A Study Of Stakeholders Knowledge And Attitudes Towards The Use Of Therapeutic Horse Riding For Children With Disability
Commissioned By Festina Lente
Completed By Ucd School Of Public Health, Physiotherapy And Population Science: September 2010
Investigators: Dr. Cliona O’Sullivan, Dr. Catherine Blake, Ailbhe Houlihan
Sponsors: Enterprise Ireland
This report is about Therapeutic Riding. Therapeutic Riding (TR) is conducted by “non-therapist riding instructors and assistants based upon their training and knowledge of the rider’s disabilities and of methods for safely using therapy-trained horses”, (Sterba 2007). The rider undergoing TR is directed and assisted by the instructor and side-walker during various activities such as reaching for an object, placing objects or imitating the instructor’s movements. The horse may initially remain still during activities and as therapy progresses may move slowly while the rider carries out the activities. Hippotherapy on the other hand is carried out by a specially trained physiotherapist or occupational therapist and the horse as well as the environment is used to challenge multiple body systems to accomplish specific treatment goals determined to be important during assessment, (Shurtleff et al 2009). “Hippo” is the Greek word for horse and hippotherapy is therefore defined as therapy using a horse. TR and Hippotherapy have become very popular in North America and TR is used more widely than hippotherapy (90% versus 10%), (Sterba 2007). At present, there is no hippotherapy service available on the island of Ireland and one therapeutic riding service available in Bray, Co. Wicklow.
Most of the research in TR and/or hippotherapy has been carried out with children with cerebral palsy (CP). There is evidence to suggest that such therapy has a positive effect on gross motor function, (Sterba 2007), symmetry of muscle activity, (McGibbon et al 2009, Benda et al 2003), dynamic trunk and head stability (Shurtleff et al 2009) and functional reach (Shurtleff et al 2009) in children with CP. The physiological mechanisms underlying such improvements are thought to be due to the rider responding to the 3 dimensional, reciprocal movement of the walking horse. Pelvic movement during horse riding resembles that of walking; displacement of the riders’ centre of gravity facilitates dynamic postural stabilisation; muscular co-contraction and joint stability. The inclusion of horses in therapy sessions is also thought to have the added benefit of engaging and motivating the child (Benda et al 2003).
SCOPE OF PROJECT
This study was commissioned by Festina Lente and carried out by the School of Public Health Physiotherapy and Population Science, University College Dublin. The aim of the study was to determine knowledge and attitudes to the use of Therapeutic Riding among parents of children who have used the service and therapists, and to establish the level of interest and demand for this service.
Festina Lente is a non-profit charity based in Bray, Co.Wicklow and provides a wide range of educational, therapeutic and employment opportunities to people with disabilities and/or people who are socially disadvantaged. In particular, through Festina Lente Riding School, there is considerable emphasis placed on facilitating children, teenagers and adults with disabilities to avail of recreational and/or therapeutic riding, or indeed any equine related experience.
In order to achieve the objectives of the study a mixed methodology was used to target the two populations of interest; (i) parents and guardians of children with disabilities who have completed a programme of therapeutic riding and (ii) clinicians (physiotherapists and occupational therapists).
Only parents of children who have used the service in the previous 6 months were invited to reduce recall bias. Clinicians were recruited from the physiotherapy and occupational therapy services in the following areas: Primary care and early intervention teams within the framework of the 11 Local Health Offices (LHOs) of the Dublin/Mid Leinster HSE area; The Central Remedial Clinic, Enable Ireland, St. Michaels House and St. John of God.
The first part of the study involved semi-structured interviews of parents/guardians of children who are current users or past users of the Therapeutic Riding service provided by Festina Lente. Parents were sent a participant information letter and consent form from Festina Lente inviting them to participate in a face-to-face interview. If they were interested in participating they were asked to contact one of the investigators (AH) to arrange a time for interview. All interviews were conducted in Festina Lente, and were audio-taped and transcribed for analysis later. A template for interview questions is attached (Appendix 1)
The second part of the study involved a cross-sectional postal survey of clinicians (physiotherapists and occupational therapists) who work with children with disability. The physiotherapists and occupational therapy managers of the services outlined above were initially contacted by e-mail to inform them of the study and to seek permission to send questionnaires to their staff. Once permission was granted by the therapy manager, the postal questionnaires were sent to them asking them to distribute the questionnaires to their staff
A pilot study was conducted on a small number of participants to determine clarity of both the questionnaire and interview questions and to establish the time taken for both data collection methods. The content of both the questionnaire and interview template was also be reviewed by a panel representative of the sample including a physiotherapist and parent/guardian.
