Horses and Education as Arthritis Therapy (HEAT)

A study will be conducted to assess if adults and older adults with arthritis who ride horses are able to move better, have less pain, enjoy nature more and have a better quality of life then people who go to class to learn about exercise. This is needed because adults with arthritis experience joint pain, stiffness, damage to their cartilage, and decreased range of motion in their hips, knees, shoulders, and back. This study will measure effects on patient's joints, pain, quality of life, muscle and cartilage before and after either arthritis exercise education or horse riding. Horses have unique movements that target joints without weight bearing and possibly show improvements without joint damage. Twenty two subjects will be assigned to either the equine-assisted therapy (EAT) group or a group receiving exercise education for 1 hour each week for 6 weeks. Outcomes of pain, joint mobility and quality of life are measured at 0, 3 and 6 weeks. Enjoyment will be determined by a survey. Safety procedures include helmets, side walking attendants for balance, and controlled by a certified riding instructor at a certified riding center. Data will be gathered and reviewed, to assess the effects of EAT on arthritis.

The purpose of the proposed research is to assess the feasibility, acceptability and effects of equine-assisted therapy on adults and older adults with arthritis. Equine-assisted therapy (EAT) is defined as any intervention using the unique qualities of horses to improve social, gross motor, and self-help skills.(Ratliffe & Sanekane, 2009) Although equine therapy has been used as a medical intervention since the second century (Ratliffe & Sanekane, 2009), no research has been conducted using equine-assisted therapy to improve arthritis. In the United States arthritis accounts for $128 billion in lost income and medical costs (Centers for Disease Control and Prevention (CDC), 2013) Incidence of arthritis is increasing due to obesity and an aging population.(Bijlsma, Berenbaum, & Lafeber, 2011) Adults aged 40 to 65 and older than 65 with arthritis experience joint pain, stiffness, damage to cartilage, and decreased range of motion particularly in hips, knees, shoulders, and back (Barten et al., 2015; George et al., 2015; Karjalainen et al., 2001). Practice recommendations of non-pharmacological management of arthritis include using a biopsychosocial approach, an individualized exercise regime, strengthening leg and hip muscles, and improving the range of motion for muscle and joint health (Fernandes et al., 2013). Healthy People 2020 reports that arthritis has a major effect on a person's quality of life, ability to work and activities of daily life with the objectives of decreasing joint pain, decrease limitations, and decreasing psychological stress. Improving arthritis includes decreasing pain and improving the arthritic impact on the individual's quality of life.(Buchbinder, Bombardier, Yeung, & Tugwell, 1995) To improve musculoskeletal and functional health, the (World Health Organization, 2010) recommends physical activity including aerobic physical activity, strength, flexibility and balance. Current treatments include the use of physical conditioning (Schaafsma et al., 2013), opioids (Chaparro et al., 2013), and injections of anti-inflammatory medications, morphine, anesthetics or steroids(Staal, de Bie, De Vet, Hildebrandt, & Nelemans, 2008). The side effects from these medications can be bothersome, thus non-pharmacologic interventions must be further explored to improve adults and older adults with arthritis. Equine assisted therapy is a promising option since unique movements of the horse translate tri-rotational movements from the horse to the human (Selby & Smith-Osborne, 2013). This targets the spine and hip joints by non-weight bearing movement and has the potential to improve outcomes without joint damage. There are both physical and psychosocial medical uses for equine assisted therapy. Previous meta-analyses of horses used to improve cerebral palsy in children, provide evidence to support the physical-neuromuscular connection and improvements in outcomes (Nimer & Lundahl, 2007; Pretty et al., 2007; Tseng, Chen, & Tam, 2013) reported significant improvement in total mood when riding horses. Anticipated implications for this research include improved range of motion, decreased pain, improved quality of life and enjoyment of nature. The bio-markers will assess the implications on cartilage and muscle to monitor improvement, destruction, or maintenance of both during equine-assisted therapy. If quality of life, enjoyment of nature and range of motion increase without muscle or cartilage destruction, then this would present evidence that EAT is a viable and desirable intervention and this will lead to further research for arthritis interventions including equines.

