Lacys Capstone Presentation

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This capstone project describes the use of hippotherapy with children who have autism spectrum disorders (ASD). It details the rationale, frames of references and a review of the literature. Also …

This capstone project describes the use of hippotherapy with children who have autism spectrum disorders (ASD). It details the rationale, frames of references and a review of the literature. Also provided are descriptions of the investigation of hippotherapy outcome measures being used by current occupational therapists. Five hippotherapy sites were visited and at least one full day of sessions was observed at each. Occupational therapists were also interviewed about current practices. Findings support the use of non-standardized testing for measuring outcomes of children with ASD. Also noted are the various methods for delivering hippotherapy services.

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  • 1. PRESENTED BY: LACY L GARDNER UNIVERSITY OF ST. AUGUSTINE FOR HEALTH SCIENCES OTD-E CAPSTONE PRESENTATION Effect of Hippotherapy on Children with Autism Spectrum Disorders: An Analysis of Outcome Measures
  • 2. Learning Objectives
    • Explain differences between classic hippotherapy, equine-facilitated therapy, and therapeutic horseback riding
    • Explore and analyze research related to hippotherapy through a literature review
    • Provide evidence supporting the use of hippotherapy with Autism Spectrum Disorders
    • Explain the impact of hippotherapy as a treatment tool in clinical practice
    • Identify aspects of theoretical frames of reference supporting effectiveness of hippotherapy
    • Identify measurement tool(s) used to demonstrate effectiveness of hippotherapy with ASD
    • Educate faculty, staff, therapists, students and community on benefits of hippotherapy
  • 3. Capstone Project
    • Extensive research of literature and information
    • Literature Review
    • Research of local hippotherapy sites
    • Visitation and Observation at each site
    • Interview of therapists and parents at each site
    • Completion of meta-analysis of information gathered
    • Designing of future research study
  • 4. What is Hippotherapy?
    • “ Hippos” is Greek for horse
    • Hippotherapy literally means “treatment with the help of a horse”
    • “ Hippotherapy is a physical, occupational, and speech-language therapy treatment strategy that utilizes equine movement as part of an integrated intervention program to achieve functional outcomes” (AHA, 2009).
  • 5. History
    • 16 th Century
      • Documented physical and mental benefits
    • 1970’s
      • U.S. PT’s began treatment programs related to equine movements
      • Travelled to Germany where hippotherapy has been used since the 1960’s
    • 1992
      • American Hippotherapy Association established
    • (Byam & Simmons, 2005)
  • 6. American Hippotherapy Association
    • Medical professionals (PT, OT, SLP) and others who are interested in the use of equine movement as a treatment strategy
    • Promote using the horse’s movement as a treatment strategy
    • Provide hippotherapy certification
    • (AHA, 2009)
  • 7. Why a horse?
    • Horse’s rhythmical movement mimics the human pelvis during gait
      • Helpful with motor control
    • Provides multi-sensory environment
    • Assists child in sensory processing skills
    • Provides medium to facilitate communication
    • (Latella & Langford, 2008)
    • See Appendix A
    • http://www.youtube.com/watch?v=WOtR7PiAHi8
  • 8. Theoretical Frames of Reference
    • Sensory Integration (SI) Model
    • Central principle of providing planned and controlled sensory input in order to facilitate a related adaptive response and enhance the brain’s organization
    • OT’s use horse to delivery controlled sensory input
      • Manipulate movement, direction, speed and gait
      • Change the horse itself, each moves differently
    • Proprioceptive:
      • The sense of where the body is in relation to other body parts
      • Concussive force transmitted to the patient with each step
    • Vestibular:
      • The sense of movement or orientation in space
      • Received just by moving through space
    • Tactile:
      • Received just through touching the horse.
    • “ It has been noted from teachers and parents that autistic children have improved in most areas of sensory processing and their reaction to the world around them much more completely after riding” (Stoner, 2004).
