THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 19, Number 7, 2013, pp. 622–626 Original Articles

ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2012.0642

Effect of Therapeutic Horseback Riding on Balance

in Community-Dwelling Older Adults with Balance Deficits

Douglas N. Homnick, MD, MPH,1 Kim M. Henning,2 Charlene V. Swain, BS, PT,2
and Tamara D. Homnick, BA, RN 2

Abstract

Objectives: Falls are an important cause of morbidity in older adults. Equine-assisted activities including
therapeutic riding (TR) benefit balance and neuromuscular control in patients with neurological disabilities but
have not been systematically studied in older adults at greater risk for falls due to balance deficits. The effect of
an 8-week TR program on measures of balance and quality of life in community-dwelling older adults with
established balance deficits was evaluated.
Design: This was a pretest–post-test single-group trial of a TR program on measures of balance and quality
of life.
Setting: The study was conducted at a Professional Association of Therapeutic Horsemanship (PATH) Inter-
national Premier riding center.
Subjects: The subjects comprised 9 adults (5 female, 4 males) with a mean age 76.4 years (range 71–83 years).
Interventions: This included an 8-week observation period followed by an 8-week TR program consisting of
1 hour per week of supervised horseback riding and an 8-week follow-up period. Subjects received balance
testing at weeks 0, 8, 16, and 24 using the Fullerton Advanced Balance Scale (FABS), and quality of life was
measured at weeks 8 and 16 using the Rand SF (short form) 36 quality-of-life measure.
Outcome measures: Outcome measures were change in the FABS and Rand SF 36.
Results: There was no significant difference in balance scores between the start and end of the observation
period. There was a significant improvement in the balance score and perception of general health from the start
to the end of the intervention period, and no significant difference between the end of the intervention and the
end of study, suggesting that improvements may have been sustained.
Conclusions: TR is a safe activity for older adults with mild to moderate balance deficits and leads to both
improvements in balance and quality of life. Longer and larger studies to assess the benefit of equine-assisted
activities on improvements in balance and reduction in fall risk are needed.

Introduction
F alls are a significant cause of morbidity in older age
groups, with 1 in 3 community-dwelling residents over 65
years experiencing at least one fall per year.1 Balance plays an
important role in determining which individuals present a
high fall risk and those with gait impairments experience
three times the fall rate and associated morbidity of those
without such disabilities.2 Decreased muscle strength and
endurance also increase fall risk.3
Balance represents a complex interaction of sensory and
musculoskeletal systems, and deficits in either can lead to
falls. At any age, exercise leads to faster postural reflexes,
improved balance and mobility, and fewer falls. This in-
cludes individuals with significant disabilities such as
chronic stroke.4 A Cochrane Database Review5 of exercise
and balance in older people identified 34 studies in which
those who exercised showed statistically significant im-
provements in balance over individuals with usual activities.
All types of exercise were represented in these studies in-
cluding those involving gait, balance, coordination, and
muscle strengthening, with combinations of multiple types
showing the greatest improvement.
Hippotherapy (HPOT) and therapeutic (horseback) riding
(TR) have become important methods of providing both a
pleasurable activity and physical exercise for individuals

