some programs refer to the therapy horse as an "equine partner". other programs view the horse as a "metaphor" with no defined role other than to "be themselves." equine facilitated wellness programs, particularly those following the efw-canada certification route view the horse as 'sentient being': "the equine is a sentient being, partner and co-facilitator in the equine facilitated relationship and process". effectiveness there is some evidence that hippotherapy can help improve the posture control of children with cerebral palsy, although the use of mechanical hippotherapy simulators produced no clear evidence of benefit. a systematic review of studies on the outcomes of horseback riding therapy on gross motor function in children with cerebral palsy was concluded in 2012 with a recommendation for a "large randomized controlled trial using specified protocols" because, although positive evidence was indicated by nine high-quality studies surveyed, the studies were too limited to be considered conclusive. overall, reviews of equine-assisted therapy scientific literature indicate "there is no unified, widely accepted, or empirically supported, theoretical framework for how and why these interventions may be therapeutic" the journal neurology published a 2014 study finding inadequate data to know whether hippotherapy or therapeutic horseback riding can help the gait, balance, or mood of people with multiple sclerosis. newer studies have found hippotherapy paired with traditional treatment can increase balance and quality of life in individuals with multiple sclerosis. there is no evidence that therapeutic horseback riding is effective in treating children with autism. there is currently insufficient medical evidence to support the effectiveness of equine-related treatments for mental health. multiple reviews have noted problems with the quality of research such as the lack of independent observers, rigorous randomized clinical trials, longitudinal studies, and comparisons to currently accepted and effective treatments. a 2014 review found these treatments did no physical harm, but found that all studies examined had methodological flaws, which led to questioning the clinical significance of those studies; the review also raised ethical concerns both about the marketing and promotion of the practice and the opportunity cost if patients in need of mental health services were diverted from evidence-based care. the review recommended that both individuals and organizations avoid this therapy unless future research establishes verifiable treatment benefits. accreditation and certification the professional association of therapeutic horsemanship (path) accredits centers and instructors that provide equine-assisted therapy. the equine assisted growth and learning association (eagala) focuses only on mental health aspects of human-equine interaction, and provides certification for mental-health and equine professionals. in canada, centers and instructors for therapeutic riding are regulated by cantra, also known as the canadian therapeutic riding association. the field of equine facilitated wellness is regulated by equine facilitated wellness – canada (efw-can) which provides a national certification program and certifies trainers and mentors to provide independent training at approved programs across canada. in the uk there are a growing number of training providers offering externally accredited equine assisted and facilitated qualifications. there is currently no overarching regulating body in the uk. some organisations are specifically offering therapeutic or coaching based approaches; others offer skills-based approaches which building on existing professional skills and practices. the american hippotherapy association offers certification for working as a hippotherapist. hippotherapy clinical specialty (hpcs) certification is a designation indicating board certification for therapists who have advanced knowledge and experience in hippotherapy. physical therapists, occupational therapists, and speech-language pathologists in practice for at least three years (6,000 hours) and have 100 hours of hippotherapy practice within the prior three years are permitted to take the hippotherapy clinical specialty certification examination through the american hippotherapy certification board. those who pass are board-certified in hippotherapy, and entitled to use the hpcs designation after their name. hpcs certification is for five years. after five years the therapist can either retake the exam or show written evidence of 120 hours of continuing education distributed over the five years. continuing education must include 50% (60 hours) in education related to equine subject matter: psychology, training, riding skills and so on; 25% (30 hours) in education related to direct service in the professional discipline and 25% (30 hours) in any other subject related to hippotherapy. an alternative is to provide written evidence of scholarly activity appropriate to the field of hippotherapy. acceptable scholarly activity may include graduate education in hippotherapy, publication of articles on hippotherapy in juried publications, scientific research related to hippotherapy, the teaching or development of hippotherapy, or acting as aha-approved course faculty. aha, inc. now recognizes two different ahcb credentials: ahcb certified therapist and ahcb certified hippotherapy clinical specialist.