Effects of hippotherapy simulation exercise vs. conventional home exercises on muscle strength and balance in people with multiple sclerosis: A randomized controlled trial

Multiple sclerosis (MS) is a neurodegenerative disease that affects an estimated 2.8 million adults worldwide. This disease manifests at a highly productive stage of life, with a wide range of symptoms including fatigue, muscle weakness, stiffness, visual symptoms, pain, cognitive dysfunction, and speech disorders. Such symptoms have been associated with health-related quality of life in MS patients. Indeed, current literature indicates that engaging in exercise has been proposed to improve and or maintain many of the consequences of MS, such as in the areas of fatigue, strength, cognition, depression, and quality of life. Comorbidities such as obesity, as well as cardiovascular and musculoskeletal comorbidities, were also shown to be associated with higher disability levels in individuals with MS. Exercise is recommended in the management of many of these comorbidities and may therefore indirectly help with MS management (Walton et al., 2020; Amatya et al., 2017).

There is increasing evidence that aerobic exercises, resistance training, and aquatic exercises provided improvements in the physical function of the studied MS patients. Also, a small number of studies support the effectiveness of Tai Chi, Pilates, yoga, and exergames on improving quality of life and functional balance in MS patients. Researchers have sought to determine the effects of the different workouts and to find or to define more relevant, specific, and attainable exercises for MS patients (Amatya et al., 2017; Khan and Amatya, 2017; Proschinger et al., 2022).

Vermöhlen et al. studied the effect of hippotherapy treatment in MS patients and demonstrated the positive effect of this kind of therapy on balance, fatigue, spasticity, and quality of life in MS patients (Vermohlen et al., 2018). The authors aimed to regulate muscle tone and breathing, strengthen the torso muscles and improve balance with a 12-week one-patient-one-horse physiotherapy treatment with the horse. The authors also point to hippotherapy helping to promote self-esteem and providing opportunities to socialize. However, the use of hippotherapy as a workout is limited in clinical practice for two main reasons: financial considerations, and accessibility. The estimated cost of a typical hippotherapy session is 50 to 250 dollars per hour, and most hippotherapy centers are located far from urban centers. In addition, fear of horses and of falling might act as a psychological barrier to hippotherapy.

Mechanical horse-riding simulator devices were developed as a means to imitate three-dimensional physical movements (up and down, forward and back, left and right) with a dynamic saddle consistent with horse riding. The main advantage of simulator devices is their potential for use indoors. In current literature, the application of horse-riding simulator devices was used especially in patients with cerebral palsy (CP) and stroke for the evaluation of balance. According to the results of these clinical studies, simulator devices seem to be effective in improving dynamic balance in subjects with CP and stroke (Dominguez-Romero et al., 2019; Guindos-Sanchez et al., 2020). Hilliere et al. published an analytical review and concluded in favor of the effectiveness of horse-riding simulation in improving balance, mobility, muscle strength, and gait speed in the elderly (Hilliere et al., 2018).

To our knowledge, there are no current studies examining hippotherapy simulation in MS patients. Therefore, this study has aimed to assess the efficacy of hippotherapy simulation exercise on the improvement of muscle strength, balance, spasticity, and quality of life.

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