Received: 20 January 2020 Revised: 14 May 2020
DOI: 10.1002/pri.1870
RESEARCH ARTICLE
Effects of horse riding simulator on sitting motor function in
children with spastic cerebral palsy
Hemachithra Chinniah1 | Meena Natarajan1
John William Felix Ambrose3
1
Division of PM&R, RMMC&H, Annamalai
University, Annamalai Nagar, Tamil Nadu, India
2
Department of Paediatrics, RMMC&H,
Annamalai University, Annamalai Nagar, Tamil
Nadu, India
3
RMMC, Annamalai University, Annamalai
Nagar, Tamil Nadu, India
Correspondence
Chinniah Hemachithra, Division of PM&R,
RMMC&H, Annamalai University, Annamalai
Nagar 608 002, Tamil Nadu, India.
Email: chitupt@gmail.com
Physiother Res Int. 2020;e1870.
https://doi.org/10.1002/pri.1870
Accepted: 5 July 2020
| Ramanathan Ramanathan2 |
Abstract
Background: Horse riding simulator (HRS) is an electronic horse, working under the
principles of hippotherapy. It is one of the advanced therapeutic methods to improve
postural control and balance in sitting, which could be recommended in the rehabili-
tation of cerebral palsy if real horses are unavailable.
Objective: To investigate the therapeutic effects of HRS on sitting motor function in
children with spastic diplegia and evaluate the changes in sitting motor function at
different periods of time (4, 8 and 12 weeks).
Methods: This study is a randomized controlled trial conducted over a period of
12 weeks. Thirty children with spastic diplegia age between 2 and 4 years with Gross
Motor Function Classification System (GMFCS) Level I–III were included and divided
into two groups. The control group received the conventional physiotherapy while
the experimental group received HRS along with conventional physiotherapy. Sitting
motor function was assessed by Gross Motor Function Measure (GMFM)-88 (sitting
dimension B) at baseline, 4, 8 and 12 weeks. Pre- and post-intervention scores were
measured and analysed.
Results: The baseline characteristics were similar in both groups before the interven-
tion with p > .01. The observed mean value of GMFM in both groups improved over
a period of 12 weeks. The results denote that the sitting motor function gradually
improved over a period of time in both groups and the experimental group showed
significant improvement (p < .01) than the control group in all the weeks.
Conclusion: The study results confirmed that gradual improvement in sitting motor
function was observed in both groups. Children exposed to HRS show better
improvement than the children in the control group. It was concluded that HRS is
effective in improving the sitting motor function in children with spastic diplegia and
the continuous provision of HRS in longer duration provide more benefits than the
shorter duration.
KEYWORDS
hippotherapy, horse riding simulator, sitting motor function, spastic diplegia
wileyonlinelibrary.com/journal/pri © 2020 John Wiley & Sons Ltd 1 of 8
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1 | I N T RO DU CT I O N
Hippotherapy is a physical therapy strategy using rhythmical equine
movement of the horses which provides a dynamic base of support and
considered as a therapeutic tool for the rehabilitation of children with
cerebral palsy (CP) (Whalen & Case-Smith, 2012; Zadnikar &
Kastrin, 2011). Several researches have been published regarding the
beneficial effects of hippotherapy: it inhibits the pathological reflexes;
corrects abnormal muscle tone and pelvic tilt; improves postural control,
motor function, balance, coordination and equilibrium in patients with
neurological dysfunction (Cherng, Liao, Leung, & Hwang, 2004; Lechner,
Kakebeeke, & Hegemann, 2007; Shinomiya et al., 2003; Shurtleff,
Standeven, & Engsberg, 2009; Snider, Korner-Bitensky, Kammann, War-
ner, & Saleh, 2007; Sterba, 2007). The therapeutic results obtained with
the application of hippotherapy treatment have encouraged research
into development of the mechanical horseback riding therapy (Kijima
et al., 2003). Horse riding simulator (HRS) is an electronic horse which
provides rhythmical and repetitive movements like real horses and has
become more accessible to patients with neurological impairment
(Quint & Toomey, 1998). Mohamed (2014) proved that hippotherapy
simulator is an alternative method for hippotherapy and could be used
for the modulation of back geometry and improving balance in CP chil-
dren. The following studies have proved the beneficial effects of HRS,
which could be a useful alternative to hippotherapy for improving bal-
ance in children with CP (Chae-Woo, Kim, & Na, 2014; Hemachithra
