ARTICLE

Effects of Hippotherapy on Postural Stability, in Persons

with Multiple Sclerosis: A Pilot Study
Debbie Silkwood-Sherer, PT, MS, and Heather Warmbier, MPT

Purpose: The purpose of this pilot study was to examine the

effectiveness of hippotherapy as an intervention for the treatment of
postural instability in individuals with multiple sclerosis (MS).
Subjects: A sample of convenience of 15 individuals with MS
(24 72 years) were recruited from support groups and assessed for
balance deficits.
Methods: This study was a nonequivalent pretest-posttest comparison group design. Nine individuals (4 males, 5 females) received
weekly hippotherapy intervention for 14 weeks. The other 6 individuals (2 males, 4 females) served as a comparison group. All
participants were assessed with the Berg Balance Scale (BBS) and
Tinetti Performance Oriented Mobility Assessment (POMA) at 0, 7,
and 14 weeks.
Results: The group receiving hippotherapy showed statistically
significant improvement from pretest (0 week) to posttest (14 week)
on the BBS (mean increase 9.15 points (x2 (2) 8.82, p 0.012))
and POMA scores (mean increase 5.13 (x2 (2) 10.38, p 0.006)).
The comparison group had no significant changes on the BBS (mean
increase 0.73 (x2 (2) 0.40, p 0.819)) or POMA (mean decrease
0.13 (x2 (2) 1.41, p 0.494)). A statistically significant difference
was also found between the groups final BBS scores (treatment
group median 55.0, comparison group median 41.0), U 7, r
0.49.
Discussion: Hippotherapy shows promise for the treatment of balance disorders in persons with MS. Further research is needed to
refine protocols and selection criteria.
Key words: hippotherapy, multiple sclerosis, postural stability,
balance, task-oriented
(JNPT 2007;31: 7784)

INTRODUCTION

mpairment of postural stability is one of the greatest deterrents to mobility and autonomy in daily activities for
persons with multiple sclerosis (MS).15 The causes of poor
balance in individuals with MS are well documented and
include decreased range of motion, weakness of trunk and
lower extremity muscles, spasticity, and fatigue.35 Specific
sensory deficits that contribute to postural instability are
Graduate Program in Physical Therapy, Central Michigan University, Mt.
Pleasant, Michigan
Address correspondence to: Debbie Silkwood-Sherer, E-mail: silkw1d@
cmich.edu
Copyright 2007 by Lippincott Williams & Wilkins
ISSN: 1557-0576/07/3102-0077
DOI: 10.1097/NPT.0b013e31806769f7

JNPT Volume 31, June 2007

dysfunctions of visual, somatosensory and vestibular systems.4,6 8 Utilizing posturogaphy, Nelson et al9 confirmed
that persons with MS (n 35) have difficulty integrating
information from the visual, somatosensory, and vestibular
systems. Fifty-eight percent of the 12 individuals whom they
classified as having low function balance scores demonstrated
either a vestibular dysfunction pattern or a combination of
visual-vestibular dysfunction or somatosensory-vestibular
dysfunction.9 Thus, postural instability (or poor balance) in
persons with MS often results from a combination of impairments of body functions and structures, making treatment of
balance in individuals with MS a challenging task.
In the early 1990s trends in the treatment of neurological disorders began to change from a primary focus on
impairments to a more goal-directed retraining of functional
tasks, or task-oriented approach.10 Utilizing the task-oriented approach for treatment of balance problems, the therapist attempts to assist the patient in developing the most
effective sensory and motor strategies to maintain postural
control while practicing under different functional conditions
and with progressive degrees of difficulty.10 12 This taskoriented approach works well for treating balance problems
in persons with MS, as the effects of the many impairments
are addressed simultaneously in concert with improving functional limitations.
According to Heine,13 hippotherapy can be considered
as one such task-oriented multisystem approach to the treatment of persons with neuromuscular disorders including MS.
Movement of the horse promotes a disassociation of the
pelvis and trunk that, along with the warmth provided by the
horses body, appears to assist in decreasing tone. Additionally, the horses movement displaces the subjects pelvis
through space in a manner similar to the pelvic movement
used during gait, but with greater excursion (see Video 1).13
Thus greater pelvic displacement increases somatosensory
input through the joints and muscles. The movement through
space also provides a constantly changing visual flow and
increases demands to the vestibular system.13,14 To maintain
balance, the client has to adjust to the pelvic movement as
well as process the sensory information, thus stimulating
righting and equilibrium reactions.14,15
Another advantage of hippotherapy is that while reacting to the movement of the horse, clients learn to discover
their own solutions to the problems of staying upright on a
surface that moves in three dimensions simultaneously. The
physical therapist can assist this process by manipulating the
environment, thereby randomizing the necessary anticipatory

