Background

Ambulation and Balance Disorders

Patients with spastic cerebral palsy frequently have impaired walking ability due to hyperactive tendon reflexes, muscle hypertonia, and increased resistance to increasing velocity of muscle stretch. These abnormalities result in a lack of selective muscle control and poor equilibrium responses.

Hippotherapy

Hippotherapy has been proposed as a technique to decrease the energy requirements and improve walking in patients with cerebral palsy. It is thought that the natural swaying motion of the horse induces a pelvic movement in the rider that simulates human ambulation. Also, variations in the horse’s movements can prompt natural equilibrium movements in the rider.

Hippotherapy is also being evaluated in patients with multiple sclerosis and other causes of gait disorders, such as strokes.

As a therapeutic intervention, hippotherapy is typically conducted by a physical or occupational therapist and is aimed at improving impaired body function. Therapeutic horseback riding is typically conducted by riding instructors and is more frequently intended as social therapy. It is hoped that the multisensory environment may benefit children with profound social and communication deficits, such as autism spectrum disorder and schizophrenia. When considered together, hippotherapy and therapeutic riding are described as equine-assisted activities and therapies.

This policy addresses equine-assisted activities that focus on improving physical functions such as balance and gait.

Regulatory Status

Not applicable.

Related Policies

• None

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

[RATIONALE: This policy was created in 2009 and has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through January 9, 2019.

Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life, and ability to function - including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, two domains are examined: the relevance, and quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice. The following is a summary of the key literature to date.

Cerebral Palsy

Systematic Reviews

A number of systematic reviews on hippotherapy in children with CP have been published. A 2013 meta-analysis included 5 studies on therapeutic horseback riding and 9 studies on hippotherapy (total n=277 children with spastic CP).^1, Included in the analysis were RCTs and observational studies that compared pre- with post-riding results; 10 of the 14 studies provided level 4 evidence. Reviewers evaluated Gross Motor Function Measures (GMFM) across studies; meta-analysis indicated that short-term hippotherapy (8-10 minutes of total riding time) significantly reduced the asymmetrical activity of the hip adductor muscles and could improve postural control in cases of spastic CP (Gross Motor Function Classification System level <5). However, long-term hippotherapy or therapeutic riding (8-22 hours) did not have a statistically significant effect on GMFM in children with spastic CP. Methodologic limitations included the use of nonvalidated outcome measures, lack of clinically meaningful differences between groups, and in the meta-analysis specifically the inclusion of observational studies (pre-post comparisons) without control groups.

Zadnikar and Kastrin (2011) published a meta-analysis of hippotherapy and therapeutic horseback riding in children with CP.^2, Eight studies meeting inclusion criteria (quantitative study design, outcomes that included postural control or balance) were selected. The meta-analysis included 84 children with CP in the intervention groups and 89 children in the comparison groups (39 with CP, 50 with a disability). The treatment effect on postural control or balance showed a positive effect in 76 (90%) of the 84 children in the intervention groups. In the comparison group of 39 children with CP, 21 (54%) experienced positive effects from the comparison treatment, which consisted of a continuation of their weekly physical therapy and/or occupational therapy, or sitting on a barrel or in an artificial saddle. Although this difference was statistically significant (p<0.001), the clinical significance of the effect cannot be determined from this analysis. Also, the analysis found heterogeneity among the studies, which typically would preclude meta-analysis, and a funnel plot showed asymmetry, indicating possible publication bias. Finally, the inclusion of poor-quality studies in the meta-analysis further limited clinical interpretation.

Randomized Controlled Trials

A 2009 RCT included children ages 4 to 12 years with CP who completed a 10-week session of hippotherapy with pre- and posttreatment assessments obtained from 72 families (representing 35 intervention, and 37 control subjects).^3, Randomization to hippotherapy or a waiting-list control with usual therapy was stratified by age and level of gross motor function. The physical therapist assessor was blinded to randomization, and 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 the parent-reported quality of life and child health scores in the domain of family cohesion. Overall, hippotherapy did not have a clinically significant impact on children with CP.

