prior authorization review panel mco policy submission a ... · cerebral palsy (cp) also known as...

Prior Authorization Review Panel MCO Policy Submission

A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date: 05/01/2019

Policy Number: 0151 Effective Date: Revision Date: 02/14/2019

Policy Name: Hippotherapy

Type of Submission – Check all that apply: New Policy Revised Policy*

Annual Review – No Revisions *All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below:

CPB 0151 Hippotherapy

This CPB has been revised to state that This CPB has been revised to state that the use of hippotherapy (also known as equine therapy) is considered experimental and investigational for the treatment of low back pain and Down's syndrome.

Name of Authorized Individual (Please type or print):

Dr. Bernard Lewin, M.D.

Signature of Authorized Individual:

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http://qawww.aetna.com/cpb/medical/data/100_199/0151_draft.html 04/25/2019

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Hippotherapy

Clinical Policy Bulletins Medical Clinical Policy Bulletins

Policy History

Last Re

view

02/14/2019

Effective: 03/31/1997

Next

Review: 02/13/2020

Review

Histor

y

Definitions

Additional Information

Number: 0151

Policy *Please see amendment for Pennsylvania Medicaid at the end of this

CPB.

Aetna considers the use of hippotherapy (also known as equine therapy)

experimental and investigational for the treatment of the following indications and

all other indications because there is insufficient scientific data in the peer reviewed

medical literature to support the effectiveness of hippotherapy for the treatment of

individuals with these indications.

▪ Anxiety

▪ Attention deficit and/or hyperactivity disorder

▪ Autism

▪ Behavioral and psychiatric disorders (including aggressive violent behavior

and eating disorders)

▪ Cerebral palsy or other motor dysfunctions (e.g., arthritis, balance deficits,

children with psychomotor impairment, head injury, multiple sclerosis,

spinal cord injury, and stroke)

▪ Down's syndrome

▪ Low back pain

▪ Post-traumatic stress disorder

▪ Rehabilitation of cancer survivors

▪ Sexual abuse and emotional stress

▪ Substance abuse disorder

http://www.aetna.com/cpb/medical/data/100_199/0151.html

https://www.aetna.com/

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Background

Cerebral palsy (CP) also known as static encephalopathy, refers to a wide variety of

non-progressive brain disorders resulting from insults to the central nervous system

during the perinatal period. The management of the motor dysfunction of patients

with CP includes the conventional orthopedic approach of range of motion, stretch,

and strengthening, as well as neurodevelopmental treatment. A general objective of

physiotherapy for children with CP is to reduce the influence of abnormal muscle

tone and facilitate the emergence of normal postural and movement components.

For many children with CP or other motor dysfunction, physical therapy is a long

and arduous process. In order to sustain patients’ interest and enthusiasm in their

continuing treatment, therapists have developed adjunctive therapeutic activities

such as dancing, swimming, and horseback riding.

Hippotherapy, also known as therapeutic horseback riding, equine-facilitated

therapy, or horse therapy, is the passive use of the physical movements of the

horse in the treatment of patients with neurological or other disabilities. This is

often performed under the direct supervision of a physical therapist or occupational

therapist who is horse-knowledgeable. By using the horse as a treatment modality,

the therapist tries to facilitate normal muscle tone and inhibit abnormal posture.

The therapist may place the patient in a variety of positions on the horse such as

prone across horse, prone lengthwise with hips abducted and knees flexed, side

sitting, or sitting. It is believed that the rhythmic, swinging movement of the horse

enhances balance, co-ordination, and motor development. Patients who participate

in therapeutic riding include not only children with CP, but also individuals with

arthritis, multiple sclerosis, head injury, and stroke. The horse is usually led at a

walking or trotting pace by a skilled equestrian to ensure safety and expert handling

of the animal. Assistants are present, usually one on each side, to help

repositioning or stabilizing the patient. For more severely disabled patients, the

therapist may also serve as a back rider.

For children with CP, hippotherapy utilizes the basic principles of Rood, Bobaths

(individuals who had put forth/developed neurodevelopment treatment concepts for

neuromuscular dysfunction), and proprioceptive neuromuscular facilitation. It is

believed that therapeutic horseback riding can reduce spasticity, maintain and

increase range of motion in the upper extremities of these children. Haskin and

colleagues (1982) described the benefits of a hippotherapy program (30 mins per

week) in a 5-year old patient who has participated in this type of therapy since she

was 2 1/2. Improvements included strengthening of the back and neck, better


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balance, ability to sit up longer, less spasticity in the lower extremities, the legs are

externally rotated and abducted, and the feet are dorseflexed. However, the

patients also swam once a week and received physical therapy for her lower

extremities 6 days a week. Thus, it is unclear whether the observed improvements

were due to hippotherapy, adjunctive therapeutic swimming, intensive physical

therapy, and/or the result of natural growth and development.

Using a repeated-measured design, Bertoti (1988) assessed postural changes in

11 children (4 girls and 7 boys, aged 28 to 114 months) with spastic CP after

participation in a 10-week hippotherapy program (1-hour session, 2 times per week).

Evaluation of posture was carried out 3 times by 3 pediatric physical therapists -- (i)

pretest-1 followed by a 10-week period of no riding, (ii) pretest-2

followed by a 10-week therapeutic riding program, and (iii) post-test. A

composite score for each test period was computed for each patient, and a median

score was calculated for the entire group at each test period. A statistical

difference was observed among the 3 test periods with significant improvement

occurring during the period of hippotherapy. Subjective clinical improvements such

as reduced hypertonicity, as well as improved weight-bearing and functional

balance skills were reported by parents and referring physical therapists. These

findings represented the first objective report that hippotherapy may have beneficial

effect on the posture of children with spastic CP. However, the author concluded

that further investigation is needed to isolate additional variables such as range of

motion, balance, weight shift, and strength, and to evaluate the effects of

hippotherapy on different disabilities.

In an article on hippotherapy, Tuttle (1987) stated that research on the effect and

application of the various forms of therapeutic horseback riding is needed to refine

program planning, and to support funding and third-party reimbursement.

Furthermore, a workshop on “The Health Benefits of Pets” sponsored by the

National Institutes of Health concluded that “solid data on the success of

therapeutic riding is limited. ... Future research is indicated to compare the efficacy

of therapeutic riding with other clinical treatment procedures that do not involve the

horse and to validate dramatic clinical observations” (NIH, 1983). Additionally, in

an article published in the Journal of American Veterinarian Medicine Association,

Potter and colleagues (1994) stated that “Lack of scientific documentation of the

benefits of therapeutic riding is a major obstacle that must be overcome. ...

Research is critically needed in all aspects of therapeutic riding”.


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Debuse et al (2005) noted that despite a substantial body of anecdotal and clinical

evidence for its benefits, research evidence for hippotherapy is sparse. In a

questionnaire survey, these researchers explored the views of physiotherapists and

people with CP who use hippotherapy. This study was aimed to: (i) establish the

pattern of hippotherapy practice in Germany and the U.K.; (ii) examine the

perceived main effects of hippotherapy on people with CP in Germany and the

U.K.; and (iii) investigate how these effects are being measured in both

countries. The results highlighted considerable differences in how hippotherapy is

practiced in the U.K. compared with in Germany. In spite of this, the study revealed

agreement among respondents on the overall perceived effects of hippotherapy on

individuals with CP, namely, the regulation of muscle tone, improvement of postural

control and psychological benefits. The results also indicated scant use of outcome

measures to evaluate these effects.

Casady and Nichols-Larsen (2004) examined if hippotherapy has an effect on the

general functional development of children with CP. The study employed a repeated-

measures design with 2 pre-tests and 2 post-tests conducted 10 weeks apart using

the Pediatric Evaluation of Disability Inventory (PEDI) and the Gross Motor Function

Measure (GMFM) as outcome measures. A convenience sample of 10 children with

CP participated whose ages were 2.3 to 6.8 years at baseline (mean +/- SD 4.1 +/-

1.7). Subjects received hippotherapy once-weekly for 10 weeks between pre-test 2

and post-test 1. Test scores on the GMFM and PEDI were compared before and

after hippotherapy. The authors concluded that results of this study suggest that

hippotherapy has a positive effect on the functional motor performance of children

with CP. Hippotherapy appears to be a viable treatment strategy for therapists with

experience and training in this form of treatment and a means of improving functional

outcomes in children with CP, although specific functional skills were not investigated.

There are 2 main drawbacks with this study: (i) the GMFM scorers were not

blinded to the order of test date and they were allowed to keep the scores

sheets, which may have biased the scorers, and (ii) with the individualized

approach to treatment, there is no protocol that would allow replication of this

study. The authors stated that hippotherapy has the potential to be a valuable

treatment strategy in treating children with CP. Future studies should use more

homogeneous patient populations in terms of age and type of CP to ascertain

precise areas of function affected most by hippotherapy.


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In a review on the use of complementary and alternative therapies for the treatment

of children with CP, Liptak (2005) noted that although studies of hippotherapy have

shown beneficial effects on body structures and functioning, unanswered questions

remain. For example, it is unclear which subgroups of children with CP would

benefit the most, what "dose" or frequency of intervention is optimal.

An assessment of the evidence for hippotherapy by the Institute for Clinical

Effectiveness and Health Policy (Pichon Riviere et al, 2006) concluded: "The

efficacy of this therapy does not seem to have been sufficiently proven for any

specific indication. Its recreational role and impact on the quality of life of these

patients have not been sufficiently analyzed."