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and reactive adjustments for postural control. This manipulation takes the form of changes in speed, direction, the
addition of abrupt halts and starts, and asking the client to
perform various exercises while atop the moving horse.
Thus a theoretical basis exists for the use of hippotherapy as an intervention tactic for persons with MS. However, there is sparse research on hippotherapy use in adults
with neurological disorders.16 The majority of published
studies and case reports relate to treatment of children with
disabilities.1722 One barrier to locating literature is a misrepresentation of the term hippotherapy. Authors have frequently used the terms hippotherapy and therapeutic
riding interchangeably. Hippotherapy is provided by rehabilitation professionals (physical, occupational, and speech
therapists) as a method of attaining functional goals in their
clients/patients.23 The client does not control the movement
or direction of the horse. Therapeutic riding (taught by
trained instructors) is focused on teaching riding skills to
persons with disabilities.23,24 Although both interventions
have benefits, improper use of these terms in the research
literature has made accurate assessment of their outcomes
more challenging.
A second problem with hippotherapy research is that
early research used small sample sizes, lacked standardized
objective measures, and frequently reported results in nonpeer reviewed magazines/journals. Recently researchers have
utilized the term hippotherapy accurately and been more
systematic in their analysis, but the literature is still plagued
by small sample sizes. Collectively these studies have demonstrated that hippotherapy has improved trunk alignment
and control,25,26 enhanced symmetrical weight bearing and
muscle activity,15,27 increased endurance,28 balance,15,20 coordination and sensory integration, improved motor performance,29 and decreased abnormal tone.30
Only 2 published studies have reported on the effects of
using horses as an intervention for adults with MS.14,15 The
earliest study by Mackay-Lyons and colleagues14 measured
the effects of therapeutic riding on postural sway, gait, and
changes in scores of the MS Minimal Record of Disability
(MRD) and the Symptom Checklist-90-Revised (SCL-90-R).
Although the subjects subjectively reported improvements in
function, such as increased endurance and balance, the results
of the MRD and postural sway assessments were not significant. There was improvement in relative speed and stride
length during free walking and the depression/global severity
scales of the SCL-90-R.14
Utilizing a single-subject experimental design, Hammer et al15 investigated the effects of hippotherapy on numerous physical functions (balance, spasticity, functional
strength, coordination, pain, and activities of daily living) and
the psychological well-being of persons with MS. Ten of the
eleven subjects demonstrated improvement in one or more of
the variables tested. Results indicated that hippotherapy intervention benefited each subject differently with the most
consistent improvements observed in balance (8/11 subjects)
and the role-emotional domain of the SF-36.15
Hippotherapy holds promise for enhancing balance and
postural control in individuals with MS, but the efficacy of

78

this intervention is still unclear. The supporting literature is

based on single-subject designs with no control groups.
Without this, it is not possible to verify that improvements in
balance are due to the hippotherapy intervention and not
fluctuations in the subjects MS symptoms. Therefore, the
purpose of this study was to assess the effects of individualized hippotherapy intervention on the balance of persons with
MS compared with individuals not receiving treatment. The
researchers hypothesized that individuals receiving hippotherapy intervention would demonstrate an improvement in
balance, while no change would be observed in a comparison
group.

METHODS
This pilot study was a nonequivalent pretest-posttest
comparison group design.31 It was approved by the institutional review board of the researchers institution as well as
the institutional review board of the therapeutic riding facility. All subjects were required to sign informed consent forms
before beginning the study. Signed liability forms from the
riding center were also required for subjects in the treatment
group.

Subjects
Subjects for this study were individuals with MS recruited through MS support groups of the Michigan Chapter
of the National Multiple Sclerosis Society (NMSS). The
inclusion criteria to participate in the study were 1) over 18
years of age, 2) ability to stand with or without an assistive
device for one minute, 3) no orthopedic or medical problems
unrelated to MS, 4) no previous experience with hippotherapy or therapeutic riding, 5) no allergies or aversions to
horses, 6) weight less than 240 lbs, and 7) physician referral.
Although we did not exclude prior riding experience (before
or after the onset of MS), none of the subjects had enough
riding experience to be considered proficient in horsemanship
skills.
Subjects were placed into two groups. The intervention
group consisted of the first 9 individuals who responded to
recruitment flyers and were willing to attend weekly hippotherapy sessions at the therapeutic riding center. Although an
additional nine individuals were sought to serve as a comparison group only 6 individuals volunteered. Subjects in the
comparison group were offered the opportunity to participate
in hippotherapy following the study if they wished. No
subjects in either group received other forms of rehabilitation
during the study.

Procedures
To make the study as clinically relevant as possible,
valid and reliable clinical measurements of balance that had
been used for persons with MS were sought.32 Criterion for
tool selection was the ability to administer the tool in the
treatment surroundings (riding facility) and ease of administration. Additionally the tools could not fatigue subjects and
needed to allow rest periods without compromising results.
Based on these criteria, the Berg Balance Scale (BBS),33,34
and the Tinetti Performance Oriented Mobility Assessment
(POMA)35 were chosen as outcome measures. The Clinical
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Effects of Hippotherapy on Postural Stability, in Persons with Multiple Sclerosis

