Hippotherapy and Therapeutic Horseback Riding for Veterans with

Hippotherapy and Therapeutic
Horseback Riding for Veterans with
Spinal Cord Injury and Multiple Sclerosis
Amberly Kushell, PT, DPT
VA Long Beach Healthcare System
Disclosures
• Amberly Kushell, PT, DPT
– Has no financial interest to disclose.
Disclosures
• This continuing education activity is managed and
accredited by Professional Education Services
Group (PESG) in cooperation with Paralyzed
Veterans of America (PVA). Neither PESG, PVA,
nor any accrediting organization supports or
endorses any product or service mentioned in
this activity.
• PESG and PVA staff has no financial interest to
disclose. Commercial Support was not received
for this activity.
Learning Objectives
• At the conclusion of this activity, the
participant will be able to:
– Describe the differences between hippotherapy
and therapeutic horseback riding.
– Identify indications, precautions, and
contraindications to equine-assisted activities and
therapies.
– Identify key resources necessary for starting an
EAAT program at their workplace.
What is Hippotherapy?
What is Therapeutic Riding?
• Hippotherapy is a physical, occupational, and
speech-language therapy treatment strategy that
utilizes equine movement as part of an integrated
intervention program to achieve functional
outcomes
• Therapeutic riding encompass the variety of
equine activities in which people with disabilities
participate.
• Both fall under the umbrella term of “EquineAssisted Activities and Therapies” (EAAT)
Systems affected by Hippotherapy
• Musculoskeletal
–
–
–
–
Strength
Flexibility
Postural alignment
Pain
• Neuromuscular
– Balance reactions
– Muscle tone/ spasticity
– Coordination
• Respiratory
– Increased inspiratory capacity
• Psychological
– Increased confidence and self-esteem
Current Research
• SCI-specific case study (Rehabilitation Nursing
2012)1
– 44 yo male, C3-4 AIS C
– Participated in TR x 2 years (no clear description of
intervention or use of objective measures)
– Subjectively reported improved muscle
awareness, increased sensation, increased
motivation to work out, improved confidence
– Is now receiving PVA-sponsorship to participate in
horse shows , considering paraolympics
Current Research- Spasticity
• Lechner et al. (2003)2 showed short-term
decrease in lower extremity Modified
Ashworth Scale values following 20-30 minute
hippotherapy treatment
• Greatest before and after differences
measured in patients with very high spasticity
• Case-series, quasi-experimental design
Current Research- Spasticity
• SCI-specific blinded randomized controlled
crossover trial with 4 interventions2
– 12 participants, AIS A or B, all 1 year post-injury
with spasticity in lower extremities (Ashworth >2
in at lease 1/10 muscle groups and sum of
Ashworth >6)
• Interventions performed 2x/week x 4 weeks,
each 25 min in duration
• H= HPOT with certified PT
• R= sitting astride Bobath roll
• S= sitting on rocker board with sagittal plane axis,
rhythm set to mimic horse’s pace
Spasticity, cont.
• Spasticity measured by clinician via MAS and subjectively
assessed with 10cm VAS
• Measurements before and after 1st weekly session
• Significant difference (P<.05) found between reduction of
MAS scores’ sum caused by HPOT in comparison to control
– Other interventions showed reductions in spasticity, but not
significant
• All 3 interventions showed significant difference between
MAS score’s sum pre and post intervention
• Significant differences between HPOT and Bobath roll and
HPOT and control on pre-and post-VAS medians.
• Significantly improved mental well being after HPOT
intervention (no significant changes caused by other
interventions)
Hippotherapy and Multiple Sclerosis
• Systematic Review in European Journal of
Physical and Rehabilitation Medicine 2010
explored effects of HPOT on balance in
persons with MS3
• 3 studies met inclusion criteria
• All 3 reported improvements in balance
– Berg Balance Scale
– Qualitative reports
Hippotherapy and MS
• Pilot study by Silkwood-Sherer examined effects
of hippotherapy on postural stability in persons
with MS5
• Nonequivalent pretest-posttest comparison
design
• Assessed Berg Balance Scale and POMA at
various intervals (0, 7, and 14 weeks)
• Hippotherapy group showed significant
improvement on BBS (mean increase 9.15 points
p= 0.012) and POMA scores (mean increase 5.13,
p= 0.006), while control group had no significant
changes in either measure
Why HPOT/TR at the VA?
