Anne Karen Czerwonka, Simone Pülschen 52 | mup 2|2016|52-60|© Ernst Reinhardt Verlag München Basel, DOI 10.2378 / mup2016art10e Relevance and therapeutic effects Keywords: Multiple sclerosis, complementary therapy of MS, equine-assisted activities and therapy (EAAT), well-being The present study, conducted within the context of a bachelor thesis, summarises the personal views on the relevance and therapeutic effects of equine-assisted activities and therapy (EAAT) for people with multiple sclerosis (MS). The participants were questioned about spending a day with and without EAAT, personal significance of EAAT, the role of the horse in such settings and the relevance of the horse for therapeutic success. The data indicate that EAAT for people with MS leads to the reduction of symptoms and increases the feeling of well-being. According to their perspectives, it is a holistic approach. The presence of horse and the pleasure make EAAT a significant therapy for the people with MS. Equine-assisted activities and therapy from the perspective of people with multiple sclerosis Czerwonka, Pülschen - Equine-assisted activities from the perspective of people with MS mup 2|2016 | 53 To increase well-being and to reduce diseaserelated symptoms, people with multiple sclerosis often make use of alternative and complementary therapies. Such a therapy is EAAT, which was being used by 2.3 % respondents in a study by Apel-Neu et al. (2009, S. 21). The present study considers EAAT among the people with MS, and analyses therapeutic effects from their point of view, the contribution of EAAT to their well-being and the role of the horse in the therapy. Multiple sclerosis Multiple sclerosis is one of the most common neurological disorders in Germany (Wiethölter 2006, S. 1005). Inflammatory and degenerative changes in the nerve cells of the central nervous system result in functional disturbances. Since the location of such damages varies, the progression of the disease and the symptoms also vary (Krämer & Besser 2006, S. 12). An overview of the common symptoms is given in Table 1. The most important therapeutic objectives in MS is to improve quality of life, as the disease results in considerable physical and social restrictions. According to the Robert-Koch-Institute (2015), it is the subjective view of the people with MS, which plays a significant role while evaluating their health related quality of life. One of the aims of the present study was to advocate use of EAAT for MS emphasising the views of MS patients. Equine-assisted activities and therapy for MS: Terminology Various forms of EAAT have been described by the German Curatorship for Therapeutic Riding (DKThR): Hippotherapy, Equine-Assisted Learning or Equine Facilitated Learning, Equine-Assisted Mental Health, Equine-Assisted Occupational Therapy and Equestrian Sports for People with disabilities (Deutsches Kuratorium für Therapeutisches Reiten 2011, S. 17). The key term Equine-Assisted Therapy for EAAT is also used (Gäng 2009, S. 13; Gomolla 2014, S. 5). Alternative and complementary therapies, such as Hippotherapy, for patients with MS often focus on therapeutic interventions to improve restricted mobility and to promote movements. Besides Hippotherapy, Equine-Assisted Mental Health is also used for promoting mental health which is often used for patients with MS. Since MS is manifested by diverse symptoms, depending on that, there are also other forms of EAAT being used. In this study, the term Equine-Assisted Activities and Therapy (EAAT) is used as a conglomerate of different terms usually implied in this context. We are less concerned with the differentiation of various forms of EAAT than its common element: the horse as a therapeutic medium and its effect on the individual client. Table 1: The symptoms of Multiple Sclerosis (according to Wiethölter, 2006; Hoffmann et al, 2009) Symptoms of Multiple Sclerosis Coordination disturbances Motor symptoms (i. e. disorders of gait, tiredness, spasticity) Pain Sensory disturbances Disturbances of depth perception, balance disturbances Optic neuritis, visual disturbances Mental and cognitive symptoms (i. e. MS-Fatigue, poor memory and concentration, depression) Autonomic dysfunction (i. e. bladder insufficiencies, disorders of the intestines) Comment: The table contains only selected symptoms. Symptoms of MS are very diverse and depend on the focus of inflammation and the progress of the disease. 