Test for Sensory Interaction on Balance (CTSIB)36,37 was

also administered to provide information for intervention on
possible sensory adaptation problems of the subjects.
The Berg Balance Test and the POMA were originally
designed for assessing balance in the elderly population,33,35
but have been routinely used in clinics to assess the balance
and fall risk for individuals with neurological impairments,
such as post stroke and traumatic brain injury.38,39 The BBS
is a 14 item balance performance battery with a maximum
score of 56. It provides information on steady state and
anticipatory postural control. Research has demonstrated that
the Berg has an interrater reliability of 0.98 and an intrarater
reliability of 0.97, within these groups.38,39 Recently, Paltamaa and colleagues40 reported the test-retest reliability for the
Berg to be 0.85, with an interrater reliability of 0.99 when
using the Berg for ambulatory persons with MS. For consistency of administration in this study during the tandem stance
task it was decided that each person would place both the
right and left leg behind with the lowest score recorded.
Subjects were also asked to stand on each leg during the
single leg stance task, again with the lowest score reported.
The POMA like the BBS provides information regarding steady state and anticipatory postural control. It consists
of 16 items divided into subtests of balance and gait with a
maximum total score of 28. The gait portion of the tool
provides challenges to the subjects balance not provided by
the BBS, in addition to the reactive postural adjustment of the
nudge test. Although the reliability of the POMA has not
been assessed specifically for persons with MS, it has good
test-retest reliability (0.82 0.86), interrater reliability (0.91
0.93), and concurrent and discriminant validity in the elderly.41 Additionally the tool has good reliability for both novice
(students whose k coefficients ranged 0.40 1.00 for all test
items) and experienced clinicians with minimal training (k
coefficients 0.40 0.75).42
The CTSIB was developed as a clinical tool to simulate
the conditions of dynamic posturography developed by Nashner.36,37 It is utilized to assess the central nervous systems
(CNS) ability to integrate the visual, vestibular, and somatosensory systems by altering one or more of the systems
during 6 test conditions. Since it has been shown that individuals with MS frequently have difficulty integrating the
information from these three systems,9 it was decided to
determine whether subjects in this study might have sensory
adaptation problems, such as dependency on a specific sense
for postural orientation or sensory selection problems. During
each test administration the conditions were presented in the
following order: standing on a firm surface, eyes open, eyes
closed, and with the dome and then on the foam eyes open,
eyes closed, dome. Subjects performed each condition 3
times for 30 seconds. Falls, stepping, opening eyes during
eyes closed tests, raising arms to maintain balance, or excessive sway (hip strategies) stopped timing of a condition.
Conditions not completed for 30 seconds in all 3 trials were
recorded as abnormal. If participants demonstrated a sensory
dependency or selection problem, then the environment and
tasks were altered during their session to either remove or
provide inaccurate information through the sensory modality
2007 Lippincott Williams & Wilkins

in question, thus forcing the subject to rely on their less

preferred senses.12 Results of the CTSIB information for all
subjects is included in Table 1 as described by ShumwayCook and Horak.12
Both groups had an initial examination prior to the
initiation of hippotherapy treatment, followed by rechecks at
7 and 14 weeks. All assessments were performed by either
the primary author (DSS), who has experience in the assessment and treatment of individuals with MS, or the second
author (HW) who was a student in the physical therapy
program of Central Michigan University. To prevent fatigue
from interfering with test results, the intervention group was
tested in a barn adjacent to the riding facility prior to a
hippotherapy session. The comparison group was assessed in
a clinic setting. Although attempts were made to test all
individuals at approximately the same time of the day, it was
not always possible. This was not a major concern to the
researchers, as it has been demonstrated that while fatigue
perception in individuals with MS statistically differed between morning and afternoon testing sessions, their balance
scores did not significantly differ between times of day.43
During the pretest assessments for each group, one
researcher administered each standardized test, while the
second observed and scored the test. The researchers then
clarified any inconsistencies in interpretation of observations
in an effort to improve interrater reliability. The 7 and 14
week retests were performed by either researcher, based on
their availability.

TABLE 1. Characteristics of Subjects

Intervention group
Type Years since
Subject Age Gender of MS Diagnosis
1
2
3
4
5
6
7
8
9

45
47
29
40
48
46
31
24
72

M
F
F
F
F
F
M
M
M

RR/SP
RR
RR
RR
PP
Unk
RR
Unk
PP

15
7
0.5
15
11
26
2
2
11

CTSIB Initial Results12

Sensory selection deficit
Surface dependent
WNL
Vestibular loss
Visually dependent
Surface dependent
Vestibular loss
Surface dependent
NT

Comparison group
1
2
3
4
5
6

46
44
53
63
44
36

F
F
F
F
M
M

PP
RR
RR
PP
Unk
RR

15
10
15
25
3
8

Visual & surface dependent

Visually dependent
Visually dependent
Surface dependent
Visual & surface dependent
Surface dependent

MS, multiple sclerosis; RR, relapsing remitting; SP, secondary progressive; PP,
primary progressive; Unk, unknown; NT, unable to complete test as subject unable
stand without assistive device.

means inability to select vestibular inputs for postural control in the absence of
useful visual and somatosensory cues.12

