Mira Lessick, PhD, RN Robyn Shinaver, BIS, MT, ASCP Kimberly M. Post, RN Jennifer E. Rivera, AS Betty Lemon, RN, MSN, CNS

Mira Lessick, PhD, RN Robyn Shinaver, BIS, MT, ASCP Kimberly M. Post, RN Jennifer E. Rivera, AS Betty Lemon, RN, MSN, CNS

Mary is a 43-year-old grade school teacher who suffered a stroke following a motor vehicle accident. She was injured three months ago and has left-sided hemiparesis, an unsteady gait and difficulty maintaining trunk control. She needs assistance in walking, and can only walk short distances. In view of her limitations, she often becomes frustrated and depressed. A nurse in the women s health center where Mary receives her primary care and rehabilitation referred her to a local therapeutic riding program. After four weeks of horseback riding Mary s balance improved. She was then able to bend forward and straighten up as the horse walked, and she could stand in the stirrups. She could also swing her left arm back and forth, but she could not get her horse to move by kicking her feet. Six months after her lessons began, Mary rode with her back straight and can now sit to trot with improved arm and leg strength. She is independent in walking and uses a cane. The horseback riding experience also improved her emotional outlook and self-concept. Horses as Therapy Agents The horse has been used as a therapeutic agent since the time of the ancient Greeks, and Hippocrates once spoke of riding s healing rhythm (Bliss, 1997). Early Greeks were reported to offer horseback rides to raise the spirits of people who had incurable illnesses (Bizub, Joy, & Davidson, 2003). The physical and emotional benefits of riding horses have been described in literature dating back to the 1600s, as riding was prescribed for such conditions as gout and neurological disorders as well as for low morale (All, Loving, & Crane, 1999; Willis, 1997). While scholars throughout history have recognized the horse as an agent of healing for bodies and minds, modern-day usage of therapeutic horseback riding (also known as equine-assisted or equine-facilitated therapy) began when Liz Hartel, a young woman from Denmark paralyzed from polio, won the silver medal for dressage in the 1952 Olympic Games (Benda, Fredrickson, Flanagan, Zembreski- Ruple, & McGibbon, 2000).

Although the most widespread presence of equine therapy is in Germany, where many hospitals maintain a therapeutic riding ring, riding programs have spread throughout Europe and North America (Benda et al., 2000).The first riding centers in North America began in the 1960s, and the North American Riding for the Handicapped Association (NARHA) was launched in 1969. Currently, about 700 NARHA centers exist in the U.S. and Canada, assisting more than 30,000 individuals with a broad range of disabilities (see Box 1, Types of Disabilities and Conditions Served by Therapeutic Horseback Riding). Therapeutic riding refers to the use of the horse and equine-oriented activities to achieve a variety of therapeutic goals, including physical, emotional, social, cognitive, behavioral and educational goals. It not only encompasses various leisure and therapeutic activities (e.g., learning riding skills) but also places emphasis on the development of the relationship between the rider and horse. Therapeutic riding utilizes a team approach to providing individualized treatment, and the riding instructor is the heart of this intervention. The trained instructor must have a strong equine background, a positive approach to diverse situations, a good understanding of the disabilities of participants, and awareness of his or her influence on the rider (All et al., 1999). Nurses who care for women with disabilities in a variety of clinical settings are met with the ongoing challenge of using interventions and practices that can effectively contribute to the health and well-being of their patients. Such interventions include traditional as well as complementary and alternative therapies. Therapeutic horseback riding is an alternative treatment modality that can be used to promote quality of life and positive health outcomes. This article discusses the use of therapeutic riding in the treatment of persons with disabilities and the implications that arise for nursing professionals providing care to women clients. The Horse as a Therapy Aid Horses are inspirational creatures that catch our attention and tickle our imagination. They allow us to mold them to our needs but yet are governed by innate flight patterns that teach Mira Lessick, PhD, RN, is an associate professor at the College of Health & Human Services, University of Toledo, in Toledo, OH. She is also a member of the AWHONN