THE EFFECTS OF HIPPOTHERAPY ON THE GROSS MOTOR …fgcu.digital.flvc.org/islandora/object/fgcu:30767/datastream/OBJ/vie… · Doctorate of Physical Therapy By Tara Lacey and Rachael

HIPPOTHERAPY FOR CHILDREN WITH CEREBRAL PALSY

THE EFFECTS OF HIPPOTHERAPY ON THE GROSS MOTOR FUNCTIONAL

ABILITIES OF CHILDREN WITH CEREBRAL PALSY USING CLINICAL

OUTCOME MEASURES AND PARENT/GUARDIAN REPORTED OUTCOMES.

Independent Research

Presented to

The Marieb College of Health and Human Services

Florida Gulf Coast University

In Partial Fulfillment

of the Requirement for the Degree of

Doctorate of Physical Therapy

By

Tara Lacey and Rachael Tutunick

2018

HIPPOTHERAPY AND CEREBRAL PALSY

APPROVAL SHEET

This research study is submitted in partial

fulfillment of the requirements for the degree of

Doctor of Physical Therapy

Tara Lacey

Rachael Tutunick

Approved: April 24, 2018

Ellen Donald, PhD, PT

Committee Chair

Sarah Fabrizi, PhD, OTR/L

Committee Member

The final copy of this research study has been examined by the signatories, and we find that both the content and the

form meet acceptable presentation standards of scholarly work in the above mentioned discipline.

HIPPOTHERAPY AND CEREBRAL PALSY

Acknowledgements

We would like to thank several people for assisting us in the development and

completion of this scholarly paper. Firstly, we would like to thank our committee, Dr.

Ellen Donald PhD, PT and Dr. Sarah Fabrizi PhD, OTR/L who have provided us with

great insight and guidance. Secondly, we appreciate the staff at Bit-By-Bit Medical

Therapeutic Riding Center for providing us the opportunity to perform our research at

their facility and assisting us with completion of the protocol. Lastly, we would like to

thank the participants and their parents/guardians for being so gracious with their time

and supporting our research.

HIPPOTHERAPY AND CEREBRAL PALSY 4

Table of Contents

Abstract 6

Introduction 8

Hippotherapy 9

Literature Review 10

Common Limitations 15

Discussion of Implications 16

Purpose and Research Questions 17

Methods 19

Facility Information 19

Bit-By-Bit Medical Therapeutic Riding Center Hippotherapy Protocol 21

Research Protocol 21

Subject Recruitment 21

Procedures 23

Data Collection 24

Data Analysis 25

Results 26

Discussion 30

Research Question A 31

Research Questions B and C 32

Conclusion 33

References 35

Appendix A. Gross Motor Function Measure 38

Appendix B. Parent/Guardian Reported Outcome Survey 44


Appendix C. Letter of Agreement 46

Appendix D. Bit-By-Bit Medical Therapeutic Riding Center Therapists 47

Appendix E. Bit-By-Bit Medical Therapeutic Riding Center Registration Packet 48

Appendix F. Informed Consent 59

Appendix G. Informed Assent 62

Appendix H. HIPAA Waiver 63

Appendix I. Recruitment Flyer 66

Appendix J. Screening Tool 67

Appendix K. Child Information Sheet 68

Appendix L. Research Protocol Flow Chart 71

Appendix M. Attendance Records 73


Abstract

PURPOSE: The purpose of this research study is to investigate whether

hippotherapy influences gross motor functional outcomes in children between three and

thirteen years of age, with a medical diagnosis of cerebral palsy, and a GMFCS level of

III or IV. METHODS: A pre-post quantitative, quasi-experimental design was utilized to

evaluate seven eligible participants using the Gross Motor Function Measure (GMFM), a

Child Information Sheet, and a Parent/Guardian Reported Outcome Survey over a ten-

week intervention period. Participants for the study were recruited through the Bit-By-Bit

Medical Therapeutic Riding Center hippotherapy program on a voluntary basis.

DATA ANALYSIS: Descriptive statistics were generated for the group of

participants. In order to determine differences in motor function, change scores were

generated for each dimension in the GMFM and for the resulting total score of the

GMFM. A paired-t-test was used to compare the mean pre- and post-intervention GMFM

scores from each dimension as well as total scores with a p≤ 0.05 level of significance.

Correlation coefficients were calculated to determine if a relationship existed between the

results of the GMFM and the parent/guardian outcome surveys. Finally, a between-

groups analysis was conducted to investigate whether participant age, gender, prior use of

Botox, or GMFCS level had any relationship to the results of the study.

RESULTS: For gross motor function, there was typically an increase in the

change scores for each dimension and for the total scores, as initially hypothesized by the

researchers. A statistically significant (p≤0.05) positive change was found to have

occurred in dimension B (sitting) and the total change score over a duration of ten weeks.

The parent/guardian reported outcomes were largely positive regardless of the size of the

changes identified by the GMFM. Additionally, the parents/guardians of six out of seven


of the participants reported that hippotherapy had an overall positive impact on their

child’s quality of life.

CONCLUSIONS: Results of this study provide preliminary and limited

quantitative evidence that hippotherapy improves gross motor function in children with

CP. The Parent/Gaurdian Reported Outcome Survey supports the benefits of

participation in hippotherapy as it indicates parents/guardians of children with CP

percieve benefits both in motor function and quality of life as a result of the intervention.

Keywords: CP, cerebral palsy, hippotherapy, equine-assisted therapy, animal-

assisted therapy, horses, gross motor function, GMFM, gross motor function measure,

GMFCS, gross motor function classification system, intervention, pediatric, child,

children, physical therapy, physiotherapy, quality of life


Introduction

Cerebral palsy (CP) is defined as a group of disorders that affect the development

of movement and posture due to injury or abnormal development in the fetal or infant

brain. Cerebral palsy is a well-documented disorder that affects two to three children out

of every thousand births and is the leading cause of physical disability among children in

the United States (Frank, McCloskey, & Dole, 2011; Gannotti et al., 2016; Jeffries, Fiss,

McCoy, & Bartlett, 2016). Children with CP experience both primary impairments (those

apparent at the time of diagnosis) and secondary impairments (those occurring over

time). Common primary impairments include abnormalities in muscle tone, postural

stability, motor function, and coordination. Common secondary impairments include

decreased range of motion, force production, and endurance (Jeffries, Fiss, McCoy, &

Bartlett, 2016). Additionally, the development of instinctive postural reactions of righting

imbalance and self-protection may be delayed or never develop in affected children

(Casady & Nichols-Larsen, 2004).

According to two recent studies, participation and health related quality of life is

lower in children with CP than compared to children without disabilities (Law et al.,

2006; Murphy & Carbone, 2008). Identifying effective rehabilitation services for children

with CP associated with positive clinical and patient-reported outcomes is a national

priority as finding a way to remediate the above differences is essential to reaching the

long-term goal of any intervention for children with CP which is to help them achieve

their maximum capacity and become healthy, dynamic, and independent members of

society (Frank, McCloskey, & Dole, 2011).


Hippotherapy

Horseback riding has been described in medical literature since the second

century as an advantageous form of therapy for patients with various disabilities (Sterba,

Rogers, France, & Vokes, 2002). As defined by the American Hippotherapy Association

(AHA), hippotherapy is part of a program integrated with other therapies that uses the

unique movement of a horse to assist in achieving specific functional goals (Frank,

McCloskey, & Dole, 2011). Since the 1970s, hippotherapy, integrated with traditional

therapeutic methods, has been used by therapists in the United States as a habilitative

strategy for persons with cerebral palsy who constitute one of the main user groups

(Casady & Nichols-Larsen, 2004; Debuse, Gibb, & Chandler, 2009).

The warmth and rhythmical movements of a horse have been theorized to help

improve circulation, reduce abnormally high muscle tone, and promote relaxation in the

rider (Davis et al., 2009). The dynamic movement pattern has been shown to mobilize the

pelvis, lumbar spine, and hip joint, normalize muscle tone, develop head and trunk

postural control, and develop proper equilibrium reactions in the trunk (Chang, Kwon,

Lee, & Kim, 2012). The resultant development of postural control has been hypothesized

to be the foundation for the acquisition of normal gross motor skills (Casady & Nichols-

Larsen, 2004). From a more functional perspective, research has documented the

sequence of muscle activation in a person sitting astride a horse as being identical to that

of a person walking upright inclusive of the rectus abdominis, erector spinae, obliques,

and gluteus muscles due to a three dimensional displacement of gravity caused by the

horse’s gait (Erdman & Pierce, 2016; Drnach, O’Brien, & Kreger, 2010).

Variations of the horse’s speed and direction, at the therapist’s discretion, provide

opportunities for randomization to facilitate anticipatory and reactive responses from the


rider (Erdman & Pierce, 2016). It has thusly been proposed that hippotherapy may

facilitate a transition from walking with ambulation aids, to walking independently, by

providing the child with repeated opportunities to practice postural control and head-

trunk stabilization in response to postural challenges with variable forces and planes of

movement (Chang, Kwon, Lee, & Kim, 2012).

The following literature review serves to summarize the current available

evidence regarding hippotherapy as it relates to gross motor function in children with

cerebral palsy.

