to calculate the treatment effect.
All studies concluded that there was a positive
effect on postural control or balance, however
the eight studies all used different research
methods, tests, instruments and duration of
therapy. They were all extremely variable.
Yes
Are the valid results of this SR important?
Appraisal Criterion
Reader’s Comments
51. Were the results homogenous from
study to study?
a. If not, what are the
consequences for this review’s
results?
52. If the paper is a meta-analysis did they
report the statistical results? Did they
include a forest plat? What other
statistics do they include? Are there CIs?
53. From the findings, is it apparent what
the cumulative weight of the evidence
is?
No there was heterogeneity among the studies.
Yes it is a meta-analysis and they did report the
statistical results. The included a forest plot and
a funnel plot.
They use a CI of 95%
Yes
Can you apply this valid, important evidence from this SR in caring
for your patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
54. Is your patient different from those in
this SR?
55. Is the treatment feasible in your setting?
Do you have the facilities, skill set, time,
No, my patient is very similar to the subjects in
these studies.
Yes, this treatment is very feasible for the Sklyine
setting they have the facilities, recourses, skills
42
3rd party coverage to provide this
treatment?
and 3rd party coverage to provide this treatment,
however this is not a practical treatment for all
pediatric clinics.
Yes
56. Does the intervention fit within your
patient/client’s stated values or
expectations?
b. If not, what will you do now?
What is the bottom line?
Appraisal Criterion
Summarize your findings and relate this back to
clinical significance
Reader’s Comments
This is a well done systemic review that found
that hippotherapy or THR has some positive
effects on postural control or balance in children
with CP. However there still needs to be more
research with larger sample sizes and with more
duration guidelines. I believe this shows me that
hippotherapy is an appropriate and beneficial
treatment to continue doing with my patient.
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones
and Bartlett Publishers, Sudbury, MA 2008
43
Systematic Review – Evidence Appraisal Worksheet
ARTILCE 5
Citation (use AMA or APA format):
Snider, L., Korner-Bitensky, N., Kammann, C., Warner, S., Snalch, M. (2007) Horseback Riding as
Therapy for Children with Cerebral Palsy: Is There Evidence of Its Effectiveness? Physical &
Occupational Therapy in Pediatrics, 27(2), 5-23
Level of Evidence (Oxford scale):
2a
Does the design follow the Cochrane method?
Appraisal Criterion
Reader’s Comments
Step 1 – formulating the question
• Do the authors identify the focus of the
review
• A clearly defined question should specify
the types of:
• people (participants),
• interventions or exposures,
• outcomes that are of interest
• studies that are relevant to
answering the question
The purpose of the systematic review is to
evaluate the literature and evidence related to
hippotherapy and therapeutic horseback riding
as an effective intervention for children with
cerebral palsy.
People - Children with cerebral palsy
Interventions – Hippotherapy or THR
Outcome – PEDro and Newcastle Ottawa Quality
Assessment Scale . They looked at body function,
structural outcome, and muscle symmetry in the
trunk and hip, and participation outcomes.
Studies – They looked at nine studies
Step 2 – locating studies
 Should identify ALL relevant literature
 Did they include multiple databases?
 Was the search strategy defined and
include:
o Bibliographic databases used as
well as hand searching
o Terms (key words and index
terms)
o Citation searching: reference lists
o Contact with ‘experts’ to identify
‘grey’ literature (body of
materials that cannot be found
easily through conventional
channels such as publishers)
o Sources for ‘grey literature’
44
The electronic databases that were search were
MEDLINE, PsychINFO, CINAHL, Current Contents,
and HealthSTAR back to the earliest available
time using the following terms. The key terms
were “horse”, “riding”, “hippotherapy”,
“horseback riding therapy”, “equine movement
therapy”, and “cerebral palsy”. They also
contacted NAEHA, CanTRA, and federation of
Riding for the Disabled International who
provided bibliographies and articles that may not
have been found in the electronic databases.
They did not mention ‘experts’ or ‘grey
literature’ in this study.
Part 3:Critical Appraisal/Criteria for Inclusion
• Were criteria for selection specified?
• Did more than one author assess
the relevance of each report
• Were decisions concerning
relevance described; completed
by non-experts, or both?
• Did the people assessing the
relevance of studies know the
names of the authors,
institutions, journal of
publication and results when
they apply the inclusion criteria?
Or is it blind?
The inclusion criteria for the articles were that
they had to be available in English or German, all
RTCs, quasi- experimental and observational
studies related to -hippotherapy or THR for
children with CP and were peer reviewed. There
were two authors that assessed the nine articles
individually. They did not mention if they knew
the names authors, institutions for publication of
the articles under review.
Part 3 – Critically appraise for bias:
• Selection –
• Were the groups in the study
selected differently?
• Random? Concealed?
• Performance• Did the groups in the study
receive different treatment?
• Was there blinding?
• Attrition –
• Were the groups similar at the
end of the study?
• Account for drop outs?
• Detection –
• Did the study selectively report
the results?
• Is there missing data?
There were three RTC’s, four quasi-experimental
and two descriptive studies. They did not go into
detail about how each study was conducted,
therefore I do not know about if they were
concealed, blinded, missing data, or if there were
any drops outs in the studies.
Part 4 – Collection of the data
 Was a collection data form used and is it
included?
 Are the studies coded and is the data
coding easy to follow?
 Were studies identified that were
excluded & did they give reasons why
(i.e., which criteria they failed).
Collection data form was not included and the
studies were not coded.
They only stated that two articles were excluded
because they used mechanical saddle riding
instead of a live horse.
45
Are the results of this SR valid?
Appraisal Criterion
Reader’s Comments
57. Is this a SR of randomized trials? Did
they limit this to high quality studies at
the top of the hierarchies
a. If not, what types of studies
were included?
b. What are the potential
consequences of including these
studies for this review’s results?
58. Did this study follow the Cochrane
methods selection process and did it
identify all relevant trials?
a. If not, what are the
consequences for this review’s
results?
59. Do the methods describe the processes
and tools used to assess the quality of
individual studies?
a. If not, what are the
consequences for this review’s
results?
They used only high quality studies that included
a total of nine articles. There was 3 RTC’s 4
Quasi-experimental, and 2 descriptive studies.
Yes
Yes, they explain how the articles where grouped
for review and they used a PICO format,
questions deemed relevant to clinician and
answered based of the current evidence. Two
reviewers scored the articles using the PEDro
score and the Newcastle Ottawa Scale. Rating
for levels of evidence were then based on the
recommendations by Sackett (2000).
They was little included about the quality and
research validity of the individual studies. Some
studies had positive outcome other and no
significant different.
Table 2 is a table of summaries of the studies.
60. What was the quality of the individual
studies included? Were the results
consistent from study to study? Did
the investigators provide details about
the research validity or quality of the
studies included in review?
61. Did the investigators address publication
bias
No
Are the valid results of this SR important?
Appraisal Criterion
Reader’s Comments
62. Were the results homogenous from
study to study?
a. If not, what are the
consequences for this review’s
results?
63. If the paper is a meta-analysis did they
report the statistical results? Did they
include a forest plat? What other
statistics do they include? Are there CIs?
64. From the findings, is it apparent what
the cumulative weight of the evidence
is?
46
No, there was heterogeneity among the studies.
If there is too much heterogeneity with a study
then it becomes too difficult to compare them.
