At the time this policy was created, the majority of the literature regarding hippotherapy consisted of small case series, most of which were published in German literature. One small randomized study of 19 patients was identified that reported no significant effects in the majority of outcome measures.
Literature searches of the MEDLINE® database have been performed periodically since 2000; the most recent search was conducted in May 2011. Several systematic reviews on hippotherapy have been published recently. One of the systematic reviews concluded that there was evidence from one or more randomized controlled trials (RCTs) of fair quality studies that a short intervention of hippotherapy is effective for treating muscle symmetry in the trunk and hip when compared with static sitting. The review found three quasi-experimental studies with positive results for gross motor function and functional performance in the home and community. Another systematic review reported that five of six moderate quality studies (small sample sizes and lack of a control non-riding group) found improved gross motor function in children with cerebral palsy (CP). A systematic review from 2009 concluded that strong evidence indicates that children and adolescents with developmental disabilities derive health benefits from participation in group exercise programs, treadmill training, or therapeutic riding/hippotherapy; however, three of the studies included in the review showed that therapeutic horseback riding is no more effective than other therapies for improving muscle tone in children with CP and that it is no more effective than no intervention for posture, self-esteem, and global behavior.
Hippotherapy for patients with multiple sclerosis (MS) was addressed in a 2010 systematic review of three studies. A case control study with nine subjects by Silkwood-Sherer and Warmbier included in the review is discussed below. Each of the other studies, both case series, had 11 subjects. The authors concluded that the studies provided emerging, but limited, evidence that hippotherapy improves balance in persons with MS acknowledging limitations of small sample size, lack of randomization, especially given the variable nature of MS, and lack of controls in two studies.
Examples of the primary literature include a study by Sterba and colleagues, who reported on the outcomes of horseback riding in 17 subjects with CP. Gross motor function measurements were assessed before and after a once weekly horseback riding program for 18 weeks. Gross motor function total scores improved by 7.6% after 18 weeks, returning to baseline six weeks after the program ended. In another study, Benda and colleagues used surface electromyography to assess outcomes in 15 children with CP who were randomly assigned to either horseback riding or to sitting stationary astride a barrel. The authors reported that the hippotherapy group showed greater symmetry of muscle activity. The clinical significance of this outcome is uncertain. Another small study of 12 patients with spastic spinal cord injury found hippotherapy to result in short-term improvements in spasticity and well-being. A study of nine patients with MS found that 14 weekly sessions of hippotherapy improved balance in comparison with a control group of six patients.
In 2009, a randomized trial was published that included 72 children (85% of the 99 families enrolled) aged 4–12 years with CP who completed a 10-week session of hippotherapy with pre- and post-treatment assessments. Randomization to hippotherapy or a waiting-list control with usual therapy was stratified by age and level of gross motor function. The physiotherapist assessor was blinded to the randomization, and the participants were asked not to mention if they had completed the intervention at the time of the assessment. No differences between the hippotherapy and control groups were found for functional status (therapist-assessed) or child-reported quality of life. Minor differences were found in parent-reported quality of life and child health scores in the domain of family cohesion. Overall, therapeutic horseback riding was not found to have a clinically significant impact on children with CP.
McGibbon et al. investigated the impact of hippotherapy on symmetry of adductor muscle during walking. In Phase I of the trial, they randomly assigned 47 children aged 4-16 years with spastic CP to receive a single 10-minute session of either hippotherapy or barrel sitting. Adductor muscle symmetry was measured before and after the session. The hippotherapy group demonstrated a statistically significant difference in adductor symmetry after this single intervention. Six of the children went on to participate in Phase II, a 36-week study (12 weeks without hippotherapy [baseline], 12 weeks of weekly intervention, and 12 weeks without intervention). Four of six subjects showed improved symmetry during walking after 12 weeks of intervention, and improvement was maintained after 12 more weeks. All six children improved on the Gross Motor Function Measure-66, and one child began walking without a walker after four weeks of hippotherapy. Five children improved in at least one area of Self-Perception Profiles. The authors note a number of limitations of the study including small sample size in Phase II, the diversity of subjects in the distribution of their spasticity, and the inclusion of children with mixed characteristics.
A series of 11 children aged 5-13 years with CP demonstrated improved trunk/head stability and upper extremity reaching/targeting after 12 weekly 45-minute sessions of hippotherapy. Results were compared with those of eight children without disability who did not receive an intervention. The impact of hippotherapy versus other forms of therapy directed to trunk/head stability and upper extremity reaching cannot be determined from this study.
Literature on hippotherapy is limited, consisting primarily of small uncontrolled case series. In the largest randomized trial conducted to date (72 children), hippotherapy was found to have no clinically significant impact on children with cerebral palsy. The literature at this time does not support the conclusion that hippotherapy is as effective as the existing alternatives and does not demonstrate improvement in net health outcome. Therefore, the treatment is considered investigational.
A search of peer reviewed literature through May 2011 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.