Literature Review

A systematic review written by Whalen and Case-Smith investigated the

therapeutic effects of horseback riding as it relates to changes in gross motor function for

children with CP. The authors analyzed nine studies and found that children with spastic

CP at gross motor function classification system (GMFCS) levels I-III, ages four and

above, are likely to have significant improvements after a hippotherapy intervention

period. Improvements in outcome measures were seen predominantly in dimension E

(walking, running, jumping) of the Gross Motor Function Measure (GMFM). A copy of

the GMFM is provided in Appendix A. They reported additional improvements in

dimension D (standing) however, the improvement margin was not enough to qualify as

statistically significant. This review also found that forty-five minute sessions, once per

week, for at least eight to ten weeks resulted in significant changes in the aforementioned

outcome areas. Finally, and of equivocal importance, the authors found hippotherapy

trials lack protocol consistency; not a single study reviewed employed the same treatment

duration and/or frequency.


Whalen and Case-Smith concluded children with CP show improvement in gross

motor performance as a result of hippotherapy. Secondarily, while the authors recognize

interventions must be individualized to each child’s strengths and limitations, they

recommend practitioners use the dosage findings in this review to develop hippotherapy

dosing guidelines, (Whalen & Case-Smith, 2011).

Sung-Hui Tseng, Hung-Chou Chen, and Ka-Wai Tam wrote a systematic review

and meta-analysis that summarized the effect of equine-assisted activities and therapies

on gross motor outcomes in children with CP from fourteen different studies. In their

analysis, the authors were unable to confirm the effect of hippotherapy on gross motor

function even though most of the cited studies reported an improvement in GMFM

scores. Factors contributing to this result included limitations such as small sample sizes,

individual variability in gross motor functions, and variable as well as insufficient

durations of interventions. Tseng et al. concluded changes in outcome measurements are

complex and may differ between levels of ICF disability. The authors suggest future

research be conducted with children diagnosed with the same category of cerebral palsy

to more clearly delineate the benefits of the intervention (Tseng, Chen, & Tam, 2013).

In a study conducted by Huyn Jung Chang, Jeong-Yi Kwon, Ji-Young Lee, and

Yun-Hee Kim, the effects of hippotherapy in thirty-three preschool and school-aged

children with spastic and bilateral cerebral palsy were evaluated. The children received

thirty minutes of hippotherapy twice per week for a total of eight weeks. The GMFM and

Pediatric Balance Scale (PBS) values were determined during a pre-riding control period,

at the onset of hippotherapy, and after the intervention reached its termination. The

results exhibited significant improvement in both outcome measures after hippotherapy,

especially in dimensions D (standing) and E (running, walking, and jumping) in the


GMFM which is consistent with the findings of Whalen and Case-Smith’s systematic

review. The authors found there were no significant improvements in dimension D

(standing) of the GMFM for children with GMFCS level I or II. The preceding discovery,

in the author’s opinion, represents the outcome measures ceiling effects. With regard to

the floor effects of the GMFM, this study cited a previous study reporting no significant

improvements for children with CP who classify as GMFCS level V (Hamill 2016).

Huyn Jung Chang, Jeong-Yi Kwon, Ji-Young Lee, and Yun-Hee Kim concluded

hippotherapy improved gross motor function and balance in children with spastic and

bilateral CP. The analysis found children with initially poor functional levels showed

improvement in significantly more areas than those who initially had higher GMFCS

scores. This reinforces Tseng et al.’s suggestion to conduct studies with groups of

participants with the same disability level to determine the specific valuable effects of

hippotherapy (Chang, Kwon, Lee, & Kim, 2012).

In a randomized control study by Kwon et al., the authors analyzed the effect of

hippotherapy on the gross motor function of ninety-two children diagnosed with cerebral

palsy between the ages of four and ten years. Each session lasted for thirty minutes twice

per week for eight consecutive weeks. The researchers used the GMFM-66, GMFM-88,

and the PBS to gauge improvement. After collecting data, they found improvements

differed between children of varying GMFCS levels. For GMFCS level I children,

progress was seen in dimension E (walking, running, jumping) of the GMFM, level II

children saw improvements in both dimension D (standing) and dimension E (walking,

running, jumping), level III children demonstrated improvements in dimensions C

(crawling, kneeling) and D (standing), and level IV children improved in dimensions B

(sitting) and C (crawling, kneeling) (Kwon et al., 2015).


Due to the varied nature of the results, the researchers of this study concluded

future studies should be performed using children of the same GMFCS level in order to

make any evidentiary-based assertions about the relationship between the intervention

method and its effect on the gross motor functional outcomes of children with CP (Kwon

et al., 2015).

In a case report, Alana Frank, Sandra McCloskey, and Robin L. Dole highlight

changes in the functional skills of a six-year-old girl with mild ataxic cerebral palsy

determined to be at GMFCS level I. The child received hippotherapy twice per week for a

period of eight weeks. Sessions were forty-five minutes in duration, consisting of ten

minutes of land based therapeutic exercise and the remainder of time (approximately

thirty-five minutes) consisting of hippotherapy interventions. Measurements of gross

motor function using the GMFM-66 were taken before the first session, at the end of the

intervention, and again two months after the intervention as a follow-up measure. The

change in scores from baseline to the end of intervention and from the end of intervention

to the follow-up evaluation far exceeded the minimum to be considered statistically

significant for large population sizes (see Table 1).

Table 1

GMFM-66 Scores

Dimension Baseline After 8-Week At 2-Month

Intervention Follow-up

Lying, rolling 100 100 100

Sitting 100 100 100

Crawling, Kneeling 100 100 100

Standing 95 95 97.4

Walking, running, jumping 87.5 93 94.4

Total 96.5 97.6 98.2

Frank, A., McCloskey, S., & Dole, R. L. (2011). Effect of Hippotherapy on perceived self-

competence and participation in a child with cerebral palsy. Pediatric Physical Therapy, 23(3),

301–308.


The authors concluded hippotherapy was effective in improving the gross motor function

in this particular child with CP. The findings of this case report also indicate integrating

hippotherapy into traditional physical therapy interventions appears to increase the

child’s self-competence and participation (Frank, McCloskey, & Dole, 2011).

Eun Sook Park, Dong-Wook Rha, Jung Soon Shin, Soohyeon Kim, and Soojin

Jung investigated the effects of hippotherapy on the gross motor function and functional

performance on children with CP. In this study, thirty-four children with spastic CP were

recruited and received forty-five minute hippotherapy sessions twice per week for eight

weeks. Unique to this case is that twenty-one children with spastic CP were recruited for

a control group. Children in both groups received thirty minutes of traditional physical

therapy and occupational therapy once per week. To measure the changes in gross motor

function, the GMFM-66 and GMFM-88 were used as primary outcome measures and the

Pediatric Evaluation of Disability Inventory (PEDI) was used as a secondary outcome

measure. After the eight-week intervention, mean GMFM-66 and GMFM-88 scores were

significantly improved in both groups. However, according to the between groups

analysis, the hippotherapy group had significantly greater improvements in the GMFM

dimension E (walking, running, jumping) and total score than the control group. The total

PEDI functional skills score and subscores of its three domains were significantly

improved in the hippotherapy group, but not the control group. (Park, Rha, Shin, Kim, &

Jung, 2014).

The authors of this study concluded the results demonstrate beneficial effects of

hippotherapy on gross motor function and functional performance in children with CP.

In agreement with Frank, McCloskey, and Dole (2011), improvements in PEDI scores

suggest that hippotherapy also helps children to engage more meaningfully in the


functional activities of daily life than traditional land-based therapy (Park, Rha, Shin,

Kim, & Jung, 2014).

Casady and Nichols-Larsen studied eleven children ages two to seven years old

with no particular cerebral palsy classification who received hippotherapy once per week

for ten weeks to determine whether hippotherapy has an effect on the general functional

development of children with cerebral palsy. Sessions lasted forty-five minutes, with the

time spent on a horse typically consisting of only twenty-five to thirty minutes. The

researchers used the GMFM as a primary measure and the PEDI as a secondary outcome

measure to evaluate participants in two pre-tests, a post-test, and a follow-up evaluation.

The results demonstrated statistically significant treatment effects after the conclusion of

the intervention. The improvement for the PEDI social scores, PEDI total scores, GMFM

dimension C (crawling, kneeling) scores, and GMFM total scores were statistically

significant. Four other subscales including the PEDI self-care and mobility, and

dimensions B (sitting) and D (standing) of the GMFM, missed the mark of significance

by only a very small margin but were still worth noting. Results for the remaining

subcategories of the two outcome measure tools varied between subjects (Casady &

Nichols-Larsen, 2004).

The authors of this study, like many others conclude the use of hippotherapy to be

a viable treatment strategy to improve functional outcomes in young children with CP

(Casady & Nichols-Larsen, 2004).

Common Limitations

Limitations common to each of the studies examined include: the lack of a

standard dosage of hippotherapy, small sample size, variability in subject disability level,

participation variance, the lack of a control group (with the exception of one study), the


lack of control for socioeconomic status, cognition or communication level, the lack of

control for (or at least acknowledgement of) concurrent therapeutic interventions, and

potential bias of the examiner.