54 | mup 2|2016 Czerwonka, Pülschen - Equine-assisted activities from the perspective of people with MS The financial support to the treatment A financial support to a treatment has an important role to play for several people with MS. There is no accreditation of EAAT by health insurance companies; therefore, the cost of the therapy is borne by the clients. If there is prescription for occupational or physical therapy, only a fraction of the cost is financed by the health insurance, but the additional costs for the horse or other expenses need to be paid by the clients. Besides this, the relevant qualification of the therapist is also necessary. In practice the costs of the therapy are often paid on a private basis or supported through donations. The impact of the horse for patients with MS In EAAT, the horse plays most important role, although not all issues are empirically based. The mode of action of EAAT in general is described in literature as follows: ■ A movement pattern similar to the human gait pattern is produced by the three-dimensional movement of horse’s swinging trunk (Riesser 1996, S. 8). This movement of horse can give an experience of movement to the people who are not able to walk because of illness or disability. A gait improvement may also be achieved. ■ By the passive movement of the pelvic girdle a tone regulation is effected that reduces spasticity (Wüthrich & Künzle 1978, S. 11). The diminishing spasticity enables a patient to perform the movements more easily. ■ A decreased tension of muscles is tonified by the horse movements (Strauß 2000, S. 23). ■ The points of contact of horse and the rider cause pressure and counter pressure, which promote distorted perceptions (Strauß 2000, S. 24). ■ To maintain the balance on horse’s back, one is stimulated by the movement dialogue between the rider and horse (Strauß 2000, S. 23). ■ The friendly manner and bearing of the horse towards the people make an emotional contact possible without being afraid of rejection (Breiter 2009, S. 75). This could also lead to an increase of motivation for therapy (Riesser 1996, S. 8). An overview of the available evidence indicates positive effects of EAAT for the people with MS (Table 2). EAAT is effective not only at a physical level, but can also be effective at the mental level by holistically addressing the client. Scientific issue and methodical approach The current study identifies clients’ wellbeing (according to Becker 1991) by emphasising: ■ the current mood ■ physical sensations and ■ the absence of complaints In this study attention was paid to the following questions: ■ Question 1: What therapeutic effects of EAAT are perceived by the people with MS and how do they explain these effects? ■ Question 2: What is the significance of EAAT for the people with MS? Why do they undergo EAAT? ■ Question 3: What role does the horse play in relation to the experienced therapeutic effects and what is the personal significance of EAAT for the people with MS? ■ Question 4: Are there changes in the subjective state of condition of people with MS caused by EAAT? The survey questionnaire consisted of two parts. In the first part (Question 1 to 3), the participants were questioned face to face or telephonically about their personal information, characteristics Czerwonka, Pülschen - Equine-assisted activities from the perspective of people with MS mup 2|2016 | 55 of the disease and details about EAAT (frequency of attendance, qualification of the therapist, etc.). A section of the questionnaire is shown in Figure 1 and 2. The response rate was 100 %. The data for Question 4 were collected on a day with and without EAAT. The participants’ well-being was determined by their self-assessment of different statements and an adjectivechecklist (Figure 3). They filled in this questionnaire at home and return in a prepaid envelope. In