Critically Appraised Paper & Understanding Impact Factors

Wood, W. H., & Fields, B. E. (2019). Hippotherapy: A systematic mapping review of peer-reviewed research, 1980 to 2018. Disability and Rehabilitation. DOI: 10.1080/09638288.2019.1653997

Journal Impact Factor: 2.054

What is an Impact Factor? 

 

Introduction:

AHA currently defines hippotherapy as the use of equine movement as a treatment tool to promote functional outcomes; occupational therapists, physical therapists, and speech-language pathologists incorporate this treatment tool as part of their plan of care. Previous reviews of hippotherapy have either been inconclusive, or established that the research supporting hippotherapy is in early stages of scientific development. In the family of review research, systematic mapping reviews are the review of choice to implement when a body of literature is in early stages of scientific development, as they are broad in scope and include literature at varying levels of rigor. This particular systematic mapping review was informed by a phased, developmental approach to understand how complex interventions are empirically advanced. That is, research on complex interventions begins with early formulation of key elements of the intervention and its underlying treatment theory, progresses to proof of concept studies, investigation of acceptability and feasibility, and finally enters into studies of treatment efficacy and effectiveness. The purpose of this systematic mapping review was to “systematically and thoroughly gather, describe, categorize, and synthesize, or map, published research of hippotherapy as a guide to future research initiatives.”

Methods:

To conduct this systematic mapping review, investigators searched 9 databases for peer-reviewed literature related to hippotherapy. Based on extensive inclusion/exclusion criteria, reviewers included 78 research studies published from 1980 – 2018 that were primarily focused on hippotherapy; papers focused solely on the horse in hippotherapy were excluded. Reviewers then used a data extraction tool to extract relevant information from each study. Extracted information was related to: countries of publication, hippotherapy definitions, participant demographics, provider’s backgrounds, dosing, intervention components, research designs, treatment theories, and outcomes. Authors then used Microsoft Excel pivot tables to produce frequency counts and proportions.

Results:

Results are presented in tables that display key data (e.g. participants, providers, intervention components, outcomes, etc.) found in each paper. These tables may be a helpful reference for researchers and clinicians, particularly if looking for hippotherapy research on a specific topic.
In general, studies were published in 18 different countries, most commonly the US, Korea, and Brazil. Definitions varied across studies on a continuum that authors differentiated as “hippotherapy-writ-small” where hippotherapy was defined as the use of equine movement as a treatment strategy or tool, to “hippotherapy-writ-large” where hippotherapy was defined in an all-encompassing manner as therapy with the help of the horse. Research participants most often were diagnosed with Cerebral Palsy, followed by Down syndrome, autism, or intellectual disability. Participant age ranged from 2 – 92, although studies including children, adolescents and young adults were most common. Physical therapists were most often identified as providers. However, contribution of providers to the intervention were often not developed. Dosage was quite variable, with number of sessions ranging from 1 – 104 (average 18), and length of sessions ranging from 8 – 90 minutes (average 38). The most commonly identified components of hippotherapy were participants mounted on a moving horse, and changes in horses gaits and speeds. Studies varied in their description of hippotherapy, from including only these basic components, to including many more dynamically-interacting components, sometimes including unmounted activities such as grooming.
Research methods were mostly quantitative; most studies implemented single-subject or pre-post designs; there were also eighteen randomized controlled trials. Outcomes largely demonstrated improvements in motor performance (e.g. postural control, balance, coordination, functional mobility). A pervasive theory of change across studies focused on the therapeutic benefit of equine movement.

Limitations

This review had few limitations. First, the searches may have missed studies not yet indexed in scientific databases, and excluded papers not published in English. Second, consistent with systematic mapping review methods, authors did not conduct a quality assessment of studies included in the review, and therefore cannot make conclusions regarding the rigor of hippotherapy research. Finally, patterns described in the review only reflect peer-reviewed literature, and may not reflect real-world practices.

Critique

Overall, the findings from this study are strong as the authors adequately reported methods, limitations, and overall trends in the literature. Consistent with limitations of systematic mapping reviews, findings from this review cannot be used to determine treatment efficacy, as rigor of the studies included in the review was not assessed.

Clinical Bottom Line

As a whole, results suggest the landscape of hippotherapy research is broadening (i.e. clients served, outcomes addressed, etc.). This review establishes proof-of-concept that hippotherapy can improve motor outcomes for specific populations: children with cerebral palsy, autism, Down syndrome, intellectual disabilities; and adults with multiples sclerosis and other neurological conditions. In addition, it supports an empirically-based treatment theory focused on the therapeutic use of equine movement. However, this review also illuminates gaps in foundational work needed to progress research of hippotherapy; namely, clarity in terminology, full formulation of intervention components, and contributions of providers to the intervention. In particular, authors recommend use of the term “hippotherapy” to mean use of equine movement as a treatment tool, not a comprehensive service in and of itself; this recommendation aligns with the AHA’s terminology guidelines. As research continues to progress, it will be necessary to clearly describe how hippotherapy is integrated into, but not synonymous with, comprehensive services provided by OTs, PTs, and SLPs. Such clarity in terminology will foreground importance of discipline-specific knowledge necessary to implement hippotherapy, and highlight important differences amongst complex interventions provided by OTs, PTs and SLPs that incorporate equine movement, but are not reducible to it.

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