Effectiveness of Simulated Horseback Riding for Patients With Chronic Low Back Pain: A Randomized Controlled Trial

in Journal of Sport Rehabilitation

Context: A simulated horseback riding (SHR) exercise is effective for improvement of pain and functional disability, but its comparative effectiveness with the other is unknown. Objective: The authors aimed to demonstrate the effect of a SHR exercise in people with chronic low back pain. Design: A randomized controlled trial. Settings: Community and university campus. Participants: A total of 48 participants with chronic low back pain were divided into 2 groups, and SHR exercises (n = 24) or stabilization (STB) exercises (n = 24) were performed. Interventions: The exercises were performed for 30 minutes, 2 days per week for 8 weeks. Main Outcome Measures: Numeric rating scale, functional disabilities (Oswestry disability index and Roland–Morris disability), and fear-avoidance beliefs questionnaire (FABQ) scores were measured at baseline and at 4 weeks, 8 weeks, and 6 months. Results: A 2-way repeated analysis of variance identified that between-group comparisons showed significant differences in the FABQ related to work scale (F = 21.422; P = .01). There were no significant differences in the numeric rating scale (F = 1.696; P = .21), Oswestry disability index (F = 1.848; P = .20), Roland–Morris disability (F = 0.069; P = .80), and FABQ related to physical scale (F = 1.579; P = .24). In within-group comparisons, both groups presented significant differences in numeric rating scale (both SHR and STB after 4 wk), Oswestry disability index (both SHR and STB after 6 mo), and Roland–Morris disability (SHR after 6 mo and STB after 8 wk) compared with baseline values. In FABQ-related physical (SHR after 4 wk) and work scales (SHR after 6 mo), there were only significant differences in the SHR compared with baseline values. Conclusions: SHR exercise for 8 weeks had a greater effect than STB exercise for reducing work-related FABQ. The SHR exercise performed in a seated position could substantially decrease pain-related fear disability in young adults with chronic low back pain.

The prevalence of nonspecific low back pain (LBP) is 80%.1 Over half of individuals with nonspecific LBP will experience chronic symptoms lasting longer than 1 year, and these symptoms result in high health care costs.2 Effective management to reduce pain intensity and to prevent a chronic pain status thus becomes an important concern for all patients who have LBP. As a result, a wide range of conservative interventions are offered for the treatment of chronic LBP (cLBP).3,4

Researchers have focused on the importance of activating muscles for motor control and stability of the trunk and lower-extremities.5,6 In recent times, horseback riding exercise has been considered as one of the therapeutic interventions that can help improve motor control capacity.7 Riding a horse requires continuous postural control during the horse gait cycle. A horse’s movements are repetitive, symmetrically rhythmic, and transferred from the back to the rider’s pelvis. The movement practice of a rider on horseback is associated with greater improvements in muscle strength8 and activation,9 and also perceived mental and emotional status.10 However, the effects of horseback riding exercise are difficult to generalize due to high cost, low accessibility, and safety concerns, such as falling.11

Several simulated horseback riding (SHR) systems have been developed recently to allow people to determine the benefits of horseback riding exercise by diminishing these shortcomings such as cost, low accessibility, and safety concerns.12 Coinciding with the SHR system generalization, previous studies on the effectiveness of SHR exercise have also shown therapeutic benefits related to improvement in motor control in people with neuromuscular disorders.8,13 Despite its effectiveness, SHR has a limitation in that the studies conducted to date did not consider whether the SHR system could mimic a real horse gait. Also, no studies have involved active control groups for comparison in patients with LBP.14,15 The current study was performed based on the evidence of SHR exercise being similar to real horse movements and having the advantages of postural control training and immersion in patients with LBP .16,17

To identify the effectiveness of SHR exercise for people with cLBP, we used SHR, verified its similarity with a real horse gait cycle through previous studies, and compared its effectiveness with that of an active control group. The active control group performed stabilization exercises, which provided a chance to restabilize trunk and pelvis repeatedly on external perturbation. The training methods kept participants’ spines in a neutral position.18 The purpose of this study was to determine whether SHR exercise in the treatment of patients with cLBP reduced patients’ pain, improved functional disabilities, and improved fear-avoidance beliefs after the treatment period better than stabilization exercises with suspension.

Methods

Study Design

The study design was a randomized controlled trial.

