Occupational Therapy, Physical Therapy, and Speech-Language Pathology Incorporating Hippotherapy is a Safe Therapeutic Option

White Paper:  Occupational Therapy, Physical Therapy, and Speech-Language Pathology Incorporating Hippotherapy is a Safe Therapeutic Option 

The American Hippotherapy Association, Inc (AHA, Inc.) promotes the integration of hippotherapy, or the purposeful manipulation of equine movement, into a client’s plan of care. AHA, Inc’s mission is to “improve lives by advancing education, best practices and resources for licensed healthcare professionals who incorporate horses in therapy”.1 Since its inception, licensed occupational therapy (OT), physical therapy (PT), and speech-language pathology (SLP) professionals have worked to ensure the safety of their clients during treatment.  This paper is intended to provide information on the safety of the incorporation of hippotherapy into therapy practice.  

Association-level Supports

The AHA, Inc. supports best safety practices by hosting courses and conferences and disseminating resources and toolkits.1 AHA, Inc. has created a “Statements of Best Practice for the Use of Hippotherapy by Occupational Therapy, Physical Therapy, and Speech-Language Pathology Professionals ” document to promote quality professional care and evidence-based practice, and include clinician expertise, environmental recommendation, equine training, and equipment use.2  Further, the AHA, Inc. has several committees which strive to develop, disseminate, and support safe, ethical, evidence-based clinical practice and education of all stakeholders.  The American Physical Therapy Association (APTA), the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA) recognize and endorse the use of hippotherapy as a standard practice tool.1 

Research

In the United States, PT, OT and SLP professionals have integrated hippotherapy into treatment since the 1980's.   Since that time, numerous research studies have been published regarding the favorable impact of this tool on PT, OT, and SLP outcomes.3-12 

In the early 2000s, Cook collected and later published over 10 years of data regarding safety considerations when equines were incorporated into PT, OT, and SLP treatment.14-17   The study found an incident rate of 0.04% across all  PT, OT, and SLP treatments incorporating hippotherapy.14-17 Further, no statistically significant relationship was found between the therapy professions (PT, OT, and SLP) and injury occurrence.  When compared to studies on general equestrian hospitalizations, treatment sessions incorporating hippotherapy demonstrated significantly lower injury hospitalization rates.14, 17, 18 Cook suggested that the top three risk management strategies were investment in staff education, screening and training of therapy horses, and proactive management of therapy during weather emergencies.  

A study by Leveille et al. (2017) highlighted parents’ perspectives on safety during OT, PT, and SLP incorporating hippotherapy.19 They found that parents have minimal fear regarding the use of equine movement and equine interactions within their child's treatment sessions, but also indicated that parents may not fully understand precautions, contraindications, and inherent risks. Most recently a descriptive survey study by Peters, Fields, and Erdman (2020) demonstrated that PT, OT, and SLP professionals reported low occurrence of incidence and injury; 0.05% of treatment sessions required basic first aid and 0.01% required additional medical care or follow up.  Their findings also demonstrated that recommended safety practices are widely adopted and include use of safety equipment such as American Society for Testing and Materials/Safety Equipment Institute (ASTM/SEI) approved riding helmets, quick release safety stirrups, and practice of preventative measures, such as emergency transfers.20 These authors plan to redistribute the survey over the next five years to continue to track practice and safety patterns.  


A review of published summaries of physical therapy liability claims report the top three locations for “severe” injury occurrence are in the long-term care/nursing home setting, school, or acute care hospital/surgical setting. 21 Peters et al report zero liability claims in their survey of clinicians incorporating hippotherapy.20 Additional liability claim/occurrence information regarding therapy incorporating equine interactions and/or equine movement by PT, OT, and SLP professionals is not reported.   The APTA in the United States and the World Confederation of Physical Therapy advocate for clinician education/knowledge of their scope of practice, inherent risks in their practice setting, and availability/use of protective equipment.22,23  

Awareness, education, and proactive risk management are strategies supported by many therapy professions.23-26 

Informed by this evidence, the AHA, Inc asserts that horses can be safely incorporated into PT, OT and SLP practice, if appropriate risk management practices are followed. Similarly to other therapeutic settings (i.e. home, clinic, hospital), providing therapy in an equine environment involves setting-specific risks and safety hazards that must be proactively managed. Therefore, the AHA, Inc suggests all therapists incorporating horses into their services follow suggestions put forth in the AHA, Inc Statements of Best Practice for the Use of Hippotherapy by Occupational Therapy, Physical Therapy, and Speech-Language Pathology Professionals.

Conclusion

In summary, the AHA, Inc. and OT, PT, and SLP professionals play a key role in educating the public as well as clients with disabilities across the lifespan about the evidence supporting equine interactions and/or equine movement used as a therapy tool in therapy practices.  Evidence indicates that, when recommended safety practices are implemented, the risk of injury from treatment incorporating hippotherapy is quite low. Knowledge of the indications, precautions, contraindications, and inherent risks are included in the continuing education provided by the AHA, Inc. to therapists. This promotes client safety through the therapist's application of the recommended guidelines for practice.


References

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  2. American Hippotherapy Association, Inc. Statements of Best Practice for the Use of Hippotherapy by Occupational Therapy, Physical Therapy, and Speech-Language Pathology Professionals, accessed 5/22/2020 at     https://www.americanhippotherapyassociation.org/assets/docs/Final-2017-Best-Practice-2.pdf.

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  1. Leveille, A., Rochette, A., Mainville, A. Perceived risks and benefits of hippotherapy among parents of children currently engaged in or waiting for hippotherapy: A pilot study. Physiotherapy Theory and Practice Volume 33, 2017 - Issue 4.

  1. Peters C, Fields B, Erdman, A. Hippotherapy Practice and Safety Patterns in the United States: A Descriptive Survey Study".  The Journal of Alternative and Complementary Medicine - Paradigm, Practice and Policy Advancing Integrative Health, publication pending.

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