Lifelines Editorial Advisory Board. Robyn Shinaver, BIS, MT, ASCP, is executive director of the Vail Meadows Therapeutic Riding Center in Oregon, OH. Kimberly M. Post, RN, NARHA, is a certified riding instructor at the Vail Meadows Therapeutic Riding Center in Oregon, OH. Jennifer E. Rivera, AS, is equine director and head instructor at the Vail Meadows Therapeutic Riding Center in Oregon, OH. Betty Lemon, RN, MSN, CNS, is an assistant professor at the College of Health & Human Services in Toledo, OH. DOI: 10.1177/1091592304263956 us to communicate nonverbally. They challenge us in many ways not only physically but also mentally and emotionally. The adage time spent in the saddle is never wasted sums up the uniqueness of the horse as a mobile therapeutic tool. Horses provide a unique neuromuscular stimulation through their movement. A horse s movement can be short, medium, or long, and can be measured by how smooth or choppy it feels to a rider. Of central importance is that the three-dimensional rhythmic movement of the horse simulates a human walk; that is, a horse s stride moves the rider s pelvis with the same rotation and side-to-side movement that occurs while walking. The horse s rhythmic, dynamic gait induces a continuous need for the rider to adjust to the movement of the horse. It s this natural physiological response elicited in the rider that is used to promote strength, balance, coordination, flexibility, and confidence (Borzo, 2002). The amount of benefit an individual with a disability gains from horseback riding depends on many factors, such as the type and severity of the disability, motivation of the rider, and match between horse and rider. In order to best benefit a rider, the riding instructor must be able to choose a horse that will fit the individual s needs. For example, a person with weakened trunk control may need a smooth, slow horse until the person has gained the strength to be challenged more. In contrast, a rider with muscle degeneration or atrophy may need a horse that provides more movement in order to stimulate the muscles. Unlike exercise machines, which tend to work only one muscle group at a time and do not require natural body movements, riding requires a person to use their entire body trunk, arms, shoulders, head, and legs to steer and con- Box 1. Types of Disabilities and Conditions Served by Therapeutic Horseback Riding Traumatic brain injury Spinal cord injury Stroke Multiple sclerosis Muscular dystrophy Cognitive deficits Autism Amputations Cerebral palsy Spina bifida Mental retardation Behavioral problems (including attention deficit disorder and substance abuse) Learning disabilities Emotional problems Hearing, speech, and visual impairments Orthopedic conditions 48 AWHONN Lifelines Volume 8 Issue 1

Box 2. Benefits of Therapeutic Riding Physical: Improved balance and muscle strength Improved coordination and faster reflexes Increased muscular control Improved postural control Decreased spasticity Increased range of motion of joints Stretching of tight or spastic muscles Increased endurance and low-level cardiovascular conditioning Stimulates sensory integration Improved visual-spatial perception Improved gross and fine motor skills Psychosocial: Improved self-confidence Increased self-esteem and self-image Development of patience Emotional control and self-discipline Expansion of locus of control Improved risk-taking abilities Sense of normality Socialization and improved interpersonal skills Increased perception of quality of life and life satisfaction Stress reduction Educational: Learning horseback riding knowledge and skills (e.g., horse-handling skills, animal science knowledge) Learning safe behaviors for riding trol the speed of the horse as well as maintain balance. Learning the cognitive and physical skills to achieve full communication with the horse awakens awareness of one s strengths and weaknesses. For a person with a disability, the perception of movement and freedom on a horse can be a catalyst for therapeutic improvement. While traditional therapies often reach a plateau where a patient may lose motivation to keep trying, the excitement of riding stimulates the rider and encourages many patients to work through discomfort and increasing challenges in seeking to improve their abilities and skills. Horseback riding provides persons with disabilities an opportunity to participate and succeed at something many ablebodied people are hesitant or afraid to try. The horse s rhythmic gaits, its ability to sense and respond to the patient, and the interactive relationship formed between horse and rider all contribute to a variety of significant therapeutic