1
Western Michigan University School of Medicine, Kalamazoo, MI.
2
The Cheff Therapeutic Riding Center, Augusta, MI.

622
THERAPEUTIC RIDING FOR OLDER ADULTS WITH BALANCE DEFICITS
with developmental and acquired disabilities. HPOT is de-
fined as a physical, occupational, or speech therapy treat-
ment strategy that utilizes equine movement, usually as part
of an integrated treatment program to achieve functional
outcomes. TR utilizes mounted activities including tradi-
tional riding disciplines or adaptive riding activities con-
ducted by a PATH International (Professional Association of
Therapeutic Horsemanship International, Denver, CO) cer-
tified instructor. Both are termed equine assisted activities
proven to improve dynamic postural stabilization, muscle
co-contraction, joint stability, weight shift, postural and
equilibrium responses, and gross motor function in children
with cerebral palsy (CP).6,7 TR has also been shown to im-
prove balance in individuals with mental retardation.8
However, few systematic studies of the potential benefit of
equine assisted therapies have been undertaken in older in-
dividuals. This article presents the results of a 10-week,
single-blind, controlled study of a 10 TR program on two
measures of balance in community-dwelling, older adults
without selecting subjects specifically for balance deficits. In
that study, we recorded improvements in balance in both the
intervention (TR) group and active, healthy controls, both
with relatively small balance deficits, emphasizing the need
to study patients with greater established balance deficits.9 In
addition, safety of the intervention in an older age group was
established.
Methods
The study was approved by the Bronson Methodist Hos-
pital Institutional Review Board (Kalamazoo, MI). A conve-
nience sample of individuals 65 years of age or older was
recruited from the local community. All subjects gave in-
formed consent, and underwent a health screening and a
balance screening. The balance screening consisted of four
questions (Short-Form Version) from the Fullerton Advanced
Balance scale (FABS), a validated measure of balance deficit
and fall risk (personal communication Debra J. Rose, PhD and
reference 2). The full FABS (Table 1) is a test of static and
dynamic balance and is especially suited to higher-functioning
individuals with slightly more challenging tasks. It consists of
10 maneuvers scored from 0 to 4 (high to low fall risk) with a
total possible score of 40 and takes approximately 20 minutes
to complete. The FABS has also been found to have high test–
retest (intra-rater) and inter-rater reliability. The short form
version of the FABS consists of questions 4, 5, 6, and 7 of the
full FABS with a total possible score of 16. A score of 9 or
Table 1. The Fullerton Advanced Balance Scale Items
1. Standing with feet together, eyes closed.
2. Reaching forward to retrieve an object held at shoulder
height.
3. Turn 360 degrees in a right and left direction.
4. Step up and over a 6-inch bench.
5. Tandem walk.
6. Standing on one leg.
7. Standing on foam with eyes closed.
8. Two-footed jump for distance.
9. Walk with head turns.
10. Reactive postural control.
Each item is scored 0–4 with a possible total score of 40 (see
reference).
623
lower indicates a reasonable high probability of fall risk.
Subjects otherwise meeting the entry criteria and scoring be-
tween 6 and 12 on the short form FABS were enrolled in the
study. In addition, physician clearance was required of all
subjects entering the study.
Subjects were excluded with any chronic condition known
to affect balance including history of stroke, Parkinson’s
disease, multiple sclerosis, vestibular dysfunction, or any
other condition leading to severe musculoskeletal or neuro-
logic dysfunction or impairment in balance. Additional ex-
clusion criteria included history of intake of more than the
equivalent of 1.5 ounces of alcohol per day, fear of horses,
and recreational or therapeutic riding within 1 year of en-
rollment. Entry into the study was at the discretion of the
physician investigator (DNH).
The FABS was administered to selected individuals at the
time of entry into the study (week 0), just prior to starting the
TR intervention (week 8), immediately upon completion of
the TR intervention (week 16), and 8 weeks after completing
the TR intervention (week 24) by a licensed and experienced
physical therapist (CVS). In addition, each subject was asked
to complete the Rand SF (Short Form) 36 quality-of-life sur-
vey at the start and end of the TR intervention (weeks 8 and
16). The Rand SF 36 is a validated tool using 36 questions
that have been used to assess physical and emotional func-
tioning in older adults.10,11 Questions from the tool are
combined to form nine domains corresponding to various
quality-of-life indicators. These include physical functioning,
role limitations due to physical health, role limitations due to
emotional problems, energy/fatigue, emotional well-being,
social functioning, pain, general health, and health change.
Each domain has a possible score of 100.
Participants underwent balance testing and the TR inter-
vention at the Cheff Therapeutic Riding Center (Augusta, MI).
The Cheff Center is a PATH International premier accredited
therapeutic riding center, established in 1970, that serves
multiple types of clients including children and adults with
physical, developmental, and psychologic disabilities includ-
ing veterans with post-traumatic stress disorder, children and
adults with autism, CP, and so on. The TR course consisted of
a once per week, 1-hour session with a PATH-trained and
certified TR instructor investigator (TDH or KMH). The TR
session included grooming and tacking, mounting, a warmup
exercise on the horse, riding skills, and dismounting. The
riding portion of the session lasted approximately 45 minutes
and consisted of walking and/or trotting, depending on the
