Review Article

https://doi.org/10.14474/ptrs.2020.9.1.55 Phys Ther Rehabil Sci

pISSN 2287-7576 2020, 9 (1), 55-65
eISSN 2287-7584 www.jptrs.org

Effects of hippotherapy on children with cerebral palsy: http://crossmark.crossref.org/dialog/?doi=10.14474/ptrs.2020.9.1.55&domain=pdf&date_stamp=2020-03-25

systematic review and meta-analysis

Kwon-Hoi Kima , Suk-Min Leeb
a
Team of Physical Therapy, Catholic University of Korea, Uijeongbu ST. Mary’s Hospital, Uijeongbu, Republic of Korea
b
Department of Physical Therapy, College of Health and Welfare, Sahmyook University, Seoul, Republic of Korea

Objective: The most important goal of hippotherapy is to improve function, gait, and balance. The purpose of this study was to in-
vestigate the effects of hippotherapy on function, gait, and balance of children with cerebral palsy (CP).
Design: A systematic review and meta-analysis.
Methods: We’ve searched the PubMed, EMBASE, and Cochrane Library CENTRAL databases for English experimental studies
published up until September 2018. To analyze the effects of hippotherapy on the function, gait, and balance of children with cere-
bral palsy, the systematic review and meta-analysis were performed on Patient/Participants/Population Problem, Intervention,
Comparison, Outcome with Timing, Setting Study Design. Papers retrieved from the database were removed from the literature
management database. Methodological quality evaluation was evaluated using Cochrane’s risk of bias. Data was analyzed using
the Revman 5.3 program of the Cochrane library.
Results: In this study, we found that the effect size of hippotherapy, denoted as d, was −3.82, and that hippotherapy had the most
effect on gait, but no statistical significant difference was observed. We also found no significant difference in function and bal-
ance after hippotherapy. It was found from the funnel plot that there was no publication bias as the plot was symmetrically dis-
tributed around the dotted line.
Conclusions: There are many unclear studies and a lack of randomized controlled trials (RCTs) in this research area. More RCTs
on the effects of hippotherapy on children with CP should be conducted in the future.
Key Words: Balance, Cerebral palsy, Function, Gait, Hippotherapy

Introduction improve the quality of life of people with CP, it is necessary

to apply a very comprehensive and multidisciplinary ap-
Cerebral palsy (CP) is a disorder characterized by impair- proach with an emphasis on appropriate rehabilitation [5].
ments in autonomic movement and posture for non-pro- Interventions must focus on all areas of the body structures
gressive disease or damage to the brain that has developed and function, level of activity, and participation in order to
into a disease of the central nervous system [1]. The preva- have a positive influence on the quality of life of the child
lence of CP worldwide is estimated to be between 2 and 3 per [6].
1,000 live births [2]. CP affects not only the motor system, Over the years, several treatment methods have been de-
but it often is connected to neurocognitive, sensory, and sen- veloped (e.g., neurodevelopmental treatment, the Vojta met-
sitive disorders [3]. Children with CP experience difficulties hod, conductive education, sensory integrative therapy) that
with controlling the body’s position in space, performing an- differ in their specific treatment strategies, but aim at leading
ticipatory adjustments for executing functional activities, children with CP toward the greatest degree of independ-
and reacting to unexpected perturbations of balance [4]. To ence possible [7]. Many traditional physical therapy inter-

Received: 25 November, 2019 Revised: 3 March, 2020 Accepted: 11 March, 2020

Corresponding author: Suk-Min Lee (ORCID https://orcid.org/0000-0002-0602-956X)
Department of Physical Therapy, College of Health and Welfare, Sahmyook University, 815 Hwarang-ro, Nowon-gu, Seoul 01795, Republic of Korea
Tel: 82-2-3399-1632 Fax: 82-2-3399-1639 E-mail: [email protected]
This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2020 Korean Academy of Physical Therapy Rehabilitation Science
56 Phys Ther Rehabil Sci 9(1)

