Hippotherapy has changed lives for the better throughout the United States of America and around the world.

This page will share some of these wonderful stories.

June/July/August/Sept/ 2011

Please click on THIS LINK to read our archived stories!

SHARING STORIES to grow: “Treatment with the help of the horse.”

“Every lock is said to have a key”

Every lock is said to have a key, One day in April 2011, I found that key for me, when I began my hippotherapy with a wonderful group of people

through the Special Strides hippotherapy program.

I am an adult who was born with cerebral palsy.

Susie Rehr, my physical therapist for this “journey,” and her team of very dedicated volunteers, make hippotherapy a  very unique experience, as they find a

way to tailor their program to the needs of each individual’s abilities, from children to adults.

And in my case, Susie had quite a task ahead of her, at least in my opinion.

Age and time for me began showing itself through more and more difficulties with my daily life of living with cerebral palsy, and slowly I began to lose the independence of my mobility.

And for me giving up hope was never an option.

Through Hippotherapy at Special Strides that is exactly what these therapist and volunteers do; they will turn over every proverbial rock to find

the right answer for you, keeping that hope alive, and the results of participating in the hippotherapy program at Special Strides is nothing short of miraculous to me.

As I have begun to regain the mobility I thought may be lost to me.

In riding my horse, I find a connection and a freedom of movement that brings me such serenity.

It is amazing to me how the horse retrains my gait through their strides, and gets me moving again.

It seems almost “effortless” on my part, but believe me it is hard work for me and the horse.

My “journey” with my ever patient and caring physical therapist, Susie, and the other fabulous people and horses in Special Strides Hippotherapy program still continues….

And for that reason I am forever thankful.

~AHA thanks Special Strides of Monroe, New Jersey for sharing this story

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AHA Approved Courses:

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LEVEL II COURSES

THE HORSE CONNECTION: LONG LINING, MAXIMIZING YOUR HORSE’S POTENTIAL

BraveHearts at the Bergmann Centre, IL                                                                                   Aug 24 & 25, 2013

BUSINESS CONNECTION: HOW TO SETUP A PRACTICE INCORPORATING HIPPOTHERAPY

SENSORY CONNECTION: SENSORY CONCEPTS, THEORY AND APPLICATIONS IN HIPPOTHERAPY

THE CORE CONNECTION:THE LINK BETWEEN HIPPOTHERAPY AND CORE CONTROL:

No classes currently scheduled. Please check back for updates on this course.

THE COMMUNICATION CONNECTION: MAXIMIZING COMMUNICATION FOR THE NON-SLP

The NEURO CONNECTION 

Therapy Services at Ride On, CA                                                                         May 3-4, 2013

THE CORE CONNECTION:THE LINK BETWEEN HIPPOTHERAPY AND CORE CONTROL

MUSCLES IN MOTION

Related Courses:

HPCS REVIEW COURSE

USEF CLASSIFIER WORKSHOP FOR PARA EQUESTRIAN

The following facilities offer therapy in which hippotherapy is an included treatment strategy:

AHA is saddened to inform its members of the death of Barbara Heine, PT on March 30, 2010. Barb had been diagnosed with Mantle Cell Cancer in August 2009 and has been battling the disease since that time.

While living in the United States, Barb served as Executive Director of NCEFT in Woodside, CA.

Barb’s contributions to hippotherapy in the states and in Australia have been numerous. Barb served as education chair for AHA and for 3 years as AHA’s President. For all the therapists and instructors who have taken the AHA courses, you have all been the recipients of the educational tapes that Barb produced while at NCEFT.

Barb was instrumental in putting together the Level II course and the Long Lining course. Barb developed a manual for Australian therapists on hippotherapy and is credited with training, establishing and the credentialing of Australian hippotherapy programs.

The International Scholarship Fund was subsidized by Barb and through her generosity therapists in Russia, China and Mexico have been able to take the Level I AHA course.

Barb was one of the founding members of the American Hippotherapy Certification Board. In honor of Barb’s superior and vast equine skills, AHA had established the Barb Heine Horse of the Year award.

For the hippotherapy community, the loss of Barb will be a void impossible to fill. To Barb’s children we send our deepest condolences.

It is with great sadness that we pass along the news that Barb Glasow, PT, HPCS passed away on May 23, 2009, after a long battle with breast cancer. For those of us that saw Barb at the AHA conference earlier this month, it is hard to believe that she is no longer with us. Barb’s intelligence, wit and foresight, her strength of character and toughness were an inspiration to friends and colleagues.

In an email Pat Sayler, Barb’s partner of 23 years, wrote: “I cannot tell you how much the visit to the Conference meant to Barb; she was on such an upswing, planning her article, excited that people still appreciated her thoughts and insights. She truly missed being involved. She was thrilled to see so many new faces in the membership, knowing that as things evolve the work of AHA and hippotherapy will continue. It was a great 2 weeks for us both and, I, too, am so glad that we made the effort to come.”

