Exercise interventions for cerebral palsy

Jennifer M Ryan; Elizabeth E Cassidy; Stephen G Noorduyn; Neil E O'Connell

doi:10.1002/14651858.CD011660.pub2

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Figure 1

8071‐7926‐Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 4

Funnel plot of comparison: 6 Resistance training and mixed training versus usual care, outcome: 6.1 Activity: gross motor function; short term.

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Figure 5

Funnel plot of comparison: 6 Resistance training and mixed training versus usual care, outcome: 6.6 Muscle strength; short term.

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Analysis 1.1

Comparison 1 Aerobic exercise versus usual care, Outcome 1 Activity: gross motor function, short term.

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Analysis 1.2

Comparison 1 Aerobic exercise versus usual care, Outcome 2 Activity: gait speed, short term.

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Analysis 1.3

Comparison 1 Aerobic exercise versus usual care, Outcome 3 Activity: walking endurance; short term.

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Analysis 1.4

Comparison 1 Aerobic exercise versus usual care, Outcome 4 Activity: gait speed, intermediate term.

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Analysis 1.5

Comparison 1 Aerobic exercise versus usual care, Outcome 5 Activity: gross motor function, intermediate term.

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Analysis 1.6

Comparison 1 Aerobic exercise versus usual care, Outcome 6 Activity: daily physical activity; short term.

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Analysis 1.7

Comparison 1 Aerobic exercise versus usual care, Outcome 7 Aerobic fitness; short term.

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Analysis 2.1

Comparison 2 Resistance training versus usual care, Outcome 1 Activity: gross motor function, children and adolescents; short term.

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Analysis 2.2

Comparison 2 Resistance training versus usual care, Outcome 2 Activity: gross motor function, children and adolescents; intermediate term.

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Analysis 2.3

Comparison 2 Resistance training versus usual care, Outcome 3 Activity: gait speed, children and adolescents; short term.

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Analysis 2.4

Comparison 2 Resistance training versus usual care, Outcome 4 Activity: gait speed, children and adolescents; intermediate term.

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Analysis 2.5

Comparison 2 Resistance training versus usual care, Outcome 5 Activity: gait speed, adults; short term.

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Analysis 2.6

Comparison 2 Resistance training versus usual care, Outcome 6 Activity: gross motor function, adults; short term.

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Analysis 2.7

Comparison 2 Resistance training versus usual care, Outcome 7 Activity: walking endurance, adults; short term.

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Analysis 2.8

Comparison 2 Resistance training versus usual care, Outcome 8 Participation, children and adolescents; short term.

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Analysis 2.9

Comparison 2 Resistance training versus usual care, Outcome 9 Participation, children and adolescents; intermediate term.

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Analysis 2.10

Comparison 2 Resistance training versus usual care, Outcome 10 Quality of life (parent‐reported), children and adolescents; short term.

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Analysis 2.11

Comparison 2 Resistance training versus usual care, Outcome 11 Quality of life (child‐reported), children and adolescents; short term.

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Analysis 2.12

Comparison 2 Resistance training versus usual care, Outcome 12 Muscle strength, children and adolescents; short term.

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Analysis 2.13

Comparison 2 Resistance training versus usual care, Outcome 13 Muscle strength, children and adolescents; intermediate term.

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Analysis 2.14

Comparison 2 Resistance training versus usual care, Outcome 14 Muscle strength, adults; short term.

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Analysis 3.1

Comparison 3 Mixed training versus usual care, Outcome 1 Activity: gross motor function; short term.

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Analysis 3.2

Comparison 3 Mixed training versus usual care, Outcome 2 Activity: gait speed; short term.

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Analysis 3.3

Comparison 3 Mixed training versus usual care, Outcome 3 Activity: walking endurance; short term.

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Analysis 3.4

Comparison 3 Mixed training versus usual care, Outcome 4 Participation; short term.

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Analysis 3.5

Comparison 3 Mixed training versus usual care, Outcome 5 Participation; intermediate term.

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Analysis 3.6

Comparison 3 Mixed training versus usual care, Outcome 6 Aerobic fitness; short term.

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Analysis 3.7

Comparison 3 Mixed training versus usual care, Outcome 7 Muscle strength; short term.

