Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

Hippotherapy

Description:

Hippotherapy, also referred to as equine movement therapy, describes physical therapy using a horse. Hippotherapy has been proposed as a type of physical therapy for patients with impaired walking related to spastic cerebral palsy.

Hippotherapy has been proposed as a technique to decrease the energy requirements and improve walking in patients with cerebral palsy. It is thought that the natural swaying motion of the horse induces a pelvic movement in the rider that simulates human ambulation. Also, variations in the horse’s movements can prompt natural equilibrium movements in the rider. Hippotherapy is also being evaluated in patients with multiple sclerosis and other causes of gait disorders, such as strokes.

As a therapeutic intervention, hippotherapy is typically conducted by a physical or occupational therapist and is aimed at improving impaired body function. Therapeutic horseback riding is typically conducted by riding instructors and is more frequently intended as social therapy. It is hoped that the multisensory environment may benefit children with profound social and communication deficits, such as autism spectrum disorder and schizophrenia. When considered together, hippotherapy and therapeutic riding are described as equine-assisted activities and therapies.

Policy/
Coverage:

Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria

Hippotherapy is a specific exclusion in the member certificate of coverage.

Hippotherapy does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.

For members with contracts without primary coverage criteria, hippotherapy is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.

Rationale:

Patients with spastic cerebral palsy frequently have impaired walking ability due to hyperactive tendon reflexes, muscle hypertonias, and increased resistance to increasing velocity of muscle stretch. These abnormalities result in a lack of selective muscle control and poor equilibrium responses. Hippotherapy has been proposed as a technique to decrease the energy requirements and improve walking in patients with cerebral palsy. It is thought that the natural swaying motion of the horse induces a pelvic movement in the rider that simulates human ambulation. In addition, variations in the horse’s movements can also prompt natural equilibrium movements in the rider.

The majority of the literature regarding hippotherapy consists of small case series published in the German literature. English language publications also consist of small case series. MacKinnon and colleagues published a small randomized study of 19 patients that reported no significant effects in the majority of outcome measures.

2008 Update

Review of peer reviewed medical literature from July 2005 through August 2008 found no studies which would recommend change in policy.

2009 Update

A search of the MEDLINE® database was performed. New literature on hippotherapy is limited; only small case series were identified. Comparative studies are lacking, and the efficacy of hippotherapy in comparison with other methods of physical therapy is not known. The literature remains insufficient to permit conclusions regarding the effect of this treatment on health outcomes. Therefore, the policy statement is unchanged.

2013 Update

A literature search was conducted using the MEDLINE database through November 2013. There was no new information identified that would prompt a change in the coverage statement. One randomized controlled trial was identified. Araujo et al. reported a randomized controlled trial with 28 participants in 2013 (Araujo, 2013). In this study, 16 hippotherapy sessions over 8 weeks resulted in greater improvement in the Berg Balance Scale and 30s Chair Stand Test compared to controls, with a trend (p= 0.068) toward greater improvement in the TUG.

One ongoing randomized trial of hippotherapy in the late recovery phase following stroke was identied NCT01372059) .The study has an expected enrollment of 120 patients with results expected in early 2014 (www.clinicaltrials.gov) .

This service remains a contract exclusion in most member benefit certificates of coverage.

2014 Update

A literature search conducted through September 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.

Balance Deficits in Older Adults

In 2014, Kim and Lee reported a randomized trial comparing hippotherapy versus treadmill in 30 community-dwelling older adults (Kim, 2014). Training was conducted for 20 minutes, 3 times per week, for 8 weeks. Eight participants withdrew during the course of the study. After 8 weeks of exercises, step lengths increased and step time decreased significantly in both groups (significance was determined at p <0.05). Sway on a balance task also decreased in both groups. The hippotherapy group had a greater decrease in sway path lengths (from 236.1 mm at baseline to 182.6 mm) than the treadmill group (from 235.5 mm at baseline to 210.6), suggesting a modest improvement in static balance with hippotherapy.