Barb will be missed by all whose lives she has touched.

Obituary for Barbara L. Glasow, PT
May 23, 2009

Barbara L. Glasow, 55, passed away on Saturday morning, May 23rd in Pocono Medical Center after a long battle with breast cancer. Born in Rochester, NY she was the daughter of Robert and the late Muriel Glasow.

Barbara was Senior Class Valedictorian at Cardinal Mooney High School in Rochester, NY and graduated Summa Cum Laude in Physical Therapy from Ithaca College, NY.

After graduating college, she lived in Warwick, NY, where she began her private practice. A gifted pediatric physical therapist, she worked with Winslow Therapeutic Riding, LTD and initiated a developmental approach in the use of the movement of the horse to create functional changes in individuals with disabilities. In 1978 she began teaching seminars, and in 1982 traveled to Denmark as the PT with the US NASCP Equestrian Team to compete in the 5th International CP Games. Called the “grandmother of Hippotherapy” by her colleagues, Barbara was instrumental in fostering the creation of the American Hippotherapy Association (AHA) and the furtherance of the use of the horse in treatment by physical, occupational and speech therapists. She was the recipient of the NARHA James Brady Professional Achievement Award and the perpetual Barbara Glasow Award for AHA Therapist of the Year.

Barbara was the PT and a former Board Member for Equi-librium, Inc. Equine Assisted Services. She was a member of Zion United Church of Christ in Stroudsburg, the American Physical Therapy Association, NARHA, and AHA.

She is survived by her partner of 23 years, Patricia J. Sayler, of Effort, PA, her father, Robert A. Glasow, her brother Timothy Glasow and his wife Maryann, her sister Andrea Glasow, her nephew, Jason Glasow and fiance Stephanie Ewert.

A Celebration of Barbara’s life will be held at 2:30pm on Sunday, June 14 at Zion United Church of Christ, 14 North 8th Street, Stroudsburg, PA with fellowship to follow after the service.

In remembrance of Barbara, memorial donations may be made to Equi-librium, Inc., P.O. Box 305, Sciota, PA 18354, Zion United Church of Christ, 14 North 8th Street, Stroudsburg, PA 18360 or American Hippotherapy Association, Inc. 9919 Towne Road Carmel, Indiana 46032. Condolences may be made online at www.poconorecord.com.

Reminiscences of a Early Pioneer
by Barbara L. Glasow, PT

To have the moniker of “grandmother of Hippotherapy” in the US makes a person feel a little old sometimes. For it was only a few years ago . . . .that I was just a college student working on a research report on “Therapeutic Riding.” Back then, in 1973, it was more than a little difficult to do a literature search on a topic that was in its infancy. Virginia Martin of Winslow Unlimited and Borderland Farm in Warwick, NY was one of my chief supporters in this endeavor. What solidified my career-long interest in TR and HPOT was being at the premiere viewing of the Winslow film “Exceptional Equestrians” that was shown at the 1973 NARHA meeting in Washington, DC It was the fact that the film focused on how riding horses could be therapeutic as well as fun that hooked me.

After graduating from Ithaca College in PT, one of my many serendipitous decisions was to live in Warwick, NY and offer my PT services to Winslow as a consultant to the TR program. In those days TR was mostly about finding ways to adapt horseback riding for people with disabilities and trying to make it safe. However, it was not always therapeutic for the most physically involved riders. Within a few years, I had helped Winslow radically change their approach to TR by taking away saddles and reins, using surcingles and pads and using a more developmental approach with a focus on developing balance, symmetry, alignment and postural control in the rider and using progressive movement variations of the horse to challenge the rider before shifting focus back to developing riding skills. This turned into the beginnings of the specialization of TR with the foundations of developmental vaulting, remedial vaulting and HPOT, but without those names.

Virginia Martin was not one to hide anyone’s light under a barrel. She felt we should share this new approach with everyone. By 1978 I was thrust into the “national” limelight and started to teach in one of many seminars offered by Winslow. Anyone attending my early seminars will tell you there were plenty of rough edges. One participant later told me she had counted 150 “ums” during the 3 day course. Nowadays, people tend to have more trouble getting me to be quiet.

By the early 1980′s, I was doing courses in the Eastern US and Canada, having an impact on the quality of programs in the region. By 1982 I had the opportunity to accompany the US NASCP Equestrian Team as the PT with Jan Spink as one of the coaches, to the 5th International CP Games in Greve, Denmark with riding as a demonstration sport. By then, I also knew that the Germans were doing some interesting things with the medical application of the horse, something called “hippotherapy.” The trip to Europe gave me the excuse to stay eight weeks longer after the competition with Jan Spink to visit a variety of German HPOT programs. We ended up at the 4th International Congress on TR in Hamburg, Germany.