Participants

Participants were eligible for the study if they fulfilled the inclusion criteria. The specific eligibility criteria included the following: (1) age of 20–64 years and (2) nonspecific LBP lasting at least 3 months, with an average numeric rating scale (NRS)19 in the previous 7 days of ≥4 (scale 0–11). Participants were excluded if they presented with (1) specific causes of LBP (eg, spinal stenosis), (2) any other sensory and motor dysfunctions resulting from neurological disorders, (3) any cardiovascular or psychological disease, (4) any other mental or physical limitation that prevented study participation, (5) any surgery or trauma within the previous 6 months, or (6) pregnancy or planned pregnancy within the intervention period.

This study was approved by the medical research ethics committee of Korea University (KU-IRB-16-105-A-2). The participants were informed of this study via informational material (eg, poster, brochures) on bulletin boards and the website of a public health center and the university website. We performed interviews and clinical examinations to prescreen potential participants according to the main eligibility criteria. During interviews, we asked all participants about the frequency with which they took their medications and about their experiences consulting with medical doctors or physical therapists regarding LBP in the last 3 months. To avoid bias regarding the effectiveness of the exercises, we asked participants to stop taking their medications during the study period. Informed consent was obtained from all individual participants included in this study. When we obtained the consent form, we informed participants that they could withdraw from the study at any point for any reason, including severe pain. Participants were recruited from November 2016 to May 2017. Follow-up assessments were completed in November 2017.

Randomization and Sample Size

The sample size was calculated with a type I error rate set at 5%, with a desired power of 95%.14 As a result, a sample size of 17 participants in each group was estimated to determine a difference in the effectiveness of the exercises. To allow for a dropout rate of 20%, 7 participants were added to each group. The participants who met the eligibility criteria and provided informed consent were registered in the preface of the database. The participants (n = 48) were randomly allocated into 2 groups (SHR exercise, n = 24; STB exercise, n = 24) using a 4-block randomization method. The randomization list was extracted by a researcher from the R software random number generator (version 3.3.2; R Development Core Team, Vienna, Austria). The randomization result was provided to each participant.

Intervention

Both exercises were based on the same manual, conducted in 16 individualized sessions for more than 8 weeks, and led by 3 physical therapists with more than 3-years clinical experience. At each session, the participants were individually supervised by the same practitioner who was allocated to the study during the overall sessions. The exercise program included warm-up, workout, and cooldown periods. The total exercise time was 46 minutes, and consisted of a stretching and cooldown period of 10 minutes, workout time of 30 minutes, and total rest time of 6 minutes (Table 1). If pain, dizziness, or any other discomfort was reported, the exercise was stopped immediately. Both exercise programs based on the specific time are provided in Table 1. As both exercises focused on the exact motion and posture, however, the repetition of exercise and time required were dependent on the individual participant.

Table 1

Contents of SHR and STB Exercise

The phase of exercise
TypeComponents1–2 wk3–4 wk5–6 wk7–8 wk
SHR exerciseWarm-up
 Stretching5555
Workout
 Walking1055
 Slow trot1015105
 Fast trot1015
 Walking1010510
Cooldown
 Stretching5555
STB exerciseWarm-up
 Stretching5555
Workout
 Supine pelvic lift151055
 Bridging exercise15201510
 Side-lying hip abduction1015
Cooldown
 Stretching5555

Abbreviations: SHR, simulated horseback riding; STB, stabilization.

SHR Exercise

Professionals of physical therapy, equine science, and motor control had several meetings to select the simulator used in this study (FORTIS-102; Daewon Fortis, Hanam, Republic of Korea; Figure 1). The SHR system used in the present study produced similar patterns to a real horse gait by using anteroposterior, vertical, and oblique motion axes.16 The workout consisted of walking, slow trotting, and fast trotting of a real horse gait (Table 1).10,17 Each pattern was provided with continuously specified velocity (walking = 80 m/min, slow trotting = 135 m/min, and fast trotting = 159 m/min).17

Figure 1
Figure 1

—(A) Simulated horseback riding system. (B) Riding simulated horseback riding system.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2018-0252

STB With Suspension

The STB exercise with suspension (Redcord AS, Arendal, Norway) consisted of a supine pelvic lift, supine and prone bridging exercise, and side-lying hip abduction (Figure 2; Table 1). STB exercise has proven effectiveness for reducing pain intensity and improving functional disability in people with LBP.20 Time required to perform each movement was about 10 seconds.

Figure 2
Figure 2

—(A) Stabilization exercise with suspension. (B) Performing stabilization exercise with suspension.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2018-0252

Outcomes Measures

Outcomes were assessed at 4 time points: baseline, 4-week postexercise, 8-week postexercise, and 6-month follow-up. The outcomes included NRS, functional disabilities (K-Oswestry disability index [ODI] and K-Roland–Morris disability [RMD]) related to LBP, and fear-avoidance beliefs questionnaire (FABQ) scores using standardized questionnaires completed by the participants.

