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Cerebral Palsy and Therapeutic
Riding
Reprinted from NARHA
Strides magazine, October 1995 (Vol. 1, No. 1)
Cerebral palsy is a
condition caused by damage to the brain, usually occurring before, during or
shortly following birth. "Cerebral" refers to the brain and
"palsy" refers to a disorder of movement or posture. Cerebral palsy
is neither progressive or communicable. It is also not curable, although
education, therapy and applied technology can help people with cerebral palsy
lead productive lives.
The causes of cerebral
palsy include illness during pregnancy, premature delivery or lack of oxygen to
the baby. Head injuries can also lead to the less common acquired cerebral
palsy. Between 500,000 and 700,000 Americans have some
degree of cerebral palsy. There are three main types of cerebral palsy:
spastic-stiff and difficult movement, athetoid-involuntary and uncontrolled
movement, and ataxic-disturbed sense of balance and depth perception.
Cerebral palsy is
characterized by an inability to fully control motor function. Depending on
which part of the brain has been damaged and the degree of involvement of the
central nervous system, one or more of the following may occur: spasms; tonal
problems; involuntary movement; disturbance in gait and mobility; seizures;
abnormal sensation and perception; impairment of sight, hearing or speech; and
mental retardation.
From Fact Sheet No. 2, National Information Center for Children and Youth
with Disabilities, Washington, DC, 1-800-695-0285.
Medical Considerations for Therapeutic Riding
People with cerebral palsy
have difficulty coordinating and producing purposeful, functional movements.
Some people have too much muscle tone, such as those with spasticity. Their
muscles hold their limbs in rather stiff postures and it is difficult to relax
these muscles. Thus, the rider cannot move his limbs easily except in the
direction the spastic muscles pull. Other types of tone abnormalities include
fluctuating tone, as seen in athetoid cerebral palsy and hypotonia, or too
little tone.
Tone is an elusive
thing to quantify. Using treatment techniques to temporarily make tone more
normal does not suddenly result in normal, coordinated movement patterns. In
fact, increased tone may be the result of pathologic weaknesses in other muscle
groups coupled with the normal human desire to move. Muscle fibers are known to
change over time, resulting in increasing, age-related difficulty in
maintaining posture. It may be true that abnormal tone, especially spasticity,
is an abnormal response to normal sensation, such as touch and movement
sensation.
Orthopedic problems
occur in people with cerebral palsy, perhaps partly because of the interaction
of the abnormal neurologic system with the muscles, joints and soft tissues.
The abnormal, usually asymmetrical pull of spastic muscles coupled with lack of
normal movement and weightbearing can result in progressive scoliosis and
dislocating hips. Other joints, such as wrists, elbows, knees and ankles, can
lose flexibility and range of motion.
Despite these factors,
the rhythmic motion, shape, warmth and inherently motivating quality of the
horse can be helpful to people with cerebral palsy throughout their lives.
Therapeutic riding can facilitate cognitive and sensorimotor development in
childhood, help develop a sense of responsibility, self-confidence and fair
play in adolescence and provide life-long recreation and sport. It can do all
this while stimulating the good posture, balance and flexibility needed for
functional independence off the horse.
Riding works best for
maintaining range of motion and joint flexibility if a well-aligned, correct
posture on the horse is always a goal. There is no
substitute for a horse with good, symmetric movement. Many riders with cerebral
palsy can achieve normal balance, posture and movement on a horse if the
instructor takes a long, slow approach, focusing on posture and alignment.
These are not "therapy" goals. Good posture, hands-free balance and a
"following seat" are prerequisites to riding with ease and comfort
for the rider and the horse.
Riding sessions for
people with cerebral palsy should never result in increased tone and
discomfort. Ask the rider (family member or personal care assistant) how he
feels after the session, when he's at home. Are the muscles relaxed or tight?
If spasticity is worse after the session, decrease the amount of stimulation.
Focus on less impulsion, more stretching and relaxation, more straight-line
work and fewer circles. Use a horse with a wider base and a smoother walk.
Offer an opportunity to sit and rest after dismounting. Try a saddle with a
suede or synthetic cover so the rider's seat and legs will stick to the saddle
better, which will increase his stability and decrease stress.
Recent articles by Ruth
DismukeBlakely, SLP/CCC, in AHA News and NARHA News, indicate that the movement
of the horse in hippotherapy sessions can increase the quantity, quality and
volume of vocalization in the rider. For children with cerebral palsy, the
horse is a wonderful motivation for speech, while the horse's movement can
improve the coordination of breathing, swallowing and sound production. The
horse naturally motivates children with cerebral palsy to move, explore and
touch. Using the horse as a large, gentle, rhytiunic and predictably moving
gross-motor platform, where the child is invited and assisted to explore, can
be even more useful than learning to ride. Instructors can encourage movement
and hopefully "disconnect" it from the fear of failure. The result is
self-confidence and courage on and off the horse.
The rider with cerebral
palsy benefits from advance preparation in many areas. Stretching before
getting on the horse, as recommended by a physical therapist, can reduce the
warm-up time on the horse. When practicing walk-halt transitions, the
instructor or therapist can use: "Prepare to walk", "Prepare to
halt", "Get ready to whoa." These preparatory phrases allow the
rider to prepare or "set" the posture needed to accomplish the task.