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Treatment Intervention
Hippotherapy intervention was provided as defined by
the American Hippotherapy Association (AHA).24,44 Subjects
were not instructed in riding skills, but were placed on the
horse so they could respond to changes in the horses movement. Horses were led by an experienced horse-handler with
two side-walkers for safety. All subjects were required to
wear a helmet during each session. In consultation with a
certified riding instructor, subjects were matched with a horse
whose width and general movement accommodated the subjects available hip range (specifically abduction) and balance
abilities. Six subjects began the study using bareback pads
and stirrups, while 3 subjects needed the support of a saddle
during the first few weeks of riding. Two of these subjects
were able to progress to a bareback pad by the midterm
evaluations.
Subjects in the intervention group rode one time per
week for 14 weeks in an indoor arena at a therapeutic riding
center. Each session was comprised of a 5-minute warm-up,
a 30 minute treatment session, and a 5 minute cool-down
period. The warm up consisted of a slow walk (90 100
steps/min) without stirrups (dependent on subjects ability) to
stretch the lower extremities, and progressed to a moderate
walk (125130 steps/min) in a large oval pattern in a right
and left direction. The cool down periods reversed this
process from a moderate walk to a slow walk.
The 30 minute treatment sessions were individually
designed by the primary researcher, an AHA registered therapist in hippotherapy, based on the results of the examination
information. Notes were kept on all sessions by the researchers and modifications to activities and exercises were made
based on the subjects response to treatment. Although sessions were individualized, similar activities were performed
by all participants. For example, all participants began their
sessions sitting forward. In this position the subject performed trunk rotation by placing one hand on the horses
shoulders and the other on the hind quarters. This was done
in both directions to provide a stretch to trunk and adductor
muscles. To practice anticipatory challenges, subjects were
asked to raise their arms overhead or out to the side while
sitting forward.
All subjects experienced changes in direction, such as
weaving among cones, riding 10 and 20 meter circles moving
both right and left, serpentine patterns, changing direction on
the diagonal, figure 8s, sudden stops and starts, walking over
ground poles, as well as changes in speed of the horse, from
a slow walk to a medium walk to a trot (150 steps/min), if
tolerated. Each time the horse changed direction and/or speed
a postural adjustment was required by the subject. Subjects
who could tolerate advanced challenges to their postural
control were asked to change positions on the horse (see
Video 2), such as standing in their stirrups with hands on the
horses shoulders (2 point-position), sitting side-ways, and
riding backward.
Information from the CTSIB was used to further manipulate the activities by either taking away the sense upon
which the subject was most reliant, or providing inaccurate
information through that sense. For example subject 5, who

80

demonstrated visual dependency, would sidebend her trunk to

the left whenever she closed her eyes while sitting on the
moving horse. To improve her postural control without relying on her visual input we had her close her eyes and made
small circles around barrels in a direction that caused her to
lean to the right based on the vestibular and somatosensory
information she was receiving. This resulted in a correction
of her trunk to neutral alignment in a frontal plane (see Video
3). She was also asked to sit sideways on the horse facing the
walls of the riding arena. This provided her with visual flow
that conflicted with her vestibular and somatosensory information. If the subject was allowed to sit sideways facing the
center of the arena, she tended to use a fixed visual point to
decrease the conflict, thus continuing to rely upon her visual
system. After 6 sessions the subject was able to independently maintain neutral trunk alignment with eyes closed
while on a moving horse.

Data Analysis
SPSS 13.0 statistical software was used for data analyses. Nonparametric statistical tests were utilized due to the
small sample size and the ordinal scales of the assessment
tools.31 Friedmans Two-Way Analysis of Variance Test
(ANOVA) was used to calculate the premid-post test within
group scores for both the Berg and POMA. For the intervention group Wilcoxons signed-rank test was used to determine
when the greatest changes in balance scores occurred. A
Mann Whitney U was used to determine between group
comparisons of balance, as well as to determine any differences between the groups in relation to age and number of
years with MS. Chi-Square analysis was used for the nominal
data of gender and type of MS. All statistical analyses were
calculated using alpha levels of 0.05.
One-tailed analysis was used when comparing the midterm and posttest assessments between the groups, since it
was expected that the intervention would improve the subjects balance scores. Two-tailed analysis was used for the
pretest and demographic comparisons.31
Post test data for one subject in the intervention group
was not used in the final analysis because this individual
began steroid treatments in week 13. Post test data for a
second person in the intervention group was not collected, as
this individual did not complete the study due to an exacerbation that began during week 9. Finally one subject in the
comparison group did not attend the final testing session. The
final number of subjects in the intervention group was 7 with
5 individuals in the comparison group.

RESULTS
Demographic data for the groups is listed in Table 1.
Ages of participants in the intervention group ranged from
24 72 years (mean 42.4, SD 14.2), while members of the
comparison group ranged from 36 63 years (mean 47.7, SD
9.3). The mean number of years that individuals in the
intervention group had been diagnosed with MS was 9.9 (SD
8.2), and 12.6 (SD 7.6) years for the comparison group.
There were no statistical differences between the groups with
regard to gender (p 1.00), type of MS (p 1.00), age
(p 0.549), or years with MS (p 0.507).
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Effects of Hippotherapy on Postural Stability, in Persons with Multiple Sclerosis