The participant’s average pain intensity over the previous week was measured using the NRS. In NRS, 0 indicates no pain and 11 indicates the worst imaginable pain. Participants were asked to write the numeric scale down on the data sheet. In addition, the participant’s average functional disability–specified scores were assessed in the Korean version of the ODI (0%–100%) at 4 weeks, 8 weeks, and 6 months.21 Additional outcomes related to functional disability is the score in the Korean version of the RMD questionnaire.22 We also assessed fear-avoidance beliefs using a self-administered questionnaire (FABQ). The FABQ includes physical and work scales.23

Statistical Analysis

The NRS, ODI, RMD, and FABQ scores are reported as means and SDs. Normal distribution of the outcomes data was assessed using the Shapiro–Wilk test. An independent t test was conducted for the homogeneity of demographic characteristics. A 2-way repeated analysis of variance was used to identify the effects of the intervention on all measured outcomes with period (baseline and at 4 wk, 8 wk, and 6 mo) as an intragroup variable and type of exercise (SHR or STB) as an intergroup variable. When a significant interaction effect was detected, post hoc analysis was performed using the Bonferroni test. Additionally, the effect size (ES) was calculated to examine the magnitude of therapeutic effect.24 The cutoff points of ES were 0.2, 0.49, and 0.8, considered as small, medium, and large, respectively.24 All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS version 21.0; IBM, Chicago, IL). Statistical significance level was set at .05.

Results

A total of 48 participants were screened to verify eligibility for the current study. Most participants were young adults who had a history of recurrent LBP (mean duration in SHR group: 58.22 mo; mean duration in STB group: 101.55 mo; P < .05). More than half of the participants (SHR: 54.55%, STB: 53.85%) had sought medical consultation for their LBP, and 5 participants took medication. No side effects occurred in either group during the 16 exercise sessions.

Eight and nine participants in the SHR and STB exercise groups, respectively, did not complete the final sessions and evaluations (Figure 3). As a result, 31 participants were included in the intention-to-treat analysis. An analysis of the dropout participants showed that they did not differ from the participants who completed the study with respect to demographic and clinical outcomes. The 2 groups showed no significant differences with regard to any of the baseline demographics, except for mean duration of LBP, which was longer in the STB exercise group (P < .05; Table 2).

Figure 3
Figure 3

—Flowchart of participants throughout the study.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2018-0252

Table 2

Participants’ Characteristics at Baseline

CharacteristicsSHR exercise group

(n = 24)
STB exercise group

(n = 24)
Mean age (SD), y26.0 (3.82)28.79 (9.05)
Gender
 Female, %7 (31.8%)15 (57.7%)
 Male, %15 (68.2%)11 (42.3%)
Mean BMI (SD), kg/m223.96 (5.76)23.50 (5.58)
Mean duration of low back pain (SD), mo58.22 (37.37)101.55 (97.12)
Medication intake because of low back pain, %2 (9.09%)3 (11.54%)
Consultation because of low back pain, %12 (54.55%)14 (53.85%)
Mean low back pain intensity (SD)4.70 (1.04)4.73 (0.82)
Low back pain/disability 1 (ODI)20.24 (7.69)21.77 (7.11)
Low back pain/disability 2 (RMD)7.0 (4.4)5.11 (2.74)
FABQ
 Physical15.35 (4.12)11.93 (5.62)
 Work17.11 (5.33)20.47 (7.89)

Abbreviations: BMI, body mass index; FABQ, fear-avoidance beliefs questionnaire; NRS, numeric rating scale; ODI, Oswestry low back pain disability questionnaire; RMD, Roland–Morris disability questionnaire; SHR, simulated horseback riding; STB, stabilization. Note: Data are presented as mean (SD).

There was a statistically significant interaction between the effects of exercise and their duration on work-related FABQ (F = 21.422; P = .01). A simple main effects analysis showed that SHR was more effective in reducing work-related FABQ at 6-month follow-up than STB (P = .01). No significant interactions were observed between exercise and its duration for the NRS (F = 1.696; P = .21), the ODI (F = 1.848; P = .20), the RMD (F = 0.069; P = .80), and the physical-related FABQ (F = 1.579; P = .24) (Table 3).

