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1988; 68:1505-1512.PHYS THER.Dolores B BertotiChildren with Cerebral PalsyEffect of Therapeutic Horseback Riding on Posture in

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Ef fec tofTherapeu t ic Ho rseback R id i ng on Pos tu reinCh i l d ren w i th C e reb ra l Pa lsyD O L O R E S B . B E R T O T I

T h e p u r p o s e o f t h i s s t u d y w a s t o m e a s u r e p o s t u r a l c h a n g e s i n c h i l d r e n w i t hs p a s t i c c e r e b r a l p a l s y a f t e r p a r ti c ip a t i on i n a t h e r a p e u t ic h o r s e b a c k r id i n g p r o g r a m . E l ev e n c h i l d r e n w i th m o d e r a t e t o s e v e r e s p a s t i c c e r e b r a l p a l s y , a g e d 2y e a r s 4 m o n t h s t o 9 y e a r s 6 m o n t h s , w e r e s e l e c t e d f o r t h i s s t u d y a n d u n d e r w e n tp o s t u r a l a s s e s s m e n t s a c c o r d i n g t o a r e p e a t e d - m e a s u r e s d e s i g n . A s s e s s m e n t o fp o s t u r e w a s p e r f o r m e d b y a p a n e l of t h r e e p e d i a t r ic p h y s i c a l t h e r a p i s t s , u s in g ap o s t u r a l as s e s s m e n t s c a l e d e s i g n e d b y t h e a u t h o r . A c o m p o s i t e s c o r e fo r e a c ht e s t i n t e r va l w a s c a l c u l a t e d f o r e a c h c h i l d , a n d a m e d i a n s c o r e w a s c a l c u l a t e df o r t h e e n t i r e g r o u p a t e a c h t e s t i n t e r v a l. D at a w e r e a n a l y z e d u s i n g a F ri e d m a ntes t , assum ing an a l pha l eve l o f . 05 . A s t a t i s t i ca l l y s i gn i f i can t d i f f e r ence w asf o u n d b e t w e e n t h e t h r e e t e s t i n t e r v a l s w i t h s i g n i f i c a n t i m p r o v e m e n t o c c u r r i n gd u r i n g t h e p e r io d o f t h e r a p e u t i c r i d i n g . C l in i c a l i m p r ov e m e n ts w e r e a l s o n o t e d i nm u s c l e t o n e a n d b a l a n c e a s e v i d e n c e d b y i m p r o v e d f u n c t i o n a l s k i l l s . T h e s er e s u l t s c o n s t i t u t e t h e f ir s t o b j e c t iv e m e a s u r e s u p p o r t in g t h e e f f i c a c y o f t h e r a p e u t ic h o r s e b a c k r id i n g o n p o s t u r e i n c h i ld r e n w i th c e r e b r a l p a l s y .Key W o r d s : erebralpalsy general;Neurodevelopmentald isorders,general; Pedi-atr ics ,general;Posture ,general.

A large portion of the pediatric physical therapist's caseloadis composed of children with cerebral palsy (CP). In CP,interference with normal development is the result ofneurological damage to cortical centers with resultant abnormalityof muscle tone, delayed reflex maturation, and the presenceof associated abnormal patterns of posture and movement.13A general goal of physical therapy for children withCP isto decrease the influence o f abnormal muscle tone whilesimultaneously facilitating the emergence of normal posturaland movement components.4-6 In children with CP, unlessnormal postural and movement components develop, abnormal development is manifested as various compensations,clinically seenaspostural deviations, asymmetries,ordeformities.2'6 Although physical therapy is ideally instituted early,CP is a chronic disability often requiring that the child beinvolved in therapeutic activities for many years. It is achallengeto thephysicaltherapisttosustainthechild sinterestand enthusiasm in therapy in the face of such continuingneeds.

In an attempt to address this issue, many adjunctive therapeutic activities have been developed, including swimming,dance, and horseback riding.713 In therapeutic riding, thehorse is used as a treatment modality similar to the use oftherapy ballsand bolsters typically seen in a pediatric physicaltherapy clinic. To facilitate particular postural responses, thetherapist m ay place theriderin various positions on the horsesuch as prone, side lying, side sitting, or sitting (Fig. 1). Inmany cases, the therapist and rider will ride together so thatthe therapist can facilitate the movem ent or desired responseas needed. Therapeutic riding is usually performed with the Fig. 1. Examples of some pos it ions used for t herapeut i c horsebackr iding.rider on a sheepskin or soft pad rather than a saddle. Thismodificationallowsthewarmthandmovement ofthewalkinghorse to be imparted to the rider. The horse is usually led ata walking pace by a skilled equestrian to ensure safety andexpert handling ofthe horse.

