Hippotherapy: Is There Science Behind That?

Written by: Kassidy Ashbeck, MS, Elizabeth Hardesty, MA, BCBA, and Thomas Zane, PhD, BCBA-D
Department of Applied Behavioral Science, University of Kansas

Is there science behind that An increasingly popular treatment used to promote physical, occupational, and speech-language goals is hippotherapy, a therapeutic approach that utilizes the multidimensional movement of a horse to achieve functional outcomes (American Hippotherapy Association, n.d.,). According to the Diagnostic and Statistical Manual of Mental Disorders (5^th edition; DSM-5-TR; American Psychiatric Association, 2022), autism spectrum disorder (ASD) is characterized by persistent deficits in social communication and social interactions across multiple contexts, along with restricted and repetitive patterns of behavior, interests, or activities. In addition to these core diagnostic features, many individuals with ASD experience challenges with gross motor coordination, postural control, and balance (e.g., Bhat, 2021), which may impact daily functioning and participation in physical activities. Given that hippotherapy has been designed to improve postural control and balance, it has been proposed as a potential intervention to address these gross motor challenges in individuals with ASD.

What is Hippotherapy?

The American Hippotherapy Association Inc. defines hippotherapy as the use of evidence-based practice and clinical reasoning for occupational therapy, physical therapy, and speech-language pathology by using the purposeful manipulation of equine movement to engage sensory, neuromotor, and cognitive systems to promote functional outcomes (American Hippotherapy Association, n.d.). During hippotherapy, licensed physical therapists, occupational therapists, and speech-language pathologists utilize the horse’s natural gait and movement to provide motor and sensory input (Casady & Smith, 1999). It’s important to note that while this definition provides a general overview of what hippotherapy is, there is quite a bit of variability in how the intervention is implemented across practitioners and settings. There are differences in how participants’ sessions are structured, the duration of sessions, therapeutic targets, and what specific activities are incorporated. Proponents of hippotherapy claim that a horse’s pelvis moves in a three-dimensional, three-axial pattern while walking that closely mimics the human gait. This similarity is thought to increase the likelihood that natural movement patterns will occur in the rider when they are off the horse. In other words, they believe that the rhythmic movements of the horse stimulate both forward and backward swinging motions in the rider, which is hypothesized to promote better balance and posture. Additionally, touch-based experiences, such as feeling the horse’s movement, along with visual and auditory stimulation from the environment, support sensory integration. While the client is riding the horse, therapists can promote visual stimulation by having clients engage in activities that enhance visual cues, such as placing objects in color-coded buckets or tossing rings onto cones. Auditory stimulation is promoted by clients following multi-step instructions or engaging in conversations.

Per the American Hippotherapy Certification Board (AHCB), exams for credentialing are voluntary. While therapists must be knowledgeable about horses and their movements, there is no requirement for a therapist to obtain a certification in hippotherapy. According to their website, the AHCB “endorses the concept of voluntary, periodic certification by examination for all professionals who use hippotherapy in their practice” (American Hippotherapy Certification Board, n.d.). There are two exams that professionals who specialize in hippotherapy can take. The AHCB Hippotherapy Certification Exam is an entry-level exam that validates those who demonstrate basic educational achievement in the field. The Hippotherapy Clinical Specialist Exam is an advanced exam that validates a professional’s extensive knowledge, clinical reasoning, and expertise in the field. Clinical specialists are licensed medical professionals who use the horse as a treatment tool for therapeutic goals. Another avenue for certification is to become a Professional Association for Horsemanship International (PATH Intl.) Certified Therapeutic Riding Instructor (CTRI). A CTRI focuses on recreational and horsemanship skills. Individuals must be at least 18 years old and hold current CPR and First Aid certifications, complete the PATH Intl. standards course and exam, apply with a teaching video, and work under the supervision of a certified instructor. Individuals then take the official CTRI certification exam. In summary, while hippotherapy is a clinical treatment delivered by licensed professionals using the horse as a therapeutic tool, a CTRI provides adaptive riding instruction focused on horsemanship and recreation rather than medical therapy.

