cerebral palsy ( cp ) is a non - progressive disease with symptoms that include neurological 
 disorders or developmental disabilities .
children with cp have spasticity , musculoskeletal 
 problems , mobility disturbances , and decreased pelvic movements that lead to awkward 
 movement and sitting posture1 , 2 . symptoms also induce unstable posture control , imbalance , 
 and aberrant control of movement .
postural control is the ability to control the body position in space , and it has a 
 relationship with the sense of balance3 . 

hippotherapy and horseback riding have been suggested as interventions for correcting the 
 balance problems of children with cp4 .
two 
 types of horseback riding are available : hippotherapy and therapeutic horseback riding 
 ( thr ) .
hippotherapy provides better pelvic , hip , and trunk movement and influences 
 childrens posture , balance , and coordination5 .
hippotherapy has short - term beneficial effects on the muscle 
 symmetry of the trunk and hip , whereas thr has no effect on muscle tone6 .
the effects of these two types of horseback riding have 
 been studied in children with cp , and both types have been demonstrated to improve gross 
 motor function and promote better standing and bipedal balance7 , 8 . a horseback riding simulator ( joba , panasonic inc . ,
it was developed to overcome the primary limitations of hippotherapy , such 
 as unavailability and high cost .
this device offers an indoor experience of horseback riding 
 and mimics the rhythmic movement of horseback riding , thereby promoting muscular strength 
 and improving sense of balance .
the objective of this study was to compare hippotherapy to the use of a horseback riding 
 simulator ( joba , panasonic inc . , japan ) with respect to their effects on the static and 
 dynamic balance of children with cp .
our results indicate that a horseback riding simulator 
 has beneficial effects as an intervention for children with cp .
this study included 26 children with cp who were receiving physical therapy at the h 
 horseback riding center and the n horseback riding center in kyung - ki in korea .
the 
 selection criteria for the subjects were a modified ashworth scale ( mas ) grade less than + 1 . 

children who could perform more than 10  m independent walking and were available for more 
 than 30  min training per day were selected .
the parents or guardians of all the participants 
 provided their written informed consent in accordance with the ethical principles of the 
 declaration of helsinki ( table 1table 1 .
general characteristics of subjectshippotherapyhrsgender ( m / f)8/59/4age ( year)10.81.610.02.2height ( cm)125.812.6122.614.3weight ( kg)25.26.425.55.7meansd , hrs : horseback riding simulator ) .
meansd , hrs : horseback riding simulator the children were randomly divided into two groups : a hippotherapy group that included 13 
 children , and a horseback riding simulator ( joba , panasonic inc .
the two groups participated in 1 hour of exercise per day , 3 times a week , 
 for 12 weeks .
the hippotherapy group carried out anterior - sitting , posterior - sitting , and 
 side - sitting exercises for 10  min each while horseback riding at a walking pace ( 6  km / h ) . 

