mp-427 - mp-427 - Medical Policies
Policy Number: MP-427
Name of Policy:
Policy #: 427 Latest Review Date: April 2019
Category: Therapy Policy Grade: B
Description of Procedure or Service:
Hippotherapy, also referred to as equine-assisted therapy movement therapy, describes a treatment strategy that uses equine movement to engage sensory, neuromotor, and cognitive systems to achieve functional outcomes. Hippotherapy has been proposed as a type of therapy for patients with impaired walking or balance.
Ambulation and Balance Disorders
Patients with spastic cerebral palsy frequently have impaired walking ability due to hyperactive tendon reflexes, muscle hypertonia, 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. 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 be beneficial to 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.
This policy addresses equine-assisted activities that focus on improving physical functions such as balance and gait.
Hippotherapy is considered not medically necessary and investigational.
The most recent literature review was updated through January 9, 2019.
The clinical evidence to determine whether the use of technology improves the net health outcome is assessed by evidence reviews. Health outcomes are assessed by the length of life, quality of life, and ability to function, including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Outcome measures are validated to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.
The net health outcome of technology is assessed by whether the evidence is sufficient enough to draw conclusions, while examining two domains: the relevance, and quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. In various conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence is determined by study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is favored to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.
A number of systematic reviews on hippotherapy in children with cerebral palsy (CP) have been published. A 2013 meta-analysis included 5 studies on therapeutic horseback riding and 9 studies on hippotherapy with a total of 277 children with spastic CP. Included in the analysis were RCTs and observational studies that compared pre- and post-riding results; 10 of the 14 studies provided level 4 evidence. Methodologic limitations of the studies included use of invalidated outcome measures and lack of clinically meaningful differences between groups. The authors evaluated Gross Motor Function Measures (GMFM) across studies; meta-analysis indicated that short-term hippotherapy (8 to 10 minutes of total riding time) significantly reduced asymmetrical activity of the hip adductor muscles and could improve postural control in cases of spastic CP (Gross Motor Function Classification System level <5). However, long-term hippotherapy or therapeutic riding (8-22 hours) did not have a statistically significant effect on GMFM in children with spastic CP. Methodologic limitations included the use of non-validated outcome measures, lack of clinically meaningful differences between groups, and in the meta-analysis specifically the inclusion of observational studies (pre-post comparisons) without a control group.
In 2011, Zadnikar and Kastrin published a meta-analysis of hippotherapy and therapeutic horseback riding in children with CP. Eight studies meeting inclusion criteria (quantitative study design, outcomes that included postural control or balance) were selected. The meta-analysis included 84 children with CP in the intervention groups and 89 children in the comparison groups (39 with CP, 50 nondisabled). The treatment effect on postural control or balance showed a positive effect in 76 (90%) of the 84 children in the intervention groups. In the comparison group of 39 children with CP, 21 (54%) experienced positive effects from the comparison treatment, which consisted of continuation of their weekly physical therapy and/or occupational therapy, or sitting on a barrel or in an artificial saddle. Although this difference was statistically significant (p<0.001), 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. Finally, the inclusion of poor-quality studies in the meta-analysis further limited clinical interpretation.
Randomized Controlled Trials
A 2009 RCT included children aged 4 to 12 years with CP who completed a 10-week session of hippotherapy with pre- and posttreatment assessments completed by 72 families (representing 35 intervention and 37 control subjects). Randomization to hippotherapy or a waiting-list control with usual therapy was stratified by age and level of gross motor function. The physical therapist 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, hippotherapy was not found to have a clinically significant impact on children with CP.