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Analysis 3.8

Comparison 3 Mixed training versus usual care, Outcome 8 Anaerobic fitness; short term.

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Analysis 3.9

Comparison 3 Mixed training versus usual care, Outcome 9 Aerobic fitness; intermediate term.

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Analysis 3.10

Comparison 3 Mixed training versus usual care, Outcome 10 Anaerobic fitness; intermediate term.

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Analysis 3.11

Comparison 3 Mixed training versus usual care, Outcome 11 Muscle strength; intermediate term.

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Analysis 4.1

Comparison 4 Resistance training versus aerobic exercise, Outcome 1 Activity: gross motor function; short term.

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Analysis 4.2

Comparison 4 Resistance training versus aerobic exercise, Outcome 2 Activity: gait speed; short term.

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Analysis 4.3

Comparison 4 Resistance training versus aerobic exercise, Outcome 3 Activity: gait speed; intermediate term.

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Analysis 4.4

Comparison 4 Resistance training versus aerobic exercise, Outcome 4 Activity: gross motor function; intermediate term.

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Analysis 4.5

Comparison 4 Resistance training versus aerobic exercise, Outcome 5 Muscle strength; short term.

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Analysis 4.6

Comparison 4 Resistance training versus aerobic exercise, Outcome 6 Muscle strength; intermediate term.

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Analysis 5.1

Comparison 5 Aerobic exercise and mixed training versus usual care, Outcome 1 Activity: gross motor function; short term.

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Analysis 5.2

Comparison 5 Aerobic exercise and mixed training versus usual care, Outcome 2 Activity: gross motor function, intermediate term.

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Analysis 5.3

Comparison 5 Aerobic exercise and mixed training versus usual care, Outcome 3 Activity: gait speed; short term.

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Analysis 5.4

Comparison 5 Aerobic exercise and mixed training versus usual care, Outcome 4 Activity: walking endurance; short term.

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Analysis 5.5

Comparison 5 Aerobic exercise and mixed training versus usual care, Outcome 5 Aerobic fitness; short term.

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Analysis 6.1

Comparison 6 Resistance training and mixed training versus usual care, Outcome 1 Activity: gross motor function; short term.

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Analysis 6.2

Comparison 6 Resistance training and mixed training versus usual care, Outcome 2 Activity: gross motor function; intermediate term.

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Analysis 6.3

Comparison 6 Resistance training and mixed training versus usual care, Outcome 3 Activity: gait speed; short term.

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Analysis 6.4

Comparison 6 Resistance training and mixed training versus usual care, Outcome 4 Participation; short term.

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Analysis 6.5

Comparison 6 Resistance training and mixed training versus usual care, Outcome 5 Participation; intermediate term.

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Analysis 6.6

Comparison 6 Resistance training and mixed training versus usual care, Outcome 6 Muscle strength; short term.

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Analysis 6.7

Comparison 6 Resistance training and mixed training versus usual care, Outcome 7 Muscle strength; intermediate term.

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Summary of findings for the main comparison. Aerobic exercise versus usual care

Aerobic exercise versus usual care
Patient or population: children and adolescents with cerebral palsy Intervention: aerobic exercise Setting: mixed (community, outpatients, home) Comparison: usual care
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with usual care	Risk with aerobic exercise
Activity Gross motor function assessed with the Gross Motor Function Measure (follow‐up 0 to 1 month)	The mean gross motor function ranged across control groups from 0.20% to 65.13%	The standardised mean gross motor function in the intervention group was 0.53 higher (0.02 higher to 1.04 higher)	—	65 (3)	⊕⊕⊝⊝ Low^a,c,d	Higher score indicates improved activity A rule of thumb for interpreting SMD is that 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect (Cohen 1988)
Activity Gait speed assessed with a timed walk test (follow‐up 0 to 1 month)	The mean gait speed ranged across control groups from 0.63 m/s to 2.40 m/s	The mean gait speed in the intervention groups was0.09 m/s faster (0.11 m/s slower to 0.28 m/s faster)	—	82 (4)	⊕⊝⊝⊝ Very low^a,b,c,d	Higher speed indicates improved activity
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; SMD: standardised mean difference.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aAll studies are at high risk of bias because it is not possible to blind personnel or participants to group allocation. ^bHeterogeneity statistically significant: P < 0.1, I² > 40%. ^cNumber of participants < 400. ^dWe did not downgrade on the basis of publication bias, as there can be no direct evidence with so few trials for any given intervention.

