Hippotherapy Policy Number: 8.03.12 Last Review: 7/2014 Origination: 7/2008 Next Review: 1/2015 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will not provide coverage for Hippotherapy. This is considered investigational. When Policy Topic is covered Not Applicable When Policy Topic is not covered Hippotherapy is considered investigational. Description of Procedure or Service Hippotherapy, also referred to as equine movement therapy, describes physical therapy using a horse. Hippotherapy has been proposed as a type of physical therapy for patients with impaired walking or balance. Background Patients with spastic cerebral palsy frequently have impaired walking ability due to hyperactive tendon reflexes, muscle hypertonias, and increased resistance to increasing velocity of muscle stretch. These abnormalities result in a lack of selective muscle control and poor equilibrium responses. Hippotherapy has been proposed as a technique to decrease the energy requirements and improve walking in patients with cerebral palsy. It is thought that the natural swaying motion of the horse induces a pelvic movement in the rider that simulates human ambulation. In addition, variations in the horse s movements can also prompt natural equilibrium movements in the rider. Hippotherapy is also being evaluated in patients with multiple sclerosis and developmental disorders such as Down syndrome. Hippotherapy is a therapeutic intervention that is typically conducted by a physical or occupational therapist and is aimed at improving impaired body function. Therapeutic horseback riding is typically conducted by riding instructors and is more frequently intended as social therapy. It is hoped that the multi-sensory environment may be beneficial to children with profound social and communication deficits, such as autism spectrum disorder and schizophrenia. When considered together, hippotherapy and therapeutic riding are described as equine-assisted activities and therapies. This policy addresses equine-assisted activities that focus on improving physical functions such as balance and gait. Simulated hippotherapy using a new device has been studied in European centers. Therapeutic interventions using such a device would be conducted in the physical/occupational therapy setting and are outside the scope of this policy. Rationale When this policy was created in 1999, the majority of the literature regarding hippotherapy consisted of small case series,(1,2) most of which were published in the German literature. One small randomized study of 19 patients was identified that reported no significant effects in the majority of outcome measures.(3) Since 1999 the policy has been updated periodically using the MEDLINE database. The
most recent literature update was conducted through September 20, 2013. Following is a summary of key studies to date. Literature Review Cerebral Palsy A number of systematic reviews on hippotherapy in children with cerebral palsy have been published. One of the systematic reviews concluded that there was evidence from 1 or more randomized controlled trials (RCTs) of fair quality studies that a short intervention of hippotherapy is effective for treating muscle symmetry in the trunk and hip when compared with static sitting.(4) The review found 3 quasi-experimental studies with positive results for gross motor function and functional performance in the home and community. Another systematic review reported that 5 of 6 moderate quality studies (small sample sizes and lack of a control nonriding group) found improved gross motor function in children with cerebral palsy.(5) A systematic review from 2009 concluded that strong evidence indicates that children and adolescents with developmental disabilities derive health benefits from participation in group exercise programs, treadmill training, or therapeutic riding/hippotherapy; however, 3 of the studies included in the review showed that therapeutic horseback riding is no more effective than other therapies for improving muscle tone in children with cerebral palsy and that it is no more effective than no intervention for posture, self-esteem, and global behavior.(6) In 2011, Zadnikar and Kastrin published a meta-analysis of hippotherapy and therapeutic horseback riding in children with cerebral palsy.(7) Included were 8 studies that met the inclusion criteria of a quantitative study design and outcomes that included postural control or balance. There was no minimum number of subjects (1 of the studies described 2 children) and the median quality score was 10.5 out of a maximum of 16 (range, 5 to 13). The meta-analysis included 84 children with cerebral palsy in the intervention groups and 89 children in the comparison groups (39 with cerebral palsy and 50 nondisabled). The treatment effect on postural control or balance, which was coded as a dichotomous outcome (positive effect or no effect), showed a positive effect in 76 of the 84 children (90%) in the intervention group. In the comparison group, 21 of the 39 children (54%) with cerebral palsy felt positive effects from the comparison treatment, which consisted of continuation of their weekly physiotherapy and/or occupational therapy, or sitting on a barrel or in an artificial saddle. Although this difference was statistically significant, the clinical significance of the effect cannot be determined from this analysis. In addition, the analysis found heterogeneity among the studies, which typically would preclude meta-analysis, and a funnel plot showed asymmetry, indicating a possible publication bias. This meta-analysis is also limited by the inclusion of poor quality studies. A 2012 meta-analysis included 5 studies on therapeutic horseback riding and 9 studies on hippotherapy with a total of 277 children with cerebral palsy.