gains (Benda et al., 2000). Horses can also be used in a similar manner as other animals such as dogs, cats, rabbits, donkeys, birds, and potbelly pigs who participate in treatment programs in a variety of inpatient and outpatient settings. A patient does not need to ride a horse to achieve therapeutic progress. For example, grooming a horse can help to increase a person s joint range of motion, and touching and petting a horse has a calming effect and fosters relaxation. Benefits of Therapeutic Horseback Riding Therapeutic horseback riding influences the whole person and has a major effect on many body systems (Daly, 2000). This type of intervention has been reported to have physical, psychosocial, and educational benefits (see Box 2, Benefits of Therapeutic Riding). The rationale explaining horseback riding as a therapeutic tool is based on the concept that riding provides a normal sensorimotor experience for the individual with a disability that contributes to the development, maintenance, rehabilitation, and enhancement of physical skills (All et al., 1999). This sensorimotor experience involves vestibular input that stimulates the rider s righting and equilibrium responses as constant adjustments are needed with the horse s stride, velocity, and direction (MacKinnon, Noh, Laliberty, Lariviere, & Allen, 1995). Research studies have documented improved conditioning of adults and children with disabilities following participation in therapeutic riding programs (Land, Errington-Povalac, & Paul, 2001; All et al., 1999; Farias-Tomaszewski, Jenkins, & Keller, 2001; Pauw, 2000). Among the reported physical benefits of riding are improved balance, coordination, posture, arm and leg strength, and back and neck strength. For example, in one study of the effects of an eight-week therapeutic riding program, participants (ages 10 to 40) with various physical February March 2004 AWHONN Lifelines 49

disabilities showed significant changes in four of eight measures of sitting posture (Land et al., 2001). The warmth and movement of the horse s body can also help to reduce muscle spasticity, especially in the adductors of the legs (Bliss, 1997). Likewise, such activities as mounting, dismounting, saddling, unsaddling, and grooming have a beneficial effect on increasing joint range of motion. An integral component of a therapeutic riding program is the application of a variety of exercises to meet individual needs and treatment goals. Such exercises include stretching, strengthening, relaxing, and developing skills in balance and coordination (see Box 3, Examples of Therapeutic Riding Exercises). For example, standing in the stirrups can be used to strengthen knee, hip, and trunk extensor muscles and improve balance. Other exercises for the upper extremities and trunk that can be carried out on the horse s back include reaching to touch the horse s ears or tail, trunk rotation with arms outstretched, and reaching down to touch the left and right stirrup. Possibly one of the most profound benefits of horseback riding is the increased confidence and self-esteem that comes from being able to control and maneuver an animal that weighs close to 1,000 pounds. The experience of riding has also been reported to improve risk-taking abilities, emotional control and self-discipline; enhance self-efficacy; and foster the development of patience (All et al, 1999; Bizub et al., 2003; Farias-Tomaszewski et al., 2001; The National Center on Physical Activity and Disability, 2000). For example, the results of a recent study involving a 10- week therapeutic riding program documented an augmented sense of self-efficacy and self-esteem in adults (ages 26 to 46) with psychiatric disabilities (Bizub et al., 2003). Similarly, another study of 22 adults (ages 17 to 61) with a variety of physical impairments reported increased physical self-efficacy and behavioral self-confidence following a 12-week therapeutic riding program (Farias-Tomaszewski et al., 2001). Riding also provides an increased sense of normality and enables individuals with disabilities, who are oftentimes isolated, to socialize with others who have similar interests. Moreover, the communication between human and horse can serve as a therapeutic outlet for stress. Despite its broad and beneficial effects, therapeutic riding may not be an appropriate intervention for some people with disabilities (see Box 4, Contraindications for Therapeutic Riding). A medical history and health care provider s statement of approval and recommendations are essential before an individual can participate in therapeutic riding activities. Health care information enables the riding instructor(s) to prepare