• We have one of the top HPOT/TR centers in
the United States located just south of Long
Beach in San Juan Capistrano
• Has the potential to affect various
components of one’s physical condition in
ways more traditional therapy cannot
• Offers an alternative form of recreation and
leisure
Indications for Participation
• Veterans actively participating in physical therapy
with functional goals related to dynamic trunk
balance, postural reeducation, spasticity
management
• Veterans actively participating in occupational
therapy with functional goals related to gross and
fine motor control
• Veterans who would benefit from the
psychosomatic aspect of caring for/ being around
horses
• Veterans seeking an adaptive recreational/
sporting activity who could potentially continue
with HPOT/TR independently outside of the VA
Precautions
• Complete Quadriplegia/ Poor trunk control
– Lowest level thus far on horse is T4 AIS A
• Moderate to severe scoliosis
• History of skin breakdown
• Severe joint contractures
Contraindications
• Open wounds or pressure ulcers
• Severe fixed scoliosis
• Requiring supplemental oxygen or ventilatory
support
Mounting Procedures
Types of Mounts
Clinical Decision Making
• Tack
• Horse choice
• Treatment
Progression
Ideal Participant
Independent Riding
The Program So Far
• Collaborating with The J.F. Shea Center for
Therapeutic Riding located in San Juan Capistrano
• They provide facilities, horses, equipment,
volunteers
• Myself and another Shea Center staff member
facilitate the sessions
• Have taken from 3-11 Veterans on the outing
• Veterans participate in hippotherapy and ground
activities
• Active duty service members from Camp
Pendleton serving as volunteers during our visits
Support for EAAT available to Veterans
• Wounded Warrior Project has partnered with the
Professional Association of Therapeutic
Horsemanship (PATH) International, a prominent
organization involved with promotion of EAAT for
individuals with special needs
– $200,000 given for the purpose of awarding
scholarships to WWP Alumni
• PATH International also has their own fundraising
campaign “Equine Services for Heroes,” where
donations go directly to Veteran scholarships
• Scholarships also support military families
Future Directions
• Monthly trips to the Shea Center in
collaboration with recreational therapy
• Hope that some Veterans will continue with
hippotherapy/ therapeutic riding on a weekly
basis
• Research opportunities
– Spasticity
– Dynamic balance
– Postural alignment
– Quality of life
Program Development
• http://www.pathintl.org -> Find a Center
– Activities: Hippotherapy, Therapeutic Riding, or
Veterans Programs
• http://www.americanhippotherapyassociation.org/hi
ppotherapy/find-a-facility/
• Recommend physical or occupational therapist
reach out to center and make connection
• Visit center, check accreditation
• Center therapists vs. VA therapists
Therapist Certification
• 2 levels of certification:
– AHCB Certified Therapist
– AHCB Certified Hippotherapy Clinical Specialist
• Requirements:
– Currently licensed or certified to practice as a PT, PTA,
OT, OTA, SLP, or SLPA in the US or the equivalent in
other countries.
– At least one year of full-time or the equivalent (2000
hours) experience in practice.
– Taking AHA, Inc Level I and II courses, or equivalent
– A minimum of 25 hrs of one on one direct treatment
in clinical practice using hippotherapy following Level
II course.
– Experience/comfort level working with horses.
References
1.
2.
3.
4.
5.
Asselin, G., Ward, C., Penning, J.,Ramanujam, S., Neri, R.
Therapeutic horse back riding of a spinal cord injured veteran: a
case study. Rehabilitation Nursing 2007; 37 (6): 270-276.
Lechner, HE., Feldhaus, S., Gudmundsen, L., Hegemann, D.,
Michel, D, et al. The short-term effect of hippotherapy on
spasticity in patients with spinal cord injury. Spinal Cord 2003; 41:
502–505.
Lechner HE, Kakebeeke, TH, Hegemann, D, Baumberger, M. The
effect of hippotherapy on spasticity and on mental well-being of
persons with spinal cord injury. Arch Phys Med Rehabil 2007; 88:
1241-8.
Bronson, C., Brewerton, K., Ong, J., Palanca, C., Sullivan, SJ. Does
hippotherapy improve balance in persons with multiple sclerosis:
a systematic review. Eur J Phys Rehabil Med 2010; 46: 347-53
Silkwood-Sherer, D., Warmbier, H. Effect of hippotherapy on
postural stability, in persons with multiple sclerosis: a pilot study. J
Neurol Phys Ther 2007; 31: 77-84.
Thank You!!
Any Questions?
Obtaining CME/CE Credit
• If you would like to receive continuing
education credit for this activity, please visit:
– http://pva.cds.pesgce.com