McGibbon et al (2009) investigated the impact of hippotherapy on symmetry of adductor muscle activity during walking in children with spastic CP. In phase 1 of the trial, 47 children (age range, 4-16 years) with spastic CP were randomized to a single 10-minute session of 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 a Phase II, a 36-week study (12 weeks without hippotherapy [baseline], 12 weeks of weekly hippotherapy, and 12 weeks without intervention). Four of six subjects showed improved symmetry during walking after 12 weeks of intervention, and improvement was maintained after 12 more weeks. All six children improved on the Gross Motor Function Measure-66, and one child began walking without a walker after 4 weeks of hippotherapy. Five children improved in at least one 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.
In a 2003 study, Benda et al used remote surface electromyography to assess outcomes in 15 children (age range, 4-12 years) with CP who were randomized to 8 minutes of hippotherapy or sitting stationary astride a barrel. The authors reported that the hippotherapy group showed greater symmetry of muscle activity. The clinical significance of this outcome is uncertain.
In 2015, Kwon et al published an RCT of hippotherapy in children (age range, 4-10 years) with CP. Ninety-one subjects were randomized to hippotherapy (30 minutes twice weekly) or home-based aerobic exercise, both for 8 consecutive weeks. Significant differences in composite measures of gross motor function improvement using the GMFM-88 and -66 were observed between groups. Trial limitations include the unclear clinical significance of the outcomes, uncertain attributes of the control group treatment, and lack of long-term outcomes.
In 2002, Sterba et al reported the results of 18-week horseback riding intervention in 17 subjects with CP. GMFM was assessed before and after a once weekly horseback-riding program; after 18 weeks, GMFM total score improved by 7.6%, and returned to baseline 6 weeks after the program ended.
Section Summary: Cerebral Palsy
We identified 4 RCTs comparing hippotherapy with a control, only one of which involved usual physical therapy and blinded outcomes assessment. The trial with blinded outcome assessment showed no difference between groups in functional status at follow-up, while other trials reported significant between-group differences, which suggests that observed differences may have been due to bias.
The use of hippotherapy for patients with multiple sclerosis (MS) was addressed in a 2010 systematic review of 3 studies. Included in the review is a comparative study by Silkwood-Sherer and Warmbier (2007), which that found that 14 weekly sessions of hippotherapy improved balance in nine subjects with multiple sclerosis in comparison with a control group of 6 patients. Each of the other 2 studies in the review, both case series, included 11 subjects; these studies also reported improvements in balance with hippotherapy. The review concluded that the studies included provided emerging evidence that hippotherapy improves balance in persons with MS, although the reviewers acknowledged the limitations of small sample size, lack of randomization (especially given the variable nature of MS), and lack of controls in 2 studies.
A 2011 study compared therapeutic horseback riding (with non-therapist riding instructors) and traditional physical therapy in 27 patients with MS. The therapeutic horseback riding focused on progressively challenging the rider’s motor skills and the individualized physical therapy consisted of aerobic, balance, strengthening, and flexibility exercise sessions. The interventions were self-selected and were provided in 20 sessions over 6 months. The therapeutic horseback riding group showed a significant improvement on the Balance subscale of the Tinetti Performance-Oriented Mobility Assessment and 2 gait parameters (stride time, ground reaction forces). Five (42%) of 12 horseback riders showed a clinically significant improvement. Gait speed and cadence and scores on the Extended Disability Status Scale and the Barthel Index did not improve. No significant change was found in the control group. It was not reported whether the changes found after therapeutic horseback riding were significantly greater than those of the physical therapy control group.
A 2015 RCT by Frevel and Maurer et al compared an Internet-based home training program to hippotherapy in 18 patients with MS. In this study, hippotherapy was considered to be the control intervention and the home training program to be the experimental intervention. Although both intervention groups showed significant improvement in static and dynamic balance capacity, no significant difference was seen between groups. The study had weak statistical power to detect a difference between treatments. The study cannot determine whether hippotherapy is effective compared to standard physical therapy.
Section Summary: Multiple Sclerosis
Current evidence on the use of hippotherapy to treat MS is inconclusive and the studies conducted have been flawed.