Discussion of Implications

The limitations of the studies examined suggest that additional studies regarding

the effectiveness of hippotherapy with regard to improving gross motor function with

more reliable study parameters (inclusive of larger sample sizes, consistent protocols, and

more randomized trials) are needed in order to definitively prove that hippotherapy, as a

stand-alone intervention, can improve gross motor function in children with CP (Whalen

& Case-Smith, 2011; Chang, Kwon, Lee, & Kim, 2012). As many of the studies

suggested, more homogenous subject populations in terms of age, type of CP, and

GMFCS level are also needed to determine which types of patients and which precise

areas of function are affected most by hippotherapy. Further, in terms of study

improvement, a correlation study that evaluates the relationship between functional

changes and hippotherapy would be valuable as no previous studies have examined

correlation coefficients (Casady & Nichols-Larsen, 2004).

Finally, as mentioned in the beginning of the review, identifying rehabilitation

services for children with CP associated with positive clinical and patient-reported

outcomes is a national priority (Institute of Medicine, Kolobe et al., 2014). Parent and

child satisfaction with hippotherapy has the potential to not only influence successful

motor skill development, but also impact emotional and psychological well-being. A

rehabilitative service that can improve a child’s overall quality of life would greatly

contribute to the aforementioned long-term goal of achieving maximum capacity and

becoming healthy, dynamic, and independent members of society (Frank, McCloskey, &


Dole, 2011). (Caro & Derevensky, 1991; Crais, Roy, & Free, 2006; Dunst, Trivette,

Davis, & Cornwell, 1988; Gannotti et al., 2016; Frank, McCloskey, & Dole, 2011;

Institute of Medicine of the National Academies, 2009; Kolobe et al., 2014; Thurston et

al., 2010).

Purpose and Research Questions

The purpose of this research study is to investigate whether hippotherapy

influences gross motor functional outcomes in children between three and thirteen years

of age, with a medical diagnosis of cerebral palsy, and a GMFCS level of III or IV.

GMFCS levels III and IV were chosen due to the opportunity for growth and change in

this particular population subset. Pre- and post-intervention GMFM scores and a

Parent/Guardian Reported Outcome Survey were utilized to obtain the evidence needed

for evaluation. What makes this research unique is the combination of a gross motor

functional outcome measurement tool and a Parent/Guardian Reported Outcome Survey.

The GMFM was chosen due to its sensitivity to changes in gross motor

performance irrespective of the type of CP or the direction of change. Dimensions of the

GMFM are labeled A through E and are organized by gross motor functional abilities

including; lying and rolling, sitting, crawling and kneeling, standing, and walking,

running, and jumping respectively. The validity of the GMFM is reported to be 0.99

(95% confidence interval) and the reliability is reported to be 0.98 (95% confidence

interval). Floor and ceiling effects, despite having been reported in multiple independent

studies, have never been officially acknowledged by the creators of the measurement

tool. Additionally, the researchers have primarily chosen the GMFM in an effort to allow

for comparison of the results to previous studies, as the majority of studies investigating


the effects of hippotherapy on gross motor functional outcomes have used the GMFM as

well.

The newly created survey used to assess the parent/guardian reported outcomes of

the ten-week hippotherapy intervention is structured similarly to the GMFM and assesses

the parent/guardian’s interpretation of the results of their child’s therapy with respect to

changes in gross motor function that translate into functional abilities. This survey was

piloted to evaluate construct validity as well as readability of the survey instrument. The

information obtained through the pilot test was used to guide revision of the survey prior

to being used in the study (please refer to Appendix B for a copy of the Parent/Guardian

Reported Outcome Survey).

This research study will attempt to answer the following questions:

● Research Question A: After a ten-week hippotherapy intervention, is there a

change in the pre- and post-intervention GMFM scores for children registered to

participate in the hippotherapy program at Bit-By-Bit Medical Therapeutic

Riding Center, with a diagnosis of cerebral palsy given by their primary care

physician (PCP), between three and thirteen years of age, with a GMFCS level of

III or IV?

● Research Question B: After a ten-week hippotherapy intervention, do

parents/guardians of children registered to participate in the hippotherapy

program at Bit-By-Bit Medical Therapeutic Riding Center, with a diagnosis of

cerebral palsy given by their PCP, between three and thirteen years of age, with a

GMFCS level of III or IV report a difference in their child’s gross motor

functional abilities?


● Research Question C: After a ten-week hippotherapy intervention, what is the

relationship between changes in the GMFM pre- and post-intervention scores

and the Parent/Guardian Reported Outcome Survey score/scores for children

registered to participate in the hippotherapy program at Bit-By-Bit Medical

Therapeutic Riding Center, with a diagnosis of cerebral palsy given by their

PCP, between three and thirteen years of age, with a GMFCS level of III or IV?

Given the information available in current literature, the researchers expect to see an

effect from the intervention reflected as an increase in the children’s GMFM scores

and anticipate the parent/guardian reported outcomes to reflect the same positive

impact.

Methods

The study is a mixed methodology design consisting of quantitative, quasi-

experimental data.

Facility Information

The researchers partnered with Bit-By-Bit Medical Therapeutic Riding Center

(see Appendix C for a copy of the letter of agreement between the researchers and the

facility), an American Hippotherapy Association (AHA) Registered Facility and a PATH

Accredited Therapeutic Riding Center (Professional Association of Therapeutic

Horsemanship International) in Davie, Florida, which provides equine-assisted services

to the special needs community. The aforementioned certifications impart a confidence

that the facility adheres to the highest levels of education, professionalism, and program

safety. In addition to hippotherapy, Bit-By-Bit Medical Therapeutic Riding Center offers

diverse medical and recreational services to people of all ages and abilities. The facility

employs specially trained therapy professionals who evaluate each patient to determine


how to best manipulate various aspects of the horse’s movement, position, management

style, equipment and types of activities to generate effective remediation protocols and to

promote functional outcomes.

Bit-By-Bit Medical Therapeutic Riding Center’s staff includes fifteen to twenty

physical, occupational, and speech therapists, PATH Certified Therapeutic Riding

Instructors, allied health student interns, and a large auxiliary support staff. Of notable

importance is Susan March, PT, the executive director and lead physical therapist, who

has been a physical therapist for over forty years. Susan is a PATH Certified Therapeutic

Riding Instructor and AHA registered therapist. She has mentored hundreds of allied

health students during their Level I and Level II clinicals from colleges and universities

and her tremendous experience in the areas of physical dysfunction, neurological

impairments, and sensory processing disorders has traversed the lifespan from pediatrics

to geriatrics. She has extensive experience with a multitude of diagnoses including

autism, cerebral palsy, traumatic brain injuries, spinal cord injuries, stroke, and many

other developmental and neurological diseases. The program director Denise Panariello,

MS, OTR/L, has been working with children and families since 1996 in the mental

health field. Denise received her Master of Science degree in Counseling Psychology

2003 and her second Master of Science degree in Occupational Therapy in 2011. She has

extensive training in applied behavior analysis/behavior therapy. Denise is a Certified

Infant & Toddler Developmental Specialist and is a also a PATH Certified Therapeutic

Riding Instructor & American Hippotherapy Association Registered Therapist. Kathleen

Pegues, MS, OTR/L, served for fourteen years as the executive director and retired in

2016 to participate in the board of directors. She obtained a Bachelor’s of Science degree

in Human Biology from the State University of New York at Albany and a Master’s of


Science in Occupational Therapy from Florida International University. Kathleen has

specialized in pediatrics and equine assisted therapies since 1998 and is both a PATH

Certified Therapeutic Riding Instructor and AHA registered therapist. Additional

physical and occupational therapists employed by the facility are listed in Appendix D.

Bit-By-Bit Medical Therapeutic Riding Center Hippotherapy Protocol.

To participate in hippotherapy at Bit-By-Bit Medical Therapeutic Riding Center,

a prescription from the child’s primary physician is required. After a prescription is

obtained, the client’s parent/guardian must fill out a registration packet including a

liability release, photo release, and medical information form as well as documents

outlining each child’s rights, responsibilities, and necessary safety measures (please see

Appendix E for a complete Bit-By-Bit Medical Therapeutic Riding Center registration

packet). Each child is individually assessed by the attending physical therapist using

standardized assessment tools including the Early Intervention Developmental Profile

(EIDP), Tinetti Performance Oriented Mobility Assessment, the Early Learning

Accomplishment Profile (ELAP), and the GMFM. Although each session is

individualized to meet the specific needs of each child, all therapy sessions utilize

techniques from the American Hippotherapy Association’s “Treatment Principles” Level

I course program. In an attempt to create a homogenous group of subjects, each child

studied will be attending one session per week. Each session lasts thirty to forty-five

minutes from arrival to departure from the facility.

Research Protocol

Subject Recruitment.

Institutional Review Board (IRB) approval was requested in the Spring of 2017.

Informed consent and assent forms, as well as a HIPAA waiver, were created with the


assistance of Florida Gulf Coast University's Office of Research and Graduate Studies

(please see Appendix F, G, and H). Subject recruitment began after IRB approval was

obtained.

