THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 21, Number 1, 2015, pp. 15–21 Original Articles

ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2014.0021

Effect of Hippotherapy on Gross Motor

Function in Children with Cerebral Palsy:
A Randomized Controlled Trial

Jeong-Yi Kwon, MD, PhD,1 Hyun Jung Chang, MD, MS,1 Sook-Hee Yi, MD,1,*
Ji Young Lee, PT, MS,2 Hye-Yeon Shin, PT, MS,2 and Yun-Hee Kim, MD, PhD1

Abstract

Objective: To examine whether hippotherapy has a clinically significant effect on gross motor function in
children with cerebral palsy (CP).
Design: Randomized controlled trial.
Setting: Outpatient therapy center.
Participants: Ninety-two children with CP, aged 4–10 years, presenting variable function (Gross Motor
Function Classification System [GMFCS] levels I–IV).
Intervention: Hippotherapy (30 minutes twice weekly for 8 consecutive weeks).
Outcome measures: Gross Motor Function Measure (GMFM)-88, GMFM-66, and Pediatric Balance Scale.
Results: Pre- and post-treatment measures were completed by 91 children (45 in the intervention group and 46
in the control group). Differences in improvement on all three measures significantly differed between groups
after the 8-week study period. Dimensions of GMFM-88 improved significantly after hippotherapy varied by
GMFCS level: dimension E in level I, dimensions D and E in level II, dimensions C and D in level III, and
dimensions B and C in level IV.
Conclusion: Hippotherapy positively affects gross motor function and balance in children with CP of various
functional levels.

H ippotherapy provides a dynamic support base for

participants, making it an excellent method for im-
proving trunk strength, control, and balance. Furthermore,
this activity can build overall postural strength and endur-
ance, address weight-bearing shifts, and improve motor
planning. Additionally, the three-dimensional reciprocal
movements of a walking horse stimulate normalized pelvic
movements in participants that closely resemble those during
ambulation.1 Hippotherapy has been used in children with
cerebral palsy (CP) for many years, and its therapeutic ben-
efits have been reported.2–13
Researchers distinguish between two types of equine-
assisted activities and therapies (EAAT): hippotherapy and
therapeutic horseback riding (THR). In hippotherapy, the
therapist sets goals aimed at improving the participant’s
impaired body function, while the goal of THR is to teach
the rider how to ride a horse. Patients undergoing hip-
potherapy take no active control of the horse and merely
receive its influence, while in THR the rider is allowed to
control the horse.10–12,14
EAAT appears to have positive effects on gross motor
function, with limited evidence.11 However, a recent meta-
analysis found insufficient evidence for any therapeutic or
maintenance effects of EAAT on gross motor function in
children with CP.10 Two randomized controlled trials
(RCTs) found no significant effects of THR on gross motor
function as assessed by the Gross Motor Function Measure
(GMFM).15,16 Davis and colleagues15 randomly assigned
children with CP (aged 4–12 years), whose disability se-
verity followed the Gross Motor Function Classification
System (GMFCS; levels I–III), to an intervention (a 30-
minute THR program administered weekly for 10 weeks) or
a control group. They found no significant difference be-
tween the changes in GMFM-66 scores between groups after
the intervention. MacKinnons and colleagues16 provided a
THR program (1 hour weekly for 6 months) to 10 children

1
Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular and Stroke Institute,
Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
2
Samsung RD Center, Samsung Equestrian Team, Gyeonggi-do, Republic of Korea.
*Present affiliation: Department of Rehabilitation, Seoul Rehabilitation Hospital, Seoul, Republic of Korea.