How enlightening! The Germans were doing the same thing on the other side of the ocean that I had been doing for the past 6 or 7 years without me knowing it! I must say the German horses might have had a little better quality of movement and training than I had been used to. The long lining was something I definitely wanted to learn. But they used the same progressions of movement (plus a few fancy ones like leg yield, side pass, and shoulder-in). However, I thought the American version, despite our horses, had a few pluses beyond the German approach. I was using more alternative positions than the Germans and had integrated principles of Sensory Integration which made it more available to a wider population of clients. I figured I could take the best of both worlds and end up with a better product.

The 4th International Congress on TR was probably the 1st congress that the Germans ever took any notice of the Americans. Beth Stanford, PT, was one of my early proteges and had started an excellent therapy program for clients with head trauma in Malvern, PA. She had enough gumption to present to this prestigious group. Well, there are head phones to listen to the simultaneous translations, which is a challenge in and of itself. Beth started her presentation with great slides of her adult head trauma clients being backridden backwards on this wonderful, one-of-a-kind horse. (Don’t try to do this in your program!) Within a few minutes the Germans were scrambling for head phones to hear her presentation with a number of questions posed at the end. Thanks to Beth, our American reputation was forever changed in a positive way. Realizing the importance of international exchange, Jan Spink and I composed a “Report on the United States” that was presented with the other country papers. The bonding was established. International relations progressed a bit further.

In 1984, NARHA sponsored Dr. Ingrid Strauss, a neurologist from Germany and a leader in HPOT, to give a 2 day course on HPOT in Amherst, MA. In November 1984, I taught my first 3 day clinical course on HPOT with the content and format that was the precursor to the present day AHA Introduction to HPOT course. The interest grew and a number of past and present AHA Board members took my early HPOT courses including Linda Mitchell, Liz Baker, Claudia Morin, and Marcee Rosenzweig.

By 1986, it was evident that more therapists were needed to be able to teach the basics of HPOT to make an impact and long term difference in the field. Enter Jean Tebay, the “mother of HPOT.” Jean was a great supporter of HPOT and had always been a visionary in TR. We were together at the 1986 NARHA annual awards banquet in Las Vegas when Jean decided to change history. Jean has many talents and is a great organizer. She pulled Jane Copeland (Fitzpatrick), PT, then prominent in the Delta Society, over to the table to confer on the idea that we needed to train a core group of PT’s and OT’s in the fundamentals of HPOT. We needed to keep the group together to develop a standardized curriculum that could be taught all across the country. Since the Germans already had a standardized curriculum in place for their PT’s, it made the most sense to ask them to create a course designed for Americans. On that night, Jean made the commitment to organize a trip to Wildbad, Germany, and Jane and I made the commitment to be part of the adventure.

Within the year, with no money and no sponsoring organization other than Jean’s non-profit Therapeutic Riding Services, Inc., Jean had made arrangements with the Kuratorium fur Therapeutische Reiten to custom tailor a composite 10 day course that combined elements of their two part course. The trio picked a cross section of 17 PT’s and OT’s from dozens who had applied; got Angela Dusenbury, PT, to be our wonderful translator; and, hired with grant money, Loretta Rowley, PhD, to be the Curriculum Development Specialist.

The infamous group from the US and Canada were:

Ellen Adolphson, PT
Liz Baker, PT
Teresa Barnes, PT
Jane Copeland Fitzpatrick, PT
Barbara Engel, OT
Barbara Glasow, PT
Jill Hansen-Byrne, OT
Judy Hillburn, OT
Pippa Hodge, PT
Carolyn Jagielski, PT
Neesa Johnson, OT
Molly Lingua-Mundy, PT
Nancy McGibbon, PT
Linda Mitchell, PT
Claudia Morin, OT
Christine Terry, PT
Colleen Zanin, OT

After the trip, Gertrude Freeman, PT, Teddy Parkinson, PT, Marcee Rosenzweig, PT and Jean Waldron, PT also played early and important roles in the group.

Further interest in HPOT was fueled in the US in June 1987, with a 6 day course taught by Frau Ursula Stamm, PT, from the Wildbad Clinic in Germany, at the National Center for Equine Facilitated Therapy in Woodside, CA, which I was fortunate enough to attend. Then, the momentous day arrived and “the group” flew from various parts of the country, and met, some for the first time, in Wildbad, for the American HPOT course of October 1987.

After long days of lessons, riding, and practicums presented by the Germans . . . the real work started. That’s when Jean Tebay and Loretta Rawley got to lead us through the DACUM (Developing a Curriculum) process. DACUM is a formal group process of curriculum development that uses workers involved in the field; identifies the duties and tasks that are used in the field; and from that, develops objectives for each task and determines the education and training needed to achieve the objectives. There we were, sitting in a classroom, tired and brain dead, being cajoled to come up with the duties and tasks of a therapist doing HPOT, writing our brilliant ideas on pieces of paper taped up all around the room. Other than our fearless leaders, we had no idea where this was going to lead.