Snider et al (2007) performed a systematic review of the literature on hippotherapy

as an intervention for children with CP. Retrieved articles were rated for

methodological quality using Physiotherapy Evidence Database (PEDro) scoring to

assess the internal validity of randomized trials and the Newcastle Ottawa Quality

Assessment Scale to assess cohort studies. Population, Intervention, Comparison,

and Outcomes (PICO) questioning was used to identify questions of interest to

clinicians for outcomes within the context of the International Classification of

Functioning, Disability and Health. Levels of evidence were then accorded each

PICO question. The authors reported that there is Level 2a evidence that

hippotherapy has short-term positive effects on muscle symmetry in the trunk and hip

and that hippotherapy is effective for improving muscle tone in children with CP when

compared with regular therapy or time on a waiting list. However, no studies

addressed participation outcomes. (Note: Level 2a evidence refers to 1 or more

"fair" quality randomized controlled trials [PEDro = 4 to 5]; 6 to 8 is considered

"good"; and 9 to 10 is considered "excellent"). An assessment of this systematic

evidence review by the Centre for Reviews and Dissemination (2009) found that this

systematic review was "poorly reported" and that, "given the potential for error or

bias during the review process, these cautious conclusions may not be reliable." In

particular, the authors did not report how many reviewers carried out study selection

and data extraction. Conclusions are limited due to heterogeneity of the primary data,

small sample sizes, and limited generalization of the patient samples.

Hamill et al (2007) examined the effects of a once-weekly, 10-week hippotherapy

program for 3 children, aged 27 to 54 months, with CP. Participants were rated as

Level V on the Gross Motor Function Classification System. The Sitting Dimension

of the Gross Motor Function Measure was used to establish a baseline of sitting


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abilities, and was administered every 2 weeks during intervention. The Sitting

Assessment Scale and the Gross Motor Function Measure were administered

before, after, and 4 weeks post-intervention. Parental perceptions of the

hippotherapy intervention were assessed using questionnaires. None of the

children made gains on any of the standardized outcome measures. However,

parental perceptions were very positive, with reported improvements in range of

motion and head control.

Lechner et al (2007) examined the effect of hippotherapy on spasticity and on

mental well-being of persons with spinal cord injury (SCI) and compared it with the

effects of other interventions. A volunteer sample of 12 people with spastic SCI

(American Spinal Injury Association Grade A or B) were included in this study;

interventions consisted of hippotherapy, sitting astride a Bobath roll, and sitting on a

stool with rocking seat. Each session lasted 25 mins and was conducted twice-

weekly for 4 weeks; the control condition was spasticity measurement without

intervention. Main outcome measures were clinical rating by a blinded examiner of

movement-provoked muscle resistance, using the Ashworth Scale; self-rating of

spasticity by subjects on a VAS; and mental well-being evaluated with the self-rated

well-being scale Befindlichkeits-Skala of von Zerssen. Assessments were performed

immediately after intervention sessions (short-term effect); data from the

assessments were analyzed 3 to 4 days after the sessions to calculate the long-

term effect. By analyzing the clinically rated spasticity, only the effect of hippotherapy

reached significance compared with the control condition (without intervention);

median differences in the Ashworth scores' sum before and after hippotherapy

sessions ranged between -8.0 and +0.5. There was a significant difference between

the spasticity-reducing effect of hippotherapy and the other 2 interventions in self-

rated spasticity by VAS; median differences of the VAS before and after hippotherapy

sessions ranged between -4.6 and +0.05cm. There were no long-term effects on

spasticity. Immediate improvements in the subjects' mental well-being were detected

only after hippotherapy (p = 0.048). The authors concluded that hippotherapy is

more efficient than sitting astride a Bobath roll or on a rocking seat in reducing

spasticity temporarily. Hippotherapy had a positive short-term effect on subjects'

mental well-being. The major drawbacks of this study were its small sample size and

that hippotherapy had no long-term effects on spasticity.


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Sterba (2007) reported on a review of evidence for hippotherapy in CP and

concluded that hippotherapy and horseback riding are effective in improving gross

motor skills. However, a critical assessment of this evidence review by the Centre

for Reviews and Dissemination (CRD, 2008) stated that "given the methodological

limitations of both included studies and the review, these conclusions should be

treated with caution." The CRD found insufficient information about the study

selection, data extraction and quality assessment process to determine whether

these had been carried out independently by more than one reviewer, "thus the

possibility of bias cannot be ruled out." The CRD stated that methodological

limitations evident in the included studies were: the inclusion of participants with

developmental disabilities other than cerebral palsy, lack of statistical analysis,

small sample sizes, use of outcome measures which have not been proven reliable

or valid, and the possibility of bias. The CRD found that "study quality and study

design do not appear to have been considered sufficiently when interpreting the

results."

McGibbon and colleagues (2009) investigated the immediate effects of 10 mins of

hippotherapy, compared with 10 mins of barrel-sitting, on symmetry of adductor

muscle activity during walking in children with CP (phase I; n = 47). These

researchers also investigated the long-term effects of 12 weekly sessions of

hippotherapy on adductor activity, gross motor function, and self-concept (phase II;

n = 6). Main outcomes measures were: for phases I and II -- adductor muscle

activity measured by surface electromyography; for phase II -- gross motor function

and self-perception profiles. In the phase I study, hippotherapy significantly

improved adductor muscle asymmetry (p < 0.001; d = 1.32). Effects of barrel-sitting

were not significant (p > 0.05; d = 0.10). In the phase II study, after 12 weeks of

hippotherapy, testing in several functional domains showed improvements over

baseline that were sustained for 12 weeks post-treatment. The authors concluded

that hippotherapy can improve adductor muscle symmetry during walking and can

also improve other functional motor skills.

McGee and Reese (2009) examined the immediate effects of a hippotherapy

session on temporal and spatial gait parameters in children with spastic CP.

Subjects comprised 9 children with a diagnosis of CP (6 girls and 3 boys, 7 to 18

years of age). Data for temporal and spatial gait parameters were collected

immediately before and after a hippotherapy session. No statistically significant

differences (p < 0.05) were noted in the post-ride temporal and spatial gait

parameter values when compared with the pre-ride values. The authors concluded


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that the findings of this study provide baseline data for future research and useful

clinical information for physical therapists using hippotherapy as a treatment

modality for children with spastic CP.

Schwesig et al (2009) tested the hypothesis that hippotherapy has both positive

short- and long-term effects on gait and posture control of persons suffering from

motoric disabilities. A total of 22 children and adolescents aged 9.69 +/- 4.01 years

(range of 9.69 +/- 4.01 years) with motoric dysfunctions were included in a

prospective matched-control study. In each participant, gait and posture control

were investigated on 4 different occasions (O1 to O4) using the Interactive balance

system and the portable gait analysis system RehaWatch. The dates of gait and

posture analysis were defined as follows: O1: immediately prior to first therapeutic

riding session (TRS); O2: immediately after first TRS; O3: after the last day of an

8-week period of daily TRS; O4: 7 weeks later after a TRS-free interval. The

following parameters were slightly improved (adjusted significance level of p <

0.003) after 8 weeks of therapeutic riding: (O1 versus O 3): (i) walking distance (p

= 0.009, eta (2) = 0.339); (ii) pace frequency (p = 0.007, eta (2) = 0.358); and (iii)

walking speed (p = 0.006, eta (2) = 0.367), and (iv) time of attachment (p = 0.007,

eta (2) = 0.360). The only short-term effect observed was a significant decrease of

the attachment phase (p = 0.002, eta (2) = 0.387). Interestingly, gait symmetry

remained unaffected. Posturography (adjusted significance level of p < 0.01) at O1

versus O2 (short-term) showed a significant decrease of the performance of both

the visual-nigrostriatal subsystem (p < 0.001) and the somato-sensory subsystem

(p = 0.001). At O1 versus O3 (long-term), the following parameters were sharply

decreased: (i) postural stability (p = 0.011), and (ii) somato-sensory performance

(p = 0.011). The authors concluded that in the individuals investigated, an 8-week

series of therapeutic riding did not improve posture control and had only a small

positive effect on gait performance. The reasons for these rather disappointing

results could have been the low number of therapeutic riding sessions (0.5

sessions per week), and the relatively short duration (30 mins) of each session. It

remains to be seen, whether a higher density and longer duration of therapeutic

riding sessions yields better results.

Oppenheim (2009) stated that there are no published studies specifically

addressing complementary and alternative methods (CAM) in adults with CP.

However, national surveys of adults with chronic disabilities document that a

majority of them use such treatments, that they are willing to pay out of pocket, if

necessary, and that they believe that pursuing such treatment relieves pain,


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reduces stress and anxiety and leads to improved feelings of fitness and well-

being. Individuals enjoy taking charge of their own health care decisions, and

frequently feel more in control with these therapies than with more traditional

methods. In contrast to adults, there is some information on CAM in children with

CP. The author discussed some of the CAM used in children that may be carried

over into adulthood, as well as the pitfalls for patients and conventional physicians

as they try to sort out what might be helpful and what might be harmful in this

arena. Practitioners of both conventional and CAM therapies believe that exercise

can be beneficial; accordingly, activities such as recreational sports, yoga, and

hippotherapy may be continued from childhood into adulthood. General treatments

for stress and anxiety, through such activities as yoga and meditation, though not

directed at CP per se, may be more popular for adults than children. Research in

this area should first identify what methods are being utilized and then subject

these methods to well-designed outcome studies that take into account any

associated risks.