Simple descriptive statistics were used to analyse findings from the questionnaires. For the interviews, qualitative comments and statements were analysed using simple thematic analysis.
Ethical approval was granted by the University College Dublin Human Research Ethics Committee, (Ref: LS-10-57).
Part 1 – Interviews
Eleven parents of children riding in Festina Lente riding school participated in the interviews. The children ranged in age from four to eleven years of age. The children had a variety of different medical conditions including Down syndrome, autism, cerebral palsy and other genetic and developmental conditions. The interview questions were grouped together according to similarity to give seven categories under which the interviews were analysed and the results reported. These categories are:
1. Pre and post therapy expectations
2. Amount of time child has been attending therapeutic riding sessions at Festina Lente riding school
3. The parent’s classification of their child’s riding as therapeutic, recreational, or both.
4. The benefits that the parents feel their child has gained from therapeutic riding at Festina Lente
5. Recommendations for change for Festina Lente
6, How the parents discovered Festina Lente riding school
7. The parent’s overall impression of the service delivered by Festina Lente riding school
The responses to the questions in categories one (expectations) and four (benefits) were analysed using the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) framework. The framework which was devised by the World Health Organisation is “designed to record characteristics of the developing child and the influence of environments surrounding the child” which was an aim of this study; to look at the effect of the therapeutic riding at Festina Lente riding school on the development of the child. We divided the responses of the parents to these questions into the three categories of the ICF-CY; 1) body structure and function, 2) participation and activity, and 3) environmental factors.
1. Pre and post therapy expectations
|Table 2: Pre-therapy Expectations|
|Body Structure & Function||Participation & Activity||Environmental Factors|
Most of the parents expressed that prior to their child starting riding at Festina Lente they didn’t have very high expectations, they didn’t really have any expectations or that they didn’t know what to expect. Some of the parents expressed specific benefits they hoped horse riding would attain for their child, as listed in table Y, but the most common expectation was that horse riding would be something their child would enjoy and would develop into an activity or interest for them. One parent described her expectations as: “Really just for her to enjoy something, just to get enjoyment out of it” (interview 4, line 20). And another parent said: “I kind of hoped it would give him an interest, like a hobby” (interview 9, line 26).
When asked about their child’s pre-therapy expectations, the majority of the parents responded that their child didn’t really have any expectations as they were either too young to understand or that they don’t really operate that way. One parent explained:
“I don’t really know if he had any to tell you the truth, he wouldn’t really have realised” (interview 3, line 27-28).
Two of the children were described by their parents as looking forward to the horse riding, one mother said:
“The first day we came up he was all excited and liked the look of it now.
He’s very cagey about anything new but the first day we came he really liked it”
(interview 9, line 33-35).
Only one parent said that their child was a bit negative about the horse riding initially. A couple of parents also said they didn’t know what their child’s expectations, as one parent described:
“I don’t quite know what they were. I didn’t talk to him about his expectations
because I didn’t want to get him too fired up in case it didn’t work out”
(interview 1, line 40-42).
Each of the eleven parents said that their expectations of their child riding as Festina Lente had been met, and many said that their expectations had been surpassed. A parent exclaimed when asked had her expectations been met:
“Absolutely, and more, and then some. It’s just fantastic” (interview 1, line 131).
Another parent expressed:
“Oh yeah, more than. I really didn’t think it would come this far, I came for one thing and
I got ten more things, or he got ten more things. It’s great to have the physical side and the developmental side dealt with. He loves it, he just adores it” (interview 3, line 90-92).
The majority of the parents said that their child didn’t have any pre-therapy expectations so they couldn’t respond as to whether their child’s expectations had been met as they didn’t really have any to begin with. However they all said that their child enjoyed horse riding at Festina Lente. One parent reported when asked had her child’s expectations been met:
“She wouldn’t have had any, but she enjoys it now” (interview 11, line 120).
The parents of the children who had been looking forward to the horse riding said their child’s expectations had been met.
