Evaluating the Gross Motor Function and Balance in Children with Cerebral Palsy: A Systematic Review and Meta-analysis

Abstract

Background: Cerebral palsy (CP) is a leading cause of childhood physical disability, with impairments in gross motor function and balance that limit independence and participation. A wide range of physical therapy (PT) approaches has been proposed, but comparative evidence across intervention types and functional severity levels remains fragmented. Objective: To synthesize randomized controlled trial (RCT) evidence on the effectiveness of PT interventions for improving gross motor function and balance in children with CP, and to explore which therapies show the most consistent benefits. Methods: PubMed, Cochrane Library, Scopus, and PEDro were searched from January 2000 to April 2025 for RCTs involving children aged 1–18 years with CP receiving PT-based interventions targeting gross motor function and/or balance. Eligible outcomes were Gross Motor Function Measure (GMFM-88 Dimensions D and E or GMFM-66) and the Pediatric Balance Scale (PBS). Two reviewers independently performed study selection, data extraction, and risk-of-bias assessment using Cochrane RoB 2.0 and the Jadad scale. Random-effects meta-analyses were conducted using standardized mean differences (SMD) with 95% confidence intervals (CI). The protocol was registered in PROSPERO (CRD420251008653). Results: Twenty-eight RCTs including 1084 children met inclusion criteria; 12 contributed to meta-analysis. Pooled analyses showed small-to-moderate benefits of PT interventions over comparison conditions for GMFM-88 Dimension D (10 studies; SMD 0.36, 95% CI 0.15–0.56; p = 0.0006; I² = 0%), GMFM-88 Dimension E (10 studies; SMD 0.48, 95% CI 0.13–0.83; p = 0.007; I² = 61%), and PBS (6 studies; SMD 0.43, 95% CI 0.16–0.71; p = 0.002; I² = 12%). Subgroup analyses suggested comparatively larger effects for task-oriented training, hippotherapy, and virtual reality–assisted programmes, particularly when added to conventional PT. Most trials were of good methodological quality, though blinding of participants and therapists was rarely feasible. Conclusion: Current evidence suggests that active, task-oriented and technology-assisted PT interventions, including hippotherapy and virtual reality delivered as adjuncts to conventional therapy, are associated with small-to-moderate improvements in gross motor function and balance in children with CP. However, heterogeneity in protocols, limited stratification by CP subtype and GMFCS level, and scarce long-term follow-up underscore the need for larger, multicenter trials with standardised outcomes and stratified analyses.