Perception of hippotherapy professionals about their practice with the elderly

Introduction: Riding therapy is a therapeutic method recently regulated in Brazil. Nevertheless, it has been studied for years, especially focusing on children and adolescents. Considering the growing number of elderly in the Brazilian population, investigations focusing on older people are increasingly necessary. Objective: To analyze the perceptions of equine therapy professionals about their practice with the elderly. Methods: This was a qualitative and cross-sectional research, in which the participants answered an online questionnaire, composed of demographic questions and questions related to horseback riding with the elderly. Data were analyzed using descriptive statistics and thematic content analysis. Results: Twenty-five professionals (23-57 years old), graduates, who had worked for at least two years with hippotherapy (mean = 6.64; standard deviation = 5.39 years) participated. This sample was composed mostly of female professionals (72%) and physical therapists (48%). Of the total, 60% reported having already assisted at least one elderly practitioner. Among those who had never worked with this public, 90% wished to do so. All professionals considered that horseback riding can be beneficial in old age, reducing depressive symptoms and promoting psychosocial (e.g., socializing) and physical (e.g., balance) variables. Despite the benefits, professionals mentioned challenges, such as difficulties of the practitioner (e.g., fear), problems with the workplace (e.g., lack of qualified staff), and low demand. Conclusion: Hippotherapy professionals consider riding therapy a method that contributes to improving biopsychosocial aspects of the elderly. However, they face challenges in this practice, hindering or preventing them from serving older people.


Introduction
Human-animal contact as a form of treatment and cure for humans has been used since antiquity.1,2 Currently, several studies show that the presence of animals, whether with a therapeutic focus or simple playful contact, helps to improve mood, socializing and the practitioner's physical and psychological well-being.3,4 One of the most used animals in animal-assisted therapy is the horse.4 Therapy with horses is referred to by various names, such as "physiotherapry based on horse movements", "equine therapy", "physiotherapy and horse-assisted therapy", "therapeutic horseback riding", and "hippotherapy", among others.5 This hinders a standard in care, in the specialization of professionals, and in the advancement of research.6 This understanding has been present for at least a decade, when Craig et al. 7 stated that scientific progress is hampered when there is no clear term to name different services.Thus, the authors emphasized the importance of having this terminology well described, so that the intervention is developed scientifically, with efficacy and confidence.
Wood and Fields 5 also reinforce the need for professionals working with hippotherapy to develop a theory for training in the area.They point out that hippotherapy needs to be defined and presented to the public through practice and research, as a therapeutic tool that involves the movement of trained horses to promote benefits to the practitioner.5 In Brazil, the most used term is hippotherapy and refers to the practice of rehabilitation that uses the horse as a mediator, and can be applied to people of all ages.8 It works with the practitioner in a global way, stimulating body awareness, the development of balance and muscle tone, improved motor coordination, awareness, self-confidence and self-esteem.9 In addition to these aspects, it can be used as a complementary treatment for emotional difficulties, trauma and mental illness.5 Hippotherapy was recently regulated in Brazil through Law No. 13.830.10 However, for at least three decades, a non-profit civil entity of philanthropic, assistive and therapeutic nature called the National Association of Equine Therapy (ANDE-BRASIL), already contributed to publicizing this practice in a national context.
For ANDE-BRASIL, 8 hippotherapy uses an interdisciplinary approach that involves the participation of health, education and riding professionals.Three professionals make up the minimum team of a hippotherapy center: a physiotherapist, a psychologist and a horseback riding professional.The second reason refers to the age profile of the Brazilian population, which is changing.There is a sharp increase in the number of elderly people, so that the estimate for 2030 is that people aged 60 years or older will make up the majority.20 Thus, based on the context presented, main aim of this study was examine the perception of hippotherapy professionals about their practice with the elderly.
Specifically, it was aimed to know the training of professionals, their experience with practitioners in old age, the demands of elderly people who seek this type of treatment, the benefits and challenges they identify in working with older people and interest in continuing to serve (or start to serve) this group of people.