Stroke

Lee et al, who had conducted the study in older adults described above, also reported a small randomized trial of hippotherapy for recovery of gait and balance in 30 patients post-stroke (Lee, 2014). Patients were included in the study if they had the ability to walk independently or with a walking aid, spasticity in a paretic lower extremity of less than 2 on the Ashworth Scale, and ability to perform training for more than 30 minutes. Patients were randomly assigned to hippotherapy or treadmill for 30 minutes, 3 days a week, for 8 weeks. At the end of training, gait speed and step length asymmetry ratio were assessed, and balance was measured with the Berg Balance Scale. Results were considered significant if they were at p<0.05. The hippotherapy group showed significant improvements in balance, gait speed, and step length asymmetry, while the treadmill training group improved only in step length asymmetry. Improvements in gait speed and step length asymmetry were significantly greater for the hippotherapy group compared with the control group.

Two small trials from Departments of Hippotherapy and Rehabilitation Science in Asia have compared hippotherapy with treadmill training in older adults and in post-stroke patients. These trials show some advantage over treadmill training. Independent replication and comparison with other established treatments for stroke rehabilitation are needed.

2017 Update

A literature search conducted using the MEDLINE database through October 2017 did not reveal any new information that would prompt a change in the coverage statement.

2018 Update

A literature search was conducted through September 2018. There was no new information identified that would prompt a change in the coverage statement.

2019 Update

Annual policy review completed with a literature search using the MEDLINE database through August 2019. No new literature was identified that would prompt a change in the coverage statement.

2020 Update

Annual policy review completed with a literature search using the MEDLINE database through August 2020. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.

The systematic review by Wood and Fields evaluated 78 studies on hippotherapy dating from 1998 to 2018, some of which are described in more detail below (Wood, 2019). Seventy-seven of the 78 studies quantified results, and 59 studies were quasi-experimental designs. The most basic definition of hippotherapy in the studies was the use of equine movement by such providers as physical, occupational, and speech-language therapists. However, the definitions also varied from a therapy to improve motor function to one that treats anything by involving a horse. Among the studies, the most commonly assessed condition for hippotherapy was cerebral palsy (51%). Other conditions were multiple sclerosis, Down syndrome, autism spectrum disorder, intellectual disability, attention deficit hyperactivity disorder, traumatic brain injury, cerebral vascular accident, and others. The most often reported providers of hippotherapy were paired physical therapists and therapeutic riding instructors. Hippotherapy sessions, on average, were 38 minutes (range=8 to 90 min; standard deviation [SD]=23.19 min), and the average number of sessions was 17.8 (range=1 to 104; SD=22.16). Across all studies, 517 outcomes were classified as either International Classification of Functioning, Disability and Health (ICF), body functions and structures, ICF activity/participation, or other outcomes. Among the ICF-body functions outcomes, movement/gait was most reported, with 70% positive reported outcomes. Less reported, but all predominantly positive were emotional fix (72%), muscle tone (74%), energy/drive (75%), pain (65%), and cognitive fix (100%). More or equally negative effects were reported with heart rate (53%), psychosocial fix (50%), and muscle power (58%). The ICF-AP outcomes showed mostly positive effects in daily mobility (78%) and self-care activities (67%), and interpersonal interactions/relationships, recreation/leisure, play, carrying/handling objects, and other activities were all 100% positive. No benefit was seen in education and domestic life tasks. Research into integrating equine movement as a therapy tool should continue, with more efficacy trials to identify the most promising interventions for further examination.

2021 Update

Annual policy review completed with a literature search using the MEDLINE database through August 2021. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.

Chinniah et al investigated the effects of a horse riding simulator (ie, an electronic horse, working under the principles of hippotherapy) on sitting motor function in 30 children (2 to 4 years of age) with spastic cerebral palsy (Chinniah, 2020). This study randomly assigned subjects to horse riding simulator along with conventional physiotherapy (n=15) or conventional physiotherapy (n=15), with the therapist blinded to group allocation and time of assessment. Sitting motor function was evaluated via the Gross Motor Function Measure-88 at baseline, 4, 8, and 12 weeks with pre- and post-intervention scores analyzed. Results revealed that the mean value of Gross Motor Function Measure improved in both groups over the 12 weeks; however, the experimental group had significant improvement over the control group at all of the assessed weeks (p<0.01). Limitations of the study included its small sample size, lack of long-term follow-up, specific patient population (ie, children with spastic diplegia with mild and moderate disability levels) and focus on sitting motor function.