Lee et al (2014) conducted a small randomized trial of hippotherapy for recovery of gait and balance in 30 patients post-stroke. Patients were included in the study if they were able to walk independently or with a walking aid, had spasticity in a paretic lower extremity as graded by a score of less than 2 on the Ashworth Scale, and were able 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. 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 treadmill group.
Section Summary: Stroke
The current evidence base on the use of hippotherapy to treat stroke is not sufficiently robust to draw conclusions about efficacy.
Other Gait and Balance Disorders
Comparative studies of hippotherapy versus other treatments for the outcomes of balance and gait have been conducted in community-dwelling subjects. Although they show some findings of improved outcomes, the study subjects included did not have any disorder in balance or gait, and so the clinical importance of the findings is unclear. A 2013 prospective U.S. study of 9 older adults (mean age, 76.4 years) with balance deficits found improvements in balance and quality of life when measured with a pretest-posttest design. Without a comparison group, it is uncertain to what extent the improvements can be attributed to hippotherapy.
Silkwood-Sherer et al (2012) reported on the efficacy of hippotherapy in a convenience sample of 16 children with mild to moderate balance deficits secondary to a variety of disorders. The most common diagnoses were CP (n=5), Down syndrome (n=3), developmental coordination disorder (n=2), and autism (n=2). Baseline and post-treatment Pediatric Balance Scale tests were videotaped and sent in randomized order to 3 pediatric physical therapists for scoring. The Activities Scale for Kids‒Performance questionnaires were completed by the children or their parents. Hippotherapy sessions, conducted twice weekly for 6 weeks, yielded significant improvements on the Pediatric Balance Scale (from a median of 49.0 to 53.0) and the Activities Scale for Kids‒Performance (from a median of 81.7 to 92.1). This study is limited by the lack of a control group.
Giagazoglou et al (2012) reported the effect of hippotherapy on balance and strength in a controlled trial of 19 adolescents with intellectual disability. Balance and strength were assessed with a pressure platform before and after 10 weeks of hippotherapy (n=10) and at the same time points in the nonintervention control group (n=9). There were no significant differences between the groups in double leg stance or left leg stance; however, there were significant group-by-time interactions in balance with the right leg stance. Measures of strength were improved following hippotherapy, with significant group-by-time interactions. This study is limited by the lack of an active therapy control group.
In another small study (2007) of 12 patients with spastic spinal cord injury, hippotherapy resulted in short-term improvements in spasticity and well-being.
Section Summary: Other Gait and Balance Disorders
Current evidence has suggested potential benefit in the treatment of other gait and balance disorders with hippotherapy, but the relevant studies lack control groups, which limits the conclusions that can be drawn.
Summary of Evidence
For individuals who have cerebral palsy, multiple sclerosis, stroke, or other gait and balance disorders who receive hippotherapy, the evidence includes systematic reviews, randomized trials and case series. Relevant outcomes include symptoms and functional status. Studies in cerebral palsy, multiple sclerosis, stroke, and other indication have had variable findings. The randomized trials are generally small and have significant methodologic problems. In the largest randomized trial conducted to date (72 children), which had blinding outcome assessment, hippotherapy had no clinically significant impact on children with cerebral palsy. There are no randomized controlled trials showing that hippotherapy is superior to alternative treatment for patients with multiple sclerosis. Hippotherapy for other indications has been compared primarily with no intervention and has not been shown to be more effective than other active therapies. The evidence is insufficient to determine the effects of the technology on health outcomes.
Practice Guidelines and Position Statements
No guidelines or statements were identified.
U.S. Preventive Services Task Force Recommendations
Equine Movement Therapy, Hippotherapy, therapeutic horseback riding, simulated hippotherapy
Approved by Governing Bodies:
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.
There is no specific CPT code for this procedure.
S8940 Equestrian/hippotherapy, per session
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Benda W, McGibbon NH and 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.