Table 2 provides the raw data from the Berg and

POMA assessments for each subject, while average means
for both groups are presented in Figure 1. Friedmans
ANOVA revealed no statistical differences between the pretest, midterm or posttest for the Berg (x2(2) 0.40, p 0.819)
or the POMA (x2(2) 1.41, P 0.494) in the comparison
group. Statistically significant differences in scores for the
Berg (x2(2) 8.82, p 0.012) and the POMA (x2(2) 10.38,
p 0.006) were found in the intervention group. The most
significant change occurred between the pre and midterm
tests (Berg pretest Md 35 and midterm Md 50, T 0,
p 0.016, r 0.790 and POMA pretest Md 17 and
midterm Md 20, T 0, p 0.016, r 0.789) (Table 3).
Specific task items from the BBS were analyzed. These
included standing with eyes closed, standing with feet together, forward reach, retrieving an object from the floor,
turning 360, alternating stool touch and standing on one foot.
There were no statistically significant changes in any of the
items for the comparison group. In contrast the mean rank
change (1.50 to 2.07) of the alternating stool touch task
showed significant change (x2(2) 4.67, p 0.037) for the
intervention group.
Between group comparisons revealed no statistical difference between the pretest Berg (p 0.813) or POMA (p
0.906) scores. There was also no statistically significant
difference between the midterm scores for either assessment
(Berg p 0.204, POMA p 0.104). A statistically significant difference was found between the posttest Berg scores
(p 0.043), but not the POMA (p 0.070) (Fig. 1, Table 3).

DISCUSSION
Consistent with the findings of Hammer et al,15 the
group receiving hippotherapy had statistically significant imTABLE 2. Raw Scores for Berg and POMA
Berg Balance Test

Pretest Midterm
Intervention group
Subject 1
2
3
4
5
6
7
8
9
Comparison group
Subject 1
2
3
4
5
6

POMA

Post
Post
test Pretest Midterm test

32
51
56
56
34
35
49
26
8

37
55
56
56
50
46
55
38
12

*
55
56
56
47
46
55
*
19

17
26
28
27
15
12
23
14
4

17
28
28
28
20
20
26
18
14

*
28
28
28
21
20
27
*
13

24
33
49
43
40
49

15
40
44
48
51
48

26
*
40
44
41
50

14
16
19
22
19
26

13
17
20
20
17
26

13
*
17
23
19
24

* Did not complete study.

2007 Lippincott Williams & Wilkins

provement in scores on both standard balance tests (BBS and

POMA) following intervention. The comparison group demonstrated no improvement in scores, although small fluctuations between the three testing sessions were observed for all
members. This may have been caused by the many factors (ie
heat sensitivity and fatigue) that can influence the ability of a
person with MS on any day. With the exception of subject 5s
BBS scores, the intervention group improved or maintained
their tests scores throughout the 14 weeks. This suggests that
hippotherapy intervention may have had an effect on postural
stability, since score fluctuations were not observed. The
effect sizes in Table 3 also demonstrate that the differences
between the groups became progressively larger as one group
received intervention. The final effect sizes of 0.43 and
0.49 for the POMA and BBS respectively, suggests hippotherapy intervention appeared to have a medium effect on the
changes in mean rank scores.45
It is important to determine if positive changes in
balance scores are clinically and functionally relevant. Cattaneo and colleagues46 found that a combination of balance,
assistive device use and ambulation were the best predictors
of fall risk in persons with MS. However, the single best
predictor was the Equiscale test, a balance test derived from
components of the POMA and BBS. Although fall risk was
not specifically measured, based on Cattaneo et als findings
it is logical that the improvement in balance scores of the
subjects who received hippotherapy correlates to a potential
decrease in fall risk.
It is also important to compare hippotherapy treatment
to other physical therapy interventions. Smedal et al47 demonstrated improved BBS scores for 2 patients with MS
following intense NDT training of 1 hour per day, 5 days a
week. Lord et al48 compared the use of neurofacilitation and
task oriented approaches. Both groups had improved BBS
scores, but there was no difference between the two techniques after 15 to 19 sessions. Our intervention group had
similar improvements in BBS scores to the individuals in
Lords study, and better gains than observed in the Smedal
study. The primary difference is that the improvement occurred with less intervention (thirteen 40 minute sessions).
Although direct comparisons cannot be made, and a specific
study comparing techniques needs to be undertaken, it appears hippotherapy intervention may be equivalent to other
traditional PT approaches and an option for improving postural stability in persons with MS.
In this study, the post intervention POMA scores were
not significantly different between the groups, despite the
significant within group improvement of the intervention
group. There are several possible explanations for this effect.
Although not statistically different, the comparison groups
POMA mean score and rank were higher than the intervention groups at initial assessment. The intervention groups
considerable improvement over their own pretest POMA
scores was not large enough to overcome the pretest difference. This may be because the POMAs incremental scale is
narrower than the BBS making it less sensitive. Tesio and
colleagues49 have also suggested the POMA may be too
redundant and easy for persons with MS.