skill of the rider. One (1) to 3 volunteers assisted the rider to
maintain safety. Close observation of the rider was main-
tained at all times for early detection of fatigue, discomfort,
etc. The Rand SF 36 was administered at the start and the end
of the TR intervention (weeks 8 and 16). Seven (7) subjects
completed both measures.
Table 2. Mean Balance Scores at Each Time Point
N Minimum Maximum Mean Std. deviation
Week 0 9 22.00 35.00 26.5556 4.21637
Week 8 9 24.00 33.00 27.8889 2.80377
Week 16 9 26.00 37.00 31.3333 3.53553
Week 24 9 26.00 38.00 31.4444 4.36208
624
FIG. 1. Mean balance scores at each time point.
Results
Eleven (11) subjects met the entry criteria and were en-
rolled in the study and 9 subjects (mean age 76.4 years, range
71–83 years, 4 male, 5 female) completed the TR intervention
and all four balance measurements. Seven (7) subjects who
finished the trial (mean age 76.1 years, range 71–83 years, 2
male, 5 female) also completed both measures of the quality-
of-life questionnaire.
Mean balance scores at each study time point are shown
in Table 2 and Figure 1. Comparison of balance scores be-
tween each time point in the study is shown in Table 3. As
noted, there was no significant change in balance scores
during the observation period (weeks 0–8, p = 0.35). There
was a significant improvement in balance scores from the
start to end of the TR intervention (weeks 8–16, p = 0.001),
and no significant difference between the end of the TR in-
tervention and the end of the follow-up period (weeks 16–24,
p = 0.908). The observation period was established to inves-
tigate and minimize the effects of learning on the balance
tests as well as to gather information on daily physical ac-
tivities of the participants. Most measures of quality of life
improved from the start to end of the TR intervention;
however, only the measure of overall perception of general
health improved significantly ( p = 0.003) (Table 4, Fig. 2). No
safety issues were encountered during the trial.
Statistical analysis
Descriptive statistics for balance scores are shown in Table 2
and comparisons of the means at paired time points are
shown in Table 3. The descriptive statistics for the quality-of-
life measures are shown in Table 4 and comparisons of the
means at paired time points in Figure 2. The paired t-test was
used throughout as the measurements were taken on the same
subjects throughout the study. The tests were conducted at a
0.05 significance level. Minitab 16 (Minitab, Inc., State College,
PA) statistical software was used for the analyses.
Table 3. Comparison of Balance Scores at Various Time Points
95% Confidence interval of the difference
Mean Std. Std.
difference deviation error mean
Pair 1 Week 0–Week 8 - 1.33333 4.03113 1.34371
Pair 2 Week 8–Week 16 - 3.44444 1.87824 0.62608
Pair 3 Week 16–Week 24 - 0.11111 2.80377 0.93459
Sig., significance; df, degrees of freedom.
HOMNICK ET AL.
Discussion
Falls are common in older individuals and have an im-
portant impact on quality of life. They are also expensive,
with the cost of fall injuries reaching $20.2 billion in 1994 and
estimated to increase to $32.4 billion in 2002, likely due to an
increasing senior population as baby boomers age.12 Factors
that increase risk of falls include disability, poor performance
on physical tests, depressive symptoms, poor executive
function, concern about falling (balance confidence), and
previous falls.13 Identification of those individuals at risk and
early intervention with medical assessment and manage-
ment, exercise programs, and environmental modification is
known to reduce fall risk and improve quality of life.
Exercise reduces fall risk in older adults. Nowalk et al.14
demonstrated the benefits of two exercise programs, resis-
tance/endurance training and t’ai chi, in reducing fall risk in
residents of two long-term care facilities. Cyarto et al.15
showed improvements in balance confidence and balance
ability in independent-living retirement village residents
undergoing either home-based resistance and balance
training or group-based walking. In another study of rela-
tively healthy community-dwelling adults age 65 and older,
Feldenkreis exercises significantly improved mobility and
balance confidence.16 Disabled older adults also benefit
from exercise programs. Miller et al.17 achieved improve-
ments in balance performance, balance confidence, and gait
in debilitated, ambulatory community-dwelling adults un-
dergoing 4 weeks of exercise and balance training. In ad-
dition, a recent Cochrane Database Systematic Review18 of
111 clinical trials of fall intervention in older community-
dwelling adults concluded that multiple-component group
exercise, t’ai chi, and individually prescribed multicompo-
nent home-based exercise all reduced fall risk and rates
of fall.
HPOT and TR are not only forms of exercise with proven
rehabilitative potential but also are pleasurable activities for
those with disabilities. The exact therapeutic benefit of
horseback riding is unknown is but thought to be due dis-
placement of the horse’s center of gravity three-dimension-
ally, leading to rhythmic movements similar to a human
gait.19 Neurosensory and neuromuscular responses are eli-
cited from underutilized muscle groups in response to this
mechanical stimulation. Although not yet defined, move-
ment of the horse may also improve vestibular responses to
alterations in posture, leading to improved fall protection in
older individuals.
TR and HPOT improve muscle tone, balance, posture,
trunk/head stability, upper extremity reach/targeting, gross
motor function, and gait speed in children with CP.19–21
Balance and quality of life are also improved in multiple
sclerosis with both TR and HPOT.22,23 However, there are no
Sig.
Lower Upper t df (2-tailed)
- 4.43193 1.76527 - 0.992 8 0.350
- 4.88819 - 2.00070 - 5.502 8 0.001
- 2.26628 2.04406 - 0.119 8 0.908
THERAPEUTIC RIDING FOR OLDER ADULTS WITH BALANCE DEFICITS 625