McGibbon et al (2009) investigated the impact of hippotherapy on the symmetry of adductor muscle activity during walking in children with spastic CP.^4, In phase 1 of the trial, 47 children (age range, 4-16 years) with spastic CP were randomized to a single 10-minute session of 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 children went on to participate in a phase 2, 36-week study (12 weeks without hippotherapy [baseline], 12 weeks of weekly hippotherapy, 12 weeks without intervention). Four of 6 subjects showed improved symmetry during walking after 12 weeks of hippotherapy; this improvement was maintained for an additional 12 weeks posttreatment. All 6 children improved on the 66-item Gross Motor Function Measure (GMFM-66), and 1 child began walking without a walker after 4 weeks of hippotherapy. Five children improved in at least one area of the Self-Perception Profile. The authors noted that the trial had a small sample size in phase 2, spasticity was diversely distributed among subjects, and inclusion criteria led to a sample with mixed characteristics.

Benda et al (2003) used remote surface electromyography to assess outcomes in 15 children (age range, 4-12 years) with CP who were randomized to 8 minutes of hippotherapy or sitting stationary astride a
barrel.^5, The authors reported that the hippotherapy group showed greater symmetry of muscle activity. The clinical significance of this outcome is uncertain.

Kwon et al (2015) published an RCT of hippotherapy in children (age range, 4-10 years) with CP.^6, Ninety-one subjects were randomized to hippotherapy (30 minutes twice weekly) or home-based aerobic exercise, both for 8 consecutive weeks. Significant differences in composite measures of gross motor function improvement using the GMFM-88 and GMFM-66 were observed between groups. Trial limitations included the unclear clinical significance of the outcomes, uncertain attributes of the control group treatment, and lack of long-term outcomes.

Case Series

Sterba et al (2002) reported on the results of an 18-week horseback riding intervention in 17 subjects with CP.^7, GMFM was assessed before and after a once weekly horseback riding program; after 18 weeks, GMFM total score improved by 7.6% and returned to baseline 6 weeks after the program ended.

Section Summary: CP

We identified four RCTs comparing hippotherapy with a control, only one of which involved usual physical therapy and blinded outcomes assessment. The trial with blinded outcome assessment showed no difference between groups in functional status at follow-up, while other trials reported significant between-group differences, which suggests that observed differences might have been due to bias.

Multiple Sclerosis

The use of hippotherapy for patients with MS was addressed in a 2010 systematic review of 3 studies.^8,Included in the review was a comparative study by Silkwood-Sherer and Warmbier (2007), which found that 14 weekly sessions of hippotherapy significantly improved balance in 9 patients with MS compared with a control group of 6 patients.⁹ Each of the other 2 studies in the review, both case series, included 11 subjects; these series also reported improvements in balance with hippotherapy. Reviewers concluded these studies provided emerging evidence that hippotherapy could improve balance in persons with MS, although they acknowledged the small sample sizes, lack of randomization (especially given the variable nature of MS), and lack of controls in two studies.

A 2011 study compared therapeutic horseback riding (with nontherapist riding instructors) with traditional physical therapy in 27 patients who had MS.^9, The therapeutic horseback riding focused on progressively challenging the rider’s motor skills and the individualized physical therapy consisted of aerobic, balance, strengthening, and flexibility exercise sessions. The interventions were self-selected and were provided in 20 sessions over 6 months. The therapeutic horseback riding group showed a significant improvement on the balance subscale of the Tinetti Performance Oriented Mobility Assessment and two gait parameters (stride time, ground reaction forces). Five (42%) of 12 horseback riders showed a clinically significant improvement. Gait speed and cadence and scores on the Extended Disability Status Scale and the Barthel Index did not improve. No significant change was found in the control group. It was not reported whether the changes found after therapeutic horseback riding were significantly greater than those of the physical therapy control group.

In an RCT, Frevel and Maurer (2015) compared an Internet-based home training program with hippotherapy in 18 patients who had MS.^10, In this trial, hippotherapy was considered the control intervention and the home training program the experimental intervention. Although both intervention groups showed significant improvements in static and dynamic balance capacity, no significant differences were found between groups. The trial had weak statistical power to detect a difference between treatments. It cannot be determined from this trial whether hippotherapy is more effective than standard physical therapy.

Section Summary: MS

Current evidence on the use of hippotherapy to treat MS is inconclusive and the studies conducted have been flawed.

