Conceptual Framework For Hippotherapy: Is it useful to the practice of physical therapy?

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Conceptual Framework For Hippotherapy Is it
useful to the practice of physical therapy?

• Victoria Haehl Nancy
  McGibbon
• University of Michigan Therapeutic
  Riding of Tucson

Nancy H. McGibbon Therapeutic Riding of Tucson
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Overview

• Conceptual Framework
• Conceptual Framework for Hippotherapy
• Application to Hippotherapy
• Conceptual Framework Nagi Model

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Conceptual Framework

• What is it?
• Is it useful?
• What Does It Do For Us As Therapists?
• Explain changes in motor behavior
• Guides our practice
• Guides our research

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Hippotherapy

• What is It?
• Intervention strategy that uses the movement of
  the horse as a treatment tool
• What Does It Do For Our Patients?
• Impacts multiple subsystems
• Promotes Problem Solving- Variability of Practice
• Dynamic and engaging

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Hippotherapy Conceptual Framework

• Our Foundation
• Dynamic Systems Theory (DST)
• Motor Learning Principles
• Research in Neuroscience

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Dynamic Systems Theory

• Key Concepts

• Self-Organization
• Multiple Constraints
• Adaptability
• Control Parameter
• Preferred Movement Patterns
• Stability

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Self-Organization ( e.g. Giuliani, 1991 Heriza,
1991 Thelen, 1995 Thelen Smith, 1995 Thelen
Ulrich, 1991 Ulrich Ulrich, 1993)
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Emergent- no specific instructions

• Multiple Constraints (Newell, 1986)
• Individual
• Task
• Environment

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Adaptability (Shumway-Cook Woollacott, 2001
Thelen and Smith, 1994)

• Perceive----Explore----Select

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Control Parameter (Clark, 1995 Heriza, 1991)

• Key constraint that results in shift in behavior
  from one form to another

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(synergies, Bernstein, 1967)
Preferred Movement Patterns

• have different levels of behavioral stability
  (Thelen Smith, 1994)

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Motor Learning Principles

• Practice (Schmidt, 1991)
• Essential to Learning
• Variability (Schmidt 1988, Gentile, 1996)
• Promotes problem-solving
• Arousal, Attention, and Motivation (Lewthwaite,
  1990 Schmidt, 1988)
• Affect motor learning

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Neurological Plausibility

• Theory of Neuronal Group Selection (Edelman,
  1987, 1993 Sporns Edelman, 1993)
• Neural Plasticity (e.g. Greenough Volkmar,
  1973, Nudo, Milliken, Jenkins, Merzenich,
  1996 Kolb Whishaw, 1998 Elbert et al.,
  1997,1998) the role of behavior in brain
  organization
• Neural diversity- no point-to-point genetically
  predetermined wiring- only a rough palette for
  experience (exploration)-dependent selection
  strengthening of connections among groups of
  neurons with experience
• Reentrant signals- groups in different areas of
  brain have reciprocal and recursive signals from
  many other groups (perceptions linked to actions
  linked to perceptions...)

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Summary

• Self-organizing- emergence of behavior
• Adaptive processes involving multiple constraints
• Constraints act as Control Parameters
• Exploration and Selection of Preferred Movement
  Patterns
• Stability
• Practice and Variability
• Neurophysiological Plausibility

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Application of the Conceptual Framework to
Hippotherapy
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Self-Organization and Multiple Constraints

• Movement patterns of the patient emerge as a
  result of the self-organizing process involving
  the interaction of multiple constraints

Hippotherapy Video
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Multiple Constraints in Hippotherapy
Multiple Constraints in Hippotherapy
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Adaptability in Hippotherapy

• Hippotherapy promotes behavioral adaptation by
  encouraging exploration and practice under a
  variety of conditions.

