ISSN 2321-1822
Original Article
HIPPOTHERAPY SIM ULATOR AS ALTERNATIVE M ETHOD FOR
HIPPOTHERAPY TREATM ENT IN HEM IPLEGIC CHILDREN
M ohamed Ali Elshafey
Lecturer of Physical Therapy, Department of Physical Therapy for Growth and Developmental disorder in Children and its Surgery, Faculty of Physical Therapy, Cairo University.
Background: Hippot herapy considered as w orldw ide t echniques used in rehabilitat ion of children wit h
neurological disorders as it improved gait pat tern, balance, post ural cont rol, strengthen, range of motion and gross and fine motor skills developm ent but it encounter some technical problems.
Purpose: The purpose of the current study was to compare between hippotherapy and hippotherapy simulators
effect on back geometry and balance in hem iplegic children.
M at erials and M ethods: Thirty ambulant hemiplegic children, their age ranges from four to six years old
participated in this study. They were randomly divided into two matched groups (control and study). The control group treated wit h hippotherapy for half hour in addition t o the selected physical therapy program, w hile the study group t reat ed with hippotherapy sim ulators for half hour in addition to the selected physical therapy program also. All children received the treat ment three tim es weekly for three successive months. Spinal geometry were evaluated by Formatric instrumentation systems and balance were evaluated by pediatric balance scale before and after treat ment
Results: There w as significant improvem ent in all the measured variables for both groups after comparing of
their pre and post-treatment mean values with non-significant difference between both groups post t reatment. Conclusion: Hippotherapy sim ulators is an alternative met hod for hippotherapy could be used for modulat ion of back geom etry and for improving balance in hem iplegic children.
Brief summary and potential implication: Hippotherapy sim ulator was used in treatment of back geometry and
balance in hemiplegic children, all the m easurement s were compared wit h hippotherapy. The results w ere nearly t he same in both groups.
KEYW ORDS: Hippotherapy, Postural Disorders, Back Geomet ry.
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International Journal of Physiotherapy and Research
ISSN 2321- 1822
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Received: 07-02-2014 Accepted: 25-02-2014
Published: 11-04-2014
ABSTRACT
INTRODUCTION
Address for correspondence: Dr. M ohamed Ali Elshafey, Lecturer of Physical Therapy, Department
of Physical Therapy for Growth and Developmental disorder in Children and its Surgery, Faculty of
Physical Therapy, Cairo University, Egypt. Email: [email protected]
Peer Review: 07-02-2014
Hemiplegic cerebral palsied (CP) children char-acterized by unilateral paresis with upper limb more severely affected than the lower limb due to larger cortical representation of the hand and the arm. 1, 2,3 The Prevalence of spastic
hemiple-gia accounted for about 0.6 per 1000 live births. Hemiplegic children account more than 38 % of CP children. 4, 5 Spinal deform it ies such as
scoliosis, kyphosis was commonly associated with CP children and lead to serious problems. The overall frequency of scoliosis in CP is 25%.
6
Hemiplegic children suffered from loss of dis-sociation between low er limb movement and less weight bearing on the affected side, affect-ing the ability to maintain an upright standaffect-ing and gait. 7, 8 A symmetrical weight-bearing
dis-tribution between legs result in spinal deformity
in hemiplegic children. 9 Hemiplegic children
depend on unaffected side for weight support.10
ISSN 2321-1822
M ETHODS
t erns w ere described: t he pro gravit at ional postural pattern, with shifting weight over the affected side, and the ant gravitational postural pattern, with shift body weight over un affected side.11
Hippotherapy improved posture, strength trunk muscles and stimulated vestibular, tactile, vi-sual, and post ural senses.12 The horse’s pelvic
movement similar to human pelvic movement thus, providing efficient proprioceptive stimu-lat ion.13 Horse’s gait provides a precise, t he
horse rhythmic and repetitive movement
simi-lar human walking pattern.14
Hippot herapy im proved post ural cont rol.1 5
Hippotherapy inhibited sustained pathological
reflexes and correct abnormal muscle tone.16
Hippot her apy im pr oved gr oss m ot or
development in CP children. 17 Hippotherapy
improved balance in CP children.18 Reduced
spasticity in patients w ith spinal cord injuries and m ult iple sclerosis.19 , 20 Im proved back
geometry in spastic diplegic children.21 Improved
coordination and balance. 22 stimulating righting
and equilibrium responses. 22, 23 There is different
designs to assimilate horse riding as Karakuri t ype st r uct ur ed t o give sensat ion of hippotherapy24 st ruct ured t rot t ing providing
combination of forward-backward and
up-and-down oscillating movements. 25
This study included treatment of back geometry and balance in hem iplegic childr en using hippt herapy simulator and comparison of it s results with hippotherapy.