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FIGURE 1. Comparisons of the mean scores at pretest, midterm and final assessments for the intervention group (open bar)
and comparison group (solid bar). Graph A demonstrates changes in the group mean scores of the BBS. Graph B shows
changes in group mean scores for the POMA. Y-axis represents the maximum score for each tool. All data were analyzed at
P 0.05.
TABLE 3. Mann Whitney Test of Between Group Comparisons
Group
Berg

Pretest (0 week)
7 weeks
14 weeks

Tinetti

Pretest (0 week)
7 weeks
14 weeks

Intervention
Comparison
Intervention
Comparison
Intervention
Comparison
Intervention
Comparison
Intervention
Comparison
Intervention
Comparison

Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group

Mean
Rank

Median
Score

Effect
Size

U Value

Exact Sig*

9
6
9
6
7
5
9
6
9
6
7
5

8.22
7.67
8.78
6.83
8.00
4.40
7.89
8.17
9.17
6.25
7.79
4.70

35.0
41.50
50.00
46.00
55.00
41.00
17.00
19.00
20.00
18.50
27.00
19.00

0.06

25.0

0.837

0.21

20.0

0.220

0.49

7.0

0.048

0.03

26.0

0.933

0.33

16.5

0.113

0.43

8.5

0.078

* Pretest analysis is two-tailed, 7 and 14 week analysis are one-tailed.

Significant p 0.05 Effect size 0.3 small effect, 0.3 0.5 medium effect, 0.5 large effect size

The intervention groups average scores for the last 7

weeks of treatment did not show a significant change, although subjects maintained the observed improvement of the
first 7 weeks. The subjects skills may have stabilized, but
this is more likely an example of Schmidt and Lees50
logarithmic law of practice. This law states that skill improvement is linearly related to the amount of improvement
left to attain. Large gains in skill seen early in the intervention
with smaller incremental changes later are consistent with
this law of practice. Another possible explanation is a ceiling
effect of the testing tools.39,43 Several of the subjects in the
intervention group (subjects 2,3,4) were near or at the maximum score for both scales during their initial examination.
This did not allow any improvement in their balance to be

82

measured by either tool. This finding is consistent with

Hammer et als15 observations.
It was expected that balance would improve after hippotherapy, since riding is considered a balance-demanding
activity.16 The movement of the horse, combined with appropriate equipment selection, is purported to provide input to
the motor, visual, somatosensory (proprioceptive, tactile),
and vestibular systems of the individual subjects.13 Individuals with impaired nervous systems tend to have fewer
movement strategies and therefore become more cautious
limiting their interaction with the environment.51 A therapist
directing a hippotherapy session can manipulate the movement of the horse, tasks, and environment in such a way that
the individuals preferred movement patterns are not ade 2007 Lippincott Williams & Wilkins

JNPT Volume 31, June 2007

Effects of Hippotherapy on Postural Stability, in Persons with Multiple Sclerosis

quate to maintain postural control. By affecting several subsystems simultaneously the subjects had to explore more
appropriate movement strategies to prevent loss of dynamic
stability. This could include a reorganization of how the
individual used and weighted sensory information while receiving conflicting sensory input.51 Hippotherapy treatments
not only allowed the subjects an opportunity to develop,
refine, and practice motor patterns, but also permitted concurrent practice in the integration of sensory information in a
controlled environment as a whole task activity.5254 Research has also demonstrated that discovery learning and
random practice are more effective for long-term retention of
a task.53,54 In this study, the therapists manipulated the environment by varying the movement, direction, and speed of
the horse as well as the subjects position on the horse,
allowing the subjects to practice postural control and balance
under a variety of unpredictable conditions. This more accurately simulates the random use of balance and postural
control of everyday tasks.
This study has limitations. Subjects were not randomly
assigned to groups. Those who volunteered for hippotherapy
intervention may have been more motivated than the comparison group members who were recruited later. The small
number of subjects necessitated the use of nonparametric
analysis and makes it difficult to generalize this information
to individuals with different types of MS. There was potential
for bias since the researchers were not masked to subject
participation. During the examination procedures the researchers were careful to utilize the same instructions with all
participants. However, there was the potential for a Hawthorne effect since the intervention group was examined at
the riding center, while the comparison group was evaluated
in a clinical setting.31 Variables that may have affected
outcome between the groups, such as cognitive impairments
that might affect motor learning, fatigue, or level of motor
and sensory impairments, were not controlled. Finally, the
Berg and POMA did not appear to be sensitive enough to
measure improvement for subjects with mild balance problems.
Additional research is needed regarding the use of this
therapeutic intervention. Suggestions to improve this study
would be a larger sample size to improve the homogeneity of
the subjects and the use of masked evaluators. Measurement
tools such as timed tandem stance, one-leg stance, and functional self-generated perturbations (functional reach and step
test) have been shown to be better measures of balance for
ambulatory individuals with mild balance difficulties,43 and
their inclusion in future research is suggested. A timed walk
test might provide more meaningful information than the gait
component of the POMA. Timing of these tests would allow
for the use of parametric data analysis. The Dynamic Gait
Index (DGI) to measure gait under conflicting sensory input
might provide information on how well the intervention
transfers to a functional task.32 Finally, the addition of a
second postintervention assessment after one month of no
intervention could provide information on the retention of
improved postural stability.
2007 Lippincott Williams & Wilkins