Stroke

Lee et al (2014) conducted a small randomized trial assessing hippotherapy for recovery of gait and balance in 30 patients poststroke.¹² Patients were selected if they could walk independently or with a walking aid, had spasticity in a paretic lower extremity as graded by a score of less than 2 on the Ashworth Scale, and could train for more than 30 minutes. Patients were randomized to hippotherapy or treadmill for 30 minutes, 3 days a week, for 8 weeks. At the end of training, gait speed and step length asymmetry ratio were assessed, and balance was measured with the Berg Balance Scale. The hippotherapy group showed significant improvements in balance, gait speed, and step length asymmetry, while the treadmill training group improved only in step length asymmetry. Improvements in gait speed and step length asymmetry were significantly greater for the hippotherapy group than for the treadmill group.

Section Summary: Stroke

The current evidence base on the use of hippotherapy to treat stroke is not sufficiently robust to draw conclusions about efficacy.

Other Gait and Balance Disorders

Comparative studies of hippotherapy and treatments for the outcomes other than balance and gait have been conducted in community-dwelling subjects.^11,12,13, Although they showed some improved outcomes, the study subjects did not have any balance or gait disorders, and so the clinical importance of the findings is unclear. A 2013 prospective U.S. study of 9 older adults (mean age, 76.4 years) with balance deficits found improvements in balance and quality of life measured with a pretest-posttest design.^14, Without a comparison group, it is uncertain to what extent the improvements can be attributed to hippotherapy.

Silkwood-Sherer et al (2012) reported on the efficacy of hippotherapy in a convenience sample of 16 children with mild-to-moderate balance deficits secondary to a variety of disorders.^15, The most common diagnoses were CP (n=5), Down syndrome (n=3), developmental coordination disorder (n=2), and autism (n=2). Baseline and posttreatment Pediatric Balance Scale tests were videotaped and sent in random order to three pediatric physical therapists for scoring. The Activities Scale for Kids-Performance questionnaires were completed by the children or their parents. Hippotherapy sessions, conducted twice weekly for 6 weeks, yielded significant improvements on the Pediatric Balance Scale (from a median of 49.0 to 53.0) and the Activities Scale for Kids-Performance (from a median of 81.7 to 92.1). This trial lacked a control group.

Giagazoglou et al (2012) reported on the effect of hippotherapy on balance and strength in a controlled trial of 19 adolescents with intellectual disability.^16, Balance and strength were assessed using a pressure platform before and after ten weeks of both hippotherapy (n=10) and the nonintervention control (n=9). There were no significant differences between groups in double leg stance or left leg stance; however, there were significant group-by-time interactions in balance with the right leg stance. Measures of strength were improved following hippotherapy, with significant group-by-time interactions. This study is lacked an active therapy control group.

In another small study (2007) of 12 patients with spastic spinal cord injury, hippotherapy resulted in short-term improvements in spasticity and well-being.^17,

Section Summary: Other Gait and Balance Disorders

Current evidence has suggested potential benefit in the treatment of other gait and balance disorders with hippotherapy but the relevant studies lack control groups, which limits the conclusions that can be drawn.

Summary of Evidence

For individuals who have CP, MS, stroke, or gait and balance disorders other than CP, MS, and stroke who receive hippotherapy, the evidence includes systematic reviews, randomized trials, and case series. The relevant outcomes include symptoms and functional outcomes. Studies in CP, MS, stroke, and other indications have had variable findings. The randomized trials are generally small and have significant methodologic problems. In the largest randomized trial conducted to date (72 children), which had blinding outcome assessment, hippotherapy had no clinically significant impact on children with CP. There are no RCTs showing that hippotherapy is superior to alternative treatments for patients with MS. Hippotherapy for other indications has been compared primarily with no intervention and has not been shown to be more effective than other active therapies. The evidence is insufficient to determine the effects of the technology on health outcomes.

SUPPLEMENTAL INFORMATION

Practice Guidelines and Position Statements

No guidelines or statements were identified.

U.S. Preventive Services Task ForceRecommendations

Not applicable.

Ongoing and Unpublished Clinical Trials

Some currently unpublished trials that might influence this review are listed in Table 1.

