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Equoterapianet.com.br& 2003 International Spinal Cord Society All rights reserved 1362-4393/03 $25.00 The short-term eﬀect of hippotherapy on spasticity in patients with spinalcord injury HE Lechner*,1, S Feldhaus2, L Gudmundsen2, D Hegemann2, D Michel2, GA Za¨ch2 and H Knecht1 1Institute for Clinical Research, Swiss Paraplegic Centre, Nottwil, Switzerland; 2Swiss Paraplegic Centre,Nottwil, Switzerland Study design: Assessment of spasticity before and after hippotherapy treatment.
Objective: To evaluate the short-term eﬀect ofhippotherapy on spasticity ofspinal cord injuredpatients (SCIs).
Setting: Swiss Paraplegic Centre, Nottwil.
Methods: 32 patients with spinal cord injury with various degrees ofspasticity had repeatedsessions (mean 11) ofHippotherapy-Ks. Spasticity ofthe lower extremities was scoredaccording to the Ashworth Scale.
Results: In primary rehabilitation patients Ashworth values after hippotherapy weresigniﬁcantly lower than before (Wilcoxon’s signed-rank test: Po0.001). Highest improvementswere observed in SCIs with very high spasticity. No signiﬁcant diﬀerence between short-termeﬀect in paraplegic and short-term eﬀect in tetraplegic subjects was found.
Conclusions: Hippotherapy signiﬁcantly reduces spasticity oflower extremities in SCIs.
Spinal Cord (2003) 41, 502–505. doi:10.1038/sj.sc.3101492 Keywords: hippotherapy; muscle spasticity; spinal cord injuries; rehabilitation; treatment Spasticity is known as an accompanying phenomenon of spasticity are even more scarce. Unlike therapeutic spinal cord injuries and was deﬁned by Lance1 as an horseback riding, which teaches riding skills to indivi- increased reﬂex activity, as well as a velocity-dependent duals with disabilities, hippotherapy is a neurophysio- increase in muscle tone elicited by passive stretching.
logical treatment that uses the movement ofthe horse.
Not every patient suﬀering from spasticity necessarily The hypothesis is that the rhythmical side ﬂexion and requires treatment. However, depending on the severity extension ofthe patient’s trunk combined with trunk ofspasticity it may interfere with activities ofdaily life.
torsion have a beneﬁcial eﬀect on spasticity. The In the Stockholm spinal cord injury study,2 for example, working mechanism ofhippotherapy on spasticity may more than 41% ofsubjects with spastic paralysis be complex. According to neurophysiological standards, reported excessive spasticity associated with additional an inhibition ofthe spasticity is achieved through the functional impairment and/or pain, and 2/3 of the saddle position in hip ﬂexion – abduction – external subjects with spastic paralysis took medication to treat rotation as well as through rhythmical and three- their spasticity.3 What other possibilities besides medi- dimensional equine movements communicated to the cation are there to reduce high muscle tone? patients’ pelvis and trunk.6,7 A further impact on For several years hippotherapy has been used in spasticity is also attributed to the psychosomatical rehabilitation ofspinal cord injured patients (SCIs) and eﬀects.5 According to Strauss8 hippotherapy gains its positive eﬀects on spasticity have been reported.4,5 unique eﬀect through a neural facilitation, sensorimotor Unfortunately, only few studies assessing the eﬀect of stimulation and psychosomatic inﬂuence.
hippotherapy on spasticity have been conducted, and We felt that there is a need for a study assessing the most ofthe existing literature is not in the English eﬀect ofhippotherapy on spasticity ofSCIs and to language. Studies that aim at explaining the mechanisms report the result in the English language. We have tested underlying the positive eﬀect ofhippotherapy on the short-term eﬀect ofhippotherapy onto the increasedmuscle tone ofthe lower extremities in 32 SCIs asfollows: the physiotherapist in charge rated the spasti- *Correspondence: HE Lechner, Institute for Clinical Research, SwissParaplegic Centre, Nottwil 6207, Switzerland city ofthe patients directly prior to and af Effect of hippotherapy on spasticity in SCIHE Lechner et al hippotherapy treatment according to the Ashworth On average each patient was tested prior and after 11(range: 5–24) hippotherapy sessions. The treatmentswere performed according the concept of Hippotherapy- Ks (HTK).11 The subject sat on a sheepskin (withoutsaddle), while the horse (Icelander) was led at walking pace by a skilled equestrian. The physiotherapist walked From June 1996 to November 1997 and from June 1999 beside the horse facilitating postural responses and to May 2001 all patients with various degrees of repositioning the patient ifnecessary. Some patients spasticity were tested by the physiotherapists prior to with high lesions needed a second physiotherapist sitting and after hippotherapy treatment. Measurements were on the horseback behind them for stabilisation. One taken from 32 SCIs. The age ranged between 16 and 72 years (mean 37), four of the patients were female, 30subjects were inpatients in primary rehabilitation (timeafter injury between 1 and 18 months, mean 5), and two were outpatients (4 and 6 years after injury). Levels of Rating of spasticity was done directly before and after the spinal cord injury were between C4 and T12 and the hippotherapy session in the riding hall. The patient between A and D according to the ‘ASIA Impairment was lying on an examining table in supine position while Scale’10 (Table 1). Informed consent of all patients was eight movement directions were rated: hip ﬂexion and obtained according to the Helsinki protocol.