No
Yes
Can you apply this valid, important evidence from this SR in caring
for your patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
65. Is your patient different from those in
this SR?
No, he is pretty similar in the fact that he is a
child with CP receiving hippotherapy as an
intervention.
Yes, this treatment is very feasible for the Sklyine
setting they have the facilities, recourses, skills
and 3rd party coverage to provide this treatment,
however this is not a practical treatment for all
pediatric clinics
Yes
66. Is the treatment feasible in your setting?
Do you have the facilities, skill set, time,
3rd party coverage to provide this
treatment?
67. Does the intervention fit within your
patient/client’s stated values or
expectations?
c. If not, what will you do now?
What is the bottom line?
Appraisal Criterion
Reader’s Comments
Summarize your findings and relate this back to
clinical significance
There is a level 2a evidence that hippotherapy is
effective for treating muscle symmetry in the
trunk and hip and that therapeutic horseback
riding is effective for improved gross motor
function when compared with regular therapy.
However there are more short-term positive
effects on muscle symmetry with hippotherapy
Therefore it is important to have a licensed
therapist work with the patient during the
treatment session to facilitate positive therapy
benefits. More research is needed to find the
true effect of hippotherapy or THR has on
children with CP, However this is a potential
beneficial treatment for my patient.
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones
and Bartlett Publishers, Sudbury, MA 2008
47
Intervention – Evidence Appraisal Worksheet
ARTICLE 6
Citation (use AMA or APA format):
Mcgee, M.C., Reese, N. B., (2009), Immediate Effects of a Hippotherapy session on Gait
Parameters in Children with Spastic Cerebral Palsy. Pediatric Physical Therapy. (21), 212-28
Level of Evidence (Oxford scale):
3b
Is the purpose and background information sufficient?
Appraisal Criterion
Study Purpose
Reader’s Comments
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a
question or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you.
Consider how the study can be applied to PT
and/or your own situation. What is the purpose
of this study?
Yes, The purpose of this study was to examine
the immediate effects of hippotherapy session on
temporal and spatial gait parameters in children
with spastic CP
Literature
Yes, there is background information provided.
They discuss the primary pathophysiogical factors
that can hider and child’s gait with CP and how
hippotherapy is theorized to help children with
CP with using the horse multi-dimensional
movement to improve posture, balance, muscle
strength and gait. They talk about the previous
studies that have been conducted. ON which
shows the effects of hippotherapy having
significant improvement in joint angles of the hip
knee and ankle, which lead to a better gait and
another that reported a significant decrease in
energy expenditure during walking along with
other studies that have been published but how
the research is still limited.
Relevant background presented?
A review of the literature should provide
background for the study by synthesizing
relevant information such as previous research
and gaps in current knowledge, along with the
clinical importance of the topic.
Describe the justification of the need for this
study
48
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
Assignment – the subjects were chosen from the
established hippotherapy programs provided by
2 pediatric physical therapy practices, The
children included had to be independent in
walking with or without an assistive device.
Attrition – This was not addressed in this study
History – There were no external events
reported in this study.
Instrumentation – The gait parameters were
measured using the GAITRite Gold Walkway
System and the GAITRIte Gold Version 3.2b
software package was used to store and
calculate the findings. No problems were
reported
Maturation – The data was collected before
hippotherapy session and after all within one day
so there was no risk for change or maturation,
there was no control group.
Compensatory Equalization - N/A no control
group
Compensatory rivalry – N/A
Statistical Regression – N/A
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
 Instrumentation
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
68. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this assignment
process for the study’s results?
69. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
70. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
No, there was no treatment group, just the same
measurements taken before and after the
hippotherpy session (pre-riding measurements
and post-riding
measurements)
No, they were no blinding and no separate
groups. There is the potential for bias here.
N/A
49
71.
72.
73.
74.
75.
76.
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Did the investigators know to which
treatment group subjects were assigned
?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the
authors do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
50
N/A
N/A
N/A
No, they were measuring the immediate results
on gait parameters after a ridding session,
therefore there was no need for a follow-up.
Yes
N/A
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
77. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
78. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
79. Do these findings exceed a minimally
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will
you still use this evidence?
The p values for the temporal gait parameters
ranged from 0.09 to 0.95 and the p values for the
spatial gait parameters ranged from 0.77 to 0.95.
No statistically significant differences were noted
in the post-ride temporal and spatial gait
parameters values when compared to the preride value.
That there are no immediate effects seen in gait
after a single hippotherapy session.
No MCID was not addressed.
Can you apply this valid, important evidence about an intervention
in caring for your patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
80. Does this intervention sound
appropriate for use (available,
affordable) in your clinical setting? Do
you have the facilities, skill set, time, 3rd
party coverage to provide this
treatment?
81. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
82. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
Measuring gait parameter prior and immediately
after a hippotherapy session is not beneficial.
Skyline is able to provide the intervention of
hippotherapy to children with CP however they
do not have the GAITRite system and cannot take
gait analysis.
Yes similar in that they are children with CP
however the participants are older than my
patients and have spastic CP instead of ataxic
and they have a different GMFCS Level.
According to this study, no, there are no
immediate effects from hippotherapy, however I
do not see any adverse effects and believe it is
still a potential treatment.
51
83. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes.
84. Are there any threats to external validity
in this study?
No.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
3
Summarize your findings and relate this back to
clinical significance
This study shows that there are no immediate
effects on temporal or spatial gait parameters in
children with spastic CP after a 30 min
hippotherapy session. However it doesn’t show if
there are positive/negative effects on gait over
an extended amount of time. Other studies have
found a decrease in energy expenditure in gait,
improved GMFM scores and an improvement in
joint alignment. So this is still a potential
treatment for my patient even though you do not
have any immediate positive effects.
52
Pedro Scoring System:
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones
and Bartlett Publishers, Sudbury, MA 2008
53
Intervention – Evidence Appraisal Worksheet
ARTICLE 7
Citation (use AMA or APA format):
Frank, A., McCloskey, S., Dole R. (2011), Percieved self-competence and Participation in a Child
with Cerebral Palsy. Pediatric Physical Therapy. (23) 301-308
Level of Evidence (Oxford scale):
4
Is the purpose and background information sufficient?
Appraisal Criterion
Study Purpose
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a
question or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you.
Consider how the study can be applied to PT
and/or your own situation. What is the purpose
of this study?
Literature
Relevant background presented?
A review of the literature should provide
background for the study by synthesizing
relevant information such as previous research
and gaps in current knowledge, along with the
clinical importance of the topic.
Describe the justification of the need for this
study
Reader’s Comments
This case reported wanted to look at the effects
of hippotherapy on the self-competence and
social acceptance, along with functional skills.
Yes, This paper talks about the prevalence and
the impairments associated with CP and how
researched has looked at the effectiveness of
hippotherapy on posture, motor function and
gait in children with CP. However this is a cap in
the research on how it effects self-competence
and social interactions.
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
Assignment and Attrition - N/A - this is a case
report on a 6 year old girl with mild ataxic CP
54





History
Instrumentation
Maturation
Testing
Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
History - Nothing was reported
Instrumentation – GMFM, PSPCSAYC, and PODCI
Maturation – Study took place over 8 weeks, no
change was report.
Testing: N/A
Compensatory Equalization of Treatments - N/A,
case report
Compensatory Rivalry – N/A
Statistical Regression - N/A
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
85. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this assignment
process for the study’s results?
86. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
87. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
88. Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
89. Did the investigators know to which
treatment group subjects were assigned
?
55
N/A
N/A
N/A
N/A
N/A
90.
91.
92.
93.
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the
authors do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
b. If the data were excluded, what
are the potential consequences
for this study’s results?
N/A
Yes, there was a two-month follow up session.
Yes.
N/A
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
94. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
56
The participant made improvements in gross
motor skills primarily in the domain E of the
GMFM-66. The most notable change occurred
between baseline and follow-up examination,
demonstrating an overlap in the 95% confidence
interval. For the PODCI the participant was below
average at baseline and she improved in all three
categories of the PODCI and by the 2 month
follow up her normative scores on all 3 scales
e. Include NNT and CI
f. Other stats should be included
here
were within 0.5 standard deviations of the
reported mean.
95. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
This particular study did not really look into how
hippotherapy effects gait and balance, although
it did some measurements through the GMFM, it
was study looking at the effectiveness of
hippotherapy on an ataxic CP girl on her selfcompetence and social interaction as well as
some gross motor effects. I believe this study
just demonstrates there are many positive things
that can be gained from participating in a
hippotherapy program for an ataxic child.
The findings in this study far exceed the
minimally important difference for a large effect
sizes
MCID large = 2.7
96. Do these findings exceed a minimally
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will
you still use this evidence?
Can you apply this valid, important evidence about an intervention
in caring for your patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
97. Does this intervention sound
appropriate for use (available,
affordable) in your clinical setting? Do
you have the facilities, skill set, time, 3rd
party coverage to provide this
treatment?
98. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
99. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
100.
Does the intervention fit within
your patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes
Yes they are both with a year of age and both
diagnosed with ataxic CP
Yes.
Yes.
101.
Are there any threats to external
validity in this study?
No.
57
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
2
Summarize your findings and relate this back to
clinical significance
This case study demonstrates that hippotherapy
may influence a child’s functional ability, level of
participation and sense of self-competence as
well as gross motor functions. There is a positive
relationship between them and hippotherapy is a
potentially beneficial treatment for a child with
ataxic CP. So not only will hippotherapy help my
patient to have better balance and a better gait,
but it may also help his social skills and selfcompetence.
58
Pedro Scoring System:
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones
and Bartlett Publishers, Sudbury, MA 2008
59
Intervention – Evidence Appraisal Worksheet
ARTICLE 8
Citation (use AMA or APA format):
Chang, H.J., Kwon, J.Y., Lee, J.Y., Kim, Y.H. (2012). The Effects of Hippotherapy on the motor
function of children with Spastic Bilateral Cerebral Palsy. J Phys Ther Sci, (24), 1277-1280
Level of Evidence (Oxford scale):
2c
Is the purpose and background information sufficient?
Appraisal Criterion
Study Purpose
Reader’s Comments
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a
question or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you.
Consider how the study can be applied to PT
and/or your own situation. What is the purpose
of this study?
Yes, It states that the aim of this study was to
investigate whether hippotherapy could improve
the functional performance of preschool and
school aged children with spastic bilateral CP.
Literature
Relevant background presented?
A review of the literature should provide
background for the study by synthesizing relevant
information such as previous research and gaps
in current knowledge, along with the clinical
importance of the topic.
Describe the justification of the need for this
study
Yes, the present what hippotherapy is, the
theories behind its benefits and discuss several
previous studies that have looked at
hippotherapy as a treatment for children with
cerebral palsy.
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
Assignment – was not randomized. The used 33
children with CP and divided them into two
groups using their GMFCS levels. Levels I and II
were placed in group A and Levels III and IV were
placed in group B. The participants served as
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
60




Instrumentation
Maturation
Testing
Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
their own controls in this within-subject
controlled study.
Attrition – Was not stated.
History – No external events on history were
reported
Instrumentation – They used the SPSS software
for their statistical analyses and the KolmogorovSmirnov test. They also used the GMFM and PBS
for measurements.
Maturation – There was no maturation reported.
The study took a total of 16 weeks (8 weeks prior
to testing and 8 weeks after intervention) There
was not much time for growth and change to
occur.
Testing – Participants were tested 3 times using
the GMFM and PBS. 8 weeks prior to the
hippotherapy, immediately before the first
session and after completion of all hippotherapy
sessions.
Compensatory Equalization of treatments – N/A
the subjects served as their own control
Compensatory rivalry – N/A the subjects served
as their own control
Statistical regression – N/A
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
102.
Did the investigators randomly
assign subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this assignment
process for the study’s results?
103.
Did the investigators know who
was being assigned to which group prior
to the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
104.
Were the groups similar at the
start of the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
No, the two groups were divided by their GMFCS
level.
There groups are not similar and therefore with
have very different outcomes.
Yes, there was no control group and the two
groups were divided by their GMFCS level. There
should be a separate control group that are
blinded to the investigators to prevent a
potential bias.
Yes, because they subjects served as their own
control.
61
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
105.
Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
106.
Did the investigators know to
which treatment group subjects were
assigned ?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
107.
Were the groups managed
equally, apart from the actual
experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
108.
Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
109.
Did all the subjects originally
enrolled complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the
authors do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
110.
Were all patients analyzed in the
groups to which they were randomized
(i.e. was there an intention to treat
analysis)?
a. If not, what did the authors do
with the data from these
subjects?
62
No, there was only one group.
No, it stats that all examiners were blinded to the
intervention in order to reduce possible bias.
Yes, they all received the same treatment.
No, there was no follow up stated, just an
immediate post test after the 8 week
intervention. Therefore we do not know if there
is a carryover or a long term effect from this
treatment.
Not stated.
N/A
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
111.
What were the statistical
findings of this study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
112.
What is the meaning of these
statistical findings for your
patient/client’s case? What does this
mean to your practice?
In group A there was a significantly increase in
score in dimension E of the GMFM and in group
B there was a significantly increased in the
dimensions of C, D and E.
There was a significantly increased after
hippotherapy compared with the pre-riding
period (p>.01)
These finding show me that hippotherapy is
more beneficial for children at a higher level or a
greater GMFCS level. There is greater
improvement in walking running jumping
(dimension E of the GMFM)
The MCID is not mentioned or discussed in this
study, however I believe this evidence is still
relevant to my patient.
113.
Do these findings exceed a
minimally important difference? Was
this brought up or discussed?
a. If the MCID was not met, will
you still use this evidence?
Can you apply this valid, important evidence about an intervention
in caring for your patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
114.
Does this intervention sound
appropriate for use (available,
affordable) in your clinical setting? Do
you have the facilities, skill set, time, 3rd
party coverage to provide this
treatment?
115.
Are the study subjects similar to
your patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
This intervention is appropriate for Skyline
because they have the available resources,
facilities and skill set to provide hippotherapy.
However this is not practical for all pediatric
clinical settings.
Yes, they are similar in the fact that they are all
children with cerebral palsy. However they have
bilateral spastic cerebral palsy and my patient
has ataxic cerebral palsy. I believe I can still use
this intervention despite the difference.
63
116.
Do the potential benefits
outweigh the potential risks using this
intervention with your patient/client?
117.
Does the intervention fit within
your patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes
118.
Are there any threats to external
validity in this study?