Subjects were recruited through the Bit-By-Bit Medical Therapeutic Riding

Center hippotherapy program on a voluntary basis by responding to a flyer (see Appendix

I) containing the researcher's contact information that was distributed by the owner of the

facility at the request of the researchers. If a potential participant met all of the

established criteria on the screening tool (Appendix J) and approval was given by the

researchers, the lead PT offered the participant and their parent/guardian a copy of the

recruitment flyer with attached copies of the consent form, assent form, and HIPAA

waiver form using the following script:

Your child meets the criteria to be able to participate in a study being conducted

by Doctor of Physical Therapy students at Florida Gulf Coast University. I am

providing you with a copy of their recruitment flyer as well as consent, assent,

and HIPAA waiver forms. Your participation is entirely voluntary and will not in

any way impact the services being provided by Bit-by-Bit Medical Therapeutic

Riding Center or future services by Florida Gulf Coast University. After

reviewing all of the information, if you decide you would like to participate in the

study, please let me know, and I will arrange for the researchers to be present at

your next session.

The parents/guardians of each participant involved in the study were required to

complete a demographic and medical information questionnaire. The participants were

screened for participation in and frequency of concurrent physical or occupational

therapies and an attempt was made to create a homogenous group in terms of


comprehensive therapy protocols (please see Appendix K for a complete participant

information questionnaire).

A sample size of fifteen was been calculated to achieve 80% power with a

significance level of p≤0.05 and an effect size of 0.8. This sample size was calculated

using an online program based on the study design. This sample size is comparable to the

sample size calculated by Park et al. for a similarly structured study. The effect size of

0.8 was found in a study conducted in 2013 by Ko and Kim which analyzed the GMFM-

88 for children with cerebral palsy. (p. 1737, 2014). The researchers determined a sample

size of at least twenty participants would be sufficient to allow for loss of follow-up.

Procedures. (See also Appendix L)

All participant records at Bit-By-Bit Medical Therapeutic Riding Center were

reviewed by the researchers to determine if the child meets the inclusion and exclusion

criteria. If they did not meet the criteria they were not included in the study. If the

participants did meet the criteria they were offered a flyer advertising the research study

participation opportunity by the owner of the facility/ lead PT. If the participant and their

parents/guardians agreed to participate in the study, the lead PT scheduled an initial

evaluation with participants to take place at Bit-By-Bit Medical Therapeutic Riding

Center and provided researchers with a copy of said schedule. All new clients to the

facility during the course of the study were screened for eligibility (meets criteria and will

fit into study timeline) and if appropriate for the study were recruited in the same manner

as described above. As the consent, assent, and HIPAA waiver forms were attached to the

flyer, the participants and their parents/guardians had adequate time to review and

complete them. At the date of the evaluation, all informed consent, assent, and HIPAA

forms were collected. Participants were evaluated by researchers using the GMFM and


parents/guardians completed the Child Information Sheet; this is standard procedure for

evaluation at Bit-by-Bit Medical Therapeutic Riding Center and only takes approximately

forty-five to sixty minutes to complete. The participants received ten weeks of

hippotherapy. If the participant attended no fewer than eighty percent of therapy sessions,

they were included in the data analysis. If the participant attended fewer than eighty

percent of the therapy sessions, they were excluded from the data analysis. After ten

weeks of hippotherapy, the lead PT scheduled a follow-up evaluation for each participant

to take place at Bit-By-Bit Medical Therapeutic Riding Center and provided the

researchers with a copy of the aforementioned schedule. Again, this is standard procedure

for re-evaluation at Bit-by-Bit Medical Therapeutic Riding Center and only takes forty-

five to sixty minutes to complete. If the participant did not attend, they were excluded

from the data analysis. If the participant did attend, they were re-evaluated using the

GMFM by the researchers and the parents/guardians completed the Parent/Guardian

Reported Outcome Survey. The information obtained was included in the data analysis.

Data Collection

Data collected for this study was coded and kept between the two researchers and

their faculty advisors. The coding process involved assigning each participant a random

and unique identification number. All identifying information, including the list of

identification numbers with corresponding names, is kept in a locked cabinet in the

secured campus office of faculty advisor Dr. Ellen Donald. The direct/indirect identifiers

and all data collected from the study will be removed from the locked cabinet after three

years at which point all paper materials and discs will be shredded and if any thumb

drives exist, they will be permanently cleared of all data.


Data Analysis

To determine the effect of hippotherapy on gross motor functional abilities of the

participants using the GMFM scores, the researchers generated descriptive statistics

regarding the demographics of the participants, their participation in hippotherapy

sessions, their participation in concurrent traditional therapy sessions, their prior use of

Botox injections (including frequency if applicable), their pre- and post-intervention

GMFM scores inclusive of change scores, and the results of the Parent/Guardian

Reported Outcome Survey. Change scores were generated for each dimension in the

GMFM and for the total score of each child’s GMFM results. SPSS software (version 25)

was then used to perform a paired-t-test comparing the mean pre- and post-intervention

GMFM scores from each dimension as well as total scores with a p≤ 0.05 level of

significance. To determine if a relationship exists between the GMFM and

parent/guardian reported outcomes, the researchers again utilized SPSS software to

identify a correlation coefficient between the change scores for each dimension of the

GMFM and the scores reported by the parent/guardian outcome survey. Additional

correlation coefficients were generated to determine if a relationship exists between the

total change scores of the GMFM and the parent/guardian outcome surveys. Finally, a

between-groups analysis was conducted to investigate whether participant age, gender,

prior use of Botox, or GMFCS level had any relationship to the results of the study.

Any missing data, and any child missing more than two treatment sessions, was

omitted from the study due to the inability to interpret change. The physical therapists

involved in this study were required to record each participant’s attendance as well as the

time spent both on and off the horse in an attendance log found in Appendix M.


Results

Initially, the study included eight participants; five females and three males. After

preliminary analysis of the attendance records to determine appropriateness for inclusion

in the data analysis, it was determined that one female did not meet the 80% attendance

criteria and for that reason she was excluded from further analysis. The participants

eligible for data analysis therefore included four females and three males for a total of

seven children. Participants ranged in age from four to eleven years old with the average

age being 6.43 years old. There were three participants with a GMFCS level of III, four

participants with a GMFCS level of IV, and all participants utilized some sort of orthotic

and/or assistive device for functional mobility. All participants had previously

participated in hippotherapy prior to the initiation of the study protocol and additionally

participated in outside physical therapy, occupational therapy, and speech therapy. Only

two of the seven participants participated in physical education in school. Four of the

seven participants also regularly received botulinum toxin injections for hypertonicity

approximately every six months. Of the eligible participants, the average attendance over

ten weeks of the hippotherapy intervention study period was 92.86% with the minimum

being 80% and maximum being 100%. In each session, the participants spent an average

of fifteen minutes performing land-based therapeutic activities and 23.57 minutes on a

horse. Time on a horse varied very little between participants with the minimum being

twenty minutes and the maximum being thirty minutes. Interestingly, the time on land

preparing to participate in the horse-based activities varied widely with a minimum of

five minutes and a maximum of forty minutes.

Aggregate pre- and post-test GMFM values as well as the minimum, maximum,

range, and mean scores are included in Table 2.


Table 2:

Aggregate Pre-test/ Post-test GMFM Scores

Pre-Intervention Post-Intervention

GMFM Dimension Min Max Range Mean Min Max Range Mean

A (Lying, Rolling) 21 51 30 37.29 27 51 24 42.49

B (Sitting) 17 53 36 36.14 21 60 39 44.43

C (Crawling, Kneeling) 0 35 35 18.43 0 39 39 20.43

D (Standing) 2 29 27 12.29 2 33 31 11.86

E (Walking, Running, Jumping) 3 47 44 19.00 5 49 44 21.29

Total 43 215 172 123.15 75 231 156 144.14

Aggregate change scores were calculated by subtracting the aggregate pre-

intervention GMFM score for each dimension and total GMFM score from the aggregate

post-intervention GMFM score for each dimension and total score. Those results are

shown in table 3 below.

Table 3:

Aggregate pre-test/ Post-test GMFM Change Scores

GMFM Minimum Change Maximum Change Range Mean

Dimension

A (Lying, Rolling) -1 13 14 5.0

B (Sitting) -1 23 24 8.29

C (Crawling, Kneeling) -7 15 22 2.0

D (Standing) -8 4 12 -0.14

E (Walking, Running, Jumping) -6 13 19 2.29

Total -11 45 56 21.0

Statistical significance of the resultant change scores was determined using a

paired t-test for each dimension of the GMFM as well as the total score. Results of this

analysis are displayed below in Table 4.


Table 4:

GMFM Change Score Significance

GMFM Dimension Significance

A (Lying, Rolling) 0.057

B (Sitting) 0.034*

C (Crawling, Kneeling) 0.452

D (Standing) 0.774

E (Walking, Running, Jumping) 0.328

Total 0.038*

* Change score is statistically significant (p value ≤ 0.05)

The GMFM results were comparatively analyzed by groups based on participant’s

age, gender, prior use of Botox, and GMFCS levels to determine if a relationship existed

between these variables and the results of the study. Results of this analysis are shown

below in Table 5.