15
16
with CP having mild or moderate degrees of impairment.
GMFM scores did not significantly improve with THR
compared with scores in 9 controls. However, these two
studies examined the effect of THR, not hippotherapy. An
RCT with a larger sample size and consistent protocol is
necessary to determine the effects of hippotherapy on gross
motor function in children with CP.
Thus, the current study was conducted to evaluate the
effects of hippotherapy on gross motor function in a rela-
tively large group of CP children with various functional
levels. The hypothesis was that there would be a greater
improvement of GMFM scores in the hippotherapy group
than in the control group and that the pattern of improve-
ment might differ according to the functional status of
children with CP.
Materials and Methods
Participants
The Institutional Review Board of the Samsung Medical
Center (Seoul, Republic of Korea) approved this study
protocol. Informed consent was provided by parents or
guardians before enrollment. Children suitable for this study
were identified using the Samsung Medical Center database.
Inclusion criteria were (1) diagnosis of CP, (2) body weight
less than 35 kg, and (3) age between 4 and 10 years. Ex-
clusion criteria were (1) having received a botulinum toxin
injection within 6 months, (2) having a selective dorsal
rhizotomy or orthopedic surgery within 1 year, (3) dis-
playing severe intellectual disability, (4) experiencing un-
controlled seizures, or (5) displaying poor visual or hearing
acuity. The body weight limit was 20% of the horse’s
weight, as recommended by the American Hippotherapy
Association. The maximum allowed weight considering the
size of the ponies used was 50 kg.
A total of 124 children were initially assessed for eligibility,
but 32 were excluded because of screening failure (n = 27)
and or a decision not to participate (n = 5) (Fig. 1). Thus, 92
children were randomly assigned to two groups (hippotherapy,
FIG. 1. Consolidated Standards of
Reporting Trials flow diagram.
KWON ET AL.
n = 46; controls, n = 46). Two children in the hippotherapy
group (one with GMFCS level III and one with GMFCS level
II) and three children in the control group (one with GMFCS
level I and two with GMFCS level II) were exposed to the
hippotherapy condition before the study in a twice-weekly
program held for 8 to 16 weeks. Table 1 shows the clinical
characteristics of children included in the analysis.
Study design
This study was an RCT. An independent statistician
performed the randomization using computer-generated ran-
dom blocks of 2 or 4, stratified by GMFCS level (I–IV).
When consenting to participate, the project officers, partici-
pants, and participants’ parents or guardians were blinded to
whether the child would be placed in the hippotherapy or
control group.
Sample size calculation
Sample size calculations were based on 90% power for an
independent t-test to compare changes in outcomes from
baseline to follow-up between the groups. Forty-one chil-
dren in each group were needed to detect a mean change of
1.6 points between groups, with a 2.2-point standard devi-
ation (SD) in GMFM-66 scores. This mean change in
GMFM-66 scores can be considered a clinically meaningful
change in motor function.17 To allow for 10% nonpartici-
pation at follow-up, the required sample size was 46 chil-
dren per group. The plan was to recruit a similar number of
participants at each GMFCS level: 12 at level I, 12 at level
II, 12 at level III, and 10 at level IV for each group.
Treatment
Children in the hippotherapy group received 30 minutes
of private hippotherapy (1 child per therapist) twice a week
for 8 weeks (16 sessions), in addition to conventional
physiotherapy. Hippotherapy sessions were provided by
Samsung RD Center of Samsung Equestrian Team in an
THE EFFECTS OF HIPPOTHERAPY ON MOTOR FUNCTION 17