this case, the response rate was 78.5 %. To recruit the participants for the survey, people were asked who were undergoing EAAT at that time and the regional association of the German Multiple Sclerosis Society promoted the study via newsletter and Facebook. Sample The survey resulted in responses from 28 individuals (22 females and 6 males), who were participating in EAAT usually once a week or who had an earlier experience with EAAT. The respondents reported undergoing EAAT for an average of five years, and the cost of the therapy was mainly paid privately (42.9 %), by donations (28.6 %) or was partly covered by their health insurance. Half of the respondents reported to participate in EAAT in a field, though some cases of indoor riding were also there. Results The results of therapy-success, the relevance of the therapy and of the horse in EAAT are presented first (Question 1, 2 and 3) and then the results of well-being (Question 4) are presented. The differences between groups were identified using Mann-Whitney U-Test. Question 1: subjective perception of therapy success A very heterogeneous picture emerged when respondents reported their symptoms. They assessed the change in their symptoms due to EAAT on a scale from 0 to 6 (where 0 corresponds to “no change” and 6 corresponds to “great improvement”) and they could also mark deterioration of the symptoms. The results showed an average improvement in symptoms (M=3.0-4.99): spasticity in both legs (M=4.36), balance disturbances (M=3.88), problems with walking (M=3.58), disturbances of coordination (M=3.56) and pain in legs or feet (M=356). The therapy success, by the respondents, was attributed to the movement of the horse (M=5.46), having fun with the therapy (M=5.21), Table 2: Summary of studies for EAAT Positive impact on Sager, Schaar, Drache & Pöhlau (2008) Schneider, Puta & Drache (2010) Bronson, Breweton, Ong, Palanca & Sullivan (2010) Stromberger (2012) Taubert (2009) Schmidt & Gomolla (2012) Balance X x x x Spasticity X x x Gait pattern X x Pain x Ability to walk x x Relaxing the muscular system x Mobility x Coordination x Ability to stand x Quality of life X x x Independence x Motivation x Confidence x General condition x Well-being x x Self-worth x Joy / enthusiasm x Comment: The cells marked by a cross indicate that an improvement after EAAT was found in this study. 56 | mup 2|2016 Czerwonka, Pülschen - Equine-assisted activities from the perspective of people with MS What symptoms do you observe and how does EAAT influence these symptoms? Symptom Improvement 0=no improvement 6=great improvement 0 1 2 3 4 5 6 Deterioration (mark, if applicable) Does not concern me Disturbances of fine motor skills (e. g. with gripping and writing) Spasticity in the legs Spasticity in arms and upper body Slack paralysis in the arms Slack paralysis in the legs Sensory disturbances in the hands Sensory disturbances in the feet Pain in hands or arm Pain in legs or feet Tremors Speech disorders Balance disturbances Disturbances of coordination Problems with walking Fatigue Others: How much impact do the following factors have on your therapy motivation? (On a scale of 1 to 6 please rate each of the following factors)  Factors influencing therapy motivation 0=not applicable; 6=applies completely 0 1 2 3 4 5 6 Fun with EAAT Therapy motivation Motion sequences you have to perform in EAAT (i.e. to mount a horse) Personality of the therapist Therapy on the back of the horse (with instruction by the therapist) Movement of the horse Warmth of the horse Character of the horse (kindness, neutral, etc.) Environment (Indoor riding arena, open country, etc.) Absence of therapy rooms To meet other people with Multiple Sclerosis Conversations Confidence Others: Please turn again to the table and mark your main factor for EAAT with a  in the first column. Figure 1: Section of the questionnaire “Symptom checklist and therapy effect on symptoms” Figure 2: Section of the questionnaire “Subjective perspective on effect factors of EAAT” confidence in therapy (M=5.15) and motivation for therapy (M=5.11). Question 2: subjective relevance of EAAT Overall, EAAT has a great