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Habitual physical activity can be increased in people with cerebral palsy: a systematic review
Theofani Bania, Karen J Dodd and Nicholas Taylor
Clin Rehabil 2011 25: 303 originally published online 15 November 2010
DOI: 10.1177/0269215510383062
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Clinical Rehabilitation 2011; 25: 303315

Habitual physical activity can be increased in people with

cerebral palsy: a systematic review
Theofani Bania Physiotherapist and Doctoral Candidate, La Trobe University, Bundoora, Karen J Dodd Deputy Dean, Health
Sciences, La Trobe University, Melbourne and Nicholas Taylor Professor of Physiotherapy, La Trobe University, Bundoora,
Australia
Received 10th February 2010; returned for revisions 18th April 2010; revised manuscript accepted 6th August 2010.

Objective: To determine if habitual physical activity could be increased in people

with cerebral palsy.
Data sources: We searched electronic databases until February 2010 using key
words related to concepts of cerebral palsy and physical activity. This search was
supplemented with citation tracking.
Methods: Studies had to include participants with cerebral palsy who have habitual
physical activity measured over at least one day after a therapy intervention. Two
reviewers independently assessed study quality with the PEDro scale (quantitative
studies) and Critical Appraisal Checklist for Qualitative Research (qualitative
studies). For quantitative studies standardized mean differences were calculated
and meta-analysis conducted. Qualitative data were synthesized thematically.
Results: Three randomized controlled trials (96 participants) and two qualitative
studies (21 participants) were reviewed. Four studies evaluated exercise
programmes, and one study an online educational and support programme.
Meta-analysis showed that exercise programmes could increase habitual physical
activity (d 1.0; 95% confidence interval (CI) 0.28 to 1.72). This result was
reinforced by reports of increased daily activity in two qualitative studies. The
online programme increased weekly minutes of moderate to vigorous physical
activity (d 0.81; 95% CI 0.17 to 1.45), and weekly step counts (d 0.62; 95%
CI 0.0 to 1.25). Positive effects were not maintained after programmes stopped.
There was insufficient evidence to determine if demographic factors or programme
characteristics, such as intensity and setting, were associated with outcomes.
Conclusion: Preliminary evidence suggests that exercise programmes and online
support programmes can increase habitual physical activity in people with cerebral
palsy, but effects are not maintained when programmes stop.

Introduction
People with cerebral palsy are known to be less
physically active than their unimpaired peers.13
Address for correspondence: Theofani Bania, School of
Physiotherapy, Health Sciences 3, La Trobe University,
Bundoora, 3086, VIC, Australia.
e-mail: tbania@students.latrobe.edu.au

Like the rest of the population, inactivity puts

people with cerebral palsy at greater risk of developing secondary health problems, such as cardiovascular disease, osteoporosis, obesity and type II
diabetes.47 Inactivity can also contribute to social
isolation and depression.8 For these reasons,
maintaining optimal physical activity levels is
very important for people with cerebral palsy.
This has led to an increasing interest in the

The Author(s), 2010.

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10.1177/0269215510383062

304

T Bania et al.

development and implementation of interventions

that aim to increase the physical activity of people
with the condition.
Physical activity has been defined as any bodily
movement produced by contraction of skeletal
muscles that results in energy expenditure.9 To
adequately measure the construct of physical
activity, however, it is important to measure its
frequency, intensity and duration. When assessing
duration of physical activity, there is a difference
between assessing discrete physical activity and
habitual (in free living conditions) physical activity.10 In investigating the relationship between
health and physical activity it is necessary to consider habitual physical activity.11 For the purposes
of this review physical activity will be defined as
habitual bodily movement produced over at least
one full day.
Physiotherapists and occupational therapists
play a key role in supporting people with cerebral
palsy to participate in society by becoming more
physically active. Therapeutic interventions to
increase habitual physical activity can address
demographic, physiological, movement skill, psychological, social and environmental factors.12
Therapy interventions addressing demographic
factors can focus on a particular age or gender
group, while interventions addressing physiological factors or movement skills are often exercise
programmes. Interventions directed at psychological factors usually are behavioural programmes,
and interventions addressing social factors normally aim at structuring social environments.13
Lastly, modifications can take place to the physical environment (e.g. more walkable neighbourhoods) as an intervention to increase physical
activity.14
Although there are a number of possible ways to
address decreased habitual physical activity levels
in people with cerebral palsy, a comprehensive
synthesis of the effects of various interventions is
not available. A literature search located two systematic reviews that included two studies examining habitual physical activity after therapy in
people with cerebral palsy; these reviews did not,
however, make the distinction between habitual
and discrete physical activity in their analysis.1518
Systematic reviews were also located that investigated the effects of a number of interventions,
including therapies, on activities of people with

