104 | mup 3|2010|104-112|© Ernst Reinhardt Verlag München Basel, DOI 10.2378 / mup2010.art09e Keywords: Hippotherapy, Parkinson’s disease, motor skills, quality of life, speech Goal of this pilot study was to monitor the effects of Hippotherapy on motor skills and general well-being of patients with Parkinson’s disease, as well as to investigate whether improvements in speech parameters can be found. Changes were documented with a variety of scales and scores (e. g. motor skills: Tinetti test; faculty of speech: analysis of different voice parameters; cognition and quality of life: Parkinson scales). This pilot study suggests that Hippotherapy leads to improved motor skills and quality of life, but a significant change in speech parameters could not be found. Hippotherapy and Parkinson’s Disease - A Pilot Study Kofler, Huber, Tautscher-Basnett, Tomantschger Kofler et al. - Hippotherapy and Parkinson’s Disease - A Pilot Study mup 3|2010 | 105 Kofler, Huber, Tautscher-Basnett, Tomantschger Preface Morbus Parkinson is a neurodegenerative disease during the course of which non-motor symptoms (e. g. Thümler 2002) develop apart from the motor cardinal symptoms Bradykinesia, Rigor, Tremor and postural instability. Bradykinesia is a slowing down of movements that does not only affect the extremities and the torso, but can also have a negative influence on the facial and speech muscles. During the course of the disease motor skills get reduced more and more, whereas movement is decelerated at first and is all in all slower than usual. The result is an extended response and movement time (Bock et al. 1999). Many Parkinson patients have a gait pattern which is different from usual ones and very typical. Walking speed is slowed down, step length is shortened, track width is decreased, and the feet get hardly lifted. There is no swinging of one or even both arms (Fries / Liebenstund 1992, 32). When turning around, the movement is carried out in an en-bloc manner of the torso, there is no counter-movement of the shoulders or the pelvis. Starting problems are characterised by tiny steps, bottleneck issues (akinesia) may occur with narrow passages such as when walking through doors (Thümler 2002, 64 ff). An impoverishment of spontaneous facial expression results in the face appearing stiff and expressionless, like a masque. Speaking can become quiet, raucous, monotonous, unclear and hardly understandable, talking speed may become slower or hasty. Abovementioned changes may result in the patient appearing sad, apathetic, anxious, less intelligent (Thümler 2002, 55-58). Apart from that, during the course of the disease letters may become smaller when written by hand. Rigor is rigidity or stiffness. This is caused by an increased state of tension of the muscles, whereas total relaxation cannot be achieved, not even during rest (Thümler 2002, 62). Rigor is often considered a shortenening of the muscle. The power of the lexor is overbalanced and forces the body into the characteristic crooked posture (Thümler 2002, 63). Tremor - an involuntary tremble - can be observed with approx. 70 % of all Parkinson patients. There is a rhythmic, alternating muscle activity at a frequency of 4-6 Hz / second. Typically for the extremities is a resting tremor, whereas a holding and action tremor may exist as well (Fries / Liebenstund 1992, 25 f). Postural instability is a disorder of balance regulating reflexes and startle reflexes (Thümler 2002, 17) which is characterised by missing reactive evasive movements. This results in the patient falling, typically forward (Wenzel et al. 2000, 17). Non-motor symptoms can span from sensorial disorders (visual impairment, pain and sensitivity disorders, smelling disorders) via insomnia and neuropsychiatric impairments (depression, dementia, behavioural disorder and hallucinations) down to autonomous disorders (disorder of the digestive tract incl. swallowing disorders, disorders of the bladder and sexual functionalities, cardiovascular regulations as well as sweat and thermal regulation). These come to the fore during later stages of the disease (Tomantschger 2010). One pillar of Parkinson therapy is medicinal treatment, non-medicinal forms of therapy such as physiotherapy, logopaedics, occupational therapy, diet consulting, psychotherapy are crucial additions (Thümler 2002, 297-308). Hippotherapy is supposed to gain more and more importance for the treatment of Morbus Parkinson patients (Strauß 2007). The way Hippotherapy works The horse has an impact via its movements (neuromotor approach), via its body (sensomotor approach) and its character (psychomotor and socialmotor approach) (Strauß 2007). Hippotherapy is supposed to have a particularly positive impact on the following areas of Parkinson patients: 106 | mup 3|2010 Kofler et al. - Hippotherapy and Parkinson’s Disease - A Pilot Study Gait-typical torso training is achieved through a multi-dimensional swinging rhythm from the horse’s back to the human sitting on the saddle. Joint mobilisation takes place in the area of the spine, the hip joints and the shoulder girdle. Stretching shortened muscles is achieved through the horse’s movements and body heat (body temperature is about 1°C higher than the one of humans). Correcting abnormal movement patterns: The riding posture (abduction, external rotation and extension of the hip joints) results in a tonus regulation in the lower extremities; the rotational movement regulates the tension state of the muscles. Coordination training - sensomotor development: While sitting on the moving horseback balance responses are called up permanently. Sensory integration training: positive impact on the body awareness, space location awareness and in-depth sensitivity. Physiological effect: The upright posture along with the rhythmic movement stimulates breathing activity, blood circulation is improved. A positive impact can be observed on neurogenic bladder and bowel functionality disorders. Psychic effect: Patients experience joy and success and are thus distracted from their problems for some time (Strauß 2007). The Gailtal Clinic pilot study: Method Three out-patients (see ill. 1) suffering from slight to moderate Parkinson each were treated with ten units of Hippotherapy lasting 45 minutes each for a period of four weeks. Medication was not changed during that time. Therapy units lasting 45 minutes each took place three times per week at a riding hall. The procedure / content of the units was as follows: Getting in touch with India, the therapy horse: The test persons stroked the horse, got in touch with it under the hippotherapist’s supervision. Riding in a walking manner: The horse was lead on the long leash by the horse therapist. Picture 1: India, our therapy horse, with Kerstin Kofler and Lydia Huber Tab. 1: Demographic patient data Patient Mr RK Mrs MP Mr MK Age 55 55 66 Sex m f m Hoehn & Yahr (Parkinson scale, see tab. 2) stage 3 stage 1-2 stage 2- 3 Kofler et al. - Hippotherapy and Parkinson’s Disease - A Pilot Study mup 3|2010 | 107 Together with the patients the hippotherapist worked to find an optimal sitting posture (e. g. symmetry, upright position). Several measures, such as e. g. stretching positions, varying the walking speed, hoofbeat figures, support working on physiological movements. Reward: At the end of the unit the patients has the chance to reward India with a carrot and thus deepen the horse-human relationship. The following scales and scores (see tab. 2) were used with the examinations before therapy started, at the end of the therapy and one month after therapy end: a) Motor skills: Tinetti-Test (TT), standing on one leg, distance between jugulum base and omphalic base, 10-metre walkig test, 2-minute walking test, pronation and supination of the hand, finger tapping, drawing circles. b) Parkinson scales: Hoehn & Yahr (H & Y), Unified Parkinson Disease Rating Scale (UPDRS), Parkinson Disease Questionnaire (PDQ 39) c) Speaking: Understandability scale from the Lee Silverman Voice Treatment (LSVT), analysis of speech parameters using Computerised Speech Lab (CSL). All examinations were documented via video or audio, respectively. Results Improvements in terms of motor skills (especially gait tests and time needed for drawing circles) as well as quality of life were able to be observed, yet no significant effects on speech parameters could be noted. Subjective statements on improved well-being were proved with the scores in UPDRS part I and relevant Picture 2: Stretching the ventral chain Picture 3: Torso training 108 | mup 3|2010 Kofler et al. - Hippotherapy and Parkinson’s Disease - A Pilot Study Tab. 2: Brief description of the deployed measuring tools Tests / Scales / Scores Brief description Tinetti-Test (1986) This test allows to evaluate sitting balance, standing up, standing balance, walking, gait quality and general balance. The result (number of points) allows for an assessment of the risk of falling and mobility restrictions (e. g. >20 points = mobility hardly restricted; < 10 points = mobility heavily restricted, great