CONCLUSION
The results of this pilot study demonstrated a statistically significant improvement in balance as measured by the
Berg Balance Scale and POMA following 7 weeks of hippotherapy intervention. The comparison group had no improvement in balance. The intervention also produced a between
group difference in the BBS scores by 14 weeks, suggesting
that improvements in the intervention group may have been
caused by the hippotherapy treatments. The small number of
participants and the use of nonparametric analysis of the data
make it difficult to state with confidence that hippotherapy
would improve balance for all persons with MS. However,
this study does strengthen the literature supporting the use of
hippotherapy as a possible intervention for balance disorders
in persons with MS. A multicenter study using timed balance
tests in addition to the BBS and DGI would be a logical step
for future research.
REFERENCES
1. National Multiple Sclerosis Society. The Library & Literature Page. Gait
or walking problems the basic facts. Available at: http://www.nmss.org/
Brochures-On%20Gait.asp. Accessed May, 23 2006.
2. Ford HL, Gery E, Johnson MH, Tennant A. Health status and quality of
life of people, with multiple sclerosis. Disabil Rehabil. 2001;23:516
521.
3. Calebresi PA. Diagnosis and management of multiple sclerosis. Am Fam
Physician. 2004;70:19351944.
4. Paty DW, Poser CM. Clinical symptoms and signs of multiple sclerosis.
In: Poser CM, ed. The Diagnosis of Multiple Sclerosis. New York:
Thieme-Stratton; 1984:2743.
5. Miller AE. Clinic features: In: Cook S, ed. Handbook of Multiple
Sclerosis. New York: M Dekker; 1990:169186.
6. Ruelen JPH, Sanders ACM, Hogenhuis LAH. Eye movement disorders
in multiple sclerosis and optic neuritis. Brain. 1983;106:121140.
7. Grenman R. Involvement of the audiovestibular system in multiple
sclerosis. An otoneurologic and audiologic study. Acta Otolaryngol
Suppl. 1985;420:195.
8. Williams NP, Roland PS, Yellin W. Vestibular evaluation in patients
with early multiple sclerosis. Am J Otol. 1997;18:93100.
9. Nelson SR, DiFabio RP, Anderson JH. Vestibular and sensory interaction deficits assessed by dynamic platform posturography in patients
with multiple sclerosis. Ann Otol Rhinol Laryngol. 1995;104:6268.
10. Heriza C. Motor development: traditional and contemporary theories. In:
Contemporary Management of Motor Control Problems. Proceedings of
the II Step Conference. Alexandria: APTA, 1991:99126.
11. Montgomery PC. Perceptual Issues in Motor Control. In: Contemporary
Management of Motor Control Problems. Proceedings of the II Step
Conference. Alexandria: APTA; 1991:175184.
12. Shumway-Cook A, Horak FB. Balance rehabilitation in the neurological
patient. Course Syllabus. Seattle: NERA, 1992. Cited in: ShumwayCook A, Woollacott MH. Motor Control: Theory and Practical Applications, 2nd ed. Baltimore: Williams & Wilkins; 2001:285287.
13. Heine B. Hippotherapy. A multisystem approach to the treatment of
neuromuscular disorders. Aust J Physiother. 1997;43:145149.
14. Mackay-Lyons M, Conway C, Roberts W. Effects of therapeutic riding
on patients with multiple sclerosis: A preliminary trial. Physiother Can.
1988;40:104109.
15. Hammer A, Nilsagard Y, Forsberg A, et al. Evaluation of therapeutic
riding (Sweden)/hippotherapy (United Stated). A single-subject experimental design study replicated in eleven patients with multiple sclerosis.
Physiother Theory Pract. 2005;21:5177.
16. Pauw J. Therapeutic horseback riding studies: problems experienced by
researchers. Physiotherapy. 2000;86:523527.
17. Wheeler A. Hippotherapy as a specific treatment: A review of literature.
In: Engel BT, ed. Therapeutic Riding II: Strategies for Rehabilitation.
Durango, CO: Barbara Engel Therapy Services; 1997:2529.

