The hippotherapy program started with a physical therapy assessment to develop specific corrective movements to be practiced while riding the horse based on the direction of the spinal curvature. Interventions were performed by a licensed physical therapist experienced with hippotherapy at two local therapeutic riding centers. The participants received 15 sessions split into two phases over 10 weeks. In the first phase, during the first 5 weeks, they performed 30 minutes of walking and sitting trot training without a stirrup iron once a week. The frequency was then raised to twice a week for the rest of the treatment program. Before the start of the intervention, two familiarization sessions were given to clarify safety guidelines, riding mistakes, and create a riding rapport with the horse. The individuals wore protective helmets during each hippotherapy session and mounted on a moving horse on walk and/or trot performing different positions, namely forward astride, side sitting, backward astride, sometimes with transitions between positions and often while the horse was moving. To restore normal alignment of the spine, participants were also asked to ride without holding on with their hands to perform self-correction movements. Examples of these movements include raising both arms high to decrease the degree of thoracic kyphosis, bending the upper trunk towards the convex side of the curve, raising the arm on the concave side with scapular adduction to level both shoulders. To correct pelvic obliquity, a small pad was put under the hip on the side of the lumbar convexity. Under the instructions of the physical therapist, a leader pulled the horse reins in front to control the horse gait, gait velocity, and orient the horse in different directions . All these movements activate the patient's neuromuscular and sensory reactions.~Both groups performed Schroth exercises that are patient-specific asymmetric exercises with rotational breathing methods used for three-dimensional correction. For the first 2 weeks, there were five 1-h long individual sessions during which the participants were trained in their home exercise program. This was followed by 1-h weekly visits and paired with their daily home exercises. These exercises aimed to provide and promote enhanced postural control by using asymmetrical standing postural exercises specifically designed to restore body balance and mobility. During ground exercises, aid pads were used to build pressure for costal protrusions and/or trunk asymmetry correction. Postural correction was facilitated by rotational breathing exercises focusing on the concave side of the thorax. During the therapy sessions, postural correction principles of the Schroth process, axial elongation, deflection, de-rotation, facilitation, stabilization, were used.
This study showed that the addition of hippotherapy to Schroth exercises is more effective in improving postural asymmetry and balance ability in adolescents with idiopathic scoliosis compared to Schroth exercises alone. Therefore, this combination should be considered during designing a rehabilitation program for AIS