If the rider has
decreased or asymmetric range of motion at the hips and knees, select the horse
that accommodates the problem so the rider can sit easily in good alignment
without being pulled to one side. If the hip is partially dislocated
(subluxed), the type of horse is essential. The lack of range of motion,
spasticity, the horse's natural shape and movement can all potentially worsen
the subluxation. In general, the rider with cerebral palsy who has orthopedic
problems at the hips or spine may benefit greatly from consultation with a
physical therapist who can assist the instructor in creating an appropriate
riding program.
-Liz Baker, PT, NARHA
Medical Committee Chairman
A Review of Relevant Literature
Information on the use
of the horse as a treatment modality for patients with neurological disorders
was first published in a 1870 thesis by Chassaine, who was studying at the
University of Paris. It was not until the 1970s that articles related to
therapy for cerebral palsy using therapeutic riding started to appear in
scientific literature on a regular basis. These early publications (in German)
lacked many of the details that are necessary to evaluate the effects of
treatment or they were general reviews of observed effects (subjective
evaluation). Horster et al (1976) gave a general review of hippotherapy and
riding therapy and their use. The study concluded that the psychological
benefit was important because patients maintained their motivation.
Improvements were noted in coordination, muscle tone and reactions.
A similar report was
used to report results of an opinion survey on the possibilities of improving
motor functions of children with cerebral palsy with the help of therapeutic
riding (Feldkamp, 1979). The consensus was that some difficulties could be
helped with therapeutic riding but some key problems, such as spasticity, would
not be helped. Again the psychological benefits (motivation) were reported.
Satter (1978) reported
the general observations of children in Austria who were treated for five
years. Contrary to the opinions expressed in Feldkamp's article, Satter reported
the ability to normalize muscle tone and an improvement in body control,
coordination of movements, rotation and orientation in space. Equilibrium and
righting reactions, symmetry, head and postural control and spasticity of
adductor groups could be helped by the three-dimensional movements of the
horse. He also noted the positive effect on motivation.
The report by
Tauffkirchen (1977) is more specific in treatment methods. The various
positions and duration of each treatment (maximum 15-20 minutes) were given. An
improvement in posture, tone, inhibition of pathological movement patterns,
facilitation of normal automatic reactions and promotion of sensimotor
perceptions was achieved. Also, the author commented on the positive motivation
factor.
Bertoti's report (1988)
is the most complete report reviewed and is objective. In this study on
posture, 27 children (spastic diplegia or quadraplegia) were followed in a
repeated-measures design: pretest, 10-week period of no riding, pretest 2, 1 0
weeks of riding and post-test. Thus, each child served as his own control. They
rode twice weekly for one-hour sessions. A specific protocol was followed for
each session and for posture evaluation. The sessions resulted in decreased
spasticity, improved weight shift, improved balance and rotational skills and
improved postural control. In addition to the objective measurements, other
subjective improvements were noted, such as improved self-confidence; less fear
of movement and position change; decreased extensor muscle hypertonus and hip
adductor muscle spasticity; improved movements for sitting, walking and stance;
and improved weight-bearing. The study demonstrated that therapeutic riding can
be a valuable treatment modality for children with cerebral palsy.
This report was
supported by Campbell's 1990 report. In contrast, Lacey (1993) reported no
beneficial effect on posture for three and four-year-olds receiving therapy for
six weeks.
In summary, additional
studies need to be conducted that will address the interactions of intensity of
the physical therapy, the duration of each therapy session, the frequency of
therapy and the duration of the treatment program. Currently, it appears that
twice weekly sessions of at least 30 minutes for a minimum of 10 weeks might be
the best therapy protocol.
References:
Bertoti, D. 1988.
"Effect of Therapeutic Horseback Riding on Posture in Children with
Cerebral Palsy," Joumal Physical Therapy, 8 (10), 1505-1512.
Campbell, S. 1990.
"Efficacy of Physical Therapy in Improving Postural Control in Cerebral
Palsy." Pediatric Physical Therapy, 90 (203), 135-140.
Feldkamp, M. 1979.
"Motor Goals of Therapeutic Horseback Riding For Cerebral Palsied
Children." Rehabilitation, 18 (2),56-61.
Fetterf, Ph.D., PT, L. "Cerebral Palsy: Contemporary Treatment
Concepts" from Contemporary Management of Motor Control Problems:
Proceedings of the II Step Conference, 1991. Foundation for Physical Therapy,
Alexandria, VA.
Horster, R., Van Horde,
H. and Riegner, C. 1976. "Hippo-Therapy and Therapeutic Horseback Riding
in the Treatment of Children and Adolescents with Cerebral Pareses and
Dysmelias," Festschrift Fur Allgemeinmedizier, 52 (1), 15-21.
Lacey, S.K. 1993. "The Effects of Therapeutic Horseback Riding
on Posture." Master Abstracts International, 31 (4), 1777.
Rieger, C. 1978.
"Scientific Principles of Hippo- and Riding- Therapy-A Compilation of
Study Results." Rehabilitation, 17 (1),15-19.
Rieger, C., Eltze, J., Ofteringer, K., and Hengst, C. 1974.
"Therapeutic Value of Horseback Riding, Comments on Riding. Therapy in the
Treatment of Cerebral Motor Disorders," Offentl Gesundheirsews, 36 (2),
130-132.
Satter, L. 1977.
"Horseback Riding Therapy for Children With Movement Malfunction
Considering Especially Cerebral Palsy Patients," Pediatric and Padologie,
13, 337-334.
Tauffkirchen, E. 1978.
"Hippotherapy-A Supplementary Treatment for Motion Disturbances Caused by
Cerebral Palsy," Pediatric and Padologie, 13 (4), 405-1 I.
-J. Warren Evans, Ph.D., NARHA Research Committee Chairman