Hippotherapy Video
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Control Parameters in Hippotherapy

• Constraints that may act as control
• parameters during hippotherapy
• Postural control
• Arousal
• Motivation
• Rhythmicity

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Postural Control

• Postural Control is integral to all purposeful
  movement (von Hofsten, 1993)
• Hippotherapy provides
• Rich multi-sensory information
• Challenging multi-dimensional movement
• Broad base of support

hippotherapy video
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Arousal

• Arousal is an internal state of alertness
• Arousal is related to
• Movement
• Stiffness
• Attention
• Breathing
• The horses movement helps modulate the patients
  arousal level

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Motivation

• Motivation influences motor behavior (Lewthwaite,
  1990 Schmidt, 1988)
• Hippotherapy provides motivation for the patient
  to actively engage in the treatment
• Demands of the task encourage participation
• Pleasurable environment
• Engaging with living, breathing animal

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Rhythmicity

• Principle constituent in our movement patterns
  (Fuchs Kelso, 1990 Thelen, 1995 Turvey, 1990)
• Source of spatial/temporal organization (Fuchs
  Kelso, 1990)
• Coupled oscillators- competitive cooperative
  processes- ENTRAINMENT (Amazeen, Amazeen
  Turvey, 1998 Haken, Kelso Bunz, 1985 Schmidt
  Turvey,1995 Turvey, 1990)
• Consistent repetitive rhythmical movement
  experiences
• Research- modulating frequency to match frequency
  of horse through adapting stiffness (Haehl,
  Ulrich, Sander, Holt, Clayton, 2002)

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Preferred Movement Patterns And Their Stability

• Hippotherapy provides patients with a unique
  range of perceptual and movement experiences that
  encourage adaptation, exploration, and the
  eventual selection of new preferred movement
  patterns.
• The horses movement perturbs patients out of
  their well of stability
• Importance of recognizing behavioral stability
  (Kamm, Thelen, Jensen, 1990)

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Practice and Variability in Hippotherapy

• During hippotherapy, the repetitive yet variable
  stride of the walking horse provides variability
  to the task
• Practice under variable conditions promotes
  exploration, active problem solving, and learning
  new behaviors (Schmidt 1988, Gentile, 1996)

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Neurophysiological Plausability of Hippotherapy

• Neural Plasticity- behavior influencing brain
  organization
• Strengthening of connections
• Processes of self-organization and
  exploration/selection

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Generalizability of Hippotherapy

• Hippotherapy encourages patients to explore,
  select and adapt appropriate behavioral
  strategies relative to the changing context.
• Hippotherapy may provide patients with a more
  diverse repertoire of potential useful behavioral
  solutions, making them more adaptable to
  different environments

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Evidence of Efficacy

• Improved Performance on Horse
• Coordination (Haehl, Giuliani, Lewis 1999)
• Symmtery of muscle activation (McGibbon, Benda,
  Grant, 2001)
• Postural Reactions (MacPhail et al., 1998)
• Improvement in Impairments
• Postural alignment (Bertoti, 1988)
• Symmetrical weight bearing (Bertoti, 1991)
• Symmetry and level of muscle activity
  (McGibbon, Benda, Grant, 2001)
• Self-esteem (Dismuke-Blakely, 1984)

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Evidence of Efficacy

• Improvements in Functional Performance
• Gross motor function (McGibbon, Andrade,
  Widener, Cintas, 1998)
• Decreased walking energy expenditure
  (McGibbon, Andrade, Widener, Cintas, 1998)
• Speech production (Dismuke-Blakely, 1984)
• Balance (Silkwood-Sherer Braun Szeidel, 2001
  Warmbier Silkwood-Sherer, 2000)
• Functional mobility-PEDI (Haehl et al., 1999)

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Nagi Disablement Model (Nagi, 1965)

• Pathophysiology... Impairments... Functional
  Limitations... Disability

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Strengths of Disablement Model

• Improved appreciation of functional goals of
  patients
• Useful in relating what impairments (individual
  constraints) may be influencing functional
  limitations
• Helps organize evaluation and treatment planning

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Limitations of Disablement Model

• Not a theoretical framework providing a
  foundation for changing motor behavior.
• Does not address
• Processes of change (e.g.self-organization/emerge
  nce and exploration/selection
• Importance of environment, task constraints
• Stability/instability in changing behaviors
• Identifying control parameters- both within and
  outside individual
• Does not recognize the capacity of our behavior
  to impact brain

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Conclusion

• This conceptual framework helps us to understand
  the processes of change in hippotherapy
• It may also be useful for other dynamic
  treatment tools or strategies used in patient
  treatment
• A CONCEPTUAL FRAMEWORK AND A DISABLEMENT MODEL
  MAY BOTH BE NECESSARY FOR BEST PRACTICE!