Funding/financial disclosures. The authors have no conflicts of interest relevant to the content of this letter. No funding was received for the preparation of this letter.

Innov Clin Neurosci. 2023;20(4–6):8.


Dear Editor:

Hippotherapy is a form of rehabilitation that includes occupational therapy, physical therapy,1–3 and speech and language therapy,1 providing effective and sensory stimulation for its rider through the variable, rhythmic, and repetitive horse movements.2–5 The horse gait mimics the swinging of the human pelvis while walking, providing the rider with a large sensory and motor input spectrum and stimulating anterior-posterior movements. The horse gait variations enable therapists to reach therapeutic goals,1–5 shortening recovery times and improving balance, muscle control, mobility, and posture.1–6 Thus, hippotherapy can be used as a therapeutic tool to engage sensory, neuromotor, and cognitive stimulation, being suitable for central and peripheral nervous system disease rehabilitation.1–3  Before starting a hippotherapy program, clinicians have to consider the potential benefits and risks related to such a treatment. In fact, the primary concern of appropriately applying hippotherapy is to provide a safe and productive treatment session. This concern must be addressed by a consensus involving the entire team (i.e., patient, parents, therapist(s), horse expert, and physicians). Moreover, to reach its proper aim, in the treatment session, other members must be involved with the hippotherapy team, including a licensed therapy professional, horse trainer, horse handler, and two side walker(s), as well as specially trained horses.4  

Demand for hippotherapy may represent a challenge because of two main aspects: 1) horse-related activities carry inherent risks, so a risk-benefit analysis is strongly recommended, and 2) the financial investment deriving from the entire team (clinicians and all hippotherapy staff, including the stable manager and horses) is very high. Indeed, this factor is related to the required presence of all team members during each therapeutic session. Moreover, presence of an experienced, skilled physician (e.g., neurologist, physiatrist, physical therapist, psychologist) is highly recommended to supervise and correct horse gait, velocity, and movements, inducing better neuromuscular and sensory reactions in the patient.7,8 Periodic reassessment allows the team to identify the potential onset of new or subclinical medical contraindications, with better and safe patient management over time.  

The economic aspect of hippotherapy cannot be neglected for both the team and the patient. In the United States (US) and in many European countries, hippotherapy is covered by general health insurance. Every year, in Italy, the Ministry of Health inaugurates multiple hippotherapy centers, but only limited service can be provided since hippotherapy requires well-trained people and horses and an arena within a riding school.  

Thus, the economic aspects have to be discussed with the national healthcare system because, to date, hippotherapy is not included in the essential levels of care (services provided by the National Health Service). Recognizing hippotherapy as a service free of charge (or upon payment of a participation fee) would guarantee that this validated rehabilitation treatment is available to more patients.4,5,7–10 

In conclusion, given that the role of hippotherapy has been acknowledged, a larger number of patients should benefit from this therapy, which has to be made more affordable and integrated into a patient’s plan of care. A cost-effectiveness analysis would support such practical considerations and focus the attention of the Italian national healthcare system on this issue.    


  1. Champagne D, Dugas C. Improving gross motor function and postural control with hippotherapy in children with Down syndrome: case reports. Physiother Theory Pract. 2010;26(8):564–571. 
  2. Meregillano G. Hippotherapy. Phys Med Rehabil Clin N Am. 2004;15(4):843–854. 
  3. Zadnikar M, Kastrin A. Effects of hippotherapy and therapeutic horseback riding on postural control or balance in children with cerebral palsy:a meta-analysis. Dev Med Child Neurol. 2011;53(8):684–691. 
  4. Portaro S, Maresca G, Naro A, et al. Role of horse-assisted therapy in the rehabilitation field: past, present, and future perspectives. Innov Clin Neurosci. 2020;17(1–3):8–9.  
  5. Portaro S, Filardi V, Naro A, et al. Force and strain during horseback riding: bridging the gap between theory and clinical practice. J Sports Med Phys Fitness. 2019;59(3):536–538. 
  6. Silkwood-Sherer DJ, Killian CB, Long TM, Martin KS. Hippotherapy—an intervention to habilitate balance deficits in children with movement disorders: a clinical trial. Phys Ther. 2012;92(5):707–717. 
  7. Shurtleff TL, Engsberg JR. Changes in trunk and head stability in children with cerebral palsy after hippotherapy: a pilot study. Phys Occup Ther Pediatr. 2010;30(2):150–163.  
  8. Maresca G, Portaro S, Naro A, et al. Hippotherapy in neurodevelopmental disorders: a narrative review focusing on cognitive and behavioral outcomes. Appl Neuropsychol Child. 2022;11(3):553–560. 
  9. Portaro S, Maresca G, Raffa A, et al. Donkey therapy and hippotherapy: two faces of the same coin? Innov Clin Neurosci. 2020;17(1–3):20–21. 
  10. Portaro S, Cacciola A, Naro A, et al. Can individuals with Down syndrome benefit from hippotherapy? An exploratory study on gait and balance. Dev Neurorehabil. 2020;23(6):

With regards,

Angelo Alito, MD; Adriana Tisano, MD; Rocco Salvatore Calabrò, MD, PhD; Barbara Aliberti; Gaetano Gemelli; and Simona Portaro, MD, PhD

Dr. Alito is with Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina in Messina, Italy. Dr. Tisano is with Department of Clinical and Experimental Medicine, University of Messina in Messina, Italy. Dr. Calabrò is with IRCCS Centro Neurolesi “Bonino-Pulejo” in Messina, Italy. Mrs. Aliberti and Mr. Gemelli are with THES in MIlazzo, Italy. Dr. Portaro is with Unit of Physical and Rehabilitation Medicine, Policlinico “G. Martino” in Messina, Italy.