5. HippotherapyStacey Travis, MPT

which strikes one as a reasonable place to begin: stimulus frequency, 45 to 50 Hz; stimulus intensity, maximum tolerated; on/off times, 10/50 seconds, or triggered; ramps, 1 to 5 seconds, or to comfort; treatment duration, 10 to 15 repetitions; frequency, 3 to 5 days per week.

There are a number of studies regarding the relative utility of resistance exercise, NMES, or both.

Results vary, but they could be summarized to say that NMES is better than nothing, and not quite as good as resistance exercise alone, but that doing both is redundant.

5. Hippotherapy Stacey Travis, MPT

Children benefit from movement and novelty. There have been some im- provements in limb placement and balance and equilibrium seen in children who worked on the Bobath balls during neurodevelopment therapy. Hippo- therapy gives them, if you will, a hairy, olfactory-stimulating, warm, four- legged Bobath ball platform on which a trained therapist can capitalize on motor control, stretching, and equilibrium as the therapist works with the child.

The North American Riding for the Handicapped Association (NARHA) has defined hippotherapy as “The use of the movement of a horse as a tool by physical therapists, occupational therapists, and speech-language pathologists to address impairments, functional limitations and disabilities in patients with neuromusculoskeletal dysfunction. This tool is used as part of an integrated treatment program to achieve functional outcomes.”

Years of traditional, clinic-based therapy can become tedious and ineffec- tive for both the therapist and the child. Hippotherapy provides therapists and their patients with a novel and effective treatment modality that can spark new interest and enthusiasm. Hippotherapy is used for rehabilitation and is not to be confused with therapeutic riding. Therapeutic riding is not a for- mal treatment and focuses on recreation or riding skills for disabled riders.

Hippotherapy subjects must have an initial evaluation, progress notes, and a discharge note, just as any therapy patients.

It is important to note that this treatment may not be suitable or safe for children with spinal instability, severe osteoporosis, hip dislocation, uncontrolled seizures, spinal fusion, poor static sitting balance (in children >70 pounds), or increased tone after rid- ing.

Individuals with CP have little experience with rhythmic movements because of impairments that limit their ability to reverse the direction of move- ment.

Researchers postulate that a walking horse simulates the triplanar movement of the human pelvis during gait, while the warmth and rhythm of the horse decrease tone and promote relaxation.

Theoretically, hippo- therapy enables a child with CP to experience rhythmic movement by de- creasing impairments and allowing for the self-organization of the move- ment patterns into functional movement strategies.

Researchers have supported this theory by reporting a number of observable benefits of hippotherapy

(Table R3).

The majority of the existing research on hippotherapy consists of subjec- tive studies.

Results of hippotherapy are difficult to measure objec- tively due to a lack of valid and reliable instruments. Poor methodology and small sample sizes in the current research cause the results to be insignificant or inconclusive. Fortunately, despite this lack of objectivity, third-party re- imbursement has been commonly received for hippotherapy sessions from a wide variety of insurance companies since 1982.

A typical hippotherapy session lasts from 45 minutes to an hour. Current research is lacking a consensus on a definitive frequency or duration for this

810 Rehabilitation Techniques

treatment, but preliminary studies recommend at least 30-minute sessions, two times per week, for at least 10 weeks.

Depending on the child, prepa- ration activities may be necessary before mounting the horse.

These activ- ities may include stretching or relaxation techniques to prepare the child’s body to be ready for the horse. Hippotherapy does not typically use a saddle, but rather a sheepskin or soft pad.

This pad allows the child to be treated in almost any position on the horse’s back (e.g., supine, prone, quadruped, sitting, side sitting, kneeling) (Figure R1). On the horse, the child wears a helmet and is accompanied by three adults: a therapist, a side walker, and a lead.

The therapist may ride along with the child or handle the child from beside the horse. The lead’s main responsibility is guiding the horse.

He/she walks alongside the horse, even with its eye. The side walker helps the therapist position and focus the child. He/she walks beside the rider’s knee using an arm-over-thigh hold. The therapist can use toys or games (rings, balls, slinky) to work on various activities in different positions, or vary the terrain the horse is walking on to further challenge the child. Following the treatment on the horse, the session should end with similar activities on land to promote functional carryover.

The American Hippotherapy Association has set specific guidelines, qualifications and responsibilities for the therapist using this modality.

It is recommended that only a properly trained therapist perform this type of treatment.

6. Aquatic Therapy

Jesse Hanlon, BS, COTA, and Mozghan Hines, LPTA

The therapeutic use of water lies in the art of careful selection to use the many physical properties of water in the most appropriate way to produce a sen- sible result. Misuse or careless application can mean that well-intended ther- apy fades into merely tender loving care. Aquatic therapy provides countless opportunities to experience, learn, and enjoy new movement skills, which leads to increase functional skills, mobility and builds self-confidence.

The relief of hypertonus in the spastic type of CP is one of the major advantages of aquatic therapy. When a body is immersed in warm water (92°

to 96°F), its core temperature increases, causing reduction in gamma fiber activity, which in turn reduces muscle spindle activity, facilitating muscle

Rehabilitation Techniques 811

Table R3. Benefits of hippotherapy.

Improves joint co-contraction Decreases tone

Decreases energy expenditure with movement

Improves stability Facilitates weight–shifting Facilitates postural and equilibrium responses

Increases visual perception Increases self-confidence Improves respiration Increases coordination

Increases attention span Mobilizes pelvis, hips, and spine Increases muscle ROM, flexibility, and strength

Increases body awareness Improves balance

Improves posture/alignment

Increases listening and vestibular skills Improves gait

Improves speech and language Improves relationships