Introduction
Primary health care has a huge responsibility in taking care of vulnerable people and/or at risk of worsening their health and/or dependency. It is at this level of care that most activities of health promotion and primary prevention are developed.
The Health Plan [1] poses as an objective: "Improve care from a comprehensive care of the person.''
Among other measures proposed:
1) Promote primary health care actions to promote an improvement in the care of people, especially those dependent, encouraging the fact of keeping people inside their family environment, whenever possible.
2)Generate scientific evidence environments in primary care respecting the improvements in quality care and set up specific interventions.
The important tasks to perform by primary care are community interventions. These actions are aimed at groups or collective groups and can be made along with other services in which their own collective groups are involved.
The group activity is a series of educational proposals that aim to encourage communication, teach people how to live in a healthy way, promote the acquisition of knowledge, skills and attitudes and develop skills in health [2].
It has been shown that teamwork can help to achieve the objectives that would hardly be achieved individually. Working in groups helps finding important social and psychological needs, and to give and receive affection and attention, and even to achieve a sense of belonging. In the field of health, work groups have proven highly effective [3].
Animal-assisted therapy (AAT) consists of having animals participate in therapeutic interventions, with the goal of promoting human health and welfare. These are complementary programs where the animals are elements which motivate participants and facilitate therapy. They contribute to creating a fluid interaction and encourage play [4], making therapy more effective and enriching.
AAT should be directed by a health professional and oriented to promoting improvements in physical, social, emotional and/or cognitive function. Sessions can be in both individual and group settings, with specific predefined objectives where progress is documented and evaluated.
Animals have been used since the 18th century to improve physical and mental health in humans. William Tuke used farm animals in 1792 to treat psychiatric patient.Some initial work was published by Boris Levinson in 1960, who observed that pets were helpful in therapy [5].
There are authors who have suggested that the presence of animals contributes to reducing agitation and aggressiveness, promoting sociable behaviour [6]. The aim of this study was to review the literature on AAT in people with intellectual disabilities measuring psychosocial outcomes. Overall there was a positive improvement reported from studies for all psychosocial outcomes (with some cognitive, behavioural, social, emotional components reaching statistical significance) [7].
In the institutionalized population, animals reduce feelings of loneliness [8] and in patients with schizophrenia; they improve socialization, basic daily activities, reduce anhedonia and increase feelings of well being [9]. Definitively, the presence of animals reduces anxiety levels and produces high levels of compliance with these programs [10].
Preliminary studies have suggested the potential benefits of animals on the physical and psychological health in humans. Despite over four decades of research, these studies remain preliminary. They are compounded by methodological problems including small sample sizes and a lack of adequate controls [11]. Some of these results come from observational studies, case series or non-controlled trials in populations that were very heterogeneous with regard to age and pathology, and have limited scientific evidence, with studies of mental disability being scarce and studies with psychomotor disorders entirely absent.
Falls are the second leading cause of accidental or unintentional injury deaths worldwide, also, falls generate severe disabilities, institutionalization and increase healthcare cost. People with intellectual disabilities experience high rates of falls. Balance and gait problems are common in people with intellectual disabilities, increasing the likelihood of falls; thus, tailored exercise interventions to improve gait and balance are recommended [12]. In fact, the best way to contribute to the prevention could be research on intervention programs.
In this sense, the referrals in the Program of Preventive Activities and Health Promotion are: practice of physical exercise as well as physiotherapy and rehabilitation of gait and balance [13].
The principal objective of this study was to evaluate the efficacy of an AAT program, in conjunction with physical therapy sessions in patients with mental disabilities and psychomotor disorders, by measuring improvements in gait and balance and evaluating their level of satisfaction with these activities.
Methods
A prospective simple-blind, parallel randomized clinical trial was conducted.
Study Population
The study sample was obtained from the Occupational Therapy Department of
the "Our House" complex of the ASPROS Foundation. Two groups were created, an intervention group (IG) who were part of the AAT program and a control group (CG) that received the same therapy, but without animals. Each subject was assigned to a group using a random number table.
Inclusion Criteria: Study subjects fulfilled all of the following criteria: a) over 18 years of age, b) diagnosed with a mental disability associated with a gait and/or balance related psychomotor disorder, c) informed, written consent for the study signed by a legal guardian.
Exclusion Criteria: Study subjects could not have any of the following: a) an animal allergy; b) fear or phobia of animals.
The sample size of 20 was calculated based on the following criteria: the power to detect differences from the hypothesis using the Student's t-test, with alpha=0.05, and an expected mean difference of 6 units (SD=5) between groups in the Tinetti Test.
Study variables
Demographic variables: age and sex.
Clinical variables: malformations of the spinal column, parkinsonian gait, distinct degrees of hemiparesis, and osteoarthritis in the lower extremities.
