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MP 8.03.12 Hippotherapy

 

Medical Policy    
Section
Therapy
 
Original Policy Date
7/16/99
Last Review Status/Date
Reviewed with literature search/11:2011
Issue
11:2011
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. 


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. Horseback riding is also being investigated as a social therapy for children with autism.

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.

It is hoped that the multi-sensory environment may also be beneficial to children with profound social and communication deficits, such as autism spectrum disorder, and also developmental disorders such as Down syndrome.

Simulated hippotherapy using a new device has been studied in European centers. Therapeutic interventions using such a device would be conducted in the physical/occupational therapy setting and are outside the scope of this policy.


Policy

Hippotherapy is considered investigational.


Policy Guidelines

In 2005, a HCPCS S code specific to this therapy became effective:

S8940 Equestrian/hippotherapy, per session.


Benefit Application
BlueCard/National Account Issues

No applicable information.


Rationale

At the time this policy was created, the majority of the literature regarding hippotherapy consisted of small case series published in the German literature. English language publications also consisted of small case series. (1, 2) MacKinnon and colleagues published a small randomized study of 19 patients that reported no significant effects in the majority of outcome measures. (3)

Literature searches of the MEDLINE® database have been performed periodically since 1999; the most recent search was conducted in January 2010. Several systematic reviews on hippotherapy have been published recently. One of the systematic reviews concluded that there was evidence from one or more randomized controlled trials of fair quality studies that a short intervention of hippotherapy is effective for treating muscle symmetry in the trunk and hip when compared with static sitting. (4) The review found 3 quasi-experimental studies with positive results for gross motor function and functional performance in the home and community. Another systematic review reported that 5 of 6 moderate quality studies (small sample sizes and lack of a control non-riding group) found improved gross motor function in children with cerebral palsy. (5) A systematic review from 2009 concluded that strong evidence indicates that children and adolescents with developmental disabilities derive health benefits from participation in group exercise programs, treadmill training, or therapeutic riding/hippotherapy, however, 3 of the studies included in the review showed that therapeutic horseback riding is no more effective than other therapies for improving muscle tone in children with cerebral palsy and that it is no more effective than no intervention for posture, self-esteem, and global behavior. (6)

In 2011, Zadnikar and Kastrin published a meta-analysis of hippotherapy and therapeutic horseback riding in children with cerebral palsy. (7) Included were 8 studies that met the inclusion criteria of a quantitative study design and outcomes that included postural control or balance. There was no minimum number of subjects (1 of the studies described 2 children) and the median quality score was 10.5 out of a maximum of 16 (range, 5 to 13). The meta-analysis included 84 children with cerebral palsy in the intervention groups and 89 children in the comparison groups (39 with cerebral palsy and 50 non-disabled). The treatment effect on postural control or balance, which was coded as a dichotomous outcome (positive effect or no effect), showed a positive effect in 76 of the 84 children (90%) in the intervention group. In the comparison group, 21 of the 39 children (54%) with cerebral palsy felt positive effects from the comparison treatment, which consisted of continuation of their weekly physiotherapy and/or occupational therapy, or sitting on a barrel or in an artificial saddle. Although this difference was statistically significant, the clinical significance of the effect cannot be determined from this analysis. In addition, the analysis found heterogeneity among the studies, which typically would preclude meta-analysis, and a funnel plot showed asymmetry, indicating a possible publication bias. This meta-analysis is also limited by the inclusion of poor quality studies.

Hippotherapy for patients with multiple sclerosis was addressed in a 2010 systematic review of three studies. (8) A case control study with 9 subjects by Silkwood-Sherer and Warmbier included in the review is discussed below. (9) Each of the other studies, both case series, had 11 subjects. The authors concluded that the studies provided emerging, but limited, evidence that hippotherapy improves balance in persons with multiple sclerosis acknowledging limitations of small sample size, lack of randomization, especially given the variable nature of multiple sclerosis, and lack of controls in two studies.