risk of falling, aids required). Standing on one leg It is measured for how long (in seconds) test persons are able to stand on one leg. Distance between jugulum base and omphalic base This measurement (in cm) gives hints on how upright the posture of the test person is. Walking tests i) 10-metre walking test: How long does the test person need for 10 metres (measured in seconds). ii) 2-minute walking test: How far can the test person walk in 2 minutes (measured in metres). Pronation and Supination The number of pronation and supination movements of hands and lower arms within 30 seconds is measured for the left and the right hand / lower arm separately. Finger tapping The number of finger tappings (thumb and index finger) within 30 seconds is measured for the left and the right hand separately. Drawing circles The time required to draw ten circles is measured for the left and the right hand separately. Hoehn and Yahr (1967) This scale distinguishes between five clinical stages of Parkinson’s disease (e. g. stage 1: little functional impairment, beginning on one side, affected persons are still independent; stage 5: patients are dependent on a wheelchair and third-party support or are bed-ridden). Unified Parkinson Disease Rating Scale (1987) The UPDRS consists of 42 areas, which are evaluated on a 5 points scale (0 = normal, 4 = heavy impairment) or with yes / no by the examining person. The symptoms typical for Parkinson’s disease are divided into four segments: I. Cognitive functions, behaviour and mood (1-4) II. Everyday activities (5-17) III. Motor skills (18-31) IV. Complications and clinical upand downturns (32-42) Parkinson’s Disease Quality of Life Questionnaire (1995) The PDQ39 consists of 39 questions, which are divided into eight segments and get evaluated on a 5 points scale (0 = never; 5 = always): I. Mobility (1-10) II. Everyday activities (11-16) III. Emotional well-being (17-22) IV. Stigma (23-26) V. Social support (27-29) VI. Cognition (30-3-3) VII. Communication (34-36) VIII. Physical discomfort (37-39) Lee Silverman Voice Treatment (1995) The LSVT is a therapy type dealing with the improvement of everyday communication through the treatment of speech volume with Parkinson patients. The LSVT understandability scale enables for an evaluation of the understandability of everyday communication ranging from 1 to 6 (1 = perfectly understandable; 6 = absolutely not understandable). Computerised Speech Lab The CSL is able to analyse different speech parameters of short speech samples and to depict them in a graphical manner. Kofler et al. - Hippotherapy and Parkinson’s Disease - A Pilot Study mup 3|2010 | 109 PDQ 39 sub-scores. Especially Mr RK (H & Y stadium III) was able to benefit in all motor and emotional areas. a) Motor skills: a. Tinetti-Test (TT): With all test persons, only one point more or less concerning the different examination times were recorded; this was no significant change. The three patients had good initial TT values (26 or 28 points, respectively). b. 10-metre walking test, 2-minute walking test: All patients were able to increase their walking distance and / or walking speed and keep their improvements also one month after therapy end (ill. 1 & ill. 2). c. Standing on one leg: This was more than 10 seconds before and after therapy with all patients; no relevant changes could be notified. d. Distance between jugulum base and omphalic base: Changes in holding an upright posture were not significant with these relatively moderately affected patients. e. Pronation and supination of the hand, finger tapping: Changes were not significant. f. Drawing circles: The test persons were able to double their speed in drawing ten large circles with their right and left hand each, in all cases they were able to keep this also one month after therapy end. b) Parkinson scales: a. H & Y: Allocation to the disease stage remains constant. b. UPDRS and PDQ39: With Mr RK UPDRS and PDQ39 displayed significant improvements in the areas of quality of life and motor skills which were able to be kept also after therapy had ended. With Mrs MP there were no changes after therapy had ended, but one month later (in the emotional area); Mr MK showed slight improvements in the field of quality of life/ well-being with both scales. At the beginning of the therapy, the disease had affected Mr RK, H&Y stage III, most, so he was able to make the most significant improvements of all. c) Speaking: Evaluation deploying the understandability scale from the Lee Silverman Voice