    • (Bracher, 2000; NARHA, 2008)
  • 9. Theoretical Frames of Reference
    • Person-Environment-Occupation (PEO) Model
    • Designed to reveal the complex relationships among these 3 factors
    • “ Occupational performance results from an individual’s engagement in purposeful tasks and activities within an environment.”
    • Achieve goals through:
      • interaction with horse environment
      • activities performed while on horseback
    • Unique relationship/interaction motivates clients to participate in intervention activities
      • People are generally attracted to horses
    • (Byam & Simmons, 2005)
  • 10.
    • Hippotherapy
    • Therapeutic Horseback Riding
    • Licensed OT, PT, SLP certified by AHA
    • Therapy based goals aimed at improved function and rehabilitation
    • Establishes a foundation for neurological function and sensory processing based on a therapeutic model
    • See Appendix B
    • THR instructor certified by NARHA
    • Equine related goals including riding, vaulting, horsemanship skills
    • Concentrates on teaching specific riding skills for recreational purposes based on a recreational/leisure model
    • Sometimes used as a progression from hippotherapy
    • (Cantu, 2005)
    What’s the difference?
  • 11. Therapist’s Role
    • Control hippotherapy session
      • Horse handler, volunteers, speed, gait, activities, etc.
      • Horse’s movement does the work!
    • Posture, Sensory Responses, Behavior
      • Facilitate change through horse movement
      • Facilitate change through cues (verbal, tactile, visual)
  • 12. Selecting a Horse
    • Horses are selected based on each individual’s needs
    • Temperament
      • 7-15 years of age
    • Gait
      • Ex: Choose a horse with increased movement for a sensory seeker or hypotonicity
      • Ex: Choose a horse with rhythmical movement for sensory avoider or hypertonicity
    • Height
      • Safety consideration for side-walkers’ height and ability to hold appropriately
      • Child’s fears or gravitational insecurities
  • 13. Selecting Tack
    • Saddle
      • External support
      • Decreased sensory input
    • Padding
      • Demands increased internal control
      • Increased sensory input
    • Handles
      • Anti-cast Roller
      • Surcingle
      • Western saddle: single point handle
    • Reigns
      • Cuff
      • Ladder
      • Color coded
    • Stirrups
      • Not used often
      • Weight bearing through lower extremities
  • 14.
    • Classic Hippotherapy
    • Equine-Facilitated Therapy
    • 30-60 minutes in duration
    • Pre-Mounting
      • Donning helmet
    • Mounting
    • Riding
      • Heavy emphasis on posture
      • Varying positions
    • Dismount
    • 30-60 minutes in duration
    • Pre-Mounting
      • Donning helmet
      • Grooming
    • Mounting
    • Warm-up
    • Riding and Activities
      • Posture
      • Varying positions
      • Incorporation of therapeutic activities while atop horse
    • Dismount
    Typical Treatment Session
  • 15. Reimbursement
    • Therapy services
      • Billed to insurance as OT/PT/ST
      • Self-pay
      • Sponsors
      • Non-profit organization
    • Barn fees
      • Non-profit organization
      • Self-pay
    • Most insurance companies consider hippotherapy as experimental due to lack of evidence supporting its efficacy
    • (Aetna, 2009)
  • 16. Searching the Literature
    • Research on hippotherapy and therapeutic horseback riding limited
    • Primarily related to motor dysfunction/recovery
      • Cerebral Palsy
      • Multiple Sclerosis
      • Spinal Cord Injuries
      • Amputations
  • 17. Literature Review
    • Literature supporting the use of hippotherapy with children with ASD
    • Criteria for inclusion established for intervention, participants and outcome of interest.