vention for children with CP focus on impairments within nificant effects on balance [14]. Previous results have been
the child at the domain of body function and structure [8]. different.
However, physical activity provides many benefits to these Meta-analyses of hippotherapy have been conducted, but
individuals, including the improvement of functional abil- this is the first meta-analysis on hippotherapy for children
ities, including balance, and delaying the progression of with CP. In addition, we’ve included studies on hippo-
some disorders [9]. Hippotherapy is used as a strategic treat- therapy for children with CP to investigate the effects of the
ment method for children with motor disabilities using hors- therapeutic intervention and to determine its effect size on
es as part of integrated therapy. This method entails teaching function, gait, and balance.
horse riding skills to individuals with disabilities. Hippo-
therapy is used to treat horses to health professionals such as Methods
physiotherapists and occupational therapists [10]. Thera-
Protocol
peutic strategies of horse movement are considered to reach
functional outcomes [11]. The method used in this study is presented in a protocol
In horseback riding, movements of the horse affect the registered with PROSPERO (PROSPERO registration num-
rider such that the rider experiences various physical changes. ber: CRD42018108721). We received approval for this study
A horse’s rhythmic movement necessitates delicate collabo- from the Institutional Review Board (IRB NO. 2-7001793-
rative movements of the rider’s neck, torso, and limb mus- AB-N-012018082HR). This review was conducted by the
cles [12]. Due to some forms of walking is similar between checklist of the Preferred Reporting Items for Systematic
horses and humans, horseback riding results in creating three- Reviews and Meta-analysis. The search strategy of the re-
dimensional movements in the rider [13]. The American view was performed by two researchers. To analyze the ef-
Equestrian Association reported that hippotherapy improves fects of hippotherapy on function, gait, and balance of chil-
muscle tone, balance, postural control, cooperation, and mo- dren with CP, a systematic review and meta-analysis were
tor development. Therefore, the most important goal of hip- performed on Patient/Participants/Population Problem, Inter-
potherapy is to improve balance, posture, function, and mo- vention, Comparison, Outcome with Timing, Setting Study
bility [14]. Design.
Hippotherapy has demonstrated short term benefits of in-
Identification and selection of studies
ducing symmetry of muscles in the trunk and hip and re-
ducing asymmetry of the adductor muscles. Moreover, it The inclusion criteria for this review were the following:
was recognized as inducing improved vestibular and pro- (1) participants were children with CP; (2) intervention used
prioceptive stimulation and increased body awareness [15]. in the study was hippotherapy; (3) outcome measurements
Recently, randomized controlled trial (RCT) studies using included function, gait, and balance. Studies were excluded
hippotherapy have been increasing. There were no RCT if: (1) the study was written in languages other than English;
studies on hippotherapy in PubMed provided by the US (2) the study was not published as the full reports; (3) any
National Library of Medicine before 1997, but since then, other types of study design other than RCTs; (4) studies not
there has been a steady increase every year, with 43 RCT providing data on baseline score or end-point outcome.
studies on hippotherapy in 2018. We searched the core electronic databases, namely PubMed,
The broader the scope of the meta-analysis, the more EMBASE, and Cochrane Library CENTRAL. The search
comprehensive it becomes; however, there is a wide range of terms included words for children with CP (Patient: P) and
outcomes of a particular disease, and a narrow scope makes words for hippotherapy (Intervention: I). After checking the
the discussion of the various effects of hippotherapy difficult medical subject headings (MeSH), which are control words
[16]. In an earlier meta-analysis of hippotherapy, the effect from PubMed, we selected 2 MeSH words (“equine-assist
of hippotherapy on all diseases was investigated. This meta- therapy” OR “cerebral palsy”). The retrieval equations were
analysis showed no significant effects on gross motor func- constructed by connecting control words, which include rel-
tion measure (GMFM) and pediatric balance scale (PBS) on evant central keywords identified in the abstract, with “OR.”
CP [9]. However, A meta-analysis of the effects of hippo- In EMBASE, which is a European electronic database, the
therapy on children with CP in regards to some of its specific control word was checked in EMTREE using the same
effects was also conducted. This meta-analysis showed sig- method as for PubMed. The search was conducted on
Kim and Lee, et al: Effects of hippotherapy on children with CP 57