Treatment (LSVT) as well as the analysis of Tests / Scales / Scores Brief description Tinetti-Test (1986) This test allows to evaluate sitting balance, standing up, standing balance, walking, gait quality and general balance. The result (number of points) allows for an assessment of the risk of falling and mobility restrictions (e. g. >20 points = mobility hardly restricted; < 10 points = mobility heavily restricted, great risk of falling, aids required). Standing on one leg It is measured for how long (in seconds) test persons are able to stand on one leg. Distance between jugulum base and omphalic base This measurement (in cm) gives hints on how upright the posture of the test person is. Walking tests i) 10-metre walking test: How long does the test person need for 10 metres (measured in seconds). ii) 2-minute walking test: How far can the test person walk in 2 minutes (measured in metres). Pronation and Supination The number of pronation and supination movements of hands and lower arms within 30 seconds is measured for the left and the right hand / lower arm separately. Finger tapping The number of finger tappings (thumb and index finger) within 30 seconds is measured for the left and the right hand separately. Drawing circles The time required to draw ten circles is measured for the left and the right hand separately. Hoehn and Yahr (1967) This scale distinguishes between five clinical stages of Parkinson’s disease (e. g. stage 1: little functional impairment, beginning on one side, affected persons are still independent; stage 5: patients are dependent on a wheelchair and third-party support or are bed-ridden). Unified Parkinson Disease Rating Scale (1987) The UPDRS consists of 42 areas, which are evaluated on a 5 points scale (0 = normal, 4 = heavy impairment) or with yes / no by the examining person. The symptoms typical for Parkinson’s disease are divided into four segments: I. Cognitive functions, behaviour and mood (1-4) II. Everyday activities (5-17) III. Motor skills (18-31) IV. Complications and clinical upand downturns (32-42) Parkinson’s Disease Quality of Life Questionnaire (1995) The PDQ39 consists of 39 questions, which are divided into eight segments and get evaluated on a 5 points scale (0 = never; 5 = always): I. Mobility (1-10) II. Everyday activities (11-16) III. Emotional well-being (17-22) IV. Stigma (23-26) V. Social support (27-29) VI. Cognition (30-3-3) VII. Communication (34-36) VIII. Physical discomfort (37-39) Lee Silverman Voice Treatment (1995) The LSVT is a therapy type dealing with the improvement of everyday communication through the treatment of speech volume with Parkinson patients. The LSVT understandability scale enables for an evaluation of the understandability of everyday communication ranging from 1 to 6 (1 = perfectly understandable; 6 = absolutely not understandable). Computerised Speech Lab The CSL is able to analyse different speech parameters of short speech samples and to depict them in a graphical manner. Ill. 1: The 2-minute walking test measures the distance (in metres) that can be walked within 2 minutes Ill. 2: The 10-metre walking test measures (in seconds) how long the patient needs to walk a distance of 10 metres Mr RK Ms MP Mr MK Mr RK Ms MP Mr MK 110 | mup 3|2010 Kofler et al. - Hippotherapy and Parkinson’s Disease - A Pilot Study speech parameters using Computerised Speech Lab (CSL) doesn’t show any significant changes of speech parameters. Please note that all test persons were clearly understandable in everyday life (LSVT-undestandability scale 5-6). Discussion In our pilot study we found hints that hippotherapy had positive effects on patients suffering from slight to medium-grade Morbus Parkinson in terms of motor skills as well as general well-being, but no significant effects on speech parameters. It cannot be clearly stated whether these positive effects are a result of that special Hippotherapy treatment, the group effect or increased attention in general. However, it’s a fact that our patients benefitted from “walking with someone else’s legs”, and that they enjoyed interacting with the horse very much. Furthermore, we would like to point out that the large part of the tests carried out can be recommended for a documentation of the treatment process. In the future, we would not measure the distance between the jugulum base and the omphalic base again, since this measurement depends on the specific situation to a very large degree. However, the deployment of the used Parkinson scales would be essential for future