Outcome variables
The Tinetti Assessment Tool [14] was used to evaluate gait (TG) and balance (TB), with the tool being applied before the program and after completion. This is a two-part scale, the first being balance when seated, standing and when standing up or sitting down, using 13 parameters and with a maximum score of 16 points. The second part evaluates different aspects of gait, using nine items and with a maximum score of 12 points. The maximum total score is 28 points.
The Analogue Visual Scale (AVS) for evaluating the grade of satisfaction upon completion of the program. This is a "thermometer" scale, a straight line which is 10 cm long and equivalent to 10 points. The subjects mark an "X" to indicate their level of satisfaction on a scale of 0 to 10.
Therapy Animal
This is an animal specifically trained to integrate itself into a therapeutic program as a facilitator therapy assistant. A dog was chosen due to their sociability, familiarity and ability to stimulate and interact with people. The same animals participated throughout the program. Specifically the two therapy animals were an 8-year-old female of Golden Retriever and a 7-year-old female of West Highland Terrier.
Both therapy dogs have not shown any sign of stress throughout the intervention; results such as those have been achieved by Ng et al. [15] who analyzed the wellbeing of the animals taking part in AAT, concluding that there is no risk for the animal.
Intervention (Annex 1)
Twenty-eight group physical therapy sessions were conducted during fourteen weeks, twice a week for 60 minutes each. The groups were divided into two sub-groups, with both sessions being held on the same morning in the IG and on the same afternoon in the CG. The sessions were overseen by a physiotherapist from the ASPROS centre who was directing the intervention and guaranteeing the right performance of the exercises; and the AAT technician who controls the interaction between the dogs and their users ensuring the wellbeing of the animals.
The sessions had concrete objectives predefined and agreed upon by the physical therapist and the AAT technician.Several physical therapy exercises addressed to working on gait and balance were conducted, with specific objectives for each session: in some the balance work predominated, using pathways with cones, rings and obstacles that, in the IG were performed with the dog; in other sessions gait work was predominant, where the control group walked alone and the intervention group walked with the dog. There were also imitation exercises: sitting, squatting, walking backward, turning in place, etc. (in the IG the dog was taught to do these exercises). The physical therapist was the same for both groups.
A collaborator from outside the program evaluated the test before and after therapy, blinded to whether the patient was in the IG or the CG.
Data Analysis
A descriptive analysis of all the variables was done. Quantitative scales were summarized as means, medians, standard deviations (SD), and group ranges. Inter-group comparisons of age were done using the Student's t-test. Categorical variables (gender and psychomotor disorders) were compared using the chi-squared test. To evaluate the effectiveness of the intervention, the two groups were compared using the Mann-Whitney test for the following variables: Tinetti scores before and after therapy (delta TM and delta TB), and the post-therapy AVS score. The 95% confidence interval was calculated for the estimated mean improvement of the scores in both groups. P-values below 0.05 were considered statistically significant.
Results
The mean (SD) age of subjects was 49 (9.2) years: 45 (10) years in the IG and 52 (7) in the CG, without statistical differences (p=0.1).
A total of nine women (45%) and 11 men (55%) were included. There were four (40%) women and six (60%) men in the IG, and five women (50%) and five men (50%) in the CG, non-differences between groups (Table 1).
The most frequent motor disorders and their prevalence among cases were: spinal column deformations, 25% (three IG and two CG); parkinsonian gait, 15% (one IG and two CG); distinct degrees of hemiparesia, 15% (two IG and one CG); osteoarthritis in the lower extremities, 10% (zero IG and two GC); and more than one disorder, 35% (four IG and three CG) (Table 2).
The Tinetti scores showed a significant improvement in balance (mean improvement = 0.85, CI95%:0.18 - 1.52) and gait (mean improvement = 2.15, CI95%: 1.17 - 3.13) in both groups.
The mean difference in Tinetti scores before and after treatment was, for balance: 0.2 (CG), 1.5 (IG) (p<0.05) and for gait: 2.4 (CG), 1.9 (IG) (p>0.05), as shown in Figures 1 and 2.
The degree of satisfaction measured on the AVS scale was a mean of seven in the CG and 10 in the IG, a statistically significant difference (Table 3).
There were no losses to follow-up and compliance was 100% in both groups for all participants.
Discussion
In recent decades animals have been incorporated into a broad range of therapies in several fields, including clinical psychology, occupational therapy, physical therapy and physical rehabilitation, speech therapy, geriatric care, mid- and long-term care institutions and nursing homes, hospitals, orphanages, juvenile centers and prisons [16].
This study shows an improvement in balance and gait in patients with mental disabilities and psychomotor disorders after a therapeutic program. This improvement is greater and statistically significant when the therapy is assisted by an animal as regards balance and satisfaction. Part of these results can be attributed to the fact that the IG developed more interest in their activities and had greater motivation to participate in exercises, because the dog was a novel, amusing and exciting element of therapy. It is difficult to compare the results of our study since no bibliography has been found on this question and in this population group.