D . Bertoti, MS, PT , is a partner in Comm unity P hysical Therapy Associates,273 Claire Dr, RD 3, Birdsboro, PA 19508 (USA). This work was supportedby the Widener Foundation, Lafayette Hill, PA, and by the West NorritonAMBUCS, West Norriton, PA. This study was conducted at Sebastian RidingAssociates, Inc, Collegeville, PA.This article was submitted May 13 1987; was with the author for revision26 weeks; and was accepted April 18 1988. Potential Conflict of Interest: 4.

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The rationale for therapeutic riding is that the horse'smovement imparts a precise, smooth, rhythmical pattern ofmovement to the rider. As the horse walks, its center ofgravity is displaced three-dimensionally with a movementvery similar to the action of the human pelvis during gait.The w armth of the horse coupled with this rhythmical movement is thought to be useful in reducing abnormally highmuscle tone and promoting relaxation in the rider with spasticCP. These sensations of normal movement, in combinationwith physical therapy techniques, can be used to facilitateimproved co-contraction, joint stability, weight shift, andpostural and equilibrium responses in children with CP . Advocates of therapeu tic riding list the following m ajor aims: 1)mobilization of the pelvis, lumbar spine, and hip joints; 2)normalization of muscle tone; 3) development of head andtrunk postural control; and 4) development of equilibriumreactions in the trunk.913Although therapeutic riding is growing in popularity, withover 200 centers in the United States alone (North A mericanRiding for the Handicapped, 111 E Wacker Dr, Suite 600,Chicago,I ;unpublished data), no objective study has beenundertaken to docum entitspropo sed effects. T he first systematic but subjective review of the effects of ridin g on disabilityis credited to Chassaigne in 1870.10He concluded that ridingwas beneficial for patie nts with various neurological disordersby stressing the observed impro vements in po sture, balance,and muscle control.10 There are no further references inrehabilitation literature until after 1946 when therapeuticriding was introduced in Scandinavia after two epidemics ofpoliomyelitis.11The growth of modern horsemanship for thedisabled was further stimulated in 1952 when Liz Hartel, apatient with poliomyelitis, won a silver medal for dressagewhile representing Scandinavia at the Olympic Games.11Eilset Bodther, a Norwegian physical therapist, was the firstto organize riding specifically as a therapeutic activity fordisabledchildren.11In 1969,the firstUScenter for therapeutichorseback riding, the Cheff Center for the Handicapped, wasestablished in Michigan.This study sought to scientifically investigate some of theproposed effects of therapeutic riding on the disabled rider.The purpose of this study was to measure po stural changes inchildren with spastic CP after participation in a therapeuticriding program. The hypothesis of the study was that thechildren would show no significant improvement in postureas measured before and after a therapeutic riding programcompared with before and after an equal period ofnoriding.

METHODS ub jec t s

Eleven children with CP (4 girls, 7 boys) were selected toparticipate in a therapeu tic riding progra m. Physician referralswere obtained, and parents of the children signed an informed consent statement. I evaluated all of the children andconsidered them to be appropriate candidates according tothe following criteria: 1) medical diagnosis of CP, spasticquadriplegia, or diplegia; 2) no other medical complicationssuch as seizures or hydrocephalus; 3) normal intelligence asdocumented by a psychologist; 4) normal spine and hiproentgenograms;5 passive hip abductiontoat least20degreesbilaterally as measured in the supine position14; 6) passiveham string m uscle mob ility to at least 60 degrees of hip flexionby a straight leg test14; and 7) functional ability to sit and

stand alone or with minimal support. The children selectedwere from a five-county area encompassing Collegeville, Pa.Ages of the children ranged from 28 to 114 mo nths ( =66.0 mon ths; = 26.0). Eight subjects had diagnoses of spasticdiplegia, and three had diagnoses of spastic quadriplegia.Table1 summarizes the subject characteristics.Expe r imen ta l Des ign