September 2, 2018, using the following keywords: (‘cere- Group. The quality of the papers was evaluated on the basis
bral palsy’/exp OR ‘brain palsy’ OR ‘brain paralysis’ OR of random sequence generation, allocation concealment,
‘central palsy’ OR ‘central paralysis’ OR ‘cerebral palsy’ blinding of participants and personnel, blinding of outcome
OR ‘cerebral paralysis’ OR ‘cerebral paresis’ OR ‘encephalo- assessment, incomplete outcome data, selective reporting,
pathia infantilis’ OR ‘palsy, cerebral’ OR ‘spastic diplegia’) and other forms of bias. Non-RCTs and single-group clinical
AND (‘hippotherapy’/exp OR ‘equine assisted therapy’ OR trials were used in quality assessment as Risk of Bias
‘equine-assisted therapy’ OR ‘hippotherapy’ OR ‘horseback Assessment Tools for Non-randomized Studies. For RoB
riding therapy’). In the Cochrane Library CENTRAL, a and RoBANS, the bias risk was divided into “high,” “low,”
search was made using the MeSH words from PubMed. and “uncertain.” A “low” bias risk indicates a low proba-
bility of bias, “high” bias risk indicates a high probability of
Data extraction
bias; and “uncertain” indicates risk that is difficult to de-
We only considered papers published in English from the termine [17]. The RevMan 5.3 program (The Cochrane Col-
date of first data entry into the electronic database to laboration, Copenhagen, Denmark) was used for the evalua-
September 2018. Papers retrieved from the databases were tion and explanation of results.
removed from the literature management database (Endnote
Data analysis
X8; Clarivate Analytics, Philadelphia, PA, USA). Duplicate
articles were eliminated. The title and abstract of the papers In the meta-analyses, the effect size of the intervention
were confirmed, and the original texts of the selected pub- was calculated using the RevMan 5.3 program of the
lications were then reviewed according to the inclusion Cochrane Library. Meta-analysis was performed when the
criteria. The exclusion criteria were described, and the final same outcome variables were analyzed or when there were
selection of materials was obtained (Figure 1). pre- and post-quantitative values for outcome variables.
Meta-analysis was also performed when more than 2 studies
Quality assessment
were conducted for each outcome variable. The mean differ-
Evaluation in the RCTs was performed using the Cochrane’s ences and standard deviations before and after the inter-
Risk of Bias tool developed by The Cochrane Bias Method vention in the selected study articles were used for analysis.
To assess the effect estimate of the selected RCTs, the mean
and standard deviation values were pooled to obtain the
mean difference and 95% confidence intervals (CI). The ef-
fect size was calculated using a random-effects model that
resets the weights considering heterogeneity among studies.
The homogeneity of study subjects was confirmed using
Cochrane’s chi-square test and the I2 test. The I2 value is 0%
when there is no heterogeneity, 30% to 60% for moderate het-
erogeneity, and 75% for severe heterogeneity [17]. Publication
bias of the included research papers was tested using a fun-
nel plot [18]. Publication bias was evaluated with a visual in-
spection of the funnel plot for asymmetry and subsequently
with Egger’s test when: 1. Asymmetry of funnel plot was ob-
served; and 2. When 10 studies were included in a meta-
analysis (http://handbook.cochrane.org). Publication bias
was not assessed as there were less than 10 studies included
for meta-analysis [19].

Results
Study selection process
Figure 1. Preferred Reporting Items for Systematic Reviews and
Meta-analysis flow diagram. A total of 205 articles were retrieved from overseas data-
58 Phys Ther Rehabil Sci 9(1)

