Hippotherapy and Therapeutic Horse-Riding
Hippotherapy? Therapeutic riding? So what is the difference? Linda Frease, OT sets about to clarify these terms as indicated by the American Hippotherapy Association. In Episode #48 of the Raising Kellan Podcast, she talks about the benefits and history of hippotherapy.
Hippotherapy
The term “hippotherapy” refers to how occupational therapy, physical therapy and speech-language pathology professionals use evidence-based practice and clinical reasoning in the purposeful manipulation of equine movement as a therapy tool to engage sensory, neuromotor and cognitive systems to promote functional outcomes. Best practice dictates that occupational therapy, physical therapy and speech-language pathology professionals integrate hippotherapy into the patient’s plan of care, along with other therapy tools and/or strategies.
Horses in a field
Adaptive Riding/Therapeutic Riding
The terms “adaptive riding” and “therapeutic riding” are synonymous. These terms are commonly used to refer to horseback riding lessons for individuals with special needs, taught by horseback riding instructors who have received specialized training and may be certified to teach riding lessons to students with disabilities. These instructors adapt their teaching style, the environment and/or equipment to facilitate acquisition of riding skills and participation in an enjoyable activity. When participating in riding lessons, opportunities may be available for riders to participate in competitive equestrian events, recreation and leisure, education, socialization, and/or fitness.
Benefits of the Horse
If you do nothing more than sit on a walking horse and allow the horse to move your body, you will receive approximately 100 neuromotor inputs per minute. Your pelvis will be moved in three dimensions (anterior/posterior tilt, lateral weight shift and rotation). The walking horse provides rhythmic movement through space with vertical displacement.
Hippotherapy offers amazing benefits but it is not right for every patient. There are both physical and behavioral precautions and contraindications for participation in activities in which the movement of the horse is part of the treatment plan.
History of Hippotherapy: The Story of Lis Hartel
Lis Hartel was a competitive equestrian rider from Denmark who contracted polio at the age of 23. She was pregnant at the time and after the birth of her second child, she rehabilitated using equine-assisted therapy. Within 8 months she was able to ride her horse Jubilee and ambulate with a pair of crutches. Although she was able to recover functional mobility she had significant permanent impairment in her hands and legs to where she was unable to mount and dismount her horse independently.
She returned to professional equestrian sports 3 years post-recovery. Lis was known for competing in dressage, a form of horse riding where riders compete to perform technical yet artistic movements to music with their horse in an arena.
At a time when only men were allowed to compete in equestrian sports Lis when on to become the first woman to compete with her male counterparts and win a silver medal at the 1952 Helsinki Olympics. As Lis was unable to mount or dismount her horse, the moment the gold medal winner, Henri Saint Cyr of Sweden, carried her from her horse to the Olympic podium is regarded as one of the most memorable acts in Olympic History.
Lis was instrumental in advocating for the use of horse riding in rehabilitation.
Kellan at Healing Horses
Resources
Tim Shurtleff, OTD, OTR/L is an Instructor at the Washington University School of Medicine and Research Scientist in the Human Performance Laboratory. He has completed a number of studies exploring the efficacy of hippotherapy including:
Bio:
Linda Frease, MHS, OTR/L, C/NDT, HPCS Born in St Petersburg Florida. She graduated from Virginia Commonwealth University with a BFA in Interior Design and spent 20 years designing and building commercial interiors. Occupational Therapy was a midlife career change for Linda and she practiced full-time in the school system and part-time utilizing equine movement as a treatment tool before retiring in 2019. She is a Hippotherapy Clinical Specialist and a Certified NDT Pediatric therapist. Currently, she serves as a member of the American Hippotherapy Certification Board which is the organization that administers certification exams for therapists utilizing Hippotherapy, and works as a volunteer adult literacy tutor for a young woman with dyslexia.
Transcript
Marsh Naidoo (00:23):
Hi guys. Welcome to the Raising Kellan podcast. My name is Marsh Naidoo and I blog at raisingkellan.org. On today's episode number 48, we are going to talk with Linda Frease, an occupational therapist in Florida, who is very much involved in the hippotherapy scene and as always, remember that this information today is for educational purposes only and is not intended as medical advice. Today's episode is brought to you by Healing Horses, a therapeutic riding center here in Dyersburg, Tennessee.
