by Simona Portaro, MD, PhD; Giuseppa Maresca, PsyD; Antonio Raffa, MSc; Gaetano Gemelli; Barbara Aliberti; and Rocco Salvatore Calabrò, MD, PhD

Dr. Portaro, Dr. Maresca, Mr. Raffa, and Dr. Calabrò are with IRCCS Centro Neurolesi “Bonino Pulejo” in Messina, Italy. Mr. Gemelli and Ms. Aliberti are with THES ASD in Milazzo, ME, Italy.

FUNDING: No funding was provided.

DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article.

ABSTRACT: Animal-assisted interventions are considered an innovative rehabilitation approach to improve social, emotional, and physical domains in several diseases. Among such treatments, the equine-assisted activities and therapies have been developed to support the conventional approaches. There is growing evidence on the beneficial effects of hippotherapy, whereas few data are available regarding donkey therapy. Herein, we compare such treatments, hypothesizing their best application field to reach the proper therapeutic outcomes.

KEYWORDS: Animal-assisted interventions, Hippotherapy, psychiatric disorders, equine-assisted activities

Innov Clin Neurosci. 2020;17(20–21):

Progress and breakthroughs in modern medicine have facilitated the development of targeted therapies aimed at improving symptoms and preventing disease exacerbation. In this context, innovative rehabilitation strategies, i.e., robotic devices, virtual reality, and animal-assisted interventions (AAIs), are emerging.1 AAIs involve deploying a rehabilitation approach using animals such as dogs, cats, rabbits, donkeys, and horses.2

Among the available rehabilitation approaches, equine-assisted activities and therapies (EAAT) in particular have been developed to support the conventional treatments.3 To date, different interventions have proven effective in improving social, emotional, and physical domains in patients suffering from anxiety, depression, autism spectrum disorder, multiple sclerosis, Parkinson’s disease, and spinal cord injury or in enhancing balance, muscle symmetry, coordination, and posture.3–5

Since patients undergoing EAAT are increasing in number, it is important to evaluate the effectiveness of such therapies and to consider the use of specific animal therapies to treat different diseases. Among equines, horses and donkeys are those employed in IAAs. One question arising is whether there is an objective way to choose which animal is more suitable in specific diseases; i.e., do horses and donkeys exhibit the same profile as cotherapists in different clinical settings?

The first possible and immediate answer to this question might be related to the predisposition of the patient toward the horse or donkey or to the presence of a specialized center in the nearby home environments. However, available data are not sufficient to decide which animal could be the best one to approach, treat, and manage a disease. Moreover, the current scientific literature on this issue is lacking, especially concerning donkeys, probably because EAAT was only recently approved as a valid rehabilitative approach.

As such, we recommend limiting the use of donkeys to treat psychiatric disorders as a preliminary therapy. The use of horses, however, could be extended to larger clinical settings, excluding cases in which hippotherapy might be contraindicated (e.g., allergies, epilepsy, atlanto-occipital instability, fear of the animal). In this regard, it is worthwhile to specify that the donkey creates only a relation, with insignificant effects on the motor function, whereas the horse enables the patient to reach better therapeutic outcomes in several neurological disorders.

Hippotherapy is a treatment method involving the aid of the horse. It is considered a complete physiotherapy having concurrent psychological, social, and educational effects on many body systems, including the sensory, musculoskeletal, limbic, vestibular, and ocular ones.6–8 Hippotherapy harnesses the sensory information produced by the horse’s gait and motion to stimulate the patient’s postural reflex mechanisms through motor and sensory inputs. It improves balance and coordination, thanks to the intrinsic cyclicity and three-dimensional synusoidal horse’s movement, rhythm, and cadence that are transmitted to the rider.9

To date, hippotherapy has been used to improve neurologic functions and sensory processes in patients with physical and mental disorders, associated with and integrated into the planned physiotherapeutic programs followed by the patient to shorten recovery times.4,10

Recently, Portaro et al demonstrated, through a finite element analysis, the pure theoretical basis with which to standardize the methodology for the use of hippotherapy in clinical settings. These authors suggested the best horse characteristics to involve to set up the optimal patient-tailored hippotherapy approach for proper treatment outcomes, together with exploring the effects on the patient’s pelvic girdle.9

On such a basis, one might inquire about the reason why horses positively affect psychological and mental health. First, psychologists and mental health therapists benefit from the fact that the horse’s mobility assists with the patient’s compliance.6,8,10 Second, grooming activities might be used to achieve therapeutic goals. On the other hand, hippotherapy, as occupational therapy, is related to the use of the horse’s movements with the intention to improve motor control, coordination, balance, attention, sensory processes, and performance in daily activities, since several systems (e.g., sensory, vestibular, proprioceptive, tactile, visual, and auditory ones) are simultaneously targeted.7,10,11

As speech therapy, hippotherapy can be associated with the conventional therapy since it might improve speech, language, cognitive, and masticatory functions.7,10,11

Moreover, improvements in gross motor skills and functional activities have been reported following hyppotherapy in many studies and different diseases.7,10–13

As far as we know, few data are available on the use of donkeys in therapy. The donkeys used in AAIs (Equus africanus) have many behavioral qualities, such as their quiet nature, that lead them to be appropriate in such interventions. Thus, the therapeutic target narrows to the psychological, cognitive, and psychiatric aspects of the rehabilitation of patients with disabilities.

In such a kind of therapy, donkey operators might realize a new relation between patient and donkey.

Moreover, the physical features of the donkey, i.e., the neotenic elements, with the long ears and the small size of the body, allow them to support some specific therapeutic interventions. Donkeys are smaller than horses but bigger than dogs or cats; thus, in some cases, they seem to be more protective of humans. This kind of approach induces a deep interaction between the patient and donkey, causing relaxation due to the donkey breathing and sharing its body warmth, an aspect that can also be gained with horses. This kind of interaction has been defined as “total grooming,” since it is related to the idea of parental care, where the patient is lulled and pampered by parents.14

Nowadays, not every donkey operator lets the patient ride the donkey, instead focusing on the physical interaction between the patient and the donkey on the ground—this represents the basis of grooming. The ethologist Marc Bekoff stated that petting an animal can reinforce social interaction and that grooming can be comparable to a sort of language between animals, thus giving life to the possibility of building mutual trust.15 The donkey can be considered a “social animal” as it searches for contact with the humans, thanks to its docile nature and behavior.16

Donkeys usually respect the human’s personal space, thus responding to the human fear of possible contact. Indeed, this special aspect can be useful in all cases of fear for animals as a first-line approach.17 By paying attention to such elements, we can sustain the hypothesis that donkeys might be more suitable for treating psychiatric and cognitive–behavioral disorders. However, horses and donkeys each have specific characteristics, and the relation between the animal and the patient is mainly subjective (even though the therapist might modulate the animal’s behavior).

Thus, we can hypothesize that horses and donkeys, even though they belong to the same Equine species, are really different from the therapeutic approach point of view.

Some might consider the horse to be more instinctive than the donkey, but we think that the training, temper, and age of the animal do have an important impact on this.

In fact, we cannot consider only the specific characteristics of these animals in nature but also must contextualize them in different clinical settings, considering their education and training performed by specialized staff, which are mandatory aspects.

In conclusion, we postulate that hippotherapy is a viable treatment modality whose effectiveness has been confirmed in large patient groups affected by several physical or mental disabilities when it is directed by an experienced therapist assisted by a properly and well-trained horse. Unfortunately, to date, convincing data for donkey therapy are lacking. Further investigations comparing the management of different disorders with these two AAIs are needed to confirm their efficacy in different settings and to establish guidelines for a correct use of EAAT.

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