Methods
This was a cross-sectional, exploratory study, with a quantitative and qualitative design, carried out from information collected with Brazilian hippotherapy professionals.It was approved by the Research Ethics Committee (CEP) of the Catholic University of Brasília (CAAE: 39650820.8.0000.0029).

Participants
The sample of this study was obtained by convenience and was composed of hippotherapy professionals.
The inclusion criteria were having a college degree and working for at least two years with hippotherapy in Brazil.It is believed that these criteria contributed to the participants having some experience with this practice on a national level.
Not answering the questionnaire completely or completing it after the deadline provided were exclusion criteria.We chose not to restrict participation to a single king of training, as the hippotherapy team is made up of professionals from different areas of knowledge.Considering the inclusion and exclusion criteria, only one of the respondents was not included in the study, as he had been working with hippotherapy for only one year.The final sample of this study consisted of 25 professionals.

Instruments
This study was carried out using a semi-structured questionnaire that we developed, and it was answered online, through the Google Forms platform.
The instrument initially contained an informed consent form, and after accepting to participate, the professional accessed the questionnaire.It was divided into two parts: sample characterization and perception of hippotherapy with the elderly.
In the first section, demographic information was collected, including age, sex, professional training, time working with hippotherapy and the region of the country in which it was practices.The second part was composed of questions encompassing, for example, the experience of the hippotherapy professional with the elderly, the demands, benefits and challenges perceived in applying this practice in older people.
If the participant had never cared for the elderly, the questions involved their perceptions about, for example, benefits and challenges that they believe exist in treating this group of patients.

Procedure
After approval by the CEP, the dissemination of the study began.Initially, it took place through the our social network and later through the "snowball" strategy, in which the responding professionals shared the investigation's electronic address with other potential participants.Data collection took place during the month of December 2020.To reach the final sample size, the saturation sampling strategy was adopted; that is, we stopped recruiting new participants when we felt that there was repetition in the data.21

Analysis of data
Quantitative data were analyzed using descriptive statistics such as mean (M), standard deviation (SD), percentage and frequency (f).Qualitative data were handled using Bardin's thematic content analysis.22 For content analysis, a pre-analysis of the participants' responses was initially carried out, followed by the exploration of the material and the treatment of the results, which occurred through establishing percentages, frequencies, inferences and interpretation.
Thus, the thematic categories identified would be discussed qualitatively and quantitatively.
With regard to professional background, only one participant (4%) stated that he had not taken a training, specialization or similar course in hippotherapy (Table 1).Of the 24 professionals who participated in some training or similar, 79.17% (n = 19) stated that one of the contents covered was about the practice with the elderly (Table 1).Just over half (60%; n = 15) of the participants reported having worked with practitioners aged 60 or over (Table 1).However, three of them (20%) reported seeing only one elderly person.the others (n = 12; 80%) between one and about 50 elderly people.
Demands, benefits and challenges: perception of professionals who had already assisted elderly people Professionals were asked to report, based on their perceptions, the demands of the elderly patients they had already attended.Among the ten categories indicated, the most frequent were: sequelae of cerebrovascular accident (CVA) (40%; f = 6); Parkinson's disease (13.33%; f = 2); and anxiety disorder (13.33%; f = 2) (Table 2).
When asked about the benefits they identify in the elderly who undergo hippotherapy, professionals more often reported improvement in socializing (33.33%; f = 5), balance (33.33%; f = 5) and self-esteem ( 26.67%; f = 4).However, benefits such as improved gait, mobility and quality of life, reduction of depressive symptoms and greater autonomy were also mentioned (Table 2).Only one participant (P14) stated that he did not want to have elderly patients, as he did not consider horseback riding a safe activity.Nevertheless, he added that he considers working on the ground safe.
Despite not having cared for the elderly, these professionals reported benefits that hippotherapy can promote in older people.The most frequent were improvement in socializing (70%; f = 7), in psychological and physical aspects (60%; f = 6) and in self-esteem (50%; f = 5) (Table 3).
When asked about the challenges they consider existing in the practice of hippotherapy with the elderly, most professionals mentioned the difficulty in commuting (40%; f = 4), acceptance/prejudice (40%; f = 4) and safety (30%; f =3) (Table 3).Some of the participants' reports that exemplify the perception of the challenges for them are: Lack of qualified staff, high costs for maintaining animals and adequate equipment, difficulty for families to take the elderly to therapy.(P1).