A repeated-measures design was used that consisted ofpretest1 followed by a 10-week period of no riding, pretest 2followed by a 10-week therapeutic riding program, and aposttest. The subjects thereby acted as their own control.Procedu re

Three pediatric physical therapists not involved in thehorseback riding program assessed the participants at each ofthe three test intervals. Each therapist on this assessment tea mhad extensive clinical experience and continuing education inassessing CP. Each child's posture was assessed and scored asdescribed below. The boys wore only shorts, and the girlswore only shorts and a halter top for each test session.Posture assessment.Academ ically,postur isdefined a s thesynergistic contraction of muscles and the organization ofsensory information that permits stability and alignment ofthe body on a base of support.15Clinically, posture is judgedvisually by noting alignment and symmetry of body parts andco-contraction of muscles aroundjoints,the summed controlof each part adding to a com posite, balanced whole. A qualitative description of posture is typically included in a physicaltherapy assessment of a child with CP . Progress or im provement is measured qualitatively in narrative form, but noobjective measure is available. For use in this study, I developed a pos ture assessment scale to ra te observable qualities ofpostural control and symmetry.During the development of the posture assessment scale,five pediatric physical therapists used the scale and judged itto be a valid measure of posture for use in CP. Before thisstudy, the three therapists on the assessment team weretrainedin its use. The Appendix presents the posture assessment scaleused in this study. The posture assessment scale allows therating therapist to visually assess and score alignment andsymmetry of five body areas: 1) head and neck, 2) shoulderand scapula, 3) truck, 4) spine, and 5) pelvis. Scoring in eachsubsection ranges from 0 to 3, with a total score achieved byadding these five subscores.For this study, scoring of each child's posture by the threemembers of the assessment team was performed simultaneously with no verbal discussion. I then calculated a compositescore for each child so that one score was obtained for eachchild's posture at pretest 1, pretest 2, and posttest. The children were instructed to stand as they normally would. Imanually assisted children needing support to stand with lightsupport at the waist, from the front. The posture assessmentwas completed in two to four minutes for each child.In addition to scoring each child's posture using the scale,additional qualitative information was gathered from num erous sources. During the adm inistration of the posture assessment scale, the author and the three testing therapists madequalitative notes describing the child's posture. W ritten com mentsweresubm itted describing observed postur al traits suchas hyperextension, asymmetry, and compensatory movements or postures. Because each child in this study wasreferred by a physical therapist in the area, I solicited written

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RESEARCHTABLE 1Summary o f Sub jec t Cha rac t e r i s t i c s

Subject1

2

3

4

5

6

7

8

9

SexM

M

F

M

F

M

M

F

M

Age(yr/mo)2/4

3/10

4/4

4/4

4/8

4/9

5/2

5/4

7/7

DiagnosisSpast ic quad -

r ip legia

Spast ic quad -r ip legia

Spast ic d ip leg ia




Spast ic quad -r ip legia



Funct ional Abi l i tyBefore Rid ing

Sat a lone wi th head h yperextended,t runk roun ded. Stood a t suppor tw i th f l exed u pper ex t remi ties(UEs); ex tended , adducted lowerext remit ies (LEs); fa i r con t rol .

Sat a lone for shor t p er iods of t imew i t h head hy pe rext ended , t r unkrounded and asymmet r i ca l. Stooda t supp o r t w i t h LEs sc i ssored inextens ion, poor con t rol .

Sat a lone wi th t runk rounded andasymmet r i ca l , UEs and LEsblocking to stabi l ize. Stood atsupp or t w i th f l exed UEs; f l exed,adduc ted LEs; poor cont ro l.

Sat alone wel l .Stood a lone wi tht runk asymmet ry, an ter ior p e lv ict i lt , LEs s l igh t ly adduc ted andf lexed, on toes.

Sat a lone wi th t runk rounded andasymmet r i ca l. Stood a lone w i tht runk asymmet ry, scapu lar re tract i on ,anter ior pelvic t i l t , LEs ad duc t ed and f l exed , on t oes .

Sat a lone wi th t runk rounded andasymmet r i ca l. Stood a lone w i tht runk asymmet ry, scapu lar re tract i on ,anter ior pelvic t i l t , LEs ad duc t ed and f l exed , on t oes .