Bertoti DB. Effect of therapeutic horseback riding on posture in children with cerebral palsy. Phys Ther 1998; 68(10):1505-12.
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.
Bunketorp Kall L, Lundgren-Nilsson A, Blomstrand C, et al. The effects of a rhythm and music-based therapy program and therapeutic riding in late recovery phase following stroke: a study protocol for a three-armed randomized controlled trial. BMC Neurol. 2012; 12:141.
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.
De Araujo TB, de Oliveria RJ, Martins WR et al. Effects of hippotherapy on mobility, strength and balance in elderly. Arch Gerontol Geriatr 2013; 56(3):478-81.
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. Feb 2015; 51(1):23-30.
Giagazoglou P, Arabatzi F, Dipla K et al. Effect of a hippotherapy intervention program on static balance and strength in adolescents with intellectual disabilities. Res Dev Disabil 2012; 33(6):2265-70.
Homnick DN, Henning KM, Swain CV et al. Effect of therapeutic horseback riding on balance in community-dwelling older adults with balance deficits. J Altern Complement Med 2013; 19(7); 622-6.
Johnson CC. The benefits of physical activity for youth with developmental disabilities: a systematic review. Am J Health Promot 2009; 23(3):157-67.
Kim SG, Lee CW. The effects of hippotherapy on elderly persons' static balance and gait. J Phys Ther Sci. Jan 2014; 26(1):25-27.
Kwon JY, Chang HJ, Yi SH, et al. Effect of hippotherapy on gross motor function in children with cerebral palsy: a randomized controlled trial. J Altern Complement Med. Jan 2015; 21(1):15-21.
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.
Lee CW, Kim SG, Yong MS. Effects of hippotherapy on recovery of gait and balance ability in patients with stroke. J Phys Ther Sci. Feb 2014; 26(2):309-311.
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.
McGibbon NH, Andrade CK, Widener G, et al. Effect of an equine-movement therapy program on gain, energy expenditure, and motor function in children with spastic cerebral palsy: A pilot study. Dev Med Child Neurol 1998; 40(11):754-62.
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(60):966-74.
Munoz-Lasa S, Ferriero G, Valero R et al. Effect of therapeutic horseback riding on balance and gait of people with multiple sclerosis. G Ital Med Lav Ergon 2011; 33(4):462-467.
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.
Silkwood-Sherer D and 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.
Silkwood-Sherer DJ, Killian CB, Long TM et al. Hippotherapy-an intervention to habilitate balance deficits in children with movement disorders: a clinical trial. Phys Ther 2012; 92(5): 707-17.
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.
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.
Sterba JA. Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy? Dev Med Child Neurol 2007; 49(1):68-73.
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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. Jan 2013; 35(2):89-99.
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Medical Policy Group, April 2010 (3)
Medical Policy Administration Committee May 2010
Available for comment May 7-June 21, 2010
Medical Policy Group, March 2011 (1)
Medical Policy Group, December 2011(3): Updated Key Points & References
Medical Policy Group, November 2012(3): 2012 Update to Description, Key Points & References
Medical Policy Panel, November 2013
Medical Policy Group, January 2014 (2): policy updated with literature search through September 2013. No change in policy statement. Description, Key Points, References updated.
Medical Policy Panel, November 2014
Medical Policy Group, November 2014 (3): Updates to Key Points and References. No change in policy statement.
Medical Policy Panel, March 2016
Medical Policy Group, March 2016 (6): Updates to Description, Key Points, Key Words and References; no change to policy statement.
Medical Policy Panel, March 2017
Medical Policy Group, March 2017 (6): Updates to Description, Key Points: no change to policy statement.
Medical Policy Panel, March 2018
Medical Policy Group, March 2018 (6): Updates to Description and Key Points.
Medical Policy Panel, March 2019
Medical Policy Group, April 2019 (3): 2019 Updates to Key Points and References. No changes to policy statement or intent.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.