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Equine-assisted therapy has been used by medical professionals such as occupational therapists, physical therapists, speech language pathologists, psychologists, social workers, and recreational therapist
Equine-assisted therapy (EAT) encompasses a range of treatments that involve activities with horses and other equines to promote human physical and mental health. The use of EAT has roots in antiquity, and EAT applies to physical health issues in modern form dates to the 1960s. Modern of horses for mental health treatment dates to the 1990s. Systematic review of studies of EAT as applied to physical health date only to about 2007, and a lack of common terminology and standardization has caused problems with meta-analysis. Due to a lack of high-quality studies assessing the efficacy of equine-assisted therapies for mental health treatment, concerns have been raised that these therapies should not replace or divert resources from other evidence-based mental health therapies.
An overall term that encompasses all forms of equine therapy is Equine-Assisted Activities and Therapy (EAAT). Various therapies that involve interactions with horses and other equines are used for individuals with and without special needs, including those with physical, cognitive and emotional issues. Terminology within the field is not standardized, and the lack of clear definitions and common terminology presents problems in reviewing medical literature. Within that framework, the more common therapies and terminology used to describe them are:
A demonstration of hippotherapy in Europe
Most research has focused on physical benefit of therapeutic work with horses, though the most rigorous studies have only been subject to systematic review since about 2007.
EAAT have been used to treat individuals with neurological diseases or disorders such as cerebral palsy, movement disorders, or balance problems. It is believed the rhythmical gait of a horse acts to move the rider's pelvis in the same rotation and side-to-side movement that occurs when walking; the horse's adjustable gait promotes riders to constantly adjust to encourage pelvic motion while promoting strength, balance, coordination, flexibility, posture, and mobility.
EAAT have also been used to treat other disabilities, such as autism, behavioral disorders and psychiatric disorders. Due to a lack of rigorous scientific evidence, there is insufficient evidence to demonstrate if equine therapy for mental health treatment provides any benefit.
Therapeutic riding is used by disabled individuals who ride horses to relax, and to develop muscle tone, coordination, confidence, and well-being.
Therapeutic horseback riding is considered recreational therapy where an individual is taught by a non-therapist riding instructor how to actively control a horse while riding. It is used as exercise to improve sensory and motor skills for coordination, balance, and posture.
Most research has focused on physical benefit of therapeutic work with horses, with the most rigorous studies being subject to systematic review since about 2007. Claims made as to the efficacy of equine therapies for mental health purposes have been criticized as lacking proper medical evidence due in large part to poor study design and lack of quantitative data. Ethical questions relating to its expense and its continued promotion have been raised in light of this lack of evidence. While such therapies do not appear to cause harm, it has been recommended they not be used as a mental treatment at this time unless future evidence shows a benefit for treating specific disorders.
Hippotherapy is an intervention used by physical therapist, recreational therapist, occupational therapist, or speech and language pathologist. The movement of the horse affects a rider's posture, balance, coordination, strength and sensorimotor systems. It is thought that the warmth and shape of the horse and its rhythmic, three-dimensional movement along with the rider's interactions with the horse and responses to the movement of the horse can improve the flexibility, posture, balance and mobility of the rider. It differs from therapeutic horseback riding, because it is one treatment strategy used by a licensed physical therapist, occupational therapist, or speech and language pathologists. They guide the rider's posture and actions while the horse is controlled by a horse handler at the direction of the therapist. The therapist guides both the rider and horse to encourage specific motor and sensory inputs. Therapists develop plans to address specific limitations and disabilities such as neuromuscular disorders, walking ability, or general motor function.
Equine-assisted psychotherapy (EAP) or Equine Facilitated Psychotherapy (EFP) is the use of equines to treat human psychological problems in and around an equestrian facility. It is not the same as therapeutic riding or hippotherapy.:221 Though different organizations may prefer one term over the other for various reasons, in practice, the two terms are used interchangeably.:287 Other terms commonly used, especially in Canada, include Equine Facilitated Wellness (EFW), Equine Facilitated Counselling (EFC) and Equine Facilitated Mental Health (EFMH).