Sat a lone momentar il y w i th headhype rex tended , t r unk roundedand asymmet r i ca l , scapu la ret rac ted, UEs and LEs f lexed.Stood a t su ppor t w i th poor con tro l ,asym met ry.

Sat a lone wi th t runk rounded andasymmet r i ca l . Stood a lone w i tht runk asymmet ry, scapu lar re tract ion,anter ior p elvic t i l t , LEsf lexed and add uc t ed .

Sat a lone w i th t runk s l igh t l yrounded and asymmet r i ca l . Stooda lone w i t h t r unk rounded andasymmet r i ca l, some scapu lar ret rac t ion,anter ior p elvic t i l t , LEsf lexed and addu c t ed .

Af ter R id ingAbi li ti es d ecreased . Sat a lonewi th head in mid l ine, t runk

extended . Stood a t suppo r t w i t h adequa t e headand t runk cont ro l , UEs ext ended , LEs ex t ended i naddu ct ion, f a ir cont ro l .Improved. Sat alone forlonger per iods of t ime w i thhead incons is ten t ly inmidl i ne, t runk extend ed andmore s ymmet r i ca l . Stoodw i t h LEs ex t ended ands l igh t l y add ucted , poorcontrol .Improved. Sat a lone w i tht r unk ex t ended andsymm et r ica l , UEs extendedat s ides , LEs re laxed.Stood a t s upp or t w i th fa ircont ro l ; s tood a lone momentar i ly.Improved. Sat alone wel l .Stood w i th t runk e longatedand symm et r ica l , pe lv ismore in neu t ra l , LEs ext ended and abduc t ed w i t hhee l contact almost 100 .

Improved. Sat alone wel l .Stood w i t h t r unk e l on ga t ed ,minimal asymmetry,sl ight anter ior pelvic t i l t ,LEs s l i gh tl y addu cted,comple te hee l contact onr ight .Improved. Sat alone wel l .Stood a lone wi th t runke longated and symmet r ica l ,sl ight anter ior pelvict i l t, LEs s l igh t l y add ucted ,incons is ten t hee l contact .Improved. Sat a lone w i thhead in m id l ine, trunk extended , arms a t s ides.S tood a t su ppo r t w i t h ade qua t e head and t r unk con tro l ,UEs extended, LEsextended in adduc t ion. Fa ircont rol .L i tt l e change. Sat a lone w i tht r unk more ex tended b u tasymmet r i ca l . Stood a lonew i t h t r unk asymmet ry , l essscapu lar re t rac t ion, an ter ior pelvic t i l t , LEs ad duc t ed .L i tt l e change. Sat a lone w i tht runk s l i gh t ly round ed andasymmet r i ca l . Stood a lonew i t h t r unk rounded andasymmet r i ca l , some scap ular ret ract ion , anter ior pelv ic t i l t , LEs f lexed and ad duc t ed . Cont inued)

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TABLE 1 Continued)Summary of Subject Characterist icsSubject

10

11

SexF

M

Ageyr/mo)8/10

9/6

DiagnosisSpastic diple-

gia

Spastic diple-gia

Functional AbilityBefore Riding After Riding

Sat alonewell.Stood alone withtrunk rounded, anterior pelvic tilt,LEs slightly flexed and adduc ted,no h eel contact left.

Sat alonewell.Stood alone withsome scapular retraction, sometrunk asymmetry, anterior pelvictilt, LEs adducted and flexed.

Improved. Sat alone well.Stood alone with trunkslightly rounded, pelvismore in neutral, LEs ab-ducted and slightly flexed.

Improved. Sat alonewell.Stood alone with increasedtrunk extension and sym-metry, less anterior pelvictilt, LEs adducted andslightly flex ed.

