80 | mup 2|2009|80 - 87|© Ernst Reinhardt Verlag München Basel mup, 1. Jahrgang, S. 3-7 (2009) © Ernst Reinhardt Verlag München Basel Julia Springer The goals of treatment for fibromyalgia (FM) are similar to the goals known of therapeutic riding. Methods: Six FM patients (5f, 1m, 45.8 years) participated in 20 therapeutic riding sessions (maximum duration: 30 minutes) during 10 weeks. Before, during and after the intervention the following diagnostic instruments were used: Fibromyalgia Impact Questionnaire (FIQ-G), Short Form-36 (SF-36), state of health questionnaire (Basler Befindlichkeitsskala, BBS), function of joint movement (Bewegungsfunktionstest, BFT) and quality and quantity of drug usage. Results: We found significant changes in pre- / post comparison of: FIQ-G (p < 0.05), SF-36 (p < 0.05), BBS (p < 0.05) und BFT (p < 0.05). Keywords: Therapeutic riding, fibromyalgia, exercise, horse, education Therapeutic Riding with Persons suffering from Primary Fibromyalgia Springer - Heilpädagogisches Reiten mit Fibromyalgie-Patienten mup 2|2009 | 81 Primary fibromyalgia is a chronic pain disorder of unknown aetiology, about 2 to 3 % of the population are affected, people of all ages (age summit between the 30th and the 40th year, women about eight times as much as men). The main symptoms are pain in many areas of the body. Stiffness, weariness and sleep disturbances, nervousness, states of anxiety and depressions. The multi-facetedness of symptoms calls for extensive therapeutic measures. Currently, however, fibromyalgia patients are usually treated for individual and separate symptoms. Today there are hardly any complex measures which combine many therapeutic goals all in one. Measures for the treatment of fibromyalgia include, but are not limited to, movement therapy aiming at the motoric / sensory sector (Fürst 2006; Lind-Albrecht 2006; Mucha 1998). Comparing the goals of fibromyalgia-specific interventions with the ones from therapeutic riding (HPR) results in finding many parallels (Fürst 2006; Lind-Albrecht 2006; Mucha 1998; Kröger 2005; Drees 1992). The methods of symptom-specific intervention, for instance, aim at lowering the muscle tone, reducing relief or false postures or regulating the local bloodflow. Apart from that, both methods strive for improving strength and stamina on the general motoric sector. But on the emotional sector many similarities can be found. Lighten up states of depression or reliefing states of anxiety on the symptom specific sector are among the goals defined here. However, generally it‘s about increasing the patient‘s selfesteem. A n a dv a nta g e of th era p e utic ridin g compared with more generalised movement therapeutic measures is mainly the aspect of exercise not considered the main part for partients participating in therapeutic riding sessions. This is of special importance for patients suffering from fibromyalgia since they often are afraid of making certain movements due to their disease pattern‘s symptomatology. Furthermore, in therapeutic riding the physical contact with the animal in general along with the species specific behaviour of the horse addresses the mental sector (Klüwer 1997). Another strength is probably the fact that the situation is considered far from being therapy related. Getting in contact with the horse is a rather natural situation in which the patients can and must fall back on rather primordial skills. Another aspect is that the situation of “going riding“ as a whole has a strong relation to the leisure time behaviour of healthy persons. At the same time, due to the special movement behaviour of the horse while walking and tolting (a quick pace without any thrusting carried out in a four-stroke movement without the floating phase), its movement dialogue skills and the horse‘s body heat in combination with specific exercises, positive effects on the functional and physiological sector can be expected (Klüwer 1997, 7 et seq.). Hence, based on theoretical approaches, one can expect therapeutic riding aiming at various goals to have a positive effect on patients suffering from fibromyalgia. In order to verify the effectiveness of this measure it was examined to which degree therapeutic riding has an impact on the mental and physical restrictions fibromyalgia patients suffer from. Study set-up, execution and