The trip to Wildbad over, the commitment to the project continued as the National Hippotherapy Curriculum Development Committee. In the next 2 years, 4 major meetings were held in Tucson, Toronto, San Francisco, and Warwick. By November 1989, pilot test copies of 3 core curricula were presented to the Delta Society (the sponsoring organization for grants) at its annual meeting in Parsippany, NJ. The curricula developed became the basis for the present AHA courses.

From 1990 to 1992, the group began to change and evolve and its purpose shifted. An average of 2 major meetings per year continued to be held in various parts of the country. The focus shifted to fleshing out the curricula and developing audiovisuals and materials to go with each course.

Participants in the courses being taught were responding positively. More and more people attending the courses were asking for more than just the course information. They wanted networking; information on topics outside of the courses; an intermediate level course; and assistance with research ideas.

It became obvious that a more formal and permanent organization needed to be formed. The field of TR was in transition. Many of the people that were more connected with health professions and academia had been attracted to the Delta Society and its tract for TR. Delta had been supportive of our group and welcomed the possibility of a more formal affiliation with us. NARHA was struggling over a variety of issues including the direction the organization should take. There were a number of elements within the NARHA membership that were pulling the organization in several directions.

Our group had many long and serious talks about what to do. We discussed becoming a separate organization, affiliating with the Delta Society; becoming a section of the APTA, AOTA or ASHA; developing a section under NARHA; or becoming a separate, non-profit, independent organization. None of us wanted the headaches of fund raising , or the responsibility of maintaining non-profit status. Section status within APTA or AOTA could develop into several separate professional organizations, potentially splintering the group. Questions arose concerning how we could maintain consistency among several groups; how we could foster quality across disciplines; how we could encourage teaming or transdisciplinary treatments. We kept coming back to either Delta Society or NARHA, which had the ability to house all the disciplines within one organization. Delta Society had the professionalism and the setting of standards that we wanted to foster. Though, TR was only one small aspect of it’s focus. NARHA, on the other hand, was the organization that most people looked to as the national organization for TR. It housed all the various people and groups that HPOT included. And, there was a part of NARHA that was very supportive of our group and liked the direction we were taking.

By 1991, the group had developed a Mission statement, Philosophy statement and Vision and had worked on an in depth strategic plan and analysis of options. The analysis included: trends and events impacting HPOT; needs of people interested in HPOT; needs of the HPOT group as an organization; strengths and weaknesses of the group and strengths and weaknesses of Delta and NARHA. Based on this analysis, we decided to approach NARHA with the idea of developing a professional section with separate bylaws, finances and Board of Directors. The idea of a section had been researched based on the structures of APTA, AOTA, the NDTA and SII (Sensory Integration International). A meeting was held on July 21,1991 with NARHA with encouragement to have the proposal formally presented to the NARHA Board. It was a momentous meeting that I was pleased to be a part of.

On February 28, 1992, the national HPOT Curriculum Development Committee formally met in Sarasota, FL with myself as the Chair. At that meeting the Mission Statement, Vision and philosophy were formally approved. Jane Copeland (Fitzpatrick) made the motion to “form an organization that promotes professional growth among physical and occupational therapists and others interested in utilizing the horse in a treatment approach based on principles of HPOT and to have the first meeting of the organization.” The motion was adopted unanimously. An additional motion made by Nancy McGibbon was that “this organization proceed as an independent organization pending the approval of Section status by the NARHA Board of Directors.” Founding member status was established as “those nationally registered and/or state licensed physical or occupational therapists who have been involved in the National HPOT Curriculum Development Committee the entire time since its inception in 1987.”

Founding members are:

Elizabeth Baker, PT
Terri Barnes, PT
Jane Copeland (Fitzpatrick), PT
Gertrude Freeman, PT
Barbara Glasow, PT
Pippa Hodge, PT
Carolyn Jagielski, PT
Linda Mitchell, PT
Molly Lingua-Mundy, PT
Nancy McGibbon, PT
Claudia Morin, OT
Marcee Rosenzweig, PT

The first meeting of the Board of Directors of the American Hippotherapy Association (AHA) was held the very next day. By the end of the meeting, Nancy McGibbon was elected as the first President, the bylaws were passed, and committee structures and goals were established. I got the role of continuing officially in the capacity of Secretary. The financial structure would be managed through support of a pass through fund working in liaison with Mary Nastan, PT and her therapeutic riding program, Suncoast Therapeutic Equestrian Program in Florida.

In the following months, a letter inviting AHA Charter membership was sent out with an invitation to get involved on the ground floor. On November 11, 1992, the first annual meeting of the membership of the AHA was held at Tyson’s Corner, VA at the same time that the NARHA annual conference was held. During the NARHA annual conference, NARHA member signatures were gathered to support a petition for Section status within NARHA. At the January 30, 1993 NARHA Board of Directors meeting, a unanimous vote was cast to accept the proposal of AHA to become the first special interest Section of NARHA. It was a landmark occasion, soon to be followed by the acceptance of additional sections within NARHA. The AHA is forever grateful to former NARHA President, Marion May, for helping it to occur.

