Review of Alternative Treatments: Hippotherapy

Abstract

This paper reviewed the research on hippotherapy to determine its benefits and provide a conclusion as to whether it is supported or refuted. I also seek to provide future research recommendations on hippotherapy based on the research. Autism is a neurological developmental disorder that is classified by deficits in social interaction, verbal and nonverbal communication, and repetitive and restricted behaviors and interests. Some characteristics of ASD include displaying challenging behaviors such as aggression, attention problems, delays in language and speech development, hyper or hyposensitivity to sensory input, and deficits in gross and fine motor skills amongst other difficulties. Hippotherapy is a form of therapy that have been used to treat the deficits of autism. The studies presented below all boasts results that display the positive effects of hippotherapy in domains such as motor functioning, social interaction, and self-regulation. Despite these results, more research needs to be conducted to examine the effects of hippotherapy.

What is Hippotherapy and is it an Effective Treatment for Autism?

Autism Spectrum Disorder (ASD) is a neurological developmental disorder. It is classified by deficits in social interaction, verbal and nonverbal communication, and repetitive and restricted behaviors and interests. Some characteristics of ASD include displaying challenging behaviors such as aggression, attention problems, delays in language and speech development, hyper or hyposensitivity to sensory input, and deficits in gross and fine motor skills amongst other difficulties (Wilkinson, 2014). Autism exists on a spectrum, meaning it doesn’t look the same in each individual.

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As the knowledge and awareness of autism continues to grow, different interventions have been developed to help treat the symptoms of autism. Applied Behavior Analysis is often recommended for treatment of autism. Other approaches with empirical support include pivotal response training and social skills training (Wilkinson, 2014).While interventions with empirical support are typically recommended, other forms of treatment that are used that are known as alternative treatments. Some types of alternative treatments include Hyperbaric Oxygen Treatments, a gluten free and casein free diet, and hippotherapy which is the focus of this paper.

Hippotherapy (also known as equine therapy) is a form of physical, occupational, and speech therapy. The movements of the horse as well as social-emotional components of tending to and learning how to ride a horse are used to treat the various deficits of autism. (Koca, Ataseven, 2016). Horses are used because “their rhythmic movement when walking stimulates anterior and posterior swinging movement”. The movement of the horse also encourages proper balance and posture while providing sensory and motor input. Variations in the gait of the horse allow therapists to measure sensory stimulation and combine that with other clinical therapies to achieve outcomes.” (Koca, Ateseven, 2016). Interaction with the horses such as brushing, mounting, riding, and forming a relationship with the horse can help improve an individual’s social interaction and adaptive skills.

Ajzenman, Standeven, and Shurtleff (2013) conducted a study to determine the effects of hippotherapy on motor control, adaptive behaviors and participation in children with ASD. Motor impairments in ASD can affect a child’s ability to perform various gross and motor movements and engage in activities which can limit positive social interactions in different settings such as school where communication and social skills are built (Ajzenman, Standeven, Shurtleff, 2013). All participants in the study were only diagnosed with autism. Hippotherapy sessions were conducted for 45 min on a therapy horse once per week for twelve weeks. Various mounting procedures and functional skills were used as treatment activities to promote motor planning and sequencing.  Attention, cognitive skills, social skills, and interactive play were targeted. The results of the study showed that postural control, adaptive behavior, and participation in everyday activities improved. The Vineland Adaptive Behavior Scales showed an improved from low functioning to moderately low functioning. Key social and communication skills such as listening and attending showed improvement. Increases in participation were seen in self-care, low demand leisure, and social interactions (Ajzenman, Standeven, Shurtleff, 2013). Some limitations of this study include its small sample size and its use of parent-report measures. Treatment fidelity was also in question as there may have been irregularities between therapists when providing treatment.