survey tools Between the initial and final diagnostics six probands (5 women and 1 man between 41 and 56 years; average age 45.8 years (SD 6.3)) participated in a total of 20 therapy sessions twice a week during a period of ten weeks. The duration of the first session was 10 minutes, the 2nd and 3rd session lasted 20 minutes each and from the 4th one on sessions had a duration of 30 minutes. The study set-up is shown in figure 1. The probands were led on a lunge sitting on horseback without a saddle while performing 82 | mup 2|2009 Springer - Heilpädagogisches Reiten mit Fibromyalgie-Patienten mobility, perception and relaxation exercises. During four sessions the probands switched to tolt. A schematic session set-up along with time schedules can be found in figure 2. At the beginning of each therapy session the horse (Iceland horse, mare, 7 years old) was welcomed by stroking and feeding it with a carrot. After a settling in period of six minutes flexibility exercises were performed. The target muscle here were the m. trapezius pars descendens, the m. erector spinae, the m. quadratus lumborum, the m. semispinalis, the m. longissimus capitis, the m. splenius capitis, the m. levator scapulae, the m. rotatores breves and longi and the m. multifidus. Target joints were the joints of the cervical spine, thoracic spine, the lumbar spine and the shoulder girdle. Afterw ard s th e pro b a n d s performed exercises aiming at increasing perception skills. Here, the probands‘ task was to sense the movement of the horse‘s legs and to tell the director of studies which leg is currently touching the ground or being moved forwards, respectively. During sessions 11 and 12 the proband moved his or her arms in tune with the horse‘s legs instead of performing the perception exercise described above. During sessions 12 to 15 each proband rode 4 times 35 metres in tolt. By the end of sessions 2 to 15 and 20 breathing exercises were performed in order to relax. Here, the probands’ task was to perform some deep abdominal breathing with eyes open (sessions 3-7, 11-14, 20) or eyes closed (sessions 2,8- 10,15). After getting off the horse the latter was rewarded with stroking and a carrot. During sessions 1 and 16 to 19 psychologicpedagogical counseling interviews were conducted. For the purpose of data collection the Fibromyalgia Impact Questionnaire, German version (FIQ-G; Offenbaecher et al. 2002), the Short Form 36 Health survey (SF-36; Bullinger et al. 1995), the Basle state of health questionnaire (BBS; Hobi 1985), the function of joint movement test (Bewegungsfuntionstest, BFT; Keitel et al. 1971) and the documentation of drug intake during inital and final diagnostics as well as during therapy phase were deployed. Table 1 shows the parameters recorded by the individual data collection tools. Fig. 1: Methodic study set-up with diagnostic methods and performed exercises in their chronological order Fig. 2: Schematic set-up of therapy sessions with time schedule Week Session 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1x 1x 1x 1x 1x 1x 1x 1x 1x 1x 1x Initial diagnostics Riding in Tolt, 4 x 35 meters R=Relaxation exercises (open eyes „shaded“, closed eyes „uni“) Perception exercises Flexibility exercises SF=SF-36=Short form 36, quality of life questionnaire nP=no programme, psychologic-pedagogical counseling BBS = state of health questionnaire per pre and post therapy sessions FIQ=Fibromyalgia Impact Questionnaire, German version Explanation BFT = test of function of joints DU=Drugs documentation Final diagnostics 2x 1x 1x 1x 1x 1x 1x 1x 1x 1x 2x 2x 1 2 3 4 5 6 7 8 9 10 11 12 Phase Time Walk type Reins Description Welcoming -5 min. Stance before getting on horseback: 5 min. horse, welcoming, stroking, feeding with carrot, -1 min. sitting correctly and relaxed 0 min. pace Lunge 6 min. for getting used to it 14 min. Flexibility exercises Intervention 18 min. Relaxation 23 min. Perception exercises 24 min. Tolt lead Tolt 30 min. Pace Lunge Relaxation Saying goodbye +3 min. Stance after riding: saying good-bye, feeding with carrot Springer - Heilpädagogisches Reiten mit Fibromyalgie-Patienten mup 2|2009 | 83 Results All statistic scores were processed using the t-test for dependent samples (STATISTICA 6.0). FIQ-G The impact of the illness along with the degree of the main symptoms on “every-day