CRITICALLY APPRAISED PAPER (CAP) Kwon, J. Y., Chang, H. J., Yi, S. H., Lee, J. Y., Shin, H. Y., & Kim, Y. H. (2015). Effect of hippotherapy on gross motor function in children with cerebral palsy: A randomized controlled trial. Journal of Alternative and Complementary Medicine, 21(1), 15 21. http://dx.doi.org/10.1089/acm.2014.0021 CLINICAL BOTTOM LINE: Cerebral palsy (CP) is the most prevalent cause of persistent motor dysfunction in pediatric populations (Case-Smith & O Brien, 2015). CP is associated with damage or lesions to one or multiple areas in the human brain, which can bring about spasticity, paralysis, and inability to control movement or posture (Case-Smith & O Brien, 2015). As a result of these lesions and damage to the human brain, sensory, perceptual, and motor areas of the central nervous system are significantly impaired. Thus, a child with CP may experience difficulty with perceiving information, planning, and performing the motor movements needed to engage in his or her everyday occupations of childhood (Case-Smith & O Brien, 2015). This study highlights the potential benefits of hippotherapy for children with CP. In particular, findings indicate that hippotherapy, given twice a week for 8 weeks and together with more a comprehensive intervention plan, may improve children s postural control; balance; and engagement in functional motor movements, such as sitting and walking. Hippotherapy seems to be an effective, complementary strategy to increase clients motivation and engagement in task-oriented activities. Thus, hippotherapy intervention may represent a unique opportunity for occupational therapists to deliver an innovative, task-oriented intervention in a novel environment to address gross motor function and daily performance among children with CP. By collaborating with a local equestrian center or community, occupational therapists can provide hippotherapy intervention to their pediatric clients to help them transfer their learning and improved motor functional skills to natural contexts and reallife activities of daily living. RESEARCH OBJECTIVE(S) List study objectives. To evaluate whether hippotherapy has a clinically significant effect on gross motor function in children with CP DESIGN TYPE AND LEVEL OF EVIDENCE: 1
Level I: Randomized controlled trial SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. A total of 92 participants were recruited and selected to participate through the Samsung Medical Center database (Seoul, Republic of South Korea). Inclusion Criteria Diagnosis of CP, body weight less than 35 kg, and age between 4 and 10 years Exclusion Criteria Having received a botulinum toxin injection within 6 months, having had selective dorsal rhizotomy or orthopedic surgery within 1 year, exemplifying severe intellectual disability, experiencing uncontrolled seizures, or displaying poor visual or hearing acuity SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) N = 92 Participants were randomized into exposure (n = 45) and control (n = 46) groups. A total of 124 participants were originally assessed for eligibility. #/ (%) Male 91/(100%) #/ (%) Female 0/(0%) Ethnicity Ethnicity is not included in participant demographics Disease/disability diagnosis CP INTERVENTION(S) AND CONTROL GROUPS Group 1: Intervention group Brief description of the intervention The intervention group included 46 boys, ranging from 4 to 10 years old. Participants parents or guardians were blinded to whether their child was going to receive the treatment during the consent to participate. Pretest measures were administered by a blind examiner and included the Gross Motor Function Measure 88 (GMFM-88) and the Gross Motor Function Measure 66 (GMFM-66) to evaluate motor function and the Pediatric Balance Scale (PBS) to evaluate functional balance. Each participant in this group received 8 weeks of private hippotherapy treatment sessions, in addition to conventional physiotherapy. Treatment sessions included a trained, 2
How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? Group 2: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who Delivered? How often? experienced horse leader to guide the horse to walk; two assistants to walk alongside the horse; and the therapist to help facilitate therapy to the participant. The program treatment focused on the following: muscle relaxation; optimal postural alignment of head, trunk, and lower extremities; independent sitting; and active exercises (stretching, strengthening, dynamic balance, and postural control). After the 8-week intervention, the same blind examiner reevaluated the participants on the GMFM-88, GMFM-66, and PBS measures. 46 18-m 27-m indoor riding arena located in Gyeonggi-do, Republic of Korea Samsung RD Center of Samsung Equestrian Team: physical therapists who were extensively trained in hippotherapy by the American Hippotherapy Association and had obtained Level II status Twice weekly; sessions were 30 min 8 weeks The control group included 45 boys, ranging from 4 to 10 years. Participants parents or guardians were blinded to whether their child was going to receive the treatment during the consent to participate. Pretest measures were administered by a blind examiner and included the GMFM-88 and GMFM-66 to evaluate motor function and the PBS to evaluate functional balance. Each participant in this group received 8 weeks of home-based aerobic exercise (walking or cycling), in addition to conventional physiotherapy. After the 8-week intervention, the same blind examiner reevaluated the participants on the GMFM-88, GMFM-66, and PBS measures. 46 Home Not reported; possibly participant s caregiver or guardian Twice weekly; sessions were 30 min 3
