Abstract
Background: Hippotherapy, a sensorimotor-rich intervention proposed for children with Autism Spectrum Disorder (ASD), is suggested to influence executive function (EF). However, the underlying electrophysiological mechanisms, particularly changes observed in resting-state Electroencephalography (EEG), remain underexplored. Methods: A total of forty-eight children with ASD, aged 9-12 years, participated in this quasi-experimental, non-randomized pre-test-post-test study. Participants were assigned to either a standardized 12-session hippotherapy program (n = 24) or a waitlist Control group (n = 24). EF was evaluated pre- and post-intervention using validated measures: the Wisconsin Card Sorting Test, Stroop Color-Word Test, Corsi Block-Tapping Task, and Tower of London. Resting-state EEG data (19 channels, 250 Hz) were recorded before and after the intervention and analyzed for spectral power, pairwise Pearson correlation, phase-based functional connectivity using the Phase Lag Index (PLI), and directed effective connectivity using Phase Transfer Entropy (PTE). EEG effects were tested with linear mixed models in MATLAB (fitlme), with the measured values in each ROI as the dependent variable, group and time as fixed effects, and SubjectID included as a random intercept; EF outcomes were analyzed with ANCOVA/MANCOVA, adjusting post-test scores for baseline. The assumptions of homogeneity of slopes, Levene's test, and the Shapiro-Wilk test were examined, and the Holm-Bonferroni correction together with partial η(2) effect sizes were reported. Results: Following baseline adjustment, the hippotherapy group showed substantial and statistically significant improvements across all EF measures compared with controls partial η(2) range = 0.473-0.855; all adjusted p < 0.001; e.g., Stroop Incongruent Reaction Time (F(1,45) = 265.80, p < 0.001, ηp(2) = 0.855). EEG analyses revealed localized Group × Time interaction effects involving frontal delta power as well as selected alpha-, theta-, and beta-band connectivity measures within frontally anchored networks. In addition to these focal interaction effects, the hippotherapy group exhibited a narrower distribution of pre-post EEG changes across spectral power and connectivity metrics compared with controls, indicating greater temporal consistency in resting-state electrophysiological dynamics across sessions. Because group allocation was non-random (based on scheduling feasibility and parental preference), results should be interpreted as associations rather than causal effects. While the hippotherapy group exhibited significant EF improvements and relative stabilization in EEG spectral and connectivity metrics, particularly in frontal delta/theta/alpha/beta bands, a direct mapping between individual EEG changes and behavioral gains was not observed. Conclusions: A standardized 12-session hippotherapy program was associated with substantial improvements in EF and with relative stabilization of resting-state electrophysiological dynamics in children with ASD. However, the direct mechanistic link between these EEG and behavioral changes warrants further investigation. Larger randomized trials employing active control conditions, task-evoked electrophysiological measures, and extended longitudinal follow-up are needed to confirm efficacy, clarify mechanisms, and establish the durability of effects.