Table 5:

Between-Groups Analyses

Covariate Mean GMFM Total Change Score

GMFCS Level III 24.67

GMFCS Level IV 18.75

Age ≤5 years 21.67

Age ≥6 years 20.5

Male 18.3

Female 23.0

Receives Botox 26.75

Does not Receive Botox 13.3

Aggregate post-intervention Parent/Guardian Reported Outcome Survey results

are reported below in Table 6.


Table 6:

Aggregate Parent/Guardian Reported Outcome Survey Results

Survey Question Minimum Change Maximum Change Range Mean

1. Bed mobility 3 5 2 4.14

2. Supported sit 3 5 2 4.14

3. Unsupported sit 3 5 2 4.14

4. Seated reach 3 5 2 3.86

5. Quadruped crawl 0 5 5 3.00

6. Quadruped reach 0 5 5 3.00

7. Half kneel 0 5 5 3.43

8. Unsupported stand 0 5 5 2.71

9. Single leg stance 0 4 4 1.43

10. Squat 0 5 5 2.71

11. Stand to sit 0 5 5 3.29

12. Standing reach 3 5 2 3.43

13. Walk 3 5 2 4.14

14. Run 0 5 5 3.14

15. Step over obstacle 0 5 5 3.00

16. Kick ball 3 5 2 4.14

17. Jump on two feet 0 5 5 3.29

18. Jump on one foot 0 4 4 1.86

19. Stairs 0 5 5 2.57

20. Overall function 3 5 2 4.14

21. Quality of life 3 5 2 4.57

Correlation between the change scores for each GMFM dimension as well as total

score and related Parent/Guardian Reported Outcome Survey questions were calculated

using the Pearson Correlation Coefficient as displayed below in Table 7.


Table 7:

GMFM Change Score and Parent/Guardian Reported Outcome Survey Correlation

GMFM A GMFM B GMFM C GMFM D GMFM E GMFM Total (Lying) (Sitting) (Crawling) (Standing) (Walking, Running)

(Rolling) (Kneeling) (Jumping)

Survey

Question R(p) R(p) R(p) R(p) R(p) R(p)

1. Bed mobility 0.300 (0.513)

2. Supported sit 0.063 (0.893)

3. Unsupported sit -0.764 (0.046*)

4. Seated reach -0.233 (0.615)

5. Quadruped crawl 0.050 (0.916)

6. Quadruped reach 0.050 (0.916)

7. Half kneel -0.088 (0.850)

8. Unsupported stand 0.687 (0.088)

9. Singe leg stance 0.341 (0.454)

10. Squat 0.687 (0.088)

11. Stand to sit 0.168 (0.719)

12. Standing reach 0.350 (0.442)

13. Walk 0.252 (0.586)

14. Run 0.629 (0.130)

15. Step over obstacle 0.077 (0.870)

16. Kick ball -0.140 (0.765)

17. Jump on two feet 0.374 (0.409)

18. Jump on one foot -0.128 (0.785)

19. Stairs 0.322 (0.481)

20. Overall function 0.150 (0.748)

* Pearson correlation coefficient (R) is statistically significant (p value ≤ 0.05)

Discussion

The purpose of the study was to identify whether hippotherapy is associated with

positive clinical and parent/guardian reported outcomes. Secondary to having very

specific inclusion and exclusion criteria to create a more homogeneous study population

than analyzed in previous available studies, the number of eligible participants in a single

location was smaller than the sample size that the researchers had determined was

necessary to achieve 80% power with a significance of p≤0.05. Despite the small


population, the results show some significant positive changes in function over the ten-

week study period and interesting relationships between the resultant change scores of the

GMFM and Parent/Guardian Reported Outcome Survey responses.

Research Question A. (Is there a change in the pre- and post-intervention GMFM

scores?)

As demonstrated in Table 3, there was an increase in the aggregate change scores

in all but one dimension and the total score. The exception of dimension D (standing) was

likely due to the influence of a single outlying score that the researchers suspect was

influenced by an item not accounted for in the data analysis; weight gain. One of the

seven participants had demonstrated an approximate thirty-pound increase in weight over

the course of the study as observed by the researchers and as confirmed by her parent

which impacted her functional mobility. The potential for weight fluctuation in subjects

was not considered as an influential factor when the research protocol was formed but

was determined to be a recommended item of interest for future studies.

With regard to the between-groups analysis, the researchers found no unexpected

results. It is logical that participants who were younger achieved more gains than those

who had essentially “aged out” of the typical natural gross motor growth stage, that those

who received Botox injections would show greater gains than those who did not, and that

those whose functional mobility status was classified as grossly greater would show

greater gains across all dimensions of the GMFM than those whose mobility status was

grossly lower. With regard to the differences between genders, the researchers postulate

that perhaps the female participants identified more with the all female staff and

researchers and/or felt comfortable putting forth more effort in front of the all female


staff and researchers than the males did as witnessed individually by the researchers

during the pre- and post-intervention assessments.

Research Questions B and C. (Do parents/guardians report a difference in their child’s

gross motor functional abilities? AND What is the relationship between changes in the

GMFM pre- and post-intervention scores and the Parent/Guardian Reported Outcome

Survey score/scores?)

With regard to the results of the correlational analysis, the parent/guardian

reported outcomes were largely positive regardless of the small changes identified by the

GMFM. Interestingly, the only statistically significant item identified was the relationship

between question three (unsupported sit) of the survey which correlated with dimension

B (sitting) of the GMFM. The Pearson correlation coefficient showed a negative

correlation between the responses on the Parent/Guardian Reported Outcome Survey and

the changes in the GMFM score indicating perceived changes when no measurable

functional changes were gained.

The relationships between questions five and six (quadruped crawl and quadruped

reach) and dimension C (crawling, kneeling) of the GMFM, questions eight and ten

(unsupported stand and squat) and dimension D (standing) of the GMFM, and question

fourteen (run) and dimension E (walking, running, jumping) of the GMFM were all

identified as strong by having an r-value of greater than .50 but were not statistically

significant as identified by a significance of p≤ .05. In the aforementioned dimensions,

the lack of a statistically significant correlation coefficient may be due to the small

sample size and/or the perception of a positive change made in a child’s gross motor

functional abilities regardless of the existence of or size of the measurable change

identified by the GMFM.


Question twenty-one of the Parent/Guardian Reported Outcome Survey inquired

about overall quality of life to determine whether, despite gross functional change,

parents/guardians found hippotherapy to have an impact on their child's quality of life.

This question was not included in the correlational analysis as it did not correspond to

any of the measured gross motor functional dimensions on the GMFM. In response to

this question, six out of seven of the parents/guardians reported that hippotherapy had a

positive impact on their child’s quality of life. The seventh child’s parent/guardian

importantly reported no change as opposed to either a positive or negative impact. It is

plausible that the perceived gross motor improvements are a result of the reported

enhanced quality of life if the child is demonstrating improved sense of self-competence

with increased participation in activities of daily living after the intervention period.

The final item of interest was the dissimilar findings between the study done by

Kwon et al. (2015) and the present study. In the study performed by Kwon et al.,

statistically significant changes were identified in dimension B (sitting), C (crawling,

kneeling), and D (standing) over a duration of eight weeks, as opposed to only dimension

B (sitting) and the total change score over a duration of ten weeks as the results of this

study indicate.

Conclusion

Results of this study provide preliminary and limited quantitative evidence that

hippotherapy improves gross motor function in children with CP. The Parent/Gaurdian

Reported Outcome Survey supports the benefits of participation in hippotherapy as it

indicates parents/guardians of children with CP percieve benefits both in motor function

and quality of life as a result of the intervention.


For future research, the authors of this study fervently encourage researchers to

consider analyzing results from a longer intervention study period. The lack of

statistically significant findings in this study is likely strongly associated with the short

intervention study period and a single child whose change scores were more reflective of

body habitus changes that were unaccounted for by the study protocol.

Other recommendations for future research include using a similarly stringent

homogenous population across multiple locations to create a larger participant pool and

increase the likelihood of achieving reproducible results, identifying and accounting for

physical habitus fluctuations, and identifying a control group (ideally consisting of the

same population concurrently participating in traditional physical therapy, occupational

therapy, and speech therapy, but no hippotherapy) to determine whether all changes are

attributable solely to the intervention as opposed to concurrent outside therapies.

Finally, investigating the psychosocial effects of hippotherapy for children with

CP would be of great value in combination with the findings of the suggested research

above in an effort to determine if hippotherapy can not only positively impact a child’s

functional mobility, but also improve self-competence leading to increased participation

in and outside of therapy resulting in earlier identifiable measurable gains. Another

implication of all the above is that hippotherapy may ultimately reduce the level of

assistance required for children with CP thereby possessing the far-reaching effect of

improving the caregiver’s quality of life and facilitating a healthier, more typical

child/guardian relationship consequently allowing the child a greater opportunity to

efficaciously achieve their long-term goals.


