Evidence-based Approach to Physical Therapy in Cerebral Palsy

Sakti Prasad Das and G Shankar Ganesh1

Department of Physical Medicine and Rehabilitation, Swami Vivekanand National Institute of Rehabilitation Training and Research, Cuttack, Odisha, India
1
Department of Physiotherapy, Composite Regional Centre for Persons with Disabilities, Lucknow, Uttar Pradesh, India
Address for correspondence: Mr. G. Shankar Ganesh, Department of Physiotherapy, Composite Regional Centre for Persons with Disabilities, Lucknow - 226 017,
Uttar Pradesh, India. E-mail: moc.liamffider@tpraknahs
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Abstract
Physiotherapy plays a key role in the management of secondary health conditions.3 CP is not a single
cerebral palsy (CP) and comprises of various therapeutic pathological entity and encompasses disorders in various
interventions in enhancing the various physiological and motor functions including but not limited to body
functional outcomes. Though physiotherapy is used movement, muscle control, muscle coordination, muscle
widely and recommended by all members of the health- tone, reflex, fine motor skills, gross motor skills, oral
care team, the effectiveness of physiotherapy is motor functioning, posture, and balance.4,5 This in turn
inconsistent. The objective of this review was to
summarize and evaluate the effectiveness of leads to poor functional strength, sedentary behavior,
physiotherapy interventions in children with CP. and dependence on others to carry out activities of daily
PubMed and Cochrane database were searched from living and reduced activity in leisure and community
January 2006 to April 2017 using the Medical Subject activities.6
Heading and general keywords. Only systematic reviews
and meta-analysis on PT interventions in children Physiotherapy plays a key role in the management of CP
diagnosed with CP were included. Two reviewers and almost all persons diagnosed as CP receive
independently assessed the methodological quality and physiotherapy services.7 The goals of physiotherapy are
retrieved the results. Thirty-four systematic reviews were facilitating the participation needs of the child with CP
identified that distinguished 15 different interventions. and reducing the physical impairments of the symptoms.
Moderate evidence of effectiveness was found for Physiotherapy helps children with CP to achieve their
constraint-induced movement therapy for upper limb maximum potential for physical independence and
recovery, goal-directed/functional training, and gait fitness levels and improve the quality of life of the
training to improve gait speed. Conflicting evidence was children and their family by minimizing the effect of
found for the role of exercises on strength training and their physical impairments.8
cardiorespiratory training. Intervention such as
neurodevelopmental therapy (NDT) was found Physiotherapists use various therapeutic interventions in
ineffective. This review suffer from limitations such as enhancing the autonomy, strength, and coordination of
including reviews that had small sample size and that voluntary movements. Physiotherapy literature for CP
had considered heterogeneity of treatment interventions. contains multiple interventions, expanding rapidly every
Hence, the effectiveness of most PT interventions is year. Though physiotherapy is used widely and
found to be limited. On the basis of the present evidence, recommended by all members of health-care team,9 the
functional goal-oriented approaches are found to be effectiveness of physiotherapy is inconsistent.10 Health
effective and future research is required to determine the care around the world has shifted its focus toward
best ways to improve functional outcomes in children evidence-based practice. Literature has shown that
with CP. considerable amount of interventions currently used by
Keywords: Cerebral palsy, exercise therapy, muscle clinicians are deemed to be ineffective and
weakness, physical activity, physical therapy techniques, unnecessary.11 The professionals involved in providing
rehabilitation therapy services have to consider the effectiveness of
these interventions during clinical decision-making.
Introduction Hence, we wanted to provide clinicians with the
Cerebral palsy (CP) is one of the most common evidence for quick reference by comparing and
developmental disabilities. The incidence of CP is contrasting the results of available systematic reviews to
around 3 cases per 1000 live births in India,1 and the provide a summary of physiotherapy evidence. The
2011 statistics indicate that there are about 25 lakh objective of this work was to summarize and evaluate
children with CP in India.2 CP is a bracket term given for the evidence for the effectiveness of various therapeutic
a set of neurological disorders characterized by disorders interventions employed in physiotherapy for children
of movement and posture causing activity limitation with CP.
attributed to a static disturbance in the developing brain,
often accompanied by associated impairments and
Materials and Methods and (5) if systematic reviews were identified in predatory
The research question (what is the evidence that journals.
physiotherapy improves functional outcomes for patients
with CP?)that could be answerable on the light of All identified articles were judged for eligibility by title
available evidence (systematic review and meta- and abstract by two reviewers and differences any, when
analysis) was structured for searching using the aroused regarding unclear articles, were resolved by
population, intervention, comparison, and outcome consensus. The quality of the evidence obtained was
format. graded using the National Institute for Health and Care
Population: Persons aged 0–20 years with a diagnosis of Excellence protocol.12 Relevant studies to the research
CP. Intervention: Use of any clinically proven question were entered into an evidence table [Table 1].
physiotherapy interventions, or a combination of
interventions. Comparison: Any other treatments or Results
control groups including placebo, sham therapy, or other Considering the complexity and heterogeneous condition
PT interventions. Outcome: Improved motor function, of CP, we included studies that considered children with
improved abilities in functional skills, and reduction in CP of any classification and any functional ability level.
spasticity. The results of the search strategy are shown in Figure 1.
The search yielded a total of 337 reviews, of which 18