for individual needs, plan supervision, and ensure riders safety. An Exemplar Riding Program: Vail Meadows Therapeutic Riding Center Vail Meadows Therapeutic Riding Center (VMTRC), located in Oregon, Ohio, is a nonprofit organization that provides therapeutic horseback riding to children and adults with physical, mental, and emotional challenges. The center s mission is to enhance the quality of life of special needs individuals of all Box 3. Examples of Therapeutic Riding Exercises Mounting and dismounting the horse Sitting on the horse, using proper posture Riding forward Riding backwards Extending arms overhead Extending arms outstretched to side Holding arms outstretched forward and then overhead, with pole or stick grasped with both hands Swinging arms alternatively forward and backward at sides Rotating the trunk with arms outstretched Standing in the stirrups Turning side to side while sitting Reaching to touch the horse's ears or tail Lying back on the horse's back, with knees bent, and pull up to a sitting position Reaching down to touch the left and right stirrup Sitting to the trot (once the walk has been mastered) Advanced activities: riding without stirrups; riding independently; cantering; maneuvering the horse in a figure eight pattern on flat ground and through poles Box 4. Contra-Indications for Therapeutic Riding Unhealed pressure sores Fragile bones Bleeding disorders (e.g., hemophilia) Epilepsy, uncontrolled by drugs Lack of desire to ride, following a trial experience Allergies ages, regardless of their financial status, by utilizing a holistic approach to life-skill development through therapeutic horseback riding, instruction, and education. VMTRC opened in August 1998, with a pilot riding program of nine individuals, a handful of volunteers, and since then has continued to grow. This 25-acre agricultural facility provides access to a climate-controlled indoor arena and an outdoor arena, both with spectator seating. The center is home to 14 therapy horses. All therapy horses at VMTRC are donated and carefully selected for suitability and safety. A gentle disposition is required and all horses must go through a 90-day screening process. VMTRC offers a variety of programs, including therapeutic riding classes, summer camp, field trips, and an adult spe- 50 AWHONN Lifelines Volume 8 Issue 1

Box 5. Vail Meadows Therapeutic Riding Center Programs Programs Therapeutic Riding Classes Summer Camp Field Trips Adult Special Needs Day Program Description This program provides one-hour weekly lessons in 10-week sessions four times/year. Classes are offered Monday through Saturday. Each class has 2-4 riders participating under the instruction of a NARHA-certified riding instructor. Each rider is assisted by a volunteer team consisting of a horse leader and 1-2 side walkers. The team is modified as needs change This educational program offers week-long day camps for children and young adults interested in learning about horses. Topics include: animal science, barn management, crafts, and riding class. Single-day camps are also provided as an enhancement to other organizations and summer camps. This year-round program serves the general community population as an educational site. A tour of the facilities and grounds is provided as well as short lessons covering animal science, barn management, and a hands-on segment. Tours are scheduled by appointment and custom-designed to meet the needs of the visiting organization. This year-round program provides vocational, recreational, and living skills development opportunities for challenged adults. Vocational opportunities are offered in-house and secured through local businesses in order to provide job development and paid employment opportunities to participating adults. Recreational activities are planned on- and off-site. cial needs day program (see Box 5, Vail Meadows Therapeutic Riding Center Programs). The major goal of these programs is to provide positive, enjoyable experiences that are physically, mentally, and emotionally beneficial as well as educational. Therapeutic riding classes are offered in 10-week sessions four times a year. The center serves approximately 45 to 50 riders each session. Riders range in age from one to 78 years, and have such disorders as cerebral palsy, developmental delay, multiple sclerosis, neuromuscular ataxia, traumatic brain injury, autism, cancer, severe depression, and attention deficit disorder. The therapeutic riding team works closely with riders and their health professionals, families, friends, aides, special educators, therapists, and others involved with the patient in order to establish individual goals and lesson