Equine Movement (Hippotherapy) as a Treatment Tool in PT, OT and ST © American Hippotherapy Association, Inc Fort Collins, Colorado americanhippotherapyassociation.org 2015

Hippotherapy origins ‘Hippo’ is the Greek derivative for horse. Literally means ‘treatment incorporating the horse.’ Also known as use of ‘equine movement’

Hippotherapy Description: Used by PT, OT or SLP professionals. Part of an integrated treatment plan to achieve functional outcomes. Best described as equine movement and related therapy activities to promote functional skills.

© American Hippotherapy Association, Inc. Clarity of Conversation  Hippotherapy is not a profession. There are no “hippotherapists”.  There is no time when the therapist stops doing PT, OT, or ST and starts doing “Hippotherapy”.

SCOPE OF PRACTICE The incorporation of equine movement into treatment (hippotherapy) is considered scope of practice by the:  American Physical Therapy Association  American Occupational Therapy Association  American Speech-Language-Hearing Association And has been since the mid 1980’s….

PT, OT and SLP professionals use evidence-based practice and clinical reasoning in the purposeful manipulation of equine movement to engage the sensorimotor and neuromotor systems to create functional change in their patient. Used with other neuromotor and sensorimotor techniques, hippotherapy is part of a patient’s integrated plan of care. - AHA, Inc. Best Practice Statement,

Principles of using Equine Movement in Treatment  Equine movement promotes active responses in the patient.  Variations in equine movement, as directed by the therapist, promote variations in the patient’s responses.  Patient responses to equine movement are intended to affect functional skills.

Population....  Age: 2 years* to Adults  Impairments: mild to severe neurologic, sensory, oral- motor, communication and/or motor deficits *Children younger than 2 years should be treated by a therapist with AHCB HPCS© (clinical specialist) certification.

Diagnoses or Medical Conditions that may benefit from hippotherapy: Autism Spectrum Disorders/ASD Chromosomal abnormalities or deletions Cerebral Palsy Cerebral Vascular Accident/Stroke Developmental Disorders/Delays Neuromuscular disease/dysfunction Sensory Processing Disorder/SPD Brain Injury Apraxia/Dyspraxia

Clinical impairments that may be addressed using equine movement: Abnormal muscle tone Impaired sensorimotor function Impaired balance Postural asymmetry Impaired postural control Impaired coordination Impaired mobility Impaired communication Delayed speech and language Impaired oral motor functioning

Walk is primary gait used 4 beat Symmetrical Rhythmic Repetitive Consistent Sustainable

BIOMECHANICS OF EQUINE MOVEMENT UP/DOWN SIDE TO SIDE FORWARD/BACKWARD FORWARD MOVEMENT THROUGH SPACE

EQUINE MOVEMENT EFFECTS on the PERSON ASTRIDE  Movement – from the horse’s hind legs and pelvis  Sensory – from the movement through space (vestibular, visual) and transmission of input from the ground (proprioception)  The biomechanical and sensory input impacts core postural control, balance, visual flow, sensory processing, arousal, respiration, and circulation.

PRIMARY IMPACT OF EQUINE MOVEMENT  The movement of the horse can be used to facilitate the neuromuscular and sensory systems that support functional skills.  Other treatment tools and strategies may be overlaid on the movement of the horse to address the treatment goals of the patient as part of their PT, OT or ST plan.

Equine movement is symmetrical, rhythmic, organized, repetitive input which affects function in these systems:

Mobility Processing Affect Arousal Respiratory Feedback Tone/stiffness Strength Timing Balance GOAL: IMPROVED FUNCTIONAL SKILL

Balance and Postural Control Good postural control and stability are necessary for function including walking, gross and fine motor tasks, ADL’s, and communication.

Components of Postural Control McGibbon, Silkwood-Sherer

Equine movement for balance and postural control Development of stability – core and joint integrity. Orientation – optical righting, organization of body parts Modulation of postural tone Coordination and timing of postural strategies Significant practice opportunities with variability

Generalization of improved function

Equine Movement impact on Fine Motor Skills Movement input followed by functional skill work

© American Hippotherapy Association, Inc. Equine Movement for Therapeutic Activities  Equine movement facilitates the neurophysiological systems that support upper extremity control, motor coordination and planning, and sensory processing.  Ideal medium on which to overlay functional fine motor tasks – ranging from ADL’s to more educational skills.

© American Hippotherapy Association, Inc. A Therapeutic Exercise Strengthening Range of Motion Dynamic Stability Core Stability Co-contraction Bi-lateral motor Coordination

© American Hippotherapy Association, Inc. A Neuromuscular Re-education Facilitory Techniques Facilitory orthotics Mid line crossing Dynamic stability Proprioceptive/Kinesthetic awareness Integrated movement opportunity Balance responses

Speech/Language Therapy The quality of human communication depends on the integrity of the physiological systems that support speech and language – BOTH STRUCTURALLY AND FUNCTIONALLY.