Johnson (2009) analyzed evidence of the benefits of physical activity for youth with

developmental disabilities. A total of 3,263 citations was found. Systematic

reviews and articles about studies quantitatively examining the effects of physical

activity in youth with developmental disabilities aged 0 to 20 years were included.

Only articles published in English in peer-reviewed journals were included; 3

systematic reviews and 14 studies were reviewed. Strong evidence indicated that

children and adolescents with developmental disabilities derive health benefits from

participation in group exercise programs, treadmill training, or hippotherapy. Lesser

levels of evidence indicated that health benefits might be present for adapted skiing

or aquatic programs. Documented benefits of physical activity include

improvements in aerobic capacity, improved gross motor function, and high levels

of participant/parent satisfaction. The author stated that further research studies

are needed that are of greater scientific rigor including larger sample sizes, control

groups, and stringent, replicable methodology.

More scientific evidence, especially controlled studies with outcome measures, is

needed to ascertain the effectiveness of hippotherapy for the treatment of CP, MS,

and other motor dysfunction.

In a pilot study, Shurtleff and Engsberg (2010) evaluated the effectiveness of

hippotherapy in improving head/trunk stability in children with CP. The participants

were 6 children with spastic diplegia and 6 children without disability. Head and


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trunk stability was challenged by using a motorized barrel and measured by a video

motion capture system before and after a 12-week intervention of 45-min of

hippotherapy a week. The variables measured were anterior-posterior (AP)

translation of the head, and spine at 5 points and average AP head angles. At pre-

testing, children with CP demonstrated significant differences in AP translation and

AP head rotation compared with children without disability. Following hippotherapy,

children with CP demonstrated significant reductions in head rotation and AP

translation at C7, eye, and vertex. At post-testing, translation at C7 did not differ

significantly between children with CP and children without disability. After

hippotherapy intervention, children with CP reduced their AP head rotation and

translation, suggesting that they had increased stability of the head and trunk in

response to perturbations at the pelvis. The findings suggested that hippotherapy

might improve head and trunk stability in children with CP. These preliminary

findings need to be validated by well-designed studies with more subjects and

follow- up.

Bronson et al (2010) reviewed the evidence for hippotherapy as an intervention to

improve balance in persons with MS. Major electronic databases were searched

for articles relating to hippotherapy, MS and balance. Only full-length articles

published in peer reviewed journals that were written in English or translated into

English were included. Articles were assessed using a modified quality index that

was used for descriptive purposes only and did not exclude any study from the

review. All studies examined in this review were either case-control or case-series.

Collectively, all 3 studies reported improvements in balance. Pre-test and post-test

Berg Balance Scale scores in 2 studies revealed that primary progressive MS

demonstrated the greatest amount of change after hippotherapy compared to other

subtypes of MS. The authors concluded that hippotherapy has a positive effect on

balance in persons with MS and has an added benefit of enhancing quality of life.

They stated that data are limited, and further research will lead to a greater

knowledge base and has the potential to increase accessibility for hippotherapy to

be used as a rehabilitation modality.

Munoz-Lasa et al (2011) examined the effect of THR on the balance and gait of

ambulatory patients with MS. A total of 27 subjects were included in the study.

Patients were divided into 2 groups: (i) 12 underwent THR, and (ii) 15 traditional

physiotherapy (for both groups, 2 series of 10 weekly sessions were

performed). Before and after the study period, the following outcome measures

were applied: Extended Disability Status Scale (EDSS), Barthel Index, Tinetti


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Performance-Oriented Mobility Assessment (POMA). In addition, patients of the

THR group underwent a gait analysis to assess spatiotemporal gait parameters and

ground reaction forces. The THR group showed a significant improvement in POMA

scores (p < 0.005) and 2 gait parameters: stride time (p < 0.04) and ground reaction

forces (p < 0.01). No statistically significant change was found in the control

group. The authors concluded that the results of the study showed that THR can

improve balance and gait of ambulatory patients with MS. Moreover, they stated

that these findings are preliminary, but promising and in line with the recent

literature.

In a meta-analysis, Zadnikar and Kastrin (2011) examined the effects of

hippotherapy and therapeutic horseback riding (THR) on postural control or balance

in children with CP. To synthesize previous research findings, a systematic review

and meta-analysis were undertaken. Relevant studies were identified by systematic

searches of multiple online databases from the inception of the database through

to May 2010. Studies were included if they fulfilled the following criteria:

▪ quantitative study design,

▪ investigation of the effect of hippotherapy or THR on postural control or

balance, and

▪ the study group comprised children and adults with CP.

The selected articles were rated for methodological quality. The treatment effect

was coded as a dichotomous outcome (positive effect or no effect) and quantified

by odds ratio (OR). The pooled treatment effect was calculated using a random-

effects model. Meta-regression of the effect size was performed against study co-

variates, including study size, publication date, and methodological quality score.

From 77 identified studies, 10 met the inclusion criteria. Two were excluded

because they did not include a comparison group. Therapy was found to be

effective in 76 out of 84 children with CP included in the intervention groups. The

comparison groups comprised 89 children: 50 non-disabled and 39 with CP. A

positive effect was shown in 21 of the children with CP in the comparison group

regardless of the activity undertaken (i.e., physiotherapy, occupational therapy,

sitting on a barrel or in an artificial saddle). The pooled effect size estimate was

positive (OR 25.41, 95 % confidence interval [CI]: 4.35 to 148.53), demonstrating a

statistically significant effectiveness of hippotherapy or THR in children with CP (p <

0.001). Meta-regression of study characteristics revealed no study-specific factors.


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The authors concluded that the 8 studies found that postural control and balance

were improved during hippotherapy and THR. They stated that although the

generalization of their findings may be restricted by the relatively small sample size,

the results demonstrated that riding therapy is indicated to improve postural control

and balance in children with CP.

Whalen and Case-Smith (2012) examined the effectiveness of hippotherapy or

THR on motor outcomes in children with CP. Databases were searched for clinical

trials of hippotherapy or THR for children with CP. A total of 9 articles were

included in this review. Although the current level of evidence is weak, this

synthesis found that children with spastic CP, Gross Motor Function Classification

System (GMFCS) levels I to III, aged 4 years and above are likely to have

significant improvements on gross motor function as a result of hippotherapy and

THR. Evidence indicated that 45-min sessions, administered once-weekly for 8 for

10 weeks, resulted in significant effects. The authors concluded that the current

literature on hippotherapy and THR is limited. They stated that large randomized

controlled trials (RCTs) using specified protocols are needed to more conclusively

determine the effects on children with CP.

Tseng et al (2013) evaluated the literature on the effectiveness of equine-assisted

activities and therapies (EAAT) on gross motor outcomes representing the ICF

component of body functions and activity in children with CP. These investigators

conducted a systematic review and meta-analysis of RCTs and observational studies

of hippotherapy (HPOT) and THR for children with spastic CP. Gross motor

outcomes, assessed via muscle activity and muscle tone, gait, posture and GMFM

were evaluated. A total of 5 THR studies and 9 HPOT studies were included. This

meta-analysis indicated that short-term HPOT (total riding time 8 to 10 mins)

significantly reduced asymmetrical activity of the hip adductor muscles. HPOT could

improve postural control in children with spastic CP, GMFCS level of less than 5.

However, the evidence did not show a statistically significant effect on GMFM after

long-term HPOT or THR (total riding time, 8 to 22 hrs) in children with spastic CP.

The authors concluded that this systematic review found insufficient evidence to

support the claim that long-term THR or HPOT provides a significant benefit to

children with spastic CP. They found no statistically significant evidence of either

therapeutic effect or maintenance effects on the gross motor activity status in CP

children.

Hippotherapy has also been used in the treatment of patients with autism.


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However, there is a lack of reliable scientific evidence regarding its effectiveness.

In a pilot study, Manikowska (2013) examined the effect of hippotherapy on spatio-

temporal parameters of gait in children with CP. A total of 16 ambulatory CP children

(GMFCS Level I to III; female: 10, male: 6; age of 5.7 to 17.5 years) qualified for

hippotherapy were investigated. Basic spatio-temporal parameters of gait, including

walking speed, cadence, step length, stride length and the left-right symmetry, were

collected using a 3-dimensional accelerometer device (DynaPort MiniMod) before

and immediately after a hippotherapy session. The Wilcoxon test was used to verify

the differences between pre- and post-session results. Changes of walking speed

were statistically significant. With the exception of step length, all spatio-temporal

parameters improved, i.e., were closer to the respective reference ranges after the

session. However, these changes were not statistically significant. The authors

concluded that 1 session of hippotherapy may have a significant effect on the spatio-

temporal parameters of gait in children with CP. The findings of this small, pilot study

need to be validated by well-designed studies.

In a single-blind RCT, Beinotti et al (2013) examined the impact of horseback riding

therapy (HBRT) on the quality of life (QOL) of individuals with hemiparesis after

stroke. A total of 24 post-stroke patients were assigned to the experimental (n =

12) and control (n = 12) groups. The control group participated in a conventional

physiotherapy program, whereas the experimental group participated in

physiotherapy plus HBRT sessions for 16 weeks. The patients were evaluated by

means of the SF-36. Data analysis was applied through the use of descriptive and

inferential statistics, with a 5 % level of significance. Significant improvement was

observed in the total score of the SF-36 in the experimental group when compared

with the control group. The combination of conventional physiotherapy and HBRT

was associated with improvements in functional capacity (p = 0.02), physical

aspects (p = 0.001), and mental health (p = 0.04) of the stroke patients. The

authors concluded that supplementation of conventional physiotherapy with HBRT,

applied in different contexts, may yield positive QOL outcomes for people with

stroke. These investigators recommended that further studies be carried out to

clarify the benefits of HBRT applied singly.