We searched computerized bibliographic databases for reviews were retrieved from the Cochrane Database of
reviews on physiotherapeutic interventions in CP in Systematic Reviews and 319 from PubMed. Totally 298
English for the last decade (January 2006 to April 2017) articles were excluded based on the screening of their
to identify systematic reviews and meta-analysis to titles and abstracts; 34 articles were reviewed in full text.
provide an overview of the current state of evidence An overview of the included studies is presented in
using PubMed and the Cochrane Database of Systematic Table 1. Table 2 provides a summary of the most
Reviews. These databases were searched using the significant findings that health care providers may wish
Medical Subject Headings keywords (systematic review) to consider in their practice based on this review. The 34
AND cerebral palsy AND physiotherapy, physical studies included children with all types of CP
therapy specialty, physical therapy modalities, exercise classification and levels of gross and fine motor
therapy, exercise movement technique, electric function. Out of the 34 reviews, 11 reviews appraised
stimulation therapy, massage and general search terms exercises including studies that considered processing
such as exercise training (in combination with strength, sensory information, early intervention, upper limb
fitness, working capacity, aerobic power, anaerobic training, and reaching activities. Five reviews were
power, endurance, cardiorespiratory physical training, or found that evaluated constraint induced movement
programme), functional training, functional therapy, therapy (CIMT); 3 reviews each on gait training,
neurodevelopmental treatment/Bobath, hydrotherapy, electrical stimulation, and physiotherapy in general and 2
hippotherapy, and goal-setting. The search settings were reviews each on cardio-respiratory training and animal
kept to maximize the retrieval of references. In addition, assisted training. Single review was identified each on
the reference lists of identified articles and systematic whole body vibration, aquatic training, taping, passive
reviews were screened for additional relevant stretching, and virtual training.
publications.
Exercises and cerebral palsy
Studies meeting the following criteria were included: (1) Eleven reviews appraised the effectiveness of exercises
reviews should have been published between January on functional outcomes in CP. Six reviews directly
2006 and April 2017; (2) papers written in English; (3) evaluated the role of exercise training in CP population.
the papers should have considered any physiotherapy Only the review by Arpino et al., 2010,22 had claimed
interventions in the treatment of children and adolescents modest evidence for the effectiveness of exercises.
(age range: 0–20 years) with CP only; and (4) should be Results by Mockford and Caulton, 2008,26 suggested that
either systematic reviews or meta-analyses. Studies were exercises can foster functional improvement without any
excluded from the review if studies (1) were written with adverse effects. One review13 suggested that a
the perspective of diagnosis, prognosis, guidelines, or combination of botulinum toxin and occupational
other interventions aimed at CP; (2) participants were therapy is more effective than occupational therapy
adults with CP; (3) reviewed general medical alone in improving upper-limb outcomes and there is an
neurological interventions (e.g., home care therapy, overall moderate evidence to suggest that intensive
spastic medications/botulinum injections, and not activity based, goal directed interventions are effective in
physiotherapy-specific interventions); (4) if no specific promoting functional outcomes.
outcome measures were mentioned/parents’ or
caregivers’ experiences were considered as outcomes;
No studied interventions have been found to be superior other hand, appraisal by Anttila et al., (2008)31 reported
to another in improving trunk control and it is also not moderate evidence for the effectiveness of upper limb
sure if improvement in postural control would lead to treatments, while the effectiveness of strength training
improvement in functional activities.29 Appraisal by was found limited for gross motor function.
Arpino et al., 2010,22 and Myrhaug et al., 2014,42
suggested that improvements may be expected from NDT is a holistic and interdisciplinary clinical practice
intensive exercise interventions. However, a high quality model that emphasizes individualized therapeutic
review by Scianni et al., 2009,25 reported that exercises handling based on movement analysis for habilitation
do not improve strength or functional activities in and rehabilitation of individuals with neurological
children with CP. disorders.48 Novak et al., (2013)47 performed a
systematic review of systematic reviews published on
The effectiveness of early interventions seems to be the effectiveness of NDT. Despite the widespread
mixed, with Morgan et al., 2016,38 suggesting that child- popularity, the authors of this review concluded the
initiated movement, environment clinical evidence of NDT as poor and unfavorable.
modification/enrichment, and task specific training have
moderate to large effect on motor outcomes (Cohen's Cardiorespiratory training and cerebral palsy
effect size >0.7) and Hadders Algra et al., 2017,37 Reviews that have looked into the effects of
reporting poor effect for early interventions. However, cardiorespiratory training in children with CP have
from the evaluation of the available data, it appears that concluded that, though the training may improve aerobic
children and adolescents with CP may benefit from fitness, the overall evidence about the effect of
exercise programs that focus on lower extremity. cardiorespiratory training in these populations is
limited.21 Similar result is reflected by Rogers et al.,
Exercises, gait, and cerebral palsy (2008)27 that aerobic training can improve physiological
20
A systematic review by Moreau et al., 2016, concluded outcomes, but the influence of these changes may not be
that, among the available evidences, gait training appears translated in activity and participation domains in
to be the most effective intervention in improving gait children with CP.
speed in children with CP who are ambulatory. Other
interventions, including strength training, have a Electrical stimulation and cerebral palsy
negligible effect on gait speed and exhibit poor Chiu and Ada, (2014)45 evaluated the effectiveness of
effectiveness. Review by Mutlu et al., 2009,28 could not functional electrical stimulation on activities in children