2. Amount of time attending
Eight of the eleven parents had children who attended Festina Lente riding school regularly for riding, the other three parent’s children are on a cancellation list and attend irregularly, and they are awaiting a permanent place at the riding school. The amount of the time the children had been attending for riding sessions varied, with the child who attended the longest having attended for 4 years and the least amount of attendance was four sessions. Of the eight children attending Festina Lente regularly, the average number of years of attending Festina Lente was 1.59 years.
3. Parent’s classification of child’s riding
Of the eleven parents interviewed, eight of them classified their child’s riding as being both therapeutic and recreational as the felt it was very beneficial to their child but it was also something the child enjoyed doing as a hobby. One parent described it:
“He enjoys it as well but he has to work hard at it” (interview 1, line 62-63).
Another parent described it as:
“it’s really good for him even if he doesn’t realise it’s good for him” (interview 7, line 50-51).
Two parents classified their child’s riding as being solely therapeutic and only one parent classified their child’s riding as solely recreational
The benefits of therapeutic riding included themes related to all three categories of the ICF-CY framework and are listed in Table 2.
Table 2: Benefits
|Body Structure & Function||Participation & Activity||Environmental Factors|
“I just love the confidence, like his confidence to let me go. Normally he likes me to hang around at parties or events outside schools so this is where he actually asks me to leave” (interview 2, line 74-76).The most common occurring themes in the interviews in the body structure and function category were increased confidence, improved posture, tone regulation, physical development, the calming effect and increased use of language/communication. One parent described their child’s increased confidence:
The calming effect of the horses and horse riding was a universal effect for all of the autistic children who participated in the study, as well as one other non-autistic child. One parent expressed this effect:
“he finds it hard to switch off usually, but you see him here stroking the horse and he just calms down” (interview 7, line 51-52).
The increased use of language/communication was confirmed by a parent:
“it definitely has prompted a lot of new phrases, and spontaneous language because he has met new situations” (interview 9, line 55-57).
The overall physical development of one child was incredible, her mother said:
“we have a video of her first time here…..and we thought she was marvellous, but looking back she couldn’t even sit up on the horse or anything like that. So now looking at her is incredible…sitting on the horse independently” (interview 11, line 109-112).
The mother also said:
“Before X started riding here, she used to come down in a walking frame. She was in a walking frame and that was pretty much controlled by me, she couldn’t control it on her own. But now she’s actually walking independently, so I don’t know if you could fully attribute it to horse riding but certainly it had some part to play” (interview 11, line 54-58).
The most common themes in the participation and activity category were enjoyment/ happiness/smiling, finding a love/passion, development of an activity/hobby/interest and the development of new skills. One mother explained her child’s horse riding:
“It’s probably his favourite activity….He never refuses to come…whereas he’d refuse to do a lot more. He’d never say no to horse riding” (interview 3, line 42, 83-85).
The same parent also added:
“He loves it, he just adores it. When he’s happy, we’re happy” (interview 3, line 92-93).
Another mother also reported how her child’s enjoyment of horse riding changed her initial scepticism towards it:
“Well I have to be honest and say for years I had absolutely no interest what so ever, in any kind of horse riding activities. I thought it might have been just faffiness really…. But I have to say after the first riding lesson, I completely changed my mind because I’ve never seen such a face of sheer joy, and I realised he’s found his passion” (interview 10, line 13-15, 18-20).
Another parent reported how therapeutic riding was an accessible activity for her child:
“A lot of things are difficult for her to participate in; one of her big challenges is communication. This doesn’t involve a lot of communication; it’s all sort of on her own terms” (interview 4, line 60-62).
The environmental factors listed in Table 2 were not recurring themes throughout the different interviews. These benefits listed in the table were mentioned individually by different parents as particular benefits to their child. Mostly the benefits of the service and the environment in Festina Lente are mentioned in the category of the parent’s overall impression of the service at Festina Lente.
5. Recommendations for change
Each of the eleven parents were asked if there were any negatives or anything they would like to change about the service in Festina Lente. None of the eleven parents had any negative comments about Festina Lente. One issue however which was raised by several parents was that they wish they could get more sessions for their child at Festina Lente, or those on the cancellation list wanted to get a permanent place for their child. As one parent described:
“I’d just love more time here. Obviously there is a huge waiting list but you know, I would love to see him progressing here, and have more time for lessons. And eventually maybe do some courses here as an adult” (Interview 3, line 66-68).