How is Hippotherapy Implemented with Individuals with Autism?

The therapy provider typically designs the hippotherapy intervention, including the position of the individual on the horse and how often the individual must change positions, based on the individual’s treatment goals (du Plessis et al., 2023). The typical positions of patients on the horse include forward sitting (one leg on each side of the horse, facing forward toward the horse’s head), prone (lying flat on one’s stomach, face down on the horse’s back), supine (lying flat on one’s back, facing upward on the horses back), backward astride (sitting facing the horse’s tail), side sit (both legs draped down on one side of the horse), kneeling (upright on one’s knees), quadruped (one’s hands and knees on the horse’s back), and standing (standing upright on the horse’s back). Hippotherapy may increase an individual’s balance and coordination. Additionally, this therapy may focus on increasing an individual’s follow through on multi-step instructions. The individual is often given multiple instructions, such as how to sit on the horse or how to engage in an activity while on the horse, like ring tossing or placing objects into color-coded buckets.

Does Science Support Hippotherapy?

Searches for hippotherapy on Google yield numerous blogs and websites explaining what hippotherapy is and highlighting the benefits of the intervention. The American Hippotherapy Association, Inc. appears in two of the top three search results. Beyond these sources, Woods and Fields (2021) conducted a systematic review of peer-reviewed studies on hippotherapy published between 1980 and 2018. They identified 78 full-text articles, with children with cerebral palsy as the most common participants and physical therapists as the primary providers. Sitting on a moving horse and adjusting the horse’s gait and speed were the most common intervention activities used by therapists during sessions. Many of the studies measured various skills before and after hippotherapy intervention to determine whether changes occurred. However, this type of research makes it difficult to determine whether changes in skills were due to hippotherapy itself or to other factors, known as confounding variables. Some studies focused on individual children using carefully controlled designs. This allowed researchers to more confidently conclude that it was the intervention that was responsible for any changes in behavior. Other studies compared groups of children who did not receive hippotherapy. However, because these participants were not randomly assigned, differences between groups may have existed before treatment, which, unfortunately, limits the confidence in the results. To summarize, the researchers found no evidence of hippotherapy’s effectiveness. This does not necessarily mean that the hippotherapy interventions never helped children, but the research methods were not strong enough to prove that it helped.

Effective research typically examines treatments as they are delivered in everyday clinical settings with a wide range of therapists and children. Many of the existing studies were not designed in ways that allowed for strong conclusions in everyday clinical settings. In the 30 years of hippotherapy research reviewed, only six studies reported individuals with ASD as study participants. As such, there is limited research regarding the effectiveness of hippotherapy for individuals with ASD, which will be examined in greater detail later in this article. This lack of research can make it difficult for caregivers to find reliable information when deciding whether hippotherapy is an appropriate intervention for their child.

When using online search engines, popular websites are often prioritized over evidence-based sources, which may lead to the spread of incorrect information. Some websites and foundations that promote hippotherapy may emphasize potential benefits without fully disclosing the drawbacks, therefore creating an unrealistic expectation for caregivers and their families. Because hippotherapy is often presented in appealing ways, families may be encouraged to pursue it without clear information about its limitations, which can affect informed decision-making for vulnerable individuals. It is important to be aware that not all interventions or therapies that are highly promoted are always supported by quality research. It is crucial for caregivers to have access to transparent, research-based information when making decisions.