cerebral palsy. These reviews, however, examined

only discrete physical activities and not habitual
physical activity observed in free living
conditions.1925
Systematic reviews provide information for
physiotherapists and occupational therapists
about the effectiveness of their interventions.
Accordingly, the primary objective of this systematic review was to evaluate the effects on habitual
physical activity of therapy interventions implemented in people with cerebral palsy. The secondary objectives were to determine if:
 more intense interventions were more effective
in changing habitual physical activity than less
intense interventions (i.e. greater total time of
session, frequency of sessions or duration of the
programme);
 specific components of therapy interventions
were associated with increases in habitual physical activity (home-based versus facility-based
programmes, individual programmes versus
group programmes with social interaction);
 any immediate post-intervention changes in
habitual physical activity were maintained at
follow-up;
 therapies were more successful with particular
demographic groups (e.g. children, males).

Methods
To identify relevant studies the following electronic
databases were searched: Medline (1950February
2010), Amed (1985February 2010), Embase
(1988February 2010), Pubmed (1950February
2010), CINAHL (1982February 2010), Cochrane
Library (1993February 2010), Sports Discus
(1975February 2010), Current contents (1993
February 2010), AUSPORTS (1970February
2010), AMI (1968February 2010), PsychInfo
(1806February 2010), PEDro (1929February
2010), Dare (1994February 2010), Index to
Theses (1970February 2010), Australian Digital
Theses
(1998February
2010),
Proquest
Dissertations and Theses (1637February 2010),
and ERIC (1966February 2010). Searching was
performed using the following keywords: cerebral

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Habitual physical activity and cerebal palsy

palsy in combination with physical activity, physical performance, physical fitness, physical endurance, motor activity, energy expenditure, energy
consumption, energy cost and oxygen consumption
(Appendix 1).
Article titles were also scanned in journals of the
Hellenic Society of Physical Therapy (1997
December 2007) and Hellenic Association of
Orthopedic Surgery and Traumatology (2001
September 2009) for potential studies in Greek.
The reference lists of included articles were also
scanned for further potentially relevant studies.
Citation tracking of included studies using Google
scholar was used to augment the electronic database
search. All references found using the search strategy
were imported into an Endnote library (Endnote X1,
Thomson Reuters), where duplicates were deleted.
The title and abstract of articles identified by the
search strategy were assessed against the following
inclusion criteria:
 at least 80% of the participants were people
with cerebral palsy, or data from participants
with cerebral palsy were analyzed and reported
separately;
 habitual physical activity was examined after
implementation of a therapy intervention that
could be administered by a physiotherapist or
an occupational therapist;
 the study evaluated habitual physical activity
over at least one day to collect data from a
variety of activities for each participant;
 all types of quantitative and qualitative designs
were eligible for inclusion except for case reports.
Articles were excluded if only an abstract was
available because it was not possible to adequately
assess methodological quality. Studies were also
excluded if they measured physical activity but not
after implementation of an intervention, for example
correlational studies. In addition, articles not published in English or Greek were excluded. Once articles clearly not relevant were deleted based on
examination of the titles and abstracts, full-text
copies of the remaining articles were obtained and
read independently for further consideration by two
reviewers (TB and KD). Where the reviewers were
uncertain if an article should be included the paper
was discussed until consensus was achieved.