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Appendix A: Gross Motor Function Measure

2013 Dianne Russell and Peter Rosenbaum, McMaster University. All rights reserved. Page 1 of 6

GROSS MOTOR FUNCTION MEASURE (GMFM) SCORE SHEET (GMFM-88 and GMFM-66 scoring)

Child’s Name: ID#:

Assessment Date:

GMFCS Level1:

year / month / day

I

II

III

IV

V Date of Birth:

year / month / day

Chronological Age: Evaluator’s Name:

year / month / day

Testing Condition (e.g., room, clothing, time, others present):

The GMFM is a standardized observational instrument designed and validated to measure change in gross motor function over time in children with cerebral palsy. The scoring key is meant to be a general guideline. However, most of the items have specific descriptors for each score. It is imperative that the guidelines contained in the manual be used for scoring each item.

SCORING KEY 0 = does not initiate 1 = initiates 2 = partially completes

3 = completes 9 (or leave blank) = not tested (NT) [used for the GMAE-2 scoring*]

It is important to differentiate a true score of “0” (child does not initiate) from

an item which is Not Tested (NT) if you are interested in using the GMFM-66 Ability Estimator (GMAE) Software.

*The GMAE-2 software is available for downloading from www.canchild.ca for those who have purchased the GMFM manual. The GMFM-66 is only valid for use with children who have cerebral palsy.

Contact for Research Group:

CanChild Centre for Childhood Disability Research, Institute for Applied Health Sciences, McMaster University,

1400 Main St. W., Room 408, Hamilton, ON Canada L8S 1C7 Email: [email protected] Website: www.canchild.ca

1GMFCS level is a rating of severity of motor function. Definitions for the GMFCS-E&R (expanded & revised) are found in

Palisano et al. (2008). Developmental Medicine & Child Neurology. 50:744-750 and in the GMAE-2 scoring software. http://motorgrowth.canchild.ca/en/GMFCS/resources/GMFCS-ER.pdf


Appendix A: Gross Motor Function Measure (Continued)


Check ( ) the appropriate score: if an item is not tested (NT), circle the item number on the right column Item

A: LYING & ROLLING

SCORE

NT

1. SUP, HEAD IN MIDLINE: TURNS HEAD WITH EXTREMITIES SYMMETRICAL ................................... 0 1 2 3 1.

* 2. SUP: BRINGS HANDS TO MIDLINE, FINGERS ONE WITH THE OTHER ................................................... 0 1 2 3 2.

3. SUP: LIFTS HEAD 45 ......................................................................................................... 0 1 2 3 3.

4. SUP: FLEXES R HIP & KNEE THROUGH FULL RANGE .................................................................... 0 1 2 3 4.

5. SUP: FLEXES L HIP & KNEE THROUGH FULL RANGE ...................................................................... 0 1 2 3 5.

* 6. SUP: REACHES OUT WITH R ARM, HAND CROSSES MIDLINE TOWARD TOY.......................................... 0 1 2 3 6.

* 7. SUP: REACHES OUT WITH L ARM, HAND CROSSES MIDLINE TOWARD TOY .......................................... 0 1 2 3 7.

8. SUP: ROLLS TO PR OVER R SIDE ............................................................................................ 0 1 2 3 8.

9. SUP: ROLLS TO PR OVER L SIDE ............................................................................................. 0 1 2 3 9.

* 10. PR: LIFTS HEAD UPRIGHT ....................................................................................................... 0 1 2 3 10.

11. PR ON FOREARMS: LIFTS HEAD UPRIGHT, ELBOWS EXT., CHEST RAISED..................................... 0 1 2 3 11.

12. PR ON FOREARMS: WEIGHT ON R FOREARM, FULLY EXTENDS OPPOSITE ARM FORWARD............... 0 1 2 3 12.

13. PR ON FOREARMS: WEIGHT ON L FOREARM, FULLY EXTENDS OPPOSITE ARM FORWARD ............... 0 1 2 3 13.

14. PR: ROLLS TO SUP OVER R SIDE ............................................................................................. 0 1 2 3 14.

15. PR: ROLLS TO SUP OVER L SIDE ............................................................................................. 0 1 2 3 15.

16. PR: PIVOTS TO R 90 USING EXTREMITIES ............................................................................... 0 1 2 3 16.

17. PR: PIVOTS TO L 90 USING EXTREMITIES ................................................................................ 0 1 2 3 17.

TOTAL DIMENSION A

Item

B: SITTING

SCORE

NT

* 18. SUP, HANDS GRASPED BY EXAMINER: PULLS SELF TO SITTING WITH HEAD CONTROL ........... 0 1 2 3 18.

19. SUP: ROLLS TO R SIDE, ATTAINS SITTING ................................................................................. 0 1 2 3 19.

20. SUP: ROLLS TO L SIDE, ATTAINS SITTING .................................................................................. 0 1 2 3 20.

* 21. SIT ON MAT, SUPPORTED AT THORAX BY THERAPIST: LIFTS HEAD UPRIGHT,

MAINTAINS 3 SECONDS .......................................................................................................... 0 1 2 3 21.

* 22. SIT ON MAT, SUPPORTED AT THORAX BY THERAPIST: LIFTS HEAD MIDLINE, MAINTAINS 10 SECONDS ....................................................................................................................... 0 1 2 3 22.

* 23. SIT ON MAT, ARM(S) PROPPING: MAINTAINS, 5 SECONDS ................................................ 0 1 2 3 23.

* 24. SIT ON MAT: MAINTAIN, ARMS FREE, 3 SECONDS .................................................................... 0 1 2 3 24.

* 25. SIT ON MAT WITH SMALL TOY IN FRONT: LEANS FORWARD, TOUCHESTOY, RE-ERECTS

WITHOUT ARM PROPPING ........................................................................................................ 0 1 2 3 25.

* 26. SIT ON MAT: TOUCHES TOY PLACED 45 BEHIND CHILD’S R SIDE, RETURNS TO START .................... 0 1 2 3 26.

* 27. SIT ON MAT: TOUCHES TOY PLACED 45 BEHIND CHILD’S L SIDE, RETURNS TO START..................... 0 1 2 3 27.

28. R SIDE SIT: MAINTAINS, ARMS FREE, 5 SECONDS ..................................................................... 0 1 2 3 28.

29. L SIDE SIT: MAINTAINS, ARMS FREE, 5 SECONDS ..................................................................... 0 1 2 3 29.

* 30. SIT ON MAT: LOWERS TO PR WITH CONTROL .......................................................................... 0 1 2 3 30.

* 31. SIT ON MAT WITH FEET IN FRONT: ATTAINS 4 POINT OVER R SIDE ................................... 0 1 2 3 31.

* 32. SIT ON MAT WITH FEET IN FRONT: ATTAINS 4 POINT OVER L SIDE .................................... 0 1 2 3 32.

33. SIT ON MAT: PIVOTS 90 , WITHOUT ARMS ASSISTING .............................................................. 0 1 2 3 33.

* 34. SIT ON BENCH: MAINTAINS, ARMS AND FEET FREE, 10 SECONDS ............................................... 0 1 2 3 34.

* 35. STD: ATTAINS SIT ON SMALL BENCH ......................................................................................... 0 1 2 3 35.

* 36. ON THE FLOOR: ATTAINS SIT ON SMALL BENCH ..................................................................... 0 1 2 3 36.

* 37. ON THE FLOOR: ATTAINS SIT ON LARGE BENCH ..................................................................... 0 1 2 3 37.

TOTAL DIMENSION B




Item

C: CRAWLING & KNEELING

SCORE

NT

38. PR: CREEPS FORWARD 1.8m (6') .......................................................................................... 0 1 2 3 38.

* 39. 4 POINT: MAINTAINS, WEIGHT ON HANDS AND KNEES, 10 SECONDS ............................................... 0 1 2 3 39.

* 40. 4 POINT: ATTAINS SIT ARMS FREE .......................................................................................... 0 1 2 3 40.

* 41. PR: ATTAINS 4 POINT, WEIGHT ON HANDS AND KNEES .................................................................. 0 1 2 3 41.

* 42. 4 POINT: REACHES FORWARD WITH R ARM, HAND ABOVE SHOULDER LEVEL .................................... 0 1 2 3 42.

* 43. 4 POINT: REACHES FORWARD WITH L ARM, HAND ABOVE SHOULDER LEVEL ..................................... 0 1 2 3 43.

* 44. 4 POINT: CRAWLS OR HITCHES FORWARD 1.8m(6') .................................................................. 0 1 2 3 44.

* 45. 4 POINT: CRAWLS RECIPROCALLY FORWARD1.8m ( 6') ............................................................. 0 1 2 3 45.

* 46. 4 POINT: CRAWLS UP 4 STEPS ON HANDS AND KNEES/FEET ......................................................... 0 1 2 3 46.

47. 4 POINT: CRAWLS BACKWARDS DOWN 4 STEPS ON HANDS AND KNEES/FEET ................................... 0 1 2 3 47.

* 48. SIT ON MAT: ATTAINS HIGH KN USING ARMS, MAINTAINS, ARMS FREE, 10 SECONDS ......................... 0 1 2 3 48.