the course leader held the reins of the horse and two side - walkers held the child s legs to 
 assist the child in sitting in the saddle in order to prevent the child from falling and to 
 help the child to exercise during the horseback riding walk .
the horseback riding simulator 
 group exercised with the same protective equipment and were assisted by the same leader and 
 side - walkers .
both groups received 20  min of conventional physical therapy before hippotherapy and 
 performed stretching on the horse or horseback riding simulator for 5  min before and after 
 the exercise .
three physical therapists , who had more than 3  years of experience in 
 pediatric physical therapy and had received education in the experimental method , 
 participated in this study .
the subjects static balance ability was measured using bpm ( software 5.3 , sms healthcare 
 inc . , uk ) as the center of pressure sway length while standing for 30 seconds with the eyes 
 open and looking to the front .
statistically significant differences between the 
 measurements obtained before and after the intervention in each group were determined using 
 the independent t - test .
the children were 
 divided into two groups and evaluated pre- and post - test using bpm ( software 5.3 , sms 
 healthcare inc . , uk ) and the pbs ( pediatric balance scale ) ( table 2table 2 .
comparison of measurement values at pre - test and post - testvariablegroupprepostpbs ( score)hippotherapy35.63.841.24.7*hrs35.84.738.55.3*sway length ( mm)hippotherapy220.127.6135.014.3*hrs219.931.7142.818.8**p<0.05 meansd , pbs : pediatric balance scale , hrs : horseback riding simulator ) .
* p<0.05 meansd , pbs : pediatric balance scale , hrs : horseback riding simulator the hippotherapy and horseback riding simulator groups showed significantly decreased sway 
 lengths in the static balance test .
comparison of the pre- and post - test sway lengths showed 
 that the hippotherapy group and the horseback riding simulator group showed significant 
 decreases in sway length of 85  mm and 80  mm , respectively ( p<0.05 ) .
both groups showed 
 improved static balance , but no significant difference was found between the two groups .
dynamic balance was also evaluated pre- and post - test using the pbs ( pediatric balance 
 scale ) .
the hippotherapy group showed an increase in score of about 4 points , while the 
 horseback riding simulator group showed an increase of 3 points .
both groups showed 
 significant improvements in dynamic balance , but no significant difference was found between 
 the two groups ( p<0.05 ) .
balance control is very important for children with cp , and maintaining balance requires 
 three distinct sensory system inputs : visual , somatosensory , and vestibular9 .
generally , the dynamic sense of balance 
 depends primarily on vestibular input on unstable surfaces ; however , static balance 
 primarily depends on somatosensory input .
many studies have investigated balance and 
 clinical tools for children with cp . a systematic review identified 22 tools that can assess 
 balance10 .
hippotherapy and thr are types of exercises that affect balance , coordination , and posture , 
 contributing to the development of sensory and perceptual motor skills6 , 11 .
a horse s 
 rhythmic movement , velocity , and variations can facilitate righting and equilibrium actions . 
 during hippotherapy and thr ,
these facilitations improve muscular co - contraction and 
 postural balance resulting in improvements in the gross motor function of children with 
 cp12,13,14,15 .
many studies of hippotherapy and thr in children with cp have demonstrated they have 
 positive effects on postural control and balance .
the horseback riding simulator has also 
 been reported to be beneficial for children with cp , improving their postural control and 
 global function , and providing enjoyment16 .
haehl et al . found no significant improvement of in hippotherapy 
 and thr but indicated that hippotherapy had positive effects on the postural control and 
 balance of children with cp17 .
other 
 studies confirmed that hippotherapy and thr are suitable interventions for children with 
 cp .
the horseback riding simulator used in the present study offers several advantages over 
 hippotherapy .
the simulator is free from space limitations , has a low price , is easy to 
 handle , and is non - affected by weather conditions16 .
use of the horseback riding simulator resulted in improved muscle 
 strength and contraction in elderly people18 . a previous study of children with cp reported that use of a 
 horseback riding simulator significantly improved their postural control and balance16 .
our data indicate that both hippotherapy and use of the horseback riding simulator improved 
 the static and dynamic balance of children with cp .
however , due to the fast learning 
 characteristics of children , the long - term 12-week exercise program might have been 
 responsible for the similar results seen in balance improvement .
many factors remain to be 
 considered regarding exercise for children with cp . therefore ,
if other tools or exercises 
 were utilized , the results might not match the results presented here .
overall , our results 
 indicate that children with cp may respond equally well to the use of a horseback riding 
 simulator as they do to hippotherapy in terms of balance improvement .
first , the number of subjects was small , and second , 
 only static and dynamic balance were evaluated . in spite of these limitations , our results 
 show that the use of a horseback riding simulator can be a good intervention for children 
 with cp .
further studies incorporating larger sample sizes , various cp types , and full 
 utilization of the programs of the horseback riding simulator might be needed . in conclusion
, the horseback riding simulator could be a useful alternative to hippotherapy 
 for improving of static and dynamic balance of children with cp .
   [ purpose ] we with respect to their effects on the compared hippotherapy with a horseback 
 riding simulator ( joba , panasonic inc . 
 jp ) static and dynamic balance of children with 
 cerebral palsy ( cp ) . 
 [ subjects and methods ] twenty - six children were randomly divided into 
 two groups : a hippotherapy group that included 13 children , and a horseback riding 
 simulator ( joba , panasonic inc . 
 , japan ) group , which was also composed of 13 children . 
 the 
 two groups participated in 1 hour of exercise per day , 3 times a week , for 12 weeks . 
 the 
 subjects static balance ability was measured using bpm ( software 5.3 , sms healthcare 
 inc . , uk ) as the center of pressure sway length while standing for 30 seconds with their 
 eyes open and looking to the front . 
 dynamic balance ability was measured using the pbs 
 ( pediatric balance scale ) . 
 [ results ] both groups showed significant improvements in static 
 and dynamic balance but significant differences between the two groups were not found . 
 
 [ conclusion ] the horseback riding simulator could be a useful alternative to hippotherapy 
 for the improvement of static and dynamic balance of children with cp . 