Coverage Policy Manual
Policy #: 2003050
Category: Rehabilitation
Initiated: July 2003
Last Review: October 2018
  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.

Policy/
Coverage:
Hippotherapy is a specific exclusion in the member certificate 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.  

CPT/HCPCS:
S8940Equestrian/hippotherapy, per session

References: 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.

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.


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.
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