importance to the clients. The respondents stated that EAAT is of great importance for them because of improvement in physical symptoms (54.5 %) and psychological well-being (54.5 %). The horse (45.5 %) and the environment of the therapy (22.7 %) are the key factors for the respondents. Among others, the following responses were given for an open question concerning the relevance of the therapy: “The feeling of happiness has an impact for a long time! ”, “It lifts the spirits! ”, “EAAT is efficient against feeling of being handicapped! ”, “EAAT is a drug for the ability to walk! ”, “It improves walking for at least one day”, “Stabilisation of core muscles and reduction of spasticity. Overall a pleasant way of exertion”, “Riding on a horse improved my sense of balance”. Compared to other therapies, EAAT has more personal meaning as reported by 52 % respondents, and it is as important as other therapies for 36 % respondents. Of the respondents, 12 % do not compare EAAT and other therapies. Table 3 presents the main motivation for joining an EAAT. Question 3: relevance of the horse for the therapy For the clients, the horse is a factor that has a great impact on the therapy success and it also has a personal meaning to them. The movements, pleasant atmosphere and the character of the horse are the main reasons to participate in an EAAT (Table 3). Czerwonka, Pülschen - Equine-assisted activities from the perspective of people with MS mup 2|2016 | 57 The respondents’ comments on the horse are as follows: “To include animals into therapy is of great importance”, “A horse can give something no human being is able to give. Horse has a feeling of sincerity”, “The relationship with horse is of great value”, “I am more motivated because of the horse”, “On the back of horse I feel more agile than everywhere else.” Question 4: comparison of mental state on a day with and without EAAT As shown by the results of the second part of the survey EAAT has a positive effect on the clients’ overall well-being. After participating in EAAT, the respondents feel being able to pursue their own interests and to carry out their duties better than usual. To cope with day to day life becomes easier after participating in EAAT, as well as dealing with other people seems to be more joyful afterwards. The item “Today I am having pain” and the item “I feel compelled to make a break” do not differ significantly on a day with and without EAAT (Table 4). The results of the adjective checklists show that participants feel less subdued as well as more powerful and more optimistic. Compared to the days without EAAT, they feel easier, happier, more balanced, active, lively, movable, satisfied and relaxed (table 5). Discussion and outlook All participants highlighted the personal significance of EAAT. As shown by the results, there are improvements in both physical and mental states; this contributes to a better quality of life by increasing the overall well-being. First of all it is the horse and its movements and character that are the main reasons for the personal relevance of the therapy and the perceived success of the therapy. Besides this, the environment of therapy and therapist are also of particular importance. To sum, it can be emphasised that this study impressively demonstrates that it is the positive relationship with the horse and the therapist, which makes the integral part of EAAT. It must be emphasised that in this study the respondents reflect their current subjective feelings and the results are also based on their subjective assessment. We did not employ any standardised procedure to measure the quality of symptoms of disease and how long an improvement would last. The results of a standardised medical examination would certainly be of interest. Furthermore, the various forms of EAAT have not been differentiated in this study. The results concerning this topic need to be exemplified in a subsequent study to examine the possible differences. Therefore, in this context, further studies could provide information about the relevance of the relationship (to the horse as well as to the therapist) as a fundamental factor in EAAT. Questionnaire on form on the day How do you assess the current day? Today I do feel able to pursue my own interests. yes partial no Today I do feel able to fulfil my obligations. yes partial no Today I am having pain. yes partial no Today I am able to cope with day to day life. yes partial no Today I am taking delight in interacting with people. yes partial no I feel compelled to make a break. yes partial no How do you feel today? 