While some mental health therapies may incorporate vaulting and riding, most utilize ground work with horses. Some programs only use ground-based work. There are also differences between programs over whether the horse is viewed as a co-facilitator, or simply as a tool.:287
The field of equine-assisted psychotherapy did not publicly become a part of the equine-assisted therapy world until the 1990s, although individuals had been experimenting with the concept prior to that time. The first national group in the United States, the Equine-Facilitated Mental Health Association (EFMHA), now a part of PATH International, formed in 1996. The mental health area of equine-assisted therapy became subject to a major rift when a second group, the Equine Growth and Learning Association (EAGALA) formed in 1999, splitting from EFMHA (now PATH) over differences of opinion about safety protocols.:285–286 Since that time, additional differences have arisen between the two groups over safety orientation, the therapeutic models used, training programs for practitioners, and the role of riding.:51 EAGALA itself had a further split between its founders in 2006 due to legal issues, with yet another new organization formed.:52
As a result, although PATH and EAGALA remain the two main certification organizations in the United States, there has been a significant amount of misunderstanding amongst practitioners, client, and within scientific literature. To resolve these differences, an independent organization, the Certification Board for Equine Interaction Professionals (CBEIP) formed, beginning in 2007, to promote professional credibility in the field.:286 However, the world of equine-assisted psychotherapy remains disorganized and has not standardized its requirements for education or credentialing.:287
Horses have been utilized as a therapeutic aid since the ancient Greeks used them for those people who had incurable illnesses. Its earliest recorded mention is in the writings of Hippocrates who discussed the therapeutic value of riding. The claimed benefits of therapeutic riding have been dated back to 17th century literature where it is documented that it was prescribed for gout, neurological disorder and low morale. In 1946 Equine Therapy was introduced in Scandinavia after an outbreak of poliomyelitis.
Hippotherapy as currently practiced was developed in the 1960s, when it began to be used in Germany, Austria, and Switzerland as an adjunct to traditional physical therapy. The treatment was conducted by a physiotherapist, a specially trained horse, and a horse handler. The physiotherapist gave directives to the horse handler as to the gait, tempo, cadence, and direction for the horse to perform. The movement of the horse was carefully modulated to influence neuromuscular changes in the patient. The first standardized hippotherapy curriculum would be formulated in the late 1980s by a group of Canadian and American therapists who traveled to Germany to learn about hippotherapy and would bring the new discipline back to North America upon their return. The discipline was formalized in the United States in 1992 with the formation of the American Hippotherapy Association (AHA). Since its inception, the AHA has established official standards of practice and formalized therapist educational curriculum processes for occupational, physical and speech therapists in the United States.
Therapeutic riding as a therapy started with Liz Hartel from Denmark. Her legs were paralyzed from polio but with therapy she was able to win the silver medal for dressage in the 1952 Olympic Games. At about that time, in Germany, therapeutic riding was used to address orthopedic dysfunctions such as scoliosis. The first riding centers in North America began in the 1960s and the North American Riding for the Handicapped Association (NARHA) was launched in 1969. Therapeutic riding was introduced to the United States and Canada in 1960 with the formation of the Community Association of Riding of the Disabled (CARD). In the United States riding for the disabled developed as a form of recreation and as a means of motivation for education, as well as its therapeutic benefits. In 1969 the Cheff Therapeutic Riding Center for the Handicapped was established in Michigan, and remains the oldest center specifically for people with disabilities in the United States.
The North American Riding for Handicapped Association (NARHA) was founded in 1969 to serve as an advisory body to the various riding for disabled groups across the United States and its neighboring countries. In 2011, NARHA changed its name to the Professional Association of Therapeutic Horsemanship (PATH) International.
In most cases, horses are trained and selected specifically for therapy before being integrated into a program. Therapy programs choose horses of any breed that they find to be calm, even-tempered, gentle, serviceably sound, and well-trained both under saddle and on the ground. As most equine-assisted therapy is done as slow speeds, an older horse that is not in its athletic prime is sometimes used.