bases using the titles and abstracts of the research papers in available in some cases and the intervention provider was
PubMed, EMBASE, and Cochrane Library CENTRAL. considered an expert. Regarding the methodological quality
Using the literature management database (Endnote X8), 54 evaluation of four single-group clinical trials, the selection
duplicate articles were identified and excluded, leaving 151 of a target group was not reported in 1 article and blinding of
of the original 205 for selection. Of the 151 articles, 86 did the evaluator was not reported in 3 papers. Results were not
not meet the inclusion criteria, leaving 65 original study ar- presented in 1 article (Figure 2).
ticles for selection. Of these 65 articles, 26 deviated from the
Effects of hippotherapy
main text, 22 did not report the mean or standard deviation
values, three were non-experimental studies, and two were In this study, the characteristics of 12 intervention studies
not published in English. Twelve studies met all inclusion on hippotherapy for children with CP were analyzed. The
criteria and constituted the final selection of studies (Figure number of participants was 2 or less (16.6%), 5 (41.7%)
1). from 11 to 20 participants, and 5 (41.7%) from 21 or more
participants. The number and percentage of children with
Methodological quality
CP who were ≤6 years, 7-8 years, and ≥9 years were 2
The RoB tool developed by the Cochrane group was used (16.6%), 5 (41.7%), and 3 (25.1%), respectively. The age of
for the eight RCT papers and the RoBANS tool for the four 2 children (16.6%) was unclear. The types of CP were spas-
single-group clinical trial papers (Figure 2). One of the eight tic, diplegic, bilateral spastic, and total in 6 (50%), 1 (8.3%),
RCT papers selected as final articles was considered to have 2 (16.6%), and 3 (25.1%) children, respectively. The inter-
a high degree of bias (＋), which was described in detail in ventions used in the included studies were hippotherapy,
the other seven articles. Allocation concealment was de- hippotherapy with conventional therapy, and hippotherapy
scribed in 4 papers, and blinding of participants and person- with active trunk extension in 6 (50%), 5 (41.7%), and 1
nel was considered to be low (−) in five papers. Blinding of (8.3%) studies, respectively. Hippotherapy was admini-
the evaluator was described in five papers and was consid- stered at a mean duration of 38.75 minutes/session 1.63
ered to be low (−). With regard to incomplete outcome data, times/week for 9.62 weeks (Tables 1, 2) [27,28,30-33,35-40].
one paper was considered as extremely weak and six were In this study, meta-analysis of the effects of hippotherapy on
considered to be mildly weak. Selective outcome reporting the function, gait, and balance of children with CP was per-
was described in all studies. A manual for intervention was formed in 9 of the 12 studies included in this study.

Figure 2. Methodological evaluation.

Kim and Lee, et al: Effects of hippotherapy on children with CP 59

Table 1. Descriptive summary of included studie (N=12)

Study Sample characteristics Interventions Control groups Outcomes (scales) Results
Lucena- RCT of the effects of a Type: hippotherapy in addition Conventional 1) MAS 1) Decreased MAS
Antón hippotherapy intervention to conventional treatment group
et al. [35] protocol on hip adductor Format (setting): hospital
spasticity in children with Providers: physical therapist
spastic CP of GMFCS levels Session: 45 min 1 time/week
IV-V (n=22) and in the for 12 wk
control group (n=22)
El-Meniaw RCT of an exercise program Type: hippotherapy in addition Conventional 1) Back geometry 1) Improvement in
y and for children with spastic to conventional treatment group back geometry
Thabet diplegia with emphasis on Format (setting): clinic
[36] posture correction (n=15) and Providers: physical therapist
of hippotherapy in addition to Session: 1 hour 3 times/week
the exercise program (n=15) for 3 mo
in children of GMFCS levels
I-II
Kwon RCT of hippotherapy effects on Type: hippotherapy in addition Conventional 1) Temporospatial 1) Improved
et al. [37] temporospatial parameters to conventional treatment group parameters temporospatial
and pelvic and hip kinematics Format (setting): riding ground 2) Pelvic and hip parameters
of gait in children with Providers: physical therapist kinematics 2) Improved pelvic
bilateral spastic CP of Session: 30 minutes/session 2 3) PBS and hip
GMFCS levels I-II (n=16) days/week for 8 wk kinematics
and in the conventional 3) Increased GFMF
treatment group (n=16) 4) Increased PBS
Kwon RCT of hippotherapy effects on Type: hippotherapy in addition Conventional 1) GMFM 1) Increased
et al. [30] the gross motor function of to conventional treatment group 2) PBS GMFM
children with CP of GMFCS Format (setting): therapy center 2) Increased PBS
levels I-IV (n=45) and in the Providers: physical therapist
control group (n=46) Session: 30 minutes/session,
twice weekly for 8
consecutive wk
Davis RCT of the impact of Type: hippotherapy Control group 1) GMFM 1) No significant
et al. [27] therapeutic horse riding on Format (setting): individual 2) CHQ changes
children with CP of GMFCS (hospital) 3) QoL (CP 2) No significant
levels I-III (n=35) and in the Providers: hippotherapist QoL-child, changes
control group (n=37) Session: 10-wk study period KIDSCREEN) 3) No significant
changes
Park RCT of hippotherapy effects on Type: hippotherapy Control group 1) GMFM 1) Increased
et al. [38] gross motor function and Format (setting): community 2) PEDI GMFM
functional performance of Providers: occupational 2) Increased PEDI
children with CP of GMFCS therapist
levels I-IV (n=28) and of the Session: 45 minutes/session
control group (n=21) twice a week for 8 wk
Herrero A stratified single-blind RCT Type: hippotherapy with active Non-simulator 1) GMFM 1) Improved
et al. [33] of the effects of a simulator extension of the trunk hippotherapy 2) Sitting GMFM
on children with CP of Format (setting): school group Assessment 2) Improved sitting
GMFCS levels I-V (n=19) or Providers: not reported Scale balance
on the control group (n=19) Session: 15 minutes/session
once a week for 10 wk
Follow-up: 3 mo post-training