Marsh Naidoo (01:10):
Good morning, guys. Today I am talking with Linda Frease, an occupational therapist based in Florida. And Linda is going to be talking to us about Hippotherapy its history and what makes horse riding an effective riding tool. Now, Linda and I do have some history together, and we actually met on the Wired Collective, which is a world-wide group of therapists that talk about pediatric care. Mindy Silva from New Zealand has actually created that subscription-based group. I would highly recommend the Wired Collective for those therapists that wanna get into pediatrics. We are going to kick off the podcast now with Linda Frease. Linda, good morning and thank you for joining us.
Linda Frease (02:12):
Good morning, Marsh.
Marsh Naidoo (02:15):
Linda, I'm pretty interested what got you into occupational therapy? What started your journey and put you on the trajectory of becoming an OT?
Linda Frease (02:29):
Well, I started riding horses in Massachusetts when I was about six years old, and I kept doing it until I was probably 16. Took a break for the last few years of high school and college. Went back to it after I graduated. Bought my first horse when I was 30. And not too terribly long after that, I read a magazine article about therapeutic horseback riding, and I thought, Oh, how magnificent. What a great way for me to knit together one of my passions with community service work. So I started volunteering with the Loudon County 4H therapeutic riding program as both a horse leader and a side walker. After about a year, I went to the Chef Center in Michigan and completed their month-long training program for therapeutic writing instructors and came back and worked for a year and decided, You know what? I love this.
(03:32):
I love the kids, I love what I'm doing. I'm gonna go back to school and get my Masters in OT. And at that point it was sort of like, Do I wanna go back and get another bachelor's degree because my undergraduate degree is in interior design, or do I wanna go get a master's degree? And they had a transitional program at the University of Florida. So I came back to Gainesville and did my three years of OT school there in Gainesville where I was fortunate enough to work with a therapist, a physical therapist by the name of Carol Hugo, who's also on the faculty for the American Hippotherapy Association and an NDT therapist. And I volunteered with her for the whole three years that I was in grad school. I did my master's level research project to develop a postural rating scale for the use for use during riding. And Carol's patients were my test subjects. So we did integrater reliability studies, and after I moved to Sarasota because they had a hippotherapy program here in Sarasota that took the horses to the school. I worked full-time in the school system where I'm also an assistive technology specialist. And on weekends I worked in the HIPPOTHERAPY setting. And then in 2019 I retired, and came back to St. Petersburg.
Marsh Naidoo (04:57):
Linda, so are you telling me you were an interior designer before you became an OT and your experience volunteering led to that decision of becoming an OT?
Linda Frease (05:11):
Absolutely. When I was at the CHEF CENTER, they had a physical therapist who came in and taught all the sections on disabilities because most of the people at the CHEF CENTER were writing instructors, not therapists. And I came out of that experience thinking, Do I wanna be a PT or do I wanna be, I was thinking of PT school after that. And then I went to a PATH conference, met up with an OT that I've known for quite a long time, talked to her and she said, With your background as a rider, you should be an OT and not a PT. Wow. And at this point, I'll give you a little anecdote that explains how that worked. I was working alternating Saturdays with a PT who did not have a strong riding background. We had a client who had had a traumatic brain injury. She had been riding for quite some time.
(06:06):
She was very, very interested in learning how to be a better writer, even though she was in a hippotherapy program. And the PT looked at me and said, We need to teach Liz how to do a pelvic tilt. So I thought, Okay, what do we do as riders that integrate a pelvic tilt? And there's a maneuver called a half halt where you basically do a pelvic tilt and that's the cue of the horse that you're gonna ask for a change. So I taught Liz how to use a pelvic tilt to cue her horse that she was gonna transition from a walk to a halt. It was a much more effective way to teach her that move the movement in the context of something that was meaningful for her, which is very much an OT kind of thought process. And she was because she was riding at that point, an advanced dressage horse, she was able to, without hands transition from walk to halt.
(07:03):
But again, it was a really effective way to teach that skill. Had I not been a rider coming into it, I wouldn't have known that there was a point when I was in Gainesville and Carol and I was working together, and the typical handhold that we use in a hippotherapy session would be our forearm over the thigh of the rider and hand tucked in underneath. And at some point, Carol realized that during a downward transition from halt to walking, there was an internal rotation of the femur. We could facilitate internal and external rotation of the femur during those transitions if we were conscious of what was happening. And it's a subtle movement, but again, with a lot of children who are participating in hippotherapy programs, one of the primary goals is either independent sitting or independent ambulation.
Marsh Naidoo (07:59):
Thank you for sharing your OT journey and how you transitioned into OT. Your horse riding skills actually laid the foundation for you going into hippotherapy because usually sometimes it works in the opposite direction, doesn't it?