49. HIGH KN: ATTAINS HALF KN ON R KNEE USING ARMS, MAINTAINS, ARMS FREE, 10 SECONDS .............. 0 1 2 3 49.

50. HIGH KN: ATTAINS HALF KN ON L KNEE USING ARMS, MAINTAINS, ARMS FREE, 10 SECONDS ............... 0 1 2 3 50.

* 51. HIGH KN: KN WALKS FORWARD 10 STEPS, ARMS FREE .............................................................. 0 1 2 3 51.

TOTAL DIMENSION C

Item

D: STANDING

SCORE

NT

* 52. ON THE FLOOR: PULLS TO STD AT LARGE BENCH ................................................................... 0 1 2 3 52.

* 53. STD: MAINTAINS, ARMS FREE, 3 SECONDS ................................................................................ 0 1 2 3 53.

* 54. STD: HOLDING ON TO LARGE BENCH WITH ONE HAND, LIFTS R FOOT, 3 SECONDS .............................. 0 1 2 3 54.

* 55. STD: HOLDING ON TO LARGE BENCH WITH ONE HAND, LIFTS L FOOT, 3 SECONDS ............................... 0 1 2 3 55.

* 56. STD: MAINTAINS, ARMS FREE, 20 SECONDS .............................................................................. 0 1 2 3 56.

* 57. STD: LIFTS L FOOT, ARMS FREE, 10 SECONDS .......................................................................... 0 1 2 3 57.

* 58. STD: LIFTS R FOOT, ARMS FREE, 10 SECONDS ......................................................................... 0 1 2 3 58.

* 59. SIT ON SMALL BENCH: ATTAINS STD WITHOUT USING ARMS................................................... 0 1 2 3 59.

* 60. HIGH KN: ATTAINS STD THROUGH HALF KN ON R KNEE, WITHOUT USING ARMS................................. 0 1 2 3 60.

* 61. HIGH KN: ATTAINS STD THROUGH HALF KN ON L KNEE, WITHOUT USING ARMS ................................. 0 1 2 3 61.

* 62. STD: LOWERS TO SIT ON FLOOR WITH CONTROL, ARMS FREE ......................................................... 0 1 2 3 62.

* 63. STD: ATTAINS SQUAT, ARMS FREE ........................................................................................... 0 1 2 3 63.

* 64. STD: PICKS UP OBJECT FROM FLOOR, ARMS FREE, RETURNS TO STAND ............................................ 0 1 2 3 64.

TOTAL DIMENSION D




Item E: WALKING, RUNNING & JUMPING SCORE NT

* 65. STD, 2 HANDS ON LARGE BENCH: CRUISES 5 STEPS TO R ............................... 0 1 2 3 65.

* 66. STD, 2 HANDS ON LARGE BENCH: CRUISES 5 STEPS TO L ................................ 0 1 2 3 66.

* 67. STD, 2 HANDS HELD: WALKS FORWARD 10 STEPS ................................................ 0 1 2 3 67.

* 68. STD, 1 HAND HELD: WALKS FORWARD 10 STEPS ................................................... 0 1 2 3 68.

* 69. STD: WALKS FORWARD 10 STEPS ............................................................................ 0 1 2 3 69.

* 70. STD: WALKS FORWARD 10 STEPS, STOPS, TURNS 180 , RETURNS ................................. 0 1 2 3 70.

* 71. STD: WALKS BACKWARD 10 STEPS ........................................................................... 0 1 2 3 71.

* 72. STD: WALKS FORWARD 10 STEPS, CARRYING A LARGE OBJECT WITH 2 HANDS.................... 0 1 2 3 72.

* 73. STD: WALKS FORWARD 10 CONSECUTIVE STEPS BETWEEN PARALLEL LINES 20cm (8")APART 0 1 2 3 73.

* 74. STD: WALKS FORWARD 10 CONSECUTIVE STEPS ON A STRAIGHT LINE 2cm (3/4") WIDE ........... 0 1 2 3 74.

* 75. STD: STEPS OVER STICK AT KNEE LEVEL, R FOOT LEADING ............................................. 0 1 2 3 75.

* 76. STD: STEPS OVER STICK AT KNEE LEVEL, L FOOT LEADING ............................................. 0 1 2 3 76.

* 77. STD: RUNS 4.5m (15’), STOPS & RETURNS ................................................................ 0 1 2 3 77.

* 78. STD: KICKS BALL WITH R FOOT ................................................................................ 0 1 2 3 78.

* 79. STD: KICKS BALL WITH L FOOT ................................................................................. 0 1 2 3 79.

* 80. STD: JUMPS 30cm (12") HIGH, BOTH FEET SIMULTANEOUSLY ........................................ 0 1 2 3 80.

* 81. STD: JUMPS FORWARD 30 cm (12"), BOTH FEET SIMULTANEOUSLY ................................ 0 1 2 3 81.

* 82. STD ON R FOOT: HOPS ON R FOOT 10 TIMES WITHIN A 60cm (24") CIRCLE ............... 0 1 2 3 82.

* 83. STD ON L FOOT: HOPS ON L FOOT 10 TIMES WITHIN A 60cm (24") CIRCLE ................ 0 1 2 3 83.

* 84. STD, HOLDING 1 RAIL: WALKS UP 4 STEPS, HOLDING 1 RAIL, ALTERNATING FEET ......... 0 1 2 3 84.

* 85. STD, HOLDING 1 RAIL: WALKS DOWN 4 STEPS, HOLDING 1 RAIL, ALTERNATING FEET .... 0 1 2 3 85.

* 86. STD: WALKS UP 4 STEPS, ALTERNATING FEET .............................................................. 0 1 2 3 86.

* 87. STD: WALKS DOWN 4 STEPS, ALTERNATING FEET ......................................................... 0 1 2 3 87.

* 88. STD ON 15cm (6") STEP: JUMPS OFF, BOTH FEET SIMULTANEOUSLY .......................... 0 1 2 3 88.

TOTAL DIMENSION E

Was this assessment indicative of this child’s “regular” performance? YES NO

COMMENTS:




GMFM-88 SUMMARY SCORE

DIMENSION CALCULATION OF DIMENSION % SCORES

GOAL

AREA

(indicated with check)

A. Lying & Rolling Total Dimension A = 100 = % A.

51 51

B. Sitting Total Dimension B = 100 = % B.

60 60

C. Crawling & Kneeling Total Dimension C = 100 = % C.

42 42

D. Standing Total Dimension D = 100 = % D.

39 39

E. Walking, Running & Jumping

Total Dimension E = 100 = % E.

72 72

TOTAL SCORE = %A + %B + %C + %D + %E

Total # of Dimensions

= = = %

5

GOAL TOTAL SCORE = Sum of %scores for each dimension identified as a goal area

# of Goal areas

= = %

GMFM-66 Gross Motor Ability Estimator Score 1

GMFM-66 Score = _________________ ___________ to __________

95% Confidence Intervals

previous GMFM-66 Score = _________________ ___________ to __________

95% Confidence Intervals

change in GMFM-66 =

1 from the Gross Motor Ability Estimator (GMAE-2) Software




TESTING WITH AIDS/ORTHOSES USING THE GMFM-88 Indicate below with a check ( ) which aid/orthosis was used and what dimension it was first applied. (There may be more than one).

AID Dimension Orthosis Dimension

Rollator/pusher ..................................... Hip Control ...........................................

Walker ................................................... Knee Control ........................................

H Frame crutches ................................. Ankle-foot Control ................................

Crutches ............................................... Foot Control .........................................

Quad Cane ........................................... Shoes ...................................................

Cane ..................................................... None ....................................................

None ..................................................... Other

Other (please specify)

(please specify)

GMFM-88 SUMMARY SCORE USING AIDS/ORTHOSES

DIMENSION CALCULATION OF DIMENSION % SCORES

GOAL

AREA

(indicated with check)

F. Lying & Rolling Total Dimension A = 100 = % A.

51 51

G. Sitting Total Dimension B = 100 = % B.

60 60

H. Crawling & Kneeling Total Dimension C = 100 = % C.

42 42

I. Standing Total Dimension D = 100 = % D.

39 39

J. Walking, Running & Jumping

Total Dimension E = 100 = % E.

72 72

TOTAL SCORE = %A + %B + %C + %D + %E

Total # of Dimensions

= = = %

5

GOAL TOTAL SCORE = Sum of %scores for each dimension identified as a goal area

# of Goal areas

= = %


Appendix B: Parent/Guardian Reported Outcome Survey


Appendix B: Parent/Guardian Reported Outcome Survey (Continued)


Appendix C: Letter of Agreement


Appendix D: Bit-By-Bit Medical Therapeutic Riding Center Physical Therapists

Physical Therapists

Susan March PT

Amanda Richello PT

Stephanie Colas-Salgado PT

Catherine Baker PT

Occupational Therapists

Denise Panariello OTR

Michelle VanNierkerk OTR

Hillary Hough OTR

Nora Halabi OTR

Therapy Assistants

Angela Jardim COTA

Jackie Calenback COTA


Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet



(Continued)



(Continued)



(Continued)



(Continued)



(Continued)



(Continued)



(Continued)



(Continued)



(Continued)



(Continued)


Appendix F: Informed Consent

Parent/Guardian Informed Consent/Permission

Please read this consent agreement carefully before you decide to have your child participate

in the study.