No
Yes
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
3
Summarize your findings and relate this back to
clinical significance
This study found that hippotherapy is more
beneficial for improving the higher level of
functions, such as walking, running, and jumping
in children with spastic cerebral palsy. Which is
clinically significant for my patient. He wants to
improve his walking and be able to run. There is
still the issue of spastic CP versus ataxic CP
however I believe this is still useful and can have
carry over to my patient.
I did not agree with using the subjects as their
own control. It is possible that the participants
could have gotten better over the 16 weeks due
to just growth and self-practice, therefore there
needs to be a control with a similar control group
64
Pedro Scoring System:
1=no, 2=no, 3=no, 4=no, 5=no, 6=yes, 7 yes, 8= yes
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones
and Bartlett Publishers, Sudbury, MA 2008
65
Systematic Review – Evidence Appraisal Worksheet
ARTICLE 9
Citation (use AMA or APA format):
Tseng, S., Chen, H., Tam, K., (2013), Systematic review and meta-analysis of the effect of equine
assisted activities and therapies on gross motor outcome in children with cerebral palsy.
Disability and Rehabilitation, 35(2), 89-99
Level of Evidence (Oxford scale):
Does the design follow the Cochrane method?
Appraisal Criterion
Reader’s Comments
Step 1 – formulating the question
• Do the authors identify the focus of the
review
• A clearly defined question should specify
the types of:
• people (participants),
• interventions or exposures,
• outcomes that are of interest
• studies that are relevant to
answering the question
To evaluate the literature on the efficacy of
equine assisted activities and therapies (EAAT) on
gross motor outcome representing the ICF
component of body functions and activity in
children with cerebral palsy.
People – Children with cerebral palsy
Interventions/exposures – hippotherpay
Outcomes –
Studies – 5 TR, 9 THOT
Step 2 – locating studies
 Should identify ALL relevant literature
 Did they include multiple databases?
 Was the search strategy defined and
include:
o Bibliographic databases used as
well as hand searching
o Terms (key words and index
terms)
o Citation searching: reference
lists
o Contact with ‘experts’ to identify
‘grey’ literature (body of
materials that cannot be found
easily through conventional
channels such as publishers)
o Sources for ‘grey literature’
Yes they identified all relevant literature by
searching the following databases, MEDLINE,
EMBASE, CINAHL, PEDro, Chochran, and SCOPUS.
They also did hand searches and searched texts
to find any other relevant articles. The key terms
were,” cerebral palsy”, “hippotherapy”,
“horseback riding”, and “therapeutic horse
riding”.
They did not mention anyone that identified the
‘grey’ literature.
66
Part 3:Critical Appraisal/Criteria for Inclusion
• Were criteria for selection specified?
• Did more than one author assess
the relevance of each report
• Were decisions concerning
relevance described; completed
by non-experts, or both?
• Did the people assessing the
relevance of studies know the
names of the authors,
institutions, journal of
publication and results when
they apply the inclusion criteria?
Or is it blind?
They inclusion criteria consisted of, the studies
had to be and RTC or observation studies, the
children evaluated had to be under the age of 18
with a diagnosis of CP, the studies inclusion and
exclusion criteria had to be clearly defined, the
protocol of the horseback riding techniques had
to be documented, and the definition and
measurement of gross motor outcome at body
function and activity level had to be clear. The
exclusion criteria consisted of, the trial included
come children without CP, the outcomes of
interested were not objectively measured,
overlap was present between patient cohorts in
the published literature, the trial had not used
real horses, or the study was no published in a
peer reviewed journal.
…………..
Part 3 – Critically appraise for bias:
• Selection –
• Were the groups in the study
selected differently?
• Random? Concealed?
• Performance• Did the groups in the study
receive different treatment?
• Was there blinding?
• Attrition –
• Were the groups similar at the
end of the study?
• Account for drop outs?
• Detection –
• Did the study selectively report
the results?
• Is there missing data?
Selection – the studies selected had to be a RTC
or an observational study.
Performance – all of the studies treatment had to
do with Hippotherapy or THR, details of each
articles intervention was not provided however is
was stated that the intervention duration ranged
from 8 minutes to 26 hours in length. Blinding
was mentioned in 7 of the 14 studies that were
looked at.
Attrition – This was not reported for the
individuals studies that were in this SR
Detections – They did not report the detection or
whether there was any missing data from the
studies that they reviewed. They did state that
they excluded any study that had incomplete
data.
Part 4 – Collection of the data
 Was a collection data form used and is it
included?
 Are the studies coded and is the data
coding easy to follow?
 Were studies identified that were
excluded & did they give reasons why
(i.e., which criteria they failed).
Yes the collection data form was used and their
coding for each article is clear. They excluded
studies that did not meet their inclusion criteria
or had a component of their exclusion criteria.
They excluded other studies that looked at
developmental delay other than CP or if there
was an absence of clearly defined intervention
protocol or incomplete data.
67
Are the results of this SR valid?
Appraisal Criterion
Reader’s Comments
119.
Is this a SR of randomized trials?
Did they limit this to high quality studies
at the top of the hierarchies
a. If not, what types of studies
were included?
b. What are the potential
consequences of including these
studies for this review’s results?
120.
Did this study follow the
Cochrane methods selection process and
did it identify all relevant trials?
a. If not, what are the
consequences for this review’s
results?
121.
Do the methods describe the
processes and tools used to assess the
quality of individual studies?
a. If not, what are the
consequences for this review’s
results?
122.
What was the quality of the
individual studies included? Were the
results consistent from study to study?
Did the investigators provide details
about the research validity or quality
of the studies included in review?
123.
Did the investigators address
publication bias
Yes, this SR looked at RCT’s and observational
studies.
Yes
Yes, they assess the quality. The study design of
each trial was assessed, and the level of evidence
for each study was ranked according the
hierarchy of evidence proposed by Sackett.
Yes the quality of the individual studies were
included they concluded that the level of
evidence for the 14 articles was a level 4
evidence.
Not all of the individual investigators and authors
reported on their research validity or quality.
No
Are the valid results of this SR important?
Appraisal Criterion
Reader’s Comments
124.
Were the results homogenous
from study to study?
a. If not, what are the
consequences for this review’s
results?
125.
If the paper is a meta-analysis
did they report the statistical results?
Did they include a forest plat? What
other statistics do they include? Are
there CIs?
No there was heterogeneity from study to study,
they duration of intervention ranged from 8min
to 26hrs and the children with CP had different
levels of impairment.
Yes this is a meta- analysis, they did report their
findings and included a forest plot.
Statistical analysis for reduced hip adductor
asymmetry scores (-32, 95% CI: -61.38 to -3.01)
68
126.
From the findings, is it apparent
what the cumulative weight of the
evidence is?
Yes
Can you apply this valid, important evidence from this SR in caring
for your patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
127.
Is your patient different from
those in this SR?
No they are very similar. My patient is a 5 year
old boy with ataxic CP who is using hippotherapy
as an intervention, the studies that were
reviewed all had children with CP from the ages
of 2 – 18 years that used hippotherapy or THR as
the intervention.
Yes, this treatment is very feasible for the Sklyine
setting they have the facilities, recourses, skills
and 3rd party coverage to provide this treatment,
however this is not a practical treatment for all
pediatric clinics.
Yes
128.
Is the treatment feasible in your
setting? Do you have the facilities, skill
set, time, 3rd party coverage to provide
this treatment?
129.
Does the intervention fit within
your patient/client’s stated values or
expectations?
d. If not, what will you do now?
What is the bottom line?