So where are we now? I stayed on the AHA Board until 1997 and then rotated off due to health and family issues. However, in this day of e-mail it seems I have almost as many AHA projects on my plate as in the past. Now, in its 7th year as a Section, AHA is operating under its 4th President. Out of the present 15 on the Board, only 3 are original Founding Members which is where we hoped we would be by now. It gives me great pleasure to see a vision come into being and have it be as much or more than the original vision. We have achieved many of the original goals and many are in process. There are 3 established curricula that are in constant change when needed. There is a registration process, and now, a well thought out certification process. We developed competencies and then standards. HPOT is now part of the NARHA accreditation process. There is still more to do but it feels good that I no longer need to worry about whether HPOT will die out if I am no longer active in the field. It has been a long road and the road still extends far into the future with research to be done and efficacy studies to be completed. At times I feel like the “grandmother of hippotherapy” but also as a proud one, with many children and grandchildren that any grandmother would be proud of to call part of the family.

By Barbara L. Glasow, PT

An exuberant therapist recently thought . . .”I just learned about the most wonderful new treatment that I have ever been involved with since becoming a therapist. It’s called hippotherapy!! The movement of the horse is almost magical with the results that can be achieved! I’m hooked! I’m going to stop using most of the other treatment approaches that I’ve used for 10 years and I going to become a hippotherapist and devote myself to learning everything I can about it. Then, I’m going to open a clinic devoted exclusively to the practice of hippotherapy and achieve amazing results. And then, we’ll need to do research to prove to everyone that this modality is the best treatment around for any patient with movement dysfunction. Where was this treatment when I needed inspiration in my career a few years ago?”

Enthusiasm and exuberance is wonderful. The energy we derive from something that excites us can carry us through some pretty rough times of rapid change in health care, increasing documentation demands, decreasing health insurance coverage and increasing scrutiny by managed care. Those of us who include hippotherapy in our practice would tend to agree that it is a very valuable treatment strategy and assists us in achieving functional outcomes sometimes more efficiently than with other means.

However, in these same times of increasing managed care, decreasing coverage and increasing scrutiny it is of critical importance that all therapists accurately state clearly what they are providing patients within their treatment plans and neither under nor overstate what is being done or why. Many of us have made hippotherapy out to be more than it really is and the word itself has not been helpful to us in gaining the recognition and reimbursement that we want for it.

Hippotherapy, from the word “hippos”, the Greek word for horse, was created by the Germans who use all kinds of compounds words in their language. Hippotherapy is a very logical word for them to create. It means “treatment with the help of the horse.” Physical therapists there get trained and certified and can say they are “hippotherapists”, physical therapists that treat with the horse, in the same manner as they have “hippologists”, people who train horses. As Americans, we have chosen to retain the use of the word, “hippotherapy”, thinking that it would be internationally easier to communicate with other professional colleagues around the world. Presently, over 24 countries are doing some type of medical treatment with the use of the horse and most are calling it hippotherapy.

In the United States, however, the use of the word “hippotherapy” is a very confusing term to physicians, researchers and third party payers. To them, the word hippotherapy implies that it is a unique and distinctly different treatment approach from what has ever been done before. In their eyes, it needs to be proven through research that it is effective; improves functional outcomes; and is as good as or better than other treatments. Until then they view hippotherapy as a new, emerging and investigational technology and so therefore it does not qualify for reimbursement at the present time.

When we argue that hippotherapy is a treatment strategy and not a modality or distinct treatment method it is argued back that other treatment tools don’t have the word “therapy” in it. An easy reply is that “Swiss therapy balls” are used in a wide variety of treatment procedures and are clearly treatment tools. But this does not make our lives any easier. Unfortunately, we have done such a good job of spreading the word about hippotherapy that we are probably stuck with the word for better or worse. So, all we can do is to take care in what we say about it.

We have all been guilty in misrepresenting what hippotherapy is or is not from NARHA to AHA to myself who wrote an article in 1984 “Hippotherapy – The Horse as a Therapeutic Modality”. Many clinicians casually use the terms “treatment tool” and “modality” interchangeably. As innocent as that is, the two terms mean very different things. Therapists use a wide variety of treatment tools (any instrument or device necessary to one’s profession or occupation) including gymnastic balls, scooters, balance beams, weights within the different treatment procedures of neuromuscular reeducation, therapeutic exercise or therapeutic activities. We expect to be reimbursed for the treatment procedure we provide NOT the treatment tool that is used. Modalities (“Any physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electric energy.”) are very different from procedures and each require their own CPT code for reimbursement. Modalities must also be FDA approved and go through the investigational technology review of insurance carriers. It is very clear, when carefully thought about, that the horse is not a modality, yet how often have we referred to hippotherapy as such?