or verbal comm ents from the child s primary therapist. Thesetherapists clinical observations of the children were invaluable throughout the course of the study. During each ridingsession,Itook notes describing each child s progress, includingstrengths, difficulties, movements, postural traits, and functional ab ilities.Therapeutic horseback riding program After pretest2 , eachchild participated in a 10-week therapeutic riding program.The children rode in groups of three, twice weekly for one-hour sessions. The horses were led at a walking pace whiletwo aides, one on each side, helped to reposition or stabilizethe child. The children rode on sheepskins in a prone, side-lying, or sitting position (Figs. 1, 2). Toward the end of thestudy, soft saddles with stirrups were alternated with thesheepskins to enable the children to ride in the squat andstanding positions (Fig. 3).Each riding session stressed the achievement of reducedspasticity and reduction of postural compensations with subsequent facilitation of normal movement skills such as trunk

control, weight shift, rotation through the body axis, anddissociation at the shoulders and pelvis. Therapeutic goalswere the same as accepted neurodevelopmental techniques.2,4-6The horse was used merely as a therapeutic medium . The children were active participants in their therapeutic program, performing various stretching, strengthening, orbalance activities according to my direction (Figs. 4-6). Attimes, group activities and therapeutic games were used tostress the therapy aims in a social and recreational way.I performed the same activities during every treatment

session. typical session would start with the child po sitionedprone o n a sheepskin as depicted in the first drawing in Figure1.The therapist would mobilize the child s pelvis or shoulderand scapula as the horse s mo vement at a slow walk inducedrelaxation. As the child s muscle tone becam e m ore manageable, progression through the side-lying position or the proneposition prop sequence followed. The children were asked toco-contract their muscles or shift their weight through theupper extremities (Figs. 1, 2). I facilitated the c hildren s m idline head and trunk control and proximal co-contraction. Thetherapist and the child used the movement of the horse tomaintain normalized muscle tone and promote weight shift.The pace of the horse could be quickened or slowed at thetherapist s discretion.In the forward seat position, the child stretched to reach forthe horse s ears, stretched to touch his own knees or toes, orrotated to reach for the horse s tail (Figs. 4, 5). With stirrupson, the child squatted in the stirrups to strengthen the lowerextremities and practice weight shifting (Fig. 3). With thechild in the squat position, the therap ist had the walking horsechange directions or ascend and descend small grades tochallenge the c hild s strength, stability, or balan ce.Balance activities were performed with the child sittingfacing either the front or the back of the horse. When facingbackward, forward and backward righting were facilitatedwith increased automatic trunk reactions because the inputfrom vision was decreased. I instructed the children to raisetheir arms into different positions to encourage increasedtrunk extension, rotation, and righting responses (Fig. 6). The

Fig 2 Child with spastic diplegia work ing on shoulder stability andweight shift in extended arm prop positionFig. 3 Child with spastic diplegia wo rking in squat position tostrengthen trunk and all four extrem ities Note stretch on Achillestendon

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RESE RCH

Fig .4 . Child with spastic diplegia performing stretching activity onhorseback

Fig. 5 Child with spastic diplegia performing abdominal musclestrengthening activities on horseback

horse was led in circles or in a serpentine fashion to achievedesired responses from the rider.Data Analysis

For each testing interval (prettest 1, pretest 2, and posttest),I calculated a com posite score for each child s posture byadding the three scores from the therapists on the assessmentteam. A Friedman test was used to determine whether asignificant change existed between th e three interva ls. Friedman test was chosen because the data were ordinal andnonparametric, and this test is indicated for use with smallsamples and with a repeated-measures design.16 According toLinton and Gallo, no follow-up statistics are needed when aFriedm an test reveals significant differences.17RESULTS

Raw composite scores for each child at each test intervalare presented in Table 2. T he results of the Friedman test aresummarized in Table 3. Interrater reliability was good (r =.82)asdeterminedbya Spearman rank-order correlation. Theresults show that posture was significantly improved df= 2,p < .05) during the period of therapeutic riding. Subjectiveclinical improvements, including decreased fear of movement, decreased hypertonicity, and improved weight-bearingand functional balance skills, were described by all referringphysical therapists and parents.

Fig .6 Child with spastic diplegia performing balance activity whileon horseback

DISCUSSIONVarious case studies have provided anecdotal support tothe theory that therapeutic horseback riding has valuableeffects for children with CP. These reports suggest that therapeutic riding contributes to decreased spasticity, improvedweight shift, improved balance and rotational skills, and

improved postural control.9-13This study is the first objectiveclinical analysis of the effect of therapeutic horseback ridingon posture in children with spastic CP. The null hypothesisthat children with spastic CP would show no significantimprovement in posture before and after participation in atherapeutic riding program as com pared with before and afteran equal period of no riding was rejected.This study documen ted significant improvem ent in posturein the children with spastic CP. Although other reasons m ayexist for some of the changes that were observed and measured, several trends were obvious. The data showed tha t 8 ofthe 11 children had improved posture, as demonstrated bysignificantly higher scores on the posttest administration ofthe posture assessment scale. Numerou s improv ements wereconsistently observed in the five areas of posture studied w iththe scale. All 8 children demon strated increased midline head