Bunketorp-Kail et al completed an evaluation of horse-riding or rhythm and music-based therapy in comparison to control in 123 subjects in the late phase after stroke (average number of days elapsed from stroke insult: 1056 days) (Bunketorp-Kail, 2019). Post-intervention, the horse riding therapy group completed the 10 minute walk test faster at both self-selected and fast speed, with fewer steps (-2.17 [95% CI, -3.30 to -1.04]; p=0.002 and -1.40 [95% CI, -2.36 to -0.44]; p=0.020, respectively), as compared to controls. The horse riding therapy group also showed improvements in functional task performance. The gains were partly maintained at 6 months among horse riding therapy participants. The authors noted that the study population was limited to individuals with moderate impairment after stroke and that future research should be extended to other populations of stroke survivors.

2022 Update

Annual policy review completed with a literature search using the MEDLINE database through August 2022. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.

A number of systematic reviews on hippotherapy in children with cerebral palsy have been published. The Agency for Healthcare Research and Quality conducted a systematic review summarizing the evidence for physical activity in people with multiple sclerosis, cerebral palsy, and spinal cord injury (Selph, 2022). Seven RCTs, 2 nonrandomized studies, and 1 cohort study enrolled children with cerebral palsy (n=464). Evidence on functional outcomes with hippotherapy in children with cerebral palsy was based on 7 studies and provided low-strength evidence that found hippotherapy associated with improved function and balance compared to control groups. The largest trial (Kwon et al 2015; n=92) was the only good-quality trial and demonstrated significantly higher Gross Motor Function Measure-66 scores after 8 weeks of hippotherapy compared with at-home exercises. The effect of hippotherapy on balance was assessed in 4 fair- and 2- poor-quality studies using the Pediatric Balance Scale. These low-strength evidence trials demonstrated improved balance scores in pooled analysis with hippotherapy compared to control measures. The inclusion of poor-quality studies in meta-analysis limited clinical interpretation.

In an RCT, Abdel-Aziem et al reported on the efficacy of hippotherapy in combination with Schroth exercises (n=27) compared to traditional physiotherapy (Schroth exercises, n=25) alone in adolescents with idiopathic scoliosis (Abdel-Aziem, 2021). Both groups received Schroth exercises 3 days weekly for 10 weeks. The experimental group additionally received hippotherapy training and pretreatment and posttreatment outcomes were assessed. Both groups experienced improvements in all examined variables posttreatment, however, the group that additionally had hippotherapy had significant improvements in posture asymmetry and balancing ability as demonstrated in all movement outcomes (scoliotic angle, kyphotic angle, pelvic obliquity, pelvic torsion, and vertical spinal rotation) compared to the control group who received Schroth exercises alone (p<.05). This trial was limited by the small sample size and absence of long-term follow-up.

2023 Update

Annual policy review completed with a literature search using the MEDLINE database through August 2023. No new literature was identified that would prompt a change in the coverage statement.

2024 Update

Annual policy review completed with a literature search using the MEDLINE database through March 2024. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.

A small RCT was conducted in 30 patients with stroke that compared the effect of 15 minutes of mechanical hippotherapy toa control intervention (postural control and balance exercises), both given in addition to 45 minutes of intensive conventional rehabilitation therapy on 5 days per week for 4 weeks (Coban, 2023). The primary outcome, change in Berg Balance Scale, was not different between groups(p=.14). This was likely due to a lack of statistical power, since the sample size calculation had assumed a much larger effect size than was observed in the study.

An RCT was conducted that compared hippotherapy to control in 34 children with Down syndrome (Kaya, 2023). All patients underwent a30-minute home exercise program consisting of balance training exercises 3 days weekly for 6 weeks, and the hippotherapy group additionally received once-weekly 30-minute hippotherapy sessions for 6 weeks. Outcomes included the Pediatric Balance Scale, the Timed Up and Go Test, and functional Independence Measure for Children. There were significant improvements in all 3 outcomes between baseline and week 6 in the hippotherapy group (all p<.05). The control group also experienced improvement in the Pediatric Balance Scale at 6 weeks (p=.001) and the Timed Up and Go Test (p=.041), but not the Functional Independence Measure for Children(p=.188). The only between group difference at 6 weeks was in the Functional Independence Measure for Children (p=.008). The authors concluded that balance and mobility improved in both groups, but functional independence only improved in the hippotherapy group.

