A randomized controlled trial of the impact of therapeutic horse riding on the quality of life, health, and function of children with cerebral palsy

Abstract

See related article on page 111. The study by Elise Davis and her Australian colleagues represents a sound effort to perform a randomized clinical trial (RCT) to explore a popular issue in the treatment of children and youth with cerebral palsy (CP), namely the use of hippotherapy. Hippotherapy refers to the presumed therapeutic benefit of horseback riding under controlled and appropriate circumstances with trained horses and human interveners. A number of perspectives on the putative benefits (functional and personal perspectives) of such therapy are offered. Like any good piece of research the study raises a number of important issues that are worthy of comment. The first point to consider relates to the huge challenges inherent in trying to carry out effective RCTs in our complex field of developmental disability. The flow diagram alone tells a number of stories about the difficulties in recruitment, with 155 of 256 families deemed eligible for the study declining to participate. Whatever the families’ reasons, this high (61%) refusal rate has been observed in other studies in CP (Law M, personal communication 2008), and reflects the reality that even when a condition is relatively prevalent (as is true for CP) it can be difficult to find the numbers needed for effective evaluations of our interventions (as determined by pre-study sample size calculations). Furthermore, even among the 99 people who did enroll in the study, 85 actually received the assigned therapy but only 71 were fully evaluated at the end of the study. The second interesting point concerns the findings of the trial. There will certainly be proponents of hippotherapy who will be disappointed at the lack of statistically significant findings from the trial. However, just because there are no apparent measured benefits from hippotherapy doesn’t mean people should not do it! There was no evidence that the intervention caused any harm, and there are suggestions from the unstructured parental observations that the experience was of value to at least some of the children. Whatever happened to people doing things because they wanted to and because they were fun, even in the absence of statistical evidence of benefit? It is also possible that the models we use to explain what our therapies are expected to do may be wrong. In the case of hippotherapy there may be benefits that were not thought about and therefore not measured in this study. Perhaps the findings should be considered in the context of the World Health Organization’s International Classification of Functioning, Disability and Health,1 where participation is one of the goals in life. These children’s experiences certainly included a new element of participation, and the changes in that dimension of life are almost certainly a good thing! Third, the authors rightly identify the challenges of measuring changes in complex constructs like quality of life, which may in fact be a relatively stable phenomenon, as has been recently reported by our group.2 What might be a useful follow-up to the present study would be qualitative studies with both parents and young people (separately) to understand what aspects of the experience were seen to be useful and to have had an impact on the children and youth. Lessons learned from such inquiries would help all of us to know about both hippotherapy and other interventions that seem to make a difference to the lives of the young people we see with CP and other developmental disorders. The investigators have undertaken a worthwhile exploration of an intervention for children with CP and have reported findings that should provide a stimulus for further discussion and research in our ever-evolving field of developmental disability.