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control and decreased neck hyperextension. In the shoulderand scapula body area, less scapular retraction was observed.Visually, the scapulae were not as prominent, and scapularmusculature, assumed to accom pany co-contraction a nd stability, appeared to be more developed. Improvement at thetrunk was described as improved symmetry with decreasedlateral trunk flexion. At the spine, any postural scoliosis orexaggerated lumbar lordosis was decreased, especially in thechildren with spastic diplegia. All 8 children demonstratedincreased trunk elongation and more erect posture. At thepelvis, a decreased anterio rpelvictiltwasnoted with increasedalignment ofthepelvis.Two of the eight children showing improve me nt had spasticquadriplegia, and six had spastic diplegia. The children withspastic diplegia demonstrated an overall improvement, asevidenced by higher scoring in all five examined areas. Thechildren with spastic quadriplegia demonstrated more improvement in the proximal head and neck and shoulder andscapula areas than in the trunk, spine, or pelvis. I attributethis difference to the possibility that the ch ildren with spasticdiplegia, being less involved than those with spastic quadriplegia, were able to participate more actively in the exerciseprogram and had less spasticity to manage. The children withspastic quadriplegia m ade notable improvem ents proximallyfirst, as maybeexpected in developing increased contro l alonga cephalocaudal sequence. Perhaps the children with spasticquadriplegia would have made more dramatic, generalizedimprovements ifthe program had extended past the 10-weekperiod.W ith respect to age, 6 of the children studied w ere underthe age of5 years. Of these 6 children, 5 showed significantimprovement. Ofthe5 children over the age of5years, only3 showed significant improvement, but they improved asdramatically as the children under the age of 5 years whodemonstrated significant improvement. The youngest child(2 years 4 months) did not show significant postural changes,probably for two ma in reasons. His initial apprehension andfear of the horse and the horse's movement never abated,even though the therapist rode with him. Because of this fear,he appeared to experience a limited decrease in hypertonicitywith subsequently limited therapeutic gains. In addition tohis fear and because of his young age, he had limited activeparticipation in the therapeutic exercises and activities. Because active m oveme nt and co-contraction are vital if strengthand postural stability are to improve, it was not surprisingthat this youngest participant showed no significant change.Ofthe two older children who did not improve significantly,one was extremely apprehensive and demonstrated limitedactive participation in the program. The other child had alengthy surgical history and had apparently longstanding postural habits and compensations.The posture assessment scale appeared to be a worthwhilemeasurement tool. It seemed to adequately reflect the clinicalimprovementsseen.Because three therapists scored each childsimultaneously, an unusually high or low score did not skewthe average score. Because each of the five sections can bescored only to a maximum of three points, variability inscoring was low. Although reliability was good, this level ofreliability could be a limitation. The therapists agreed that thepostu re assessment scale can be used to quantify frequentlyobserved clinical postures and that the test can be administered easily and quickly. Because it could be administeredquickly, posture could be analyzed before the children tiredor became inattentive.

TABLE 2Posture Assessment of Interval Composite Scores

n1234567891011

Pretest 13214173020201821223128

Pretest 22516222726221811162623

Posttest2826313927292722223336

TABLE 3Friedman Test ResultsTest

IntervalPretest 1Pretest 2Posttest

n111111

fMMM

Composite ScoreMedian Range

202227

14-32)11-27)22-39)