conclude the effectiveness of partial bodyweight with CP. The results of this systematic review showed
supported treadmill training in children with CP. Based that functional electrical stimulation has a similar effect
on these reviews, it may be concluded that gait training as activities. Cauraugh et al., (2010)44 performed a
alone is an effective intervention to improve gait speed systematic review on the effect of electrical stimulation
in CP ambulatory children. on gait outcomes. This review identified 17 studies, and
meta-analysis of the available data revealed medium
Constraint-induced movement therapy effect sizes for electrical stimulation on gait outcomes.
Four out of the five reviews included in this Wright et al., (2012)46 studied the performance of
review15,16,17,18 concluded that there is a definite role for electrical stimulation on gait or upper-limb function in
CIMT to improve upper limb functions in children with children with CP. The results of this review concluded
CP. However, the Cochrane database, highest level of that there is moderate evidence for electrical stimulation
research evidence,19 reported limited evidence for the in improving muscle strength, range of motion, and
effectiveness of CIMT. Based on the results, we may function in children with CP. Electrical stimulation along
conclude that there is moderate evidence for the with dynamic splinting has been shown to be further
effectiveness of CIMT on functional hand use. effective in improving function and posture. Though two
of the three reviews showed moderate evidence for the
Physiotherapy approaches including role of electrical stimulation, these results may be
neurodevelopmental therapy subjected to study bias and we may conclude that the
Reviews that had evaluated the effectiveness of evidence to be limited.
commonly used physiotherapy interventions for children
with CP reported that strengthening targeted muscle Hippotherapy and cerebral palsy
groups and functional training23 have the strongest Hippotherapy is commonly used to improve balance,
evidence. These results are supported by the results of posture, and gross and fine motor skills by placing the
Franki et al., (2012)32 that concluded that goal oriented person on a horse's back and/or using equine movements
therapy and functional training were effective on the with an objective to control the horse. Tseng et al.,
attainment of functional goals and participation. On the (2013)34 evaluated if hippotherapy or horseback riding is
effective in improving the motor outcomes and body deficit, health-care professionals shall first determine the
functions in children with CP. The results of the most appropriate functional goal and then may utilize a
metaanalysis showed that 8–10 min of horse riding single or combination of therapeutic approaches that are
reduced asymmetrical activity of hip adductor muscles individually tailored to achieve the goals.
and improved postural control. However, the results
showed that long term riding did not produce any CIMT for upper limb recovery, goal directed/functional
statistically significant effect on improving gross motor training, strength training for lower limb, and gait
activity status. A previous review33 had concluded that training to improve gait speed are the interventions
hippotherapy improved muscle symmetry in the trunk recommended based on the available evidence. The
and hip, but the effectiveness was no more better evidences are not strong for hippotherapy, virtual
compared to other therapies in improving muscle tone in training, whole body vibration, early intervention (for
children with CP. The results of this review have to be motor outcomes), and functional electrical stimulation.
taken with caution as the methods were not properly When used, these interventions should be based on
explained and the articles considered for this review did clinical judgment, child and family preferences, and the
not consider abstracts/conference proceedings and gray child's motor control and functional abilities.
literature. Given the potential for error and bias and Interventions such as NDT have not shown any
heterogeneity of interventions provided, the results may effectiveness and may be withdrawn from standard care.
not be reliable. The earlier consensus that exercises in this population
has to be avoided because of the adverse impact exercise
Results of other studied reviews on spasticity and movement patterns49 has been rebuked.
Though the studies included in this review showed Research has shown that children with CP require more
effectiveness for taping,36 aquatic therapy,35 whole-body energy for walking compared to healthy children. 4,50
vibration,39 virtual reality,18 and stretching,14 low quality This reduced ability has been attributed to below-
of studies included in these reviews, multiple outcomes average aerobic and anaerobic capacity found in these
measured, and heterogeneity of interventions offered populations.51,52,53 This reduced physical fitness, lower
imply that these results have to be approached with health status, and well-being lead to the development of
caution. disorders such as obesity or diabetes54,55,56 and a
sedentary adulthood.57 Results of this review that
Discussion cardiorespiratory training does not result in anticipated
This study was conducted with intent to examine only benefits are a problem for people with CP, health-care
the highest level of evidence by including systematic providers, and policymakers.
reviews or meta-analyses to provide a summary of the
existing research on the effectiveness of various There are several potential limitations worth mentioning
interventions on CP. This review of systematic reviews with the current review. Only PubMed and Cochrane
found that there is a lack of effectiveness in majority of database were searched, excluding EMBASE, Sports
the physiotherapy interventions studied. This review Discus, CINAHL, and PEDro. We did not include
analyzed 34 systematic reviews on physiotherapy reviews that included children with CP along with
interventions in children with CP published after 2006. persons suffering from other neurological disorders as
Fifteen different types of intervention categories were part of their inclusion criteria. Similarly, we had
identified. The interventions and outcomes differed in all excluded studies that included adult CP population.
categories, which may limit our comparisons in the Another limitation is that we considered systematic
evidence synthesis. reviews that had been published within the last 10 years.