Randomized Controlled Trial. One group will receive equine-assisted therapy and the second group will receive arthritis exercise education

Participants, care provider, and outcomes assessor will be masked as to which is the intervention and which is the control

This group will interact and ride horses for 1 hour each week for 6 weeks. Horses will remain at a walk and an standard Therapeutic Riding curriculum will be used including safety, mounting, riding, tasks while riding, dismount, bonding with the horse.

This group will receive exercise education that targets arthritis symptoms for 1 hour each week for 6 weeks. This will be based on the exercise education from the Arthritis foundation How-to Exercise With Arthritis. (n.d.).

Participants will groom and ride horses. Horses will be kept at a walk with tasks such as serpentine, circles, and zig zags to complete. Stretching, and tasks like throwing a ball into a net from horseback will be completed

Standard of Care from the Arthritis Foundation - How-to Exercise With Arthritis. (n.d.). Retrieved April 18, 2016, from http://www.arthritis.org/living-with-arthritis/exercise/how-to). This intervention will consist of 6 -1 hour education sessions once a week on exercise to improve symptoms of arthritis

Data on attendance will be collected at 0 (screening), 1, 2, 3, 4, 5, and week 6. Tracking of de-identified will be measured. Data will be aggregated according to intervention vs. control group.

Participant data will include: : Identified, Approached, Screened, Consented, and attending week 1 of either intervention

Each time a roadblock or difficulty in implementation occurs a Protocol Impediment Form will be completed. Data from these forms will be aggregated for reporting of findings from the study

Fidelity to the Protocol - This is measured by a researcher or research assistant observing with a protocol checklist.

Each time there is a Protocol Violation the researcher or Research Assistant will correct the violation and mark that is was corrected. Data will be aggregated and reported for protocol violations in each arm

Number of participants approached will be compared to number of participants who meet inclusion criteria and then start week 1.

Completeness - This will be measured by number of Protocol Impediment incidences, Protocol violations noted on the Protocol checklists.

Compliance - This will be measured by number of Protocol Violations due to refusal or inability to comply with the protocol

Protocol Violations will be categorized into researcher violations, participant violations, therapeutic riding instructor violations.

Open ended question will be administered upon exit of the study asking about acceptability of the study protocol for each arm

Do the study participants intend to continue the intervention after the end of the study? This will be asked at the end of the study and a follow-up phone call to assess if they continued will be made at 8 weeks. Data will be aggregated and reported.

Do the participants stay in the assigned groups, e.g. not wanting to move from control group to treatment group? Note of any desire to change groups will be documented and counted. Data will be aggregated and reported.

Blinding - Measured by number of responses of participants checking if they were in the intervention or control group

Do participants know that they are in the treatment group or control group at the end of the study? At the conclusion of the study this will be asked. Data will be aggregated and reported.

Do the participants feel the time spent per session is too long, too short, or just right? This will be asked at the conclusion of the study. Data will be aggregated and reported.

Do the participants feel the time spent in the study (6 weeks) was too long, too short or just right? This will be asked at the conclusion of the study. Data will be aggregated and reported.

Do the participants feel the measures were too extensive. This will be asked and measured at the conclusion of the study. Data will be aggregated and reported.

Any other suggestions for improving the study. Responses for improvement will be asked, documented and collated for themes.

What is the effect of an equine-assisted therapy intervention compared to an exercise attention-control intervention on pain in adults and older adults with arthritis? Visual Analog Pain Scale will be used to measure

What is the effect of an equine-assisted therapy intervention compared to an exercise attention-control intervention on range of motion in adults and older adults with arthritis? Goniometer will measure joint range of motion

What is the effect of an equine-assisted therapy intervention compared to an exercise attention-control intervention on serum troponin for muscle in adults and older adults with arthritis? Serum Troponin will be used to measure this.