Table 1. Characteristics of Participants jumping. The GMFM-88 total score and dimension scores for
Included in the Analysis B, C, D, and E were calculated. The GMFM-88 was ad-
ministered before and after the intervention by the same blind
Hippotherapy Control examiner. GMFM-66 scores were calculated from the
Characteristic (n = 45) (n = 46)
GMFM-88 using the Gross Motor Ability Estimator.
Boys, n (%) 20 (44) 29 (63)
Mean age (y) 5.7 – 1.9 5.9 – 1.8 Pediatric Balance Scale. To assess balance, the Pediatric
GMFCS level (n) Balance Scale (PBS) was used. This 14-item, criterion-
I 12 12 referenced measure evaluates functional balance in everyday
II 12 12 tasks.20 The items assess the functional activities that children
III 11 12 must perform to safely and independently function within the
IV 10 10 home, school, or community. This scale has also been vali-
Neuromotor type (n) dated for children with CP21,22 and has good test–retest and
Spastic 41 43 interrater reliability when used with school-age children with
Dyskinetic 2 2 mild to moderate motor impairment.20 The same blinded ex-
Ataxic 2 1 aminer administered the PBS before and after the intervention.
Unilateral, n (%) 4 (9) 6 (13)
Previous surgery, n (%) 6 (13) 7 (15) Statistical analyses
Mean body weight (kg) 18.7 – 5.4 19.9 – 4.8
Mean height (cm) 107.7 – 11.6 110.1 – 10.0 Data were analyzed by using paired t-tests or Wilcoxon
Mean physiotherapy 3.3 – 1.3 3.1 – 1.5 signed-rank tests to compare changes from baseline to post-
time per week (h) intervention within groups, depending on whether data were
normally distributed (according to the Shapiro-Wilk test).
Values expressed with a plus/minus sign are the mean – standard Changes in outcome measures between groups were assessed
deviation.
GMFCS, Gross Motor Function Classification System. using independent t-tests or Mann-Whitney tests. The signifi-
cance level was set at < .05. All analyses were performed with
SPSS software, version 19.0 (IBM Corp., Armonk, New York).
18 m · 27 m indoor riding arena located in Gyeonggi-do,
Republic of Korea. Sessions were conducted by physical Results
therapists extensively trained in hippotherapy by the Ameri-
can Hippotherapy Association and had obtained level II status. Demographic characteristics
Horses walked during sessions with a trained, experienced One participant (GMFCS level III) in the hippotherapy
horse leader. Two volunteers walked along either side of the group dropped out; thus, 45 and 46 children in the hip-
horse, assisting participants. Thus, four people assisted in one potherapy and control groups were available for the final
hippotherapy session: a therapist, a horse leader, and two side analysis, respectively. The groups were similar in terms of
walkers. sex, age, GMFCS level, neuromotor type, laterality, body
A soft saddle (made of fleece) was selected to maximize weight, height, history of surgery, and amount of physio-
contact between participants and the pony. For safety, all therapy they were currently receiving (Table 1).
patients wore helmets.
Four ponies were trained by staff to participate (mean GMFM
height – SD, 135 – 7.5 cm; mean weight, 294 – 44.6 kg).
Ponies and participants were matched according to the size Baseline GMFM-66 and GMFM-88 total and dimension
and functional status of the children and the movement scores did not significantly differ between groups. GMFM-
characteristics of the ponies as best as possible. 66, GMFM-88 total, and GMFM dimensions B, C, D, and E
This study used the hippotherapy treatment protocol de- increased significantly in the hippotherapy group ( p < 0.05).
scribed by McGibbon and colleagues,3 directed by the thera- In contrast, no significant change was noted in the control
pist. The protocol included muscle relaxation; optimal postural group between the two assessments. Changes in the GMFM-
alignment of the head, trunk, and lower extremities; indepen- 66, GMFM-88 total score, and GMFM dimensions B, C, D,
dent sitting; and active exercises (stretching, strengthening, and E scores significantly differed between the hippotherapy
dynamic balance, and postural control). and Control groups ( p < 0.05). When a secondary analysis
Children in the control group received 30 minutes of was performed according to GMFCS levels, GMFM-88 total
home-based aerobic exercise (walking or cycling) twice a score was significantly increased among all levels and
week for 8 weeks with conventional physiotherapy. GMFM-66 scores were significantly increased for children
with levels II, III, and IV. Dimensions of GMFM-88 that
Outcome measures demonstrated significant improvement after hippotherapy
varied by the patients’ GMFCS level; dimension E in level I,
GMFM. This study applied the GMFM-88, a widely used, dimensions D and E in level II, dimensions C and D in level
validated tool for assessing motor function in children with III, and dimensions B and C in level IV (Table 2).
CP.18 It is also an outcome assessment tool for clinical in-
terventions in children with CP and those with delayed motor
PBS
development.19 The GMFM-88 consists of 88 items in five
dimensions: (A) lying and rolling; (B) sitting; (C) crawling Baseline PBS scores did not differ between groups
and kneeling; (D) standing; and (E) walking, running, and ( p > 0.05). After the intervention, the hippotherapy group
18 KWON ET AL.

Table 2. Changes in Gross Motor Function Measures Between Hippotherapy and Control Groups
Hippotherapy (n = 45) Control (n = 46)
p-Value for difference
GMFCS and GMFM Preintervention Postintervention p-Value a
Preintervention Postintervention p-Valuea between groupsb

