THE EFFECTS OF HIPPOTHERAPY ON THE GROSS MOTOR...
Transcript of THE EFFECTS OF HIPPOTHERAPY ON THE GROSS MOTOR...
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.
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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
HIPPOTHERAPY AND CEREBRAL PALSY 5
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
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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
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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
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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).
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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
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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.
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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
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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).
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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.
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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
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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
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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, &
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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
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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?
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● 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
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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
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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
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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
HIPPOTHERAPY AND CEREBRAL PALSY 23
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
HIPPOTHERAPY AND CEREBRAL PALSY 24
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.
HIPPOTHERAPY AND CEREBRAL PALSY 25
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.
HIPPOTHERAPY AND CEREBRAL PALSY 26
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.
HIPPOTHERAPY AND CEREBRAL PALSY 27
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.
HIPPOTHERAPY AND CEREBRAL PALSY 28
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.
HIPPOTHERAPY AND CEREBRAL PALSY 29
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.
HIPPOTHERAPY AND CEREBRAL PALSY 30
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
HIPPOTHERAPY AND CEREBRAL PALSY 31
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
HIPPOTHERAPY AND CEREBRAL PALSY 32
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.
HIPPOTHERAPY AND CEREBRAL PALSY 33
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.
HIPPOTHERAPY AND CEREBRAL PALSY 34
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.
HIPPOTHERAPY AND CEREBRAL PALSY 35
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HIPPOTHERAPY AND CEREBRAL PALSY 38
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
HIPPOTHERAPY AND CEREBRAL PALSY 39
Appendix A: Gross Motor Function Measure (Continued)
2013 Dianne Russell and Peter Rosenbaum, McMaster University. All rights reserved. Page 2 of 6
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
HIPPOTHERAPY AND CEREBRAL PALSY 40
Appendix A: Gross Motor Function Measure (Continued)
2013 Dianne Russell and Peter Rosenbaum, McMaster University. All rights reserved. Page 3 of 6
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
HIPPOTHERAPY AND CEREBRAL PALSY 41
Appendix A: Gross Motor Function Measure (Continued)
2013 Dianne Russell and Peter Rosenbaum, McMaster University. All rights reserved. Page 4 of 6
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:
HIPPOTHERAPY AND CEREBRAL PALSY 42
Appendix A: Gross Motor Function Measure (Continued)
2013 Dianne Russell and Peter Rosenbaum, McMaster University. All rights reserved. Page 5 of 6
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
HIPPOTHERAPY AND CEREBRAL PALSY 43
Appendix A: Gross Motor Function Measure (Continued)
2013 Dianne Russell and Peter Rosenbaum, McMaster University. All rights reserved. Page 6 of 6
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
= = %
HIPPOTHERAPY AND CEREBRAL PALSY 44
Appendix B: Parent/Guardian Reported Outcome Survey
HIPPOTHERAPY AND CEREBRAL PALSY 45
Appendix B: Parent/Guardian Reported Outcome Survey (Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 46
Appendix C: Letter of Agreement
HIPPOTHERAPY AND CEREBRAL PALSY 47
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
HIPPOTHERAPY AND CEREBRAL PALSY 48
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
HIPPOTHERAPY AND CEREBRAL PALSY 49
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
(Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 50
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
(Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 51
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
(Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 52
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
(Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 53
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
(Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 54
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
(Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 55
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
(Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 56
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
(Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 57
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
(Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 58
Appendix E: Bit-By-Bit Medical Therapeutic Riding Center Registration Packet
(Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 59
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
HIPPOTHERAPY AND CEREBRAL PALSY 60
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
HIPPOTHERAPY AND CEREBRAL PALSY 61
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.
HIPPOTHERAPY AND CEREBRAL PALSY 62
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
HIPPOTHERAPY AND CEREBRAL PALSY 63
Appendix H: HIPAA Waiver
HIPPOTHERAPY AND CEREBRAL PALSY 64
Appendix H: HIPAA Waiver (Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 65
Appendix H: HIPAA Waiver (Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 66
Appendix I: Recruitment Flyer
HIPPOTHERAPY AND CEREBRAL PALSY 67
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
HIPPOTHERAPY AND CEREBRAL PALSY 68
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…
HIPPOTHERAPY AND CEREBRAL PALSY 69
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…
HIPPOTHERAPY AND CEREBRAL PALSY 70
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:________________________________________________________________
HIPPOTHERAPY AND CEREBRAL PALSY 71
Appendix L: Research Protocol Flow Chart
HIPPOTHERAPY AND CEREBRAL PALSY 72
Appendix L: Research Protocol Flow Chart (Continued)
HIPPOTHERAPY AND CEREBRAL PALSY 73
Appendix M: Attendance Records
Date of Therapy
(dd/mm/yyyy)
Time spent on horse
(Minutes)
Time spent on land
(Minutes)
Signature of therapist