Another parent expressed:
“we’d love to be on it permanently, it is limited by its size, there are only so many personnel they have trained up to do this, and so many horses. It is just unfortunate that people for whom it is so important can’t all participate and benefit from it on a regular basis” (interview 1, line 90-93).
However the same parent praised Festina Lente:
“the fact that anywhere is prepared to devote time and energy and effort to make this riding work for him is brilliant. I can only stand in admiration of them” (interview 1, line 87-89).
Another parent commented about the benefit of recent change in Festina Lente:
“I usually have to drag all my other kids with me as well but since the shop opened, it’s fine, we have something to do” (interview 10, line 96-97).
6. How parents discovered Festina Lente
Many of the parents cited multiple sources for having discovered the riding school. The largest group, of seven parents, heard about the service through a friend. Three parents heard about the service through a family member, two parents were advised of the service by a healthcare professional (one physiotherapist and one psychiatrist). One parent heard about the service through word of mouth, one parent saw the Festina Lente van driving around and enquired then, one parent saw a programme on television about the service and one parent saw an article in a national newspaper about the service.
7. Parent’s overall impression of service
Each of the eleven parents had very strong positive impressions of the overall service provided by Festina Lente. This included the instructors, the approach towards the children, the environment, and the centre.
One mother praised the centre:
“I think it’s just fantastic…..The whole place, you can come and buy plants and bring them home to plant in your garden, and there are the turtles and lots of kind of stuff” (interview 1, line 134-136).
She also added:
“It’s nice to come somewhere and nobody is asking questions and nobody is pointing or looking at him” (interview 1, line 147-148).
Another parent exclaimed:
“We just feel so lucky to be here, to have got a place here” (interview 3, line 99-100).
And another said:
“it’s just a great place to be linked in with” (interview 7, line 97).
One mother explained how it isn’t just the kids that benefit from attending Festina Lente:
“I mean even coming around for half an hour yourself, you feel great after half an hour. So it’s for the parents as well” (interview 9, line 76-77).
Many of the parents are appreciative of riding sessions focused on making horse riding accessible for children with a wide range special needs, where the instructors can adapt the sessions to the individual and are flexible in their approach so as to make riding a positive experience for the client. For some parents this was the first riding school that would take on their child due to their special needs;
“Festina Lente were the first ones that would take her” (interview 11, line 15-16).
Other parents had tried other riding schools and it had proved unsuccessful, a parent reported:
“She was doing horse riding lessons before but they were group session, and she was lost completely in the sessions because she was in with other, well typical children that were learning at a faster pace than her and this goes at her own pace” (interview 4, line 13-15). Some parents realised it was the only centre suitable to send their child, as one mother explained:
“He couldn’t have managed a lesson in an ordinary riding school; he wouldn’t have got the same level of teaching” (interview 8, line 21-22).
One mother in particular was very impressed with Festina Lente’s ability to make horse riding accessible for her child:
“I was a bit pessimistic about how it would go and what anybody would be prepared to do to accommodate his needs, particular needs. But I had heard great things about here and I just thought well if anywhere, is going to do anything for him, it will be Festina Lente……The fact that they have given a lot of thought to how they can best proceed, I can’t ask for any more than that” (interview 1, line 26-29 and 86-87).
The parents praised the instructors many times throughout the interviews, as one parent expressed:
“The teachers are brilliant….because they’re not only good with the children but good with the horses, so they’re a real unusual breed of people really” (interview 8, line 99-101).
Another parent reported:
“Everybody here has such a really calm approach to everything that I think it really reassures the kids” (interview 9, line 75-76).
Finally one parent summed up the general positive impression of Festina Lente:
“We’ve just been really happy with everyone that we’ve met here, and there’s just a great attitude to the kids, and a lovely atmosphere, and it’s just very nice” (interview 9, line 109-110).
Part 2 – Therapists’ Survey
The results of the postal survey are divided into 2 sub-sections; (i) characteristics of respondents and (ii) knowledge of and attitudes towards therapeutic riding and hippotherapy
Characteristics of respondents
One hundred and forty questionnaires were distributed by post and 60 people responded giving a response rate of 43%. The speciality areas where respondents worked are outlined in Figure 1. Most respondents worked in paediatric rehabilitation, followed by primary care and community care. It must be noted that X respondents worked across 2 or more specialities.