Linda Frease (08:17):
It's very frequently in the opposite direction
Marsh Naidoo (08:21):
They may not be a full understanding of the difference between hippotherapy and therapeutic horsemanship. Can you kindly give us some of your input into the differences between hippotherapy and therapeutic horsemanship?
Linda Frease (08:37):
Sure. And I'm gonna start this by giving you a little bit of history. There was a woman named LIZ HARTEL. She was, I'm pretty sure from Denmark. She contracted polio. Her doctors told her she would never walk again, and forget about riding. I should go back and say she was at that point, a world-class equestrian. She was already competing at international levels. She has written there are sections of a chapter on athletes who have overcome extraordinary hardships where she describes having her mother and her husband hold her up with a towel by her trunk when she was trying to learn to crawl across the floor at the same time that her toddler daughter was crawling across the floor. So she refused to accept the doctor's prognosis and she started riding again. And she ultimately went to the Helsinki Olympics in 1952 and won a silver medal.
(09:42):
And in dressage, when she writes about it, she says it was significant for three reasons. Number one, it was the first time that women had been allowed to compete in equestrian events. Number two, she won a silver medal, which was no small feat. And number three, the gold medal-winning rider lifted her off her horse and carried her to the podium because she still couldn't walk independently. So after that accomplishment with the number of post-polio patients that there were all over Europe and the United Kingdom, they didn't have enough rehab facilities, but they had lots of horses and lots of riding facilities. So the field of therapeutic horseback riding was born at that point based on what happened with Liz Hartel. And 1990 or thereabouts, 18 occupational physical therapists from the US went to Germany to study what the German therapists were doing using the horse as a therapeutic tool.
(10:48):
They came back and formed the American Hippotherapy Association, which started as a subset of its new path. It used to be the North American Handicap Association. After a few years, AHA became a separate 5 0 1 (C) 3 corporation because they weren't entirely comfortable with the way PATH was interacting with them. And since then, there's been an ongoing conflict about terminology because as with many things, there's always a terminology issue. The term therapeutic writing, which is what was the term terminology that was coined originally back in the 1950s, has become very, very confusing for both parents and third-party payers. They look at therapeutic riding, which is basically teaching people with disabilities how to ride horses, and hippotherapy, which is using the movement of the horse as a therapy tool. And they get very, very confused. So AHA, for a long time has been advocating a terminology change and they're saying we should be calling it adaptive riding because any other adapted sport like adapted skiing or adapted snowboarding or adapted anything would be more consistent with other adapted sports.
(12:14):
So many facilities have all their branding done around therapeutic riding, and then there's also the issue of third-party payment. Most third-party payers will not pay for your children to take writing lessons. They will pay for therapy. So we're very conscious of it. It's just one of those things. Now the American Hippotherapy Association has, I'm gonna read to you the definition that the AHA has published. The term hippotherapy refers to how occupational therapy, physical therapy, and speech-language pathology professionals use evidence-based practice and clinical reasoning in the purposeful manipulation of equine movement as a therapy tool to engage sensory neuromotor and cognitive systems to promote functional outcomes. Best practice dictates that occupational therapy, physical therapy, and speech-language pathology professionals integrate hippotherapy into the patient's plan of care along with other therapy tools and strategies. Whereas, again, adapted riding is about teaching riding skills.
Marsh Naidoo (13:23):
Okay. So we've got a little bit about the history of hippotherapy and how pulse writing became came to be used as a therapeutic tool. Can you tell me a little bit about the benefits of hippotherapy and horse riding as a therapy tool, Linda, that you have seen in evidence in your practice?
Linda Frease (13:49):
Because the horse has very rhythmic movement and the rate is predictable, I think the average horse takes about a hundred steps a minute. So some estimates will say that in a typical 25-minute session, there are as many as 2,500 neuromuscular inputs. The horse pelvis is also at a 90-degree angle to ours. So as the horse is walking, if the patient or client is doing nothing more than sitting on the back of the walking horse, the movement that the horse is providing stimulates lateral weight shifts of the pelvis, anterior-posterior weight, shifts of the pelvis and rotational movement of the pelvis, which are all components of normal ambulation depending on the horse because every horse is a little different. The range of motion that's been measured is very, very close to normal human ambulation. Now I think Mindy's been talking on the WIred Collective or the wire on development group about the SATCO
(14:57):
And when I first discovered the SATCO, I thought, Ooh, how great is that? Because that helps me frame where I'm supporting patients to. I did a lot of what they talked about in the SATCO, intuitively, depending on the independence of the rider, sometimes my hand would be under the axle, sometimes my hand would be, sometimes my hand would be on the iliac crest. It just depended on how much support the rider needed. Sometimes I would have some kind of support for the rider, and my arm would be running all the way up the spine so that I could support the head. It just depended on the rider. But Sacco gave me a framework to sort of say, Okay, if I quantify my levels of support in accordance with this tool, I can be more structured about the way I change the levels of support and reduced them.
