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Abstract
Objective: To examine whether hippotherapy has a clinically significant effect on gross motor function in
children with cerebral palsy (CP).
Design: Randomized controlled trial.
Setting: Outpatient therapy center.
Participants: Ninety-two children with CP, aged 410 years, presenting variable function (Gross Motor
Function Classification System [GMFCS] levels IIV).
Intervention: Hippotherapy (30 minutes twice weekly for 8 consecutive weeks).
Outcome measures: Gross Motor Function Measure (GMFM)-88, GMFM-66, and Pediatric Balance Scale.
Results: Pre- and post-treatment measures were completed by 91 children (45 in the intervention group and 46
in the control group). Differences in improvement on all three measures significantly differed between groups
after the 8-week study period. Dimensions of GMFM-88 improved significantly after hippotherapy varied by
GMFCS level: dimension E in level I, dimensions D and E in level II, dimensions C and D in level III, and
dimensions B and C in level IV.
Conclusion: Hippotherapy positively affects gross motor function and balance in children with CP of various
functional levels.
1
Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular and Stroke Institute,
Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
2
Samsung RD Center, Samsung Equestrian Team, Gyeonggi-do, Republic of Korea.
*Present affiliation: Department of Rehabilitation, Seoul Rehabilitation Hospital, Seoul, Republic of Korea.
15
16
KWON ET AL.
Participants
Treatment
Hippotherapy
(n = 45)
Control
(n = 46)
20 (44)
5.7 1.9
29 (63)
5.9 1.8
12
12
11
10
12
12
12
10
41
2
2
4 (9)
6 (13)
18.7 5.4
107.7 11.6
3.3 1.3
43
2
1
6 (13)
7 (15)
19.9 4.8
110.1 10.0
3.1 1.5
17
18
KWON ET AL.
Table 2. Changes in Gross Motor Function Measures Between Hippotherapy and Control Groups
Hippotherapy (n = 45)
Control (n = 46)
I
GMFM-66
GMFM-88 total
A
B
C
D
E
79.2 8.8
94.2 5.4
100.0 0.0
100.0 0.0
99.2 2.7
92.3 10.0
83.2 13.3
83.1 9.7
95.8 4.7
100.0 0.0
100.0 0.0
99.6 1.4
94.2 6.4
88.0 13.5
0.01
0.01
0.99
0.99
0.32
0.33
0.01
81.8 7.5
95.4 4.6
100.0 0.0
100.0 0.0
99.0 2.4
92.3 6.5
87.8 12.3
82.3 7.5
95.7 4.2
100.0 0.0
100.0 0.0
99.6 0.9
92.1 7.0
88.8 11.3
0.26
0.14
0.99
0.99
0.18
0.29
0.12
0.01
0.05
0.99
0.99
0.76
0.18
0.01
GMFM-66
GMFM-88 total
A
B
C
D
E
64.6 8.6
81.0 10.3
100.0 0.0
99.4 1.5
91.9 10.2
70.3 19.3
51.7 23.6
67.4 8.8
84.3 9.8
100.0 0.0
99.9 0.5
95.2 8.7
76.9 16.1
57.8 24.2
< 0.01
< 0.01
0.99
0.18
0.02
< 0.01
< 0.01
62.4 5.0
79.4 7.3
100.0 0.0
99.3 2.4
92.7 6.2
69.0 14.8
45.9 16.1
62.8 5.5
80.1 7.7
100.0 0.0
100.0 0.0
95.2 4.5
67.1 21.0
47.5 16.6
0.46
0.24
0.99
0.32
0.03
0.68
0.26
< 0.01
0.01
0.99
0.80
0.63
0.01
0.03
GMFM-66
GMFM-88 total