Homnick et al (2013) examined the effect of an 8-week therapeutic riding (TR)

program on measures of balance and QOL in community-dwelling older adults with

established balance deficits. The study was conducted at a Professional

Association of Therapeutic Horsemanship (PATH) International Premier riding


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center. Subjects comprised 9 adults (5 females, 4 males) with a mean age of 76.4

years (range of 71 to 83). Treatment included an 8-week observation period

followed by an 8-week TR program consisting of 1 hour/week of supervised

horseback riding and an 8-week follow-up period. Subjects received balance

testing at weeks 0, 8, 16, and 24 using the Fullerton Advanced Balance Scale

(FABS), and QOL was measured at weeks 8 and 16 using the Rand SF-36 QOL

measure. Outcome measures were change in the FABS and Rand SF-36. There

was no significant difference in balance scores between the start and end of the

observation period. There was a significant improvement in the balance score and

perception of general health from the start to the end of the intervention period, and

no significant difference between the end of the intervention and the end of study,

suggesting that improvements may have been sustained. The authors concluded

that TR is a safe activity for older adults with mild-to-moderate balance deficits and

leads to both improvements in balance and QOL. Moreover, they stated that longer

and larger studies are needed to ascertain the benefit of equine-assisted activities

on improvements in balance and reduction in fall risk.

Dezutti (2013) noted that patients with eating disorders may have the most complex

inter-disciplinary treatment plans of any mental illness. Nurses need innovative

evidence-based treatment interventions to assist their patients with eating disorders

on their road to recovery. Although much has been written about equine-assisted

psychotherapy (EAP) and equine-facilitated psychotherapy, the literature has not

described a detailed session that can help nurses understand how this experiential

treatment works and the impact it can have on the patient.

In a pilot study, Cerulli et al (2014) evaluated the physiologic and psychological

effects of an equine-assisted therapy (EAT) protocol in breast cancer survivors. A

total of 20 women (mean age of 45.61 ± 2.71 years) whose breast cancer treatment

had concluded at least 6 months previously underwent a screening protocol to

certify their eligibility to participate in non-competitive sports. The patients were

randomly assigned to an intervention group (n = 10) or a control group (n = 10).

Intervention patients participated in a 16-week EAT protocol consisting of 2 hours of

activity per week. All patients were tested before and after the intervention for

maximal oxygen consumption (VO2max), fat mass percentage, total body water

percentage, strength of principal muscular groups (measured on 5 weight-lifting

machines [leg press, leg extension, leg curl, shoulder press, vertical traction]), and

quality of life using the Functional Assessment of Chronic Illness Therapy-Fatigue

questionnaire (FACIT-F). After intervention, the intervention group showed an


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improvement in VO2max (28.29 %; p < 0.001), a decrease in fat mass percentage

(change, -7.73 %; p < 0.002), an increase in total body water percentage (6.90 %; p

= 0.027), and an increase in strength (leg press, 17.75 % [p = 0.018]; leg extension,

21.55 % [p = 0.005]; leg curl, 26.04 % [p < 0.001]; shoulder press, 49.72 % [p =

0.003]; vertical traction, 19.27 % [p = 0.002]). Furthermore, the increase in the 3

FACIT-F scores (FACIT-F trial outcome: 9.29 % [p = 0.010]; Functional Assessment

of Cancer Therapy-General total score, 14.80 % [p = 0.022]; and FACIT-F total score,

11.48 % [p =0.004]) showed an increase in quality of life. No significant changes for

any variable were found for the control group. The authors concluded that EAT had

positive effects on both physiologic and psychological measures, enhancing quality of

life of breast cancer survivors. They stated that these results suggested a new

method for rehabilitation intervention strategies after cancer in a non-medical

environment. These findings from a pilot study need to be validated by well-designed

studies.

Nurenberg et al (2015) stated that animal-assisted therapy (AAT), most frequently

used with dogs, is being used increasingly as an adjunctive alternative treatment for

psychiatric patients. Animal-assisted therapy with larger animals, such as horses,

may have unique benefits. In this randomized controlled study, equine and canine

forms of AAT were compared with standard treatments for hospitalized psychiatric

patients to determine AAT effects on violent behavior and related measures. The

study included 90 patients with recent in-hospital violent behavior or highly

regressed behavior. Hospitalization at the 500-bed state psychiatric hospital was 2

months or longer (mean of 5.4 years). Participants were randomly selected to

receive 10 weekly group therapy sessions of standardized EAP, canine-assisted

psychotherapy (CAP), enhanced social skills psychotherapy, or regular hospital

care. Participants' mean age was 44, 37 % were female, 76 % had diagnoses of

schizophrenia or schizoaffective disorder, and 56 % had been committed

involuntarily for civil or forensic reasons. Violence-related incident reports filed by

staff in the 3 months after study intake were compared with reports 2 months pre-

intake. Interventions were well-tolerated. Analyses revealed an intervention group

effect (F = 3.00, df = 3 and 86, p = 0.035); post-hoc tests showed specific benefits

of EAP (p < 0.05). Similar AAT effects were found for the incidence of 1:1 clinical

observation (F = 2.70, df = 3 and 86, p = 0.051); post-hoc tests suggested benefits

of CAP (p = 0.058) as well as EAP (p = 0.082). Co-variance analyses indicated

that staff can predict which patients are likely to benefit from EAP (p = 0.01). The

authors concluded that AAT, and perhaps EAP uniquely, may be an effective


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therapeutic modality for long-term psychiatric patients at risk of violence. These

preliminary findings need to be validated by well-designed studies with longer

follow-up.

Del Rosario-Montejo et al (2015) stated that equine therapy is used to treat patients

susceptible to psychomotor delays. These researchers examined development of

gross motor function compared to other psychomotor skills in patients undergoing

this therapy and analyzed how this improvement affects general health status and

quality of life. The study included 11 children with delayed psychomotor

development (aged 8.82 ± 3.89; 6 boys, 5 girls). The main study variables were

gross motor function (GMFM-88) and perceived quality of life (Pediatric Quality of

Life Inventory, PedsQL). Three measurements were performed: (i) before and after

a period of inactivity, (ii) 2 months after the second measurement, and (iii) following

completion of a sustained period of therapy.

These investigators observed significant differences in overall results on the GMFM-

88 between the initial and final tests and between the intermediate and final tests.

Regarding the PedsQL quality of life scale, no statistically significant results were

recorded. The authors concluded that noticeable changes in motor control were

recorded throughout the course of the intervention, which suggested that equine

therapy may be appropriate treatment in cases of delayed psychomotor

development. These preliminary findings need to be validated by well-designed

studies.

Cerebral Palsy

Dewar et al (2015) evaluated the efficacy and effectiveness of exercise interventions

that may improve postural control in children with CP. These investigators performed

a systematic review using American Academy of Cerebral Palsy and Developmental

Medicine (AACPDM) and Preferred Reporting Items for Systematic Reviews and

Meta-Analyses (PRISMA) methodology. Six databases were searched using the

following keywords: ('cerebral palsy' OR ‘brain injury'); AND ('posture*' OR 'balance'

OR 'postural balance' [MeSH]); AND ('intervention' OR 'therapy' OR 'exercise' OR

'treatment'). Articles were evaluated based on their level of evidence and conduct.

Searches yielded 45 studies reporting 13 exercise interventions with postural control

outcomes for children with CP. Five interventions were supported by a moderate

level of evidence: gross motor task training, hippotherapy, treadmill training with no

body weight support (no-BWS), trunk-targeted training, and reactive balance training.

Six of the interventions had


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weak or conflicting evidence: functional electrical stimulation (FES), hippotherapy

simulators, neurodevelopmental therapy (NDT), treadmill training with body weight

support, virtual reality, and visual biofeedback. Progressive resistance exercise

was an ineffective intervention, and upper limb interventions lacked high-level

evidence. The authors concluded that the use of exercise-based treatments to

improve postural control in children with CP has increased significantly in the last

decade. Improved study design provided more clarity regarding broad treatment

efficacy. Moreover, they stated that research is needed to establish links between

postural control impairments, treatment options, and outcome measures. Low-

burden, low-cost, child-engaging, and mainstream interventions also need to be

explored.

An UpToDate review on “Management and prognosis of cerebral palsy” (Miller,

2015) states that “Not recommended -- In a comprehensive review, physical therapy

approaches that were not recommended because of lack of efficacy include

neurodevelopmental therapy (NDT) and sensory integration therapy (SIT). NDT is

the direct passive handling of limbs by the therapist, with guidance intended to

normalize the patterns of movement. It is not recommended because of the

availability of more effective alternatives. Any gains in range of motion that are

achieved during an NDT session do not carry over. Better functional gains are

achieved with motor-learning approaches, and BTX is more effective than NDT for

managing spasticity. Similarly, systematic reviews conclude that SIT is not effective

and should be replaced by effective alternatives such as those listed above. Many

other activities' interventions are supported only by low-quality or inconclusive

evidence, precluding a recommendation for or against their use.