CP is usually classified into various heterogeneous The search was limited to reviews published in English
diagnostic subgroups as spastic diplegia, hemiplegia, only because of our limited language skills. These
tetraplegia, ataxic, or mixed. The study population factors might have drastically limited the numbers of
included in this review had representations from all types systematic reviews analyzed. Further, a review of
of CP and it is difficult to conclude if different subtypes systematic reviews is a study limitation in its own right
would respond differently to various interventions. as it does not provide any new information that is not
Based on the overall results of the study, it may be available at the first place and we have not performed
concluded that intensive functional-based training will any re-synthesis of the data.
benefit this population irrespective of the type of CP. 22,23
CIMT results in greater improvements in improving the Conclusion
functions of impaired arm in children with hemiplegic It has been widely accepted that children with CP lack
CP.15,16,18 As the goals of rehabilitation in CP are not motor skills, and physiotherapy interventions should try
intended at treating the primary central neurological to improve both the quantity and quality of motor
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(Neuro-Developmental Treatment/Bobath) Definition.
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Table 1

Evidence table

Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

Forty-two trials involving 13

Outcomes are
Studies that To systematically upper-limb interventions
measured in terms of
evaluated the review the efficacy were studied. The overall
unimanual or bimanual Despite the small
Sakzewski efficacy of upper- of nonsurgical results suggested that there is
capacity and sample size of studies Meta-
et al., limb therapy in upper-limb modest evidence that 1++
13 performance, included, the result analysis
2013 children between 0 therapies for intensive activity-based, goal-
achievement of seems valid
and 18 years of age children with directed interventions are
individualized goals, or
with unilateral CP unilateral CP more effective in improving
self-care skills
outcomes

Seven studies including three

Though adequate
RCTs, one crossover RCT, one
Studies other than information about
before-and-after study, and
Studies that included expert opinions that The outcomes the included studies
two multiple single-subject
children with CP evaluated the measured were was provided, several
Pin et al., studies. Results show limited Systematic
14 (aged younger than effectiveness of changes in range of studies assessed 1−
2006 evidence that manual review
18 years) with passive stretching in motion, spasticity, and multiple outcomes
stretching can increase range
spasticity children with spastic gait and the numbers of
of motion, reduce spasticity,
CP participants were
and improve walking
rather low
efficiency in children with CP