Equine-assisted therapy programs try to identify horses that are calm but not lazy and physically suited with proper balance, structure, muscling and gaits. Muscling is not generally considered to be as important as the balance and structural correctness, but proper conditioning for the work it is to do is required. Suitable horses move freely and have good quality gaits, especially the walk. Unsound horses that show any signs of lameness are generally avoided.
The welfare of the horse is taken into consideration. Each individual animal has natural biological traits but also has a unique personality with its own likes, dislikes and habits. Paying attention to what the animal is trying to communicate is helpful both in sessions of EAAT, but also to prevent burnout for the horse. Some programs refer to the therapy horse as an "equine partner". Other programs view the horse as a "metaphor" with no defined role other than to "be themselves." Equine Facilitated Wellness programs, particularly those following the EFW-Canada certification route view the horse as 'sentient being': "The equine is a sentient being, partner and co-facilitator in the equine facilitated relationship and process".
There is some evidence that hippotherapy can help improve the posture control of children with cerebral palsy, although the use of mechanical hippotherapy simulators produced no clear evidence of benefit. A systematic review of studies on the outcomes of horseback riding therapy on gross motor function in children with cerebral palsy was concluded in 2012 with a recommendation for a "large randomized controlled trial using specified protocols" because, although positive evidence was indicated by nine high-quality studies surveyed, the studies were too limited to be considered conclusive.
Overall, reviews of equine-assisted therapy scientific literature indicate "there is no unified, widely accepted, or empirically supported, theoretical framework for how and why these interventions may be therapeutic"  The journal Neurology published a 2014 study finding inadequate data to know whether hippotherapy or therapeutic horseback riding can help the gait, balance, or mood of people with multiple sclerosis. There is not evidence that therapeutic horseback riding is effective in treating children with autism.
There is currently insufficient medical evidence to support the effectiveness of equine-related treatments for mental health. Multiple reviews have noted problems with the quality of research such as the lack of independent observers, rigorous randomized clinical trials, longitudinal studies, and comparisons to currently accepted and effective treatments. A 2014 review found these treatments did no physical harm, but found that all studies examined had methodological flaws, which led to questioning the clinical significance of those studies; the review also raised ethical concerns both about the marketing and promotion of the practice and the opportunity cost if patients in need of mental health services were diverted from evidence-based care. The review recommended that both individuals and organizations avoid this therapy unless future research establishes verifiable treatment benefits.
The Professional Association of Therapeutic Horsemanship (PATH) accredits centers and instructors that provide equine-assisted therapy. The Equine Assisted Growth and Learning Association (EAGALA) focuses only on mental health aspects of human-equine interaction, and provides certification for mental-health and equine professionals.
In Canada, centers and instructors for Therapeutic Riding are regulated by CanTRA, also known as The Canadian Therapeutic Riding Association. The field of Equine Facilitated Wellness is regulated by Equine Facilitated Wellness - Canada (EFW-Can) which provides a national certification program and certifies trainers and mentors to provide independent training at approved programs across Canada.
The American Hippotherapy Association offers certification for working as a hippotherapist. Hippotherapy Clinical Specialty (HPCS) Certification is a designation indicating board certification for therapists who have advanced knowledge and experience in hippotherapy. Physical therapists, occupational therapists, and speech-language pathologists in practice for at least three years (6,000 hours) and have 100 hours of hippotherapy practice within the prior three years are permitted to take the Hippotherapy Clinical Specialty Certification Examination through the American Hippotherapy Certification Board. Those who pass are board-certified in hippotherapy, and entitled to use the HPCS designation after their name. HPCS certification is for five years. After five years the therapist can either retake the exam or show written evidence of 120 hours of continuing education distributed over the five years. Continuing education must include 50% (60 hours) in education related to equine subject matter: psychology, training, riding skills and so on; 25% (30 hours) in education related to direct service in the professional discipline and 25% (30 hours) in any other subject related to hippotherapy. An alternative is to provide written evidence of scholarly activity appropriate to the field of hippotherapy. Acceptable scholarly activity may include graduate education in hippotherapy, publication of articles on hippotherapy in juried publications, scientific research related to hippotherapy, the teaching or development of hippotherapy, or acting as AHA-approved course faculty. AHA, Inc. now recognizes two different AHCB credentials: AHCB Certified Therapist and AHCB Certified Hippotherapy Clinical Specialist.