One of the few studies that directly examined hippotherapy for children with ASD was conducted by Ajzenman et al. (2013). In this small pilot study, six children with autism between the ages of 5 and 12 participated in weekly hippotherapy sessions for 12 weeks. Sessions lasted 45 minutes and were led by a licensed occupational therapy professional working alongside a certified riding instructor. Participants were recruited from local school districts and government agencies and were included only if they had an ASD diagnosis and were able to follow one-step instructions independently. Exclusion criteria included individuals who had severe sensory impairments, cerebral palsy, epilepsy, or other neurological or psychiatric conditions; severe behavioral issues resulting in physical harm to others; physical limitations preventing them from sitting unaided; serious health conditions; or prior exposure to equine-assisted activities or therapies. During sessions, children participated in activities on the horse, including following multi-step directions to change positions and to complete obstacle courses. These activities were designed to support attention, cognitive skills, communication, and social interaction through movement-based tasks, turn-taking, planning, sequencing, and interaction with other children in the arena. To measure changes in postural control, participants stood on a three-dimensional force plate that used motion-tracking cameras. Small markers were placed on participants’ bodies to record their movement off the horse before and after the intervention. Additionally, parents completed questionnaires regarding their child’s daily functioning (e.g., throwing a ball with one hand, standing supported, and reaching without falling). Results suggested that children showed better postural control (i.e., improved balance, steadier movement, and improved body control) after receiving hippotherapy treatment. Parents and therapists also reported improvements in listening, following instructions, and overall participation in daily activities. However, parent questionnaires did not show meaningful improvements in daily living skills, communication, or social skills. Because independence and social functioning are often key goals for individuals with ASD, these findings limit the overall impact of the intervention.

Several limitations weaken the findings of this study. First, the extensive exclusion criteria raise some concerns. The narrow criteria to be included in this study limits the ability to confidently apply this intervention to a broader group of people. Second, it’s important to note that one child was unable to complete the program due to aggressive behavior. This suggests that hippotherapy may not be appropriate for all individuals with ASD, especially those who engage in challenging behaviors. Additionally, it is unclear whether all therapists followed the same treatment steps throughout the study. Because the study only compared results before and after treatment, it is difficult to confidently determine whether changes were caused solely by the treatment or if there were other factors that might be involved. For example, it is unknown if the participants in the study had any major life changes that influenced their behavior (e.g., starting a new therapy or medication). Furthermore, it is unclear whether all participants improved or if some participants improved while others regressed, as data was taken on the group, rather than at the individual level. While balance was measured objectively, many outcomes relied on parent reports, which can make small changes harder to detect consistently and may introduce a bias, as parents who know their child is receiving the therapy may “see” improvements that are not objectively present. Finally, this study did not use multiple independent data collectors. Using more than one observer helps to increase confidence in research findings by ensuring that observed behavior change is a result of the intervention rather than due to a measure or data collection error. Overall, this study provides early, but limited, evidence that hippotherapy may support balance and participation for some children with autism, but stronger research is needed before more confident conclusions can be made.

Rezaour-Nasrabad and Tayyar-Iravanlour (2022) conducted a single-group clinical trial (pre-test-post-test) with nine children aged 9 to 12 years, who had an ASD diagnosis and were members of the Autism Association of Urmia in 2019. Children participated in 10 hippotherapy sessions lasting 45-60 minutes over 10 weeks. Parents and teachers completed questionnaires before and after the program to report on children’s behavior and executive functioning, such as attention, self-regulation, and problem solving. During the sessions, the participants engaged in various structured activities. These included learning safety rules, how to sit on the horse, riding the horse, stretching on the horse, guiding the horse to the ground, feeding and petting the horse, throwing or reaching for objects while on the horse, and participating in games and social interactions. Many of these activities were designed to promote balance, coordination, attention, and following directions. Parents were interviewed throughout the intervention to share any changes they may have noticed. Results of parent reports following the hippotherapy intervention suggested that hippotherapy may improve behavioral problems and executive functioning in children with ASD. The authors suggest that repetitive or stereotyped movements were likely reduced due to the constant movement of the horse providing a consistent sensory input that competed with these behaviors. However, these findings should be interpreted with caution. This study included a very small number of participants; it did not include a sample group and relied heavily on parent or teacher reports rather than direct observation. Because of these limitations, it is difficult to determine whether the reported improvements were due to the hippotherapy intervention alone or whether other factors may have contributed. The authors suggest that future research should investigate how the length and intensity of hippotherapy may impact participation and performance in daily activities.

