Effects of equine-assisted activities on attention and quality of life in children with cerebral palsy in a randomized trial: examining the comorbidity with attention-deficit/hyperactivity disorder

Abstract

Background Attention problems and decreased quality of life are frequently accompanied in Cerebral Palsy (CP), which can negatively affect rehabilitation of physical disability. However, the majority of affected children remain untreated in the aspects of attention or psychosocial factors. Equine-Assisted Activities and Therapies (EAAT) use horse as a therapeutic modality including grooming as well as mounted riding activities in which patients exercise and experience mounted stimulation. It is known to help improve attention in children with ADHD, so that it can be an exercise therapy that is expected to improvement of attention as well as rehabilitating effects in CP patients. EAA may be a promising strategy to address the unmet need for CP patients. This study aims to investigate the efficacy of EAA for children with CP, those with both CP and ADHD and confirm the comorbidity between CP and ADHD. Methods Forty-six children with cerebral palsy participated in this study. For the exercise group, they participated in a 40-min session twice a week for a 16-week period, while the control group engaged in daily life without any special treatments. Each children individually were assessed on attention and psychological wellbeing at baseline and post-treatment. Comorbidity were identified based on the Diagnostic and Statistical Manual of Mental Disorder 5th edition (DSM-5) and confirmed by Korean Kiddie-Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K-SADS-PL). Results Perseveration rated using the Conner’s Performance Test (CPT) showed a significant decrease only in the exercise group (p < .024). However, no significant improvement in children’s quality of life was observed after EAA program compared with control group. Among the total participants, fifteen children (31.91%) were diagnosed with ADHD. When conducting an additional analysis with the subsample of CP patients diagnosed with ADHD, the d’, commission error and perseveration showed a significant decrease only in the exercise group. Children with CP and ADHD reported an improvement in quality of life both in exercise and control group, but only in the exercise group social functioning exhibited a significant difference. Conclusion The positive effects of the EAA on attention and quality of life were confirmed. Children with CP in the exercise group were more capable to sustain their attention longer. Those with CP and ADHD showed an increase in attention and perceived to have better social skills after receiving 16 weeks of EAA compared to those in the control group. Considering high comorbidity of CP and ADHD, it seems that the EAA program could be the better alternative treatment for CP with attentional problem. The results of this study will contribute to growing evidence for the efficacy of EAA in children especially with CP and ADHD. Trial registration This trial was registered on ClinicalTrials.gov (NCT03870893). Registered 26 July 2017.

Building up bit by bit, parent’s experiences of equine–assisted intervention among children and adolescents with mental illness: a grounded theory study

“…This study demonstrates quite positive outcomes for children and adolescents with mental ill health who took part in an EAS intervention. Our findings are in line with other EAS studies with participants who had autism spectrum disorders (Xiao et al, 2023 ), attention-deficit/hyperactivity disorder, or cerebral palsy (Ahn et al, 2021 ). Therefore, it could be argued that the findings are transferable to different contexts and children or adolescents with different health problems.…”

Effects of different physical activity interventions on children with attention-deficit/hyperactivity disorder: A network meta-analysis of randomized controlled trials

“…The included experimental and control groups’ mean age was less than or equal to 16 years. Interventions included cognitive-motor training (6 studies) ( Hoza et al, 2015 ; Pan et al, 2016 ; Meßler et al, 2018 ; Benzing and Schmidt, 2019 ; Kadri et al, 2019 ; Mansson et al, 2019 ), combination exercise (6 studies) ( Kang et al, 2011 ; Choi et al, 2015 ; Ziereis and Jansen, 2015 ; Bustamante et al, 2016 ; Memarmoghaddam et al, 2016 ; Lee et al, 2017 ), traditional aerobic exercise (5 studies) ( Ahmed and Mohamed, 2011 ; Hoza et al, 2015 ; Gelade et al, 2017 ; Meßler et al, 2018 ; Kadri et al, 2019 ), acute aerobic exercise (4 studies) ( Chang et al, 2012 ; Gawrilow et al, 2016 ; Ludyga et al, 2017 ; Benzing et al, 2018 ), aquatic exercise (3 studies) ( Chang et al, 2014 ; Da Silva et al, 2020 ; Sabzi et al, 2021 ), horsemanship (3 studies) ( García-Gómez et al, 2016 ; Oh et al, 2018 ; Ahn et al, 2021 ), perceptual-motor training (3 studies) ( Yazd et al, 2015 ; Hattabi et al, 2019 ; Sani et al, 2022 ), mind-body exercise (2 studies) ( Jensen and Kenny, 2004 ; Milligan et al, 2019 ), as well as sensory integration training (1 study) ( Faramarzi et al, 2016 ). The outcome indicators for ADHD consisted of motor ability, social problems, attention problems, cognitive flexibility, inhibition switching, as well as the working memory.…”

“…Fourteen studies ( Jensen and Kenny, 2004 ; Ahmed and Mohamed, 2011 ; Kang et al, 2011 ; Hoza et al, 2015 ; Bustamante et al, 2016 ; García-Gómez et al, 2016 ; Janssen et al, 2016 ; Pan et al, 2016 ; Meßler et al, 2018 ; Oh et al, 2018 ; Kadri et al, 2019 ; Milligan et al, 2019 ; Da Silva et al, 2020 ; Ahn et al, 2021 ) reported on the attention problems of children with ADHD, and a total of ten interventions are involved. As shown in Table 3 , there is no statistical significance for each intervention in the network meta-analysis results.…”

“…Five studies ( Pan et al, 2016 ; Meßler et al, 2018 ; Oh et al, 2018 ; Ahn et al, 2021 ; Sabzi et al, 2021 ) reported on the social problems of children with ADHD, and a total of six interventions are involved. As shown in Table 4 , the statistically significant results of the network meta-analysis were as follows: Aquatic exercise [ MD = −3.70, 95% CI = (−5.03, −2.37)] was more effective than that with no intervention.…”

Effect of physical activity on attention in school-age children with ADHD: a systematic review and meta-analysis of randomized controlled trials

“…After full-text reading, 111 articles were further excluded, of which 44 did not report the outcomes of interest, 30 had inconsistency in experimental design, 8 had no full-text available, and 29 had no available data. Finally, 10 studies (Jensen and Kenny, 2004;Kang et al, 2011;Hoza et al, 2015;Bustamante et al, 2016;García-Gómez et al, 2016;Pan et al, 2016;Geladé et al, 2017;Oh et al, 2018;Silva et al, 2020;Ahn et al, 2021) were included for quantitative synthesis (Figure 1). The inter-rater reliability between the two reviewers at this stage was classified as good (Cohen's kappa = 0.79).…”