fect size was −2.24 (95% confidence interval [CI]: −5.72,

Effect on function
1.24). The effect size on function was not statistically sig-
The GMFM-66 was assessed in 4 studies; no hetero- nificant (p=0.21). A total of 3 articles from studies that as-
geneity was found between the studies (I2=0%), and the ef- sessed GMFM-88 were selected for meta-analysis. There
60 Phys Ther Rehabil Sci 9(1)

Table 1. Continued
Study Sample characteristics Interventions Control groups Outcomes (scales) Results
Cherng RCT of the effectiveness of Type: therapeutic horseback Control group 1) GMFM 1) Improved
et al. [31] therapeutic horseback riding riding in addition to regular 2) MAS GMFM
in children with spastic CP treatment 2) No significant
(n=9) and in the control group Format (setting): training center changes in
(n=5) Providers: pediatric physical muscle tone
therapist
Session: 40 minutes/session 2
sessions/week for 16 wk
Kang RCT of hippotherapy effects on Type: hippotherapy Physical therapy 1) Left/right 1) Decreased
et al. [32] the sitting balance of children Format (setting): individual group and no pathway left/right
with severe CP (n=15), a (hospital) treatment 2) Total pathway pathway
physical therapy group Providers: physical therapist group 3) Left/right 2) Decreased total
(n=15), and a control group Session: 45 minutes/session velocity pathway
(n=15) twice a week for 8 wk 4) Total velocity 3) Decreased
left/right velocity
4) Decreased total
velocity
Benda Single pre-post test of Type: hippotherapy None 1) Improved
et al. [39] hippotherapy effects on Format (setting): community 1) Muscle activity symmetry in
muscle activity in children Providers: physical therapist muscle activity
with spastic CP (n=15) Session: 8 min
McGee Single pre-post test of Type: hippotherapy None 1) Temporal and 1) Increased
et al. [28] hippotherapy effects on gait Format (setting): university spatial gait temporal and
parameters in children with Providers: pediatric physical parameters spatial gait
spastic CP of GMFCS levels therapist parameters
I-III (n=9) Session: 1 session lasting
30-45 min
Deutz A randomized open-label Type: hippotherapy None 1) GMFM 1) Improved
et al. [40] crossover study of hippotherapy Format (setting): hospital 2) CHQ GMFM
effects on children with (center) 3) KIDSCREEN 2) Improved CHQ
bilateral CP of GMFCS levels Providers: physical therapist 3) improved
II-IV in early (n=35) and late Session: 1-2 sessions/week for KIDSCREEN
(n=38) treatment groups 16-20 wk scores
RCT: randomized controlled trial, CP: cerebral palsy, GMFCS: gross motor function classification system, MAS: modified aschworth scale,
GMFM: gross motor function measure, PBS: pediatric balance scale, QoL: quality of life, PEDI: pediatric evaluation of disability inventory,
CHQ: child health questionnaire.

