Fourteen female subjects with multiple sclerosis participated in hippotherapy one time per week for 16 weeks. The subjects completed the movement behavior test three times: first, before the hippotherapy sessions began; second, in the week after their sixteen sessions of hippotherapy ended; and, third, 16 weeks after the end of their hippotherapy sessions. At each movement test session, subjects were given a series of questionnaires to complete. The standardized questionnaires included the Bladder Control Scale (BLCS, 4 questions), Bowel Control Scale (BWCS, 5 questions), Fatigue Severity Scale (FSS, 9 questions), and UCLA Loneliness Scale (20 questions). One questionnaire (36 questions) was created specifically for the project, asking subjects to describe different aspects of their hippotherapy experience.
Although analyses of the FSS, UCLA Loneliness Scale, BLCS, and BWCS yield trends toward improvements from pre-hippotherapy to post-hippotherapy as well as improvements from pre-hippotherapy to 16 weeks after therapy concluded, no significant group differences are seen in any of the standardized questionnaire measures. Similarly, in the movement behavior data, a trend toward improvement was seen in the category of “toe balance;” however, there were no scales which showed significant group changes between timepoints. This lack of statistical significance in standardized measures between pre- and post-hippotherapy is a common outcome in the majority of studies on hippotherapy for persons with MS in case studies and pilot studies undertaken in the United States, Germany, New Zealand, and Sweden over the past 15 years. Indeed, there is one study of hippotherapy for persons with MS where significant differences were found between an intervention group and control group on standardized questionnaire scores (Vermöhlen, et al., 2017) and one study where significant physical differences were measured post-hippotherapy (Menezes, et al., 2013). Limitations such as small group size, instability and variability of multiple sclerosis disease activity, and dependence on question interpretation and self-report are a few of the challenges to isolating the impact of hippotherapy.
Although there were not statistically significant results in the movement scales and questionnaires, the questionnaire written for this study yielded highly significant results. In open-ended responses, patients commonly reported that they experienced less back pain, better walking (balance/stability/less spasticity), improved bladder control, feelings of happiness, and an enjoyment of being near and on the horse. Hence, involvement in hippotherapy made clearly positive changes in the lives of persons living with MS; however, as noted above, these very striking improvements are not reflected via statistical significance in standardized questionnaires. Perhaps no significant changes were found in the BLCS due to the small group size and use of catheters. Similarly, perhaps the items in the UCLA Loneliness Scale may not be impacted by patients’ feelings of happiness and enjoyment of being on and near the horse.
The results of this study have been communicated via in-person meetings to local DMSG (the German Multiple Sclerosis Foundation) Contact Groups, to the EOS Equine Therapy Center in the USA, and at the International Conference on Multimodal Communication in Osnabrück, Germany. This work has also been communicated in the USA via television interview, and in the USA and Germany via newspaper articles and will be submitted for journal publication. Links to this information can be found at the project webpage (
https://sites.google.com/site/amylynnhubbard/current-projects(opens in new window)).
Addressing the second of the two project goals, the first manuscript to be submitted for publication from this project will be a review of the historical and current understanding of “MS fatigue.” Indeed, Dr. Lauren Krupp—creator of the long-established clinical measure of MS fatigue (FSS, c. 1989)—has, herself, suggested that stagnation in research on MS fatigue is limited by “terminology and assessment. (Kluger et al., 2013)” In the current project, a close examination of the plethora of information on MS-related daily symptoms, including debilitating tiredness, is a necessary precursor to future study design and data collection.