Summary of findings for the main comparison. Aerobic exercise versus usual care

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Summary of findings 2. Resistance training versus usual care

Resistance training versus usual care
Patient or population: children and adolescents with cerebral palsy Setting: mixed (home, physiotherapy clinic, school, community gym) Intervention: resistance training Comparison: usual care
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with usual care	Risk with resistance training	Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
Activity Gross motor function assessed with the Gross Motor Function Measure (follow‐up 0 to 1 month)	The mean gross motor function ranged across control groups from 60.80% to 81.30%	The standardised mean gross motor function in the intervention groups was 0.12 higher (0.19 lower to 0.43 higher)	—	164 (7)	⊕⊕⊝⊝ Low^a,b,c	A rule of thumb for interpreting the SMD is that 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect (Cohen 1988) Higher score indicates improved activity
Activity Gross motor function assessed with the Gross Motor Function Measure (follow‐up > 1 month to 6 months)	The mean gross motor function ranged across control groups from 61.80% to 74.30%	The standardised mean gross motor function in the intervention groups was 0.13 higher (‐0.30 lower to 0.55 higher)	—	85 (3)	⊕⊕⊝⊝ Low^a,b,c	A rule of thumb for interpreting SMD is that 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect (Cohen 1988) Higher score indicates improved activity
Activity Gait speed assessed with a timed walk test (follow‐up 0 to 1 month)	The mean gait speed ranged across control groups from0.30 m/s to 1.17 m/s	The mean gait speed in the intervention groups was 0.03 m/s faster (0.02 m/s slower to 0.07 m/s faster)	—	185 (8)	⊕⊕⊝⊝ Low^a,b,c	Higher speed indicates improved activity
Activity Gait speed assessed with a timed walk test (follow‐up > 1 month to 6 months)	The mean gait speed ranged across control groups from 0.68 m/s to 1.06 m/s	The mean gait speed in the intervention groups was 0.03 m/s slower (0.17 m/s slower to 0.11 m/s faster)	—	84 (3)	⊕⊕⊝⊝ Low^a,b,c	Higher speed indicates improved activity
Participation Assessed with various measures (follow‐up 0 to 1 month)	The mean participation in the control group ranged from 7.40 to 31.14	The standardised mean participation in the intervention groups was 0.34 higher (0.01 lower to 0.70 higher)	—	127 (2)	⊕⊕⊝⊝ Low^a,b,c	A rule of thumb for interpreting SMD is that 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect (Cohen 1988) Higher score indicates improved participation
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; SMD: standardised mean difference.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aAll trials are at high risk of bias because it is not possible to blind personnel or participants to group allocation. ^bNumber of participants < 400. ^cWe did not downgrade on the basis of publication bias, as there can be no direct evidence with so few trials for any given intervention.

Summary of findings 2. Resistance training versus usual care

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Summary of findings 3. Mixed training versus usual care

Mixed training versus usual care
Patient or population: children and adolescents with cerebral palsy Setting: mixed (school, home) Intervention: mixed training Comparison: usual care
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with usual care	Risk with mixed training
Activity Gross motor function assessed with the Gross Motor Function Measure (follow‐up 0 to 1 month)	The mean gross motor function in the control groups ranged from 30.76% to 90.11%	The standardised mean gross motor function in the intervention groups was 0.02 higher (0.29 lower to 0.33 higher)	—	163 (4)	⊕⊕⊝⊝ Low^a,b,c	A rule of thumb for interpreting SMD is that 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect (Cohen 1988) Higher score indicates improved activity
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; SMD: standardised mean difference.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aAll trials are at high risk of bias because it is not possible to blind personnel or participants to group allocation. ^bNumber of participants < 400. ^c We did not downgrade on the basis of publication bias, as there can be no direct evidence with so few trials for any given intervention.