A systematic review was published of 17 studies (N=596) of equine therapies in children with cerebral palsy (Qin, 2024). The interventions were equine-assisted therapy, horse riding simulators, and therapeutic horseback riding. Sessions ranged from 15 to 60 minutes per week, in 1 to 3 sessions per week. The outcomes of interest were related to gross motor function. In the 8 RCTs that evaluated GMFM-66 scores, there was no difference between individuals who received equine-assisted therapy and those who did not (p=.101). Similarly, there was no difference in GMFM-88 scores among those who received equine-assisted therapy and those who did not (p=.162). However, a pooled assessment of the effect on gross motor function (GMFM-66 and GMFM-88) did suggest a significant benefit of equine therapies (standard mean difference [SMD], 0.19; 95% confidence interval [CI], 0.02 to 0.36; p=.031).

CPT/HCPCS:

References:

Abdel-Aziem AA, Abdelraouf OR, Ghally SA, et al.(2021) A 10-Week Program of Combined Hippotherapy and Scroth's Exercises Improves Balance and Postural Asymmetries in Adolescence Idiopathic Scoliosis: A Randomized Controlled Study. Children (Basel). Dec 30 2021; 9(1). PMID 35053648

Bertoti DB.(1998) Effect of therapeutic horseback riding on posture in children with cerebral palsy. Physical Therapy 1998; 10:1505-12.

Bertoti DB.(1998) Effect of therapeutic horseback riding on posture in children with cerebral palsy. Physical Therapy 1998; 10:1505-12.

Bunketorp-Kall L, Pekna M, Pekny M, et al.(2019) Effects of horse-riding therapy and rhythm and music-based therapy on functional mobility in late phase after stroke. NeuroRehabilitation. Dec 18 2019; 45(4): 483-492. PMID 31868694

Chinniah H, Natarajan M, Ramanathan R, et al.(2020) Effects of horse riding simulator on sitting motor function in children with spastic cerebral palsy. Physiother Res Int. Oct 2020; 25(4): e1870. PMID 32808394

de Araujo TB, de Oliveira RJ, Martins WR et al.(2013) Effects of hippotherapy on mobility, strength and balance in elderly. Arch Gerontol Geriatr 2013; 56(3):478-81.

Kim SG, Lee CW.(2014) The effects of hippotherapy on elderly persons' static balance and gait. J Phys Ther Sci. Jan 2014;26(1):25-27. PMID 24567669

Lee CW, Kim SG, Yong MS.(2014) Effects of hippotherapy on recovery of gait and balance ability in patients with stroke. J Phys Ther Sci. Feb 2014;26(2):309-311. PMID 24648655

MacKinnon JR, Hog S, Lariviere J, et al.(1995) A study of therapeutic effects of horseback riding for children with cerebral palsy. Phys Occup Ther Ped 1995;15:17-34.

MacKinnon JR, Hog S, Lariviere J, et al.(1995) A study of therapeutic effects of horseback riding for children with cerebral palsy. Phys Occup Ther Ped 1995;15:17-34.

McGibbon NH, Andrade CK, Widener G, et al.(1998) Effect of an equine-movement therapy program on gain, energy expenditure, and motor function in children with spastic cerebral palsy: a pilot study. Develop Med Child Neurol 1998; 40:754-62.

McGibbon NH, Andrade CK, Widener G, et al.(1998) Effect of an equine-movement therapy program on gain, energy expenditure, and motor function in children with spastic cerebral palsy: a pilot study. Develop Med Child Neurol 1998; 40:754-62.

Selph SS, Skelly AC, Wasson N, et al.(2022) Physical Activity and the Health of Wheelchair Users: A Systematic Review in Multiple Sclerosis, Cerebral Palsy, and Spinal Cord Injury. Number 241. Agency for Healthcare Research and Quality, US Department of Health and Human Services; 2021. Accessed February 16, 2022. https://www.ncbi.nlm.nih.gov/books/NBK574875/#ch4.s5

Wood WH, Fields BE.(2019) Hippotherapy: a systematic mapping review of peer-reviewed research, 1980 to 2018. Disabil Rehabil. 2019 Sep;1-25:1-25. PMID 31491353

Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association.