What is the effect of an equine-assisted therapy intervention compared to an exercise attention-control intervention on Cartilage Oligomeric Matrix Protein biomarker for cartilage in adults and older adults with arthritis? Serum COMP will be measured

What is the effect of an equine-assisted therapy intervention compared to an exercise attention-control intervention on quality of life in adults and older adults with arthritis? Arthritis Impact Measurement Scale 2 (AIMS 2) short-form will be used to measure this.

What is the effect of an equine-assisted therapy intervention compared to an exercise attention-control intervention on enjoyment of nature in adults and older adults with arthritis? Environmental Attitudes Inventory Scale Sub-scale #1 will measure this.

Inclusion Criteria: - Ages 45 and older Joint pain inclusion will be considered with a mild [Mild pain (0-44)] to moderate pain level [Moderate pain (45-74 mm)] (Hawker, Mian, Kendzerska, & French, 2011) not completely relieved by medications. Measured decreased range of motion by 20% (back, shoulder, knee and hip) and hip abduction wide enough to straddle a horse without discomfort. Written physician's or advanced practice registered nurse's (APRN) clearance to ride a horse. Ability to read and understand English as evidenced by the capacity to follow verbal and written directions at the screening interview. Exclusion Criteria: Self-reported: fear of horses. Self reported allergies to horses. Self reported osteoporosis. Inability to abduct hips wide enough to straddle a horse comfortably. Lack of transportation to the Therapeutic Riding Center. Horse riding for the previous six months.

Aranda-Garcia S, Iricibar A, Planas A, Prat-Subiran JA, Angulo-Barroso RM. Comparative effects of horse exercise versus traditional exercise programs on gait, muscle strength, and body balance in healthy older adults. J Aging Phys Act. 2015 Jan;23(1):78-89. doi: 10.1123/japa.2012-0326. Epub 2014 Jan 14.

Araujo TB, Silva NA, Costa JN, Pereira MM, Safons MP. Effect of equine-assisted therapy on the postural balance of the elderly. Rev Bras Fisioter. 2011 Sep-Oct;15(5):414-9. doi: 10.1590/s1413-35552011005000027. Epub 2011 Oct 14. English, Portuguese.

Barten DJ, Swinkels LC, Dorsman SA, Dekker J, Veenhof C, de Bakker DH. Treatment of hip/knee osteoarthritis in Dutch general practice and physical therapy practice: an observational study. BMC Fam Pract. 2015 Jun 27;16:75. doi: 10.1186/s12875-015-0295-9.

Beil K, Hanes D. The influence of urban natural and built environments on physiological and psychological measures of stress--a pilot study. Int J Environ Res Public Health. 2013 Mar 26;10(4):1250-67. doi: 10.3390/ijerph10041250.

Beinotti F, Christofoletti G, Correia N, Borges G. Effects of horseback riding therapy on quality of life in patients post stroke. Top Stroke Rehabil. 2013 May-Jun;20(3):226-32. doi: 10.1310/tsr2003-226.

Beinotti F, Correia N, Christofoletti G, Borges G. Use of hippotherapy in gait training for hemiparetic post-stroke. Arq Neuropsiquiatr. 2010 Dec;68(6):908-13. doi: 10.1590/s0004-282x2010000600015.

Bijlsma JW, Berenbaum F, Lafeber FP. Osteoarthritis: an update with relevance for clinical practice. Lancet. 2011 Jun 18;377(9783):2115-26. doi: 10.1016/S0140-6736(11)60243-2.

Bizub AL, Joy A, Davidson L. "It's like being in another world": demonstrating the benefits of therapeutic horseback riding for individuals with psychiatric disability. Psychiatr Rehabil J. 2003 Spring;26(4):377-84. doi: 10.2975/26.2003.377.384.