Appraisal Criterion
Summarize your findings and relate this back to
clinical significance
Reader’s Comments
This systematic review looked at 14 studies and
reported the effectiveness of hippotherapy and
THR intervention on gross motor outcomes in
children with CP they found that there are
positive short term effects from hippotherapy
and THR that can reduce asymmetrical hip
adductor activity and asymmetrical muscle
activity. They found that hippotherapy but not
THR is effective in improving postural control.
However they were unable to confirm the long
term effects of hippotherapy and THR on gross
motor function in children with CP and how it
effects gait patterns. Hippotherapy is potentially
a beneficial treatment for my patient to improve
his gait.
69
APPENDIX B: STUDY SUMMERIES
Kwon. J., Chang, H.J., Young Lee, J., Ha, Y,. Lee, P., Kim, Y., (2011). Effects of Hippotherapy on
Gait parameters in Children With Bilateral Spastic Cerebral Palsy. Arch Phys Med Rehabil, (92),
774-779
Level of evidence: 2c
PEDro: 4
Purpose: To evaluate the effects of hippotherapy on temporospatial parameters and pelvic/hip
kinematics of gait in children with bilateral spastic cerebral palsy.
Methods: This study was a nonrandomized prospective controlled trial that involved 32
children. They received 30 minutes of hippotherapy twice a week for 8 consecutive weeks in
addition to conventional physiotherapy. The inclusion criteria included: diagnoses of spastic
bilateral CP, a Gross Motor Function Classification System Level of I or II, body weight of less
than 35kg, and between the ages of 4 and 10. They exclusion criteria was: botulinum toxic
injection with the past 6 months, selective dorsal rhizotomy or othorpedic surgery within the
past year, moderate to severe intellectual disability, uncontrolled seizures and poor visual or
hearing acuity. They analyzed their temporospatial and kinematics of their gait with the Vicon
612 Motion Analysis system
Results: Walking speed increased in both groups after intervention. In the hippotherapy group
the stride length increased significantly with no change in cadence. In the control group the
cadence increased. There was no statistical significance differences in the pelvic and hip
kinematic parameters in the sagittal plane between the 2 groups however in the hippotherapy
group a decrease in average pelvic anterior tilt was noted during gait at terminal stance and
initial contact. There was a statistically significant interaction between interventions were
noted in the scores for dimension E of the GMFM and the PBS
Critique/Bottom line: This is the first prospective controlled clinical trial to show the beneficial
effects that hippotherapy can have on temporospatial parameters and pelvic kinematics on
gait. This study showed that hippotherapy can improve walking speed, stride length and pelvic
kinematics and can improve a child’s GMFM score. If hippotherapy is used in conjunction with
standard physical therapy in may help improve gait and balance in a child with bilateral spastic
cerebral palsy. However this study did not use a control group, it was a small sample size and
their gait parameters did not reach sufficient statistical power. Therefore more randomized
control trial need to be done to research the effects of hippotherapy on gait parameters in
children with CP.
70
Davis, E., Davis, B., Wolfe, R., Raadsveld, R., Heine, B., Thomason, P., Dobson, F., Graham H.K.,
(2009). A randomized controlled trail of the impact of therapeutic horse riding on the quality of
life, health, and function of children with cerebral palsy. Developmental Medicine and Child
Neurology, (51), 111-119
Level of Evidence: 1b
PEDro: 5
Purpose:
This Randomized controlled trial examined whether therapeutic horse riding has a clinically
significant impact on the physical function, health and quality of life of children with cerebral
palsy.
Methods:
There were 99 children that participated in the study, they had to have a diagnosis of cerebral
palsy, be between the ages of 4 to 12, never had prior horse riding experience, had to live
within a 50 to 100 km radius of the riding venue, and had to have a Gross Motor Function
Classification System GMFCS Level of I to III. They participants could not have participated in a
previous THR program. The participated were recruited from the Victorian Cerebral Palsy
Register. This was a randomized controlled trial and the participants were randomly allocated
to the intervention or control groups. They performed a quality of life questionnaire, GMFM-66,
a child health questionnaire 1 to 6 weeks before the intervention and then in the 6 weeks after
the 10 week riding program
Results:
They found no significance difference in the GMFM score between the intervention group and
the control group after the 10 week riding program. (p=0.45) There was no difference in the
Quality of Life scores and Child Health scores between the 2 groups after the 10 week riding
program.
Critique/Bottom line:
The results of this study demonstrated that a 10 week therapeutic horse riding program did not
increase the gross motor function, health, quality of life in children with cerebral palsy.
However this was therapeutic riding and not hippotherapy where a licensed physical therapist
is present for the session to facilitate proper alignments and movements. This study also was
more interested in investigating the effects that riding has on quality life and general health
instead of gait, balance and gross motor abilities.
71
Whalen, C., Case-Smith, J. (2011) Therapeutic Effects of Horseback Riding Therapy on Gross
Motor Function in Children with Cerebral Palsy: A Systematic Review. Physical & Occupational
Therapy in Pediatrics, (32), 229-242
Level of Evidence: 2a
PEDro: N/A
Purpose: The purpose of this systematic review is to examine the efficacy of hippotherapy and
therapeutic horseback riding in children with cerebral palsy on motor outcomes through
synthesis of research evidence.
Methods: They following databases were search to identify the appropriate studies: PubMed,
Cochrane Reviews, CINAHL plus with full text, Ovid Medline and EBSCOhost Medline with full
text. The following keywords were used “cerebral palsy”, “therapeutic riding”, “therapeutic
horseback riding”, “horse riding”, “horseback riding”, “hippotherapy”, “equine-assisted
therapy”, “developmental riding therapy”, and “riding for the disabled”. They authors also
searched relevant article links on the databases and research reports from their referenced lists
to assemble a comprehensive list of hippotherapy and THR studies to find any other potential
articles. The inclusion criteria included that subjects all had to be diagnosed with CP, the
primary intervention was hippotherapy or THR, mobility or gross motor outcomes was
investigated and a PT, OT or accredited therapeutic riding instructor was present during
intervention. The exclusion criteria excluded any studies that included horse simulation or
barrel sitting, was published prior to 1985, or older the age of 18 and was not available in full
text or English.
Results: A total of 63 articles were identified but only nine of these articles met the criteria and
quality the authors were looking for. All of these studies had similar types of intervention and
treatment session. Six out of the nine studies looked as spastic CP. They found that the current
available evidence is weak however 6 out of those 7 studies found a positive outcome of
hippotherapy and THR on gross motor function and mobility with moderate to large effects and
the studies demonstrated positive effects on the samples of children that were 4 years or older.
They overall found that children with CP age 4 or older are likely to have a significant
improvement on gross motor function as a result of hippotherapy or THR.
Critique/Bottom line: The current level on hippotherapy and THR is limited and rather weak.
There needs to be more research done with larger sample size and using randomized control
trial protocols. However the evidence indicates that a 45 min session of hippotherapy or THR
has positive effects on gross motor function in children with CP.
72
Zadnikar, M., Kastrin, A., (2011) Effects of hippotherapy and therapeutic horseback riding on
postural control or balance in children with cerebral palsy: a meta-analysis Developmental
Medicine and Child Neurology. (53) 684-691
Level of Evidence: 2a
PEDro: N/A
Purpose: The purpose of this SR and meta-analysis it to present an overview of the effects of
hippotherapy and therapeutic horseback riding on postural control or balance in children with
cerebral palsy.