Figure 1: Area of work
Most respondents treated both children and adult clients (48%) with almost a third of respondents working solely in paediatrics (Figure 2) Figure 3 displays the distribution of conditions encountered by clinicians, the most common being cerebral palsy and intellectual disability.
Figure 2: Client Group
Figure 3: Conditions treated
Key: CP: Cerebral palsy, MS: Multiple sclerosis, SCI: spinal cord injury, MND: motor neurone disease, ID: intellectual disability.
Knowledge of therapeutic riding and hippotherapy
The responses to the questions in categories one (expectations) and four (benefits) were analysed using the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) framework. The framework which was devised by the World Health Organisation is “designed to record characteristics of the developing child and the influence of environments surrounding the child” 1 which was an aim of this study; to look at the effect of the therapeutic riding at Festina Lente riding school on the development of the child. We divided the responses of the parents to these questions into the three categories of the ICF-CY; 1) body structure and function, 2) participation and activity, and 3) environmental factors.
Interestingly more respondents had heard of therapeutic riding (81%) than hippotherapy (71%). Tables 3 and 4 outline the keywords which therapists used to describe therapeutic riding and hippotherapy respectively. These keywords are categorised using the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) framework, to reflect how therapeutic riding and hippotherapy may influence different aspects of child development, (i.e. at the level of body structure and function, activity and participation or influencing a child’s environment). In responding this question regarding the therapists understanding of therapeutic riding and hippotherapy, most respondents focused on the outcomes of this intervention at the level of body structure and function. More respondents described therapeutic riding as having more positive outcomes than hippotherapy in the domain of participation and activities; e.g. enjoyment and social interaction. Descriptions of therapeutic riding and hippotherapy services were also classified under environmental factors. Many different descriptions were offered, including that of two respondents who described therapeutic riding as riding for the disabled. Eight therapists believed that therapeutic riding and hippotherapy was the same thing.
Table 3: Therapists understanding of therapeutic riding
|Body Structure & Function||Participation & Activity||Environmental factors|
Table 4: Therapists understanding of hippotherapy
|Body Structure & Function||Participation & Activity||Environmental Factors|
Fifty seven respondents cited numerous benefits to therapeutic riding. Most benefits cited were in the domains of body structure and function and participation and activity. The main themes are summarised in Table 5. One respondent said that they were unsure of the benefits of therapeutic riding while 3 did not respond to this question.
Table 5: Benefits of therapeutic riding
|Body Structure & Function||Participation & Activity||Environmental Factors|
When asked who would benefit most from therapeutic riding, therapists cited clients with neurological or movement disorders, intellectual disabilities and mental health problems. Cerebral palsy was the specific condition that was cited most frequently but autism, multiple sclerosis, spinal cord injury; traumatic brain injury, back pain, chronic pain, Rett’s syndrome, Down syndrome, spina bifida, dyspraxia and developmental coordination disorder were also listed. Three therapists also said that they had observed positive effects of therapeutic riding on clients with autism, cerebral palsy, intellectual disability and developmental coordination disorder. Some respondents also said that this therapy was more suited to children.
While only 13% (Figure 6) of respondents considered therapeutic riding as a valuable service to their clients, 58% (Figure 7) would recommend such a service to their clients.
Figure 6: Value of Therapeutic Riding to Clients
Figure 7: Recommend to clients
When reasons for not recommending therapeutic riding to clients were examined; 6 therapists felt that they didn’t know enough about it or where to access the service. Two therapists cited transport and cost to be a barrier to recommending the service. Finally six therapists said that their caseload wasn’t appropriate for the service (e.g. musculoskeletal caseload), two of whom said they would refer if they had appropriate clients.
When asked about their expectations from a therapeutic riding service, client enjoyment and therapeutic benefits were most commonly cited. Respondents also said that they would expect staff to be well trained, that appropriate assessments would be carried out, parents and family would be included and that they as therapists would be liaised with if appropriate.