Many of us feel that we are able to achieve quicker and better functional outcomes with the use of the horse, and in the future, hopefully sufficient research will support this conclusion. In the meantime though, we need to be educating others that hippotherapy is an inclusive term that refers to all the ways the horse can be used as a treatment strategy. Hippotherapy is NOT one separate new treatment method. Instead, therapists use the horse in a variety of treatment approaches that been used in the therapy field for years, including the neurodevelopmental treatment approach, sensory integration, motor learning, motor control, psycholinguistics. The way the horse is used for each patient depends on the needs of the specific patient, the expertise of the therapist and the training of the horse.

When we refer to using the horse or equine movement as a treatment strategy within a therapeutic procedure it is then very appropriate to bill for units of service depending on how the strategy is used. APTA and AOTA have both agreed that use of the CPT codes 97110 (therapeutic exercise), 97112 (neuromuscular education), 97530 (therapeutic activities) or 97770 (sensory integrative activities) could all be appropriate codes depending on how the tool of the horse is used by a therapist within a treatment procedure. However, when therapists call the reimbursement department of APTA to inquire how the treatment approach of “hippotherapy” should be coded, APTA has been reluctantly but correctly recommending recently (since the Korokti administrative insurance hearing occurred) that therapists use the code 97799 (for unlisted therapeutic procedure) which then requires that additional documentation be submitted in order to be reviewed for reimbursement. In this case, the therapist has presented hippotherapy as a unique treatment and since it does not have its own code number, the unlisted procedure code should be used. If instead, the therapist inquires how to code a treatment session in which neuromuscular reeducation is used in order to improve the patient’s postural control, balance and body awareness and the horse is used as a treatment tool to assist in that process, APTA would concur that use of the code 97112 for neuromuscular reeducation would be appropriate. I think you begin to see the importance of how we state what we are doing.

Many of us state that we have hippotherapy practices or that we are hippotherapists. We offer hippotherapy programs and we often market hippotherapy as a unique treatment approach to potential patients. We probably all have stated something to that effect in the past. This is great from a marketing perspective but has helped in creating the insurance backlash that we are currently facing. How might we state more clearly and correctly what we are doing?

When we are trained in hippotherapy we do not become hippotherapists but remain therapists (physical therapists, occupational therapists, speech-language pathologists) that include hippotherapy in their practice.

We offer physical therapy services (or OT, SLP) that include:

• hippotherapy
• hippotherapy as a treatment strategy
• the use of the horse in treatment
• the movement of the horse in treatment
• equine movement in treatment. Hippotherapy can be a strategy of choice used by therapists within their treatments. The new definition of hippotherapy very succinctly states what it is and what it is used for. The hippotherapy certification exam, if passed, allows therapists to state that they are a hippotherapy clinical specialist, (a clinician that includes hippotherapy in their practice and has a high level of knowledge in hippotherapy). When we obtain prescriptions for treatment the prescriptions state PT, OT, or SLP not hippotherapy since the prescription needs to state the service that is being requested. (It may state “. . . that includes hippotherapy.”)

When we use semantics correctly it sometimes seems that it takes a lot spontaneity out of life. Is it really that important to be politically correct all the time? That’s a hard question. Many of us speak more casually when explaining to a lay person what treatment they will be getting and what it will do for them in less technical terms. However, if we want to get reimbursed for the treatment we need to document what we do in much more technical and medical terms. It seems that we need to clearly make the same distinction in semantics when we speak about hippotherapy. It may require a little reflection on our part to become aware of what we are saying and in doing so we may become better educators of others in what hippotherapy is really all about.

Summary of the Do’s & Don’t of Hippotherapy Semantics

• Hippotherapy is a treatment strategy NOT a modality, unique treatment approach, form of therapy or treatment.
• Hippotherapy is NOT new. It’s been used for over 20 years in the U.S. in treatment.
• Therapists are NOT hippotherapists nor do they practice hippotherapy or have a hippotherapy practice.
• Therapists DO include hippotherapy in their practice; use the horse as a treatment tool; use the horse in treatment; use the movement of the horse in treatment or use equine movement in treatment.
• Hippotherapy can be considered a “strategy of choice.”
• Hippotherapy can be considered an inclusive term that refers to all the ways the horse can be used as a treatment strategy by PT’s, OT’s and SLP’s.

When certified by the American Hippotherapy Certification Board the therapist is a hippotherapy clinical specialist.

Hippotherapy has begun to attract attention from the medical community.
One physician even owns a program.

By Greg Borzo
AMNews correspondent.

June 17, 2002

Whoever put up the old sign in a corner of the stable probably had no idea how it would apply so poignantly. “Time spent in the saddle is never wasted,” it reads. And some say this adage sums up hippotherapy — including the program run by the physician-owned EquiTherapy Center from the back arena of an elegant stable in suburban Chicago.

But many of the patients with developmental disorders, neuromuscular disabilities or skeletal impairments who receive hippotherapy here don’t need to look to the sign for motivation. They’re already fired up.