Methods: A systematic literature search was completed in 11 medical, scientific and arts
bibliographical databases to identify relevant studies to the effectiveness of hippotherapy and
THR for children with CP. The databases used were: Web of Science, MEDLINE, ProQuest,
Current Contents, The Cochran Library, Cochrane Database of Systematic Reviews, The
Cochrane Controlled Trials Registers, Ovid, Embase, CINHAL, and Google Scholar. The key
Terms that were used were “developmental riding therapy”, “equine-movement therapy”,
“riding therapy”, “riding for disabled”, “therapeutic horseback riding”, “therapeutic riding”,
“hippotherapy”, “cerebral palsy”, “posture control”, “balance”. Inclusion criteria included a
quantitative study design, the investigation of the effect of hippotherapy or THR on postural
control or balance and the study group comprised of children or adults with cerebral palsy. The
study-specific treatment effects were quantified by odds ratio with a 95% confidence interval.
Results: They found a total of 77 potentially relevant studies however only eight studies met
their inclusion criteria and were agreeable with the others. These 8 studies include 84 children
with CP in the intervention group, 76 of them had positive effects. The comparison groups
included 89 children, 21 of those children felt positive effects from continuations of their
regular PT and/or OT. There was heterogeneity found among the studies, the studies used
different research methods and test, the instruments for measuring the effects were very
diverse and the duration of therapy was extremely variable. All studies showed a positive
effect after treatment with hippotherapy or THR, however only 3 studies found a statistically
significant association.
Critique/Bottom line: The current literature found by this SR states that postural control and
balance were improved during hippotherapy and THR. Although the generalization of these
finding may be restricted by the relatively small sample size, the results clearly demonstrate
that hippotherapy is indicated to improve postural control and balance with children with CP.
73
Snider, L., Korner-Bitensky, N., Kammann, C., Warner, S., Snalch, M. (2007) Horseback Riding as
Therapy for Children with Cerebral Palsy: Is There Evidence of Its Effectiveness? Physical &
Occupational Therapy in Pediatrics, 27(2), 5-23
Level of Evidence: 2a
PEDro: N/A
Purpose: the purpose of the systematic review is to evaluate the literature and evidence related
to hippotherapy and therapeutic horseback riding as an effective intervention for children with
cerebral palsy.
Methods: The electronic databases that were search were MEDLINE, PsychINFO, CINAHL,
Current Contents, and HealthSTAR back to the earliest available time using the following terms.
The key terms included “horse”, “riding”, “hippotherapy”, “horseback riding therapy”, “equine
movement therapy”, and “cerebral palsy”. The inclusion criteria for the articles were that they
had to be available in English or German, all RTCs, quasi- experimental and observational
studies related to -hippotherapy or THR for children with CP and were peer reviewed. They
included a total of nine articles, there was 3 RTC’s 4 Quasi-experimental, and 2 descriptive
studies. The articles were put into a hippotherapy or a THR group. They looked at the
population, intervention, comparison/controls and the outcome measurements of each study.
There were two reviewers that rated the articles independently and if there was any
discrepancies they would discusses it to come to an agreement. Rating for levels of evidence
were based on recommendations by Sackett (2000) which was adapted to include the PEDro
score
Results: The results were put into two groups, evidence for Hippotherapy and evidence for
Therapeutic Horseback Riding. They looked at 1) In children with CP is hippotherapy more
effective than no intervention, placebo intervention, or alternative intervention for body
function and structure outcomes. They found a Level 2a evidence for hippotherapy and for THR.
In children with CP is hippotherapy more effective than no intervention, placebo intervention,
or alternative intervention for activities outcomes. They found a Level 3 evidence for
hippotherapy and a Level 2a evidence for THR. 3 In children with CP is hippotherapy more
effective than no intervention, placebo intervention, or alternative intervention for
participation outcomes. They found a Level 5 for both hippotherapy and THR. So there is
evidence suggesting that for children with CP, THR and Hippotherapy may be beneficial for
improving body function and structure and activities.
Critique bottom line: There is a level 2a evidence that hippotherapy is effective for treating
muscle symmetry in the trunk and hip and that therapeutic horseback riding is effective for
improved gross motor function when compared with regular therapy. However there are more
short-term positive effects on muscle symmetry with hippotherapy Therefore it is important to
have a licensed therapist work with the patient during the treatment session to facilitate
positive therapy benefits. More research is needed to find the true effect of hippotherapy or
THR has on children with CP, However this is a potentially beneficial treatment for my patient.
74
Mcgee, M.C., Reese, N. B., (2009), Immediate Effects of a Hippotherapy session on Gait
Parameters in Children with Spastic Cerebral Palsy. Pediatric Physical Therapy. (21), 212-228
Level of Evidence: 3b
PEDro: 3
Purpose: The purpose of this study was to examine the immediate effects of hippotherapy
session on temporal and spatial gait parameters in children with spastic CP
Methods: This study used 9 children, 6 girls and 3 boys that were from the ages of 7 to 18 and
who had a diagnosis of CP. The subjects were chosen from the established hippotherapy
programs provided by 2 pediatric physical therapy practices. The children included had to be
independent in walking with or without an assistive device. The inclusion criteria for this article
was the participants had to be able to walk a minimum of 10 ft on the GAITRite walkway
independently using usual footwear, including any orthoses typically worn, they had to be able
to walk with in the width of the GAITRite walkway independently, and they had to be able to
follow directions, and have no lower extremity casting or surgical procedures within 3 months.
The gait parameters were measured using the GAITRite Gold Walkway System and the GAITRIte
Gold Version 3.2b software package was used to store and calculate the findings. The
participates gait data was collected on location at the hippotherapy facility immediately before
and after they had the hippotherapy session.
Results: The p values for the temporal gait parameters ranged from 0.09 to 0.95 and the p
values for the spatial gait parameters ranged from 0.77 to 0.95. No statistically significant
differences were noted in the post-ride temporal and spatial gait parameters values when
compared to the pre-ride value. The results indicated that there are no significant changes that
occur with gait parameters immediately after hippotherapy session for children with CP.
Critique/Bottom line: This study just looked at the immediate effects on gait after just one
hippotherapy session. They did not look at if there were any long term effects or effects after
multiple session. They also had a very small sample size and the subjects were very different.
So for this study they found that there is no statistically significant changes on the gait
parameters post-ride as compared to the pre-ride gait parameters. There needs to be further
research done on how hippotherapy effects gait in children with CP.
75
Frank, A., McCloskey, S., Dole R. (2011), Perceived self-competence and Participation in a Child
with Cerebral Palsy. Pediatric Physical Therapy. (23) 301-308
Level of Evidence: 4
PEDro: 2
Purpose: This case reported wanted to look at the effects of hippotherapy on the selfcompetence and social acceptance, along with functional skills.
Methods: This is a case study on a 6 year old girl who is diagnosed with mild ataxic cerebral
palsy, she is a level I on the Gross Motor Function Classification System. They used the Gross
Motor Function Measure – 66 the Motor Ability Interval Scores, the Pediatric Outcome Data
collection Instrument score and normative score and the Pictorial of Perceived Competence
and Social Acceptance for Young Children Scores and tested her at her baseline prior to any
hippotherapy intervention, after the 8 week intervention and at a 2 month follow up. The 8
week hippotherapy program consisted of 2 times a week for a total of 16 session over the 8
weeks. Each session was 45 minutes which included hippotherapy and land-based therapeutic
exercise. The same physical therapist provided each treatment and gathered all measurements
at baseline, end of the 8 week intervention and at the 2 month follow up
Results: The patient had an improvement if the GMFM particular in dimension E between
baseline and the follow-up examination. She showed improvement in all 3 scales of the POCDI.
