Hippotherapy Simulation for Multiple Sclerosis Helps Mobility, Muscle Strength

Hippotherapy simulation has a positive effect on balance, mobility skills, and muscle strength among people with MS.

The use of horse-riding simulation exercises — known as hippotherapy — has demonstrated a positive effect on health conditions, balance, muscle strength, and mobility skills in individuals with multiple sclerosis (MS). These are the findings of a study published in Multiple Sclerosis and Related Disorders.

Prior studies have shown hippotherapy to be a workout of the whole body, which is carried out using core muscles and many joints. Researchers of the current study sought to establish the efficacy of hippotherapy simulation exercise on the improvement of muscle strength, spasticity, balance, and quality of life in patients with MS.

The randomized, controlled trial (ClinicalTrials.gov Identifier: NCT04651725) was conducted at the outpatient clinic of the rehabilitation clinic at the University of Usak, located in Usak, Turkey. All participants were recruited and enrolled between September 2020 and February 2022 according to the following inclusion criteria:

  • Confirmed diagnosis of MS (relapsing-remitting or secondary-progressive) by a neurologist based on 2017 revised McDonald criteria;
  • Age of 18 to 64 years; and
  • Expanded Disability Status Scale  score of <7.

Study participants were randomized into either the hippotherapy simulation exercise group or the conventional home exercise group following pre-intervention evaluations.

To adhere to physical activity and exercise over the long term, we anticipate that horse-riding simulation might be a non-pharmacological intervention for people with MS.

The participants in each group received 36 treatment sessions (each lasting for
35 minutes), 3 times per week, for a total of 12 consecutive weeks. Each session comprised a:

  • 5-minute warm-up (side-stepping, side lunges, half-squatting, triceps warm-up),
  • 5-minute static stretching (triceps stretches, hip flexor stretches, lying hamstring stretch), followed by
  • 20 minutes of exercise, and a
  • 5-minute static stretching session (triceps stretches, hip flexor stretches, lying hamstring stretches) to conclude the workout.

The primary outcome measures were the Monitoring My Multiple Sclerosis (MMMS) scale, the Berg Balance Scale (BBS), and the Timed Up and Go (TUG) test. A dynamometer was used to measure muscle strength.

A total of 40 patients with MS were enrolled in the study. During the intervention period, 3 individuals from the hippotherapy simulation exercise group and 2 individuals from the conventional home exercise group withdrew from the follow-up. Thus, 35 of the 40 participants completed the postintervention evaluation and follow-up at month 6. Overall, 72.5% of the cohort was female. The mean participant age was 37.4 years.

Results of the study showed that under exercise conditions and from baseline to week 12, MMMS total scores improved significantly in both groups (Hippotherapy stimulation exercise: P =.008; Conventional Home Exercise: P =.010). No significant difference was reported between the 2 groups at week 12 (P =.126).

At the activity level, strong evidence showed the TUG performance increased from baseline to week 12 (P =.001 for both groups). No difference was observed, however, in TUG times between baseline and the 6-month evaluation in both of the groups. Between baseline and 12 weeks, a significant improvement was seen in BBS scores and muscle strength in each of the groups.

A trend toward improvement in MMMS total score was reported in both groups. It is well known that the MMMS is a measure used to assess a patient’s overall health and activity level. The current results with respect to the physical and energy subscale of the MMMS are encouraging. Following a 36-session exercise program, physical activity, energy, and mental health levels demonstrated significant differences.

Several limitations of the current study warrant mention. The relatively small sample size and the multiple variables being analyzed indicate that the results should be interpreted with caution. Further, the quantification of exercise intensity was controlled with a subjective Borg Rating of Perceived Exertion Scale, which is a recommended measurement for the quantification of exercise intensity in patients with MS.

The researchers concluded that the use of horse-riding simulation can “improve the joint range of movements and enable [individuals with MS] to recover the ability to walk, boost the sense of balance and coordination, and increase muscle strength.”

They continued, “To adhere to physical activity and exercise over the long term, we anticipate that horse-riding simulation might be a non-pharmacological intervention for people with MS.”

Future research is warranted, which should focus on the effectiveness of hippotherapy in the high disability MS group.


Salbaş E, Karahan AY. Effects of hippotherapy simulation exercise vs. conventional home exercises on muscle strength and balance in people with multiple sclerosis: a randomized controlled trial. Mult Scler Relat Disord. Published online August 19, 2022. doi: 10.1016/j.msard.2022.104111