(8) Both randomized controlled trials and observational studies were included that evaluated preriding compared with postriding results; 10 of the 14 studies provided level 4 evidence. Methodologic limitations of the studies included use of nonvalidated outcome measures and lack of clinically meaningful differences between groups. Meta-analysis indicated that 8-10 minutes of hippotherapy reduced asymmetrical activity and improved postural control, but long-term hippotherapy or therapeutic riding (8-22 hours) did not have a statistically significant effect on Gross Motor Function Measures in children with spastic cerebral palsy. A limitation of this meta-analysis is the inclusion of observational studies (pre-post comparisons) without a control group. In 2009, a randomized trial was published that included 72 children (85% of the 99 families enrolled) aged 4 to 12 years with cerebral palsy who completed a 10-week session of hippotherapy with pre- and posttreatment assessments.(9) Randomization to hippotherapy or a waiting-list control with usual therapy was stratified by age and level of gross motor function. The physiotherapist assessor was blinded to the randomization, and the participants were asked not to mention if they had completed the intervention at the time of the assessment. No differences between the hippotherapy and control groups were found for functional status (therapist-assessed) or child-reported quality of life. Minor differences were found in parent-reported quality of life and child health scores in the domain of family
cohesion. Overall, hippotherapy was not found to have a clinically significant impact on children with cerebral palsy. McGibbon et al. investigated the impact of hippotherapy on symmetry of adductor muscle during walking.(10) In Phase I of the trial, they randomly assigned 47 children aged 4-16 years with spastic cerebral palsy to receive a single 10-minute session of either hippotherapy or barrel sitting. Adductor muscle symmetry was measured before and after the session. The hippotherapy group demonstrated a statistically significant difference in adductor symmetry after this single intervention. Six of the children went on to participate in a Phase II, a 36-week study (12 weeks without hippotherapy [baseline], 12 weeks of weekly intervention, and 12 weeks without intervention). Four of 6 subjects showed improved symmetry during walking after 12 weeks of intervention, and improvement was maintained after 12 more weeks. All 6 children improved on the Gross Motor Function Measure-66, and 1 child began walking without a walker after 4 weeks of hippotherapy. Five children improved in at least 1 area of Self-Perception Profiles. The authors note a number of limitations of the study including small sample size in Phase II, the diversity of subjects in the distribution of their spasticity, and the inclusion of children with mixed characteristics. Other examples of the primary literature include a study by Sterba et al., who reported on the outcomes of horseback riding in 17 subjects with cerebral palsy.(11) Gross motor function measurements were assessed before and after a once weekly horseback-riding program for 18 weeks. Gross motor function total scores improved by 7.6% after 18 weeks, returning to baseline 6 weeks after the program ended. In another study, Benda et al. used surface electromyography to assess outcomes in 15 children with cerebral palsy who were randomly assigned to either horseback riding or to sitting stationary astride a barrel.(12) The authors reported that the hippotherapy group showed greater symmetry of muscle activity. The clinical significance of this outcome is uncertain. A series of 11 children aged 5 to 13 years with cerebral palsy demonstrated improved trunk/head stability and upper extremity reaching/targeting after 12 weekly 45-minute sessions of hippotherapy.(13) Results were compared with those of 8 children without disability who did not receive an intervention. The impact of hippotherapy versus other forms of therapy directed to trunk/head stability and upper extremity reaching cannot be determined from this study. Multiple Sclerosis Hippotherapy for patients with multiple sclerosis was addressed in a 2010 systematic review of 3 studies.(14) Included in the review is a case control study by Silkwood-Sherer and Warmbier that found that 14 weekly sessions of hippotherapy improved balance in 9 subjects with multiple sclerosis in comparison with a control group of 6 patients.(15) Each of the other studies, both case series, included 11 subjects. The review concluded that the studies provided emerging, but limited, evidence that hippotherapy improves balance in persons with multiple sclerosis while acknowledging limitations of small sample size, lack of randomization, especially given the variable nature of multiple sclerosis, and lack of controls in 2 studies. Another nonrandomized controlled study compared therapeutic horseback riding (with nontherapist riding instructors) versus traditional physiotherapy in 27 patients with multiple sclerosis.(16) The therapeutic horseback riding focused on progressively challenging the rider s motor skills while the individualized physiotherapy consisted of aerobic, balance, strengthening, and flexibility exercise sessions. The interventions were self-selected and were provided in 20 sessions over 6 months. The therapeutic horseback-riding group showed a significant improvement in the balance subscale of the Performance-Oriented Mobility Assessment (POMA) and 2 gait parameters (stride time and ground reaction forces). Five of 12 horseback riders (42%) showed a clinically significant improvement. Gait speed and cadence and the Extended Disability Status Scale and the Barthel Index were not significantly improved. No significant change was found in the control group. It was not reported if the changes found after therapeutic horseback riding were significantly greater than those of the physiotherapy control group.