Boonstra AM, Schiphorst Preuper HR, Reneman MF, Posthumus JB, Stewart RE. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res. 2008 Jun;31(2):165-9. doi: 10.1097/MRR.0b013e3282fc0f93.

Borioni N, Marinaro P, Celestini S, Del Sole F, Magro R, Zoppi D, Mattei F, Dall' Armi V, Mazzarella F, Cesario A, Bonassi S. Effect of equestrian therapy and onotherapy in physical and psycho-social performances of adults with intellectual disability: a preliminary study of evaluation tools based on the ICF classification. Disabil Rehabil. 2012;34(4):279-87. doi: 10.3109/09638288.2011.605919. Epub 2011 Oct 12.

Boswell, S., Gusowski, K., Kaiser, A., & Flachenecker, P. (2009). Hippotherapy in multiple sclerosis - results of a prospective, controlled, randomised and single-blind trial. Poster presentation.

Buchbinder R, Bombardier C, Yeung M, Tugwell P. Which outcome measures should be used in rheumatoid arthritis clinical trials? Clinical and quality-of-life measures' responsiveness to treatment in a randomized controlled trial. Arthritis Rheum. 1995 Nov;38(11):1568-80. doi: 10.1002/art.1780381108.

Burch PM, Pogoryelova O, Goldstein R, Bennett D, Guglieri M, Straub V, Bushby K, Lochmuller H, Morris C. Muscle-Derived Proteins as Serum Biomarkers for Monitoring Disease Progression in Three Forms of Muscular Dystrophy. J Neuromuscul Dis. 2015 Sep 2;2(3):241-255. doi: 10.3233/JND-140066.

Carr, A. (2003). Adult Measures of Quality of Life: The Arthritis Impact Measurement Scales (AIMS/AIMS2), Disease Repercussion Profile (DRP), EuroQoL, Nottingham Health Profile (NHP), Patient Generated Index (PGI), Quality of Well-Being Scale (QWB), RAQoL, Short Form-36 (SF-36), Sickness Impact Profile (SIP), SIP-RA, and World Health Organization's Quality of Life Instruments (WHOQoL, WHOQoL-100, WHOQoL-Bref). Arthritis Care & Research, 49(S5), S113-S133. http://doi.org/10.1002/art.11414

Centers for Disease Control and Prevention (CDC). Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation--United States, 2010-2012. MMWR Morb Mortal Wkly Rep. 2013 Nov 8;62(44):869-73.

Cerulli C, Minganti C, De Santis C, Tranchita E, Quaranta F, Parisi A. Therapeutic horseback riding in breast cancer survivors: a pilot study. J Altern Complement Med. 2014 Aug;20(8):623-9. doi: 10.1089/acm.2014.0061. Epub 2014 Jun 25.

Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC. Opioids compared to placebo or other treatments for chronic low-back pain. Cochrane Database Syst Rev. 2013 Aug 27;(8):CD004959. doi: 10.1002/14651858.CD004959.pub4.

Cho SH, Kim JW, Kim SR, Cho BJ. Effects of horseback riding exercise therapy on hormone levels in elderly persons. J Phys Ther Sci. 2015 Jul;27(7):2271-3. doi: 10.1589/jpts.27.2271. Epub 2015 Jul 22.

Dawson, S., & Liddicoat, K. (2009). "Camp Gives Me Hope": Exploring the Therapeutic Use of Community for Adults with Cerebral Palsy. Therapeutic Recreation Journal, 43(4), 9-24.

de Araujo TB, de Oliveira RJ, Martins WR, de Moura Pereira M, Copetti F, Safons MP. Effects of hippotherapy on mobility, strength and balance in elderly. Arch Gerontol Geriatr. 2013 May-Jun;56(3):478-81. doi: 10.1016/j.archger.2012.12.007. Epub 2013 Jan 3.