was no heterogeneity between the studies (I2=0%), and the However, no statistical significance was observed (p=0.40)
effect size was −1.73 (95% CI: −5.89, 2.43). The effect (Figure 3).
size on function was not statistically significant (p=0.41).
Effect on balance
Three research papers reported on GMFM-B, and no hetero-
geneity was found between the studies (I2=0%). The effect Two studies that reported PBS values were selected in a
size in these studies was −0.62. (95% CI: −4.55, 3.30), but meta-analysis of balance. There was no heterogeneity be-
no statistical significance was observed (p=0.76) (Figure 3). tween the studies (I2=0%). The effect size was calculated us-
ing the random-effects model. The effect size in these stud-
Effect on gait
ies was −3.60 (95% CI: −9.07, 1.87) but no statistically
Four studies assessed GMFM-E (gait-related measure- significant difference was observed between the studies (p=
ments) and were selected for the meta-analysis. There was 0.20) (Figure 3).
2
no heterogeneity between the studies (I =0%), and the effect
Bias test and reliability test for calculated effect size
size was calculated using the random-effects model. The ef-
fect size in these studies was −3.82 (95% CI: −12.71, 5.06). It was found from the funnel plot that there was no pub-
Kim and Lee, et al: Effects of hippotherapy on children with CP 61

Table 2. Descriptive summary of included studies (N=12) Table 2. Continued

Characteristics Value Characteristics Value
General Duration (mean) 38.75 minutes/session
Year Hippotherapy 1.63 times/week for 9.62 wk
≤2010 4 (30.0) Outcomes and measurements
2011-2013 4 (30.0) Physical activity
2014-2016 2 (20.0) GMFM-66 4 (30.0)
≥2017 2 (20.0) GMFM-88 3 (25.1)
Country GMFM dimension A 2 (16.6)
Korea 4 (30.0) GMFM dimension B 3 (25.1)
USA 2 (20.0) GMFM dimension C 2 (16.6)
Spain 2 (20.0) GMFM dimension D 2 (16.6)
Other countries (Egypt, Australia, 4 (30.0) GMFM dimension E 4 (30.0)
Thailand, Germany) Gait (walking)
Study design Temporospatial parameters 2 (16.6)
RCT 8 (70.0) Balance
Single-group clinical trial 4 (30.0) Pediatric balance scale 2 (16.6)
Participants Sitting assessment scale 1 (8.3)
Sample size: clinical trial QoL
≤10 2 (16.6) KIDSCREEN 2 (16.6)
11-20 5 (41.7) Spasticity
≥21 5 (41.7) MAS 2 (16.6)
Age (y)
Values are presented as mean (SD) or n (%).
≤6 2 (16.6)
CP: cerebral palsy, GMFCS: gross motor function classification system,
7-8 5 (41.7)
QoL: quality of life, RCT: randomized controlled trial, GMFM:
≥9 3 (25.1) gross motor function measure, MAS: modified aschworth scale.
Unclear 2 (16.6)
CP type
Spastic 6 (50.0)
lication bias as the plot was symmetrically distributed around
Diplegia 1 (8.3)
Bilateral spastic 2 (16.6) the dotted line (Figure 4). For objective verification, Egger’s
Total 3 (25.1) regression test [20], which is a statistical analysis method for
GMFCS level publication errors, was used to examine the relationship be-
I-II 2 (16.6)
I-III 2 (16.6)
tween the effect size and the standard error. In this study, less
I-IV 2 (16.6) than 10 studies were included in the meta-analysis, so no
I-V 1 (8.3) Egger’s regression test was conducted.
II-IV 1 (8.3)
IV-V 1 (8.3)
Unclear 3 (25.1) Discussion
Interventions
Type The aim of this study was to investigate the effects of hip-
Hippotherapy 6 (50.0)
potherapy on function, gait, and balance of children with CP.
Hippotherapy＋conventional therapy 5 (41.7)
Hippotherapy＋active trunk 1 (8.3) The most important goal of hippotherapy is to improve func-
extensions tion, gait, balance. In this study, we aimed to determine sys-
Setting tematically and objectively the therapeutic intervention ef-
Home/community 2 (16.6)
fect of hippotherapy on children with CP through meta-
Hospital/clinic 7 (58.5)
Riding ground 1 (8.3) analysis. We included 12 trials from a total of 205 and found
School 2 (16.6) evidence of the effects of hippotherapy on function, gait, and
Providers balance of children with CP. Of the 12 studies included, 9
Physical therapist 7 (58.5)
Occupational therapist 1 (8.3) were meta-analyses, and 3 were systematic reviews. Meta-
Pediatric physical therapist 2 (16.6) analyses can provide information for establishing a rational
Hippotherapist 1 (8.3) and valid basis for clinical decision-making, avoiding un-
Self/Unclear 1 (8.3)
necessary repetitive research, and finding comprehensive
62 Phys Ther Rehabil Sci 9(1)