plans. This approach is meant to enhance any traditional therapies that riders may be involved in outside the center. The therapeutic riding team consists of the rider, a NARHA-certified riding instructor, volunteer side walkers and horse leaders, family or other caregivers, and the horse itself. Riders are matched with the most appropriate horse in terms of gait, pace, size, and character. The riding team is modified as needs change. For instance, an individual progressing to independent riding skills may trim the team down to a spotter (a volunteer who observes rider and horse and helps with safety as needed). A typical therapeutic riding class includes pre-class grooming, tacking (saddling), mounting, open riding, exercising, planned activity, dismounting, and post-class grooming. Therapeutic riding is an important part of the lives of many women with disabilities. For example, a 34-year-old woman with multiple sclerosis began riding at Vail Meadows in the spring of 2000. Having required one to two volunteers to maintain balance in the saddle prior to one year ago, she has now become an independent rider. She grooms and tacks her horse, and can trot the circumference of the indoor riding arena independently. This mother of two young children credits therapeutic riding for the increased strength in her legs and arms and increase in balance, enabling her to continue to walk up and down stairs without the use of a handrail and perform routine household chores. Another 30-year-old woman with Brown-Séquard syndrome began at the center in the fall of 2003. After three months of therapeutic riding, she no longer depends on her cane constantly, and the range of motion in her shoulders has dramatically increased. Riding has played a major role in her regaining independence and self-esteem. February March 2004 AWHONN Lifelines 51

Nursing Implications An important area of concern for women with disabilities is achieving the highest level of wellness possible. The nurse may be the first person that women with disabilities consult for information and advice about alternative therapies for promoting, maintaining, and restoring health and well-being. Because of their holistic approach to patient care, women s health nurses need to be aware of the positive effects on health and social development that therapeutic horseback riding can bring to the treatment and rehabilitation process. Numerous resources are available to assist nurses in increasing their knowledge and awareness about this nontraditional form of intervention (see Box 6, A Sampling of Resources on Therapeutic Riding). Nurses awareness of equine-assisted intervention will increase their ability to provide comprehensive services to their patients. Therapeutic riding requires teamwork between health care and rehabilitation professionals, the patient, and the family. Nurses can be an integral member of the therapeutic riding team. A riding program, such as Vail Meadows, can be incorporated as part of the discharge planning process for many patients. The potential use of therapeutic riding in individual patient situations must be carefully assessed for appropriateness and calculated benefits. Accordingly, pertinent nursing interventions include (See Box 7, Examples of Therapeutic Riding Programs): taking a careful history of actual and potential health problems of the patient discussing aspects of equine-facilitated therapy, including indications, contraindications, and associated safety issues determining the individual s level of interest and motivation to participate in a riding program collaborating with other health care and rehabilitation professionals in establishing treatment goals locating and referring the patient to a therapeutic riding program that can best meet the needs of the patient Nurses must ensure that women clients and their families are given ample opportunity to discuss issues and concerns about therapeutic riding and to have their questions answered in an informed, meaningful, and supportive manner. They can also help identify reliable educational resources where patients can obtain additional information about this treatment option. Nurses can take a leadership role and act as community liaisons for alternative therapies such as therapeutic horseback riding. Nurses can assist individual patients or communitybased programs in designing programs that incorporate equine therapy. By educating the community, patients and families will have a greater understanding about equinefacilitated therapy and its health and rehabilitative benefits. Riding centers that provide therapeutic riding and equinerelated activities also offer unique employment