An assent (consent) form for your child is attached. Please review the assent form with

your child.

Study Title: The Effects of Hippotherapy on the Gross Motor Functional Abilities of

Children with Cerebral Palsy using Clinical Outcome Measures and Parent/Guardian

Reported Outcomes.

Principal Researcher: Tara Lacey

Co-Researcher: Rachael Tutunick

Faculty Advisors: Ellen Donald and Sarah Fabrizi

You are being asked to allow your child to participate in a research study conducted

through Florida Gulf Coast University. Your child’s participation in this study is

voluntary. In order for your child to participate in this study, the University requires that

we obtain your signed consent in order for your child to participate in this project. This

study is being conducted as a requirement of the researchers’ doctoral degree in physical

therapy from Florida Gulf Coast University.

The researchers will explain to you in detail the purpose of the study, the procedures to

be used, the expected duration or frequency of your child's participation, and the potential

benefits and possible risks of participation. You may ask the researchers any questions

you have to help you understand the study.

If you choose not to allow your child to participate or your child does not want to

participate in the study, it will have no effect on any future services you or your child

may be entitled to from Florida Gulf Coast University or Bit-by-Bit. Anyone who

chooses to participate in the study is free to withdraw from the study at any time with no

penalty.

The purpose of the study is to investigate whether hippotherapy influences the gross

motor functional abilities in children with cerebral palsy

We are asking your child to take part in the study because your child meets the inclusion

criteria (Registered to participate in the hippotherapy program at Bit-by-Bit Medical

Therapeutic Riding Center, a diagnosis of cerebral palsy by their PCP, between 3-13

years of age, a GMFCS level between 3 and 4. Participants must also be able to commit


Appendix F: Informed Consent (Continued)

to attending no less than 80% of the scheduled sessions within the ten-week research

period).

If your child joins the study, your child will be asked to attend at least eight thirty-minute

sessions during the ten-week research period in addition to the initial and final

evaluations (which will take approximately 45 minutes to an hour to complete) performed

by the researchers at Bit-By-Bit. The participants in this study are at no further risk of

participating in the research study as they would be during a normally scheduled

intervention session with Bit-By-Bit as no activity/activities will be outside of the regular

intervention protocol.

At the completion of the ten-week research period, the parents/guardians of the

participants will be asked to complete a “Parent/Guardian Reported Outcome Survey.”

The purpose of the survey is to report what differences, if any, the parents/guardians have

observed in their child as a result of the hippotherapy intervention.

We hope the information we get from this study will help others who have cerebral palsy

identify rehabilitation services associated with positive clinical and parent/guardian

reported outcomes.

If your child joins the study, we will take the following steps to keep your child’s

information confidential and secure. Data collected for this study will be coded and kept

between the two researchers as well as their faculty advisors at Florida Gulf Coast

University. The coding process will involve assigning each participant a random and

unique identification number. All identifying information, including the list of

identification numbers with corresponding names as

well as any demographic information, will be kept in a locked cabinet in the secured

campus office of faculty advisor Dr. Ellen Donald.

Neither you nor your child will be paid to take part in this study.

We do not foresee any medical problems from participating in this study. However, if

your child experiences any research related injury, please contact Ellen Donald at 239-

590-7531.

If you have any questions about this study, you may contact Ellen Donald at 239-590-

7531.

If you have any questions about your child’s rights as a participant in this research, or if

you feel your child has been placed at risk, you can contact the Chair of the Human


Appendix F: Informed Consent (Continued)

Subjects' Institutional Review Board through Sandra Terranova, Office of Research and

Sponsored Programs, at 239-590-7522.

I have read this form and I understand it. I understand that if at any time I or my child

become uncomfortable with the study I am free to stop my child's participation. I also

understand that it is not possible to identify all potential risks in a study, and I believe that

reasonable safeguards have been taken to minimize both the known and potential but

unknown risks. I agree to allow my child to participate in the research study described

above.

Signature of Parent/Guardian _____________________________ Date ____________

Signature of Parent/Guardian _____________________________ Date ____________

Child’s Name, please print _________________________________________________

The dated approval stamp on this consent form indicates that this study has been

reviewed and approved by the Florida Gulf Coast University Institutional Review Board

for the Protection of Human Subjects in Research.


Appendix G: Informed Assent

Assent Form for Children Ages 7 – 13

The Effects of Horseback Riding on the Gross Motor Functional Abilities of

Children with Cerebral Palsy using Clinical Outcome Measures and

Parent/Guardian Reported Outcomes.

I have been told that my mother/father /parent/grandparent/guardian (circle one) said it’s

okay for me to take part in a study about horseback riding and how it affects my

functional abilities.

I will be asked to continue participating in horseback riding at Bit-by-Bit for ten weeks

and take part in a pre- and post-test where I will show the researchers and my therapists

how well I can complete functional tasks.

I am doing this because I want to. I know that it is okay if I want to stop. I know that I

can stop at any time if I want to and nothing will happen to me if I stop.

______________________________ ___________________________

Child’s Signature (or checkmark)/Date Child’s Name Printed

Witness:

In my judgment, my child understands about the study and agrees to be in the study.

_____________________________ ___________________________

Parent/Guardian Date


Appendix H: HIPAA Waiver


Appendix H: HIPAA Waiver (Continued)


Appendix H: HIPAA Waiver (Continued)


Appendix I: Recruitment Flyer


Appendix J: Screening Tool

Inclusion Criteria

Registered to participate in hippotherapy program ☐ ☐ Yes No

Has a diagnosis of cerebral palsy from PCP ☐ Yes ☐ No

Is between the ages of 3 and 13 years old ☐ ☐ Yes No

Has a GMFCS level of III or IV ☐ ☐ Yes No

Exclusion Criteria

Has had chemodenervation with the past 6 months ☐ ☐ Yes No

Has had an orthopedic operation within the past 1 year ☐ ☐ Yes No

Has had a dorsal rhizotomy ☐ ☐ Yes No

Has unpredictable seizures ☐ ☐ Yes No

Is non-ambulatory ☐ ☐ Yes No


Appendix K: Child Information Sheet

Name (Last, First, MI):_____________________________________________________

Age:______ Gender: _____________ Date of Birth (mm/dd/yyyy):_________________

Does the child use an assistive device? ☐ ☐ Yes No

If yes to the previous question, what type of assistive device?

☐ Crutches ☐ Walker

☐ ☐ Cane Wheelchair (motorized)

☐ Wheelchair (standard) ☐ Other: ______________________

☐ Orthotics (Braces)

If yes to Orthotics (Braces) please list them below:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

_________________

Gross Motor Function Classification System Level:______________________________

Has your child participated in hippotherapy before? ☐ ☐ Yes No

If yes, how many years has your child been in hippotherapy?_______________________

Sessions per week:________________ Minutes per session:_________________

Does your child participate in P.E.? ☐ ☐ Yes No

Continued on next page…


Appendix K: Child Information Sheet (Continued)

Other concurrent forms of therapy:

Type of Therapy Years in therapy Sessions per week Minutes per session

Physical Therapy

Occupational Therapy

Other: ____________

Other: ____________

Does your child receive Botox injections? ☐ ☐ Yes No

If yes to Botox injections, in what muscle/muscle group does your child receive an

injection/injections?

_______________________________________________________________________

If yes to Botox injections, how frequently does your child receive an injection?

_______________________________________________________________________

If yes to Botox injections, when was your child’s most recent administration?

(mm/dd/yyyy):___________________________________________________________

Continued on next page…


Appendix K: Child Information Sheet (Continued)

Please indicate by checking “yes” or “no” if the following applies or does not apply to the

child:

Is registered to participate in the hippotherapy program

at Bit-by-Bit Medical Therapeutic Riding Center

☐ ☐ Yes No

Has a diagnosis of cerebral palsy from PCP ☐ ☐ Yes No

Is between the ages of 3 and 13 years old ☐ ☐ Yes No

Has a GMFCS level of III or IV ☐ ☐ Yes No

Can commit to attending at least 80% of scheduled therapy

sessions in a 10-week period

☐ ☐ Yes No

Has had chemodenervation with the past 6 months ☐ ☐ Yes No

Has had an orthopedic operation within the past 1 year ☐ ☐ Yes No

Has had a dorsal rhizotomy ☐ ☐ Yes No

Has unpredictable seizures ☐ ☐ Yes No

Is non-ambulatory ☐ ☐ Yes No

Printed name of Parent/Guardian__________________________________________

Signature of Parent/Guardian_____________________________________________

Date:________________________________________________________________


Appendix L: Research Protocol Flow Chart


Appendix L: Research Protocol Flow Chart (Continued)


Appendix M: Attendance Records

Date of Therapy

(dd/mm/yyyy)

Time spent on horse

(Minutes)

Time spent on land

(Minutes)

Signature of therapist

Documents

THE EFFECTS OF HIPPOTHERAPY ON THE GROSS MOTOR …fgcu.digital.flvc.org/islandora/object/fgcu:30767/datastream/OBJ/vie… · Doctorate of Physical Therapy By Tara Lacey and Rachael