    • Intervention
      • hippotherapy, therapeutic horseback riding, equine assisted therapy, and animal assisted therapy
    • Participants
      • children ages 18 and under presenting with ASD or related symptoms (delayed social skills or language disabilities)
    • Outcomes of interest
      • sensory processing skills, social functioning, motivation and occupational performance
    • See Appendix C for Evidence Table
  • 18. Research on Equine Therapy and ASD
    • Taylor, R. R., Kielhofner, G., Smith, C., Butler, S., Cahill, S. M., Ciukaj, M. D., & Gehman, M. (2000). Volitional change in children with autism: A single-case design study of the impact of hippotherapy on motivation. Occupational Therapy in Mental Health, 25 , 192-200.
    • Hippotherapy
      • 45 min/session x 1 session/wk x 16 wks
      • Session included donning helmet, mounting, 20-30 mins on horse, dismounting
    • 3 children with Autism ages 4-6 yrs
      • Each child served as own control
    • Pre/Post: Pediatric Volitional Questionnaire
    • Hippotherapy improved motivation/volition
  • 19. Research cont.
    • Macauley, B. L., & Gutierrez, K. M. (2004). The effectiveness of hippotherapy for children with language-learning disabilities. Communication Disorders Quarterly, 25 (4), 205-217.
    • Hippotherapy
      • 60 min/session x 2 sessions/wk x 6 wks
    • 3 children with language-learning disabilities ages 9-12 yrs
      • Each child served as own control
    • Pre/Post: 21-item Questionnaire
    • Speech and language abilities
      • Parents reported improvements after hippotherapy
      • Participants reported no difference after hippotherapy
  • 20. Research cont.
    • Stoner, J. B. (2004). Riding high. Advance for Occupational Therapy Practitioners, 20 (13), 42.
    • Therapeutic horseback riding
      • 60 min/wk x 10 wks
      • Session included 30 mins pre-mounted activities and 30 mins mounted activities
    • 12 children with autism or PDD-NOS ages 4-10 yrs
      • 6 children received THR
      • 6 children were placed on a waiting list
    • Sensory Profile
      • Pre/Post
    • Question: “Within the 12 hours following the session, did you notice a change in your child’s behavior?”
      • Three possible answers (Yes, positive; Yes, negative; No)
      • Following each therapy session
    • Improved long-term and short-term sensory processing skills
  • 21. Research cont.
    • Bass, M. M., Duchowny, C. A., & Llabre, M. M. (2009). The effect of therapeutic horseback riding on social functioning in children with autism. Journal of Autism and Developmental Disorders, 39 , 1261-1267.
    • Therapeutic horseback riding
      • 60 min/wk x 12 wks
      • Session included 5 mins mounting/dismounting, 10 mins warm-up, 15 mins riding skills, 20 mins mounted games, 10 mins horsemanship/grooming
    • 34 children with ASD ages 4-10 yrs
      • 19 children received services
      • 15 children were placed on a waiting list
    • Pre/Post: Sensory Profile and Sensory Responsiveness Scale
    • Improvements in social functioning and sensory processing skills
  • 22. Research cont.
    • Candler, C. (2003). Sensory integration and therapeutic riding at summer camp: Occupational performance outcomes. Physical and Occupational Therapy in Pediatrics, 23 (3), 51-64.
    • One week summer day camp:
      • Therapeutic horseback riding
      • Sensory integration intervention
      • Camp arts and crafts
    • 12 children with sensory modulation disorders ages 5-13 yrs
      • Each child served as own control
    • Pre/Post: COPM (modified for summer camp setting)
    • Improved occupational performance and satisfaction
  • 23. Research cont.
    • Sams, M. J., Fortney, E. V., & Willenbring, S. (2006). Occupational therapy incorporating animals for children with autism: A pilot investigation. American Journal of Occupational Therapy, 60 (3), 268-274.
    • OT incorporating animals
      • average 28.5 mins/session x 1 session/wk x 15 wks
    • 22 children with autism ages 7-13 yrs
      • Each child served as own control
    • Social interaction and language use measured by number of behaviors
    • Improvements after therapy incorporating animals
  • 24.