et al., 2019b; Mohamed, 2014; Quint & Toomey, 1998).
CP is a common disorder that causes physical disability in children
throughout life and begins in early childhood. Spastic type was the most
common type of CP, about 65% in which diplegia constitutes about
23% (Pallavi, Sharma, Jamwal, Digra, & Saini, 2019). Defective postural
control is one of the most significant problems in children with
CP. Bulent, Bozkurt, Oskay, and Oksuz (2017) stated that children with
spastic diplegia had significant muscle weakness and insufficient propri-
oception and tactile sense in trunk and postural muscles. Children with
CP have decreased pelvic movements that lead to awkward movements
and poor postural control in sitting posture. Postural control in sitting
correlated with the hand reaching performance and interacts with upper
extremity control to ensure successful movement of hand (Nur, Saat, &
Kamaralzaman, 2016). Maintaining postural control is required for the
performance of the activities of daily living (ADL; Van der Heide
et al., 2004). Sitting ability is very important for the child to achieve the
upright posture against gravity and also essential to provide the postural
background required for the functional movements of upper extremity.
Children with spastic diplegia suffer from poor postural reflexes, poor
alignment of the trunk and abnormal back geometry which lead to
rounded back with kyphotic curvature of the spine and asymmetry of
the trunk while sitting (Graham, 2003; Park, Park, Lee, & Cho, 2001).
HRS is one of the advanced therapeutic methods to improve pos-
tural control and balance in sitting, which could be recommended in
the rehabilitation of CP if real horses are unavailable (Peeraya,
Lekskulchai, Akamanon, Ritruechai, & Sutcharitpongsa, 2015). Evalua-
tion of subtle changes in sitting ability is required to monitor the
effectiveness of assigned intervention. The Gross Motor Function
CHINNIAH ET AL.
Measure (GMFM)-88 (sitting dimension B) is a standard measure
which is generally used to examine various dimensions of sitting
motor function (Brunton & Bartlett, 2011). Limited studies have
addressed the beneficial effects of HRS on postural control in sitting
 ski & Słonka, 1999; Zurek, Dudek,
(Kijima et al., 2003; Kuczyn
Pirogowicz, Dziuba, & Pokorski, 2008). Unavailability of this mechani-
cal device challenges the use of this technology in routine care and
lack of periodical assessment. The aim of the study was to evaluate
the therapeutic efficacy of HSR on the sitting ability of CP children at
different periods of time. The specific objective of this study was to
investigate whether HRS may improve the postural control and sitting
motor function of children with spastic diplegia.
2 | METHODS
2.1 | Study design
The randomized controlled trial (RCT) was carried out in the depart-
ment of Physical Medicine & Rehabilitation (PM&R). The study was
conducted over the period from July 2018 to December 2019.
2.2 | Subjects
Forty children with spastic diplegia were recruited from the division of
PM&R based on the inclusion and exclusion criteria. Inclusion criteria:
clinically diagnosed spastic diplegia, age between 2 and 4 years, both
sex, Gross Motor Function Classification System (GMFCS) level (1, 2
and 3), adductor spasticity level (0, 1, 1+ and 2 as per modified ashworth
scale), ability to sit upright with support. Exclusion criteria: children
exposed to recent neurological and orthopaedic surgeries, uncontrolled
seizures, unable to tolerate the oscillatory movements, visual and hear-
ing impairment. The procedure for this RCT is summarized in Figure 1.
They were divided into two groups: Group A – the experimental group;
Group B – the control group. Each group consists of 20 children. Group
allocations were carried out by concealed random allocation method.
The pre-assessment were recorded including the basic data such as age,
sex, level of motor function by GMFCS and the sitting motor function
by GMFM-88 (sitting dimension – B). After the pre-assessment, each
child received an intervention according to the group and further post-
assessment, the important study variable GMFM-88 scores for sitting
motor function were recorded.
2.3 | Materials
2.3.1 | Horse riding simulator
OSIM U-Gallop (OS-950 Gallop 2) was used in this study. It is an innova-
tive indoor exercise equipment which utilizes the oscillatory action of the
seat to stimulate the horse riding experience. It has four manual speed
modes and one auto program with variations in speed. Strategically
CHINNIAH ET AL. 3 of 8