Subjects, Instrumentations and Procedures:
The st udy design w as randomized cont rolled t rials. t he pr ocedur es f ollow ed w er e in accordance with the ethical standards and after approval of the children families.
Subjects: Thirty spastic hemiplegic CP children participated in this study. Their ages ranges from four to six years old. They were selected from the Outpatient Clinic of the Faculty of Physical Therapy, Cairo University. They w ere divided randomly int o t w o groups of equal number, cont rol group consist s of fift een hemiplegic children (nine female and six male) and study group consist s also of f ift een hem iplegic children (seven female and eight male).
Inclusive criteria: All children were ambulant hemiplegic children and had spasticity grade1 and 1+ according to modified ashworth scale and could follow orders. Exclusive criteria: Children w ere excluded if t hey had hip dislocat ion, st r uct ured scoliosis, fixed cont ract ures or deformity and uncontrolled convulsions, visual, auditory and vestibular disorders.
Instrumentation: For Evaluations:
For metric instrumentation system (AESCULAP-M EDITEC G(AESCULAP-M BH, Holland): This system serves for determining spinal geometry of the human being based on non-contact three dimensional scan and spat ial reconst ruct ion of t he spine derived f r om it by m eans of a specif ic mathematical model. The For metric instrument syst em cont ains t he f ollow ing m aj or subassemblies a- Scan syst em b- Comput er c- Black background screen. d- Laser printer. The Pediat ric Berg Balance Scale (BBS): This scale was developed to measure balance among children with impairment in balance function by assessing the performance of functional tasks. It is a valid inst rument used for evaluat ing effectiveness of interventions and quantitative descriptions of function in clinical practice and research. Equipment needed for this scale is: Ruler, two standard chairs (one with arm rests, one without), footstool or step, stopwatch or wristwatch, 15 ft walkway.
For Treatm ent:
Well trained horse was selected walking with speed 6.4 km/ h, during each session the horse walk in rectangular shape around the treatment arena in clock wise and anti-clock wise direction, directed by the handler who rides another horse walked in front of the child horse, holding the two rein lines together to direct the horses. The horse saddle in training consists of leather seat, st ir rups, leat her flaps, panel, or padding, surcingle, monkey grip, D shape ring and Safety helmets.
ISSN 2321-1822 in Japan used to control the three phase inductive m ot ors speed and t ransfer elect ricit y from interrupted to direct current for the motors. The horse body made from fiber glass reinforced by iron at the base to be strongly attached to the main machine, the horse is equipped with handle for grasp and foot rest. The horse perform rocking m ovem ent in ant eropost erior direct ion at 10,20,30 degree from t he vert ical line and 5,10,15 degree in lat eral direct ions from the vert ical line. The horse is covered by heat bearable leather. The saddle equipped by four sm all t w o phase m ot or s pr oducing low frequency vibration (50-60 HZ) and equipped by elect rical heat ing pad t hat , raise t he saddle temperature up to (40-44Cº ). (figure 1).
Physical therapy equipment including balance board, bounce board, parallel bars, wedges and rolls of different sizes.
Fig 1: Hippotherapy simulators.
An electronic horse provides rocking movement in anteroposterior, lateral directions and com-binat ion of bot h direct ions. The horse w as equipped w it h tw o three phase motor (code COSQ 0.72), speed 1500 cycle / sec, 1.8 amps. The industrial invertors (code VF-NC1) controls t he t hree phase inductive mot ors speed and transfer electricity to direct current.