    • Implications
    • Limitations
    • Provide support for the use of equine-assisted therapies in promoting positive occupational and behavioral outcomes in children with ASD
    • Further research needed to validate findings
    • Population
    • Small sample size
    • Lack of control group
    • Lack of control for internal and external validity
    • Choice of reliable and valid outcome measures
      • What are therapists currently using?
    Summary of Research
  • 25. Methods
    • Research locations
      • Conventional research methods (internet, phone book, word of mouth)
      • Local hippotherapy sites within a 100 mile radius of St. Augustine, Florida
      • See Appendix D for listing
    • Contact OT at each site and schedule visit
    • Observation of at least one full day of sessions administered to children with ASD
    • Interview each OT
      • Current practices
      • Outcome measures currently used
  • 26. Interview Questions
    • What diagnoses are treated at this hippotherapy facility?
    • What age is this population?
    • What is the cost of hippotherapy services? How are these services funded, billed, or reimbursed?
    • What measurement tools are being used at initial evaluation and follow-ups?
    • What measurement tools are viewed as the most effective in demonstrating improvements for children with ASD?
    • How is progress monitored?
    • Is there a specific child that “sticks out” as demonstrating significant improvements as a result of hippotherapy treatment sessions?
  • 27. Results: Access of Information
    • Information about local hippotherapy sites is not easily accessible to the community
      • Therapists offering hippotherapy services are not advertised or publicized
    • Families in the community may not know the many ways in which hippotherapy can benefit a child with ASD
  • 28. Results: Delivery Methods
    • Observed a significant difference in delivery of hippotherapy services across each site visited.
    • Each therapist administered services with personal variations:
      • some adhered strictly to classic hippotherapy guidelines
      • some added more traditional therapeutic activities to treatment sessions
    • All methods appear to benefit children with ASD
    • Influenced development of personal preference for equine-facilitated therapy
  • 29.
    • Non-Standardized
    • Standardized
    • Clinical observations
    • Parent/teacher interview
    • Most valuable information
    • BOT, PDMS, VMI, SP, etc.
    • Used for billing purposes
      • insurance companies request the report of standardized scores.
    • Administration is difficult
    • Scores are inaccurate
    Results: Outcome Measures See Appendix E for Meta-Analysis of Sites
  • 30. Development of Future Study
    • Hypothesis:
      • Children participating in hippotherapy will demonstrate improvements in social functioning and sensory processing skills compared to participants not receiving the treatment.
    • Participants:
      • 50 children diagnosed with ASD between 4 and 18 years of age
      • Randomly assigned to control group or experimental group
      • Control group: wait-listed and will continue to receive any conventional therapies.
      • Experimental group: hippotherapy x 60min/sessions x 1 session/wk x 16 weeks
    • Outcome Measures:
      • SP, SRS, Video Analysis
      • Pre and Post
  • 31. Sensory Profile
    • Measures responses to sensory events in everyday life that support or interfere with function
    • Ages 3+ yrs
    • 125 item questionnaire completed by caregiver
    • Rated on 5-pt Likert scale
    • Reliable
      • Internal consistency: 0.47-0.91
      • Test-retest: 0.639-0.775
    • Valid
      • Content validity
    • Used in previous study by Bass, Duchowny and Llabre (2009)
  • 32. Social Responsiveness Scale
    • Designed to screen for behaviors characteristic of children with ASD
    • Used to measure severity of ASD symptoms in 5 areas:
      • Social awareness, Social cognition, Social communication, Social motivation, Autistic mannerisms
    • Ages 4-18 yrs
    • 65 item questionnaire completed by caregiver
    • Rated on a 4-pt Likert scale
    • Reliable
      • Internal consistency: 0.93-0.97
      • Interrater reliability: 0.75-0.91
    • Valid
      • Concurrent validity when measured against the Autism Diagnostic Interview-R
    • Used in previous study by Bass, Duchowny and Llabre (2009)
  • 33. Video Analysis
    • 15 minute video recorded during the first and last hippotherapy session
    • Viewed by blinded therapist to rate the children’s performance on a categorized Likert scale
      • percentage or number of occasions identified behaviors are observed
    • Prevent bias and establish inter-rater reliability
    • Allows the therapists’ highly valued clinical observations to be quantified
  • 34. Follow-Up for Long-Term Effects
    • Hippotherapy discontinued after 16 weeks
    • Resume traditional therapeutic interventions
    • Follow-up after 8 weeks to measure continued benefits
    • Hypothesis:
      • Children participating in hippotherapy will demonstrate decreased social functioning and sensory processing skills after services are discontinued.