FIGURE 1 Consort flow

diagram

FIGURE 2 Horse riding simulator

4 of 8 CHINNIAH ET AL.

located control panel allows easy access, stirrup and handle strap are
available for more comfort. The simulator is shown in Figure 2. HRS pro-
vides oscillations in both directions, antero-posterior and lateral which
cover movements in all planes (sagittal, frontal and transverse planes).
2.4 | Study procedure
Brief explanation about the study procedures was given to the parents
and guardians and informed consent was obtained from them. The
experimental group received HRS along with the conventional physio-
therapy management while the control group received conventional
physiotherapy only. Both groups were exposed to 30 min of conven-
tional physiotherapy and the experimental group was allowed to ride
HRS for an additional 15 min. During the treatment session, children
(experimental group) were placed on the saddle and asked to maintain
sitting posture. The therapist helped the patients to be safe by stabiliza-
tion of pelvis and provide support to the children whenever needed.
The mechanical horseback riding therapy produces the movement of
the saddle at three pre-defined tilt levels. Basic conditioning (flat), for-
ward tilt and backward tilt and lateral tilt. Children in the intervention
group received 15 min of riding session, three times per week for
12 weeks along with the conventional physiotherapy, while the children
in control group received conventional physiotherapy (positioning,
stretching and balance activities in sitting position) for 30 min. The
speed of the machine was set at Level 1 for the first week and slowly
increased to Level 2 and Level 3 depending upon the accessibility of the
children for consecutive weeks. All the children were treated by experi-
enced paediatric physical therapist. Clinical outcomes were assessed at
regular intervals in 4, 8 and 12 weeks. The therapist was blinded to the
group allocation and time of assessment. Pre- and post-assessment
were taken by the same examiner to reduce the possible bias.
2.5 | Outcome measures
Sitting motor function was assessed by GMFM-88 (sitting dimen-
sion B).
3 | STATISTICAL ANALYSIS AND RESULTS
Chi-square test was applied to find out the association of age, sex and
level of motor function (GMFCS) between the control group and the
experimental group at baseline. Student's t-test has been applied to
find out the significant difference in height, weight and sitting motor
function (GMFM) between the groups at baseline. “2 × 4 ANOVA
test” and “Repeated contrast test” have been applied to find out the
difference within the group and between the groups. Statistical ana-
lyses were done by SPSS version 18 with the level of significance set
at .05.
Table 1 shows the distribution of age, sex and GMFCS by group.
The purpose of the table is to find out whether a variation exists
between the experimental and the control group children based on
the above-mentioned variables. Chi-square test was applied. The non-
significant p-values indicate that age, sex and level of motor function
(GMFCS) scores were similar in both groups. The values observed in
Table 2 demonstrate the difference exists in anthropometric measure-
ments such as height, weight and GMFM scores between the groups
at baseline. Student's t-test has been applied and the observed p-
value is insignificant which denotes that the above-mentioned vari-
ables are similar between the groups before the intervention. Table 3
displays the mean and SD of observed GMFM scores at different
periods of assessment in the control group. The significant p-value
(<.001) shows that a gradual improvement occurred from baseline to
4, 4–8 and 8–12 weeks. Similar results were found in the experimen-
tal group displayed in Table 4.
The observed mean value of GMFM in the control group is
49.21% at baseline and increased to 64.28% at the end of 12 weeks.
In the experimental group, it was observed as 54.18% at baseline
which increased to 82.74% at the end of 12 weeks, as shown in
Table 5. The results indicate that GMFM scores have improved from
baseline to end of 12 weeks in both groups, but comparatively the
experimental groups show higher mean values than the control group.
Table 5 shows the significant difference within the groups and
between the groups among the study population. 2 × 4 ANOVA test
with last variable as a repeated measures was applied; in this test,
2 refers to the two groups, that is, the control group and the

T A B L E 1 Distribution of age, sex and

Variables Control group (N = 15) Experimental group (N = 15)
gross motor function level (GMFCS) of
Age N Percentage N Percentage Chi-square test p-Value children (both groups)
2 7 46.7 11 73.3 2.22 .136*
3 8 53.3 4 26.7
Gender
Male 5 33.3 8 53.3 1.22 .269*
Female 10 66.7 7 46.7
GMFCS
Level 1 2 13.3 2 13.3 1.38 .500*
Level 2 5 33.3 8 53.3
Level 3 8 53.3 5 33.3

p – level of significance, * – non-significant.