305

Two reviewers independently assessed the methodological quality of the studies (TB and KD) and
any discrepancies were settled by consensus.
Quantitative studies were assessed with the
PEDro scale,26 which was developed to assess
quality of randomized controlled trials. The scale
has demonstrated evidence of validity in measuring the methodological quality of clinical trials,27
and the inter-rater reliability of the cumulative
PEDro score was found to be high (ICC 0.91;
95% confidence interval (CI) 0.84 to 0.95) for
studies of non-pharmacological interventions.28
It has 11 criteria, however only criteria 2 to 11
are scored and a total score of 0 to 10 is given.
We deemed the quantitative studies to be of high
methodological quality if they received a total
PEDro score of 8 to 10, moderate methodological
quality if they received a total PEDro score of 5 to
7 and low methodological quality if they received a
score of 4 or less.
The quality of the qualitative studies was
assessed with the Critical Appraisal Checklist for
Qualitative Research Studies (CACQRS).29 This
recently developed checklist was chosen because
guidelines for its use have been published and
this rendered the CACQRS potentially more reliable than other qualitative checklists that have not
been tested for reliability and that do not have
clearly defined criteria available to help reviewers
evaluate whether criteria are satisfied or not. The
CACQRS consists of 10 questions, each with subquestions. A yes or no answer was given to each
sub-question and then a rating scale comprising
four scoring levels (adapted from Cesario et al.30
checklist scoring system) was used to assign a
score to each study. The CACQRS and the scoring
system used are presented in Appendix 2. Studies
were regarded as of high methodological quality if
more than 75% of the total CACQRS criteria were
met, moderate quality if 5074% of the total criteria were met, and low quality if less than 50% of
the total CACQRS criteria were met.30
Relevant information from the included studies
was extracted by one reviewer (TB). A second
reviewer (KD) checked the extracted data. Any
discrepancies were resolved by discussion with
reference to the full-text copy of the included
study. The following data were extracted: study
objective(s), study design, participant inclusion/
exclusion criteria, recruitment procedures used,

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T Bania et al.

participant details (subject number, sex, age,

experimental and control group characteristics),
description of the intervention(s) (type, frequency,
duration of session, duration of the programme),
description of any co-intervention(s), habitual
physical activity outcome measures used (quantitativequalitative, primarysecondary), where/
when outcomes were measured, reliability and
validity of physical activity measurement tools,
results on habitual physical activity, and any
study limitations.
For data analysis of quantitative studies, effect
sizes and CIs were calculated. Effect sizes were
calculated as standardized mean differences
(d Hedges unbiased estimator), defined as the difference in post-intervention means divided by the
pooled standard deviation. Data were pooled with
a random effect model using a web-based metaanalysis programme.31 Statistical homogeneity
was tested using the I squared test, to find out
whether the summed effect sizes differed from
the population effect size because of sampling
error or due to variability of the underlying population parameters.32 For clinical significance
average improvement of the intervention group
participants over controls was calculated using
Cohens U3 improvement index.33 An average
improvement of the intervention group by at
least 25% over the control group was considered
clinically significant with a broad range of outcome measures.34 For qualitative studies, results
relevant to habitual physical activity were
recorded for each study in the form of themes.
For the purpose of the primary objective of the
review we grouped the studies according to the
type of therapy. Therapies were grouped into
the following categories: structured, unstructured,
and mixed. A programme was considered as structured when participants followed pre-determined
rules regarding type and volume of exercises or
activities, and unstructured when participants did
not follow any rules and they performed exercises/
activities they wanted or liked. Mixed programmes
combined structured and unstructured programmes. The nature of the intervention, which
was determined by the factor they influenced,
was also taken into account. Therefore, we
grouped programmes into exercise programmes if
they predominantly addressed physiological or
motor skill factors, behavioural programmes if

they predominantly addressed psychological factors, social programmes if they predominantly

focused on social factors, and environmental if
they focused on environmental factors.