The main challenge I believe would be to overcome the barrier of prejudice. (P7)
Show that it is a therapy for all ages and not just for As for the benefits perceived by the professionals, both by those who have cared for the elderly and by those who have not yet had this experience, there is an improvement in balance, quality of life, autonomy, selfesteem and socializing.In general, they are in line with those found by Matarazo.12 In that review, the author found that the most analyzed variables were balance, With regard to deepening in hippotherapy, almost all participants said they had done so.Nevertheless, in about 20% of background training, practice with the elderly was not addressed.Although this was an apparently good result, since almost 80% of the courses contemplated old age, it is worrying, especially nowadays, when there is a marked aging of the population. In

FISIOTERAPIATable 1 -
EM MOVIMENTO Physical Therapy in Movement Matarazo JB, Freitas ER.Fisioter Mov.2022;35:e35147 5 When asked if they wanted to continue caring for the elderly, most professionals (n = 14; 93.33%) answered yes.The following are two examples of reports made by the participants when complementing their statement: Yes.It has a good evolution!(P6) Characterization of professionals who participated in the study (n = 25) Have you done any training, specialization or related course on hippotherapy?
people with disabilities.(P18) Matarazo JB, ER.Fisioter Mov.2022;35:e35147 7 the elderly.This reality experienced by the participants is also observed in studies in the literature.Of the 20 articles on hippotherapy retrieved by Zamo and Trentini, 25 only three contained elderly participants, and of the 78 articles retrieved by Wood e Fields, 5 only six.Research and practice in hippotherapy, especially in Brazil, therefore, seem to emphasize the first two phases of life, especially childhood.It is possible that the focus on this stage of development is an a priori objective of the hippotherapy center or a consequence of the greater demand for care by this group.The lack of knowledge of this practice with the elderly and the low dissemination of its results can cause a lower demand, fewer referrals to hippotherapy centers and higher prices, as can be seen in the report of one of the professionals: [...] the greatest demand in the city/state where I am is for ASD children (autistic spectrum disorder) and long-stay institutions (hospices) are not so interested in diversifying the forms of care, due to the financial situation of the elderly, which makes it a difficulty for them, since the practice of hippotherapy is a therapy with a high cost.(P15) When questioned about the demands of elderly people they had seen, it is observed that the results obtained in this investigation are in line with those of Matarazo.12 The author found, through a systematic review of the literature on hippotherapy with the elderly, that patients with CVA sequelae, multiple sclerosis, post-traumatic stress disorder (PTSD), balance deficit, Alzheimer's or other dementia and spinal cord injury have made up samples of investigations in this area.It is noteworthy that, of these, only PTSD was not mentioned as a demand by the participants of this study.Nevertheless, it should be noted that in previous editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), PTSD was part of the group of anxiety disorders.26 Thus, it is possible that some of the participants in this study referred to PTSD as an anxiety disorder.

Table 2 -
Demands, benefits and challenges perceived stated that he did not want to continue working with elderly practitioners, since the focus of his workplace was children.Among the challenges faced in caring for the elderly through hippotherapy, the professionals mentioned the motor limitation of practitioners (26.67%;FISIOTERAPIA EM MOVIMENTO Physical Therapy in Movement Matarazo JB, Freitas ER.Fisioter Mov.2022;35:e35147

Table 3
An elderly person who wanted to practice hippotherapy never came up.I believe that the lack of knowledge of this possibility by both health professionals and society ends up creating an image that hippotherapy is for children and that the elderly will not be able to ride a horse.(P7) Among the ten professionals who did not see elderly, nine (90%) reported interest in working with older people.The reasons listed were, in summary, the fact that the practice is an alternative therapy for advanced-age people, which can contribute to improving quality of life and help in the recovery of physical and psychological illnesses.