Overall and modality-specific exercise doses for motor skill improvement in cerebral palsy: a systematic review and Bayesian network dose-response meta-analysis

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.