Results
After duplicates were deleted, a total of 6,716 articles remained in the Endnote library. After screening for titles and abstracts, a total of 25 articles
remained. From these, 18 studies were excluded
after full-text review because they did not measure
habitual physical activity as an outcome. Another
study was excluded because it did not analyze data
for people with cerebral palsy separately and
another one because it measured physical activity
for less than a day.3536 Citation tracking of
included articles yielded no new studies. One
unpublished thesis was located37 because its
author was a key author of articles about habitual
physical activity in people with cerebral palsy. This
left a total of five studies for review.15,16,3739
However, one study implemented a project using
two different designs: a randomized controlled
trial that implemented exercise training for nine
months four times per week, and then after the
completion of the randomized controlled trial a
single group pre-post design that implemented
similar training two times per week for a further
nine months. Therefore, these data were analyzed
separately.15 Figure 1 summarises the study selection procedure.
Table 1 presents the participants characteristics, study designs and details about the interventions implemented in each study. Three of the
included studies used a quantitative research
design15,37,39 while the remaining two used a qualitative research design.16,38 All quantitative
research designs were randomized controlled
trials. In one study, however, a single group prepost intervention design followed the randomized
controlled trial.15
Studies contained small sample sizes ranging
from 10 to 41 participants and most recruited children except for a single study that focused on
adults.38 Most participants had spastic diplegia,
with a mix of ambulatory and non-ambulatory
participants. The cognitive level of participants

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Habitual physical activity and cerebal palsy

307

6,716 studies after

duplicated deleted

6,700 studies deleted on title

18

did not measure

habitual physical activity
as an outcome

and abstract

24 hard copies were retrieved

20 studies were
excluded

1 CP data not analyzed

separately

1 measured physical
activity for less than
one day

0 studies from
references lists
4
1

Figure 1

unpublished thesis

studies included in the review

Flowchart of the studies selection process.

was not reported in four of the studies. The

remaining study, reported that participants cognitive levels ranged from normal intelligence to mild
mental retardation.15
Four of the five therapy interventions were structured exercise programmes,15,16,38,39 and one was a
mixed structured and unstructured behavioural
programme (Table 1).37 Two of the structured exercise programmes comprised progressive resistance
exercise training,16,38 one comprised aerobic
exercises,15 and one comprised closed-kineticchain exercises such as calf-raises in a circuit.39
The behavioural programme delivered online tailored feedback about participants physical activity,
and provided information about positive role
modelling, and information that directed and assisted participants to develop physical activity goals.37
All programmes were supervised by exercise
trainers or physiotherapists. Three programmes

were facility based15,38,39 and two were home

based.16,37 Two programmes were run as a
group,38,39 one was an individual programme,16
and one was an individual programme with
online group interaction.37 Programmes were typically conducted two to three times a week, with
each session lasting around 45 minutes. Most of
the programmes were of a relatively short duration
of between six and 12 weeks. The control group
attended an upper limb training programme in one
randomized controlled trial,39 and continued with
usual care in the other two.15,37
The methodological quality of the three randomized controlled trials15,37,39 ranged from moderate to high, while the methodological quality
of the pre-post single group design was low
(Table 2).15 The methodological quality of the
two qualitative studies ranged from moderate to
high.16,38

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Van den
Berg-Emons
et al. (1998)
RCT

Crompton et al.
(2007) RCT

Exp: 20 Con: 21

Maher (2008)
RCT

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Normal intelligence
and mild mental
retardation

Half ambulant,
half wheelchair-bound

11 males, 9 females
16 diplegia (14 spastic,
2 mixed spastic and
ataxic) 4 spastic
tetraplegia

a.r. 713 yrs

m.a. 9.2 yrs

Exp: 10 Con: 10

GMFCS I, II, III

All spastic diplegia

6 males, 9 females

a.r. 614yrs
m.a. 10.6 yrs

Exp: 8 Con: 7

GMFCS level I, II or III

16 hemi, 18 diplegia,
1 tetra, 1 ataxic,
5 unspecified

26 males, 15 females

a.r. 1116 yrs

m.a. 13.5 yrs

Participants

Methods

Study

Table 1
Total time
of session

Con: usual care (therapy based

on personal needs and gymnastic
lessons)

Exp: extra training activities- aerobic

exercises, such as cycling, wheelchair driving, running, swimming,
training on a flying saucer, and
mat exercises.