Studies that involved Studies that Unimanual, bimanual, Seven studies including six Results of the review
Dong et al., Systematic
15
hemiplegic children randomized and and overall functional RCTs and one quasi- may not be reliable as 1−
2013 with CP aged compared the performance were randomized trial. Constraint- the review was review
between 2 and 16 efficacy of measured using a induced movement therapy restricted to studies
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

years constraint-induced variety of different for children with hemiplegic that were published
movement therapy measures CP resulted in greater before 5 years;
with bimanual improvements in the hence, the probability
training in unimanual capacity of the of missing other
improving impaired impaired arm than bimanual relevant studies is
arm function and training; bimanual training abundant. Further,
overall functional improved bimanual only one of the
performance among performance and overall life studies had a true
children with goals control group. Results
hemiplegic CP may be because of
lack of statistical
power

Body function and

Twenty-one studies were Inconsistencies exist
structure (grasp
Studies that included in this review. The around the review
To investigate the strength and modified
evaluated children report concludes that there is methodologies used,
Huang et effectiveness of Ashworth Scale) and Systematic
16 (younger than 18 positive support for the use of and there are high 1−
al., 2009 CIMT in children activity (Jebsen-Taylor review
years) with CIMT to improve the upper- probabilities that
with CP test of hand function
hemiplegic CP extremity use for children relevant studies could
and caregiver functional
with hemiplegic CP be missed
use survey)

Despite the small

To compare the Twenty-one
Activity and sample size of studies
effectiveness of randomized/quasi-controlled
Studies that involved participation included and absence
Chiu and CIMT against the trials were included. CIMT is Systematic
17 hemiplegic children components of the ICF, of data from some of 1+
Ada, 2016 same dose of no more effective than the review
with CP disability, and health the studies, the
upper-limb therapy same dose of upper-limb
framework results seem valid
without restraint practice without restraint
and reliable
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

The individual outcome Twenty-seven RCTs were

measures measured in identified that met the
To systematically RCTs were calculated in criteria. The overall results
Studies that Despite the variable
examine the terms of Cohen’s effect showed that the CIMT is an
evaluated children intervention
Chen et al., effectiveness of size. Further, where effective therapy to Systematic
18 with CP between protocols used, the 1+
2014 CIMT on improving multiple outcome improving arm function in review
birth and 21 years of results seem to be
arm function in measures were utilized, children with CP. The results
age reliable
children with CP the outcome measures are more pronounced for
were classified in terms those children who practised
of the ICF CIMT at home

To evaluate the This result is based on

effectiveness of Three trials were included for small trials with poor
Various upper-limb
Children with CIMT, modified review. There is limited methodology and not
motor outcome scales,
Hoare et hemiplegic CP who CIMT, or forced use evidence for the use of CIMT, so reliable outcome Systematic
19 with and without 1−
al., 2007 are under 19 years in the treatment of modified CIMT, and forced measures. Hence, review
psychometric
of age the affected upper use in children with results should be
properties
limb in children with hemiplegic CP accepted with
hemiplegic CP caution

Twenty-four studies (only one

To determine the trial was case-controlled trial;
Ambulatory children effectiveness of others were RCTs) were
Gait speed was the
Moreau et with CP who are interventions for considered for review. Gait Systematic
20 Gait speed only parameter 1++
al., 2016 under 18 years of improving gait training was the most review
analyzed
age speed in ambulatory effective intervention in
children with CP improving gait speed for
ambulatory children with CP
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

Intervention
included
cardiorespiratory
training programs
Measures of aerobic Three RCTs were found; there
Studies that included consisting of either
Butler et fitness such as peak is limited evidence about the Results based on Systematic
21 school-age children individual activities 1++
al., 2010 oxygen uptake and 6- effect of cardiorespiratory limited data review
with CP or combination
min walk test training in children with CP
programs that were
progressed in
duration and
intensity

Reliability of this
Four RCTs were included. result is uncertain as
RCTs that compared
Results showed modest effect the review has
Studies that included the efficacy of
Changes in GMFM were size and limited evidence that reported limited
Arpino et children with CP intensive versus Systematic
22 considered as an intensive conventional trials; variation in the 1++
al., 2010 with an age range nonintensive review
outcome measure therapy could improve the included trials and
from 1 to 18 years rehabilitation in
functional motor outcome in contribution of small
children with CP
children with CP samples are other
limitations

Prospective studies Thirty-four studies, of which

of any design except Measures of strength as 15 RCTs were retrieved and
Studies that included single-case studies considered for review. The Results based on
measured on
Martin et children with CP were considered to studies that were Systematic
23 dynamometry and the results concluded that there 1++
al., 2010 aged from 4 to 18 evaluate the small and with high review
GMFM, endurance, gait was strong evidence for
years effectiveness of risk of bias
speed, and stride length interventions and functional
commonly used training to strengthen
physiotherapy targeted muscle groups in
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

interventions, for children with CP

children with CP

RCTs and Twenty studies including five

The following outcomes
observational RCTs were considered for this Despite the inclusion
were measured:
studies were systematic review. The review of nonrandomized or
Verschuren Studies that included changes in body
considered to concluded that interventions low-quality trials, the Systematic
et al., children and function and structure, 1−
24 assess the focusing on lower-extremity recommendations of review
2008 adolescents with CP activity or participation
effectiveness of muscle strength and this review appear
in the ICF, disability and
exercise programs cardiovascular fitness may reliable
health framework
for children with CP benefit children with CP