activities“ and the “ability to work“ were captured during initial examination with an average value of 74 % (SD 14), during final eamination with an average value of 45 % (SD 20). This is a significant improvement by 29 % (p < 0.05). Figure 3 shows the results of the FIQ-G with the 10 available measurement points. Highly significant changes can be Table 1: Data collection tools deployed along with parameters gathered and data collection point Method of data collection and respective parameters Data collection tool covered parameters Time of data collection BFT (test consisting of 24 movement tasks for monitoring movement restrictions of extremities) Restriction of movement funtions of: upper extremities lower extremities - Initial diagnostics (ID), final diagnostics (FD) FIQ-G (Questionnaire concerning restrictions of every-day activities and work and degree of main symptoms) Restricitons of: Every-day activities - Ability to work - Degree of: Pain - Stiffness - Weariness - Feeling rested after getting up - Nervousness - Depressivity - ID, always done before 2nd, 4th, 6th, 8th, 10th, 12th, 14th, 16th, 19th session, FD SF-36 (is a questionnaiere concerning health related quality of life) by asking question concerning 8 areas: Body functions - Emotional role function - Physical pain - General health - Vitality - Mental well-being - Social functionality - ID, 6th, 14th, FD BBS (Self-evaluation questionnaire concerning measuring the progress of current mental state) Questions concerning 4 areas: Vitality - Intramental balance - Social extrovertedness - Vigility, cognitive control and perfor- mance 2nd, 10th, 19th per pre and post Drug documentation Monitoring all drugs taken along with doses ID, 10th, FD 84 | mup 2|2009 Springer - Heilpädagogisches Reiten mit Fibromyalgie-Patienten verified through comparing measurement 1 with measurements 2 (p = 0.005) and 3 ( p = 0 . 0 0 7 ) . S i g n ifi c a n t c h a n g e s w it h measurements 4 (p = 0.03), 5 (p = 0.02), 8 (p = 0.047), 9 (p = 0.03), 10 (p = 0.0101) and 11 (p = 0.02). The results of the individual FIQ-G parameters are described in the following: The impairment of every-day activities has improved significantly (p < 0.05) from 50 % (SD 10) during the initial examination to 38 % (SD 8) with the final examination. The impairment of the ability to work was determined with the initial examination with an average of 81 % (SD 9) , with the final examination with 56 % (SD 24). This is a significant (p < 0,05) change of 25 %. The degree of pain with the initial examination was measured resulting in an average value of 83 % (SD 15), with the final examination this value with 58 % (SD 30) was significant (p < 0.05) lower by 25 %. The average value of the degree of wearyness was significantly lower with (p < 0.05) by 28 % with the initial diagnostics of 75 % (SD 22) compared with the final diagnostics of 47 % (SD 35). The average value of the feeling rested after getting up was significantly lower (p < 0,05) by 26 % comparing the initial examination with a value of 83 % (SD 22) with the final examination value of 57 % (SD 39). The measured values of the degree of stiffness parameter during the initial examination were at an average of 74 % (SD 20), with the final examination at an average of 48 % (SD 40), which is by 26 % lower (p < 0,05). The average value of the degree of nervousness during the initial examination was at 69 % (SD 25), during the final examination with 35 % (SD 36) lower by 34 % (p < 0,05). During data collection for depression the average value during the initial examination was at 64 % (SD 27), with the final examination at 31 % (SD 28) by 33 % lower (p < 0,05). SF-36 The SF-36 is divided into eight parts which are evaluated individually. The body functions displayed high significant changes with the third and fourth measurement (p < 0.01) compared with the first one. During the initial examination the average value resulted in 36.4 points (SD 20,4), with data collection point three 60,8 (SD 20,4). This is a difference of 24.4 points (p < 0.01). In terms of physical pain no significant changes (25 (SD 11.7) pre vs. 35.7 (SD 9.8) post) were able to be found compared with the final examination, yet the v a l u e s c h a n g e d s i g n ifi c a ntly ( p < 0 . 