Exp: Circuit of 7 closed-kinetic-chain

exercise stations: treadmill,
stationary bicycle, step-ups, calfraises, a bridge of stairs, sit-tostand from adult chair, squats
leaning against wall, moving
around course of cones, lateral
step-over of two bars and kicking
a ball hanging by a string
Con: upper limb training

Con: usual care

45 min

1 hour

Exp: Interactive online programme

21.2 min
to promote physical activity,
improve exercise knowledge,
attitudes, self-efficacy and intention and reduce sedentary activity.
The programme was based on
Social Cognitive Theory, which
emphasises enhancement of
participants self-efficacy, positive
role modelling and goal-setting

Type of intervention

9 months
(4/wk)

6 weeks
(2/wk)

8 weeks
(1/wk)

physiological

group

social

(continued)

facility-based

not clear

supervised

structured

facility-based

supervised

structured

home-based

individual with on-line

group interaction

mixed structured and

unstructured
supervised

Structured/unstructured
Supervised/unsupervised
Group/individual
Home based/facility
based

motor skills

physiological

social

Psychological

Programme PA
duration
influential
(frequency) factors

308
T Bania et al.

10 : 5 spastic diplegia
Muscle strengthening using
4 athetoid quadriplegia
6080% RM
1 spastic hemiplegia
1 Leg press
a.r. 4056 yrs
2 Knee extension
m.a. 45.8 yrs
3 Lat pull down
4 Chest press
6 males, 4 females
5 Seated row
3 ambulant
6 Abdominals
7 non-ambulant
Muscle strengthening using
11 spastic diplegic CP
6080% RM
a.r. 818 yrs
Bilateral heel raises on a step
ma: 12.75 yrs
(height 20 cm); bilateral half
squats using a large inflatable ball
4 males, 7 females
to guide exercise; and step-ups
onto/off a standard aerobic step
GMCS levels:
7 III 2 II, 2 I

Ambulatory level: not

clear

Total time
of session

2045 min

6090 min

Usual care extra training activities: 45 min

aerobic exercises, such as cycling,
wheelchair driving, running, training on a flying saucer, and mat
exercises.

Type of intervention

6 weeks
(3/wk)

10 weeks
(2/wk)

9 months
(2/wk)

physiological

physiological
social

physiological

Programme PA
duration
Influential
(frequency) factors

home-based

individual

unsupervised

structured

facility-based

group

supervised

facility-based
structured

not clear

supervised

structured

Structured/unstructured
Supervised/unsupervised
Group/individual Home
based/facility based

RCT, randomised controlled study; exp, experimental group; con, control group; a.r, age range; m.a., mean age; hemi, hemiplegia; tetra, tetraplegia; GMFCS,
gross motor function classification system; yrs, years; wk, week; mos, months; min, minutes; RM, repetition maximum; cm, centimetres; PA, physical
activity.

McBurney et al.
(2003)
Qualitative
study

Qualitative
study

Allen et al.
(2004)

Single group
design

Exp group: 17

Van den
Berg-Emons
et al. (1998)

a.r. children

Participants

Continued

Study

Table 1

Habitual physical activity and cerebal palsy

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309

310

T Bania et al.