Balance training is an important component of physical activity interventions, with growing evidence that it can be beneficial for people with intellectual disabilities. In other study, postural balance and functional strength showed significant improvements in the balance training group (p<0.05) as compared to baseline [17]. The Tinetti balance and gait instrument was successfully administered to adults with intellectual disabilities and resulted in high diagnostic accuracy for identifying individuals at risk for falls [18].
As reported by other authors, AAT is an innovative resource for the management of situations of functional dependence, psychiatric or behaviour disorders and care of people with disabilities and special educational needs [4].
In a clinical trial performed among the elderly population, improvement in pain and functional capacity through physical therapy sessions was assessed; the results obtained with therapy dogs were the following: a statistical significance obtained in the IG of the values "Walking on flat ground" and "Raising and descending stairs" of the WOMAC Questionnaire in patients with osteoarthrosis, which means a greater facility to leave home. Other items that showed a higher and meaningful improvement in IG were "Getting in and out of the bathtub" and "Performing light domestic tasks". All of this means a protection factor of the fragility and dependence of the elderly population. Therefore, AAT, as a complementary therapy to physical therapy, seems to be effective [19].
As other authors claim, AAT helps participants improve their functionality using their own capabilities [20]. The improvement obtained in the walking ability of the participants is similar to the results obtained by other authors with significant improvements, such as the AAT being included in the re-education of the gait [21].
In a bibliographic review by Munoz et al. in which they analyzed a total of 23 publications of important medical journals related to the field of rehabilitation of neurological diseases, it was seen that AAT increasingly shows scientific evidence as a complementary method to other existing therapies [22].
Patients appeared more involved in exercises with the animal, increasing the spontaneity of the sessions up to the point that subjects began to do exercises on their own initiative or in response to prompting by the animal, promoting social interaction between members of the group, with a better degree of satisfaction.
Participants of the two groups expressed high satisfaction with the intervention which was reflected in the satisfaction survey; this improvement is greater and statistically significant in the IG. This was similar to another controlled study with 52 patients, where 83.33% of the participants of the IG made a positive comment in the survey and only 27.27% from the CG. This difference was statistically significant (p=0.0002) [23]. This satisfaction concerning AAT is also reflected in other studies by other researchers [24,25].
AAT favours relationships as the animals open an emotional communication pathway between the therapist and the animal, thus changing the initial resistance of the patient to initiate any therapy [4]. In fact, in this project the presence of the dog apparently draws and holds the attention of the patients and this was used to achieve more productive sessions. Cherniack [11] argued that animals often constitute an important focus of attention and are a topic of conversation.
Aspects such as motivation, empathy, concentration and attention are difficult to measure objectively and quantify, but it is important to take them into account when planning any type of therapy, because they help improve outcomes. AAT is going to promote a better communication with health professionals. The results of this study suggest that AAT may provide benefits, but the goals will mean a bigger opportunity for a greater adherence to the therapeutic sessions and to explore more deeply the patient's feelings in a comfortable environment [25].
This study was focused on measuring and evaluating whether balance and gait improved, which are more easily quantified variables.
An important limitation of the study was the variability in psychomotor disorders and degrees of handicaps. Another limitation of the study was the small sample size, affecting its statistical power to detect differences and the possibility of an analysis adjusted by age groups or psychomotor disorders. However, the sample size was bigger than in the majority of studies found in our search of the literature [26] and sufficient to detect some differences in responses (AVS, Tinetti scale). With this study we aim to contribute to the knowledge on the therapeutic benefits of these animal assisted therapies, but we highlight the need of developing wider research on this field.
Other fields that have adopted AAT are the treatment of spinal injury rehabilitation [27] and AAT also elicits a good response in the treatment of communication problems and speech disorders, having been applied in persons with aphasia [28], because the presence of the animal stimulates both verbal and non-verbal communication [29].
Based on bibliographic searches and the results obtained, it appears that AAT is a therapeutic modality which promotes quality of life and provides positive health benefits and that in recent decades this type of therapy has gained followers and its use is increasing [11]. Nevertheless, it is necessary to provide a theoretical and scientific basis for its use, with objective parameters and results.
Primary health care needs to develop non-pharmacological methods and treatments for the comprehensive treatment of people; these have become an important part of the management of chronic disorders, often used as a complement to pharmacological treatment. These include AAT [30], where the literature has shown that animal-assisted interventions can bring benefits to people's living standards [26].
Animal assisted therapy can be of great utility in occupational therapy centres and centres for the treatment and support of people with special needs, to improve physical function. It is a resource that has shown its usefulness and novelty as a community intervention performed by professionals at primary care centers.
Acknowledgements
The authors would like to thank the "Our House'' centre (ASPROS) for their collaboration in carrying out the study and the clients who participated in it, as well as the Affinity Foundation for maintaining and making their dogs available to us.
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