Randomized, quasi-
randomized, and
controlled trials Five RCTs and one quasi-
were evaluated to randomized trial were
Studies that included Outcomes were
see if muscle- included in the review.
Scianni et children with CP measured in terms of Results are likely to Systematic
25 strengthening Results found that 1++
al., 2009 aged from 4 to 19 10-min walk test, or be reliable review
interventions can strengthening interventions
years GMFM
increase strength did not improve strength or
and improve activity activity in these populations
in children and
adolescents with CP

Studies that included To analyze the

Mockford Thirteen articles were Results are
children who were effects of
and Outcomes were included for review. Function questionable as the Systematic
ambulatory and progressive strength 1−
Caulton, and gait improved in younger systematic review has review
26 aged from 4 to 20 training on function measured objectively
2008 population included many
years and gait in
uncontrolled trials for
ambulatory children
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

and adolescents this analysis

with CP

Thirteen studies were

To assess the
Studies that included considered for the review.
evidence regarding Poor methodological
children with CP of Though aerobic exercises are
Rogers et the effectiveness of Activities and rigor and variable Systematic
27 any type and who found to increase 1−
al., 2008 aerobic training participation training preclude the review
were aged between physiological outcomes, the
interventions for conclusion
2 and 17 years translation into activities and
children with CP
participation are unknown

To evaluate the
effectiveness of Seven studies comprising 41
partial bodyweight- Variable outcome children were considered in Despite including
Studies that included
supported treadmill measures including this review. The review studies of low-quality
Mutlu et children with CP who Systematic
28 training on GMFM score, the PEDI concluded that partial small studies, the 1−
al., 2009 are under 18 years review
functional score, and measures of bodyweight-supported results are found to
of age
outcomes and ambulatory status treadmill training did not be reliable
ability to walk in result in gait improvement
children with CP

Body structure and Fourteen studies, single-case Only English-language

Studies of functions, activities, and experimental designs, studies were
Studies that included
interventions and participation comprising 176 participants considered. Other
nonambulatory
Chung et involving adaptive components of ICF. were included in the review. limitations are Systematic
29 children with CP 1−
al., 2008 seating for Other outcomes that The results of the review diversity of the review
aged from 2 to 23
nonambulatory were considered were showed that no single studies, moderate
years upper-extremity intervention was more quality of the studies
children with CP
function, mobility, and effective than others in included, small
social skills and improving sitting posture or samples, and lack of
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

performance in ADL postural control in children control groups in

with CP majority of the
studies

Fourteen studies including

122 children and three RCTs
Clinical and
were considered for this
The outcomes methodological
To consider studies review. The authors of this
measured are: upper- differences across the
Studies included that evaluated the review recommended that
extremity movements studies, the statistical
Chen et al., children diagnosed effect of virtual more high-quality research is Meta-
30 (such as reaching, methods employed, 1−
2014 as CP between 6 and reality on upper- warranted in this area and the analysis
grasping), or upper- and small sample
14 years of age extremity function available evidence suggest
extremity function as sizes lead to
in children with CP that virtual reality is a viable
measured by GMFM nonreliable
tool to improve upper-
conclusions
extremity function in children
with CP

Twenty-two RCTs utilizing

To assess the Despite the poor
Studies that included eight different interventions
effectiveness of The outcomes of the quality of involved
children with CP were identified. Results of
Anttila et physical therapy trials were classified studies, the reliability Systematic
31 aged between 3 this review showed 1++
al., 2008 interventions on using the ICF, disability, of the review appears review
months and 20 years moderate, limited, and
functioning in and health to be valid and of
of age conflicting evidence for few
children with CP high quality
interventions

Studies that have To evaluate the Outcomes were Thirty-seven studies that
Only English-language
Franki et included children effectiveness of classified on the basis of concentrated on conceptual Systematic
32 studies were 1+
al., 2012 less than 18 years of conceptual the ICF model: body approaches and 21 studies on review
age receiving approaches and structure and function, additional therapies were considered
physiotherapy additional therapies activities and identified. Goal-oriented
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

interventions used in lower-limb participation, personal therapy and functional

targeting lower limb physical therapy of factors, and training were found to be
and trunk children with CP environmental factors effective