Table 2

Results

Study

Design

Methodological
quality

Outcome measures

Maher (2008)

RCT

Pedometer for 7 days (wkly step

counts, wkly distance, wkly
MVPA minutes)
MARCA (average daily PA, average daily MVPA)

Crompton et al.
(2007)

RCT

Van den
Berg-Emons
et al. (1998)

RCT

Van den
Berg-Emons
et al. (1998)
Allen et al.
(2004)
McBurney et al.
(2003)

Single group
pre-post
design
Qualitative
study
Qualitative
study

4
23 (QI)
21 (QII)

Physical activity results

No difference between groups for

self-reported daily PAL postintervention (d 0.14,
CI 0.75 to 0.47) and follow up
(d 0.06, CI 0.68 to 0.55)
as well as daily MVPA postintervention (d 0.05, CI 0.56
to 0.66) and follow up (d 0.13,
CI 0.74 to 0.49)
At post-intervention difference
between groups was not significant for wkly distance-pedometer
(d 0.57, CI 0.5 to 1.20), but
was significant for wkly step
counts (d 0.62, CI 0.0 to 1.25)
and for wkly MVPA minutes
(d 0.81, CI 0.17 to 1.45). This
had reduced at follow-up for wkly
distance (d 0.39, CI 0.23 to
1.01), for wkly step counts
(d 0.39, CI 0.23 to 1.01) and
for wkly MVPA min (d 0.36,
CI 0.26 to 0.98)
Uptimer for 4 days (2 weekdays Non-significant changes between
and 2 weekend days)
the two groups after 6 weeks
(d 0.93, CI 0.14 to 2.00) and
at follow-up (d 0.30, CI 0.79
to 1.40)
Significant changes between experiTEE/SMR or TEE/RMR
mental and control groups in daily
TEE heart rate (for a day) SMR
(respiration chamber/indirect
PA (d 1.1, CI .12 to 1.99)
calorimeter-overnight) RMR
ventilated hood (20 min)
TEE/RMR
PA levels were not increased postTEE Heart rate (for a day)
training in relation to pretraining
RMR ventilated hood (20 min)
(d 0.54, CI 0.15 to 1.22)
Semi-structured interviews
7 participants walked longer
(participants)
distances
Semi-structured interviews
Some children were able to walk
(participants having received
longer distances
intervention and their parents)

RCT, randomised controlled trial; MARCA, multimedia activity recall for children and adolescents; MVPA, moderate to vigorous
physical activity; TEE, total energy expenditure; RMR, resting metabolic rate; SMR, sleep metabolic rate; PA(L), physical
activity (level); d, effect size; wkly, weekly; min, minutes; CACQRS, Critical Appraisal Checklist for Qualitative Research;
QI, 75100% of the total CACQRS criteria were met; QII, 5074% of the total CACQRS criteria were met.

The blinding of participants and of therapists

criterion was not met by any trial, and only one
trial met the allocation was concealed criterion.37
With regard to the qualitative studies, a single
study satisfied the criterion concerning whether
an appropriate rationale was provided for using

a qualitative approach.38 Additionally, none of

the qualitative studies had carried out an audit
trail and ground interpretation, had made appropriate generalization or had kept a record of
progressive subjectivity for the criterion Does
the researcher address the treats to reliability

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Habitual physical activity and cerebal palsy

and validity in data collection, analysis and
interpretation?

Outcomes
There was preliminary evidence that structured
exercise programmes can increase habitual physical activity levels in people with cerebral palsy.
Two randomized controlled trials,15,39 one single
group design study15 and two qualitative studies16,38 implemented structured exercise programmes. One of the randomized controlled
trials reported statistically significant changes in
energy expenditure between experimental and
usual care control group immediately after intervention (d 1.1; CI 0.12 to 1.99),15 whereas the
other randomized controlled trial did not find significant differences in uptime between intervention
and upper limb training control groups (d 0.93;
CI 0.14 to 2.00) (Table 2).39 On average, participants of the BergEmons experimental group
increased energy expenditure by 36%15 and participants of the Crompton experimental group
increased uptime by 32% over the control
group.39 When data from these two trials were
pooled in a meta-analysis a significant difference
in favour of exercise was found between groups

311

(d 1.0; CI 0.28 to 1.72; I2 0%) (Figure 2).