CHINNIAH ET AL. 5 of 8

TABLE 2 Mean and SD of height, weight and GMFM (sitting dimension) scores of children in both groups before intervention

Control group Experimental group

Variables Mean SD Mean SD t-Value p-Value

Height 81.47 8.45 80.93 7.74 0.180 .858*
Weight 9.08 1.59 9.51 1.59 0.734 .469*
GMFM (B) 49.21 7.72 54.18 7.43 1.002 .325*

Abbreviation: GMFM, Gross Motor Function Measure (sitting dimension B).

p – level of significance,* – non-significant.

TABLE 3 Mean and SD and ANOVA of GMFM (sitting B) in control group at different periods

Control group ANOVA repeated Repeated contrast test

GMFM (B) Mean SD F value p-Value Comparison F value p value

Baseline 49.21 7.72 134.79 <.001 Baseline vs. 4 weeks 47.05 <.001
4 weeks 54.59 7.64 4 weeks vs. 8 weeks 107.84 <.001
8 weeks 59.62 8.05 8 weeks vs. 12 weeks 138.54 <.001
12 weeks 64.28 8.59

Abbreviation: GMFM, Gross Motor Function Measure (sitting dimension).

p – level of significance.

TABLE 4 Mean SD and ANOVA of GMFM (sitting B) in experimental group at different periods

Experimental group ANOVA repeated Repeated contrast test

GMFM (B) Mean SD F value p-value Comparison F value p value

Baseline 54.18 7.43 199.37 <.001 Baseline vs. 1 week 130.09 <.001
4 weeks 64.32 8.8 1 week vs. 2 weeks 92.90 <.001
8 weeks 73.35 8.60 2 weeks vs. 3 weeks 109.44 <.001
12 weeks 82.74 8.82

p – level of significance.

T A B L E 5 Comparison of GMFM
Repeated contrast test value
within subjects and between subjects in
the control and experimental group (2 * 4 Source F value p value Comparison F value p value
ANOVA repeated measures test results)
Between subjects
Group 5.37 .028
Within subjects
Assessment 329.74 <.001 Baseline vs. 4 weeks 171.36 <.001
4 week vs. 8 weeks 177.73 <.001
8 weeks vs. 12 weeks 205.15 <.001
Assessment* 31.01 <.001 Baseline vs. 4 weeks 16.08 <.001
4 weeks vs. 8 weeks 14.37 <.001
8 weeks vs. 12 weeks 23.22 <.001

Abbreviation: GMFM, Gross Motor Function Measure (sitting dimension).

p – level of significance.
*Interaction effect between two groups.