There may be differences in hormone levels in individuals with autism when compared with neurotypicals. Oxytocine is a hormone that is related to sexual and parental patterns which plays a role in the display of affection and social relationships. Studies have shown that children with autism have low levels oxytocine (Alejo, Aparicio, Cubero, Sannchez, Tabares, Vicente, 2012). Alejo, Aparicio, Cubero, Sannchez, Tabares, and Vicente (2012) sought to explore if hippotherapy would lead to an increase in social attitudes in children with autism. The hormones that were measured were cortisol and progesterone because cortisol has an inverse relation to oxytocine while progesterone has a more direct relation. Cortisol is indicative of stress levels. Participants in this study were males aged 8-16 diagnosed with autism. There were four hippotherapy sessions in a month where the participants would perform various activities such as stroke the horse, help out with the saddle, and mount the horse. Learning and attention were taught through learning how to control the horse. Saliva samples were taken to measure hormone levels. Results showed an increase in cortisol the first post therapy sessions, however the levels of post therapy cortisol decreased from the first session to the last. Similar to cortisol, progesterone also showed increases post session, however, post therapy progesterone continued to increase across sessions. The authors concluded that hippotherapy can decrease cortisol but raise progesterone. They attribute the higher post therapy cortisol in the first session to adjusting to a new routine with can cause anxiety in individuals with autism. The increased progesterone levels showed that hippotherapy was beneficial in creating emotional ties and therefore can create oxytocine production (Alejo, Aparicio, Cubero, Sannchez, Tabares, Vicente, 2012).

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Bass, Duchowny, Llabre (2009) examined the effect hippotherapy can have on social relationships in children with autism in a pilot study. Deficits in social and communication skills impacts the ability to form and maintain reciprocal relationships. Participants were assessed after receiving hippotherapy for 3 months and then again 2 months after the end of the intervention to study if the effects were sustainable. The experimental group received free hippotherapy sessions. Sessions consisted of horsemanship training, mounting, warm-up exercises, and riding skills. Parent and teacher reports were used as pre and post intervention assessment methods. Results showed that the experimental group exhibited “greater sensory seeking, sensory sensitivity, social motivation, and less inattention, distractibility and sedentary behaviors” (Bass, Duchowny, Llabre, 2009). A weakness of this study was the use of parent and teacher report measures which could be subject to bias.

Agnew, Brim, Dechant, Gabriels, Mesibov, and Pan (2015) conducted a study to evaluate the effectiveness of hippotherapy on self-regulation, socialization, communication, adaptive, and motor behaviors in adolescents with ASD. Individuals were diagnosed on the spectrum and aged 6-16, they received 10 week interventions. Assessments were administered to determine baseline levels of functioning and post therapy functioning. Results showed improvement in self-regulation, improved social cognition and communication, and an increase in verbal communication for individuals who were already verbal. Limitations include the use of caregiver report measures and a lack of observational methods (Agnew, Brim, Dechant, Gabriels, Mesibov, Pan, 2015).

Conclusion and Future Research

Hippotherapy appears to be supported by the literature. It has been shown to have benefits that address the different deficits that autism presents. It can improve some motor deficits as well as help improve participation and social interaction. Other deficits that hippotherapy can help treat are adaptive skills, self-regulation, socialization, and cognitive skills. Despite the promising finding in these studies, research and studies on hippotherapy are not plenty. The main limitations I came across while reviewing the studies were the use of parent reports as assessments and treatment fidelity across professionals. More research needs to be done on hippotherapy to make more definite conclusions on the effects of the therapy on children with autism. Direct measurement and assessment should be utilized more when taking baseline and post treatment data to avoid any bias or placebo effects. In order to maintain treatment fidelity, training procedures can be improved as well as increased supervision during the process of the intervention and the administration of assessments. Increasing the sample size of future studies and expanding the demographic of the sample sizes to a wider age range and individuals with comorbid disorders can lower margin of error and determine if hippotherapy can be effective with other populations.

References

• Ajzenman, H. F., Standeven, J. W., & Shurtleff, T. L. (2013). Effect of hippotherapy on motor control, adaptive behaviors, and participation in children with autism spectrum disorder: a pilot study. American Journal of Occupational Therapy, 67(6), 653-663.
• Bass, M. M., Duchowny, C. A., & Llabre, M. M. (2009). The effect of therapeutic horseback riding on social functioning in children with autism. Journal of autism and developmental disorders, 39(9), 1261-1267.
• Gabriels, R. L., Pan, Z., Dechant, B., Agnew, J. A., Brim, N., & Mesibov, G. (2015). Randomized controlled trial of therapeutic horseback riding in children and adolescents with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 54(7), 541-549.
• Koca, T. T., & Ataseven, H. (2015). What is hippotherapy? The indications and effectiveness of hippotherapy. Northern clinics of Istanbul, 2(3), 247.
• Tabares, C., Vicente, F., Sánchez, S., Aparicio, A., Alejo, S., & Cubero, J. (2012). Quantification of hormonal changes by effects of hippotherapy in the autistic population. Neurochemical Journal, 6(4), 311-316.
• Wilkinson, L. (2014). A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools, Second Edition ISBN