A Review of the Article, “An Equine Assisted Therapy Intervention to Improve Pain, Range of Motion, and Quality of Life in Adults and Older Adults With Arthritis: A Randomized Controlled Trial” by White-Lewis et al, 2019.1

The Research Sub-Committee of the American Hippotherapy Association, Inc. recently reviewed the article, “An Equine Assisted Therapy Intervention to Improve Pain, Range of Motion, and Quality of Life in Adults and Older Adults With Arthritis: A Randomized Controlled Trial” by White-Lewis et al, 2019.1 

It is wonderful to see more research investigating the use of horse-related activities to improve the health and well-being of individuals with specific medical diagnoses. To date, the majority of published literature describes the incorporation of equine movement by physical therapists, occupational therapists, and speech-language pathologists in treatment to promote functional changes in their patients, with the majority of these studies conducted with patients with neurological disorders and associated impairments, primarily for the pediatric population. White-Lewis, et al completed a trial with adults with arthritis, a musculoskeletal diagnosis, reporting improvements in participant quality of life, range of motion, and pain perception. While this is commended, readers need to interpret the findings with caution. Terminology, clarity of the provided intervention, the small number of participants, and conclusions require careful consideration.

In their literature review, White-Lewis et al cite many studies describing interventions provided by licensed physical or occupational therapists utilizing equine movement (hippotherapy) as a strategy for individual therapy sessions. Describing hippotherapy as a strategy does not align with the current American Hippotherapy Association, Inc.’s description of this intervention. White-Lewis et al refer to their investigation as “equine assisted therapy”. The term “therapy” implies that the service is being provided by a licensed therapist. The use of this term is misleading and not current industry terminology. According to the AHA, Inc’s latest terminology document, “the term, equine assisted therapy does not clarify what the service or profession is within which equine interactions or equine movement are incorporated, which creates the potential for confusion and issues around appropriate conceptualization of the service. The inclusion of equine interactions in treatment is not a stand-alone intervention or a separate form of therapy, which this term may imply. When referring to therapy incorporating horses, it is advised that therapists specify the professional license that they are working under (i.e. physical therapy, occupational therapy, speech-language pathology, or mental health/psychotherapy) and utilize a term that leads with the professional service being provided”.2 In this publication, physical therapy, occupational therapy, and/or speech-language pathology are not being provided. The activities described in this study consist of learning horsemanship skills, riding skills, completing stretches/movements in the equine environment, and bonding with the horse. The movement imparted by the horse, while present, was not individually manipulated by a licensed therapist to the specific needs of the participants. Adaptive riding (AR) more accurately describes the study protocol. It is critical to describe the differences to help promote clarity about the proper utilization of services amongst the healthcare and recreational communities, payment sources, and clients. Additional information about terminology is available on the Resource Page of the American Hippotherapy Association, Inc’s website2, accessed at https://www.americanhippotherapyassociation.org/.

White-Lewis et al describe a study where twenty adults with arthritis were divided into two groups, each receiving an intervention one hour per week for six weeks. A quality of life questionnaire, pain assessment, and goniometry were used to measure changes before and after the six-week experimental activity. One group participated in adaptive riding with grooming/horse related tasks and 30 minutes of mounted stretching and riding skills. The described activities of mounted toe-touches, ankle circles, opposite knee touches, and riding skills provided opportunity for active range of motion and strengthening throughout the sixty-minute session. These sessions were administered by a registered nurse and a PATH Intl. (Professional Association of Therapeutic Horsemanship International) registered instructor. The other group received education on the management of arthritis and were guided to develop an exercise program. The exercise/education group did not participate in any exercise, a well-documented intervention for arthritis.3,4

The authors report changes in joint range of motion (ROM), reported quality of life, via the Arthritis Impact Measurement Scale, a self-report of nine areas: mobility, physical activity, activities of daily living, dexterity, household activities, social activities, depression, and anxiety, and pain.5 The data reflect greater positive changes in all areas in the adaptive riding group versus the education group. The authors conclude that the changes in the adaptive riding were attributed to the mounted component, as well as the human-animal interaction. When interpreting this claim, the following must be carefully considered, as the results may be correlation vs a causative effect:     

  • The group participating in adaptive riding engaged in regular exercise activity, which is proven to decrease pain and improve muscular strength, flexibility, and therefore quality of life,

  • Exercise that is enjoyable, includes social interaction, is purposeful, and varied may promote consistent engagement,

  • The sample size of twenty participants, ten in each group, is small and generalization is difficult,

  • Both groups generally reported significant improvement in pain levels,6

  • The opportunity to engage in horseback riding is a likely motivator for participation/compliance, and this intrinsic benefit cannot be overlooked. 

In summary, we appreciate this investigation comparing adaptive riding to exercise education for individuals with arthritis. With healthcare provider supervision, regular activity will benefit individuals with arthritis. 7,8,9,10 However, we strongly encourage readers of this published study to carefully consider the terminology, the activities of each group, and the stated conclusions.

Thank you for your time and consideration of our critique.

 

The American Hippotherapy Association, Inc. 


References: 

  1. White-Lewis S., Johnson R., Ye S., & Russell C., An equine-assisted therapy intervention to improve pain, range of motion, and quality of life in adults and older adults with arthritis: A randomized controlled trial. Applied Nursing Research. 2019;49:5-12.

  2. AHA, Inc. Terminology for Healthcare, accessed at https://www.americanhippotherapyassociation.org/assets/docs/AHA- %20Recommended%20Terminology.pdf 11/20/2020.

  3. Fernandes L., Hagen K., Bijlsma J., et al, EULAR recommendations for the non pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72:1125–1135. doi:10.1136/annrheumdis-2012-2027. 

  4. Hurley MV, Muscle, Exercise and Arthritis, Annals of the Rheumatic Diseases. 2002;61:673-675. 

  5. Arthritis Impact Measurement Scale (AIMS), Accessed 11/30/2020 at https://www.rheumatology.org/I-Am-A/Rheumatologist/Research/ClinicianResearchers/Arthritis-Impact-Measurement-Scales-AIMS 

  6. Myles P.S., Myles D.B., Galagher W., et al, Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state, BJA: British Journal of Anaesthesia, 2017;118:3;424–429, https://doi.org/10.1093/bja/aew466 

  7. Theis, K.A., Brady, T.J., Helmick, C.G., Murphy, L.B. and Barbour, K.E. Associations of Arthritis‐Attributable Interference with Routine Life Activities: A Modifiable Source of Compromised Quality‐of‐Life. ACR Open Rheumatology, 2019;1: 412-423. https://doi.org/10.1002/acr2.11050

  8. Sokka, T., Häkkinen, A., Kautiainen, H., Maillefert, J.F.,et al. Physical inactivity in patients with rheumatoid arthritis: Data from twenty‐one countries in a cross‐ sectional, international study. Arthritis & Rheumatism, 2008:59: 42-50. https://doi.org/10.1002/art.23255 

  9. Plasqui G., The role of physical activity in rheumatoid arthritis, Physiology & Behavior, 2008;94:2;270-275. ISSN 0031-9384, https://doi.org/10.1016/j.physbeh.2007.12.012

  10. Wallis J.A., Webster K.E., Levinger P., Taylor N.F.,What proportion of people with hip and knee osteoarthritis meet physical activity guidelines? A systematic review and meta-analysis, Osteoarthritis and Cartilage, 2013;21:11:1648-1659, ISSN 1063-4584, https://doi.org/10.1016/j.joca.2013.08.003.

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