Balance Deficits in Older Adults Araujo et al. reported a nonrandomized controlled trial with 17 older adults in 2011 and a randomized controlled trial with 28 participants in 2013.(17,18) In the 2011 study, 16 hippotherapy sessions led to an improvement in the Timed Up and Go (TUG) test in the hippotherapy group compared both with baseline performance and with controls. Balance on a force platform did not differ significantly between the groups. In the 2013 study, 16 hippotherapy sessions over 8 weeks resulted in greater improvement in the Berg Balance Scale and 30s Chair Stand Test compared to controls, with a trend (p= 0.068) toward greater improvement in the TUG. A prospective U.S. study of 9 older adults (mean age, 76.4 years) found improvements in balance and quality of life when measured with a pretest-posttest design.(19) Other Silkwood-Sherer et al. reported on the efficacy of hippotherapy in a convenience sample of 16 children with mild to moderate balance deficits secondary to a variety of disorders.(20) The most common diagnoses were cerebral palsy (n=5), Down syndrome (n=3), developmental coordination disorder (n=2), and autism (n=2). Baseline and post-treatment Pediatric Balance Scale tests were videotaped and sent in a randomized order to 3 pediatric physical therapists for scoring. The Activities Scale for Kids-Performance questionnaires were completed by the children or their parents. Hippotherapy sessions, conducted twice per week for 6 weeks, resulted in a significant improvement on the Pediatric Balance Scale (from a median of 49.0 to 53.0) and the Activities Scale for Kids-Performance (from a median of 81.7 to 92.1). This study is limited by the lack of a control group. Giagazoglou et al. reported the effect of hippotherapy on balance and strength in a controlled trial of 19 adolescents with intellectual disability.(21) Balance and strength were assessed with a pressure platform before and after 10 weeks of hippotherapy (n=10) and at the same time points in the nonintervention control group (n=9). There were no significant differences between the groups in Double Leg Stance or Left Leg Stance; however, there were significant group-by-time interactions in balance with the Right Leg Stance. Measures of strength were improved following hippotherapy, with significant group-by-time interactions. This study is limited by the lack of an active therapy control group. Another small study of 12 patients with spastic spinal cord injury found hippotherapy to result in shortterm improvements in spasticity and well-being.(22) Ongoing Clinical Trials Bunketorp Kall et al. have reported an ongoing randomized trial of hippotherapy in the late recovery phase following stroke (NCT01372059).(23) The study has an expected enrollment of 120 patients with results expected in early 2014. Summary Literature on hippotherapy is limited, primarily consisting of uncontrolled case series and small controlled trials from outside the U.S. In the largest randomized trial conducted to date (72 children), hippotherapy was found to have no clinically significant impact on children with cerebral palsy. Hippotherapy for other indications has been compared primarily with no intervention and has not been shown to be more effective than other active therapies. The literature at this time does not support the conclusion that hippotherapy is as effective as the existing alternatives and does not demonstrate improvement in net health outcome. Therefore, the treatment is considered investigational. References
1. Bertoti DB. Effect of therapeutic horseback riding on posture in children with cerebral palsy. Phys Ther 1988; 68(10):1505-12. 2. McGibbon NH, Andrade CK, Widener G et al. Effect of an equine-movement therapy program on gait, energy expenditure, and motor function in children with spastic cerebral palsy: a pilot study. Dev Med Child Neurol 1998; 40(11):754-62. 3. Mackinnon JR, Noh S, Lariviere J et al. A study of therapeutic effects of horseback riding for children with cerebral palsy. Phys Occup Ther Pediatr 1995; 15(1):17-34. 4. Snider L, Korner-Bitensky N, Kammann C et al. Horseback riding as therapy for children with cerebral palsy: is there evidence of its effectiveness? Phys Occup Ther Pediatr 2007; 27(2):5-23. 5. Sterba JA. Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy? Dev Med Child Neurol 2007; 49(1):68-73. 