Results from the pre-post single group design
study reported no significant difference in habitual
physical activity post-training in comparison with
baseline (d 0.54; CI 0.15 to 1.22) (Table 2).15
Both qualitative studies reported examples of
increased habitual physical activity in the community in that participants could walk longer distances after completing the exercise programme
(Table 2). For example, the parent of one participant said now she can walk one to two kilometres,
and likes walking. Another participant who went
to Japan with school for three weeks said that was
heaps and heaps of walking. I loved it.16 A further
participant said his walking was better and that he
could walk longer distances.38
There was preliminary evidence that a mixed
structured and unstructured behavioural programme can increase habitual physical activity in
people with cerebral palsy.37 A single study implemented a mixed structuredunstructured behavioural programme. A significant difference was
found in favour of the experimental group compared with the control group immediately after
intervention for weekly minutes of moderate to vigorous physical activity (d 0.81; CI 0.17 to 1.45),
and for weekly step counts (d 0.62; CI 0.0 to
1.25) assessed by a pedometer. On average the

Crompton d = 0 .93 (CI 0.14 to 2.00)

BergEmons d = 1.1 (CI 0.12 to 1.99)

d = 1.0 (CI 0.28 to 1.72)

0 .5

0.5

1.5

2.5

Figure 2 Effect sizes (d) of individual randomized controlled trials are presented as squares, each horizontal line represents
their 95% confidence interval (CI) around the mean. Delta effect size of the meta-analysis is presented as a diamond,
where the left and right apices represent the 95% CI limits. Squares/diamonds to the right of the vertical axis represent an
effect favouring the intervention condition, whereas those to the left favour the control. Sizes of shapes are representative
to sample sizes.

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T Bania et al.

intervention group increased weekly minutes of

moderate to vigorous physical activity by 29% and
weekly steps by 23% over controls. No significant
effects were observed immediately after intervention
for increased distance walked each week assessed by
a pedometer (d 0.57; CI  0.5 to 1.20), selfreported energy cost of daily physical activities
(d 0.14; CI  0.75 to 0.47), or self-reported
daily minutes of moderate to vigorous physical
activity (d 0.05; CI  0.56 to 0.66) (Table 2).
No study specifically examined whether more
intense interventions were more effective in changing habitual physical activity than less intense
interventions. However, all the structured exercise
programmes had a greater total session time and a
greater frequency of sessions than the behavioural
programme.
More studies supported the effectiveness of facilitybased programmes15,38,39 compared with home-based
programmes,16,37 but the studies were not designed to
examine whether facility-based interventions were
more effective than home-based interventions.
Although some studies included a social component
by including group interaction as part of their programme no study evaluated social factors by manipulating this factor as an experimental variable.
Immediate post-intervention changes in habitual physical activity were not maintained at
follow-up. Two of the six studies carried out
follow-up assessments, and their follow-up periods
were six weeks39 and 10 weeks.37 Most of the effect
sizes had decreased at follow-up.
There was inconclusive evidence about whether
interventions were more successful with particular
participant groups. However, Maher10 investigated
the relationship of age, gender, baseline habitual
physical activity level and type of school attended
to weekly step counts immediately post-intervention
and reported no evidence of a relationship between
these characteristics and weekly step counts.

Discussion
The results of this review provide preliminary evidence that structured exercise programmes can
increase habitual physical activity in people with
cerebral palsy. When data from two randomized
controlled trials were pooled in a meta-analysis, a
statistically significant difference between groups