A
B
C
D
E
IV
GMFM-66
GMFM-88 total
A
B
C
D
E
Total
GMFM-66
GMFM-88 total
A
B
C
D
E
51.7 2.6
62.2 5.1
99.3 2.3
96.7 4.7
75.4 9.8
32.7 13.8
15.5 3.9
54.0 2.3
66.7 3.9
100.0 0.0
98.9 2.5
82.7 8.3
44.8 10.7
18.9 6.6
< 0.01
< 0.01
0.32
0.39
0.01
0.01
0.02
53.8 4.1
66.7 6.5
100.0 0.0
97.9 3.9
81.5 7.7
40.8 15.9
22.6 11.7
54.2 4.1
67.0 6.7
100.0 0.0
98.6 3.8
81.9 8.9
41.0 17.7
22.5 10.6
0.44
0.86
0.99
0.11
0.89
0.50
0.72
0.01
0.01
0.74
0.59
0.01
0.04
0.18
44.3 4.6
47.7 9.9
98.4 3.2
75.8 16.6
53.8 24.7
10.0 9.0
5.3 6.0
46.03 4.1
51.3 8.8
99.0 3.1
81.5 13.5
60.5 22.4
13.8 8.7
7.2 5.8
0.01
0.01
0.18
0.01
0.01
0.03
0.07
45.0 6.5
50.2 10.7
97.8 6.8
83.8 19.3
56.9 20.2
12.6 13.7
5.6 5.1
44.9 6.6
50.6 11.8
97.8 6.8
84.8 19.2
55.0 23.0
12.3 14.4
7.4 5.9
0.35
0.52
0.99
0.34
0.40
0.99
0.18
< 0.01
< 0.01
0.48
0.01
< 0.01
0.12
0.44
60.8 14.9
72.7 19.2
99.5 1.9
93.9 12.5
81.7 21.6
54.1 34.2
41.0 34.1
63.5 15.8
75.7 18.3
99.8 1.5
95.6 9.8
85.6 19.0
59.7 32.5
45.1 35.4
< 0.01
< 0.01
0.11
< 0.01
< 0.01
< 0.01
< 0.01
61.4 14.8
73.9 17.9
99.5 3.2
95.7 11.0
83.6 18.8
55.5 32.2
42.0 33.2
61.8 15.0
74.3 18.1
99.5 3.2
96.3 10.7
84.2 20.4
54.9 33.2
43.0 33.0
0.26
0.26
0.99
0.05
0.15
0.82
0.15
< 0.01
< 0.01
0.08
0.03
< 0.01
< 0.01
< 0.01
II
III
GMFM-66 values are expressed as mean standard deviation. GMFM-88 values are expressed as mean percentage standard deviation.
a
Paired t-test or Wilcoxon signed-rank test to compare between preintervention and postintervention within groups.
b
Independent t-test or Mann-Whitney test to compare changes between hippotherapy group and control group.
GMFCS, Gross Motor Function Classification System; GMFM, Gross Motor Function Measure; A, lying and rolling; B, sitting; C, crawling and
kneeling; D, standing; E, walking, running, and jumping.
This study appears to be the first RCT showing the beneficial effects of hippotherapy on gross motor function in
children with CP. Children undergoing hippotherapy had
significant improvements in GMFM scores (both GMFM-66
and -88) and PBS scores. The strengths of the study were the
strict inclusion and exclusion criteria, relatively large sample size, and inclusion of children with various functional
levels. These factors enable analysis of the functional dimensions showing main effect of hippotherapy according to
patients functional levels.
19
Control (n = 46)
47.2 6.4
32.6 12.9
11.1 7.3
4.0 4.6
25.1 18.9
50.5 6.1
37.3 12.2
16.2 6.3
7.0 4.2
28.9 18.8
< 0.01
< 0.01
0.01
0.01
< 0.01
48.8 6.6
31.6 11.0
18.2 9.4
5.2 5.2
26.9 18.3
49.2 6.1
31.6 12.0
18.5 8.5
6.0 7.3
27.1 18.3
0.16
0.34
0.50
0.41
0.33
p-Value for
difference between
groupsb
< 0.01
< 0.01
0.01
0.01
< 0.01
20
KWON ET AL.
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