Debuse D, Gibb C, Chandler C. Effects of hippotherapy on people with cerebral palsy from the users' perspective: a qualitative study. Physiother Theory Pract. 2009 Apr;25(3):174-92. doi: 10.1080/09593980902776662.

Duclos ME, Roualdes O, Cararo R, Rousseau JC, Roger T, Hartmann DJ. Significance of the serum CTX-II level in an osteoarthritis animal model: a 5-month longitudinal study. Osteoarthritis Cartilage. 2010 Nov;18(11):1467-76. doi: 10.1016/j.joca.2010.07.007.

Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977 Apr 8;196(4286):129-36. doi: 10.1126/science.847460.

Farias-Tomaszewski, S., Jenkins, S. R., & Keller, J. (2001). An evaluation of therapeutic horseback riding programs for adults with physical impairmnets. Therapeutic Recreation Journal, 35(3), 250.

Fazio E, Medica P, Cravana C, Ferlazzo A. Hypothalamic-pituitary-adrenal axis responses of horses to therapeutic riding program: effects of different riders. Physiol Behav. 2013 Jun 13;118:138-43. doi: 10.1016/j.physbeh.2013.05.009. Epub 2013 May 15.

Felson DT, Lohmander LS. Whither osteoarthritis biomarkers? Osteoarthritis Cartilage. 2009 Apr;17(4):419-22. doi: 10.1016/j.joca.2009.02.004. Epub 2009 Feb 23. No abstract available.

Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, Doherty M, Geenen R, Hammond A, Kjeken I, Lohmander LS, Lund H, Mallen CD, Nava T, Oliver S, Pavelka K, Pitsillidou I, da Silva JA, de la Torre J, Zanoli G, Vliet Vlieland TP; European League Against Rheumatism (EULAR). EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013 Jul;72(7):1125-35. doi: 10.1136/annrheumdis-2012-202745. Epub 2013 Apr 17.

Fieseler G, Molitor T, Irlenbusch L, Delank KS, Laudner KG, Hermassi S, Schwesig R. Intrarater reliability of goniometry and hand-held dynamometry for shoulder and elbow examinations in female team handball athletes and asymptomatic volunteers. Arch Orthop Trauma Surg. 2015 Dec;135(12):1719-26. doi: 10.1007/s00402-015-2331-6. Epub 2015 Sep 19.

Frevel D, Maurer M. Internet-based home training is capable to improve balance in multiple sclerosis: a randomized controlled trial. Eur J Phys Rehabil Med. 2015 Feb;51(1):23-30. Epub 2014 Apr 23.

George SZ, Wallace MR, Wu SS, Moser MW, Wright TW, Farmer KW, Borsa PA, Parr JJ, Greenfield WH 3rd, Dai Y, Li H, Fillingim RB. Biopsychosocial influence on shoulder pain: risk subgroups translated across preclinical and clinical prospective cohorts. Pain. 2015 Jan;156(1):148-156. doi: 10.1016/j.pain.0000000000000012.

Hakanson M, Moller M, Lindstrom I, Mattsson B. The horse as the healer-a study of riding in patients with back pain. J Bodyw Mov Ther. 2009 Jan;13(1):43-52. doi: 10.1016/j.jbmt.2007.06.002. Epub 2007 Aug 24.

Hammer A, Nilsagard Y, Forsberg A, Pepa H, Skargren E, Oberg B. Evaluation of therapeutic riding (Sweden)/hippotherapy (United States). A single-subject experimental design study replicated in eleven patients with multiple sclerosis. Physiother Theory Pract. 2005 Jan-Mar;21(1):51-77. doi: 10.1080/09593980590911525.

Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011 Nov;63 Suppl 11:S240-52. doi: 10.1002/acr.20543. No abstract available.

Homnick DN, Henning KM, Swain CV, Homnick TD. Effect of therapeutic horseback riding on balance in community-dwelling older adults with balance deficits. J Altern Complement Med. 2013 Jul;19(7):622-6. doi: 10.1089/acm.2012.0642. Epub 2013 Jan 29.