Table 4. Quality of Life Measurements at Start and End of the Therapeutic Horseback Riding Intervention

95% Confidence
interval of the difference
Mean Std. Std. error Sig.
QOL measures difference deviation mean Lower Upper t df (2-tailed)

Pair 1 Phys func2–Phys func 6.071 8.643 3.267 - 1.922 14.065 1.859 6 0.112
Pair 2 Role PH2–Role PH 0.000 43.301 16.366 - 40.047 40.047 0.000 6 1.000
Pair 3 Role EP2–Role EP 9.514 16.249 6.141 - 5.513 24.542 1.549 6 0.172
Pair 4 Energy2–Energy 12.143 13.496 5.101 - 0.339 24.625 2.380 6 0.055
Pair 5 Emot WB2–Emot WB 4.286 5.219 1.973 - 0.541 9.112 2.173 6 0.073
Pair 6 Soc Func2–Soc Func 7.143 14.174 5.357 - 5.966 20.251 1.333 6 0.231
Pair 7 Pain2–Pain 2.143 15.236 5.759 - 11.948 16.234 0.372 6 0.723
Pair 8 Gen Hlth2–Gen Hlth 21.429 18.420 6.962 4.393 38.464 3.078 6 0.022
Pair 9 Hlth Chg2–Hlth Chg 4.167 10.206 4.167 - 6.544 14.877 1.000 5 0.363

QOL, quality of life; Std., standard; df, degrees of freedom; Sig., significance; Phys func, physical functioning; Role PH, role limitations due
to physical health; Role EP, role limitations due to emotional problems; Energy, energy/fatigue; Emot WB, emotional well-being; Soc Func,
social functioning; Pain, pain; Gen Hlth, general health; Hlth Chng, health change.