Procedures: For Evaluation:
For metric instrumentation system: Each child in bot h groups was evaluated in a warm and quite room before and after three mont hs of treatment using For metric instrument system t o measure back geomet ry. Child data w ere entered to the computer and the child was asked to stand facing the black back ground screen at a distance of 2 m away from the scan system either on the ground or on the blocks (according to his/ her height). The horizontal line of scan
system should lie below the inferior angles of scapulae. It is important that t he child’s back (including but t ocks) w as complet ely bare t o avoid disturbed image structures. Each child was asked t o assume t he usual nat ural standing attitude with chin in to improve the presentation of the vertebral prominence. The child was also asked to keep his/ her both upper extremities freely extended beside t he body as much as possible. Height adjust ment of t he opt ical column was done before capturing to obtain the suitable image. When the camera was ready for im age r ecor ding, a gr een hor izont al line appeared on t he comput er screen and t he project or lamp w as aut omat ically sw it ched. During capture, the child was asked to hold on breat h. Full back shape t hree-dim ensional analysis was recorded and printed out for each child. Through one capt ure, t he follow ing parameters w ere measured t runk imbalance vertebral prominence (VP) –dimples mid points (DM ) , pelvic tilt VP-DM , pelvic torsion dimple right (DL) – dimple left (DR), surface rotation maximum (max) and lateral deviation (max) for all children of both groups. (Figure 2)
Fig 2. Formetric instrum entation syst em.
ISSN 2321-1822 reaching forward with outstretched arm, The choices of which leg to stand on or how far to reach are left t o t he child, t he scale scoring, ranging from 0-4. “ 0” indicates the lowest level of function and “ 4” the highest level of function. For Treatm ent:
The control group treated with hippotherapy for three times weekly for three successive months in addition to the selected physical program, the first session is a preparatory session for the child and his parents. The child sit on the horse alone during treatment, the horse walks in rectangular shape around the treatment arena in clock and anti-clock wise direction, directed by the handler who rides another horse walked in front of the child horse, holding the two rein lines together to direct the horses.21 The horse’s legs moves in
this pattern left hind leg left front leg, right hind
leg, right front leg 26 The horse speed was 55
w alking st eps per m inut e. 1 2 The physical
therapist walked beside of the horse to ensure child safety and to give verbal guide to the child to maintain proper upright posture and prevent child falling. 27, 28 The child allowed to had 10
min rest during the session.
The st udy group t reat ed w it h hippot herapy sim ulat or s t hr ee t im es w eekly f or t hr ee successive months in addition to the selected physical program also. The first session is a preparatory session for the child and his parents, the child sits on the horse holding the handle t he hip joint flexed, abduct ed and ext ernally rot at ed and feet hold in dorsiflexion during treatment by belt. Each child rode the simulators for 30 min with 10 minutes rest in between, the Child exposed to the rocking movement by the simulators in the anteroposterior direction 20 degree from the vertical for 10 minutes and to both sides for 15 degree from the vertical for10 minutes and combination of both directions for anot her 10 m inut es, t he low f requency mechanical vibration and heating applied during treatment. The child allowed to having 10 min rest during the session.
The select ed physical t herapy pr ogr am conducted for an hour for each groups, including post ural correct ion exercise, correct ion of abnor m al gait pat t er n via t ask analysis t echnique, t runk cont rol exercise, st ret ching exercises for tight muscles and strengthening
exercise for weak muscle.
Statistical analysis: Chi- squared was conducted to ensure equivalence of both groups. T-test was conducted to compare the differences between both groups pre and post treatment. Paired t test was conducted to compare between pre and post treatment measurements within each group. The level of significance for all statistical tests was set at p < 0.05 . Non parametric analysis was carried out post treatment for both groups by W ilcoxon Signed Ranks Test . All stat ist ical measures were performed through the statisti-cal package for social studies (SPSS) version 19 for windows.
RESULTS AND TABLES
The demographic and other baseline charac-teristics:
There was no significant difference betw een both groups in their age, height, gender, affected side and spasticity as illustrated in Table 1-2.
Table 1: Com pariso n bet w een bo t h gro ups in m ean age an d heigh t .
±SD: m ean ± st andar d deviat io n p: level o f signif icant * : no n si gni f icant
Table 2: Co m par ison bet w een bo t h groups in gender, af f ect ed sid e an d spast ici t y gr ad e.
Age 4.84 ± 0.58 4.98 ± 0.75 -0.14 0.55* Height 120.93 ± 5.67 122.4 ± 6.54 -0.65 0.51* Variable
t- value p-value Control group
±SD
St udy group ±SD
X²: Chi-squared value * : non significant
Pre treatment stat istics for both groups (Table 3):
There was no significant difference betw een both groups in all measured variables pre treat-ment as illustrated in Table 3.
Table 3: Co m par ison bet w een pret r eat m ent m ean
values f o r bo t h gr o ups.