05 ) comparing the second (26.3; SD 8.2) and the fourth (35.7; SD 9.8) data collection point. The values concerning mental well-being displayed significant changes related to the initial diagnostics (33.3; SD 11.8) and data collection point three (56.7; SD 10.6; p < 0.05) and four (66; SD 11.5; p < 0.01). The results of the five other areas emotional role function , social function , vitality , general health and physical role function did not show any significant changes (p < 0.05). BBS When measuring the direct effect on the mental state through therapeutic riding significanct changes (p < 0.05) within the second session (measurement 1: 63.8; SD 16.5 before therapy session vs. 83.75; SD 13.8 after the session) and highly significant changes (p < 0.01) within the 10th session (measurement 2: 62.4; Overall impairment FIQ 1 2 3 4 5 6 7 8 9 10 11 Data collection time 0 20 40 60 80 100 Overall impairment (%) ** ** * * * * * * Fig. 3: Results of FIQ-G at various data collection times Springer - Heilpädagogisches Reiten mit Fibromyalgie-Patienten mup 2|2009 | 85 SD 12.9 vs. 75.7; SD 10.8) were able to be verified. Within the 19th session (measurement 3: 76.5; SD 12 vs. 79.3; SD 30.3) changes were not significant (p > 0.05). The result can be viewed in figure 4. The results of the four subareas of the mental state data collection are described in the following: Vitality changed only significantly during the 19th session (measurement 3) (p < 0.05) from 15.3 (SD 4.3) points by 5.5 points to 20.8 (SD 3.1). Within the second measurement (measurement 1) and the tenth measurement (measurement 2) changes were not significant. Changes of intramental balance through therapeutic riding changed significantly (p < 0.05) with the second data collection (16.8; SD 5.7 vs. 22.7; SD 3.5) and the third data collection (21.3; SD 4.1 vs. 23.8; SD 3.8). With data collection point one (18.4; SD 5.9 vs. 22.7; SD 3.5) no significant changes were able to be verified (p > 0.05). Regarding Vigility / cognitive control and performance all three data collections displayed significant changes (Messung 1: 17.1; SD 5.3 vs. 20.5; SD 4.3; p < 0.05, measurement 2: 18; SD 5.1 vs. 20.8; SD 4.3 and 3: 18.8; SD 3.8 vs. 23.3; SD 3.1; p < 0.01)). The results of social extrovertedness showed significant changes only with the the third data collection (21.3; SD 4.7 vs. 23.6; SD 3.4; p < 0.05). BFT A significant change (p < 0.05) of the BFT results by 9.83 % (84.2 %; SD 7.7 before intervention phase to 94 %; SD 4.4 after intervention phase were displayed; a higher value means less restrictions). The limitations of movement functions of the upper extremities were at an average of 42 (SD 5.7) points with a maximum of 52 achievable points before the intervention which is 80.8 %, after the intervention at 48 (SD 3.4) points (92.3 %). This is a difference of 11.5 % (p<0.05) with the lower extremities restrictions before the intervention were at 42.17; (SD 2.3) with a maximum of 48 achievable points, after the intervention they were at 46 (SD 1.3). This is a percentaged increase by 7.9 % (p < 0.01). BFT results can be viewed in figure 5. Drugs documentation The drugs taken were analgetics, antidepressants, hypnotics, antihistamine preparations, thyroid hormones and Parkinson drugs. The deployed analgetics were, due to the different degrees of strength based on the stage pattern for pain therapy published by the WHO, divided into three stages. Stage 1 comprises all “peripherally active analgetics“, stage 2 the “lighter opioids“. Stage 3 drugs “stronger opioids“ were not taken. Antidepressants were divided into two groups, tricyclic antidepressants and SNRI (serotonin-noradrenaline retake retardants). Changes (p > 0.05) were able to be verified regarding the take-in of analgetics and antidepressants. While two probands didn‘t require any analgetics at all during data collection and one proband didn‘t show any changes, one proband switched to a weaker preparation of the same WHO stage (one). Another proband was able to replace his WHO stage two preparation with a WHO stage one preparation; another proband managed to do with only half the dosis he had needed so far. While one proband didn‘t need any Overall drive 2. pre 2. post 10. pre 10. post Data collection time 20 30 40 50 60 70 80 90 100 110 Change of overall drive * ** 19. pre 19. post Fig. 4: Change of overall drive before and after