systematic studies of the effects of TR or HPOT in older
adults with any medical condition, including the effects on
balance.
A total score on the FABS of 25 or lower has been deter-
mined to be a predictor of increased fall risk in older sub-
jects.2 Mean FABS score for the group in the current study at
baseline was 26.5 and increased to 31.33 at the end of the TR
intervention. This would indicate that these subjects had
reasonable balance deficits at the start of the trial with clear
improvement after completing the TR course. Of interest is
the maintenance of the mean balance score at the follow-up
measure and above the baseline balance score, suggesting
persistence of effect, although no subjects continued to ride
after completing the TR intervention. The subjects, however,
were not queried as to whether they may have increased
other physical activities during the follow-up period, possi-
bly accounting for the apparent persistence of effect. The
small sample size precludes any definite conclusions re-
garding this.
A control group was not used for this study, but rather a
single-group pretest–post-test design was chosen to mini-
mize the effects of other confounding variables such as
other exercise in a comparison group. Sterba et al.,6 in dis-
cussing a study design for assessment of the effects of TR on
children with CP, pointed out that using intervention sub-
jects as their own controls was a sensitive way to determine
small therapeutic changes. They felt that an interventional
before–after trial with subjects serving as their own controls
was useful for evaluation of effects on gross motor function
in the evaluation of sports therapy. This may also prove
true for balance studies involving exercise. Additional is-
sues include determining optimal frequency and duration
of TR or HPOT therapy for balance and what is the duration
of a possible sustained effect once therapy is discontinued.
Since falls and fall risk rather than balance per se are the
ultimate clinically significant outcomes, a future study with
a longer (perhaps 1 year) TR course while measuring not
only balance but actual falls and fear of falling, perhaps
compared to a nonintervention matched control group
would clarify the true benefit of equine-assisted activities
on reducing fall risk.
However, this study demonstrates the practicability,
safety, and benefit on improvement in balance of a short-
term TR course in older individuals with established mild-to-