Figure 3. Forest plots of the effects of hippotherapy. GMFM: gross motor function measure, PBS: pediatric balance scale.

results that can be generalized by integrating and analyzing therapy reported statistically insignificant results for GMFM
individual research results systematically [21]. In the 9 meta- [9]. Most of the studies showed a trend toward a beneficial
analyses on the therapeutic intervention of children with CP, effect of hippotherapy on balance and gross motor function.
the important outcome variables were function, balance, and About the function in this study, GMFM 66 analyzed four
gait. Function relates to physical activity, is evaluated in studies, GMGM 88 analyzed four studies, and GMFM-B an-
terms of GMFM, and is the most researched outcome alyzed three studies. The effect of the hippotherapy was evalu-
variable. A recent meta-analysis on the effects of hippo- ated by d=−2.24, p>0.05 for the GMFM 66, d=−1.73,
Kim and Lee, et al: Effects of hippotherapy on children with CP 63

Figure 4. Funnel plot of standard error by standardized mean difference. GMFM: gross motor function measure, PBS: pediatric balance scale.

p>0.05 for the GMFM 88, d=−0.62 and p>0.05 for the hippotherapy [25]. This study report shows that the stat-
GMFM-B, respectively, and the results were not significant. istical results were different in each study. In the study by
In the previous study, no significant heterogeneity was ob- Casady and Nichols-Larsen [26], 10 children with CP aged
served for participants with CP, the Q statistic was equiv- 2.3-6.8 years showed improved results when GMFM was
alent to 1.11 (p=0.77), and the I2 was found equal to 0%, in- evaluated following 10 weeks of a weekly rehabilitation
dicating that there was no heterogeneity between the studies. regimen. In contrast, Davis et al. [27] reported that GMFM
The results of the meta-analysis showed the following p> scores were not significantly different after hippotherapy.
0.05 results and showed the same results as the results of this The meta-analysis performed in our study showed statisti-
study [9]. cally insignificant differences in function after hippotherapy.
According to a recent study, hippotherapy for CP is elec- GMFM-E was used to evaluate gait, and 4 meta-analyses
tive and geared toward improving function [22]. Hippotherapy were conducted. An improvement in GMFM-E represents
is an effective treatment option for improving function and improvement in gait [28]. The study by McGibbon et al. [29]
balance of children with CP [23]. Children with neuro- reported that an average of 9.6 children with CP who com-
muscular disorders can benefit from hippotherapy if they pleted the rehabilitation regimen twice a week for 8 weeks
have a problem with balance [24]. In addition, the evaluation had improved GMFM-E values. In our study, the effect size
of gait and balance in children with CP who have undergone on gait was high (d=−3.82) but not statistically significant.
hippotherapy is a good way to assess the long-term effects of PBS was used to evaluate balance, and the results of 2 stud-
64 Phys Ther Rehabil Sci 9(1)

ies were meta-analyzed. Increase in PBS scores is an effect lack of clarity and a considerable lack of RCTs in this re-
of hippotherapy in children with CP [30]. An earlier meta- search area. Therefore, it is essential that many more RCTs
analysis reported no statistically significant differences in be conducted on hippotherapy for children with CP in the
PBS [31]. However, a study reported significant results in future.
balance [32]. Herrero et al. [33] reported that the sitting bal-
ance ability of 19 children with CP improved after hippo- Conflict of Interest
therapy. However, the study did not report any statistically
significant differences. Previous study report shows that the The authors declared no potential conflicts of interest
statistical results were different in each study. It is necessary with respect to the authorship and/or publication of this
to present data in a more objective and scientific way to article.
measure hippotherapy.
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