Examples of the primary literature include a study by Sterba and colleagues, who reported on the outcomes of horseback riding in 17 subjects with cerebral palsy. (10) Gross motor function measurements were assessed before and after a once weekly horseback riding program for 18 weeks. Gross motor function total scores improved by 7.6% after 18 weeks, returning to baseline 6 weeks after the program ended. In another study, Benda and colleagues used surface electromyography to assess outcomes in 15 children with cerebral palsy who were randomly assigned to either horseback riding or to sitting stationary astride a barrel. (11) The authors reported that the hippotherapy group showed greater symmetry of muscle activity. The clinical significance of this outcome is uncertain. Another small study of 12 patients with spastic spinal cord injury found hippotherapy to result in short-term improvements in spasticity and well-being. (12) A study of 9 patients with multiple sclerosis found that 14 weekly sessions of hippotherapy improved balance in comparison with a control group of 6 patients. (9)

In 2009, a randomized trial was published that included 72 children (85% of the 99 families enrolled) aged 4–12 years with cerebral palsy who completed a 10-week session of hippotherapy with pre- and post-treatment assessments. (13) Randomization to hippotherapy or a waiting-list control with usual therapy was stratified by age and level of gross motor function. The physiotherapist assessor was blinded to the randomization, and the participants were asked not to mention if they had completed the intervention at the time of the assessment. No differences between the hippotherapy and control groups were found for functional status (therapist-assessed) or child-reported quality of life. Minor differences were found in parent-reported quality of life and child health scores in the domain of family cohesion. Overall, therapeutic horseback riding was not found to have a clinically significant impact on children with cerebral palsy.

McGibbon et al. investigated the impact of hippotherapy on symmetry of adductor muscle during walking. (14) In Phase I of the trial, they randomly assigned 47 children aged 4-16 years with spastic cerebral palsy to receive a single 10-minute session of either hippotherapy or barrel sitting. Adductor muscle symmetry was measured before and after the session. The hippotherapy group demonstrated a statistically significant difference in adductor symmetry after this single intervention. Six of the children went on to participate in Phase II, a 36-week study (12 weeks without hippotherapy [baseline], 12 weeks of weekly intervention, and 12 weeks without intervention). Four of 6 subjects showed improved symmetry during walking after 12 weeks of intervention, and improvement was maintained after 12 more weeks. All 6 children improved on the Gross Motor Function Measure-66, and 1 child began walking without a walker after 4 weeks of hippotherapy. Five children improved in at least 1 area of Self-Perception Profiles. The authors note a number of limitations of the study including small sample size in Phase II, the diversity of subjects in the distribution of their spasticity, and the inclusion of children with mixed characteristics.

A series of 11 children aged 5-13 years with cerebral palsy demonstrated improved trunk/head stability and upper extremity reaching/targeting after 12 weekly 45-minute sessions of hippotherapy. (15) Results were compared with those of 8 children without disability who did not receive an intervention. The impact of hippotherapy versus other forms of therapy directed to trunk/head stability and upper extremity reaching cannot be determined from this study.

Summary
Literature on hippotherapy is limited, consisting primarily of small uncontrolled case series. In the largest randomized trial conducted to date (72 children), hippotherapy was found to have no clinically significant impact on children with cerebral palsy. The literature at this time does not support the conclusion that hippotherapy is as effective as the existing alternatives and does not demonstrate improvement in net health outcome. Therefore, the treatment is considered investigational.