Are Hippotherapy and Equine-Assisted Therapy the Same Thing?

While hippotherapy uses the horse as a therapeutic tool within a clinical framework, equine-assisted therapy represents a broader category of interventions using horses to improve mental health, emotional regulation, and life skills, and is led by a mental health professional (Sussex Publishers, n.d.). Srinivasan et al. (2018) conducted a systematic review examining the effects of equine therapy on individuals with ASD. The review included 15 experimental and quasi-experimental studies involving a total of 294 participants with ASD, focusing on therapeutic horseback riding (THR), where the focus is on teaching the student different types of riding skills, and hippotherapy (HIP) interventions, where the focus is on using the horse and its movement as a tool to achieve therapeutic goals. A majority (81%) of studies examining social communication outcomes reported improvements in these skills following equine-assisted interventions. These skills included, but were not limited to, maintaining eye contact and positive social interactions. Regarding behavioral skills, 71% of studies found positive effects of equine-assisted interventions. Behavioral skills included, but were not limited to, stereotyped/problem behavior and the ability to regulate behaviors and moods. Four studies reported assessing sensorimotor skills. In 3 out of 4 studies that assessed these skills reported positive effects following therapy. A little over half (57%) of studies suggested positive effects regarding assessing gross and fine motor skills. Overall, the review found consistent and reliable positive effects of short-term equine therapies on behavioral skills in individuals with ASD. However, the authors highlighted the need for more rigorous research to evaluate the potential of equine therapy to enhance social communication, sensory processing, and perceptual-motor skills. They also noted that current evidence is insufficient to draw conclusions about the effects of these therapies on cognitive functioning, physiological measures, functional skills, or quality of life in this population. It is important to note that only a quarter of the reviewed studies assessed treatment fidelity (i.e., how accurately and consistently the intervention is implemented according to its design) across the training period, and few studies evaluated the long-term effects or generalization of skills beyond the therapeutic setting. Many studies relied on caregiver-reported questionnaires to measure outcomes, while others used broad assessment tools that spanned multiple developmental domains, or more domain-specific instruments. Overall, there is a clear need for large-scale studies with well-defined inclusion criteria, standardized outcome measures, and comprehensive designs to more accurately assess the impact of equine therapy on individuals with ASD.

Recently, behavior analysts have begun to use interventions derived from behavior analytic principles to contribute to equine-assisted services by improving staff and volunteer training. St. Peter et al. (2021) found that using behavioral skills training (BST) and interactive computer training (ICT) were both effective in teaching side walkers (volunteers who walk on the side of the horse during therapeutic horseback riding) to engage in the behavior with fidelity. This study highlights how behavior analysts can systematically train and evaluate the performance of staff and volunteers to ensure treatment fidelity, an issue that much of the research has left unaddressed. If hippotherapy interventions can be implemented consistently, researchers can evaluate whether the treatment can lead to positive outcomes for individuals with ASD. By having consistent procedures, researchers can ensure that the intervention is being implemented in the same way and as designed across all participants.

What’s the Gist?

Overall, hippotherapy may be beneficial in improving balance, motor skills, and reducing challenging behavior. However, it’s important to note that there is no standardized hippotherapy program for ASD, which leads to wide variability in therapy quality and outcomes depending on providers and settings. Additionally, quality hippotherapy programs that meet clinical and safety standards by having licensed therapists, well-trained horses, safe and accessible facilities, and are PATH certified can be expensive. For example, to receive services through an Equine Assisted Growth and Learning Association (EAGALA) facility, the cost of therapy ranges from $80 to $250 per session. This price does not include additional fees that some facilities may add, such as fees for initial assessments, equipment fees, facility or barn fees.