Table 3

Means, SDs, and Difference Between Groups: Primary Outcome Measure, VAS; Secondary Outcomes Measure, Functional Disabilities Specified by ODI and RMD; Tertiary Outcome Measure, FABQ

Treatment period
VariableGroupPre4 wk8 wk6 moGroup difference

F (P value)
NRSSHR4.70 (1.04)2.25 (1.06)**1.27 (0.90)**1.42 (1.27)**1.696 (.21)
STB4.73 (0.82)2.09 (1.46)**1.64 (1.57)**1.22 (1.03)**
ODISHR20.24 (7.69)14.72 (8.08)11.55 (8.95)8.28 (6.26)**1.848 (.20)
STB21.77 (7.11)19.46 (9.32)14.81 (9.37)9.23 (3.34)**
RMDSHR7.00 (4.40)3.30 (3.77)2.90 (4.50)1.85 (1.21)**0.069 (.80)
STB5.11 (2.74)4.76 (2.52)2.46 (2.25)**1.77 (1.09)**
FABQ physicalSHR15.35 (4.12)9.00 (3.64)**8.80 (5.94)**4.14 (4.05)**1.579 (.24)
STB11.93 (5.62)16.33 (9.55)11.10 (9.09)9.66 (7.08)
FABQ workSHR17.11 (5.33)15.22 (7.06)11.40 (7.45)13.85 (7.11)**21.422 (.01)*
STB20.47 (7.89)22.40 (5.62)14.69 (6.49)16.50 (9.02)

Abbreviations: FABQ, fear-avoidance beliefs questionnaire; NRS, numeric rating scale; ODI, Oswestry low back pain disability questionnaire; RMD, Roland–Morris disability questionnaire; SHR, simulated horseback riding; STB, stabilization; VAS, visual analog scale. Note: Values are presented as mean (SD).

*Significant interaction between period and groups, P < .05. **Significant within-group difference between baseline and 4 weeks, 8 weeks, and 6 months in each group.

Both groups showed significant intragroup differences in NRS, ODI, and RMD variables during exercise (P < .05). The NRS in both groups significantly decreased at 4 weeks, 8 weeks, and 6 months compared with baseline values. The ODI in both groups was significantly decreased at 6-month follow-up. The RMD was significantly decreased at 6 months in the SHR group and at 8 weeks and 6 months in the STB group. However, in physical- and work-related FABQ, there were significant intragroup differences only in the SHR group. The physical-related FABQ significantly decreased at 4 weeks, 8 weeks, and 6 months, and work-related FABQ significantly decreased at 6 months only in the SHR group.

The ES in both groups showed a medium effect in NRS, ODI, and FABQ at the 6-month follow-up period. Meanwhile, in physical-related FABQ, the ES in the SHR groups showed a medium decrease at the 6-month follow-up (Table 4).

Table 4

Within-Group Effect Size in Both Groups

Treatment period
VariableGroupPre–4 wkPre–8 wkPre–6 mo
NRSSHR−0.22−0.03−0.24
STB−0.19−0.02−0.40
ODISHR−0.09−0.03−0.24
STB−0.03−0.02−0.41
RMDSHR−0.22−0.14−0.49
STB−0.05−0.16−0.77
FABQ physicalSHR−0.42−0.04−0.67
STB−0.07−0.01−0.06
FABQ workSHR−0.05−0.032122−0.36
STB0.04−0.02−0.06

Abbreviations: FABQ, fear-avoidance beliefs questionnaire; NRS, numeric rating scale; ODI, Oswestry low back pain disability questionnaire; RMD, Roland–Morris disability questionnaire; SHR, simulated horseback riding; STB, stabilization. Note: Values are indicated as the effect size.

Discussion

The main finding of this study was the significant interaction between the effect of exercise and periods in work-related FABQ. In addition, intragroup differences showed reduced work-related FABQ scores when compared with baseline scores in the SHR group.

The results of the current study indicate that the SHR exercise is more effective for reducing work-related FABQ in participants with cLBP compared with STB exercise at 6-month follow-up. A surprising finding in the current study was that only participants who performed SHR exercise demonstrated a statistically significant work-related FABQ score decrease by periods. During the 8-week exercise and the 6-month follow-up periods, the SHR exercise group showed significant decreases and medium therapeutic effects in the work-related FABQ scores. A possible explanation for why the work-related FABQ improvement was only noted in the SHR group may be that participants rode the simulator in a sitting position similar to the position they adopt in their work environments. Most study participants were students or office workers who maintained a sitting position for more than 6 hours a day. Maintaining an upright sitting posture on a rhythmical and repetitive horse simulator could affect pain intensity reduction due to fear of disability at work. However, the work-related FABQ results of both groups tended to increase slightly during the follow-up period. Work-related fear-avoidance beliefs play an important role in chronic pain improvement.23,25,26 The reason why participants had suffered from cLBP for more than 5 years is that, although their pain severity was not high, the participants had high scores in work-related fear-avoidance beliefs. Therefore, when using SHR exercises, clinicians and physical therapists must consider performing a program that is known to improve pain-related beliefs such as fear avoidance, disability, and pain intensity for people with cLBP. Even so, the present study suggests that SHR exercise may also be a feasible therapeutic exercise option to improve pain-related beliefs during an exercise period.