Homnick TD, Henning KM, Swain CV, Homnick DN. The effect of therapeutic horseback riding on balance in community-dwelling older adults: a pilot study. J Appl Gerontol. 2015 Feb;34(1):118-26. doi: 10.1177/0733464812467398. Epub 2012 Nov 28.

Hughes DC, Wallace MA, Baar K. Effects of aging, exercise, and disease on force transfer in skeletal muscle. Am J Physiol Endocrinol Metab. 2015 Jul 1;309(1):E1-E10. doi: 10.1152/ajpendo.00095.2015. Epub 2015 May 12.

Lee S, Lee D, Park J. Effects of the Indoor Horseback Riding Exercise on Electromyographic Activity and Balance in One-leg Standing. J Phys Ther Sci. 2014 Sep;26(9):1445-7. doi: 10.1589/jpts.26.1445. Epub 2014 Sep 17.

Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B. Multidisciplinary biopsychosocial rehabilitation for subacute low back pain in working-age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine (Phila Pa 1976). 2001 Feb 1;26(3):262-9. doi: 10.1097/00007632-200102010-00011.

Keren O, Reznik J, Groswasser Z. Combined motor disturbances following severe traumatic brain injury: an integrative long-term treatment approach. Brain Inj. 2001 Jul;15(7):633-8. doi: 10.1080/02699050010009568.

Kim HS, Lee CW, Lee IS. Comparison between the Effects of Horseback Riding Exercise and Trunk Stability Exercise on the Balance of Normal Adults. J Phys Ther Sci. 2014 Sep;26(9):1325-7. doi: 10.1589/jpts.26.1325. Epub 2014 Sep 17.

Kim SG, Lee CW. The effects of hippotherapy on elderly persons' static balance and gait. J Phys Ther Sci. 2014 Jan;26(1):25-7. doi: 10.1589/jpts.26.25. Epub 2014 Feb 6.

Kim SR, Cho SH, Kim JW, Lee HC, Brienen M, Cho BJ. Effects of horseback riding exercise therapy on background electroencephalograms of elderly people. J Phys Ther Sci. 2015 Jul;27(7):2373-6. doi: 10.1589/jpts.27.2373. Epub 2015 Jul 22.

Kolber MJ, Hanney WJ. The reliability and concurrent validity of shoulder mobility measurements using a digital inclinometer and goniometer: a technical report. Int J Sports Phys Ther. 2012 Jun;7(3):306-13.

Lechner HE, Feldhaus S, Gudmundsen L, Hegemann D, Michel D, Zach GA, Knecht H. The short-term effect of hippotherapy on spasticity in patients with spinal cord injury. Spinal Cord. 2003 Sep;41(9):502-5. doi: 10.1038/sj.sc.3101492.

Lechner HE, Kakebeeke TH, Hegemann D, Baumberger M. The effect of hippotherapy on spasticity and on mental well-being of persons with spinal cord injury. Arch Phys Med Rehabil. 2007 Oct;88(10):1241-8. doi: 10.1016/j.apmr.2007.07.015.

Aliev RG, Gaziev RM, Abdulaev MA, Daitbegov MKh. [Experience with the treatment of acute pancreatitis with 5-fluorouracil in the light of late results]. Vestn Khir Im I I Grek. 1988 Jun;140(6):28-31. Russian.

Lee CW, Kim SG, An BW. The effects of horseback riding on body mass index and gait in obese women. J Phys Ther Sci. 2015 Apr;27(4):1169-71. doi: 10.1589/jpts.27.1169. Epub 2015 Apr 30.

Mackay-Lyons, M., Conway, C., & Roberts, W. (1988). Effects of therapeutic riding on patients with multiple sclerosis: a preliminary trial... horseback riding. Physiotherapy Canada, 40(2), 104-109.