FIG. 2. Quality-of-life
measurements at 8 and 16
weeks. Phy Func, physical
functioning; Role PH, role
limitations due to physical
health; Role EP, role
limitations due to emotional
problems; Energy, energy/
fatigue; Emot WB, emotional
well-being; Soc Func, social
functioning; Pain, pain; Gen
Hlth, general health; Hlth
Chng, health change.
*p = 0.022.
626
moderate balance deficits. As the general population ages, is
generally healthier and more active than their parents, and
desire to continue to undertake physical activities, equine
activities and equine-assisted therapies may prove beneficial
for maintenance of balance with resultant decrease in the fall
risk and improved quality of life. Additional studies in this
area would help clarify the benefits of this type of activity in
older individuals.
Acknowledgments
All listed authors contributed significantly to the design,
implementation, and reporting of results of this study. The
statistical services of Robert Flikkema, MS, Department of
Statistics, Western Michigan University, Kalamazoo, Michi-
gan are greatly appreciated. Funding Source: The Cheff
Therapeutic Riding Center.
Disclosure Statement
The authors do not indicate any conflicts of interest in
regard to this study. Tamara D. Homnick, Kim Henning, and
Charlene Swain are employed by the Cheff Therapeutic
Riding Center. Douglas Homnick reports no financial inter-
est in regard to this study. The Cheff Therapeutic Riding
Center provided in-kind support of this project.
References
1. American Geriatrics Society, British Geriatrics Society,
American Academy of Orthopedic Surgeons Panel on Falls
Prevention. Guideline for the prevention of falls in older
persons. J Am Geriatr Soc 2000;18:141–158.
2. Hernandez D, Rose DJ. Predicting which older adults will or
will not fall using the Fullerton advanced balance scale. Arch
Phys Med Rehabil 2008;89:2309–2315.
3. Rose DJ, Lucchese N, Wiersma LD. Development of a multi-
dimensional balance scale for use with functionally indepen-
dent older adults. Arch Phys Med Rehabil 2006;87:1478–1485.
4. Marigold DS, Eng JJ, Dawson AS, et al. Exercise leads to
faster postural reflexes, improved balance and mobility, and
fewer falls in older persons with chronic stroke. JAGS
2005;53:416–423.
5. Gillepsie LD, Gillespie WJ, Robertson MC, et al. Interven-
tions for preventing falls in elderly people. Cochrane Data-
base Syst Rev 2003;4:CD000340.
6. Sterba JA. Does horseback riding therapy or therapist-
directed hippotherapy rehabilitate children with cerebral
palsy? Dev Med Child Neurol 2007;49:68–73.
7. Snider L, Korner-Bitensky N, Kammann C, et al. Horseback
riding as therapy for children with cerebral palsy: is there
evidence of effectiveness? Phys Occup Ther Pediatr 2007;
27:5–23.
8. Biery MJ, Kaufmann N. The effects of therapeutic horseback
riding on balance. Adapted Phys Act Quart 1989;6:221–229.
9. Homnick TD, Henning KM. The effect of therapeutic
horseback riding on balance in community – dwelling older
adults – a pilot study, Athens, Greece, April 25, 2012.
HOMNICK ET AL.
10. Cleary KK, Howell DM. Using the SF-36 to determine per-
ceived health-related quality of life in rural Idaho seniors. J
Allied Hlth 2006;35:156–161.
11. Walters SJ, Munro JF, Brazier JE. Using the SF-36 with older
adults: A cross sectional community-based survey. Age
Aging 2001;30:337–343.
12. Englander F, Hodson TJ, Terregrossa RA. Economic dimen-
sions of slip and fall injuries. J Forensic Sci 1996;41:733–746.
13. Delbaere K, Close JC, Heim J, et al. A multifactorial ap-
proach to understanding fall risk in older people. J Am
Geriatr Soc 2010;58:1679–1685.
14. Nowalk MP, Prendergast JM, Bayles CM, et al. A random-
ized trial of exercise programs among older individuals
living in two long-term care facilities: The FallsFREE pro-
gram. J Am Geriatr Soc 2001;49:859–865.
15. Cyarto EV, Brown WJ, Marshall AL, Trost SG. Comparative
effects of home- and group-based exercise on balance con-
fidence and balance ability in older adults: Cluster ran-
domized trial. Gerontology 2008;54:272–280.
16. Ullmann G, Williams HG, Hussey J, et al. Effects of Fel-
denkrais exercises on balance, mobility, balance confidence,
and gait performance in community-dwelling adults age 65
and older. J Altern Complement Med 2010;16:97–105.
17. Miller KL, Magel JR, Hayes JG. The effects of a home-based
exercise program on balance confidence, balance perfor-
mance, and gait in debilitated, ambulatory community-
dwelling older adults: A pilot study. J Geriat Phys Ther
2010;33:85–91.
18. Gillespie LD, Robertson MC, Gillespie et al. Cochrane Da-
tabase Syst Rev 2009;15:CD007146.
19. Shurtleff TL, Standeven JW, Engsberg JR. Changes in dy-
namic trunk/head stability and functional reach after hip-
potherapy. Arch Phys Med Rehabil 2009;90:1185–1195.
20. Berototi DB. Effect of therapeutic horseback riding on
posture in children with cerebral palsy. Phys Ther 1988;68:
1505–1512.
21. Winchester P, Kendall K, Peters H, et al. The effect of ther-
apeutic horseback riding on gross motor function and gait
speed in children who are developmentally delayed. Phys
Occup Ther Ped 2002;22:37–50.
22. Hammer A, Nilsagard Y, Forsberg A, et al. Evaluation of
therapeutic riding (Sweden)/hippotherapy (United States):
A single-subject experimental design study replicated in
eleven patients with multiple sclerosis. Phys Theory Pract
2005;21:51–77.
23. Bronson C, Brewerton K, Ong J, et al. Does hippotherapy
improve balance in persons with multiple sclerosis? A sys-
tematic review. Eur J Phys Rehabil Med 2010;46:347–353.
Address correspondence to:
Douglas N. Homnick, MD, MPH
Western Michigan University School of Medicine
1000 Oakland Drive
Kalamazoo, MI 49008
E-mail: douglas.homnick@med.wmich.edu