Trunk imbalance
VP-DM (mm) 9.06 ± 1.75 9.46 ±1.99 -0.58 0.56* Pelvic tilt DL-DR (mm) 7.26± 1.9 7.53±1.55 -0.42 0.67*
Pe lvic torsion DL-DR
(degree ) 5.26 ± 1.03 5.33±1.49 -0.14 0.88* Surface rotation (max)
(degree ) 5.66 ± 1.44 5.93± 1.48 -0.49 0.62* Late ral deviation
(max) (mm) 4.46 ±1.06 4.7± 1.08 -0.59 0.55* Berg balance test 28 ±2.2 28.33 ±2.35 -0.4 0.69* p-value Study group
±SD Control group
±SD
Variable t- value
±SD:m ean±st andar d d eviat io n p: l evel o f sign if icant * : no n signif icant
Control group
Study
group X² value p-value
M ale (6) 40% (8) 53.3 % Female (9) 60% (7) 46.7% Right (7) 46.7% (6) 40%
Left (8) 53.3 % (9) 60% Grade 1 (7) 46.7% (8) 53.3 % Grade 1+ (8) 53.3 % (7) 46.7%
Gender 0.6 0.43*
Affected
side 0.67 0.79*
Spasticity 0.13 0.71*
ISSN 2321-1822 Pre and Post Treatment statistics for control group:
Ther e w as a significant decr ease in post t reat ment m ean value for cont rol group as illustrated in Table 4.
Table 4: Co m par iso n bet w een pr e and post t r eat m ent m ean values fo r co nt r ol gr oup.
Trunk imbalance VP-DM
(mm) 9.06± 1.75 6.26±1.66 12.58 0.0001* Pelvic tilt DL-DR (mm) 7.26± 1.9 4.76±1.49 8.91 0.0001*
Pelvic torsion DL-DR
(degree) 5.26± 1.03 2.86±0.83 12.61 0.0001* Surface rotation (max)
(degree) 5.66± 1.44 3.43±1.27 12.29 0.0001* Lateral deviation (max)
(mm) 4.46 ±1.06 2.4±1.05 13.48 0.0001* Berg balance test 28 ±2.2 31.93±2.78 -17.23 0.0001*
Variable ±SD
Pre Post t- value p-value
± SD: m ean ± st andar d deviat io n p: level o f significant * : significant
Pre and Post Treatm ent statistics for study group:
Ther e w as a significant decr ease in post t reat m ent m ean value for st udy group as illustrated in Table 5.
Table 5: Co m par iso n bet w een pr e and post t r eat m ent
m ean values f or st udy gr o up.
Trunk imbalance
VP-DM (mm) 9.46 ±1.99 6.73±1.79 10.25 0.0001* Pelvic tilt DL-DR
(mm) 7.53±1.55 5±1.41 19 0.0001* Pelvic torsion DL-DR
(degree) 5.33±1.49 3±.94 10.27 0.0001* Surface rotation
(max) (degree) 5.93± 1.48 3.8±1.29 16 0.0001* Lateral deviation
(max) (mm) 4.7± 1.08 2.63±1.04 16.16 0.0001* Berg balance test 28.33 ±2.35 33.13±2.85 -18.33 0.0001*
Variable ±SD
Pre Post t- value p-value
Non parametric analysis for both groups post treatment:
Six variables were tested forboth groups post treatment.The results seem to indicate that the after the measurements there was no increase and no decrease (average rank of zero vs. aver-age rank of zero). The Wilcoxon signed rank test shows that t he observed difference between both measurements is not significant. The test statistics assume that the novel method is the same like the control method and no significant differences as illustrated in Table 7-8.
Table 7: Wilcoxon signed ranks test . Ranks.
N M ean rank Sum of ranks
Negative ranks 0a 0 0
Positive ranks 0b 3.5 21
Ties 0c
Total 6 Study- control
a. Study < control b. study > control c. study= control
Table 8: Wilcoxon signed ranks test . Test statistics.
Study- control
Z -2.201a
Asymp.sig.(2 tail ) 0,028 Test statistics b
a. Based on negative ranks b. Wilcoxon Signed Ranks Test
DISCUSSION
Hippotherapy is effect ive met hod used in CP children rehabilitation but it is limited in clini-cal practice for various reasons such as fear, difficulty of mounting a horse, climate, finan-cial consider at ions and r equire huge space.Therape- ut ic result obt ained f rom hippotherapy treatmets has encouraged r esearch int o developing an advanced hippotherapy simulators that “ imitate” the horse
movement. 29
The purpose of this study was to investigate the eff icacy of a new designed hippot her apy simulators on spinal geometry and determine its effect on balance in hemiplegic children by comparing it ’s effect with hippotherapy.