In within-group comparisons, both groups demonstrated significant differences in NRS (both SHR and STB after 4 wk), ODI (both SHR and STB after 6 mo), and RMD (SHR after 6 mo and STB after 8 wk) when compared with baseline values. However, in FABQ-related physical (SHR after 4 wk) and work scales (SHR after 6 mo), there were only significant differences in SHR group compared with the baseline values.

During the 6-month follow-up phase, although both groups showed statistically significant changes and medium therapeutic effects in all variables, the STB group showed greater therapeutic effects in the NRS, ODI, and RMD scores compared with the SHR group. The STB group showed a decrease of 74.20% in the NRS and a medium therapeutic effect at the 6-month follow-up that was greater than the effect of SHR with decreased NRS by 69.78%. Although the therapeutic effects of NRS, ODI, and RMD in the STB group were greater than those in the SHR group, the rate of decreased ODI and RMD were greater than those in the STB group. The SHR group showed a decrease of 59.60% and 73.57% in ODI and RMD, respectively, which was greater than those of the STB group, 57.60% and 65.36% in ODI and RMD, respectively. We think that there are wide variations in results from the SHR group. Thus, although the mean differences for all outcomes between the groups were too small to conclude clinical significance, SHR showed clinical relevance for reducing cLBP.

The therapeutic exercise effects of SHR in the present study concur with those reported in a previous real horse study10 and an earlier study that used another SHR system for 8 weeks.14 In addition, the results of the present study could provide more evidence that SHR is an effective exercise for cLBP at the 6-month follow-up. These findings may have resulted from the training effect, which provides a challenge to postural stability, and the participants have to restabilize their trunk and pelvis repeatedly. The movement of SHR could serve as therapeutic perturbation for a challenge to postural stability.8,9

There was also significant improvement of pain release, functional disability–specified ODI, and fear-avoidance beliefs in the STB group. In previous studies, however, stabilization exercise with suspension was not associated with any improvements of pain release and functional disability at 1-year follow-up.20 This disparity between our current study results and previous results may be because participants of the current study performed exercises 2 to 3 times per week, and they were younger than participants of the previous studies (mean age: ∼40 y).

There are several limitations to this study. The different results detected in the therapeutic effects and real decreasing rate in functional disabilities, ODI and RMD, could have arisen from the small sample size and the absence of participants with severe LBP (NRS score > 7). Although no upper limit was set on the NRS in the process of recruiting participants, most participants were young adults (20–30 y old) with mild to moderate LBP. Thus, the results can be limited to young adults with mild cLBP and should be applied in clinical decision making with caution. Also, this study had a dropout rate that was higher than expected. The most common reason participants (n = 11; SHR = 5, STB = 6) dropped out of this study was that the distance between the clinic and their home or workplace was too far away and public transportation was inconvenient. Another reason was that participants did not have enough time to participate for 8 weeks because of their studies and working life (n = 4; SHR = 2, STB = 2). The others (n = 2; SHR = 1, STB = 1) did not finish the intervention because they moved to another city. Therefore, these limitations must be addressed while developing further therapeutic strategies in cLBP.

Conclusions

Our results indicate SHR exercise for 8 weeks could improve work-related fear-avoidance beliefs by the 6-month follow-up point. These findings imply that in young adults with cLBP, SHR exercise that is performed in a seated position is more effective for improving work-related FABQ than STB exercise that is performed in a supine, prone, or side-lying position.

Acknowledgments

The authors would like to thank all the participants who volunteered for this study. No competing financial relationships exist.

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T. Kim, Lee, S. Kim, and Yoon are with Graduate School, Korea University, Seoul, Republic of Korea. Oh is with Medical Health Research Center, Korea University, Seoul, Republic of Korea. S. Kim is also with the Department of Physical Medicine & Rehabilitation, Korea University Anam Hospital, Seoul, Republic of Korea. Yoon is also with the Department of Physical Therapy, College of Health Sciences, Korea University, Seoul, Republic of Korea.

Yoon (yoonbc@korea.ac.kr) is corresponding author.

Supplementary Materials

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    —(A) Simulated horseback riding system. (B) Riding simulated horseback riding system.

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    —(A) Stabilization exercise with suspension. (B) Performing stabilization exercise with suspension.

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    —Flowchart of participants throughout the study.

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