(15:54):
So I've had riders who started, I had one little girl who had she had a heart attack when she was eight. She and her twin sister both had congenital heart defects that they didn't know about until she stopped breathing. She presented very much like someone with cerebral palsy. So when I started with her, I did a lot of work where I put her in a supine position because again, the rotation of the horse's pelvis would simulate the same pelvic rotation and a lot of the movement that an infant would get if they were rolling to sit again. I'm also an NDT-certified therapist, so I do a lot of that developmental stuff. Eventually, when we had her sitting up because her endurance was very poor, I would just have her count. I'd say, I want you to sit upright without your hands for a count of 10 steps.
(16:51):
We'd take a break, and then we'd go to 15 steps and we'd take a break and we'd go to 20 steps and we'd take a break. And eventually, she was pretty much sitting independently. We had another little guy who had a diagnosis of SMA type two. When he started, he couldn't sit independently at all. He was bracing with his hands. He needed his hands to hold himself up. We could do very, very short movement activities. His mom got him involved in the initial drug trials for that great drug that they have now. But once he actually started on the drug, we did the same thing with him. We would challenge him to hold a ball or clap his hands or just touch the side walker's hands or do anything, keep from bracing with his hands. And we'd count. I mean, he loved the phone. So I put the timer on for the phone and I challenge him to hold it, to keep his hands up for 30 seconds or 45 seconds. So eventually his ability to maintain an upright posture without extremity support got better. <laugh>, I can't tell you how much better because I don't remember. But again, we'd start with short stints and we'd just build up gradually over weeks. So I've had a lot of children develop much, much more stability in sitting posture. I've had a lot of children develop a more predictable ability to control their heads.
(18:19):
I've had one kiddo who developed a rudimentary communication system because he was multiply impaired. He was blind, he was hearing impaired, was non-ambulatory tube fed really, really involved kiddo. But one day I was transitioning onto the horse, and as soon as he got on the horse, I noticed that he was leaning forward. He was anticipating that forward movement. So we started to play with that a little bit. And I thought You know what? He's getting it because it's so predictable that he's starting to anticipate what's gonna happen. And then he started to click. That was one of the things he did. He could click. So he would go and I would go and he would go and I would go. And that was just sort of a playful exchange, right? And then one day the horse stopped and he was looking a little frustrated because the horse had stopped. And I said, Gus, you can click to your horse and make him go. So you clicked twice to your horse and he'll go, And of course, by saying it out loud, the horse leader knew what I wanted her to do. So he went and she right away took off.
Marsh Naidoo (19:29):
So that cause and effect, he would, he put those two together.
Linda Frease (19:34):
So for probably three or four months, we worked just on the go. And then one of the things he would do, and I had to watch him for quite a long time to figure out how his behavior was, telling me what he wanted to do, He would fling himself backward, which was pretty dangerous because he was a tall kid too. And I thought I wonder if that's a symbol that he wants to stop. Because what I also realized he was doing was putting his hand out behind him before he'd flung over backward. He's reassuring himself that there's something back there, <affirmative>. So I said, Okay, Gus, I see that you're putting your hand behind you, and what I think you're telling me is that you wanna take a break. So in the future, every time you put your hand behind you, we're gonna stop. So that's what we did.
(20:22):
And the sidewalks would complain that we stop every three minutes. I said I don't care if we stop every three minutes. This kid has one 30-minute section of his entire week where he has some control over what's happening. And if he wants to say, Go and stop 50 times in the session, I don't care. Go and stop 50 times in the session. But we did develop. He was then because I worked at the same school where he attended, I was able to tell the vision-impaired teacher and his classroom teacher that he knows to stop and go, These are the symbols for stop and go. So it was integrated across settings. And I think that it really changed a lot of perceptions that people had about him when they realized that he had some ability to understand cause and effect.
Marsh Naidoo (21:11):
Linda talked about communication and how that evolved gusted through his writing. I just have to quickly mention this as well. I mean, I noticed with our writing how that actually improved Karen's trunk support, his air control, and his volume control to where his clarity and speech became. I know it's where PTs an old, but honestly, I really believe that helped with his air volume control and his speech production.