Summary of findings 3. Mixed training versus usual care

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Summary of findings 4. Resistance training versus aerobic exercise

Resistance training versus aerobic exercise
Patient or population: children with cerebral palsy Setting: home or not reported Intervention: resistance training Comparison: aerobic exercise
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with aerobic exercise	Risk with resistance training
Activity Gross motor function assessed with various measures (follow‐up 0 to 1 month)	The mean gross motor function in the aerobic exercise groups ranged from 44.09% to 63.30%	The standardised mean gross motor function in the intervention groups was 0.02 higher (0.50 lower to 0.55 higher)	—	56 (2)	⊕⊕⊝⊝ Low^a,b,c	Higher score indicates improved activity
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; SMD: standardised mean difference.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aAll trials are at high risk of bias because it is not possible to blind participants or personnel to group allocation. ^bNumber of participants < 400. ^cWe did not downgrade on the basis of publication bias, as there can be no direct evidence with so few trials for any given intervention.

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Table 1. Additional methods table

Binary data	We planned to present the relative risk (or risk ratio) with a 95% confidence interval, and calculate the number needed to treat for an additional beneficial outcome as an absolute measure of treatment effect. We will report the odds ratio (OR) with a 95% confidence interval in future updates of this review, as most studies with a dichotomous outcome report the OR.
Cluster trials	We planned to seek direct estimates of the effect from an analysis that accounted for cluster design. Where the analysis in a cluster trial did not account for the cluster design, we planned to use the approximately correct analysis approach, presented in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011c).
Crossover trials	Where studies presented repeated measurements over time, we planned to only include data from 1 time point from an individual study in any single meta‐analysis. If inadequate data were available to conduct this analysis, we planned to only include data from the first phase of the cross‐over trial, as if it were from a parallel trial design. We planned to combine the results of cross‐over studies with those of parallel studies by imputing the post‐treatment, between‐condition correlation coefficient from an included study that presents individual participant data, and use this to calculate the standard error of the SMD, using the generic inverse‐variance method.
Assessment of reporting biases	Where we identified evidence of publication bias, we planned to consider its likely influence on the observed effect sizes in our interpretation of the results. However, as common tests of publication bias lack sensitivity, we planned to consider the possible influence that a dominance of small trials might have on pooled effect sizes in our interpretation.
Subgroup analysis and identification of heterogeneity	We planned to further explore possible clinical heterogeneity through preplanned subgroup analysis based on important clinical features. We predicted that some trials would include ambulatory participants only (i.e. people who could walk with or without a mobility aid; GMFCS level I, II, and III), and some studies would include participants who could walk without a mobility aid only (i.e. GMFCS level I and II). Where adequate data allowed, we planned to undertake 2 subgroup analyses for studies that included ambulatory people only (i.e. GMFCS level I, II, and III), and for studies that included ambulatory people who walk without a mobility aid only (i.e. GMFCS level I and II).
Sensitivity analysis	We planned to explore the impact of studies at high risk of bias by reanalysis after excluding studies rated at overall high risk of bias. We also planned to explore the impact of excluding studies at high risk of bias for missing data through reanalysis. We planned to explore the influence of using imputed correlation coefficients in our approach to including cross‐over and cluster trials by reanalysing these data with adjusted (higher and lower) coefficient values.
GMFCS: Gross Motor Function Classification System; SMD: standardised mean difference.

Table 1. Additional methods table

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Comparison 1. Aerobic exercise versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Activity: gross motor function, short term Show forest plot	3	65	Std. Mean Difference (IV, Random, 95% CI)	0.53 [0.02, 1.04]

2 Activity: gait speed, short term Show forest plot	4	82	Mean Difference (IV, Random, 95% CI)	0.09 [‐0.11, 0.28]

3 Activity: walking endurance; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

4 Activity: gait speed, intermediate term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

5 Activity: gross motor function, intermediate term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

6 Activity: daily physical activity; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

7 Aerobic fitness; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

Comparison 1. Aerobic exercise versus usual care

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Comparison 2. Resistance training versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Activity: gross motor function, children and adolescents; short term Show forest plot	7	164	Std. Mean Difference (IV, Random, 95% CI)	0.12 [‐0.19, 0.43]

2 Activity: gross motor function, children and adolescents; intermediate term Show forest plot	3	85	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.30, 0.55]

3 Activity: gait speed, children and adolescents; short term Show forest plot	8	185	Mean Difference (IV, Random, 95% CI)	0.03 [‐0.02, 0.07]

