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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 1 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. 2 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. 3 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 4 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. 5 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% 6 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 7 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. 8 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. 9 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. 10 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 11 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. 12 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 14 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 15 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 16 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 17 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 18 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. 19 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. 20 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. 21 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