extension, abduction and adduction, knee ﬂexion and Effect of hippotherapy on spasticity in SCI extension, as well as ankle dorsi- and plantarﬂexion. Thephysiotherapist moved the limb in the directions asquickly as possible. The knees and the ankles weremeasured with extended hips, while the lower legsdangling oﬀ the end ofthe testing bed. Each directionwas repeated three to ﬁve times. She rated the elicitedspasticity according to the Ashworth Scale between 1and 5 (Ashworth-value, ASV) (Table 2). The ASV oftheeight movement directions ofboth sides were recordedas a sum of16 scores ranging from a minimum of16 to amaximum of80.
Testing was performed prior to and after the HTK treatment by the same physiotherapist. Seven diﬀerentphysiotherapists performed the overall testing of the 32patients. All seven physiotherapists were instructed onthe testing by the same person and met on a regularbasis to exchange testing experiences and to check inter-and intrarater reliability.
Scatterplot ofthe 32 subjects: means ofsums of For each patient and examination sums ofthe ASV ASV before versus sums of ASV after HTK treatment. The 451 from all directions on both sides were calculated (2 Â 8 line indicates values ofno change. All measured values show movement directions, minimum score ¼ 16, maximum smaller sums of ASV after than before HTK treatment. Note: score ¼ 80). Means and standard deviations were score of16 signiﬁes a patient with no spasticity calculated ofthe repeated HTK treatments f patient. The existence ofa statistical diﬀerence between the ASV before and after HTK treatment was assessed (X10.0) was observed in six patients with severe by performing Wilcoxon’s signed-rank test. Statistical before-session spasticity (ASV over 38).
signiﬁcance12 was set at the 5% level.
There was no signiﬁcant diﬀerence between short-term eﬀect in paraplegic subjects and the short-term eﬀect in tetraplegic subjects (Wilcoxon’s signed rank test:P ¼ 0.4). The mean ofall diﬀerences between before- and A total of351 hippotherapy treatments were performed after-session values for paraplegic subjects (n ¼ 18) was and 327 ofthese sessions (93%) lead to a lower ASV À3.4 (SD72.2) and for all tetraplegic subjects (n ¼ 14) it immediately after as compared than before the sessions.
was À2.8 (SD71.0). There was no longitudinal eﬀect In all, 20 sessions (6%) did not lead to a change in the (downward trend overall sessions in each patient) and ASV score; these sessions were completed by 10 patients the variance within the before-session values in each with low ASV (p24) prior to treatment. In only two single patient ranged from 0.81 to 77.4 (SD70.9–78.8).
patients with very low ASV (p18) an increase ofthe Also, there was no detectable trend ofthe before- and value was measured twice in each patient (1%).
after-session diﬀerences (data not shown).
Hippotherapy led to a substantial decrease ofmuscle tone in the lower extremities ofthe 32 SCI patients. Thecalculated means ofall individual patients ranged from 17.6 to 53.3 prior to treatment and from 16.6 to 42 after Our results show that hippotherapy causes an immediate treatment (Table 1). Group scores after the treatment reduction ofspasticity ofthe lower extremities ofSCI were signiﬁcantly lower than group scores before patients. The ASV was signiﬁcantly lower after the treatment than before. The greatest before- and after-session diﬀerences were measured in patients with very Hippotherapy and its reducing eﬀect on the muscle tone was described earlier in connection with otherclinical entities associated with spasticity such as multi- ple sclerosis (MS) and cerebral palsy (CP): in the ‘Swiss Slight increase in tone giving a ‘catch’ when the limb Study’ by Kuenzle and Wuethrich13 including 255 patients with MS, relaxation and decrease in muscle More marked increase in tone but limb easily ﬂexed tone was the most frequent eﬀect of hippotherapy, Considerable increase in tone – passive movement according to subjective records ofpatients, therapists and treating doctors. However, these results were not backed up by Ashworth Scale. In another study with Effect of hippotherapy on spasticity in SCIHE Lechner et al MS patients, a reduction in the muscle tone ofthe lower valuable supplement to the conventional physiotherapy extremities after hippotherapy was measured by electro- approach in holistic rehabilitation ofSCIs.
Tarnow15 ascertained that children and teenagers with a spastic quadriplegia had shown a clear improvement We thank all the subjects who participated in the study and we in their trunk ﬂexibility and their functional ability after gratefully acknowledge the ﬁnancial support of the Swiss treatment with hippotherapy. She attributed the results to a decrease in muscle tone as a result ofthis treatment.