Among these, early intervention for motor outcomes is a promising approach

because of supporting evidence in populations without CP. Interventions with weak

evidence are animal-assisted therapy, assistive technology, hippotherapy

(therapeutic horse-riding) …..

Behavioral and Psychiatric Disorders

Anestis et al (2014) stated that equine-related treatments (ERT) for mental

disorders are becoming increasingly popular for a variety of diagnoses; however,

they have been subjected only to limited systematic investigation. These

researchers examined the quality of and results from peer-reviewed research on

ERT for mental disorders and related outcomes. Peer-reviewed studies (n = 14)

examining treatments for mental disorders or closely related outcomes were


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identified from databases and article reference sections. All studies were

compromised by a substantial number of threats to validity, calling into question the

meaning and clinical significance of their findings. Additionally, studies failed to

provide consistent evidence that ERT is superior to the mere passage of time in the

treatment of any mental disorder. The authors concluded that the current evidence

base does not justify the marketing and utilization of ERT for mental disorders.

Such services should not be offered to the public unless and until well-designed

studies provide evidence that justify different conclusions.

Multiple Sclerosis

In a single-subject experimental design study (n = 11), Hammer and associates

(2005) examined whether therapeutic riding (TR, Sweden), also known as

hippotherapy (HT, United States) may affect balance, gait, spasticity, functional

strength, coordination, pain, self-rated level of muscle tension (SRLMT), activities of

daily living (ADL), and health-related quality of life in patients with multiple sclerosis

(MS). The intervention comprised 10 weekly TR/HT sessions of 30 mins each.

The subjects were measured a maximum of 13 times. Physical tests were: The

Berg balance scale, taking a figure of 8, the timed up and go test, 10-m walking, the

modified Ashworth scale, the Index of Muscle Function, the Birgitta Lindmark motor

assessment, part B, and individual measurements. Self-rated measures were: the

visual analog scale (VAS) for pain, a scale for SRLMT, the Patient-Specific

Functional Scale for ADL, and the Medical Outcomes Study 36-item Short-Form

health survey (SF-36). Data were analyzed visually, semi-statistically and

considering clinical significance. Results showed improvement for 10 subjects in

one or more of the variables, particularly balance, and some improvements were

also seen in pain, muscle tension, and ADL. Changes in SF-36 were mostly

positive, with an improvement in Role-Emotional seen in 8 patients. These

investigators concluded that balance and Role-Emotional were the variables most

often improved, but TR/HT appeared to benefit the subjects differently.

In a case-series study, Lindroth et al (2015) examined if there were observable

changes in sensory processing for postural control in individuals with MS following

physical therapy using HPOT or changes in balance and functional gait. This pre-

test non-randomized design study, with follow-up assessment at 6 weeks, included

2 females and 1 male (age range of 37 to 60 years) with diagnoses of relapse-

remitting or progressive MS. The intervention consisted of twelve 40-min physical

therapy sessions which included HPOT twice-weekly for 6 weeks. Sensory


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organization and balance were assessed by the Sensory Organization Test (SOT)

and Berg Balance Scale (BBS). Gait was assessed using the Functional Gait

Assessment (FGA). Following the intervention period, all 3 participants showed

improvements in SOT (range of 1 to 8 points), BBS (range of 2 to 6 points), and

FGA (average of 4 points) scores. These improvements were maintained or

continued to improve at follow-up assessment; 2 of the 3 participants no longer over-

relied on vision and/or somatosensory information as the primary sensory input for

postural control, suggesting improved use of sensory information for balance. The

authors concluded that these findings indicated that HPOT may be a beneficial

physical therapy treatment strategy to improve balance, functional gait, and enhance

how some individuals with MS process sensory cues for postural control. Moreover,

they stated that randomized clinical trials are needed to validate results of this study.

Vermohlen and associates (2018) examined the effect of hippotherapy plus

standard care versus standard care alone in MS patients. A total of 70 adults with

MS were recruited in 5 German centers and randomly allocated to the intervention

group (12 weeks of hippotherapy) or the control group. Primary outcome was the

change in the Berg Balance Scale (BBS) after 12 weeks, and further outcome

measures included fatigue, pain, QOL, and spasticity. Co-variance analysis of the

primary end-point resulted in a mean difference in BBS change of 2.33 (95 % CI:

0.03 to 4.63, p = 0.047) between intervention (n = 32) and control (n = 38) groups.

Benefit on BBS was largest for the subgroup with an EDSS of greater than or equal

to 5 (5.1, p = 0.001). Fatigue (-6.8, p = 0.02) and spasticity (-0.9, p = 0.03) improved

in the intervention group. The mean difference in change between groups was 12.0

(p < 0.001) in physical health score and 14.4 (p < 0.001) in mental health score of

Multiple Sclerosis QOL-54 (MSQOL-54). The authors concluded that hippotherapy

plus standard care, while below the threshold of a minimal clinically important

difference, significantly improved balance and also fatigue, spasticity, and QOL in

MS patients.

Munoz-Lasa and colleagues (2019) stated that hippotherapy is a promising method in

the physical treatment of MS. These researchers carried out a comparative, open,

clinical pre-post study into hippotherapy intervention (non-randomized) during a 6-

month period in patients with MS (n = 6) and a h control group (n = 4). A statistically

significant improvement was observed in the therapy group in: spasticity pre-post

measured by the modified Ashworth scale (p = 0.01). Statistically significant

improvement in fatigue impact (p < 0.0001) measured with fatigue


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impact scale (FIS); in general, perception of heath outcome in urinary QOL scale

King's Health Questionnaire (KHQ) (p = 0.033), and in subscales 2, 3 and 4 of

MSQOL-54 (p = 0.011). Control group showed no improvement in any scale. The

authors concluded that the findings of this study reinforced current literature that

supports hippotherapy as an adequate intervention for MS patients. Moreover, they

stated that further studies with more participants, control groups and blinded research

would be logical steps for future research in this field.

Anxiety and Post-Traumatic Stress Disorder

Earles and colleagues (2015) examined the effectiveness of the Equine Partnering

Naturally(©) approach to equine-assisted therapy for treating anxiety and post-

traumatic stress disorder (PTSD) symptoms. Participants were 16 volunteers who

had experienced a Criterion A traumatic event, such as a rape or serious accident,

and had current PTSD symptoms above 31 on the PTSD Checklist (PCL-S;

Weathers, Litz, Herman, Huska, and Keane). Participants engaged in tasks with

horses for 6 weekly 2-hour sessions. Immediately following the final session,

participants reported significantly reduced post-traumatic stress symptoms, d =

1.21, less severe emotional responses to trauma, d = 0.60, less generalized

anxiety, d = 1.01, and fewer symptoms of depression, d = 0.54. As well,

participants significantly increased mindfulness strategies, d = 1.28, and decreased

alcohol use, d = 0.58. There was no significant effect of the treatment on physical

health, proactive coping, self-efficacy, social support, or life satisfaction. Thus, the

authors found evidence that the Equine Partnering Naturally (©) approach to

equine-assisted therapy may be an effective treatment for anxiety and post-

traumatic stress symptoms. They stated that future research should include larger

groups, random assignment, and longer-term follow-up.

Attention Deficit and/or Hyperactivity Disorder

Lee and colleagues (2015) examined the effects of hippotherapy on brain function

and levels of blood-derived neurotrophic factor (BDNF) in children with attention

deficit and/or hyperactivity disorder (ADHD). The hippotherapy group (HRG) included

20 children with ADHD and the control group (CG) included 19 children. All

participants' physical fitness, functional magnetic resonance imaging (fMRI) brain

scans, and blood BDNF levels were measured at baseline and after 32 weeks of

participating in hippotherapy. After 32 weeks of participating in hippotherapy, the

body fat of the HRG was significantly decreased (-1.12 ± 4.20 %) and the body fat


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of the CG was increased (2.38 ± 6.35 %) (p = 0.049). There was no significant

difference of physical fitness in both groups (p > 0.05). Although there was a higher

decrease in the activated insular area in the HRG (-1.59 ± 0.99) than in the CG (-

1.14 ± 1.41), there was no significant difference between the 2 groups (p > 0.05).

Furthermore, there was a higher increase in the activated cerebellum area in the

HRG (1.97 ± 1.45) than in the CG (1.92 ± 1.81). However, there was no significant

difference between the 2 groups (p > 0.05); BDNF levels showed an increased

tendency in the HRG (166.29 ± 277.52 pg) compared to the CG (21.13 ±

686.33 pg); otherwise, there was not any significant difference in these blood levels

between the 2 groups (p > 0.05). It can be assumed that big individual differences

in the level of ADHD in the study participants might not cause any significant

results, although there might be positive changes in the brain function of children

with ADHD. The authors concluded that the findings of this study suggested that

hippotherapy training would need to be modified and developed to increase the

effectiveness of hippotherapy in children with ADHD.