Horseback riding simulators are intended to allow people to gain the benefits of therapeutic horseback riding or to gain skill and conditioning for equestrian activity while diminishing the issues of surrounding cost, availability, and individual comfort level around horses. Horseback therapy has been used by many types of therapists (ie: physical, occupational, and speech therapists) to advance their physical, mental, emotional, and social skills.
Simulators used for therapeutic purposes can be used anywhere (ie: clinic or a patient home), do not take up much space, and can be programmed to achieve the type of therapy desired. Additionally, difficulty level can be set by the therapist and increased gradually in subsequent sessions to reflect the patient’s progress and abilities. Some people use these simulators as personal exercise machines to tone core muscles in an easy and low-impact manner.
Products that attempt to accurately imitate the movement of a real horse and are sometimes used for therapeutic purposes as well as for developing equestrian skills or conditioning are the Equicizer, an American-developed mechanical product that resembles the body of a horse, imitates the movement of a race horse, and can be used at slower speeds for therapeutic and rehabilitation purposes. Another product that resembles and moves like a real horse is the line of Racewood Equestrian Simulators, with 13 models to imitate actual movement of horses in various disciplines, including a simple walk and trot model.
Simulators that do not resemble horses but imitate certain aspects of equine motion are popular in some Asian countries such as Japan and South Korea, in part because land for keeping actual horses is quite limited. One such commercial product is the Joba, created in Japan by rehabilitation doctor Testuhiko Kimura and the Matsushita Electric Industrial Company. The Joba does not resemble a horse, but rather just looks like a saddle, with plastic handle and stirrups, attached to a base that allows it to pitch and roll, exercising core muscles. A similar product manufactured in the US is a stool-like device called the iGallop, which was commercially available in the mid 2000s and moves in a side-to-side and circular motion with various speed settings. However, it was criticized for not delivering the results claimed.
There has been increased research regarding use of horseback riding simulators compared to conventional therapy methods. One 2011 study by Borges et al. compared children with cerebral palsy and postural issues who received conventional therapy to similar children who received therapy involving a riding simulator. The results from this study showed that children who received riding simulator therapy exhibited a statistically significant improvement regarding postural control in the sitting position, specifically regarding the maximal displacement in the mediolateral and anteroposterior directions. Parents of these children noted that their children executed activities of daily living that demanded greater mobility and postural control better than before. In a 2014 study by Lee et. al, 26 children with cerebral palsy were divided into two groups: a hippotherapy group and a horseback riding simulator group. The children in each group underwent the same kind of therapy for the same amount of time using either a real horse or the simulator. Conventional physical therapy sessions were attended before each hippotherapy or horseback riding simulator session. It was found that both static and dynamic balance improved for the children in both groups following their 12-week-long programs and there was not a statistically significant difference between the results from the two groups. This indicates that using a horseback riding simulator can be as effective as hippotherapy for improving balance in children with cerebral palsy.
Another area of research involves horseback riding simulation with stroke patients. Trunk balance and gait were assessed before and after the stroke patients were treated using a horseback riding simulator. Because stroke patients are not able to keep both feet on the floor and weight distributed equally between them, it is very easy for them to lose trunk muscle strength and control of the trunk on one or both sides. In a 2014 study, 20 non-traumatic, unilateral stroke patients underwent therapy using a horseback riding simulator. Their therapy included six 30-minute sessions a week for five weeks. The Trunk Impairment Scale (TIS) used to assess the patients before and after their therapy showed that they had better trunk control in a seated position following their sessions. Upon gait analysis, improvements in the areas of velocity, cadence, and stride length of the affected and non-affected sides were all observed. Additionally, the percentage of time spent in the double support phase was decreased. More research studies in which more subjects are tested for longer amounts of time are currently being investigated.
Colorado equine therapy for veterans with ptsd