Horse Riding, Music Therapy Benefit Late-Stage Stroke  

Pauline Anderson

June 16, 2017

Even patients in a relatively late stage of stroke recovery can reap benefits from a rehabilitation program, a new randomized trial suggests.

The research showed that a multisensory program that involved horseback riding or rhythm and music therapy enhanced perceived recovery and improved gait, strength, balance, and cognition in patients who had experienced a stroke up to 5 years earlier.

Dr Michael Nilsson

"This is adding to the increasing knowledge around brain plasticity and the ongoing capacity for change and learning," study author Michael Nilsson, MD, PhD, director, Hunter Medical Research Institute, New South Wales, Australia, told Medscape Medical News.

"I'm very pleased to see that results are accumulating in support of long-term rehabilitation programs. Right now, there is not much available for stroke survivors after 12 months because of the old-fashioned view that nothing can be done after that point."

The study was published online June 15 in Stroke.

The analysis included 122 patients, ranging in age from 50 to 75 years, who were recruited from a comprehensive hospital-based stroke register in Gothenburg, Sweden, where Dr Nilsson had been based. They had experienced a stroke 10 or more months before but within the last 5 years and had a range of cognitive and physical dysfunction.

Participants were randomly allocated to one of three groups: rhythm- and music-based therapy (R-MT), horse-riding therapy (H-RT), or a control group that was promised R-MT a year later.

Both the R-MT and H-RT interventions created a stimulating environment in which participants engaged in challenging instructor-led physical movements and mental activities, in a social context. But the interventions differed in dosage, execution, activities, and targeted outcomes.

In both intervention groups, participants attended two sessions a week for 12 weeks.

Control group participants received standard of care and were asked not to start any new therapies during the study. Assessors were blinded to the group allocations.

The primary outcome measure was the individual's global perception of stroke recovery using item 9 (stroke recovery) of the Stoke Impact Scale (SIS) (version 2.0). This was presented in the form of a visual analogue scale from 0 (indicating no recovery) to 100 (full recovery).

Gait and balance were measured with the Timed Up and Go test; the Berg Balance Scale; and the Bäckstrand, Dahlberg, and Liljenäs Balance Scale (BDL-BS). Hand strength was measured with Grippit. (Because the BDL-BS and Grippit were added after the start of the trial, only 92 patients underwent these assessments.)

General cognition was assessed with the Barrow Neurological Institute screen for higher cerebral function and working memory with the letter-number sequencing test.

High Attendance

Mean attendance rates were high — 88% for the R-MT and 83% for H-RT — which is equivalent to at least 21 treatment sessions for R-MT and 20 for H-RT.

Of the 122 patients, only 8 (7%) dropped out of the study (5 at postintervention, 1 at 3 months, and 2 at 6 months).

There were no serious adverse events, including injuries.

At postintervention, the analysis showed that the proportion of patients reporting a meaningful recovery on the SIS was significantly higher in the R-MT group (38%) and H-RT group (56%) than in controls (17%)  (P = .048 and P < .0001, respectively).

These results were sustained at 3 months (P = .002 and P = .012, respectively) and at 6 months (P = .054 and P = .001, respectively).

At 6 months, the mean change in gait ability and balance significantly differed between groups. Analyses showed that the difference in gait ability was significant in favor of the H-RT group compared with controls and that the difference in balance was in favor of the R-MT group compared with controls.

As for grip strength, analyses after treatment completion showed that the R-MT group significantly improved their right-sided maximum grip force and left-sided final grip force. The left-sided improvements were sustained at 6 months.

The slightly better overall outcome following H-RT could be because this group received more total intervention time, including time for socializing, the researchers speculate.

Study results could be due to the nature and unique combination of modalities used in the two interventions, said the authors. For example, H-RT involves rhythmic movement of the horse, which continually challenges the rider's posture and gives vestibular, proprioceptive, and visual input that may facilitate improvements in gait and balance.

And R-MT involves repeated motor skill training, postural stability, and weight shifting, in combination with rhythmic, coordinated hand movements that facilitate improvements in balance and grip strength.

For working memory, the overall group analysis showed a statistically significant difference at 6 months. The favorable improvement was ascribed to the R-MT group compared with controls.

The observed improvements in working memory in the R-MT group may reflect the cognitively challenging nature of R-MT, said the authors.

It's not clear whether any individual component of either intervention explained the improvements. In rehabilitation, it's very difficult to find a single "turn-key solution," said Dr Nilsson, adding that an additive and even a synergistic effect on brain plasticity probably underpin stroke recovery.

Success probably depends on having an enriched environment that combines social interaction with physical and cognitive stimulation, he said.

"I'm quite convinced that the functional networks in the brain are changed as a result of this intervention, but that needs to be studied further."

The authors noted that the controls weren't blinded and knew they were not getting the intervention. In such situations, study patients may experience "resentful demoralization" and become discouraged and as a result perform worse on outcome measures, they said.

However, in this case, they were promised R-MT in a year. "This was to provide an element of expectation, which in itself could contribute to perception of recovery," the authors write.

In the control, performance did not decline on any outcome, which "further strengthens the validity of the study," they added.

Although Dr Nilsson acknowledged that horseback riding may not be accessible, especially in urban areas, he noted that rhythm and movement are "very easy to implement" in a rehabilitation program "in outpatient settings, in homes, or anywhere."

Less Traditional

This new study adds to the literature and represents "a very good stroke recovery finding," Daniel T. Lackland, DrPH, professor of epidemiology and neurology, Department of Neurology, Medical University of South Carolina, Charleston, told Medscape Medical News when asked to comment.

He was impressed with how the authors described how horseback riding might improve function in stroke patients. "The neat thing is that horseback riding was so much better than other traditional stroke recovery approaches."

This might be because it involves several muscles and body parts, as well as coordination and thinking, whereas traditional programs may require only walking and movements that involve fewer muscles.

There might also be something akin to "pet therapy" involved with horseback riding, said Dr Lackland.

Cats and dogs, and perhaps also horses, can have a calming effect, and a stroke survivor may get some comfort from the relationship and develop a degree of compassion for the animal, he said.

A positive aspect of the study was that "it tried multiple things instead of just this versus placebo or usual care," said Dr Lackland.

The study results "suggest that there may be valuable stroke recovery therapies that are perhaps a little bit less traditional," he said.

"We don't have all the answers in the traditional stroke recovery modalities, and some of these other things are providing good outcomes. We should really think about that and expand that a bit further."

Dr Lackland noted that while the effects "are very very strong," the sample sizes were relatively small and there is "probably some selection bias."

This work was supported by grants from Sten A Olsson Foundation for Research and Culture, the Swedish Brain Foundation, the Swedish Arts Council, the Swedish Governmental Program for Clinical Research, AFA Insurance, the Swedish Stroke Association, Rune and Ulla Amlöv's Foundation for Neurological and Rheumatological Research, Edith Jacobson Foundation, Per-Olof Ahl Foundation for Neurological Research, Sigurd and Elsa Goljes Memorial Foundation, Wilhelm and Martina Lundgren Scientific Foundation, Doktor Felix Neubergh's Foundation, the Swedish Society of Medicine, the Foundation for Rehabilitation and Medical Science, and the Gladys M. Brawn Fund at University of Newcastle. The authors have disclosed no relevant financial relationships.

Stroke. Published online June 15, 2017. Abstract

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