In a 12-week, prospective, open-label trial, Jang and associates (2015) examined

the clinical effects of equine-assisted activities and therapy (EAA/T) for treating

ADHD in children aged 6 to 13 years. This study entailed 24 sessions of EAA/T

with 20 participants (19 boys and 1 girl) completed 12 weeks of EAA/T. Various

clinical tests were administered at baseline and after EAA/T. Assessments included

the investigator-administered ADHD-Rating Scale (ARS-I), Clinical Global

Impressions-Severity Scale (CGI-S), Clinical Global Impressions-Improvement Scale

(CGI-I), Gordon Diagnostic System, Korea-Child Behavior Checklist

(K-CBCL), Self-Esteem Scale, second edition of the Bruininks-Oseretsky test of

motor proficiency (BOT-2), and quantitative electroencephalography. The primary

efficacy measure was the response rate. The response rate was 90 % based on a

30 % or greater decline in the ARS-I score or 85 % based on CGI-I scores of 1 or

2. The mean ± standard deviation ARS-I score decreased from 33.65 ± 6.42 at

baseline to 16.80 ± 6.86 after 12 weeks of EAA/T (p < 0.001, paired t-test). It was

reported that EAA/T also resulted in significant improvement in the social problems

subscale of the K-CBCL and in the manual dexterity, bilateral coordination, and total

motor composite subscales of the BOT-2. The theta/beta ratio on

electroencephalography was decreased significantly at the Pz electrode after 12

weeks of EAA/T. The authors concluded that this was the first study demonstrating

that EAA/T is effective for improving core ADHD symptoms. They stated that on

the basis of these results, EAA/T could be a viable treatment strategy as a part of a

multi-modal therapy for children with ADHD. The main drawbacks of this study


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were its small sample size (n = 20), short-term follow-up (12 weeks) and its open-

label design. These preliminary findings need to be validated by well-designed

studies.

Furthermore, an UpToDate review on “Attention deficit hyperactivity disorder in

children and adolescents: Overview of treatment and prognosis” (Krull, 2015) does

not mention hippotherapy as a therapeutic option.

In a pilot study, Yoo and colleagues (2016) examined the effects of EAA/T on

participants with ADHD by comparing resting-state fMRI (rs-fMRI) signals and their

clinical correlates. A total of 10 subjects with ADHD participated in a 12-week

EAA/T program without any medication; 2 rs-fMRIs were acquired for all subjects

before and after EAA/T. For estimating therapeutic effect, the regional

homogeneity (ReHo) method was applied to capture the changes in the regional

synchronization of functional signals. After the EAA/T program, clear symptom

improvement was found even without medication. Surface-based pair-wise

comparisons revealed that ReHo in the right precuneus and right pars orbitalis

clusters had significantly diminished after the program. Reduced ReHo in the right

precuneus cluster was positively correlated with changes in the scores on DuPaul's

ADHD Rating Scale-Korean version. The authors concluded that these findings

indicated that EAA/T is associated with short-range functional connectivity in the

regions related to the default mode network and the behavioral inhibition system,

which are associated with symptom improvement. They stated that for equine

therapy to be accepted as an adjunct therapeutic option for ADHD, additional

studies with larger samples, controlled designs, and purposeful fMRI sessions are

needed.

This pilot study had several drawbacks: (i) the study included only a subset of

ADHD subjects who finished the 12-weeks of EAA/T. Comparison with the typically

developing children would be needed in the future, (ii) these researchers only

analyzed resting-state data, and thus, the direct effects of EAA/T on task-related

performance such as attention, emotion, and cognition could not be estimated.

Investigating those effects requires task-specific fMRI designs for each domain, and

(iii) long-term effects could not be examined from a single 12-week EAA/T session.

Lee and colleagues (2017) examined the effect of hippotherapy and

electroencephalography (EEG) neurofeedback on brain function and blood BDNF

level in children with ADHD. A total of 16 children with ADHD participated in this


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study and were randomly divided into 2 groups: (i) a 1-time hippotherapy group

(W1G, n = 8), and (ii) a 2-time hippotherapy group (W2G, n = 8). All the

participants attended 8 weeks of hippotherapy program in the primary training, and

then 7 children with ADHD attended 8 weeks of hippotherapy program combined

with neurofeedback training in the secondary training. Blood BDNF levels were

measured, and fMRI was performed. The EEG neurofeedback training program

was used to train and measure psychological factors. The combined effect of

hippotherapy and neurofeedback on BDNF level showed a decreased tendency in

W1G (pre-training, 1,766.03 ± 362.54 pg/ml; post-training, 1,630.65 ± 276.70

pg/ml). However, the BDNF level of W2G showed an increased tendency (pre-

training, 1,968.28 ± 429.08 pg/ml; post-training, 1,976.28 ± 425.35 pg/ml).

Moreover, combined training showed a significant group x repetition interaction in

W1G (pre-training, 1,436.57 ± 368.76 pg/ml; post-training, 1,525.23 ± 346.22 pg/ml;

F = 3.870, p = 0.039); fMRI results showed that the left thalamus activity in both

groups had a decreased tendency and a significantly lower change in W2G than in

W1G (p < 0.05). The authors concluded that the findings of this study suggested

that hippotherapy combined with various psychological interventions would be

useful for improving brain function in children with ADHD. Moreover, they

recommended that future studies consider consistency of ADHD level and unified

exercise intensity application for better understanding of the effects of hippotherapy

and neurofeedback training on children with ADHD.

This study had 2 major drawbacks: (i) the ADHD level of each subject might be

inconsistent, which might have negatively affected the study results, and (ii)

the progress of each subject in hippotherapy differed because of the different

levels of learning ability. This might have caused a variation in exercise intensity,

although the study set the same exercise intensity.

Oh, and co-workers (2018) examined the effects of hippotherapy versus

pharmacotherapy for children with ADHD. A total of 34 subjects with ADHD were

randomly assigned at a 1:1 ratio to either 24 sessions of a twice-weekly

hippotherapy or pharmacotherapy. To assess therapeutic effects, the ARS was

used pre-treatment and post-treatment as the primary outcome measure.

Secondary outcomes included the CBCL, Self-Esteem Scale (SES), PedsQL child

and parent report version, Developmental Coordination Disorder Questionnaire

(DCDQ), CGI-S, and quantitative electroencephalography (qEEG). Both groups

showed marked improvements in ADHD symptoms, CGI-S. No significant

differences between the 2 groups were detected regarding treatment outcome


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except thought problem subscales of CBCL; 12 weeks of hippotherapy improved

attention, impulsivity/hyperactivity, and QOL. The authors concluded that the

findings of this trial are promising, but further studies are needed to evaluate the

long-term clinical effectiveness of hippotherapy.

Sexual Abuse and Emotional Stress

Guerino et al (2015) evaluated 2 women aged 18 and 21 years, who had suffered

sexual violence when they were children between the ages of 6 and 7 years old.

The subjects did not have mental dysfunction, but they were regular students

registered at a school of special education; patients presented with severe motor

limitation, difficulty with coordination, significant muscular retractions, thoracic and

cervical kyphosis, cervical protrusion, which was basically a function of the postures

they had adopted when they were victims of the sexual violence suffered in

childhood. The patients performed 20 sessions of 30-min of HPOT on a horse.

The activities were structured to stimulate coordination, proprioception, the

vestibular and motor-sensorial systems for the improvement of posture, muscle

activity and cognition. The activities provided during HPOT sessions elicited

alterations in postural adjustment resulting in 30 % improvement, 80 %

improvement in coordination in, 50 % improvement in corporal balance and in

sociability and self-esteem. The authors concluded that HPOT proved to be an

effective treatment method for coordination, balance and postural correction, and

also improved the patients' self-esteem that had suffered serious emotional stress.

These preliminary findings need to be validated by well-designed studies.

Traumatic Brain Injury

In a single-case study, Erdman and Pierce (2016) described the use of

hippotherapy with a boy who sustained a traumatic brain injury (TBI). A 13-year old

boy, 6 months after TBI received 12 physical therapy sessions, which included

hippotherapy. Improvements were noted in balance, strength, gross motor skills,

gait speed, functional mobility, and reported participation. The authors concluded

that hippotherapy used with a 13-year old boy after TBI may have had a positive

effect in the body structure, activity, and participation domains. These preliminary

findings need to be validated by well-designed studies.


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Rigby and Grandjean (2016) summarized the physical benefits of therapeutic

horseback riding and hippotherapy and suggested directions for future research.

Databases included Medline via Ebsco, Web of Science, PubMed, Google Scholar,

and Academic Search Complete. Articles were limited to those with full-text access

published in English since 1987. Acute and residual improvements in physical

benefits, such as gross motor function (e.g., walking, running, jumping), spasticity,

muscle symmetry, posture, balance, and gait occurred in adults and children with

varying disabilities. The benefits appeared to be greatest following multi-week

interventions with 1 or more sessions per week. Modest acute cardiovascular

responses were observed during EAA/T with little or no evidence for training

improvements in heart rate or blood pressure at rest or during riding. The authors

concluded that the present body of literature provided evidence that EAA/T are an

effective means of improving many measures of physical health. However, more

controlled trials are urgently needed to strengthen the current knowledge base,

establish dose-response characteristics of EAA/T, and explore the physiologic

basis for the promising results suggested from the literature.

Marquez and associates (2018) stated that evaluation of the merit of hippotherapy

in adults with acquired brain injury (ABI) is lacking. These researchers examined if

hippotherapy could improve motor function in adults with ABI. They carried out a

systematic review of all available controlled studies investigating the use of

hippotherapy, in adults with ABI. The primary outcome of interest was movement

related function and secondary outcomes included impairment, QOL, and adverse

events (AEs). A total of 9 studies with 256 participants were included, of which 6

studies with 204 participants were included for meta-analysis. When the data were

pooled, hippotherapy did not produce statistically significant improvements in

balance (standard mean difference [SMD] = 0.24, 95 % CI: -0.05, 0.54, p = 0.1) or

gait parameters (SMD = -0.04, 95 % CI: -0.79, 0.72 p = 0.92) when compared to

control and measured immediately after the intervention. Long-term effects remain

unknown due to lack of follow-up evaluation. The authors concluded that the

findings of this review suggested that hippotherapy is safe and well-tolerated by

adults with ABI; short-term functional benefits were not associated with the use of

hippotherapy. These investigators stated that further high-quality research is

needed before hippotherapy can be endorsed as a modality in adult neurological

rehabilitation.