experimental group, and 4 refers to the number of assessments, such the experimental group with respective scores of GMFM. To get more
as baseline, 4, 8 and 12 weeks. The corresponding p value of “group” details of the difference within the subjects, a comparison has been
indicates that there is a significant difference between the control and done. Assessment * group (Interaction effect): the significant p value
6 of 8
(p < .001) infers that the changes occurring between the four assess-
ments for the two groups are statistically different. “Repeated con-
trast test” has been applied. The results strongly suggest that all the
comparisons, that is, baseline and 4 weeks, 4 and 8 weeks, 8 and
12 weeks, were found to be statistically different. These results indi-
cate that more improvement has been observed in the experimental
group from the first week onwards than the control group. Hence, it
has been proven that children exposed to HRS have attained better
sitting ability than the children in the control group.
4 | DISCUSSION
Hippotherapy works under the principle of generation of motor
impulses from the back of the horse to the rider. These locomotor
impulses transformed from the horse's body to the rider in three
movement planes. These rhythmical movements and the three-
dimensional sway of horseback riding stimulate the postural reflex
mechanism resulting in balance and coordination training in patients
with neurological impairment (Janura, Peham, Dvorakova, & function was significantly different between the groups. The interven-
Elfmark, 2009). Many studies have proved the therapeutic effects of
hippotherapy (El-Meniawy & Thabet, 2012; Hemachithra et al.,
2019a; Lechner et al., 2003). HRS is working under the same princi-
ples of hippotherapy which imitates the movement of a horse riding
by producing three-dimensional movements similar to the horse walk-
ing pattern (Fernandes, Chitra, & Metgud, 2008; Herrero, Gómez-
ski &
Trullén, Asensio, & Garcia, 2012; Kijima et al., 2003; Kuczyn
Słonka, 1999; Silva e Borges, Werneck, da Silva, Gandolfi, &
Pratesi, 2011). Even though hippotherapy has many therapeutic bene-
fits, it has some primary and secondary constraints like difficulty in
mounting the horses, higher costs, fear of horses, allergic conditions,
weather conditions and high risk of injuries (Ball, Ball, Kirkpatrick, &
Mulloy, 2007; Janura et al., 2009; Thomas, Annest, Gilchrist, & Bixhy-
Hammett, 2006). Mechanical HRS was invented to overcome these
constraints, which could be used at any place and more accessible and
adaptable to the patients.
The purpose of the study was to investigate the therapeutic effi-
cacy of HRS on sitting ability of children with spastic diplegia. Thirty
children with spastic diplegia were included in this study and they
were divided into two groups: the control group and the experimental
group, and each group consist of 15 children. The basic characteristics
of the study population in both groups were evaluated and observed
for similarity between the groups, which was confirmed by the results,
that is, both groups are homogeneous at baseline. Gender was evenly
distributed in both groups and the anthropometric measurements also
show similarity between the groups. This study includes children aged
2–4 years. In the control group, it was equally distributed. In the
experimental group, it shows inequality in which more number of chil-
dren observed as younger. It happened accidentally, not skewed or
biased. Even though some imbalance existed, this does not affect the
results because the age group interval is minimal. The sitting motor
function of the children in both groups was evaluated by GMFM-88
(sitting dimension B); the scores obtained were similar between the
CHINNIAH ET AL.
groups before the intervention. GMFM (sitting dimension B) consists
of 20 items that cover all the movement patterns used in the daily life
situations. It is sufficient to find out the improvements in the sitting
ability in daily life. Moreover, in this study, GMFCS as a functional
scale is used for the evaluation of the functional level of children, and
not used as an outcome measure. The experimental group exposed to
mechanical horse riding with HRS for 15 min per day, 3 times/week
for 12 weeks along with the conventional physiotherapy, whereas the
control group was exposed to the conventional therapy only. The
periodical improvements in GMFM scores were evaluated at different
levels at baseline, at the end of 4, 8 and 12 weeks in both groups.
Regarding the treatment protocol, this study is similar to the study
done by Bagheri et al. (2017) who conducted study with the same
protocol, that is, 15 min of HRS, 3 times per week and addressed the
benefits of HRS improving motor functions.
The main findings from the study revealed that GMFM scores
were gradually improved in both groups at different periods of treat-
ment. This denotes that the sitting motor function gradually improved
over a period in both groups. The improvement in the sitting motor
tion group, that is, children exposed to HRS, showed significant
improvement than the children in the control group. The observed
mean value of GMFM in both groups has been improved over a
period of 12 weeks such as baseline to 4 weeks, 4–8 weeks and
8–12 weeks. Even though both groups have shown improvement in
sitting motor function, the experimental group showed better
improvement than the control group in all the weeks. In the experi-
mental group, the children accommodated well on the saddle and
mastered in executing the anticipatory postural adjustments within
4 weeks. In the initial period (4 weeks), the development was faster
and later saturation level exists in the speed of development of motor
function due to learning effect, which is not statistically significant.
While riding the simulator, body awareness in space was continuously
facilitated to maintain the centre of gravity within the base of support.
Anticipatory and compensatory postural adjustments produced by the
children while riding the HRS improve postural control in sitting. The