12.86a,b

In addition to these objective findings, many subjectiveclinical improvements were noted by the author, by theclinical physical therapists who referred the children, and bythe children's parents. The children appeared to make dramatic improvements in self-confidence, with less fear ofmovement and position change. Clinicians felt that the children's decreased fear of movement resulted in improvedmobility and ease of handling during physical therapy in theclinic. Therapists also reported that hypertonicity, especiallyextensor muscle hypertonus and hip adduc tor muscle spasticity, was decreased, contributing to improvem ent in achievement of functional movements such as sitting, stance, andwalking. Therapists reported thatthequality of weight-bearingimproved in bo th uppe r and lower extremities, as evidencedby more controlled and symmetrical weight-bearing in positions such as prone pro p, quadruped, kneeling, and standing.Slight improvement was reported in the ch ildren's ability toshift weight in upper extremity reaching, creeping, and transitional movement. Trunk control and voluntary strength ofthe abdominal, trunk extensor, hip extensor, and shouldermusculature seemed to improve with obvious functionalgains. Improvements in sitting balance were evidenced byincreased ability to right the trunk in all directions afterminimal to moderate displacement. These clinical findingsweredemonstratedby thechildren regardless of age or severityofdisability. These objective and subjective findings supportthe subjective, descriptive improvements noted in previouscase studies.913

This study demonstrates that therapeutic riding can be avaluable therapeutic modality for children with spastic CP.This therapeutic riding program was carefully structured withspecific therapeu tic activities chosen to facilitate achieve men tof specific therap eutic goals. A typical riding session requiredthe child to perform a closely supervised series of stretching,strengthening, and balance activities (Figs. 4-6). The childwas not a passive recipient but an active, working participant.

aSignificant at p 05A single Friedman test value is derived by computing the datadifference among the three test intervals



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RESEARCHAPPENDIXPosture Assessment Scale

Rater views child at stance anteriorly, laterally, and posteriorly by walking around the child.One score 0-3) is given foreachof theiv sectionsonthe scale. Child wears shorts or shorts and halter top only.1. H e a d a n d Ne c kScore 3 if neck is in good symmetrical alignment, head is in midline.Score 2 if child demonstrates minimal lateral neck flexion, asymmetry, or capital hyperextension.Score if child demonstrates moderate lateral neck flexion, asymmetry, or capital hyperextension.Score 0 if child demonstrates severe lateral neck flexion, asymmetry, or capital hyperextension.

2. S h o u ld e r a n d S c a p u l aScore 3 if shoulders are symmetrical and not protracted and if scapula show evidence of symmetrical alignment and stability.Score 2 if child demonstrates minimal asymmetry of shoulders, minimal protraction, or minimal scapular retraction.Score if child dem onstrates m oderate asymmetry of shoulders, moderate protraction, or moderate scapular retraction.Score 0 if child demonstrates severe asymmetry of shoulders or severe scapular retraction.

T r u n kScore 3 if child demonstrates evidence of symmetrical trunk control.Score 2 if child demonstrates evidence of minimal trunk asymmetry or weakness, such as minimal lateral trunk flexion orminimal shortening on one side.Score if child dem onstrates evidence of moderate trunk asymmetry or w eakness, such as moderate lateral trunk flexion ormoderate shortening on one side.Score 0 if child demonstrates evidence of severe trunk asymmetry or weakness, such as severe lateral trunk flexion or severeshortening on one side.

4. Sp ineScore 3 if child demonstrates evidence of symm etry and normal curvatures of spine.Score 2 if child demonstrates evidence of minimal asymmetry, lateral curve, or exaggeration of any of three normal curves.Score if child demonstrates evidence of moderate asymmetry, lateral curve, or exaggeration of any of three normal curves.Score 0 if child demonstrates evidence of severe asymmetry, lateral curve, or exaggeration of any of three normal curves.

5. Pe lv i sScore 3 if child demonstrates an obviously stable, neutral pelvis in symmetry.Score 2 if child demonstrates evidence of only minimal anterior or posterior pelvic tilt or only minimal asymmetry.Score if child demonstrates evidence of moderate anterior or posterior pelvic tilt or moderate asymmetry.Score 0 if child demonstrates evidence of severe anterior or posterior pelvic tilt or severe asymmetry.

TOTAL

Itis wellaccepted that active involvem entiscrucial for successin any therapeutic intervention. The program must be designed and directed by a physical therapist with a soundbackground in the principles of evaluation an d treatm ent forthe child with CP. An experienced therapist can modifyaccepted handling and treatm ent approaches to maximize thebenefits offered by this unusual, but unmistakably enjoyable,modality. The therapist must also have riding skills to bestund erstan d a nd c orrectly use this modality. A certified* ridinginstructor is a helpful adjunct to the therapist.This study constitutes merely the first step in examiningand docume nting some of the proposed therapeutic effects ofhorseback riding for the disabled. Further study is needed onthe effects of riding o n range of motio n, balanc e, weight shift,and strength. In addition to children with CP, therapeuticriding centers also typically serve clients with Down syndrome, amputations, head trauma, and adult hemiplegia.