6. Johnson CC. The benefits of physical activity for youth with developmental disabilities: a systematic review. Am J Health Promot 2009; 23(3):157-67. 7. Zadnikar M, Kastrin A. Effects of hippotherapy and therapeutic horseback riding on postural control or balance in children with cerebral palsy: a meta-analysis. Dev Med Child Neurol 2011; 53(8):684-91. 8. Tseng SH, Chen HC, Tam KW. Systematic review and meta-analysis of the effect of equine assisted activities and therapies on gross motor outcome in children with cerebral palsy. Disabil Rehabil 2012. 9. Davis E, Davies B, Wolfe R et al. A randomized controlled trial of the impact of therapeutic horse riding on the quality of life, health, and function of children with cerebral palsy. Dev Med Child Neurol 2009; 51(2):111-9; discussion 88. 10. McGibbon NH, Benda W, Duncan BR et al. Immediate and long-term effects of hippotherapy on symmetry of adductor muscle activity and functional ability in children with spastic cerebral palsy. Arch Phys Med Rehabil 2009; 90(6):966-74. 11. Sterba JA, Rogers BT, France AP et al. Horseback riding in children with cerebral palsy: effect on gross motor function. Dev Med Child Neurol 2002; 44(5):301-8. 12. Benda W, McGibbon NH, Grant KL. Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy). J Altern Complement Med 2003; 9(6):817-25. 13. Shurtleff TL, Standeven JW, Engsberg JR. Changes in dynamic trunk/head stability and functional reach after hippotherapy. Arch Phys Med Rehabil 2009; 90(7):1185-95. 14. Bronson C, Brewerton K, Ong J et al. Does hippotherapy improve balance in persons with multiple sclerosis: a systematic review. Eur J Phys Rehabil Med 2010; 46(3):347-53. 15. Silkwood-Sherer D, Warmbier H. Effects of hippotherapy on postural stability, in persons with multiple sclerosis: a pilot study. J Neurol Phys Ther 2007; 31(2):77-84. 16. Munoz-Lasa S, Ferriero G, Valero R et al. Effect of therapeutic horseback riding on balance and gait of people with multiple sclerosis. G Ital Med Lav Ergon 2011; 33(4):462-7. 17. Araujo TB, Silva NA, Costa JN et al. Effect of equine-assisted therapy on the postural balance of the elderly. Rev Bras Fisioter 2011; 15(5):414-9. 18. de Araujo TB, de Oliveira RJ, Martins WR et al. Effects of hippotherapy on mobility, strength and balance in elderly. Arch Gerontol Geriatr 2013; 56(3):478-81. 19. Homnick DN, Henning KM, Swain CV et al. Effect of therapeutic horseback riding on balance in community-dwelling older adults with balance deficits. J Altern Complement Med 2013; 19(7):622-6. 20. Silkwood-Sherer DJ, Killian CB, Long TM et al. Hippotherapy--an intervention to habilitate balance deficits in children with movement disorders: a clinical trial. Phys Ther 2012; 92(5):707-17. 21. Giagazoglou P, Arabatzi F, Dipla K et al. Effect of a hippotherapy intervention program on static balance and strength in adolescents with intellectual disabilities. Res Dev Disabil 2012; 33(6):2265-70. 22. Lechner HE, Kakebeeke TH, Hegemann D et al. The effect of hippotherapy on spasticity and on mental well-being of persons with spinal cord injury. Arch Phys Med Rehabil 2007; 88(10):1241-8. 23. Bunketorp Kall L, Lundgren-Nilsson A, Blomstrand C et al. The effects of a rhythm and music-based therapy program and therapeutic riding in late recovery phase following stroke: a study protocol for a three-armed randomized controlled trial. BMC Neurol 2012; 12:141.
Billing Coding/Physician Documentation Information S8940 Equestrian/Hippotherapy, per session Additional Policy Key Words N/A Policy Implementation/Update Information 7/1/08 New policy; considered investigational. 1/1/09 No policy statement changes. 7/1/09 No policy statement changes. 1/1/10 No policy statement changes. 7/1/10 No policy statement changes. 1/1/11 No policy statement changes. 7/1/11 No policy statement changes. 1/1/12 No policy statement changes. 7/1/12 No policy statement changes. 1/1/13 No policy statement changes. 7/1/13 No policy statement changes. 1/1/14 No policy statement changes. 7/1/14 No policy statement changes. State and Federal mandates and health plan contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The medical policies contained herein are for informational purposes. The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents Blue KC and are solely responsible for diagnosis, treatment and medical advice. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, photocopying, or otherwise, without permission from Blue KC.