In the PSPSAYC her self-assessment yielded higher rating in the areas of physical competence
and maternal acceptance. She was able to make progress towards her goals.
Critique/Bottom line: Hippotherapy can be used as a therapeutic intervention to not only
improve a child with CP gross motor function but also help them carry out functional activities
and participate in life situation that improve their quality of life. This study demonstrated the
hippotherapy has positively affected this girl with ataxic CP functional ability, level of
participation, gross motor ability and sense of self-competence
76
Chang, H.J., Kwon, J.Y., Lee, J.Y., Kim, Y.H. (2012). The Effects of Hippotherapy on the motor
function of children with Spastic Bilateral Cerebral Palsy. J Phys Ther Sci, (24), 1277-1280
Level of Evidence:
PEDro: 3
Purpose: The purpose of this study was to investigate whether hippotherapy could improve the
functional performance of children with spastic bilateral cerebral palsy. They assessed whether
the therapeutic effects of hippotherapy would be different according to the functional statuses
of the participants.
Methods: There was 34 children, 19 males and 14 females with a mean age of 72.3 months,
that participated in the study who received 30 minutes of hippotherapy twice a week for 8
consecutive weeks. The used the Gross Motor Function Measure and the Pediatric Balance
Scale to obtain values during pre –riding control period, right before the received their 1st
session of hippotherapy and after they completed the 8 week sessions of hippotherapy. The
exclusion criteria included botulinum toxin injection within six months, orthopedic operations
such as tendon lengthening within one year, history of selective dorsal rhizotomy, moderate to
severe intellectual disability and poor visual or hearing acuity. The children were divided into
two groups, Group A which consisted on children with GMFCS levels I and II and Group B which
included children with a GMFCS level III and IV. All examiners were blinded to the intervention
in order to prevent bias and the individual children served as their own controls in this withinsubject controlled study.
Results: The total GMFM scores and the PBS did not change during the pre-riding control
period, however the GMFM total score and the PBS scores significantly improved after the
hippotherapy session in the children with CP. In the GMFM there was significant increase in
dimensions D and E after hippotherapy compared to the pre-riding scores. The PBS scores that
were taken 8 weeks before hippotherapy in the pre-riding control period, were
28.2 +/- 16.6. The scores that was taken right before the first hippotherapy session was 28.0
+/- 15.8 and the score after completion of hippotherapy sessions was 32.6 +/- 16.4. The PBS
scores significantly increased after the hippotherapy session compared to the pre-riding control
period.
Critique/Bottom line: This study shows that hippotherapy can improve gross motor function
and balance in children with spastic bilateral CP without having any adverse effects. This is a
potentially good intervention that should be considered as an effective therapeutic method for
children with spastic CP.
77
Tseng, S., Chen, H., Tam, K., (2013), Systematic review and meta-analysis of the effect of equine
assisted activities and therapies on gross motor outcome in children with cerebral palsy.
Disability and Rehabilitation, 35(2), 89-99
Level of Evidence: 1a
PEDro:
Methods:
They searched the following databases, MEDLINE, EMBASE, CINAHL, PEDro, Chochran, and
SCOPUS. They also did hand searches and searched texts to find any other relevant articles.
The key terms were,” cerebral palsy”, “hippotherapy”, “horseback riding”, and “therapeutic
horse riding”. They inclusion criteria consisted of, the studies had to be and RTC or observation
studies, the children evaluated had to be under the age of 18 with a diagnosis of CP, the studies
inclusion and exclusion criteria had to be clearly defined, the protocol of the horseback riding
techniques had to be documented, and the definition and measurement of gross motor
outcome at body function and activity level had to be clear. The exclusion criteria consisted of,
the trial included come children without CP, the outcomes of interested were not objectively
measured, overlap was present between patient cohorts in the published literature, the trial
had not used real horses, or the study was no published in a peer reviewed journal.
Results:
This systemic review looked at 14 studies and reported the effectiveness of horseback riding
intervention on gross motor outcomes in children with CP. They found a level 4 evidence
between these studies. They looked at postural control muscle tone, gait and GMFM scores
The found the there is a positive short term effect on asymmetrical hip adductor activity and
reduced asymmetrical muscle activity in their body. They found that hippotherapy but not THR
is effective in improving postural control. However they were unable to confirm the long term
effects of hippotherapy and THR on gross motor function in children with CP and how it effects
gait patterns.
Critique/Bottom line:
This is a high level SR that only looked at higher quality studies. The found that equine assisted
activities and therapies may help improve asymmetrical muscles and improve postural control
in children with CP. Some of the studies limitations were the intervention was not used in
isolation, making it difficult to conclude what treatment they were responding to. Most of the
studies also had small samples sizes and recruited their participants from a convenient group of
clients. There needs to be more structured studies done on how hippotherapy and THR effect
children with CP.
78
APPENDIX C: TABLES
Table 1. Grading and Results
#
1
2
Study
&
Origin
Accept
Results to
Answer
Clinical
Question
Oxford
Level of
Evidence
Pedro
Score
Purpose of
Study
Outcome
Measures
Results
Kwon, JY.
(2011)
Gunpo,
Republic
of Korea
2c
4
To evaluate the effects of
hippotherapy on
temporospatial parameters
and pelvic/hip kinematics
of gait in children with
bilateral spastic cerebral
palsy.
Temporospatial
parameters and pelvic and
hip kinematic parameters
in 3-dimensional motion
analysis, Gross Motor
Function Measure, and
score for dimensions D and
E of the GMFM and
Pediatric Balance Scale
Hippotherapy significantly improved
walking speed, stride length and pelvic
kinematics, Scores for dimension E of
the GMFM and PBS also increased
Yes
Davis, E.
(2009)
Melbourn
e,
Australia
1b
5
This Randomized
controlled trial examined
whether therapeutic horse
riding has a clinically
significant impact on the
physical function, health
and quality of life of
children with CP
Quality of life, Gross Motor
Function Measure,
Quality of life, Child’s
health status.
A 10 week Therapeutic horse riding
program did not have a clinically
significant impact for a child with CP
quality of life, Gross Motor Function
measure or health status.
No
79
2a
n/a
This SR examined the
efficacy of hippotherapy or
THR on children with CP
PEDro Score, Effects of
hippotherapy and THR
Current literature on hippotherapy and
THR is limited. From current evidence it
appears that hippotherapy and THR
have positive effects on gross motor
function in children with CP
Yes
3
Whalen C.
(2011)
Columbus
OH, USA
2a
n/a
To present and overview of
the effects of
hipppotherapy and THR on
postural control balance in
children with CP
Effects on postural control
or balance.
2a
n/a
3b
3
No statistically significant differenced
were noted in the post-ride temporal
and spatial gait parameter values when
compared with the pre-ride values.
Yes
6
McGee, M.
(2009)
Conway
AK, USA
The purpose of the
systematic review is to
evaluate the literature and
evidence related to
hippotherapy and
therapeutic horseback
riding as an effective
intervention for children
with cerebral palsy.