More likely, it’s the therapists, volunteers and staff who take the message to heart. They are part of a growing, national effort to show hippotherapy makes a difference, at least for some patients some times.

Despite facing initial and widespread skepticism, HPOT supporters are increasingly having success demonstrating its value.

“Awareness and acceptance are growing,” says Norman White, MD, medical director at Presbyterian Health Plan in Albuquerque, N.M., which recently began reimbursing for HPOT on a case-by-case basis.

“It may appear to have a recreational flavor, but hippotherapy holds immense promise of therapeutic benefit for a variety of conditions, when used in concert with other therapies,” says Stephen T. Glass, MD, child neurologist in Woodinville, Wash. He refers patients for hippotherapy so frequently that it’s printed on his prescription pad.

Why a horse?

Hippotherapy uses the multidimensional movements of a horse to achieve specific therapeutic functional outcomes. Specially trained physical therapists, occupational therapists and speech-language pathologists use selected horses as mobile therapeutic treatment tools.

A horse’s rhythmic, repetitive movements work to improve muscle tone, balance, posture, coordination, strength, flexibility and cognitive skills. The movements also generate responses in the patient that are similar to and essential for walking. In addition, adjusting to and accommodating for the horse’s movements increases sensorimotor integration.

Therapists address various therapeutic goals by having patients ride in different positions: sitting or laying forwards, backwards or sideways; standing in the stirrups; and riding without holding. In addition, therapists have patients stretch, reach or play games — such as catch — while on the horse.

Used widely in Europe for more than 50 years, HPOT was introduced in the United States in the 1970s. Today the North American Riding for the Handicapped Assn. has accredited some 700 therapeutic riding centers. About 150 offer HPOT, according to the American Hippotherapy Assn. — a section of the riding association formed in 1992. AHA has registered almost 400 therapists to provide HPOT and certified about 35 hippotherapy clinical specialists.

The difference between therapeutic riding and HPOT is important. Therapeutic riding is supervised recreational riding for people with disabilities. HPOT, on the other hand, is a medical therapy provided under a physician’s prescription. Patients who are successful with HPOT often progress to therapeutic riding.

In most cases, sessions are weekly and last 30 minutes. Horses must be gentle, patient and trained. The horses are often small to accommodate the most typical HPOT patients: children, even as young as 18 months.

Supporters maintain a horse can provide better results than conventional methods for some outcomes. “In some cases HPOT is the only way I can achieve certain treatment goals,” says Joann Benjamin, a physical therapist certified in hippotherapy who is also secretary of AHA.

“We’re not talking about pony rides,” says Don Vichick, MD, an Albuquerque orthopedic surgeon. “Hippotherapy can be an effective component of a total therapy package.”

Able-bodied people don’t realize how hard it is on kids with disabilities and their families, says emergency physician Jeff Lee, MD, the owner of EquiTherapy in Morton Grove, Ill. “Their disabilities are forever, but hippotherapy can make a difference, medically and functionally.”

Motivation plays a big part. Many children with disabilities have spent a lot of time hospitalized, sometimes tethered to machines, says Bethany Lee, executive director of the National Center for Equine Facilitated Therapy in Woodside, Calif., the nation’s largest HPOT program. “Many of them come to dislike their therapist, at least in a traditional setting.”

Put kids on a horse, though, and they light up, says Ellen In, a physical therapist at EquiTherapy. “Sometimes they don’t even realize they’re working, because just sitting on a horse is comparable to working on a ball. Riding a horse presents constant yet engaging balance and postural challenges.”

HPOT gets results because kids love the experience, Lee says. “Some have a picture of their horse on the wall. For countless kids, their first word was not ‘mama’ but ‘giddy up’ or the name of their horse!”

Limited but mounting evidence

Still, HPOT faces a certain degree of skepticism, mainly because there continues to be a lack of hard research supporting such heart-warming sentiments. “The lack of evidence-based research is hindering further acceptance,” Dr. White says.

AHA calls promoting research one of its main challenges. Still, a growing body of scientific study is building a case.

A 1998 study in Developmental Medicine & Child Neurology investigated the effects of an eight-week course of twice-weekly HPOT on five children with spastic cerebral palsy. After HPOT, all children showed a significant decrease in energy expenditure during walking and a significant increase in scores on walking, running and jumping of the gross motor function measure. In addition, a trend toward increased stride length and decreased cadence was observed.

“The strong results warrant further investigation,” says lead author Nancy McGibbon, a therapist at Therapeutic Riding of Tucson, Ariz. “Unfortunately, physical therapists are not, by nature, researchers.”

One reason HPOT is hard to study is that scientists have yet to devise ways to measure its impact objectively. The Institute for Human Performance, Rehabilitation and Biomedical Research at the State University of New York’s Upstate Medical University has set out to rectify this, combining clinical and applied research spaces. Two case studies using computerized gait analysis have demonstrated that HPOT improves kinematic parameters of gait in children with CP.