Linda Frease (21:46):
Good. I have a good friend who's an SLP and she didn't understand how SLPs could use because there are a number of SLPs that are very involved in the American Hippotherapy Association. And I said, Think about breath control. Think about what happens to you when you're not sitting up straight. So if we can get you sitting up straight and just the whole trunk piece of it. And plus there is some research that says for some children sitting on the back of a walking horse is an aerobic activity. That's some of the very, very early research on hippotherapy demonstrated that. So, if you don't move normally and you're challenged just to do that, it becomes, reaches the level of aerobics. So it improves all your breast support and, think of all the Mary Massy stuff. And Mary Massy was actually the keynote speaker at the last American Hippotherapy Association conference. She's a huge advocate for hippotherapy and for kids who need to work on breath support.
Marsh Naidoo (22:56):
Would you say, what would your recommendations be, Linda, to a parent that is considering therapeutic horsemanship or hippotherapy? What would your advice to that parent be? Are there any children that HIPPOTHERAPY may be better suited to? Are there any resources out there for parents to consider before they make that informed decision?
Linda Frease (23:25):
I think number one, the American Hippotherapy Association is the organization that trains therapists to utilize equine movement. The American Hippotherapy Association also utilizes the Professional Association of Therapeutic Horsemanship standards for equine facilities as a reference. So that's the path center. So within the PATH standards, there are contraindications and precautions. Among the contraindications is spinal fixation, because the movement of sitting on a horse inherently involves movement. So if there's a spinal fixation, you're gonna exacerbate movement immediately above and below the fixed segments of the spine. Atlanta axial instability of any kind. And there used to be a requirement that children with Down syndrome have x-rays before they ride. Some of that has changed any kind of behavior that would put either the horse or the horse handlers at risk. Horses are prey animals, and their first instinct, if something startles them is to run. And I don't care how fit you are, you're not gonna keep up with a horse <laugh>, Right? Yeah. And we do a lot to train our horses, but we've had children who are just behaviors inconsistent with being safe on the back of a horse.
(25:04):
Let's see, a S spinal, We had one rider. I think if you look at the path Path standards, they'll tell you a spinal cord injury above a certain level is contraindicated. However, when I was working with Carol, we had a young man who had had a C7 incomplete spinal cord injury when he was a teenager. He wanted to ride a horse. So she got a special team together. And I mean, this is a very experienced therapist. She had two handlers working with her who were also very experienced horse people. We spent a lot of time problem-solving it. How we get him on, get him off. I should also mention he was six foot five. So he came out and he participated. We initially tried a saddle, we tried a bunch of different things. I think he did ride in a saddle as opposed to a bareback pad for a long time because that helped.
(25:59):
Being able to put his feet in stirs was better stability for him. But he went on to go out west with his parents to a due branch, and Carol sent the saddle that he was using and they put the saddle on the horse and they got him on from the back of a truck, and he went for a ride with his family. But he was also, I say an incomplete spinal cord injury. He could use both upper extremities. He had some involvement in the ulnar side of his wrist. He was independent getting in and out of his car. He was independent, folding up his wheelchair. He was employed, he was cognitively intact, and he was verbal. He could monitor skin breakdown. So there were a lot of extenuating circumstances that led us to say, Okay, let's try it with him, even though the standard says nothing above this level because he was an exception. But that means having an experienced therapist.
Marsh Naidoo (26:55):
That's right. Thank you again for your time, Linda.
Linda Frease (26:58):
You're welcome. Marsh. Let me know if you have any follow-up questions. I'll, I'll be around
Marsh Naidoo (27:04):
<laugh>. Absolutely. I will do that. And as I would love to share, I mean you sharing the history of that Danish question, right? I had no idea that was even, I had no idea about the history of Hippotherapy and when that started, and I think I always believe that's good. You gotta know where things started off to get a sense of how fortunate we are to have what we have at present. So thank you so much.
Linda Frease (27:38):
You're welcome. I hope it was helpful.
Marsh Naidoo (27:40):
Absolutely, ma'am. See you soon. Okay.
Linda Frease (27:43):
Okay. Bye. Bye
Marsh Naidoo (27:45):
Guys. Thank you so much for listening in with us today. Remember to give this podcast episode a rate and a review. And as always, if you need to contact us, we can be reached at raisingkellan@gmail.com. Thank you to Healing Horses for sponsoring today's episode. And guys, if you are in the Dyersburg, Tennessee area Healing Horses will be holding their fifth annual Farm to Table event coming up on September 23rd, which is a Thursday and just five weeks away. So stay tuned for more details about that. Until we see you guys the next time, remember as always, to get to the top of your mountain. This is Marsh Naidoo signing off.