I
GMFM-66 79.2 – 8.8 83.1 – 9.7 0.01 81.8 – 7.5 82.3 – 7.5 0.26 0.01
GMFM-88 total 94.2 – 5.4 95.8 – 4.7 0.01 95.4 – 4.6 95.7 – 4.2 0.14 0.05
A 100.0 – 0.0 100.0 – 0.0 0.99 100.0 – 0.0 100.0 – 0.0 0.99 0.99
B 100.0 – 0.0 100.0 – 0.0 0.99 100.0 – 0.0 100.0 – 0.0 0.99 0.99
C 99.2 – 2.7 99.6 – 1.4 0.32 99.0 – 2.4 99.6 – 0.9 0.18 0.76
D 92.3 – 10.0 94.2 – 6.4 0.33 92.3 – 6.5 92.1 – 7.0 0.29 0.18
E 83.2 – 13.3 88.0 – 13.5 0.01 87.8 – 12.3 88.8 – 11.3 0.12 0.01
II
GMFM-66 64.6 – 8.6 67.4 – 8.8 < 0.01 62.4 – 5.0 62.8 – 5.5 0.46 < 0.01
GMFM-88 total 81.0 – 10.3 84.3 – 9.8 < 0.01 79.4 – 7.3 80.1 – 7.7 0.24 0.01
A 100.0 – 0.0 100.0 – 0.0 0.99 100.0 – 0.0 100.0 – 0.0 0.99 0.99
B 99.4 – 1.5 99.9 – 0.5 0.18 99.3 – 2.4 100.0 – 0.0 0.32 0.80
C 91.9 – 10.2 95.2 – 8.7 0.02 92.7 – 6.2 95.2 – 4.5 0.03 0.63
D 70.3 – 19.3 76.9 – 16.1 < 0.01 69.0 – 14.8 67.1 – 21.0 0.68 0.01
E 51.7 – 23.6 57.8 – 24.2 < 0.01 45.9 – 16.1 47.5 – 16.6 0.26 0.03
III
GMFM-66 51.7 – 2.6 54.0 – 2.3 < 0.01 53.8 – 4.1 54.2 – 4.1 0.44 0.01
GMFM-88 total 62.2 – 5.1 66.7 – 3.9 < 0.01 66.7 – 6.5 67.0 – 6.7 0.86 0.01
A 99.3 – 2.3 100.0 – 0.0 0.32 100.0 – 0.0 100.0 – 0.0 0.99 0.74
B 96.7 – 4.7 98.9 – 2.5 0.39 97.9 – 3.9 98.6 – 3.8 0.11 0.59
C 75.4 – 9.8 82.7 – 8.3 0.01 81.5 – 7.7 81.9 – 8.9 0.89 0.01
D 32.7 – 13.8 44.8 – 10.7 0.01 40.8 – 15.9 41.0 – 17.7 0.50 0.04
E 15.5 – 3.9 18.9 – 6.6 0.02 22.6 – 11.7 22.5 – 10.6 0.72 0.18
IV
GMFM-66 44.3 – 4.6 46.03 – 4.1 0.01 45.0 – 6.5 44.9 – 6.6 0.35 < 0.01
GMFM-88 total 47.7 – 9.9 51.3 – 8.8 0.01 50.2 – 10.7 50.6 – 11.8 0.52 < 0.01
A 98.4 – 3.2 99.0 – 3.1 0.18 97.8 – 6.8 97.8 – 6.8 0.99 0.48
B 75.8 – 16.6 81.5 – 13.5 0.01 83.8 – 19.3 84.8 – 19.2 0.34 0.01
C 53.8 – 24.7 60.5 – 22.4 0.01 56.9 – 20.2 55.0 – 23.0 0.40 < 0.01
D 10.0 – 9.0 13.8 – 8.7 0.03 12.6 – 13.7 12.3 – 14.4 0.99 0.12
E 5.3 – 6.0 7.2 – 5.8 0.07 5.6 – 5.1 7.4 – 5.9 0.18 0.44
Total
GMFM-66 60.8 – 14.9 63.5 – 15.8 < 0.01 61.4 – 14.8 61.8 – 15.0 0.26 < 0.01
GMFM-88 total 72.7 – 19.2 75.7 – 18.3 < 0.01 73.9 – 17.9 74.3 – 18.1 0.26 < 0.01
A 99.5 – 1.9 99.8 – 1.5 0.11 99.5 – 3.2 99.5 – 3.2 0.99 0.08
B 93.9 – 12.5 95.6 – 9.8 < 0.01 95.7 – 11.0 96.3 – 10.7 0.05 0.03
C 81.7 – 21.6 85.6 – 19.0 < 0.01 83.6 – 18.8 84.2 – 20.4 0.15 < 0.01
D 54.1 – 34.2 59.7 – 32.5 < 0.01 55.5 – 32.2 54.9 – 33.2 0.82 < 0.01
E 41.0 – 34.1 45.1 – 35.4 < 0.01 42.0 – 33.2 43.0 – 33.0 0.15 < 0.01

