Background: Mechanical horse-riding simulator (HRS) exercises are a type of therapy based on the use of robotic or mechanical devices that produces movement similar to a real horse with the aim of simulating hippotherapy. This review analyses the effectiveness of HRS therapies in patients with cerebral palsy (CP). Methods: A systematic review and a meta-analysis were carried out by searching studies in PubMed Medline, SCOPUS, Web of Science, CINAHL, PEDro and SciELO up until October 2022. We selected clinical trials that assessed the effectiveness of HRS therapy, compared to other interventions, in patients with CP. The main variables were gross motor function (its global score and dimensions, such as sitting ability), functional balance, spasticity, hip range of motion (ROM), posturographic balance and satisfaction. The risk of bias was assessed using the Cochrane Risk of Bias Tool. The pooled effect was calculated using Cohen’s Standardized Mean Difference (SMD) for a 95% confidence interval (95% CI). Results: Twelve studies were included in the systematic review, and 10 were included in the meta-analysis, providing data from 343 patients with spastic diplegic CP. Our findings revealed that HRS plus physiotherapy is more effective than physiotherapy in improving the total gross motor function (SMD 0.98; 95% CI 0.35–1.62), sitting ability of the gross motor function (SMD 0.84; 95% CI 0.32–1.36) and functional balance (SMD 0.6; 95% CI 0.1–1.08), and HRS therapy is better than sham to improve pelvic abduction ROM (SMD 0.79; 95% CI 0.21–1.37). Conclusions: Horse-riding simulator-based therapy is an effective therapy to improve gross motor function, functional balance and abduction pelvic ROM in children with CP, in comparison to physiotherapy or sham