Menezes, K., Mendonça, Copetti, F., Wiest, M., Joner, Trevisan, C., Morais, & Silveira, A., Ferreira. (2013). Effect of hippotherapy on the postural stability of patients with multiple sclerosis: a preliminary study. Fisioterapia E Pesquisa, 20(1), 43-49.

Milfont, T. L., & Duckitt, J. (2010). The environmental attitudes inventory: A valid and reliable measure to assess the structure of environmental attitudes. Journal of Environmental Psychology, 30(1), 80-94. http://doi.org/10.1016/j.jenvp.2009.09.001

Munoz-Lasa S, Ferriero G, Valero R, Gomez-Muniz F, Rabini A, Varela E. Effect of therapeutic horseback riding on balance and gait of people with multiple sclerosis. G Ital Med Lav Ergon. 2011 Oct-Dec;33(4):462-7.

Nimer, J., & Lundahl, B. (2007). Animal-Assisted Therapy: A Meta-Analysis. Anthrozoos, 20(3), 225-238. http://doi.org/10.2752/089279307X224773

Ratliffe, K. T., & Sanekane, C. (2009). Equine-assisted therapies: Complementary medicine or not? Australian Journal of Outdoor Education, 13(2), 33-43.

Sager, A., Drache, M., Schaar, B., & Pöhlau, D. (2008). Hippotherapy for multiple sclerosis - Pilot study assessing effects on balance, spasticity, ability to walk and quality of life. Multiple Scerosis, 14(1), S151.

Schaafsma FG, Whelan K, van der Beek AJ, van der Es-Lambeek LC, Ojajarvi A, Verbeek JH. Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain. Cochrane Database Syst Rev. 2013 Aug 30;2013(8):CD001822. doi: 10.1002/14651858.CD001822.pub3.

Selby A, Smith-Osborne A. A systematic review of effectiveness of complementary and adjunct therapies and interventions involving equines. Health Psychol. 2013 Apr;32(4):418-32. doi: 10.1037/a0029188. Epub 2012 Aug 13.

Silkwood-Sherer D, Warmbier H. Effects of hippotherapy on postural stability, in persons with multiple sclerosis: a pilot study. J Neurol Phys Ther. 2007 Jun;31(2):77-84. doi: 10.1097/NPT.0b013e31806769f7.

Boxem KV, Zundert JV, van Kleef M. Re: Staal JB, de Bie R, de Vet HC, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev 2008:CD001824. Spine (Phila Pa 1976). 2009 Jul 1;34(15):1628-9; author reply 1629. doi: 10.1097/BRS.0b013e3181aa1ffa. No abstract available.

Sunwoo H, Chang WH, Kwon JY, Kim TW, Lee JY, Kim YH. Hippotherapy in adult patients with chronic brain disorders: a pilot study. Ann Rehabil Med. 2012 Dec;36(6):756-61. doi: 10.5535/arm.2012.36.6.756. Epub 2012 Dec 28.

Tseng SH, Chen HC, Tam KW. Systematic review and meta-analysis of the effect of equine assisted activities and therapies on gross motor outcome in children with cerebral palsy. Disabil Rehabil. 2013 Jan;35(2):89-99. doi: 10.3109/09638288.2012.687033. Epub 2012 May 26.

Global Recommendations on Physical Activity for Health. Geneva: World Health Organization; 2010. Available from http://www.ncbi.nlm.nih.gov/books/NBK305057/

Yorke, J., Adams, C., & Coady, N. (2008). Therapeutic value of equine-human bonding in recovery from trauma. ANTHROZOOS, 21(1), 17-30.

http://www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Arthritis-Impact-Measurement-Scales-AIMS

https://www.google.com/webhp?sourceid=chrome-instant&rlz=1C1AVNE_enUS621US621&ion=1&espv=2&ie=UTF-8#q=range+of+joint+motion+evaluation+chart