GMFM-66 values are expressed as mean – standard deviation. GMFM-88 values are expressed as mean percentage – standard deviation.
a
Paired t-test or Wilcoxon signed-rank test to compare between preintervention and postintervention within groups.
b
Independent t-test or Mann-Whitney test to compare changes between hippotherapy group and control group.
GMFCS, Gross Motor Function Classification System; GMFM, Gross Motor Function Measure; A, lying and rolling; B, sitting; C, crawling and
kneeling; D, standing; E, walking, running, and jumping.

showed a significant improvement in PBS scores ( p < 0.05),
but no significant difference was observed in the control
group. The hippotherapy group showed increased PBS
scores compared with the control group ( p < 0.05) (Table 3).
In a secondary analysis according to GMFCS levels, PBS
significantly increased in all functional levels (Table 3).
Participant attendance
Of the 45 children in the hippotherapy group, 11 missed
one session, 5 missed two sessions, 3 missed three sessions,
and 2 missed four sessions.
Adverse effects
Two participants (2.2%) fell during the study period. No
major adverse effects, such as brain injury or fractures, were
found after an immediate medical examination that included
radiography. One participant returned to the therapy and
finished, while the other dropped out.
Discussion
This study appears to be the first RCT showing the ben-
eficial effects of hippotherapy on gross motor function in
children with CP. Children undergoing hippotherapy had
significant improvements in GMFM scores (both GMFM-66
and -88) and PBS scores. The strengths of the study were the
strict inclusion and exclusion criteria, relatively large sam-
ple size, and inclusion of children with various functional
levels. These factors enable analysis of the functional di-
mensions showing main effect of hippotherapy according to
patients’ functional levels.
THE EFFECTS OF HIPPOTHERAPY ON MOTOR FUNCTION
Table 3. Changes of Pediatric Balance Scales in Hippotherapy and Control Groups
Hippotherapy (n = 45)
GMFCS Preintervention Postintervention p-Valuea Preintervention Postintervention p-Valueb
I 47.2 – 6.4 50.5 – 6.1 < 0.01
II 32.6 – 12.9 37.3 – 12.2 < 0.01
III 11.1 – 7.3 16.2 – 6.3 0.01
IV 4.0 – 4.6 7.0 – 4.2 0.01
Total 25.1 – 18.9 28.9 – 18.8 < 0.01
Values are expressed as mean – standard deviation.
a
Paired t-test or Wilcoxon signed-rank test to compare between preintervention and postintervention values.
b
Independent t-test or Mann-Whitney test to compare changes between hippotherapy group and control group.
The GMFM, the primary outcome variable in this study, is
the most widely used measure for evaluating CP; indeed, it
was used in previous clinical trials to assess the effect of
EAAT on children with CP.3,4,7,9,13,15,16 In the present study,
GMFM-66 scores, GMFM-88 total scores, and scores on
GMFM dimensions B, C, D, and E improved. These results
are consistent with those of previous studies reporting im-
provements in gross motor function after EAAT.3,4,7,13
McGibbon and colleagues3 reported that five children with
CP (mean age, 9.6 years) showed a significant increase in
dimension E scores after 30-minute hippotherapy sessions
held twice weekly for 8 weeks. Casady and Nichols-Larsen7
also reported significant differences in GMFM total scores
after hippotherapy administered once weekly for 10 weeks
among 10 children with CP aged 2.3–6.8 years. In addition,
Kwon et al13 reported significant improvement in dimension
E scores and GMFM-66 scores among 16 children with bi-
lateral spastic CP after hippotherapy (30 minutes twice
weekly for 8 weeks). In contrast, two studies by Davis et al.15
and MacKinnon et al.16 reported no significant improvement
of GMFM scores in their intervention groups compared with
controls. These two studies used THR, but not hippotherapy;
furthermore, interventions used by Davis et al. were less in-
tense (30 minutes of THR weekly for 10 weeks) than that
used in the current study.
Previous researchers investigating the effect of EAAT on
motor function of children with CP have mostly included
participants with mild to moderate disability (GMFCS levels
I–III)3,13,15,16 or did not report GMFCS levels.3 For example,
Davis et al15 randomly assigned children with CP GMFCS
levels I–III into an intervention or control group, and
MacKinnons et al16 conducted their study with children with
CP who had mild to moderate impairment. Kwon et al13 also
included patients who had bilateral spastic CP with GMFCS
levels of I or II. In the current study, gross motor function and
balance improved among children with CP, not only those
with GMFCS levels I–III but also those with GMFCS level
IV. However, the dimensions that show main improvement
effect of hippotherapy differed according to their GMFCS
levels. Thus, hippotherapy can be considered helpful for
