Hippotherapy and Playfulness in Child Rehabilitation

Rene Schubert

Corresponding Author: Rene Schubert, Consultant / Specialist Registrar Family, Internal Medicine FMTH, Lahore., Family Emergency Specialist MOH KSA

CopyRight: © 2022 Rene Schubert, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: February 24, 2022

Published Date: March 02, 2022

Implemented at the beginning of 2008, the Riding Therapy Center located in a child socio-educational rehabilitation institution in the North Zone of São Paulo, developed equine therapy services aimed at the special public for a year. From a group of 13 patients (6 private spaces, 7 free spaces) attended every week, on Wednesdays, for 30 minutes in each session, one of the clinical pictures was selected for the present experience report.

This exhibition aims to demonstrate the successful application of this complementary rehabilitation technique in a neurological and psychiatric clinical case and to guide the creative and playful uses of this practice in different areas and rehabilitation practices.

About the Institution

The institution in question is a non-profit organization, which provides full-time care, in the form of specialized educational support classes and therapeutic groups, to children with Mental Disabilities (mild or moderate), genetic syndromes, neurological disorders and psychiatric disorders aged between 6-18 years, previously evaluated and approved by the center's outpatient team. The Ambulatory is open to the public, receiving requests from the Education Department, the Health Department and acts as a multiprofessional team including pediatric neurology, psychiatry, physiotherapy, psychology, psychopedagogy, speech therapy, and occupational therapy for diagnostic evaluation, referral and/or treatment of the referred population. At the institution, children participate in educational programs, workshops, outings, playful-recreational activities and therapeutic projects designed uniquely for each one (MENDES & SCHUBERT, 2006).

The Riding Therapy Center has a multi-professional team formed by a Neuropediatrician, Physiotherapist, Psychologist, Speech-Language Pathologist, Occupational Therapist and Pedagogue, all able and trained to work in Riding Therapy (by ANDE-Brasil). As with any equine therapy center, it has an external team of specialized care for the 4 horses available for equine therapy and a equine keeper and driver who is present at the institution. The center assists children aged 3 to 14 years with indication and need for follow-up in the complementary treatment of hippotherapy. Even coming with an external medical indication, the child is evaluated by the multidisciplinary team and later, in clinical discussion, it is decided whether the child will be monitored by the team and what proposals and strategies are used to obtain improvements in each individual case. The team provides 13 vacancies for individual work in hippotherapy, every patient is attended weekly with 30-minute sessions for 6 uninterrupted months. The Equine Therapy team also performs groups of playful riding, approaching animals and pet therapy with the internal client.

Hippotherapy: Brief Rationale

Equo therapy (Equo: from the Latin aequus, relating to Equus, 'horse' / Therapy: relating to therapy, which is the part of medicine that studies and puts into practice the appropriate means to relieve or cure the sick) is a therapeutic method and educational program that uses the horse within an interdisciplinary approach, in the areas of health, education and riding, seeking the biopsychosocial development of people with disabilities and/or special needs. She uses the horse as an agent to promote physical, psychological and educational gains. This activity requires the participation of the whole body, thus contributing to the development of strength, muscle tone, flexibility, relaxation, awareness of one's own body and improvement of motor coordination and balance. The interaction with the horse, including the first contacts, the act of mounting and the final handling, develops new forms of socialization, self-confidence and self-esteem according to ANDE-BRASIL (2008).

During the hippotherapy session, 3 professionals must be present: The driver is always present, and the two side guides, who in this case can be the physiotherapist, psychologist, speech therapist, occupational therapist and/or pedagogue/psychopedagogue.

As exposed by LEAL & NATALIE (2007), in an article addressing the therapeutic gains that patients have in contact and affective exchanges with animals of the most diverse types and sizes: “Equotherapy is the only form of treatment with animals usually prescribed by doctors. (...) the treatment was recognized as a therapeutic method in Brazil by the Federal Council of Medicine in 1997”.

UZUN (2005) lists some deficiencies and diseases that improve through hippotherapy: cerebral palsy, cerebrovascular accident; delay in neuropsychomotor development; down syndrome and other syndromes; traumatic brain injury; spinal cord injury; multiple sclerosis; dysfunction in sensory integration; learning or language difficulties; behavior disorders; hyperactivity; autism; traumas; depression; stress, among others.

GUIMARÃES (1993) and WICKERT (1995) explain how hippotherapy achieves such results using the kinesiology involved in horse riding: comparing the human movements performed in its displacement (at step), we can see that this is identical to that performed by the horse , when it also moves in step. It is this movement that generates the impulses that trigger the nervous system to produce the responses that will continue the movement and allow the displacement (neurophysiological action). The one who rides the horse is forced to make thousands of body adjustments during the ride to maintain balance and motor coordination - and still receives the stimulation proper to the horse's gait (which follows three-dimensionally, just like a man's gait: forwards and backwards). , to both sides and up and down).