Table 1. Summary of Key Trials

NCT No.	Trial Name	Planned Enrollment	Completion Date
Unpublished
NCT01372059	The Effects of a Rhythm and Music-based Therapy Program and Therapeutic Riding in Late Recovery Phase Following Stroke18,	123	Jun 2014 (completed)

NCT: national clinical trial.]
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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Hippotherapy
Equine Movement Therapy

References:
1. Tseng SH, Chen HC, Tam KW. Systematic review and meta-analysis of the effect of equine assisted activities and therapies on gross motor outcome in children with cerebral palsy. Disabil Rehabil. Jan 2013;35(2):89-99. PMID 22630812

2. Zadnikar M, Kastrin A. Effects of hippotherapy and therapeutic horseback riding on postural control or balance in children with cerebral palsy: a meta-analysis. Dev Med Child Neurol. Aug 2011;53(8):684-691. PMID 21729249

3. Davis E, Davies B, Wolfe R, et al. A randomized controlled trial of the impact of therapeutic horse riding on the quality of life, health, and function of children with cerebral palsy. Dev Med Child Neurol. Feb 2009;51(2):111-119; discussion 188. PMID 19191844

4. McGibbon NH, Benda W, Duncan BR, et al. Immediate and long-term effects of hippotherapy on symmetry of adductor muscle activity and functional ability in children with spastic cerebral palsy. Arch Phys Med Rehabil. Jun 2009;90(6):966-974. PMID 19480872

5. Benda W, McGibbon NH, Grant KL. Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy). J Altern Complement Med. Dec 2003;9(6):817-825. PMID 14736353

6. Kwon JY, Chang HJ, Yi SH, et al. Effect of hippotherapy on gross motor function in children with cerebral palsy: a randomized controlled trial. J Altern Complement Med. Jan 2015;21(1):15-21. PMID 25551626

7. Sterba JA, Rogers BT, France AP, et al. Horseback riding in children with cerebral palsy: effect on gross motor function. Dev Med Child Neurol. May 2002;44(5):301-308. PMID 12033715

8. Bronson C, Brewerton K, Ong J, et al. Does hippotherapy improve balance in persons with multiple sclerosis: a systematic review. Eur J Phys Rehabil Med. Sep 2010;46(3):347-353. PMID 20927000

9. Munoz-Lasa S, Ferriero G, Valero R, et al. Effect of therapeutic horseback riding on balance and gait of people with multiple sclerosis. G Ital Med Lav Ergon. Oct-Dec 2011;33(4):462-467. PMID 22452106

10. Frevel D, Maurer M. Internet-based home training is capable to improve balance in multiple sclerosis: a randomized controlled trial. Eur J Phys Rehabil Med. Feb 2015;51(1):23-30. PMID 24755773

11. Kim SG, Lee CW. The effects of hippotherapy on elderly persons' static balance and gait. J Phys Ther Sci. Jan 2014;26(1):25-27. PMID 24567669

12. Araujo TB, Silva NA, Costa JN, et al. Effect of equine-assisted therapy on the postural balance of the elderly. Rev Bras Fisioter. Sep-Oct 2011;15(5):414-419. PMID 22002189

13. de Araujo TB, de Oliveira RJ, Martins WR, et al. Effects of hippotherapy on mobility, strength and balance in elderly. Arch Gerontol Geriatr. May-Jun 2013;56(3):478-481. PMID 23290005

14. Homnick DN, Henning KM, Swain CV, et al. Effect of therapeutic horseback riding on balance in community-dwelling older adults with balance deficits. J Altern Complement Med. Jul 2013;19(7):622-626. PMID 23360659

15. Silkwood-Sherer DJ, Killian CB, Long TM, et al. Hippotherapy--an intervention to habilitate balance deficits in children with movement disorders: a clinical trial. Phys Ther. May 2012;92(5):707-717. PMID 22247403

16. Giagazoglou P, Arabatzi F, Dipla K, et al. Effect of a hippotherapy intervention program on static balance and strength in adolescents with intellectual disabilities. Res Dev Disabil. Nov 2012;33(6):2265-2270. PMID 22853887

17. Lechner HE, Kakebeeke TH, Hegemann D, et al. The effect of hippotherapy on spasticity and on mental well-being of persons with spinal cord injury. Arch Phys Med Rehabil. Oct 2007;88(10):1241-1248. PMID 17908564

18. Bunketorp Kall L, Lundgren-Nilsson A, Blomstrand C, et al. The effects of a rhythm and music-based therapy program and therapeutic riding in late recovery phase following stroke: a study protocol for a three-armed randomized controlled trial. BMC Neurol. Nov 21 2012;12:141. PMID 23171380

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

S8940