therapy sessions 86 | mup 2|2009 Springer - Heilpädagogisches Reiten mit Fibromyalgie-Patienten antidepressants at all, two probands managed to quit taking the drug, the doses taken by the other 3 probands remained the same. Doses of muscle relaxation drugs, antirheumatic agents, antihistamine preparations, thyroid hormones and Parkinson agents remained the same. Discussion The fact that none of the probands quit the programme prematurely speaks for the feasibility of the therapy. Apart from that, positive effects occurred with many of the measured parameters, which confirms the statement that therapeutic riding has a positive effect on the symptoms shown by fibromyalgia patients: an impairment of everyday activities and the degree of main symptoms pain, weariness, depressions, nervousness and stiffness (measured with FIQ-G) showed significant changes (p < 0.05). The significant improvement of the mental state (by deploying BBS) right after riding compared with the values before the session emphasises the strong effect on mental parameters. The fact that participants were able to cut down on their drug consumption or even managed to do without is a sign for the therapy ‘ s high p h y s i o l o g i c a l i m p a c t eve n t h o u g h n o physiological data were collected. All individual factors “ body fu nctions “ , “ medication “ , “flexibility“, “mental well-being“ and “social extrovertedness“ have a direct impact on the proband‘s quality of life and must be considered crucial for evaluating the therapy success of fi b r o m y a l g i a p a ti e n t s . E v i d e n c e t h a t therapeutic pedagogical riding does not have the same effect on all probands is shown by the increasing standard deviance (SD) with the FIQ-G results. This was the case after the first effects occurred and thus speaks for a timely different effect on probands. A large variance of results is a general problem of the group of probands due to varying symptom degrees. The positive trend of the collected measured values allows the assumption that a longer therapy would result in even more improved parameters. Future studies should be carried out with more probands to guarantee for a higher statistical validity of results. The therapy should be carried out with smaller groups to enable the establishment of social contacts. Bibliographical references Bullinger, M., Kirchberger, I., Ware, J. (1995): Der deutsche SF-36 Health Survey, Übersetzung und psychometrische Testung Change of overall flexibility pre post Data collection time 74 76 78 80 82 84 86 88 90 92 94 96 98 100 Degree of flexibility * Fig. 5: Change of overall flexibility Julia Springer Graduate sports scientist, working in the field of therapeutic riding. Contact: Julia Springer · WSS Systems · Gleueler Str. 373 a 50935 Cologne ·Germany e-mail: j.springer@staps-online.com The author Springer - Heilpädagogisches Reiten mit Fibromyalgie-Patienten mup 2|2009 | 87 eines krankheitsübergreifenden Instrumentes zur Erfassung der gesundheitsbezogenen Lebensqualität. Zeitschrift für Gesundheitswissenschaften 1, 21-36 Drees, J. (1992): Befunderhebung und Therapiekontrolle in der Hippotherapie. Diss., Frankfurt am Main Fürst, G. (2006): Physikalische Therapie bei Fibromyalgie-Syndromen. Orthopädische Praxis 3, 177-180 Hobi, V. (1985): Basler Befindlichkeitsskala. Ein Self-Rating zur Verlaufsmessung der Befindlichkeit. Manual. Beltz, Weinheim Keitel, W., Hoffmann, H., Weber, G., Krieger, U. (1971): Ermittlung der prozentualen Funktionsminderung der Gelenke durch einen Bewegungsfunktionstest in der Rheumatologie. Deutsches Gesundheitswesen 26, 1901-1903 Klüwer, C. (1997): Die spezifischen Wirkungen des Pferdes in den Bereichen des therapeutischen Reitens. In: DKThR (Hrsg.): Heilpädagogisches Voltigieren und Reiten. Sonderheft 1995. 2. Aufl. o. V., Warendorf, 5-11 Kröger, A. (2005): Partnerschaftlich miteinander umgehen. FN Verlag, Warendorf Lind-Albrecht, G. (2006): Patientenschulung in der Rehabilitationsbehandlung bei Fibromyalgie. Orthopädische Praxis 3, 181-186 Mucha, C. (1998): Physikalische Therapie bei Fibromyalgie. In: Moorahrend, U. (Hrsg.): Problemdiagnose „Fibromyalgie“. Spitta Verlag, Balingen, 103 Offenbaecher, M., Walz, M., Schoeps, P. (2000): Validation of a German version of the Fibromyalgia Impact Questionnaire (FIQ-G). J Rheumatol 27, 1984-1988