The purpose of this study
was to examine the
immediate effects of
hippotherapy session on
temporal and spatial gait
parameters in children with
spastic CP
PEDro Score, Newcastle
Ottawa Quality Assessment
Scale
5
Sinder, L.
(2007)
Montreal,
Canada
The current literature found that
postural control and balance were
improved during hipppotherapy and
THR. Although the generalization of
these finding may be restricted by the
relatively small sample size, the results
clearly demonstrate that riding therapy
is indicated to improve postural control
and balance with children with CP
There is a level 2a evidence that
hippotherapy is effective for treating
muscle symmetry in the trunk and hip
and that therapeutic horseback riding
is effective for improved gross motor
function when compared with regular
therapy
Yes
4
Zadnikar
M. (2011)
Kamnik,
Slovenia
Temporal and spatial
parameters of gait
80
Yes
7
8
9
Frank, A.
(2011)
West
Chester,
PA, USA
4
2
This case reported wanted
to look at the effects of
hippotherapy on the selfcompetence and social
acceptance, along with
functional skills.
Chang, H.J.
(2012)
Seoul,
South
Korea
2c
3
The purpose of this study
was to investigate whether
hippotherapy could
improve the functional
performance of preschool
and school aged children
with spastic bilateral CP.
Tseng, SH,
(2012)
Taipei,
Taiwan
1a
To evaluate the literature
on the efficacy of equine
assisted activities and
therapies (EAAT) on gross
motor outcome
representing the ICF
component of body
functions and activity in
children with cerebral palsy
GMFM-66, Pediatric
outcomes Data Collection
Instrument (PODCI), and
the Pictorial Scale of
Perceived Competence and
Social Acceptance for
Young Children (PSPCSAYC)
GMFM and PBS
This case study demonstrates that
hippotherapy may have influenced and
improved a child with CP functional
ability, level of participation and sense
of self-competence
No
The total GMFM scores and the PBS did
not change during the pre-riding
control period, however the GMFM
and the PBS of children with CP
improved significantly after
hippotherapy. Specifically in
dimensions D and E of the GMFM, they
increased after hippotherapy
compared with the pre-riding effects.
Yes
Postural control with
(BPAS) muscle activity and
tone (MAS), gait, GMFM66, and GMFM-88
Short term effects of hippotherapy and
THR can reduce asymmetrical hip
adductor activity and asymmetrical
muscle activity. Hippotherapy but not
THR is effective in improving postural
control. They were unable to confirm
the long term effects of hippotherapy
andTHR on gross motor function in
children with CP and how it effects gait
patterns
81
Yes
Table 2. Inclusion / Exclusion Criteria
#
Study
Inclusion Criteria
Exclusion Criteria
1
Kwon, JY. (2011)
Diagnosis of bilateral spastic cerebral palsy. GMFCS level of I
or II. Body weight less than 35kg. Age 4-10 years.
Botulinum toxin injections within 6 months, Selective dorsal
rhizotomy or orthopedic surgery within one year, moderate to
severe intellectual disability, uncontrolled seizure, poor visual
or hearing acuity.
2
Davis, E. (2009)
Child with CP between the ages 4-12 with a GMFCS level of I
to III, have previously not been involved with hippotherapy or
THR. Live within a 50 or 100km radius of the riding venues
N/A
3
Whalen C. (2011)
4
Zadnikar M. (2011)
Subjects in study have a diagnosis of CP. Hippotherapy or THR
was a primary treatment, mobility or gross motor outcomes
were investigated. Physical therapist, or occupational
therapist or accredited therapeutic riding instructor
implemented the intervention.
Quantitative study design. Investigation of the effect of
hippotherapy or THR on postural control or balance. Study
group comprised of children and adults with CP.
Barrel sitting or other types of horse simulation was used as
primary intervention. Study was published prior to 1985.
Subjects were adults 18 or older study was not available in full
text, study was available in English. Study had not yet been
published. A qualitative research design was used.
N/A
5
Sinder, L. (2007)
The inclusion criteria for the articles were that they had to be
available in English or German, all RTCs, quasi- experimental
and observational studies related to -hippotherapy or THR for
children with CP and were peer reviewed.
Mechanical saddle ridding
82
6
McGee, M. (2009)
The inclusion criteria for this article was the participants had
to be able to walk a minimum of 10 ft on the GAITRite
walkway independently using usual footwear, including any
orthoses typically worn, they had to be able to walk withing
the width of the GAITRite walkway independently, and they
had to be able to follow direction, and have no lower
extremity casting or surgical procedures within 3 months.
N/A
N/A
7
Frank, A. (2011)
8
Chang, HJ. (2012)
Children age 4 or older, diagnosed with spastic bilateral CP,
were identified from the hippotherapy waiting list.s
The exclusion criteria included botulinum toxin injection
within six months, orthopedic operations such as tendon
lengthening within one year, history of selective dorsal
rhizotomy, moderate to severe intellectual disability and poor
visual or hearing acuity.
9
Tseng, SH. (2013)
The inclusion criteria consisted of, the studies had to be and
RTC or observation studies, the children evaluated had to be
under the age of 18 with a diagnosis of CP, the studies
inclusion and exclusion criteria had to be clearly defined, the
protocol of the horseback riding techniques had to be
documented, and the definition and measurement of gross
motor outcome at body function and activity level had to be
clear
The exclusion criteria consisted of, the trial included come
children without CP, the outcomes of interested were not
objectively measured, overlap was present between patient
cohorts in the published literature, the trial had not used real
horses, or the study was no published in a peer reviewed
journal.
83
N/A
Table 3. Article Summaries
Study name
Kwon, 2011
Type of study
Nonrandomized prospective
controlled trial
Intervention
Hippotherapy – 30 min twice weekly
for 8 consecutive weeks
Results
Hippotherapy significantly improved walking, speed,
stride length, and pelvic kinematics
Davis, 2009
Randomized controlled trial
Therapeutic horse riding program for
10 weeks
Whalen, 2011
Systematic Review
Electronic database search for articles
related subject; 9 articles analyzed
Zaddnikar, 2011
Systematic Review
Snider, 2007
Systematic review
Relevant studies were identified by
search of online databases. 10 articles
analyzed
Electronic databases and hand search
for related articles; 9 articles analyzed.
McGee, 2009
Research Report: One group
pretest – posttest
Immediate effects of hippotherapy on
gait parameters
Therapeutic horse riding program did not increase gross
motor function, quality of life or overall health in
children with CP
Current level of evidence is weak, but found significant
improvements on gross motor function as a result of
hippotherapy and THR
Statistically significant positive effectiveness of
hippotherapy or THR in children with CP. More research
is needed
Level 2a evidence that hippotherapy is effective for
treating muscle symmetry in trunk/hip and is effective
for improved gross motor function.
No statistically significant difference were noted in post
ride gait parameters
Frank, 2011
Case Report
Chang, 2012
Research Report
Tseng, 2012
Systematic review and metaanalysis
Hippotherapy 8 week program effect
on self-competence, social acceptance
and functional skills.
Hippotherapy 30 min twice a week for
8 consecutive weeks
Electronic database search and hand
search for related articles; 14 published
articles analyzed
84
Effective intervention to improve functional gross motor
development, positive changes in all areas.
Hippotherapy can improve gross motor function and
balance in pediatric CP patients
There is insufficient evidence to support the clam of
long-term hippotherapy and THR provide significant
benefit to children with spastic CP