    • Sometimes effects become evident when an intervention is removed
    • Interrupted time-series withdrawal design in which the treatment is removed then re-introduced
      • O 1 X 1 O 2 X 0 O 3
  • 35. Parent Testimonial
    • “ Morgan had started going every other week for therapy and she missed 3 sessions which amounted to 6 weeks. Well, her teacher called me and wanted to talk about her behavior and at home I have been having a hard time with her on doing homework. She would say, ‘Mom, my head is feeling funny,’ so I would make her do some wall pushups, etc. Well, it finally dawned on me that she had missed hippo and her body was getting out of sync again! [The therapist] felt the same way so now Morgan is back to weekly therapy sessions, but it's only been 2 weeks so no major improvement yet, but I know by the end of this year she will be doing much better.”
    • – Chante McNeal
  • 36. Conclusion
    • Literature supporting the use of hippotherapy with children with ASD is very limited.
    • Therapists, parents and families of children with ASD who have participated in this unique treatment have reported the immense benefits.
      • “ More people need to understand that [hippotherapy] is helpful – I even have a hard time with Morgan’s elementary school teachers understanding the impact it has on her.” - Chante McNeal
    • More research needed in order to further assess its therapeutic benefits
  • 37.
    • Questions?
  • 38. References
    • Aetna. (2009) Clinical policy bulletin: Hippotherapy. Retrieved on October 31, 2009 from http://www.aetna.com/cpb/medical/data/100_199/0151.html.
    • American Hippotherapy Association. (2007). Retrieved on October 31, 2009 from http://www.americanhippotherapyassociation.org.
    • Bass, M. M., Duchowny, C. A., & Llabre, M. M. (2009). The effect of therapeutic horseback riding on social functioning in children with autism. Journal of Autism and Developmental Disorders, 39, 1261-1267.
    • Bracher, M. (2000). Therapeutic horse riding: What has this to do with occupational therapists?. British Journal of Occupational Therapy, 63 (6), 277-282.
    • Byam, E., & Simmons, D. (2005). Environment and occupation in hippotherapy. OT Practice, 10 (7), 13-18.
    • Candler, C. (2003). Sensory integration and therapeutic riding at summer camp: Occupational performance outcomes. Physical & Occupational Therapy in Pediatrics, 23 (3), 51-64.
  • 39. References Cont.
    • Cantu, C. O. (2005). Hippotherapy: Facilitating occupational performance. Exceptional Parent, 35 (3), 51-53.
    • Latella, D., & Langford, S. (2008). Hippotherapy: An effective approach to occupational therapy intervention. OT Practice, 13 (2), 16-20.
    • Macauley, B. L., & Gutierrez, K. M. (2004). The effectiveness of hippotherapy for children with language-learning disabilities. Communication Disorders Quarterly, 25 (4), 205-217.
    • Sams, M. J., Fortney, E. V., & Willenbring, S. (2006). Occupational therapy incorporating animals for children with autism: A pilot investigation. American Journal of Occupational Therapy, 60 (3), 268-274.
    • Stoner, J. B. (2004). Riding high. Advance for Occupational Therapy Practitioners, 20 (13), 42.
    • Taylor, R. R., Kielhofner, G., Smith, C., Butler, S., Cahill, S. M., Ciukaj, M. D., & Gehman, M. (2000). Volitional change in children with autism: A single-case design study of the impact of hippotherapy on motivation. Occupational Therapy in Mental Health, 25, 192-200.