SYSTEMS INTERACTION FOR COMMUNICATION Arousal Postural Motor Control Speech & Control Integration Processing Language

Equine Movement Paired with Speech and Language Tasks

UNIQUE CONTRIBUTIONS of EQUINE MOVEMENT AS A TREATMENT STRATEGY  Multi-modal sensorimotor input that is repetitive, precise, naturally variable, and can be graded by the therapist based on patient needs.  Opportunity for the patient to experience and participate in organized, rhythmic, reciprocal multidimensional and multisensory input.  Provides a predictable and symmetrical dynamic surface on which the patient can develop and practice functional postural control and balance.

UNIQUE CONTRIBUTIONS of EQUINE MOVEMENT AS A TREATMENT STRATEGY  For most patients, is a novel experience, allowing for development of movement strategies outside of the habitual patterns; moving beyond their wells of stability.  Input to both sides equally, symmetrical and reciprocally, reflective of most functional tasks.  Average 2500 neurophysiologic inputs per session – variable practice in a safe environment.

A SAFE TREATMENT STRATEGY  Safety protocols include: training of the horse and therapy team, use of safety equipment, and treatment in a select environment  Safety results: over the past 10 years have shown patient injuries as negligible, with even fewer experiences with treatment lead by experienced and credentialed therapists Combined data from AHA, Inc. Injury Statistics: 10 reported injuries in 72,754 treatment sessions that included hippotherapy – 9 were to staff and 1 involved a client.  Perceived risk: benefit to patients

© American Hippotherapy Association, Inc. One More Standard Therapy Tool for the PT, OT or SLP to use

SPECIFIC BENEFITS OF HIPPOTHERAPY Potential for improvement in:  Arousal and attention  Balance strategies  Belief in one’s functional capabilities  Bilateral integration  Body awareness  Circulation  Dynamic postural stability  Endurance  Expressive and/or receptive speech and language  Midline orientation  Mobility of pelvis, spine, and hip joints

 Modification of muscle tonus  Motivation  Muscle strength  Musculoskeletal alignment  Neurogenic bladder  Neuromotor function  Oral-motor function  Posture  Problem-solving movement strategies  Respiratory function  Self-confidence  Sensorimotor integration  Symmetry and alignment  Timing and coordination of motor strategies

Documentation  The incorporation of equine movement/hippotherapy into a physical, occupational and/or speech-language therapy plan is documented in the same manner as any other standard practice tool/strategy.  This includes: treatment plans, treatment goals, data collection & treatment notes/reports as per discipline and payer source.

© American Hippotherapy Association, Inc. Reimbursement Codes / CPT AMA Coding Guidelines mandate: Use of the CPT Code that most accurately describes the clinical reasoning process and the services provided by the therapist. Standard physical medicine codes best reflect what the therapist is doing when equine movement is included in PT, OT and/or ST.

 HCPCS Level I (CPT Codes):  Developed and maintained by the AMA  HCPCS = Health Care Common Procedure Coding System  Level I = CPT  Incorporates standard medical procedures used by health professionals including PT, OT and ST  Used to determine the amount of reimbursement by the insurance provider based on  The resource-based relative value scale (RBRVS) The geographic practice cost indexes (GPCIs) The monetary conversion factor Current Procedural Terminology / CPT

© American Hippotherapy Association, Inc. Codes:  HCPCS Level II Codes Standardized coding system used primarily for products, supplies, and services not included in the CPT-4 codes. Examples: ambulance services, durable medical equipment prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. These codes are NOT used by PT, OT and ST

The S Code…  S8940: Hippotherapy/Equestrian Therapy  HCPCS Level II code – not used by standard medical/therapy professionals  Does not accurately represent PT/OT/ST sessions in which equine movement is being used as a strategy/tool to impact function.  “Equestrian Therapy” does not exist  There are no licensed “Equestrian Therapists”  Not a viable/accurate code used to describe treatment by a licensed PT, OT or SLP.

Research Evidence  Substantial body of evidence in peer reviewed journals internationally showing hippotherapy/equine movement as beneficial  Subject populations include: Cerebral Palsy, Multiple Sclerosis, Down Syndrome, Postural instability, Spinal Cord Injury, Language-learning Disability, Stroke  Detractors include poor consistency in the terminology used

Certification of Therapists  Voluntary certification administered by the American Hippotherapy Certification Board (AHCB)  Prerequisite is PT, OT or SLP professional with clinical experience. TWO LEVELS OF CERTIFICATION  Entry level certification – exam following hippotherapy continuing education.  Advanced - Hippotherapy Clinical Specialist (HPCS©)

Considered scope of practice, hippotherapy is incorporated in evidence based treatments to address the functional goals of the PT, OT or SLP patient, and improve the lives of many.