Substance Abuse Disorder


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Kern-Godal et al (2016) noted that inclusion of horse-assisted therapy (HAT) in

substance abuse disorder treatment is rarely reported. The authors’ previous

studies showed improved treatment retention and the importance of the patient-

horse relationship. This qualitative study used thematic analysis, within a social

constructionist framework, to explore how 8 patients experienced contextual

aspects of HAT's contribution to their substance abuse disorder treatment.

Participants described HAT as a "break from usual treatment". However, 4

interrelated aspects of this experience, namely "change of focus", "activity",

"identity", and "motivation," suggested HAT is more than just a break from usual

substance abuse disorder treatment. The stable environment is portrayed as a

context where participants could construct a positive self: one which is useful,

responsible, and accepted; more fundamentally, a different self from the

“patient/self" receiving treatment for a problem. The authors concluded that the

implications extend well beyond animal-assisted or other adjunct therapies; and

their relevance to broader substance abuse disorder policy and treatment practices

warrants further study.

Autism Spectrum Disorder

In a pilot study, Ajzenman et al (2013) examined if hippotherapy increased function

and participation in children with autism spectrum disorder (ASD). These

researchers hypothesized improvements in motor control, which might increase

adaptive behaviors and participation in daily activities. A total of 6 children with

ASD aged 5 to 12 participated in 12 weekly 45-min hippotherapy sessions.

Measures pre- and post-hippotherapy included the Vineland Adaptive Behavior

Scales-II and the Child Activity Card Sort. Motor control was measured pre-

intervention and post-intervention using a video motion capture system and force

plates. Postural sway significantly decreased post-intervention. Significant increases

were observed in overall adaptive behaviors (receptive communication and coping)

and in participation in self-care, low-demand leisure, and social interactions. The

authors concluded that these results suggested that hippotherapy has a positive

influence on children with ASD and can be a useful treatment tool for this population.

The findings of this small, pilot study need to be validated by well- designed studies.

O'Haire (2013) stated that the inclusion of animals in therapeutic activities, known

as animal-assisted intervention (AAI), has been suggested as a treatment practice

for ASD. These investigators presented a systematic review of the empirical


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research on AAI for ASD. A total of 14 studies published in peer-reviewed journals

qualified for inclusion. The presentation of AAI was highly variable across the

studies. Reported outcomes included improvements for multiple areas of

functioning known to be impaired in ASD, namely increased social interaction and

communication as well as decreased problem behaviors, autistic severity, and

stress. The author concluded that despite unanimously positive outcomes, most

studies were limited by many methodological weaknesses; this review showed that

there is preliminary "proof of concept" of AAI for ASD and high-lighted the need for

further, more rigorous research.

Srinivasan and colleagues (2018) noted that literature on effects of equine therapy

in individuals with ASD has grown in recent times. Equine therapy is an alternative

multi-modal intervention that involves utilizing a horse to enhance core impairments

in ASD. Recent systematic reviews in this area have several limitations including

inclusion of populations other than ASD, assessment of a variety of animal-assisted

interventions other than equine therapy, and a failure to conduct quantitative

analyses to provide accurate effect size estimates. These investigators conducted

a focused systematic review to address these limitations. This review suggested

that equine therapy has beneficial effects on behavioral skills and to some extent

on social communication in ASD. The authors concluded that the evidence for

positive effects of equine therapy on perceptuo-motor, cognitive, and functional skills

is currently limited.

Down's Syndrome

De Miguel and colleagues (2018) noted that Down's syndrome is the main cause of

intellectual disability and the most common human genetic alteration. Motor

impairments are among the most important alterations presented by Down's

syndrome subjects. Hippotherapy is currently being used as a therapy to correct

those dysfunctions. These investigators review published literature on the effect of

hippotherapy on the gross motor function of people with Down's syndrome. The

bibliography in the following databases has been widely searched: CINAHL,

Medline, the Cochrane Library, PEDro, Scopus, and Web of Science. The journals

Fisioterapia and Cuestiones de Fisioterapia have also been consulted. The

electronic literature search strategy was addressed in 2 thematic fields: Down's

syndrome and hippotherapy. Studies selection was carried out following inclusion

and exclusion criteria and rejecting duplicate papers. That search included articles

published between 2000 and 2016. A total of 23 articles were found, 15 of which


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were discarded for different reasons, leaving 8 valid ones. The authors concluded

that there is no strong evidence on the improvement of gross motor function in

people with Down's syndrome after treatment with hippotherapy. They stated that

more studies with higher methodological quality are needed to verify the

effectiveness of hippotherapy in the treatment of gross motor function in subjects

with Down's syndrome.

Low Back Pain

In a randomized, single-blind, clinical trial, Rahbar and colleagues (2018) evaluated

the effects of a hippotherapy simulator on pain, disability, and range of motion

(ROM) of the spinal column in subjects with mechanical low back pain (LBP). A

total of 80 subjects were randomly assigned to either the control or intervention

groups. All subjects underwent routine physiotherapy. In addition, the intervention

group underwent hippotherapy with a hippotherapy simulator for 15 sessions, each

lasting 15 mins. Pain, disability, and ROM of the lumbar spinal column of the

subjects were measured in the first and last physiotherapy sessions respectively.

Improvement in pain intensity was higher in the hippotherapy simulator group over

the first 8 days of treatment (hippotherapy versus control point changes: Day 12: p

= 0.010; after treatment: p = 0.005). The hippotherapy simulator group had

significantly higher improvement in disability score in comparison to the control

group (p < 0.001); mean changes in the modified Schober test were not significant

(p = 0.423). The authors concluded that the hippotherapy simulator decreased pain

and disability in subjects with LBP; however, no additional improvement in lumbar

spine ROM was observed. This study used a hippotherapy simulator; its findings

need to be validated in the “real world” hippotherapy setting.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

HCPCS codes not covered for indications listed in the CPB:

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):

A88.1

F01.50 - F99


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F50.00 - F50.9

G80.0 - G80.9

H81.01 - H82.9

H83.2X1 -

H83.2X9

I60.00 - I69.998 Cerebrovascular diseases

M00.00 - M99.9

R25.0 - R29.9

R42

R48.0 - R48.9

R62.0 - R62.7

R63.2 Polyphagia

R68.0 - R68.89

S02.0XX+ -

S02.92X+

S02.0XXS -

S02.92XS

S06.0X0+ -

S06.9X9+

S06.0X0S -

S06.9X9S

S09.0X+ -


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T76.21 - T76.22

Z62.810

Z73.3

Z87.81

Z87.820

Z91.411

The above policy is based on the following references:

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4. National Institutes of Health (NIH), Office of Medical Applications of

Research (OMAR). The health benefits of pets. OMAR Workshop,

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movement therapy program on gait, energy expenditure, and motor


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function in children with spastic cerebral palsy: A pilot study. Dev Med

Child Neurol. 1998;40(11):754-762.

7. Benda W, McGibbon NH, Grant KL. Improvements in muscle symmetry in

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8. Hammer A, Nilsagard Y, Forsberg A, et al. Evaluation of therapeutic riding

(Sweden)/hippotherapy (United States). A single-subject experimental

design study replicated in eleven patients with multiple sclerosis.

Physiother Theory Pract. 2005;21(1):51-77.

9. Debuse D, Chandler C, Gibb C. An exploration of German and British

physiotherapists' views on the effects of hippotherapy and their

measurement. Physiother Theory Pract. 2005;21(4):219-242.

10. Casady RL, Nichols-Larsen DS. The effect of hippotherapy on ten children

with cerebral palsy. Pediatr Phys Ther. 2004;16(3):165-172.

11. Liptak GS. Complementary and alternative therapies for cerebral palsy.

Ment Retard Dev Disabil Res Rev. 2005;11(2):156-163.

12. Pichon Riviere A, Augustovski F, Alcaraz A, et al. Usefulness of

hippotherapy [summary]. Report ITB No. 28. Buenos Aires, Argentina:

Institute for Clinical Effectiveness and Health Policy (IECS); 2006.

13. Snider L, Korner-Bitensky N, Kammann C, et al. Horseback riding as

therapy for children with cerebral palsy: Is there evidence of its

effectiveness? Phys Occup Ther Pediatr. 2007;27(2):5-23.

14. Centre for Reviews and Dissemination (CRD). Horseback riding as therapy

for children with cerebral palsy: Is there evidence of its effectiveness?

Database of Abstracts of Reviews of Effectiveness (DARE). York, UK:

University of York; 2009.

15. Lechner HE, Kakebeeke TH, Hegemann D, Baumberger M. The effect of

hippotherapy on spasticity and on mental well-being of persons with

spinal cord injury. Arch Phys Med Rehabil. 2007;88(10):1241-1248.

16. Hamill D, Washington KA, White OR. The effect of hippotherapy on postural

control in sitting for children with cerebral palsy. Phys Occup Ther Pediatr.