Outcomes were
English and German measured using a
To appraise the A total of nine studies
studies that variety of tools
evidence on the comprising 108 participants Considering the
evaluated the including Bertoti
effectiveness of were included in this review. potential for error
Snider et effectiveness of Posture Assessment Systematic
33 hippotherapy and The review concluded that and bias in the review 1−
al., 2007 horseback riding in Scale, GMFM, EMG, gait review
therapeutic some fair evidence are found process, these results
children between 2 parameters and
horseback riding in for hippotherapy on muscle may not be reliable
and 12 years of age kinematics, PEDI,
children with CP symmetry in the trunk and hip
diagnosed as CP BOTMP, PDMS, and
VABS

The heterogeneity of
interventions
provided means that
Studies that the results cannot be
Fourteen studies were
evaluated the attributed to
To evaluate the The outcomes were considered. Though short-
effectiveness of horseback riding
Tseng et efficacy of equine- represented in the ICF term effectiveness was found, Systematic
34 horseback riding in alone. Further, small 1−
al., 2013 assisted activities component of body the review did not find any review
children who had CP samples and
and therapies functions and activities significant benefits on the
and were under 18 conventional
longer term in CP children
years of age sampling in the
studies included limit
the reliability of the
results
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

To review the Eleven studies met the

Studies that included
literature on the inclusion criteria including
children with any
Roostaei et effects of aquatic GMFM should serve as two RCTs. Evidence showed Poor quality of Systemic
35 type of CP aged 1−
al., 2016 intervention on one of the outcomes no adverse reaction to studies included review
between 1 and 21
gross motor skills aquatic therapy but the
years of age
for children with CP effectiveness is limited

The differences in
results may be
attributed to the area
Outcome variables Nine studies including five of application of tape,
Studies with all
were grouped by the RCTs were considered. variability in
research designs To investigate the
Güçhan ICF, disability, and Though the immediate effect application
that evaluated effectiveness of Systematic
and Mutlu, health. Model as body of taping is unclear, there techniques, the time 1−
36 children with CP taping in the review
2017 structure/function, seems to be some long term period for which the
under 18 years of children with CP
activity, and effect on activity in children outcomes were
age
participation with CP followed, and poor
sample size renders
the review
nonreliable

For the evaluation of Thirteen articles were

motor development, Poor methodological
To review the considered for review. The
Children/infants the Griffith studies and
evidence on the overall evidence is poor and
Hadders- during the first developmental scales, heterogeneous
effect of early the results of the review Systematic
Algra et al., postnatal year who Alberta Infant Motor interventions 1−
37 intervention in suggested that minimal review
2017 are diagnosed with Scale, Bayley Scales of preclude arriving at a
children at the risk application of postural
very high risk of CP Infant Development, conclusion based on
of diagnosed as CP support techniques is
Infant Motor Profile, the review
beneficial for infants with CP
and the Peabody
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

Developmental Motor
scales were used.
Cognitive development
was assessed with the
Griffith Developmental
scales. The Bayley
Scales of Infant
Development, the
Neonatal Behavioral
Assessment Scale,
Hempel Assessment,
PEDI, the Goal
Attainment Scaling, and
Canadian Occupational
Performance Measure
or a nonstandardized
questionnaire

Children/infants Thirty-four studies including

Studies varied in
diagnosed with very ten interventions were
To systematically quality, interventions,
high risk of CP from considered. Child-initiated
review the evidence Any outcome and participant
Morgan et birth to 2 years movement, environment Systematic
38 on the effectiveness assessment of motor inclusion criteria. Lack 1−
al., 2016 diagnosed with CP as modification/enrichment, and review
of motor skills/development of high-quality
assessed on the task-specific training had
interventions studies makes the
General Movements moderate-to-large effect on
review less reliable
Assessment motor outcomes

Saquetto et Studies that To evaluate the The main outcomes of Six studies with 176 patients Small studies and Systematic
39 evaluated the effects effects of whole- interest were motor compared whole-body heterogeneity of 1−
al., 2015 review
of whole-body body vibration on function and functional vibration to other analysis mean that
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

vibration on motor physiologic and performance including interventions. Whole-body the results can be
function and functional gait speed, GMFM, and vibration may improve gait interpreted with
functional measurements in bone density speed and standing function caution only
performance in children with CP in children with CP
children with CP who
are under 13 years
of age