and a large effect size was found. This evidence is

reinforced by the results of qualitative studies that
also reported increases in habitual physical activity.
The effect in favour of structured exercise programmes was clinically significant for uptime and
energy expenditure, with average improvement of
the intervention group by at least 25% over the
control group. Our findings that structured exercise
programmes can improve habitual physical activity
in people with cerebral palsy add to the available
evidence that exercise is beneficial for people with
other long-term neurological conditions.4042
Finding clinically significant increases in uptime
and energy expenditure as a result of increased habitual physical activity levels is encouraging for people
with cerebral palsy, since they tire more easily during
activities43 and are less active than their peers without impairment.13 As inactivity has often been
related to increased risk for developing various
health problems,46,8 structured exercise programmes can be useful for people with cerebral
palsy because they can increase habitual activity.
Furthermore, programmes that did not directly
aim to increase daily physical activity such as
muscle strengthening brought about increases in
habitual walking activity. Finding evidence that
programmes that did not directly target physical
activity can increase the habitual physical activity
of people with cerebral palsy is important, because
it means that people with the condition can use
different ways to deal with decreased habitual
physical activity levels and the risk of developing
secondary health problems.
The results of this review also provide preliminary evidence from a single trial that a mixed structured and unstructured behavioural programme,
which provided tailored physical activity feedback,
exercise suggestions, positive role modelling and
goal-setting guidance to participants in an online
computer format can increase the habitual physical
activity of adolescents with cerebral palsy. The
behavioural programme brought about statistically
significant and clinically significant increases in
weekly moderate to vigorous physical activity
levels. This finding is important because people
with cerebral palsy often engage in less vigorous
activities compared to peers without impairment2,44 and increased moderate to vigorous physical activity has been reported to decrease the risk
of developing health problems.4,7,8

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Habitual physical activity and cerebal palsy

Effect sizes had decreased at follow-up for both
structured exercise and mixed structuredunstructured behavioural programmes. For clinical practice this suggests that any benefits from the
interventions tended to reduce over time after
training stopped suggesting the need to possibly
provide programmes of longer duration or ongoing maintenance programmes if effects are to be
maintained in the longer term.
Reviews exploring the effectiveness of interventions on habitual physical activity of people with
cerebral palsy or of comparable neurological conditions were not located. Therefore, the findings of the
present review were compared with findings of
reviews on people without impairment. In one systematic review, the reviewers examined the effectiveness of health behaviour change programmes
adapted to the individuals needs and interests and
they reported strong evidence of the effectiveness of
these programmes.13 This finding is consistent with
the present review finding of preliminary evidence of
effectiveness of the behavioural programme on habitual physical activity of people with cerebral palsy.
There was inconclusive evidence about the
effectiveness of more intensive interventions in comparison with less intensive interventions and homebased interventions compared with facility-based
interventions. There was also inconclusive evidence
about whether interventions were more successful
with certain participant groups as no relationship
was found between age or gender and the effects of
therapy in habitual physical activity assessed as step
counts. However, most of the participants of the
included studies were children or adolescents. There
is limited information on the habitual physical activity of adults with cerebral palsy after implementation
of therapy although habitual physical activity is particularly important for this group for the prevention
of secondary health problems.45 The number of
included studies was small. It remains unclear, therefore, what the optimal intensities of programmes, and
the optimal specific components of programmes are,
how long effects last and whether interventions are
more effective with certain participants.
This is the first systematic review to evaluate the
effectiveness of interventions to improve the habitual
physical activity of people with cerebral palsy.
However, a limitation of the present review is the
fact that we extracted data and assessed the methodological quality of included studies without being

313

blinded to authorship, title and other study information. In addition, only studies published in English
and Greek were included and potential studies published in other languages may have been missed. This
review only provides preliminary evidence as there are
few published studies available investigating the
effects of interventions aimed at increasing the everyday physical activity of people with cerebral palsy.
Most of the participants included in the currently
available studies were children with diplegia and
results therefore cannot be generalized to all people
with cerebral palsy. Most intervention programmes
have also been of relatively short duration.
In conclusion, the results of this systematic
review provide preliminary evidence that structured exercise programmes and online behavioural
support programmes can be effective in increasing
the habitual physical activity of people with cerebral palsy. However, the positive effects of these
programmes do not appear to be maintained when
they are stopped.

Clinical messages
 Structured exercise and online behavioural
programmes can increase physical activity
of people with cerebral palsy.
 Any benefits in physical activity for people
with cerebral palsy appear to be reduced or
lost after the programme finishes suggesting
that for long-term benefit maintenance programmes may need to be implemented.
 We do not know yet the optimal intensities,
and optimal components of a programme
aimed at increasing physical activity in
people with cerebral palsy.

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