Just under a quarter of respondents were aware of the therapeutic riding services provided by Festina Lente, (Figure 8). Seventy percent of respondents (n=42) would like more information on the services provided by Festina Lente. The particular types of information requested are outlined in Figure 9, with cost, referral mode and criteria for inclusion to most frequent information requested.
Figure 8: Knowledge of Festina Lente
Figure 9: Types of information requested
Key: Avail: Availability; Ref: Mode of referral; WL: Waiting list; Descrip: Description; Inc/Ex Crit: Inclusion and exclusion criteria; Fac: facilities; Staff Qual: staff qualifications; Info. Horses: Information on Horses.
DISCUSSION AND RECOMMENDATIONS
This is the first study to investigate the attitudes and beliefs about therapeutic riding among parents of children who have used the service and clinicians in the Republic of Ireland. The experiences of parents whose children have undergone therapeutic riding sessions in Festina Lente is extremely positive, with all respondents saying that their expectations had been met or surpassed. This response is validated by lengthy list of benefits observed by parents, (Table 2) which surpasses that of their pre-therapy expectations, (Table 1). An important benefit to parents was the participatory effect of therapeutic riding, with benefits such as enjoyment/happiness/smiling repeatedly cited. In studies which examine the benefits of therapeutic riding or indeed any intervention among children with disability, most outcomes measured are those of body structure and function. No studies to date have examined the effects of therapeutic riding (or hippotherapy) on participation or activity, a point noted by Snider et al (200X). The results of this study suggest numerous benefits of therapeutic riding on participation and activity of children with various disabilities.
Other attributes of the service offered included benefits to parents and siblings, an issue which could be explored further in future studies. The instructors were also commended numerous times for the approach that they take with children.
There was great variation in the regularity of sessions attended by children with 8 of the children regularly and 3 children who were on a cancellation list and therefore attended irregularly. As reported in the previous section, several parents wished for more sessions for their child. In the long term, this would be achievable by expansion of both the facilities and the service. However a short term solution could be made by arranging therapy sessions into blocks whereby therapy lasts for a period where a therapeutic benefit would be expected to be seen, (e.g. 8 to 10 sessions), followed by a “rest” period, and followed by another “block of therapy”. While more research is needed on the optimal frequency and duration of therapy, such a strategy may enable more access to the therapeutic riding service.
While most therapists had heard of both therapeutic riding and hippotherapy, there was evidence of confusion between the two modalities among some therapists. Eight of the 60 respondents believed them to be the same thing, while two respondents described therapeutic riding as being riding for the disabled. Overall, the majority of respondents demonstrated a good understanding of both therapeutic riding and hippotherapy which was evident from their descriptions of both interventions.
Therapists recognised the benefits of therapeutic riding and the list of benefits outlined was comprehensive (Table 5). While 58% of respondents would refer their clients to a therapeutic riding service, only 13% of respondents felt that therapeutic riding would be of value to their clients. The disparity between these 2 figures may reflect the lack of scientific evidence behind therapeutic riding: The small number of intervention studies that have been carried out on therapeutic riding and hippotherapy have lacked control groups, had small numbers of participants or looked at specific impairments rather than global function and participation. Furthermore, there is a need for a cost benefit analysis of therapeutic riding. As outlined above, the results of the parental interviews suggest a significant beneficial effect on participation and activity levels of children with disability who take part in therapeutic riding. The effect of therapeutic riding on participation and activity need to be established so that publicly funded disability services may include therapeutic riding, ensuring increased access to children with disability.
Of those who would not refer clients to such a service, most cited lack of knowledge as a reason for non-referral. The information packs that were included in the survey should help this situation but also better advertising is warranted among this group; e.g. in professional journals or during annual conferences. The findings of this survey give us a clear indication of the type of information which therapists are looking for. Furthermore, the therapeutic benefits of therapeutic riding need to be investigated and findings disseminated through high impact journals. The inclusion of therapeutic riding as a topic in undergraduate therapy education or opportunities for training among postgraduate therapists warrants discussion.
|1. Alteration of structure of services to aid accessibility|
|2. Further research which would examine the therapeutic benefits of therapeutic riding across the domains of body structure and function, participation and activity and environmental factors|
|3. The effects of therapeutic riding on parents and siblings need to be established|
|4. A cost benefit analysis of therapeutic riding is warranted|
|5. Opportunities for undergraduate and postgraduate education and training days for therapists need to be explored|