children actively started to generate the protective mechanism to pre-
vent falling off and maintain the posture. These are all the responsible
factors to improve postural stability, balance and equilibrium reactions
and correction of upright alignment in sitting (El-Meniawy &
ski & Słonka, 1999;
Thabet, 2012; Kitagawa et al., 2001; Kuczyn
Mitani et al., 2008; Shurtleff et al., 2009). These explanations there-
fore strongly support the improvement of active and reactive sitting
motor function in the present study. Literature have proved that the
HRS produces continuous and rhythmic muscular contractions on the
riders to maintain the upright posture and also repeated three-
dimensional movement patterns promote the activation of trunk
flexors and extensors (Kitagawa et al., 2001; Nakajima et al., 1999;
Shinomiya et al., 2001; Shinomiya, Wang, Ishida, & Kimura, 2002).
Therefore, it was assumed that repetitive postural adjustments would
have led to induce contraction of pelvic, lumbar and abdominal mus-
cles, finally improving the sitting motor function in children with spas-
tic diplegia (Encheff, Armstrong, Masterson, Fox, & Gribble, 2012).
CHINNIAH ET AL.
The study results were consistent with the study done by Peeraya
et al. (2015) which stated that astride sitting posture on simulator
improves active control in sitting and moreover the author used the
similar equipment (OSIM U-Gallop) in his study to provide riding inter-
vention and explored the immediate effect of HRS in improving sitting
ability in children with CP. He concluded that HRS is effective in
improving sitting postural control in CP similar to hippotherapy. Fur-
ther, this study results are supported by Herrero et al. (2012).
 ski and Słonka (1999) justified the therapeutic effects of
Kuczyn
mechanical horse riding in improving sagittal plane stability with the
treatment protocol for 3 months but they did not include the evalua-
tion of sitting ability at different periods of treatment with HRS. This
study results show that a gradual improvement in sitting ability was
observed in both groups over a period of time at different levels.
Improvement in GMFM scores in longer duration observed was better
than that in the shorter duration, which denotes the sitting motor
function of the children was much improved in 12 weeks than
8 weeks and 4 weeks. Continuous provision of HRS in longer duration
along with the conventional physiotherapy provides more benefits
than the shorter duration.
4.1 | Limitations of the study
There are several limitations in the study: the major limitations include
small sample size and lack of long-term follow-up. Evaluation of addi-
tional outcome measures such as spasticity, muscle strength, sensory
parameter, gait analysis and ADL may be included in the future trail
design. Even though GMFM (B) includes various activities of sitting
ability, attention was not paid into detail on the different items of sit-
ting dimension and participation level of children was not evaluated.
This study included only one type of CP, that is, children with spastic
diplegia with mild and moderate disability levels, so results of this
study can be interpreted with respect to this type only. Further study
should be focused on children with various types and severity levels
of CP. Despite the several limitations mentioned above this, study has
some important strengths: this is the first study analysing the effect of
HRS on sitting motor function at different periods of time, that is,
baseline to 4 weeks, 4–8 weeks and 8–12 weeks while other studies
were done with single and standardized period of time. Periodical
evaluation of such new intervention is needed to formulate the suit-
able protocol for children with CP. Moreover, this study includes chil-
dren of younger age (2 and 3 years) but most of the studies were
done with older children (more than 4 years).
5 | IMPLICATIONS FOR PHYSIOTHERAPY
PRACTICE
The observed results declared that the HRS along with the conven-
tional therapy is fruitful in improving sitting motor function. These
types of complementary therapies are mandatory for the rehabilita-
tion of children with CP. It also plays a significant role in the part of
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motivation and participation. The children enjoyed a lot during the rid-
ing session without any adverse effects. From the results, it was
observed that the children who received HRS along with the conven-
tional treatment show better improvement in sitting motor function in
all different durations, 4, 8 and 12 weeks, than the children who
received conventional treatment alone. The observed level of
improvement was better in 12 weeks than 4 and 8 weeks, which
denotes that the treatment in longer duration (12 weeks) is more ben-
eficial than the shorter duration. It was concluded that the HRS is
effective in improving sitting motor function in children with spastic
diplegia. Provision of this kind of complementary therapy added more
fun in the rehabilitation of children with CP. It is also safe and cost-
effective in clinical set-up when the real horse is unavailable.
ET HICAL APPROVAL
This study was approved by the Institution Human Ethics Committee
(IHEC), Rajah Muthiah Medical College, Annamalai University.
AC KNOW LEDG EME NT
The authors would like to acknowledge the participation of children
and their families who cooperated well throughout the research
process.
CONFLIC T OF INT ER E ST
The authors declare no conflict of interest.
AUTHOR CONTRIBU TIONS
All the authors equally contributed to the concept of the study. Dr
N. Meena and Dr R. Ramanathan were involved in the conceptualiza-
tion and review of the manuscript. Dr A. J. W. Felix helped in data
analysis and interpretation.
OR CID
Hemachithra Chinniah https://orcid.org/0000-0002-7967-6657
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How to cite this article: Chinniah H, Natarajan M,
Ramanathan R, Ambrose JWF. Effects of horse riding
simulator on sitting motor function in children with spastic
cerebral palsy. Physiother Res Int. 2020;e1870. https://doi.org/
10.1002/pri.1870