4 Activity: gait speed, children and adolescents; intermediate term Show forest plot	3	84	Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.17, 0.11]

5 Activity: gait speed, adults; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

6 Activity: gross motor function, adults; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

7 Activity: walking endurance, adults; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

8 Participation, children and adolescents; short term Show forest plot	2	127	Std. Mean Difference (IV, Random, 95% CI)	0.34 [‐0.01, 0.70]

9 Participation, children and adolescents; intermediate term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

10 Quality of life (parent‐reported), children and adolescents; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

11 Quality of life (child‐reported), children and adolescents; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

12 Muscle strength, children and adolescents; short term Show forest plot	8	247	Std. Mean Difference (IV, Random, 95% CI)	0.53 [0.00, 1.06]

13 Muscle strength, children and adolescents; intermediate term Show forest plot	3	84	Std. Mean Difference (IV, Random, 95% CI)	0.50 [0.06, 0.94]

14 Muscle strength, adults; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

Comparison 2. Resistance training versus usual care

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Comparison 3. Mixed training versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Activity: gross motor function; short term Show forest plot	4	163	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.29, 0.33]

2 Activity: gait speed; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

3 Activity: walking endurance; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

4 Participation; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

5 Participation; intermediate term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

6 Aerobic fitness; short term Show forest plot	2	78	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.39, 0.50]

7 Muscle strength; short term Show forest plot	3	150	Std. Mean Difference (IV, Random, 95% CI)	0.08 [‐0.24, 0.40]

8 Anaerobic fitness; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

9 Aerobic fitness; intermediate term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

10 Anaerobic fitness; intermediate term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

11 Muscle strength; intermediate term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

Comparison 3. Mixed training versus usual care

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Comparison 4. Resistance training versus aerobic exercise

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Activity: gross motor function; short term Show forest plot	2	56	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.50, 0.55]

2 Activity: gait speed; short term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

3 Activity: gait speed; intermediate term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

4 Activity: gross motor function; intermediate term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

5 Muscle strength; short term Show forest plot	2	56	Std. Mean Difference (IV, Random, 95% CI)	‐0.11 [‐0.64, 0.41]

6 Muscle strength; intermediate term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

Comparison 4. Resistance training versus aerobic exercise

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Comparison 5. Aerobic exercise and mixed training versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Activity: gross motor function; short term Show forest plot	7	228	Std. Mean Difference (IV, Random, 95% CI)	0.36 [0.09, 0.62]

2 Activity: gross motor function, intermediate term Show forest plot	2	77	Std. Mean Difference (IV, Random, 95% CI)	0.25 [‐1.15, 1.64]

3 Activity: gait speed; short term Show forest plot	5	140	Mean Difference (IV, Random, 95% CI)	0.10 [‐0.05, 0.24]

4 Activity: walking endurance; short term Show forest plot	2	73	Mean Difference (IV, Random, 95% CI)	8.43 [‐12.38, 29.23]

5 Aerobic fitness; short term Show forest plot	3	98	Std. Mean Difference (IV, Random, 95% CI)	0.06 [‐0.34, 0.45]

Comparison 5. Aerobic exercise and mixed training versus usual care

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Comparison 6. Resistance training and mixed training versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Activity: gross motor function; short term Show forest plot	11	327	Std. Mean Difference (IV, Random, 95% CI)	0.21 [‐0.01, 0.43]

2 Activity: gross motor function; intermediate term Show forest plot	4	150	Std. Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.41, 0.24]

3 Activity: gait speed; short term Show forest plot	9	243	Mean Difference (IV, Random, 95% CI)	0.03 [‐0.01, 0.08]

4 Participation; short term Show forest plot	3	192	Std. Mean Difference (IV, Random, 95% CI)	0.35 [0.07, 0.64]

5 Participation; intermediate term Show forest plot	2	101	Mean Difference (IV, Random, 95% CI)	0.15 [‐0.24, 0.54]

6 Muscle strength; short term Show forest plot	11	397	Std. Mean Difference (IV, Random, 95% CI)	0.38 [0.01, 0.76]

7 Muscle strength; intermediate term Show forest plot	4	149	Std. Mean Difference (IV, Random, 95% CI)	0.28 [‐0.16, 0.71]

Comparison 6. Resistance training and mixed training versus usual care

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