Hippotherapy is a treatment indicated for children mainly because of the differential that the animal brings, such as physical presence and relational possibility. Through contact with the animal, children often begin to talk, tell stories, smile, play spontaneously - the fearful, painful or boring image that the child has of what his treatment involves is broken. The animal opens the possibility of working with the child as it soon becomes an attractive and differential in the treatment being proposed. The horse works as a seduction point in relation to the child(and even to the adult) for the grandeur and power transmitted by it. Sometimes, it is through contact with an animal that the child becomes more relaxed to talk and more receptive to the guidelines or questions made by the professional who is accompanying them (SCHUBERT, 2005).

The praxis: exposition of a clinical case

Tobias, born in June 1999, was evaluated by our multiprofessional team in an outpatient clinic during the months of February and March 2008, and a diagnostic hypothesis of Klinefelter Syndrome (Q981) with psychiatric comorbidity of atypical autism (F84.1) was raised. He doesn't speak, except for gestures and shouts. Framework of social isolation and aloof from physical contact. The parents were looking for exactly a treatment aimed at hippotherapy, claiming to have been indicated by several doctors in Tobias' long clinical path.

Due to his aggressive, negativistic behavior, accentuated mood instability and fear of horses, we raised as a therapeutic proposal to work on discipline and tolerance through hippotherapy. A long work of approximation would be necessary, for Tobias to bond with the team and allow him to mount the horse, which he admired from afar but which he did not dare approach.

From the first sessions with Tobias we had more data to elaborate the therapeutic strategy. The same reacted aggressively to the arrival of the physiotherapist and psychologist, kicking, screaming and spitting. As he did not use the linguistic code, except for shouting and using signs and gestures, it was very difficult to assess what was happening to him and what bothered him so much. However, the approach of the horse driver was allowed and it was at this point that we were able to outline our strategy. The horse driver became the reference professional who received Tobias at the clinic, near the riding ramp. He introduced Tobias to the rituals of general care, hygiene and feeding of horses and asked for the patient's help to prepare the horse for riding.

This opening scene worked well. Tobias arrived excited and was not aggressive, he helped the horse rider to take care of the horse, he no longer showed fear towards the horses and he liked to take them for a walk – leading them along with the rider by the lead.

Gradually, physical therapists and psychologists approached the scenario – sometimes we were ignored, other times viewed with suspicion. It was in Tobias’ sixth session that, after the driver had mounted him on the horse, he invited us, after a certain moment of insecurity about the horse and a nervous smile at the driver, with a gesture of “come” with his hand, to accompany him. it sideways.

The next strategy would be to make use of the blanket and various mats for proper stimulation while Tobias mounted – we soon realized that physical exercises and stretching were initially out of the question for him, being repelled with spitting, kicking and screaming.

After the fifteenth session, our scores for his negative and moody behavior became more punctual and firm. We pointed out that he would not continue riding if he maintained such behavior and we would not allow to do the activities she loved so much if she insisted on her puerile and tantrum behavior. This put him, the therapists and the horse he loved so much at risk. Sometimes such interventions worked perfectly, when they failed, we realized that not paying attention to his behavior and ignoring it worked as well as a firm intervention: he gave up and gesturally asked us to give him exercises or indicate what to do.

And such exercises were then done in a lively and playful way. Using hula hoops, colored letters, miniature animals, balls and cones. We described the path we were following and told stories. The achievements that Tobias achieved were cheerfully pointed out: whether hitting the ball in the basketball hoop, while riding a horse; either managing to balance several colorful hula hoops on both arms; whether directing the horse in a zigzag pattern through the cones or even pointing out the colors requested on the pedagogical boards.

If during the Riding Therapy session, whether performed by a physical therapist, a psychologist, a speech therapist, a physical educator, the activity is performed through playfulness, then something positive is happening beyond the expected physical results, since playing is for therapy itself (WINNICOTT, 1975).

The mother pointed out that Tobias knew exactly the day of the hippotherapy because he asked early to go to the clinic – he drew horses at home – said that her son seemed more sure of himself, he had lost his fear of climbing stairs, a fact he had before.

UZUN (2005) points out in his book that hippotherapy, among other benefits, would bring: socialization; self confidence; balance and would act to relieve stress. We realized that despite the difficult connection, through the riding therapy Tobias allowed 3 new people to enter his life and even allowed them to direct him during the consultations. Due to the physical and psychological performance that hippotherapy achieves, in the activation and stimulation of various functions of the human body such as breathing, speech, attention, memory, cognition, self-image, self-confidence, among others, the The child is encouraged to move forward and actively participate in the treatment. Sometimes it sets challenges to be overcome little by little (SCHUBERT, 2005).

In an individual office work, whether psychotherapeutically or physiotherapeutically, breaking Tobias' resistance would be something in the long term and would compromise the bond conquered itself - a fact reported several times by Tobias' father and mother - how difficult it was to socialize him and how many treatments failed for not having Tobias' participation, will and attachment involved.