Future studies can focus on therapeutic horseback riding as itaffects these patient populations as well as manipulating oneof the previously m entioned dependent variables.

CONCLUSIONThe results of this study constitute the first objective analysis ofthetherapeutic effects of horseback riding for the childwith CP. The results show that children with spastic CPdemonstrated significant improvement in posture during aperiod of therapeutic riding. Clinically subjective improvement in quality of muscle tone, balance, and weight-bearingabilities were also noted by the author and by the referringphysical therapists. Further study is needed to isolate additional variables and to examine the effects of therapeuticriding on different disabilities.Acknowledgments. I gratefully acknowledge the editorialand statistical assistance of Rebecca Craik and Carol Leiper.I also thank Timothy Brough for the artwork.

* Certification available following training from Cheff Center for the Handicapped, RR 1, PO Box 171, Augusta, MI 49012, or North American Ridingfor the Handicapped.

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REFERENCES1. Chus idJ:Correlat ive Neuroanatomy and Funct ional Neurology. Los Al tos,CA, Apple ton & Lange, 1973, pp 153-1612. Pearson PH , Wil liams CE (eds): Physical Therapy Services in the Developmen tal Disabi l i t ies. Springf ield, IL, Charles C Thom as, Publ isher, 1980,pp 31 -1853. Fay T: The n europhys ical aspec ts o f therapy in cerebra l pa lsy . Arch PhysMed 29: 327-334,19484. Farber SD: Neurorehabi l i tat ion: A Mult isensory Approach. Phi ladelphia,PA, W B Saunders Co, 19825. Bobath B, Bobath K: Motor Development inthe Dif fe rent Types o f Cerebra lPalsy. London, England, Wi l l iam Heinemann Medical Books Ltd, 19786. Bly L : Components o f normal and abnormal movementduringthe f i rs t yearof l i fe. In Slaton DS (ed): Development of Movement in Infancy. ChapelHil l,NC , The Univers ity o f North Caro lina Press , 1981, pp 85-1237. Harris SR: Neurodevelopmental treatment ppro chforte chingswimmingto cerebra l pa ls ied c h i ld ren. Phys Ther 58:979-983,19788. Wisecup LC: Dance therapy . Cl in i ca l Management in Phys ica l Therapy1(4):26-27,19819. Freeman G: Hipp otherapy / therapeut i c horseback r id ing. Clin i cal Management in Phys ica l Therapy 4(3) :20-25,1984

10. Chassaigne R: Physiologie de I'equi tat ion, de son appl icat ion aI hygieneet a la therapeutique. Thesis. Paris, France, Univers i ty of Paris, 1870(French)11 . Baine A: Pony riding for the disabled. Physiotherapy 51(8):263-265,196512. Hask in MR, Erdman WJ, Bream J, e t a l : Therapeut i c h orseback r id ing fo rthe hand icapped. Arch Phys Med Rehabi l 55:473-474,197413. Harpoth U: Horseback r id ing fo r hand icapped ch i ld ren. Phys Ther 50: 235-236,197014. Bleck E(ed):Orthopedic Management o f Cerebra l Pa lsy . Ph i lade lph ia, PA,W B Saund ers Co, 197915. Nashner L M, Shumw ay-Cook A, Mar in O: Stance p os ture cont ro l in se lec tgroups o f ch i ld ren w i th cerebra l pa lsy : Def ic i ts in sensory org an izat ion an dmuscu lar coord inat ion. Exp Bra in Res 49:393-409,198316. Meyers LS, Grossen NE: Behaviora l Research, Theory , Prac t i ce andDesign .San Franc isco, CA, W H Freeman & Co Publ i shers , 1974, pp 28 9-29117. Linton M, Gal lo PS Jr: The Pract ical Stat is t ic ian: Simpl i f ied Handbook ofStat is t ics. Monterey, CA, Brook s/Cole Publ ishing C o, 1975, p 275



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1988; 68:1505-1512.PHYS THER.Dolores B BertotiChildren with Cerebral PalsyEffect of Therapeutic Horseback Riding on Posture in

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