McGibbon et al16 described a standardised protocol ofhippotherapy treatment and documented its eﬀect on gait, energy expenditure, and gross motor function inchildren with spastic CP. Bertoti6 examined the eﬀect of 1 Lance JW. Symposium synopsis. In: Feldman RG, Young RR, Koulla WP (eds). Spasticity: Disordered Motor Control.
hippotherapy on the posture ofchildren with CP and Yearbook Medical Publishers: Chicago 1980, pp 485–494.
described improved posture because ofthe hippother- 2 Levi R, Hultling C, Nash MS, Seiger A. The Stockholm apy’s reducing eﬀect on spasticity. Exner et al4 described Spinal Cord Injury Study: 1. Medical problems in a a ‘clear suppression ofthe spasticity’ with a ‘remarkable regional SCI population. Paraplegia 1995; 33: 308–315.
duration ofeﬀect’; however, the degree ofthe decrease 3 Skold C, Levi R, Ake S. Spasticity after traumatic spinal in spasticity was not stated quantitatively.
cord injury: nature, severity and location. Arch Phys Med In our study, the spasticity was rated according to the ASV directly prior and after treatment in primary 4 Exner G, Engelmann A, Lange K, Wenck B. Grundlagen rehabilitation patients. Our results represent a short- und Wirkung der Hippotherapie im Konzept der umfas- term eﬀect ofhippotherapy. However, it would be interesting to quantitatively evaluate the duration ofthe 5 Hegemann D, Za¨ch G. Hippotherapie zur Behandlung der eﬀect as well as a possibly persisting eﬀect in the context Spastizita¨t bei Para- und Tetraplegikern (German). In: urther prospective study, since in the ‘Swiss Grueninger W (ed). Spinale Spastik. Ueberreuter Verlag: Study’13 in over 70% ofMS patients a beneﬁt of2 days 6 Bertoti DB. Eﬀect oftherapeutic horseback riding on Naturally, medication would have to be kept constant posture in children with cerebral palsy. Phys Ther 1988; ifchanges in the severity ofspasticity over a series of hippotherapy sessions were to be investigated. This 7 Wuethrich R, Kuenzle U. Hippothe´rapie chez des patients would have to be conducted with chronic SCIs, as atteints de scle´rose en plaques. J Beige Med Phys Rehabil during ﬁrst rehabilitation there are many more con- 8 Strauss I. Hippotherapy: Neurophysiological Therapy on the founding factors like psychological stress, bladder Horse. Ontario Therapeutic Riding Association: Thornhill, infections or bowel complications, changes of therapies 9 Ashworth B. Preliminary trial ofcarisoprodol in multiple have an eﬀect on muscle tone. To evidence a long- sclerosis. Practitioner 1964; 192: 540–542.
itudinal eﬀect ofhippotherapy on spasticity, we just 10 Maynard FMJ et al. International standards for neurolo- started a blinded long-time prospective study on chronic gical and functional classiﬁcation of spinal cord injury.
SCIs with stable antispastic medication, who are at least American Spinal Injury Association. Spinal Cord 1997; Regarding the rating ofmuscle tone with the Ash- 11 Kuenzle U. Hippotherapie auf den Grundlagen der Funktio- worth Scale, it needs to be mentioned that it is clearly a nellen Bewegungslehre Klein-Vogelbach. Hippotherapie-K:Theorie, Praktische Anwendung Wirksamkeitsnachweis.
subjective method. Additionally, the physiotherapist Springer-Verlag: Berlin Heidelberg, 2000.
conducting the measurement was not blinded to the 12 Sheskin DJ. Handbook of Parametric and Nonparametric treatment and ratings may have been inﬂuenced by Statistical Procedures. 2nd edn. Chapman & Hall/CRC 13 Kuenzle U, Wuethrich R. Schweizerische Studie u¨ber die Wirksamkeit der Hippotherapie K bei Multiple-Sklerose- Patienten. In: Kuenzle U (ed). Hippotherapie auf denGrundlagen der Funktionellen Bewegungslehre Klein-Vogel- We show that hippotherapy has an alleviating short- bach. Springer-Verlag: Berlin, Heidelberg 2000, pp 359–381.
term eﬀect on spasticity ofthe lower extremities in SCI 14 Weber A. Hippotherapie bei Multiple-Sklerose-Kranken.
patients. In 32 patients such an eﬀect could be shown with the help ofthe Ashworth Scale. There was a 15 Tarnow A. Hippotherapeutische Behandlungsergebnisse – signiﬁcant diﬀerence between the spasticity before and (German). Oeﬀ Gesundh Wesen 1979; 41: 201–205.
16 McGibbon NH, Andrade CK, Widener G, Cintas HL.
Further studies regarding the duration ofthe eﬀect Eﬀect ofan equine-movement therapy program on gait, are necessary and will be performed with blinded energy expenditure, and motor function in children with assessment ofspasticity reduction, comparing it with spastic cerebral palsy: a pilot study. DevMed Child Neurol other interventions. In summary, hippotherapy is a
Tuberculin Skin Testing What is It? How is the TST Read? The Mantoux tuberculin skin test (TST) is the The skin test reaction should be read between 48standard method of determining whether a person isand 72 hours after administration. A patient whoinfected with Mycobacterium tuberculosis. Reliabledoes not return within 72 hours will need to beadministration and reading of the T