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17. Sterba JA. Does horseback riding therapy or therapist-directed

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18. Centre for Reviews and Dissemination (CRD). Does horseback riding

therapy or therapist-directed hippotherapy rehabilitate children with


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cerebral palsy? Database of Abstracts of Reviews of Effectiveness (DARE).

York, UK: University of York; 2008.

19. McGibbon NH, Benda W, Duncan BR, Silkwood-Sherer D. Immediate and

long-term effects of hippotherapy on symmetry of adductor muscle

activity and functional ability in children with spastic cerebral palsy. Arch

Phys Med Rehabil. 2009;90(6):966-974.

20. McGee MC, Reese NB. Immediate effects of a hippotherapy session on gait

parameters in children with spastic cerebral palsy. Pediatr Phys Ther.

2009;21(2):212-218.

21. Oppenheim WL. Complementary and alternative methods in cerebral

palsy. Dev Med Child Neurol. 2009;51 Suppl 4:122-129.

22. Johnson CC. The benefits of physical activity for youth with developmental

disabilities: A systematic review. Am J Health Promot. 2009;23(3):157-167.

23. Shurtleff TL, Engsberg JR. Changes in trunk and head stability in children

with cerebral palsy after hippotherapy: A pilot study. Phys Occup Ther

Pediatr. 2010;30(2):150-163.

24. Bronson C, Brewerton K, Ong J, et al. Does hippotherapy improve balance

in persons with multiple sclerosis: A systematic review. Eur J Phys Rehabil

Med. 2010;46(3):347-353.

25. Zadnikar M, Kastrin A. Effects of hippotherapy and therapeutic horseback

riding on postural control or balance in children with cerebral palsy: A

meta-analysis. Dev Med Child Neurol. 2011;53(8):684-691.

26. Munoz-Lasa S, Ferriero G, Valero R, et al. Effect of therapeutic horseback

riding on balance and gait of people with multiple sclerosis. G Ital Med Lav

Ergon. 2011;33(4):462-467.

27. Whalen CN, Case-Smith J. Therapeutic effects of horseback riding therapy

on gross motor function in children with cerebral palsy: A systematic

review. Phys Occup Ther Pediatr. 2012;32(3):229-242.

28. Tseng SH, Chen HC, Tam KW, et al. Systematic review and meta-analysis of

the effect of equine assisted activities and therapies on gross motor

outcome in children with cerebral palsy. Disabil Rehabil. 2013;35(2):89-99.

29. Manikowska F, Jozwiak M, Idzior M, et al. The effect of a hippotherapy

session on spatiotemporal parameters of gait in children with cerebral

palsy - pilot study. Ortop Traumatol Rehabil. 2013;15(3):253-257.

30. Beinotti F, Christofoletti G, Correia N, Borges G. Effects of horseback riding

therapy on quality of life in patients post stroke. Top Stroke Rehabil.

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31. Ajzenman HF, Standeven JW, Shurtleff TL. Effect of hippotherapy on motor

control, adaptive behaviors, and participation in children with autism

spectrum disorder: A pilot study. Am J Occup Ther. 2013;67(6):653-663.

32. O'Haire ME. Animal-assisted intervention for autism spectrum disorder: A

systematic literature review. J Autism Dev Disord. 2013;43(7):1606-1622.

33. Homnick DN, Henning KM, Swain CV, Homnick TD. Effect of therapeutic

horseback riding on balance in community-dwelling older adults with

balance deficits. J Altern Complement Med. 2013;19(7):622-626.

34. Dezutti JE. Eating disorders and equine therapy: A nurse's perspective on

connecting through the recovery process. J Psychosoc Nurs Ment Health

Serv. 2013;51(9):24-31.

35. Park ES, Rha DW, Shin JS, et al. Effects of hippotherapy on gross motor

function and functional performance of children with cerebral palsy.

Yonsei Med J. 2014;55(6):1736-1742.

36. Cerulli C, Minganti C, De Santis C, et al. Therapeutic horseback riding in

breast cancer survivors: A pilot study. J Altern Complement Med. 2014;20

(8):623-629.

37. Nurenberg JR, Schleifer SJ, Shaffer TM, et al. Animal-assisted therapy with

chronic psychiatric inpatients: Equine-assisted psychotherapy and

aggressive behavior. Psychiatr Serv. 2015;66(1):80-86.

38. Del Rosario-Montejo O, Molina-Rueda F, Munoz-Lasa S, Alguacil-Diego IM.

Effectiveness of equine therapy in children with psychomotor impairment.

Neurologia. 2015;30(7):425-432.

39. Anestis MD, Anestis JC, Zawilinski LL, et al. Equine-related treatments for

mental disorders lack empirical support: A systematic review of empirical

investigations. J Clin Psychol. 2014;70(12):1115-1132.

40. Dewar R, Love S, Johnston LM. Exercise interventions improve postural

control in children with cerebral palsy: A systematic review. Dev Med Child

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serial]. Waltham, MA: UpToDate; reviewed November 2015.

42. Lindroth JL, Sullivan JL, Silkwood-Sherer D. Does hippotherapy effect use of

sensory information for balance in people with multiple sclerosis?

Physiother Theory Pract. 2015;31(8):575-581.

43. Earles JL, Vernon LL, Yetz JP. Equine-assisted therapy for anxiety and

posttraumatic stress symptoms. J Trauma Stress. 2015;28(2):149-152.


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44. Guerino MR, Briel AF, Araújo Md. Hippotherapy as a treatment for

socialization after sexual abuse and emotional stress. J Phys Ther Sci.

2015;27(3):959-962.

45. Lee N, Park S, Kim J. Effects of hippotherapy on brain function, BDNF level,

and physical fitness in children with ADHD. J Exerc Nutrition Biochem.

2015;19(2):115-121.

46. Jang B, Song J, Kim J, et al. Equine-assisted activities and therapy for

treating children with attention-deficit/hyperactivity disorder. J Altern

Complement Med. 2015;21(9):546-553.

47. Krull KR. Attention deficit hyperactivity disorder in children and

adolescents: Overview of treatment and prognosis. UpToDate [online

serial]. Waltham, MA: UpToDate; reviewed November 2015.

48. Lee PT, Dakin E, McLure M. Narrative synthesis of equine-assisted

psychotherapy literature: Current knowledge and future research

directions. Health Soc Care Community. 2016 May;24(3):225-246.

49. Yoo JH, Oh Y, Jang B, et al. The effects of equine-assisted activities and

therapy on resting-state brain function in attention-deficit/hyperactivity

disorder: A pilot study. Clin Psychopharmacol Neurosci. 2016;14(4):357

364.

50. Erdman EA, Pierce SR. Use of hippotherapy with a boy after traumatic

brain injury: A case study. Pediatr Phys Ther. 2016;28(1):109-116.

51. Rigby BR, Grandjean PW. The efficacy of equine-assisted activities and

therapies on improving physical function. J Altern Complement Med.

2016;22(1):9-24.

52. Kern-Godal A, Brenna IH, Arnevik EA, Ravndal E. More than just a break

from treatment: How substance use disorder patients experience the

stable environment in horse-assisted therapy. Subst Abuse. 2016; 10:99

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53. McDaniel Peters BC, Wood W. Autism and equine-assisted interventions: A

systematic mapping review. J Autism Dev Disord. 2017;47(10):3220-3242.

54. Lee N, Park S, Kim J. Hippotherapy and neurofeedback training effect on

the brain function and serum brain-derived neurotrophic factor level

changes in children with attention-deficit or/and hyperactivity disorder. J

Exerc Nutrition Biochem. 2017;21(3):35-42.

55. Vermohlen V, Schiller P, Schickendantz S, et al. Hippotherapy for patients

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HIPPO). Mult Scler. 2018;24(10):1375-1382.


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56. Oh Y, Joung YS, Jang B, et al. Efficacy of hippotherapy versus

pharmacotherapy in attention-deficit/hyperactivity disorder: A randomized

clinical trial. J Altern Complement Med. 2018;24(5):463-471.

57. Srinivasan SM, Cavagnino DT, Bhat AN. Effects of equine therapy on

individuals with autism spectrum disorder: A systematic review. Rev J

Autism Dev Disord. 2018;5(2):156-175.

58. De Miguel A, De Miguel MD, Lucena-Anton D, Rubio MD. Effects of

hypotherapy on the motor function of persons with Down's syndrome: A

systematic review. Rev Neurol. 2018;67(7):233-241.

59. Rahbar M, Salekzamani Y, Jahanjou F, et al. Effect of hippotherapy

simulator on pain, disability and range of motion of the spinal column in

subjects with mechanical low back pain: A randomized single-blind clinical

trial. J Back Musculoskelet Rehabil. 2018;31(6):1183-1192.

60. Marquez J, Weerasekara I, Chambers L. Hippotherapy in adults with

acquired brain injury: A systematic review. Physiother Theory Pract. 2018

Jul 17:1-12 [Epub ahead of print].

61. Munoz-Lasa S, Lopez de Silanes C, Atín-Arratibel MA, et al. Effects of

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58.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in

private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible

for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to

change.

Copyright © 2001-2019 Aetna Inc.

http://qawww.aetna.com/cpb/medical/data/100_199/0151_draft.html 04/25/2019 Proprietary


AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0151 Hippotherapy

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania revised 02/14/2019

http://www.aetnabetterhealth.com/pennsylvania

prior authorization review panel mco policy submission a ... · cerebral palsy (cp) also known as...

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