“Given the growing interest in hippotherapy, we’ll continue to broaden our search for objective results,” says Suchita Kulkarni-Lambore, PhD, an assistant professor at SUNY Upstate and a physical therapist who co-authored the studies.

In a yet-to-be published study, Bill Benda, MD, associate research scientist at the University of Arizona in Tucson, investigated the effect of eight minutes of hippotherapy on 15 children with spastic CP. They measured truncal and upper leg muscle activity during sitting, standing and walking using remote surface electromyography. All subjects were randomized to HPOT or sitting astride a stationary barrel.

Muscle activity in microvolts was recorded from electrodes placed on bilateral thoracic, lumbar, abductor and adductor muscles. The difference between each pretest and posttest asymmetry was calculated and converted to a percentage score.

The mean change toward symmetry was 65% after eight minutes of HPOT and no change after eight minutes astride a barrel. “The difference was statistically significant,” Dr. Benda says. “The next step is to replicate the study with a larger sample size, followed by a multicenter study of 12 weeks.”

Reimbursement issues, questions

Because scientific findings are limited, HPOT reimbursement policies and practices vary considerably. Although AHA does not track third-party payment, it recently launched a survey to determine which payers have HPOT reimbursement policies and what those policies are.

Typical of those who cover HPOT is Harvard Pilgrim Health Care, which pays only when HPOT is part of a supervised physical or occupational therapy program provided by one of the plan’s contracted vendors.

On the other hand, Aetna Inc. does not cover HPOT. Its policy: “There is insufficient scientific data in peer-reviewed medical literature to support the effectiveness of hippotherapy for the treatment of patients with CP or other motor dysfunction.”

Meanwhile, many payers do not have a policy or pay for therapy without determining the type of treatment. And in rare situations, this ambiguity has led to difficulties. One Maryland therapist was asked to return $56,000 in reimbursement payments because the payer felt the use of HPOT had been concealed. The therapist filed a complaint with the state insurance commission, maintaining that she had coded her work appropriately. This action first led to a ruling in the therapist’s favor, which was later reversed on appeal.

Still, many HPOT programs, including EquiTherapy, accept only out-of-pocket payments. Rates range from $70 to $150 per half-hour session.

Even though billing questions persist, there is considerable agreement that when HPOT is provided it should be done under a physician’s order. There are many contraindications for HPOT, and only a physician can determine whether HPOT is safe and appropriate for a given patient.

“In many cases, physicians are not aware of hippotherapy until a patient’s family brings it to their attention, but a physician should be the one to evaluate the patient and approve the therapy,” McGibbon says.

When they first hear about HPOT, many physicians question the safety of putting a person with disabilities on a horse. Nevertheless, HPOT’s safety record is outstanding, according to AHA. Often, the therapist rides with a patient the first few sessions. And sidewalkers on each side of the horse ensure the rider’s safety.

“We’ve had plenty of riders fall or get hurt on the able-bodied side of this stable, but none on the therapy side,” says Nicholas Coyne, EquiTherapy manager and owner of the center’s 12 horses. Coyne carefully selects suitable horses. Some are former police horses that are “unflappable.” Thanks to the number of horses, therapists are able to match patients with the most appropriate horse in terms of gait, pace, size and character.

The quality of horses as well as the training and skills of therapists are crucial. Some programs are not reputable and others are not medically qualified, Dr. Vichick warns. “Hippotherapy can be effective, but check out any program before you make a referral.”

“If someone invented a pill that achieved the benefits of hippotherapy, you can be sure it would be prescribed and reimbursed,” Dr. Benda says.

ADDITIONAL INFORMATION:

Conditions most often treated by hippotherapy:

• Cerebral palsy
• Multiple sclerosis
• Down syndrome
• Developmental delay
• Autism
• Stroke
• Traumatic brain injury
• Spinal cord injury
• Spina bifida
• Convulsive disorders
• Amputation
• Muscular dystrophy

Riders taught him value of HPOT

When Jeff Lee, MD, bought the Morton Grove Equestrian Stables in 1995, he didn’t know anything about hippotherapy. Some of his riders did, however, and he soon became intrigued.

Dr. Lee, an emergency physician, joined the North American Riding for the Handicapped Assn., took HPOT courses and worked as a sidewalker for several months. Then, in 1997, he started the EquiTherapy Center, hiring Nicholas Coyne as manager in 1999. Two therapists now work there part-time, but Coyne wants to hire several more.

The program’s 12 horses, together with the automobile traffic they generate, kick up a lot of dust — which sometimes triggers efforts by local residents to try to curtail his activities. “They want us to become invisible,” he says.

Instead, Dr. Lee plans to expand. This summer, he hopes to begin operating from a large new stable he built expressly for HPOT. It may even include an area for conventional therapy. Meanwhile, he plans to affiliate with a university to train students and conduct HPOT research.

Dr. Lee understands why many physicians are skeptical about HPOT, in part because of its unconventionality and in part because of stories of nefarious activity surrounding horses.