For how long? 8 weeks Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: Comment: Three participants in the control group were exposed to a twiceweekly, 8- to 16-week hippotherapy program before the 8-week study. Co-intervention: Timing: YES NO Site: Comment: Participants in the intervention and control groups received conventional physiotherapy in addition to the hippotherapy private sessions. Comment: The intervention was short in duration (8-week time period), and improvements could not have resulted from natural maturation. Comment: The two interventions were implemented at different sites. The control group received home-based intervention, which included walking or cycling, whereas the hippotherapy group received intervention at the equestrian center. The difference in intervention sites might have accounted for differences in gross motor outcomes. Use of different therapists to provide intervention: Comment: This article does not specify how many physical therapists delivered the intervention. However, the article does state that the hippotherapy sessions were provided by the Samsung RD Center of the Samsung Equestrian Team. MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1: Name/type of measure used: What outcome was The GMFM-88 is a well-recognized assessment tool to analyze motor function in children with CP and delayed motor functioning. The measure includes 88 items in five dimensions: lying and crawling; siting; crawling and kneeling; standing; and walking, running, and jumping. In addition to this measure, GMFM-66 scores were calculated from the GMFM-88 with the Gross Motor Ability Estimator. Motor function 4
measured? reliable? valid? When is the measure used? Measure 2: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? Before and after the 8-week intervention The PBS is a 14-item, criterion-referenced measure that evaluates balance in everyday, functional tasks. These items assess functional performance in activities that children need to perform independently and safely in the home, school, and community. Balance Before and after the 8-week intervention Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Comment: The same blind evaluator administered the baseline and outcome assessments. Recall or memory bias. Check yes, no, or NR, and if yes, explain. YES Comment: Assessments were not survey based. NO RESULTS List key findings based on study objectives Include statistical significance where appropriate (p<0.05) Include effect size if reported Key findings include the following: GMFM-66, GMFM-88 total, and GMFM Dimensions B, C, D, and E increased significantly in the hippotherapy group (p <.05). No significant difference was noted in the control group on the GMFM or PBS. When a secondary analysis was performed on the motor outcomes of the hippotherapy group, it indicated that improvements in motor function were observed across all levels of CP severity. GMFM-88 total score was 5
significantly increased among all levels, and GMFM-66 scores significantly increased for children with Levels I, II, and IV CP. After the intervention, the hippotherapy group showed significant improvement in PBS scores (p <.05), but no significant difference was observed in the control group. Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. Comment: Yes, the sample size was adequate to detect statistically significant differences between groups. Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. Comment: Yes, outcome measures were appropriate (reliable and valid) to measure motor function and balance among the CP population. Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. Comment: Statistics were appropriately reported in written and table format. The authors analyzed data using paired t tests or Wilcoxon signed-rank tests to compare changes from baseline to postintervention within groups. Was the percent/number of subjects/participants who dropped out of the study reported? Comment: One participant in the hippotherapy group dropped out. Limitations: What are the overall study limitations? The study only involved boys; therefore, it is unclear whether these findings generalize to the female population. Also, ethnicity and race were not included in participant demographics. This indicates uncertainty as to whether these findings generalize to a variety of racial and ethnic groups. The study could not analyze the single effect of the hippotherapy intervention and could not control participants engagement in other therapeutic interventions, such as physiotherapy. Therapists did not supervise aerobic home-based interventions for the control group. Also, the researchers did not determine the intervention s cost-effectiveness before the study, such as the expense of the four assistants during the private treatment sessions. Finally, the study only analyzed the short-term effects of hippotherapy for its experimental participants. 6
CONCLUSIONS State the authors conclusions related to the research objectives. The authors concluded that this study supports the benefits of hippotherapy on gross motor function and balance for boys with CP. The authors further stated that meaningful horse human interaction possibly accounted for boys increased motivation to engage in therapeutic activities. Also, the authors suggested that the task-oriented training involved in hippotherapy facilitated learning and refinement of new motor skills. Overall, hippotherapy is a promising, effective treatment protocol to promote boys gross motor function, such as balance, postural control, and walking. References Case-Smith, J., & O Brien, J. C. (Eds.). (2015). Occupational therapy for children and adolescents (7th ed.). Maryland Heights, MO: Mosby Elsevier. This work is based on the evidence-based literature review completed by Alyssa Guerrero, OTS, and Sarah-Jeanne Salvy, PhD, faculty advisor, University of Southern California. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. 7