83

Silkwood-Sherer and Warmbier

18. Bertoti D. Effects of therapeutic horseback riding on posture in children

with cerebral palsy. Phys Ther. 1988;68:15051512.
19. Hansen K. A group case study: hippotherapy as a means of improving
gross motor function in children with cerebral palsy. In: Engel BT, ed.
Therapeutic Riding II: Strategies for Rehabilitation. Durango, CO:
Barbara Engel Therapy Services;1997:233240.
20. Biery MJ, Kauffman N. The effects of therapeutic horseback riding on
balance. Adapted P Act Q. 1989;6:129.
21. Wingate L. Feasibility of horseback riding as a therapeutic and integrative program for handicapped children. Phys Ther. 1982;62:184186.
22. McKinnon J, Noh S, Laliberte D, Lariviere J, Allan D. Therapeutic
horseback riding: a review of the literature. Phys Occup Ther Pediatr.
1995;15:115.
23. Silkwood-Sherer D. The difference lies in the perspective. NARHAs
Stride. 2003;9:1416.
24. Meregillano G. Hippotherapy. Phys Med Rehabil Clin N Am. 2004;15:
843854.
25. Haehl V, Giuliani C, Lewis C. Influence of hippotherapy on the kinematics and functional performance of two children with cerebral palsy.
Pediatr Phys Ther. 1999;11:89101.
26. MacPhail HEA, Edwards J, Golding J, et al. Trunk postural reactions in
children with and without cerebral palsy during therapeutic horseback
riding. Pediatr Phys Ther. 1998;10:143147.
27. Benda W, McGibbon NH, Grant KL. Improvements in muscle symmetry
in children with cerebral palsy after equine-assisted therapy (hippotherapy). J Altern Complement Med. 2003;9:817825.
28. McGibbon N, Andrade C, Widener G, Cintas H. Effect of an equinemovement therapy program on gait, energy expenditure, and motor
function in children with spastic cerebral palsy: a pilot study. Dev Med
Child Neurol. 1998;40:754762.
29. Casady RL, Nichols-Larsen DS. The effect of hippotherapy on ten
children with cerebral palsy. Pediatr Phys Ther. 2004;16:165172.
30. Lechner HE, Feldhaus S, Gudmundsen L, et al. The short term effect of
hippotherapy on spasticity in patients with spinal cord injury. Spinal
Cord. 2003;41:502505.
31. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. Upper Saddle River, NJ: Prentice Hall, Inc.; 2000:
473490.
32. Cattaneo D, Regola A, Meotti M. Validity of six balance disorder scales
in persons with multiple sclerosis. Disabil Rehabil. 2006;30:789795.
33. Berg KO, Wood-Dauphinee SL, Williams JI,. Gayton D. Measuring
balance in the elderly: preliminary development of an instrument.
Physiother Can. 1989;41:304311.
34. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Publ Hlth.
1992;83:8792.
35. Tinetti M. Performance-oriented assessment of mobility problems in
elderly patients. J Am Geriatr Soc. 1986;34:119126.
36. Shumway-Cook A, Horak F. Assessing the influence of sensory interaction of balance. Suggestion from the field. Phys Ther. 1986;66:1548
1550.
37. Horak F. Clinical measurement of postural control in adults. Phys Ther.
1987;67:18811885.

84

JNPT Volume 31, June 2007

38. Berg KO, Wood-Dauphinee SL, Williams JI. The balance scale: reliability assessment with elderly residents and patients with an acute
stroke. Scand J Rehabil Med. 1995;27:2739.
39. Newstead A, Hinman M, Toberlin J. Reliability of the Berg Balance
Scale and Balance master limits of stability tests for individuals with
brain injury. JNPT. 2005;29:1823.
40. Paltamaa J, West H, Sarasoja T, Wikstrom J, Malkia E. Reliability of
physical functioning measures in ambulatory subjects with MS. Physiother Res Int. 2005;10:93109.
41. Faber MJ, Bosscher RJ, van Wieringen PCW. Clinemetric properties of
the performance oriented mobility assessment. Phys Ther. 2006;86:944
954.
42. Cipriany-Dacko LM, Innerst D, Johannsen J, Rude V. Interrater reliability of the Tinetti balance scores in novice and experienced physical
therapy clinicians. Arch Phys Med Rehabil. 1997;78:11601164.
43. Frzovic D, Morris ME, Vowels L. Clinical tests of standing balance:
performance of persons with multiple sclerosis. Arch Phys Med Rehabil.
2000;81:215221.
44. American Hippotherapy Association. The present use of hippotherapy in
the United States page. Available at: htpp://www.americanhippotherapy
association.org/aha_hpot_A-use.htm. Accessed May 23, 2006.
45. Field A. Discovering Statistics Using SPSS, 2nd ed. Thousand Oaks,
CA: SAGE Publications Ltd; 2005:3133.
46. Cattaneo D, Nuzzo C, Fascia T, et al. Risk of falls in subjects with
multiple sclerosis. Arch Phys Med Rehabil. 2002;83:864867.
47. Smedal T, Lygren H, Myhr KM, et al. Balance and gait improved in
patients with MS after physiotherapy based on the Bobath concept.
Physiother Res Int. 2006;11:104116.
48. Lord SE, Wade DT, Halligan PW. A comparison of two physiotherapy
treatment approaches to improve walking in multiple sclerosis: a pilot
randomized controlled study. Clin Rehabil. 1998;12:477486.
49. Tesio L, Perucca L, Franchignoni FP, Battaglia MA. A short measure of
balance in multiple sclerosis: validation through rasch analysis. Functional Neurol. 1997;12:255265.
50. Schmidt RA, Lee TD. Motor Control and Learning: A Behavioral
Emphasis. Champaign, IL: Human Kinetics; 2005. Cited in: ShumwayCook A, Woollacott MH. Motor Control: Translating Research into
Clinical Practice, 3rd ed. Baltimore: Lippincott Williams & Wilkins;
2007:35.
51. Shumway-Cook A, Woollacott MH. Abnormal postural control. In:
Shumway-Cook A, Woollacott MH. Motor Control: Theory and Practical Applications, 2nd ed. Baltimore: Williams & Wilkins; 2001:248
270.
52. Horak FB. Assumptions underlying motor control for neurological
rehabilitation. In: Contemporary Management of Motor Control Problems. Proceedings of the II Step Conference. Alexandria: APTA; 1991:
1127.
53. Nicholson DE. Motor learning. In: Fredericks CM, Saladin LK, ed.
Pathophysiology of Motor Systems: Principles and Clinical Presentations. Philadelphia: FA Davis Company; 1996:238251.
54. Schmidt RA. Motor learning principles for physical therapists. In:
Contemporary Management of Motor Control Problems. Proceedings of
the II Step Conference. Alexandria: APTA; 1991:4963.

2007 Lippincott Williams & Wilkins