The result of t he st udy show ed significant improvement in the spinal geometry and balance in the study groups and this could be attributed to hippotherapy simulators is design to assimi- ± SD: m ean ± st andar d deviat io n
p: level o f significant * : significant
Post treatment statistics for both groups: There was no significant difference betw een both groups in all measured variables post treat-ment as illustrated in Table 6.
Table 6: Com pariso n bet w een po st t r eat m ent m ean
values f o r bo t h gr o ups.
Control group Study group
±SD ±SD
Trunk imbalance VP-DM
(mm) 6.26±1.66 6.73±1.79 -0.73 0.46* Pelvic tilt DL-DR (mm) 4.76±1.49 5±1.41 -0.43 0.66*
Pelvic torsion DL-DR
(degree) 2.86±0.83 3±.94 -0.41 0.68* Surface rotation (max)
(degree) 3.43±1.27 3.8±1.29 -0.78 0.44* Lateral deviation (max)
(mm) 2.4±1.05 2.63±1.04 -0.6 0.54* Berg balance test 31.93 ±2.78 33.13 ±2.85 -1.16 0.25*
t- value
Variable p-value
±SD: m ean ± st andar d deviat io n
ISSN 2321-1822 -late pelvic movement of the horse, stimulating t runk and pelvis propriocept ors and correct abnormal pelvic tilting posture. The heating pad and the low frequency vibration in the saddle and with hip adductors stretching during sitting on t he simulat ors leading t o damping low er extremities spasticity correcting abnormal pelvic tilting, improving trunk proprioceptive function and improving balance and spinal geometry. The hippotherapy simulators perform rocking movement in separate and in combined way not as life horse riding but this way was effective and improved balance and back geometry this due to the rocking movement stimulated trunk and pelvic pr opr iocept ive funct ion and stimulating the vestibular system in linear and rot at ory directions. Cerebral palsied children t reat ed w it h m echanical saddle, replicat ing horse riding, significantly increased their passive range of antero-posterior pelvic tilt and hinder hypertonia compared to those who sit on a static saddle. Sitting positioned with the hips abducted reduces electromyography (EM G) activity in the hip adductors, knee extensors, plantar flexors
and back extensors. 30
The saddle was equipped with heating pad to prevent decreased lower extremity temperature and damp spasticity. Zurekiet., al. 31 concluded
that mechanical horse riding, causes a sustained lowering of skin temperature in children with spast ic cerebral palsy, indicat ing acut ely diminished skin blood flow ; a liable effect of intensified vasoconstriction. Tillman 32 stated
t hat t herapeut ic heat ing increased nerve conduct ion velocit y t ype II fibers, decreased latency time for both sensory and motor nerves and decreased firing rate of type II muscle spindle afferents and gamma efferent. The hippotherapy sim ulat ors is equipped w it h low frequency vibration to damp spasticity in cerebral palsied childr en. Hebert 33 st at ed low fr equency
mechanical vibration reduced H- reflex leading to muscle relaxation.
The post treatment statistic was performed with T t est demonstrated no significant difference between both groups and the non parametric t est also show ed t hat t here is no significant difference between the results of both groups. The study limitation includes small number of
available hemiplegic CP children and high cost of the Hydraulic design of the control unit of the simulators, so the mechanical design was used. The knowledge acquired during the development of t he project w ould lead t o furt her lines of research in very important areas such as effect of the simulator on gross motor development and other pediatric disorders. The opportunity of offering new evidence based treatments for physical disabled child was of great interest at a social level not only for the benefits derived from the therapy but also for the recreational character of the activity and the possibility of combining with other types of therapy.
CONCLUSION
Hippotherapy simulat ors showed results that make it an efficient alternative met hod for hippotherapy and could be used in modulation of back geomet ry and t reat ment of balance disorders in hemiplegic children.
List of abbreviations: BBS- Berg Balance Scale CP- Cerebral palsy DL- Dimple Left
DM - Dimples M id point
DR- Dimple Right
EM G- Electromyography M ax- M aximum
SPSS- st atistical package for social studies
VP- Vertebral prominence
Conflicts of interest: None Source of funding: None
ACKNOW LEDGEM ENT:
I am so sincere gratitude grateful to Dr. Rana Elmarzouki physiot herapist in M it- Ghamer hospital for her partici-pat ion in this study and support to complete this work, I am also grateful to engineering M ohamed elshreef for designing the hippotherpay simulator unit . Finally, I cannot find words t o express m y deep t hanks to all children who participated in this study.
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