Exercise improves motor function in children with cerebral palsy, with optimal dose range identified

OBJECTIVE: To examine the nonlinear dose-response of overall and modality-specific exercise interventions on motor skill improvement in children and adolescents with cerebral palsy (CP) using a Bayesian model-based network meta-analysis. METHODS: Randomized controlled trials (RCTs) involving participants aged ≤18 years with cerebral palsy (CP) were retrieved from five databases (PubMed, Embase, Web of Science, Cochrane Library, SPORTDiscus; up to Aug 10, 2025). Gross motor function, assessed using the Gross Motor Function Measure (GMFM-66/88), was the main outcome. Exercise dose was standardized as metabolic equivalents (METs) × minutes per week, and model-based network meta-analysis (MBNMA) was used to estimate overall and modality-specific nonlinear effects. Study quality and evidence certainty were evaluated using the Physiotherapy Evidence Database scale (PEDro) and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. RESULTS: Twenty randomized controlled trials were included. Most studies applied aerobic exercise, body control training, or resistance training. The mean PEDro score was 6.7, indicating moderate-high quality. Overall, exercise improved GMFM scores with a small-to-moderate effect (standardized mean difference (SMD) = 0.295; 95% credible interval (CrI) 0.016-0.613). The dose-response relationship showed an inverted U-shape, peaking near 560 METs × min/week, with stable gains between 330-560. By modality, body control training yielded the most consistent improvements at ~330 METs × min/week (SMD = 0.313; 95% CrI 0.014-0.666), while aerobic and resistance training showed smaller and less stable effects that declined at higher doses. Evidence certainty was moderate, with minimal publication bias. CONCLUSION: Exercise improved motor function in children with cerebral palsy, with optimal benefits observed at 330-560 METs × min/week. Body control training around 330 METs × min/week produced the most stable gains, whereas aerobic and resistance training declined at higher doses. These findings highlight the importance of defining effective dose ranges; larger multicenter RCTs with standardized dose reporting are needed to refine clinical guidelines.