opportunities for nurses and other health care professionals with an equine background. Nurses are especially well suited to the therapeutic riding setting as they have an in-depth knowledge and understanding of disease processes and related assessment and management considerations. Building an awareness of or training as a therapeutic riding instructor could also be a new area of service for nurses. Therapeutic riding programs such as Vail Meadows Therapeutic Riding Center are having a positive impact on the lives and health of women with disabling conditions. With their expertise in patient education and health promotion, nurses are in a unique position to communicate the outcomes of equine-assisted therapy in a manner that promotes informed decisions by women regarding this intervention. With education of the community and the involvement of medical, nursing, and other professional groups, the therapeutic riding industry will continue to evolve and many will benefit. Box 6. A Sampling of Resources on Therapeutic Riding STRIDES Therapeutic Riding P.O. Box 572455 Tarzana, CA 91357-2455 (818) 341-4737 http://www.strides.org/what.html American Equestrian Alliance Therapeutic Riding Program P.O. Box 4053 Scottsdale, Arizona 85261 (602) 992-1570 http://www.americanequestrian.com/therapy.htm North American Riding for the Handicapped Association (NARHA) P.O. Box 33150 Denver, CO 80233 (800) 369-RIDE (7433) http://www.narha.org The National Center on Physical Activity and Disability Horseback Riding University of Illinois at Chicago 1640 W. Roosevelt Road Chicago, IL 60608-6904 (800) 900-8086 http://www.ncpad.org/factshthtml/ HorseRiding.htm 52 AWHONN Lifelines Volume 8 Issue 1

Box 7. Examples of Therapeutic Riding Programs Vail Meadows Therapeutic Riding Center 6118 Cedar Point Rd Oregon, Ohio 43618 (419) 697-8960 Greater New Orleans Therapeutic Riding Center P.O. Box 23284 New Orleans, LA 70183-3284 (504) 466-9960 or (504) 651-LADY Riding Unlimited, Inc. Riding Unlimited, Inc. 9168 T.N. Skiles Road Ponder, Texas 76259 (940) 479-2016 Critter Creek Therapeutic Riding Rt. 2 Box 59 D Lawton, OK 73501 (580) 353-5472 Fran Joswick Therapeutic Riding Center, Inc 26284 Oso Road San Juan Capistrano, CA 92675 (949) 240-8441 Colorado Therapeutic Riding Center 11968 Mineral Road Longmont, CO 80504 (303) 652-9131 Thorncroft Therapeutic Horseback Riding 190 Line Road Malvern, PA 19355 (610) 644-1963 Circle of Hope Therapeutic Riding, Inc. P.O. Box 463 Barnesville, MD 20838-0463 (301) 916-2040 Ranch+ 227 Rang Lepage Ste-Anne-des-Plaines, PQ J0N 1H0 (450) 838-0000 info@ranchplus.org www.ranchplus.org Pacific Riding for the Disabled Association 1088-208 Street Langley, BC V2Z1T4 (604)530-8717 prda@uniserve.com www.prda.ca North Okanagan Therapeutic Riding Association P.O. Box 328 Vernon BC V1T 6M3 (250) 549-0105 dvarabians@telvs.net References All, A. C., Loving, G. L., & Crane, L. L. (1999). Animals, horseback riding, and implications for rehabilitation therapy. Journal of Rehabilitation, July/August/ September, 49-57. Benda, W., Fredrickson, M., Flanagan, S., Zembreski-Ruple, J., & McGibbon, N. H. (2000). Animal-assisted therapy: A highly versatile modality. Complementary Medicine for the Physician, 5(6), 41-48. Bizub, A. L., Joy, A., & Davidson, L. (2003). It s like being in another world : Demonstrating the benefits of therapeutic horseback riding for individuals with psychiatric disability. Psychiatric Rehabilitation Journal, 26(4), 377-384. Bliss, B. (1997). Complementary therapies Therapeutic horseback riding? RN, 60(10), 69-70. Borzo, G. (2002). Horsepower. American Medical News, 45 (23), 24-26. Daly, M. (2000). Rehabilitation in the therapeutic riding arena. Rehabilitation Nursing, 25(5), 167-168. Farias-Tomaszewski, S., Jenkins, S. R., & Keller, J. (2001). An evaluation of therapeutic riding programs for adults with physical impairments. Therapeutic Recreation Journal, 35(3), 250-257. Land, G., Errington-Povalac, E., & Paul, S. (2001). The effects of therapeutic riding on sitting posture in individuals with disabilities. Occupational Therapy in Health Care, 14(1), 1-12. MacKinnon, J. R., Noh, S., Laliberte, D., Lariviere, J., & Allan, D.E.(1995).Therapeutic horseback riding: A review of the literature. Physical and Occupational Therapy in Pediatrics, 15(2), 1-15. The National Center on Physical Activity and Disability. (2000). Horseback riding. http://www.ncpad.org/ Factshthtml/HorseRiding.htm Pauw, J. (2000). Therapeutic horseback riding studies: Problems experienced by researchers. Physiotherapy, 86 (10), 523-527. Willis, D. A. (1997). Animal therapy. Rehabilitation Nursing, 22(2), 78-81. February March 2004 AWHONN Lifelines 53