There is simply not enough evidence-based research examining the different aspects of hippotherapy to determine whether it is suitable for individuals with autism. The current research lacks the rigor needed to provide a clear picture of how individuals with ASD may respond to various aspects of the intervention package. The few studies that focus on the effects of hippotherapy on individuals with ASD often include a small sample size, contain inconsistent methodologies, and have varied outcome measures. Hippotherapy may not be the best intervention for all individuals with ASD, as some may not enjoy the activity and engage in challenging behavior to leave the area. Additionally, because each individual presents unique strengths, challenges, and therapeutic needs, a single intervention like hippotherapy is unlikely to be universally effective. Therefore, for an individual to have an intervention that meets their unique needs, consultation with a team of professionals, including a board-certified behavior analyst, an occupational therapist, a physical therapist, and a speech-language pathologist, is recommended to determine whether hippotherapy could support the individual’s current and long term goals.

What Else Should We Consider?

The National Autism Center (2015) identified various established interventions that have been validated through research for the treatment of individuals with ASD. The report outlines many evidence-based approaches; however, this article will primarily discuss behavioral interventions and readers are encouraged to refer directly to the full report for a more comprehensive review. Behavioral interventions (p.43) are described as an antecedent-based package of strategies that have been shown to improve motor skills, communication, interpersonal skills, play, and self-regulation. These approaches have also been effective in reducing problem behaviors and difficulties related to sensory or emotional regulation. Examples of behavioral interventions include function-based interventions, reinforcement schedules, discrete trial training, most-to-least prompting with natural consequences, and interspersing activities (p. 44). Comprehensive behavioral treatment (i.e., applied behavior analysis), often involving early behavioral interventions (i.e., early intensive behavioral intervention), target increasing skills such as play, communication, cognition, interpersonal, personal responsibility, and motor. Behaviors that are targeted for reduction are often general symptoms, defined as “a combination of symptoms that may be directly associated with ASD or be a result of psychoeducational needs that are sometimes associated with ASD” (National Autism Center, 2015, p. 39) and problem behaviors. These services are typically delivered 25-40 hours per week.

Additionally, Hume et al. (2020) conducted a systematic review of the intervention literature and identified 28 evidence-based practices (EBPs), defined as focused intervention practices with scientific evidence demonstrating positive effects for autistic children (p. 4014). Hume et al. (2020) provide a detailed summary of which EBPs have been identified for specific deficit areas. For motor skills, EBPs include antecedent-based interventions, behavioral momentum, exercise and movement, reinforcement, differential reinforcement, parent-implemented interventions, and sensory integration. For challenging behaviors, some identified EBPs include differential reinforcement, peer-based instruction and intervention, naturalistic intervention, functional behavior assessment, and functional communication training. A few of the EBPs identified for communication include social skills training, video modeling, direct instruction, and augmentative and alternative communication. This article has highlighted only a few of the practices outlined by Hume et al. (2020), but readers are encouraged to review the article for a more complete description of all identified EBPs.

In conclusion, the inconsistent quality of the available evidence for hippotherapy as a treatment for ASD highlights the need for more robust, large-scale, and well-controlled studies that use reliable and objective measurement tools beyond parent reports. For example, future research needs to clearly explain what improvements in “motor skills” actually mean. It is unclear whether the reported motor skill improvements that occurred while participants were riding the horse carried over to everyday activities at home or school. The persistent methodological challenges highlighted in the current literature emphasize the value of using established experimental designs in research to evaluate client outcomes through the use of direct observation, repeated measurement, and experimental control on the individual level. This is crucial before hippotherapy can be considered a reliable intervention for individuals with ASD. Until stronger research is available, it is important for caregivers to ask questions about what specific goals are being targeted, how progress will be measured, and whether skills are expected to transfer outside of the riding environment. Because individuals with ASD face many different challenges, each unique in their own way, more intervention research is needed to help us understand which children with autism, with what patterns of strengths and weaknesses, would benefit. Treatment decisions should always be individualized and made in collaboration with qualified professionals who understand your child’s specific needs.

References

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Reference for this article:

Ashbeck, K., Hardesty, E., & Zane, T. (2026). Is there science behind that?: Hippotherapy. Science in Autism Treatment, 23(5).

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