 

References:

  1.  
    1. Bertoti DB. Effect of therapeutic horseback riding on posture in children with cerebral palsy. Phys Ther 1988; 68(10):1505-12.
    2. McGibbon NH, Andrade CK, Widener G et al. Effect of an equine-movement therapy program on gait, energy expenditure, and motor function in children with spastic cerebral palsy: a pilot study. Dev Med Child Neurol 1998; 40(11):754-62.
    3. Mackinnon JR, Noh S, Lariviere J et al. A study of therapeutic effects of horseback riding for children with cerebral palsy. Phys Occup Ther Pediatr 1995; 15(1):17-34.
    4. Snider L, Korner-Bitensky N, Kammann C et al. Horseback riding as therapy for children with cerebral palsy: is there evidence of its effectiveness? Phys Occup Ther Pediatr 2007; 27(2):5-23.
    5. Sterba JA. Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy? Dev Med Child Neurol 2007; 49(1):68-73.
    6. Johnson CC. The benefits of physical activity for youth with developmental disabilities: a systematic review. Am J Health Promot 2009; 23(3):157-67.
    7. Zadnikar M, Kastrin A. Effects of hippotherapy and therapeutic horseback riding on postural control or balance in children with cerebral palsy: a meta-analysis. Dev Med Child Neurol 2011; 53(8):684-91.
    8. Bronson C, Brewerton K, Ong J et al. Does hippotherapy improve balance in persons with multiple sclerosis: a systematic review. Eur J Phys Rehabil Med 2010; 46(3):347-53.
    9. Silkwood-Sherer D, Warmbier H. Effects of hippotherapy on postural stability, in persons with multiple sclerosis: a pilot study. J Neurol Phys Ther 2007; 31(2):77-84.
    10. Sterba JA, Rogers BT, France AP et al. Horseback riding in children with cerebral palsy: effect on gross motor function. Dev Med Child Neurol 2002; 44(5):301-8.
    11. Benda W, McGibbon NH, Grant KL. Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy). J Altern Complement Med 2003; 9(6):817-25.
    12. Lechner HE, Kakebeeke TH, Hegemann D et al. The effect of hippotherapy on spasticity and on mental well-being of persons with spinal cord injury. Arch Phys Med Rehabil 2007; 88(10):1241-8.
    13. Davis E, Davies B, Wolfe R et al. A randomized controlled trial of the impact of therapeutic horse riding on the quality of life, health, and function of children with cerebral palsy. Dev Med Child Neurol 2009; 51(2):111-9; discussion 88.
    14. McGibbon NH, Benda W, Duncan BR et al. Immediate and long-term effects of hippotherapy on symmetry of adductor muscle activity and functional ability in children with spastic cerebral palsy. Arch Phys Med Rehabil 2009; 90(6):966-74.
    15. Shurtleff TL, Standeven JW, Engsberg JR. Changes in dynamic trunk/head stability and functional reach after hippotherapy. Arch Phys Med Rehabil 2009; 90(7):1185-95.
  2.  

Codes

Number

Description

CPT  No Specific code  
ICD-9 Diagnosis  343  Infantile cerebral palsy 
HCPCS  S8940  Equestrian/hippotherapy, per session 
ICD-10-CM (effective 10/1/13) Investigational for all diagnoses
G80.0-G80.9 Cerebral palsy code range
ICD-10-PCS (effective 10/1/13)    ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for this procedure
Type of Service  Therapy 
Place of Service  Outpatient 
 

Index

Equine Movement Therapy
Hippotherapy 


Policy History

Date Action Reason
07/16/99 Add to Rehabilitation section New policy
04/15/02 Replace policy Policy reviewed without literature review, new review date only
10/9/03 Replace policy Policy reviewed with literature search; no change in policy statement
03/15/05 Replace policy Policy reviewed with literature search; no change in policy statement. Reference number 5 added
03/7/06 Replace policy Policy reviewed with literature search; no change in policy statement. HCPCS S code added to policy guidelines and code table
01/10/08 Replace Policy Policy reviewed with literature search; references 6-9 added; no change in policy statement.
2/12/2009 Replace policy  Policy updated with literature search through December 2008; references reordered; no change in policy statement
02/11/10 Replace policy Policy updated with literature search through December 2009; references added; no change in policy statement
2/10/11 Replace policy Policy updated with literature search, reference numbers 7, 13, 14 added, policy statement unchanged
11/10/11 Replace policy Policy updated with literature search through August 2011, reference 7 added, policy statement unchanged