However, because this link was made in a playful and challenging way, it seems to have conquered Tobias' will. In play, the person has the opportunity to externalize their fears, fears, their internal dangers projected on the external world, and with an attentive listening by the therapist, they can come to triumph over their difficulties. Play acts as a facilitator of a healthier internal organization. The accumulation of rewarding experiences can lead the practitioner to strengthen his belief in good relationships and self-confidence, which strengthens his emotional aspect (WINNICOTT, 1975)

The therapist who realizes that for the practitioner, the horse is a transitional object, understands that Riding Therapy is much more than using the animal's movement as a rehabilitation technique. It is a global therapeutic instrument, which acts in different dimensions, biopsychosocial and even affective, and can bring a new spirit to someone's life. (RAMOS, 2007)

In the last sessions, although Tobias always presented some scene of displeasure, negativism, resistance, before or after the treatment - he always mounted the horse, participated in the stretching, physical and pedagogical exercises, promptly obeying the commands made by both the side guide, the physiotherapist and psychologist he sometimes participated by joking, smiling and making fun.

WINNICOTT (1975) postulates that: “It seems to me to be valid the general principle that psychotherapy is carried out in the superposition of two play areas, that of the patient and that of the therapist. If the therapist cannot play, then he is not suited to work. If it is the patient (practitioner) who cannot, then something needs to be done to help him become able to play, after which psychotherapy can begin. Playing is essential because in it the patient manifests his creativity”. There was in Tobias's aggressiveness and resistance a language of connection with the world – at times it was accepted and turned into a joke, at times punctuated and inhibited. In this modulation, little by little Tobias began to realize what was allowed and what was forbidden in the practice of hippotherapy. This notion developed, in addition to the concept of right and wrong, the notion of affection, respect and aggression, disrespect. From the horse's own reaction, Tobias could see how pulling the mane or hitting the horse's ear caused reactions of displeasure – the animal stopped walking – the game ceased. The repetition of this was forming a notion of action and consequence.

It is a case that will have a lot of benefit following the riding therapy treatment, mainly because of its postural difficulties and even for the social and bonding benefits achieved by the contact with the riding therapy team. We noticed that after 6 months of treatment Tobias became more sociable, allowing the team to get closer and showing greater tolerance to commands and requests made by such a team. We know how important it is, for the work on inclusion and rehabilitation of this clientele, to count on the support and active participation of the patient, because without him, there is no possible treatment. The mother brought positive returns to work, reporting the joy her son felt and how much this brought comfort to the family, realizing the possibilities of coping and treating the clinical condition presented by the same.

Conclusion

Despite the clinical picture involved in the present description, hippotherapy, as a complementary rehabilitative method, proved to be punctual in the development of positive results, especially regarding: interpersonal bonding, trust and affective exchanges with therapists, reduction in the phenomena of aggression and phobia, patient safety for new challenges, adequacy and postural balance on the horse.

Reference

1. NATIONAL ASSOCIATION OF RIDING THERAPY (ANDE-Brasil). Official home page, Brasília, verified in February 2022 - http://equotherapy.org.br/

2. ICD 10 - International Statistical Classification of Diseases and Related Health Problems. Tenth edition, Publisher of the University of São Paulo, 2007

3. GUIMARÃES, F. L. – Hippotherapy: concept and indications. Themes on Development, Scientific Editions Memnon, v.3, N.14, São Paulo, 1993

4. LEAL, G & NATALIE, K – Animal Therapists. Living Mind & Brain Magazine. Duetto Editorial and Scientific American, N.169, São Paulo, February 2007

5. MENDES, V. & SCHUBERT, R. - Rehabilitation Center for children with special needs Recanto Nossa Senhora de Lourdes. Presented at the II Brazilian Congress of Psychology, São Paulo, Brazil, September 2006

6. SAMPEDRO, R.M.F. & FORESTI, J. – Effects of hippotherapy in relation to the functionality of a person with cerebral palsy. Equotherapy Magazine ANDE, Brasília, N.11, July 2005

7. RAMOS, R. M. - Riding therapy and playing - transferential relationships in equine therapy and the horse as a transitional object. Brasilia, 2007.

8. SCHUBERT, R. - Hippotherapy as a therapeutic alternative for agitated children - Revista Equoterapia ANDE, Brasília, N.12, December 2005

9. SCHUBERT, R. & BARATELLI, L. - Riding therapy: case report. 2010. III Congress of Psychology: science and profession. Poster presentation, São Paulo, Brazil, September 3-7, 2010

10. UZUN, A.L. – Riding therapy: application in balance disorders. Vector Publisher, 2005

11. WICKERT, H. - The horse as a kinesiotherapeutic instrument - ANDE-BRASIL course, Brasília, 1995. Available via internet: http://equoterapia.org.br/

12.       WINNICOTT, Donald W. Play and Reality. Rio de Janeiro: Imago, 1975.