children with various functional levels; notably, significant
improvements were observed among the dimensions for
participant goals.
The observed improvement in PBS scores in this study was
consistent with and thus strengthens the findings of previous
studies,2,8,13 which have reported significant improvements in
19
Control (n = 46) p-Value for
difference between
groupsb
48.8 – 6.6 49.2 – 6.1 0.16 < 0.01
31.6 – 11.0 31.6 – 12.0 0.34 < 0.01
18.2 – 9.4 18.5 – 8.5 0.50 0.01
5.2 – 5.2 6.0 – 7.3 0.41 0.01
26.9 – 18.3 27.1 – 18.3 0.33 < 0.01
postural control after THR or hippotherapy. Bertoti2 reported
that children with spastic CP showed significant improvement
in posture, measured with the Posture Assessment Scale.
Shurtleff et al.8 also reported that hippotherapy improved the
abilities of children with CP to control trunk and head move-
ments. In addition, the previous study,13 a nonrandomized
prospective controlled trial, demonstrated an improvement in
PBS after hippotherapy in children with CP.
Locomotor impulses from the horse’s back are trans-
ferred to the participant at a frequency of 90–110 impulses a
minute (1.5–1.8 Hz) in three movement planes.23 During a
30-minute hippotherapy session, children could have ex-
perienced approximately 2700–3300 repetitions of forced-
use postural challenge. As McGibbon et al.5 proclaimed,
motor strategies that could be improved with hippotherapy
included control of mediolateral and anteroposterior pos-
tural sway, postural adaptation to a changing environment,
anticipatory and feedback postural control, and more ef-
fective use of multisensory inputs related to posture and
movement.
Habilitation of postural control in children with balance
deficit should include activities that address the muscu-
loskeletal, motor, and sensory processing rate-limiting
factors. Further, these intervention should focus on static
and dynamic equilibrium tasks during mass and ran-
dom practice so that children can actively participate.24,25
Hippotherapy is a task-oriented training that meets the
above requirements.25 For optimal skill acquisition in
task-oriented training, training must be sufficiently chal-
lenging to facilitate learning, progressive and adaptable so
users will continue to acquire or refine new skills, and
sufficiently interesting and meaningful to engage the user
in active problem solving.26 The tasks must also be salient
to the performer to influence the person-task-environment
triad. In the current study, most participants were expe-
riencing hippotherapy for the first time; thus, it could be
presented as a set of novel tasks involving massive pos-
tural challenges. Furthermore, participants found hip-
potherapy to be an exceedingly enjoyable and meaningful
activity. Another potential reason for the beneficial effect
of hippotherapy could be the human–horse interaction
acting as a powerful motivator for engaging children’s
participation.27
This study could not evaluate the sole effect of hip-
potherapy on motor function because it did not control for
the participants’ other therapeutic activities. Because
20
hippotherapy is still regarded as a complementary therapy in
many countries, the study did not control for participation in
conventional physiotherapy. Moreover, the therapist did not
completely supervise aerobic exercises performed by the
control group. However, considering that children in both
groups received enough conventional physiotherapy (3
hours per week), the differences in improvement between
the two groups after 8 weeks of intervention might be
counted as an effect of hippotherapy. Another limitation is
that despite the possible beneficial effect of complemen-
tary hippotherapy, this study did not determine its cost-
effectiveness; hippotherapy needs more assistance (four
versus one assistant) and therefore usually incurs higher
costs (e.g., maintaining horses, an arena, and training
volunteers) than conventional physiotherapy. Finally, the
current study only showed the short-term effects of hip-
potherapy in children with CP. Future studies must assess
the maintenance effects of hippotherapy over time.
In conclusion, this study demonstrated the beneficial ef-
fects of hippotherapy on gross motor function and balance
in children with CP. Hippotherapy provided by licensed
health professionals may be used in conjunction with
standard physical therapy for improving gross motor func-
tion and balance in children with CP at various functional
levels.
Acknowledgments
This research was supported by IN-SUNG Foundation for
Medical Research CB08161.
Author Disclosure Statement
No competing financial relationships exist.
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THE EFFECTS OF HIPPOTHERAPY ON MOTOR FUNCTION 21

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E-mail: yunkim@skku.edu, yun1225.kim@samsung.com