1Not applicable 2 3 4Applies partial 5 6 7Applies completely Easy Shiftless Tired Happy Balanced Subdued Powerful Energetic Optimistic Active Lack of drive Impatient Lively Fearful Movable Satisfied Relaxed Figure 3: Questionnaire on form on the day 58 | mup 2|2016 Czerwonka, Pülschen - Equine-assisted activities from the perspective of people with MS Although respondents report an improvement in symptoms and mental state because of EAAT as a therapy; however, this improvement of symptoms needs further investigation with objective measurements. It would also be of interest to examine the sustainability of the increase of well-being. Therefore, further longitudinal studies are needed to examine the influence of EAAT on habitual well-being as a stable personal characteristic because in this study respondents were asked about their well-being directly after EAAT. In-depth insights and results could contribute to receive EAAT an approval by health insurances which would enable more and more clients with MS to undergo in EAAT. References ■ Apel-Neu, A., Greim, B., König, N. & Zettl, U. (2009): Alternative und komplementäre Therapien bei Multipler Sklerose. Nervenarzt, Suppl 1, 20-21, http: / / dx.doi.org/ 10.1007/ s00115-009-2749-6 ■ Becker, P. (1991): Theoretische Grundlagen. In A. Abele & P. Becker (Hrsg.), Wohlbefinden. Theorie, Empirie, Diagnostik (S. 13-49). Weinheim, Juventa. ■ Breiter, A. (2009): Therapeutisches Reiten in der Psychiatrie. In Gäng, M. (Hrsg.), Reittherapie (S. 67-83). München, Ernst Reinhard Verlag. ■ Bronson, C., Brewerton, K., Ong, J., Palanca, S. & Sullivan, S. J. (2010): Does Hippotherapy improve balance in persons with multiple sclerosis: a systematic review. European Journal of Physical and Rehabilitation Medicine, 46, 347-353. In: http: / / www.minervamedica.it/ en/ getfreepdf/ T% 252FXOrdoblufkkINAORYdcyONPmHuinChQE2t- NQA5Ejq311oxRLRBRp2V6mu3xxukgr9vJ%25 2FXyGO4ObVkN%252BsLVXQ%253D%253D/ R33Y2010N03A0347.pdf, 25.03.2015 ■ Deutsches Kuratorium für Therapeutisches Reiten (Deutsches Kuratorium für Therapeutisches Reiten, Hrsg.) (2011): Pferde für Körper, Geist und Seele. Faszination Therapeutisches Reiten. In: https: / / www.dkthr.de/ fileadmin/ redaktion/ downloads/ DKTHR-Brosch%C3%BCrelow-2012.pdf, 18.03.2015 ■ Gäng, M. (2009): Einleitung: Therapieren mit dem Pferd - Therapeutisches Reiten. In Gäng, M. (Hrsg.), Reittherapie (S. 12-20). München, Ernst Reinhardt Verlag. ■ Gomolla, A. (2014): Merkmale der Reittherapie. Ergebnisse einer qualitativen Dokumenten- und Videoanalyse reittherapeutischer Einheiten. mensch & pferd international. Zeitschrift zur Förderung und Therapie mit dem Pferd 1, 4-12, http: / / dx.doi.org/ 10.2378/ mup2014. art02d ■ Hoffmann, S., Vitzhum, K., Mache, S., Spallek, M., Quarcoo, D., Groneberg, D.A. & Uibel, S. (2009): Multiple Sklerose: Epidemiologie, Table 4: Results for the assessment of the day Item T1 T2 To pursue one’s own interests * 2.64 1.76 Carrying out duties * 2.77 1.86 Pain 2.32 1.57 To cope with everyday life * 2.41 1.71 To deal with people * 2.00 1.43 Make a break 3.52 2.76 Comment scaling: The more the results tend to 1, the more successful the therapy is. T1= mean on a day without EAAT. T2= mean on a day after participating in EAAT. Statistically significant data ( α < 0.05) are marked with *. Table 3: Main therapy motivations for participating in EAAT Main therapy motivation for participating in EAAT Percent Movement of the horse and being moved by the horse 92.9 % Fun at the therapy 67.8 % Character of the horse 53.8 % Environment in which the therapy is carried out 48.1 % Personality of the therapist 48.0 % Czerwonka, Pülschen - Equine-assisted activities from the perspective of people with MS mup 2|2016 | 59 Pathophysiologie, Diagnostik und Therapie. Praktische Arbeitsmedizin, 17, 12—18. In: ■ http: / / www.bsafb.de/ fileadmin/ downloads/ pa17_9_2009/ pa17_9_2009_multiple_sklerose.pdf ■ Krämer, G. & Besser, R. (2006): Multiple Sklerose. Antworten auf die 111 wichtigsten Fragen. Expertenwissen verständlich gemacht: Hilfen für einen sicheren Umgang mit der Erkrankung. Stuttgart, Trias Verlag. ■ Riesser, H. (1996): Hippotherapie. In Deutsches Kuratorium für Therapeutisches Reiten (Deutsches Kuratorium für Therapeutisches Reiten, Hrsg.), Hippotherapie. Sonderheft 1996. Warendorf, Eigenverlag. ■ Robert Koch Institut (23.04.2015): Allgemeines zu Gesundheitsbezogener Lebensqualität. In: http: / / www.rki.de/ DE/ Content/ Gesundheitsmonitoring/ Gesundheitsberichterstattung/ GesundAZ/ Content/ G/ Gesbez_Lebensqualitaet/ Inhalt/ Lebensqualitaet.html, 23.04.2015 ■ Sager, A., Schaar, B. Drache, M. & Pöhlau, D. (2008): Hippotherapie bei Multipler Sklerose - Pilotstudie zur Erfassung der Auswirkungen auf Gleichgewicht, Spastik, Gehfähigkeit und Lebensqualität. [Abstract]. In: http: / / johannisberg.net/ wissenschaftliche-studien/ , 25.03.2015 ■ Schmidt, J. & Gomolla, A. (2012): Auswirkungen der Reittherapie auf die psychische Befindlichkeit von Patienten mit neurologischen Erkrankungen. mensch & pferd international. Zeitschrift zur Förderung und Therapie mit dem Pferd 4, 148—152, http: / / dx.doi.org/ 10.2378/ MuP2012.art07d ■ Schneider, J., Puta, C. & Drache, M. (2010): Auswirkungen der Hippotherapie auf den Krankheitsverlauf der Multiplen Sklerose. Pilotstudie zur Erfassung der Auswirkungen auf Spastik, dynamisches / statisches Gleichgewicht, Fatigue, Lebensqualität und Schmerzempfinden. [Abstract] In: http: / / johannisberg.net/ wissenschaftliche-studien/ , 25.03.2015 ■ Strauß, I. (2000): Hippotherapie. Neurologische Behandlung mit und auf dem Pferd. Stuttgart: Hippokrates Verlag. ■ Stromberger, L. (2012): Hippotherapie bei neurologischen Erkrankungen - Auswirkungen einer 30-minütigen Einheit auf die Standphase. Eine Anwendungsbeobachtung. Mitteilungsheft des Österreichischen Kuratoriums für Therapeutisches Reiten 2, 36-44. ■ Taubert, A. (2009): Reittherapie in Neurologie und Psychotherapie. Frankfurt am Main, Peter Lang GmbH Internationaler Verlag der Wissenschaften. ■ Wiethölter, H. (2006): Multiple Sklerose. In Berlit, P. (Hrsg.): Klinische Neurologie (S. 1105-1137), http: / / dx.doi. org/ 10.1007/ 3-540-31176-9_43 ■ Wüthrich, R. & Künzle, U. (1978): Hippotherapie bei Multipler Sklerose. Therapiewoche. Forschung Fortbildung Fortschritt. Reittherapie. Sonderdruck aus der Therapiewoche 28, 4615-4656. Table 5: Results for assessment of well-being Item T1 T2 Easy * 3.77 5.18 Shiftless 4.55 5.00 Tired 3.95 5.14 Happy ** 4.73 5.90 Balanced ** 4.38 5.77 Subdued * 5.27 6.27 Powerful * 3.50 4.68 Energetic 4.23 5.18 Optimistic * 4.49 5.67 Active ** 3.64 5.05 Lack of drive 4.33 5.14 Impatient 4.76 5.82 Lively ** 3.90 5.55 Fearful 6.09 6.45 Movable ** 3.64 5.00 Satisfied ** 4.27 5.82 Relaxed ** 4.24 5.55 Comment: Scaling: 1 = not applicable to 7 = applies completely. The more the results tend to 1 the more successful the therapy is. T1= mean on a day without EAAT. T2= mean on a day after participating in EAAT. Statistically significant data ( α < 0.05) are marked with *. very high statistically significant data ( α < 0.05) are marked with **. 60 | mup 2|2016 Czerwonka, Pülschen - Equine-assisted activities from the perspective of people with MS Personal details for authors Anne Karen Czerwonka Occupational therapist and qualified for Therapeutic Riding and Equine- Assisted Learning, Bachelor of Arts Currently: University student Master Special Education at Europa-Universität Flensburg Dr. Simone Pülschen Special Educator, qualified for Equine- Assisted / Equine Facilitated Learning (DKThR), currently working at Europa- Universität Flensburg, Institute of Special Education, Department of Special Educational Psychology as research assistant. Correspondence address: Europa-Universität Flensburg · Dr. Simone Pülschen Institut für Sonderpädagogik · Abtl. Sonderpädagogische Psychologie · Auf dem Campus 1 · D-24943 Flensburg