Forty-five studies evaluated

It is possible for other
the effects of exercise
interventions to have
interventions on postural
To evaluate the influenced the
At least one outcome control in children with CP.
efficacy and outcomes. Studies
Studies that measure should be Gross motor task training,
effectiveness of belonging to evidence
evaluated children either postural stability hippotherapy, treadmill
Dewar et exercise range between I to V Systematic
40 diagnosed with CP, (static or dynamic training, trunk-specific 1−
al., 2015 interventions that were studied that review
and aged between 0 balance), or postural training, and reactive balance
claim to improve might have affected
and 18 years orientation (e.g., training were supported by
the postural control the outcomes.
postural alignment) moderate level of evidence.
in children with CP Despite the
Other interventions including
limitations, results
neurodevelopmental therapy
seem reliable
had low-quality evidence

Eleven observational studies Considering the small

To systematically
Children and Outcome measures that that fulfilled the criteria and samples and the
appraise the
adolescents evaluated postural studied the effect of sensory heterogamous nature
Pavão et literature Systematic
41 diagnosed with CP control including force information on postural of studies considered, 1−
al., 2015 concerning effects review
who are younger plate and surface control in children with CP. the conclusions of
of sensory
than 18 years of age information on electromyography The results showed a dearth authors may be
of high-quality studies in this considered valid
postural control in
area and recommended
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

children with CP further studies in this area to

assess the role of sensory
information on postural
control during performance of
functional activities

To analyze the
Controlled trials that effects of intensive Consideration of
evaluated the effects motor function and Thirty-eight studies (including studies with small
Tinderholt of motor function functional skill The activity and 29 RCTs) that included 1407 samples and
Systematic
Myrhaug et and functional skill training in participation children were considered. The heterogeneity of 1−
42 review
al., 2014 training in children improving components of the ICF results factored the use of interventions studied
with CP who are <7 functional CIMT in improving outcomes might affect the
years of age outcomes in validity of results
children with CP

PEDI; Paediatric
Seven studies were selected
Reaching Test, GMFM, Most studies included
Studies that To evaluate the for this systematic review.
House Functional were of moderate
evaluated reaching effectiveness of The studies showed that
Visicato et Classification, quality. Hence, the Systematic
43 in children with CP studies that had children with CP show deficits 1−
al., 2014 Melbourne Assessment results have to be review
who are <18 years of investigated on in several spatio-temporal
of Unilateral Upper interpreted with
age manual reaching variables of reaching
Limb Function caution
compared to typical children
Approach of Claeys

Studies that Seventeen studies that used Heterogeneous

Cauraugh To determine the Impairment and activity
evaluated the electrical stimulation were stimulation Systematic
et al., effect of electrical limitations as per the 1−
44
effectiveness of considered for review. The parameters, limited review
2010 electrical stimulation stimulation on gait ICF studies showed medium followup, and lack of
in all children with effect sizes for electrical blinded trials in this
 Evidence
Study Population/setting Intervention/aim Outcomes Results Comments Design
level/quality

CP from a mean age stimulation on gait review may affect the

of 3 years to 12 parameters reliability of this
years review

Randomized
controlled trials that To determine the Outcomes that Five RCTs were included for
The results are not
Chiu and evaluated children effectiveness of measured either review. Results suggest that Systematic
45 based on high-quality 1++
Ada 2014 with spastic CP functional electrical walking speed or the results of FES are similar review
evidence
younger than 18 stimulation GMFM to activity training
years of age.

To evaluate the Thirty studies were analyzed. Lack of controlled

Children with CP effectiveness of Muscle strength, range The overall results were that trials and inclusion of
Wright et Systematic
46 between 1 and 16 NMES on gait or of motion, and function NMES may be used to small studies may 1−
al., 2012 review
years of age upper limb function in children with CP improve functional gains in affect the reliability
in children with CP children with CP of the results

CP=Cerebral palsy, NMES=Neuromuscular electrical stimulation, GMFM=Gross Motor Function Measure, CIMT=Constraint-induced movement therapy,
PEDI=Pediatric Evaluation of Disability Inventory, ICF=International Classification of Functioning, EMG=Electromyography, BOTMP=Bruininks-Oseretsky
Test of Motor Proficiency, PDMS=Peabody Developmental Motor Scales, VABS=Vineland Adaptive Behavior Scales, ADL=Activities of daily living

Table 2

Most significant findings from the review

Intensive activity-based, goal-directed interventions are more effective13,22,23,32,38

The ability of manual stretching to increase range of motion and reduce spasticity is limited14
There is positive support for the use of CIMT to improve the upper-extremity functioning15,16,18,42

Gait speed can be improved most effectively by gait training20

NDT has low-quality evidence40,47

Electrical stimulation is associated with fewer functional gains44,46

NDT=Neurodevelopmental therapy, CIMT=Constraint-induced movement therapy

Articles from Indian Journal of Orthopaedics are provided here courtesy of Indian Orthopaedic Association