tests. With speech parameters, we would have a CLS analysis depend on the changes in understandability, since analyses such as these are complex and, even though some speech parameters change slightly, these do not necessarily have a direct positive effect on everyday communication. Future prospects Positive treatment results of this pilot study with three patients after short-term Hippotherapy treatment let us expect patients suffering from chronical Parkinson to improve their well-being through long-term treatment or interval treatment. However, the question occurs which group of patients (slight - medium - heavily affected) will benefit most from this type of therapy and how long these effects will last. Hippotherapy is a fixed part of the neurorehabilitation programme at the Gailtal Clinic in Hermagor (Austria) and is gladly made use of by patients suffering from nerologic diseases, especially Parkinson patients. Since these patients usually also get their medical therapy within the scope of their stay optimised and also get further neurorehabilitative treatment, it is still going to be hard to allocate improvements to one or several specific factor/ s. Possibilities of carrying out controlled therapy studies within the scope of neurorehabilitation are limited already within the scope of everyday life at a clinic, since there Ill. 3: PDQ39 shows the change in quality of life (the less points, the higher the quality of life) Ill. 4: UPDRS shows changes in different areas relevant for Parkinson patients (the less points, the less restrictions in everyday life) Mr RK Ms MP Mr MK Mr RK Ms MP Mr MK Kofler et al. - Hippotherapy and Parkinson’s Disease - A Pilot Study mup 3|2010 | 111 The authors Kerstin Kofler Graduate nurse and physiotherapist with an additional training in Hippotherapy (OKTR), working at the Gailtal Clinic as a physiotherapist and a Hippotherapy treatment department staff member since 2004 Lydia Huber Graduate physiotherapist with an additonal training in Hippotherapy (OKTR), working at the Gailtal Clinic since 1994 as a physiotherapist and participates in the introduction and buildup of the Hippotherapy department at the Gailtal Clinic MSc Gusti Tautscher-Basnett Bachelor in Language and Linguistics und Master of Science in Human Communications (emphasis: Pathologic Communications), working at the Gailtal Clinic as a linguist since 2001, as a clinical linguist since 2003, she also deals with the development of concepts and study designs as well as the compilation of posters and articles Dr. med. Volker Tomantschger Working in the field of Parkinson since 1991 and a specialist for neurology since 1996, working at the Gailtal Clinic since 1997, also in the field of research with several studies and many articles on Parkinson’s disease Contact: Mag. Gusti Tautscher-Basnett · Gailtal-Klinik, Radniger Str. 12 · 9620 Hermagor . Austria E-mail: gusti.tautscherbasnett@gailtal-klinik.at · Internet: www.gailtal-klinik.at 112 | mup 3|2010 Kofler et al. - Hippotherapy and Parkinson’s Disease - A Pilot Study are too many different factors that might have an influence on results. However, at this point we would like to point out the patients’ subjective sensation: We keep observing in everyday life that our neurological patients feel Hippotherapy to have a very encouraging effect on them and they also describe this type of treatment to have a positive impact on their motor skills, sensory and psyche and the one of their relatives as well. Literature Bock, K., Nittner, K., Rösner, I., Berger, E., ■ (1999): M. Parkinson. Leben mit einer Krankheit, Deutsche Parkinson Vereinigung, Peter Pfeiffer Verlag, o. O. Fries, W., Liebenstund, I. (1992): ■ Krankengymnastik beim Parkinson-Syndrom. Pflaum, München Strauß, I. (2007): Hippotherapie: ■ Physiotherapie mit und auf dem Pferd. Thieme, Stuttgart Thümler, R. (2002): Morbus Parkinson. Ein ■ Leitfaden für Klinik und Praxis. Springer, Berlin Tomantschger, V. (2010): Nichtmotorische ■ Symptome bei Morbus Parkinson - ein Überblick. Mediziner H. 5, 20-22 Wenzel, K., Ott, E., Homann, C. N., Bukalo, ■ N., Dresler, K. & Holl, A. (2000): Morbus Parkinson - Clinic, diagnostics and medicinal therapy. Forum Dr. med. 2000 About the deployed diagnostic tools: The deployed diagnostic tools are used in the field of Parkinson research on a regular basis and are considered to be generally well-known. Hence, they are not listed extra in the literature reference. In case you have any questions on individual tools please get in touch with the authors.