Which gait training intervention can most effectively improve gait ability in patients with cerebral palsy? A systematic review and network meta-analysis

Abstract

Background: A vital objective to treat people with cerebral palsy (CP) is to increase gait velocity and improve gross motor function. This study aimed to evaluate the relative effectiveness of gait training interventions for persons with CP.

Methods: Studies published up to October 26, 2022 were searched from four electronic databases [including Medline (via PubMed), Web of Science, Embase and Cochrane]. Studies with randomized controlled trials (RCTs), people with CP, comparisons of different gait training interventions and outcomes of gait velocity and gross motor function measures (GMFM) were included in this study. The quality of the literature was evaluated using the risk of bias tool in the Cochrane Handbook, the extracted data were analyzed through network meta-analysis (NMA) using Stata16.0 and RevMan5.4 software.

Results: Twenty RCTs with a total of 516 individuals with CP were included in accordance with the criteria of this study. The results of the NMA analysis indicated that both external cues treadmill training (ECTT) [mean difference (MD) = 0.10, 95% confidence interval CI (0.04, 0.17), P < 0.05] and partial body weight supported treadmill training (BWSTT) [MD = 0.12, 95% CI (0.01, 0.23), P < 0.05] had better gait velocity than over ground gait training (OGT), BWSTT [MD = 0.09, 95%CI(0.01,0.18), P < 0.05] had a better gait velocity than robot-assisted gait training (RAGT), BWSTT [MD = 0.09, 95% CI (0.06, 0.13) P < 0.05] had a better gait velocity than treadmill training (TT), and BWSTT [MD = 0.14, 95% CI (0.07, 0.21), P < 0.05] had a better gait velocity than conventional physical therapy (CON). The SUCRA ranking indicated that BWSTT optimally improved the gait velocity, and the other followed an order of BWSTT (91.7%) > ECTT (80.9%) > RAGT (46.2%) > TT (44%) > OGT (21.6%) > CON (11.1%). In terms of GMFM, for dimension D (GMFM-D), there was no statistical difference between each comparison; for dimension E (GMFM-E), RAGT [MD = 10.45, 95% CI (2.51, 18.40), P < 0.05] was significantly more effective than CON. Both SUCRA ranking results showed that RAGT improved GMFM-D/E optimally, with rankings of RAGT (69.7%) > TT (69.3%) > BWSTT (67.7%) > OGT (24%) > CON (20.3%), and RAGT (86.1%) > BWSTT (68.2%) > TT (58%) > CON (20.1%) > OGT (17.6%) respectively.

Conclusion: This study suggested that BWSTT was optimal in increasing the gait velocity and RAGT was optimal in optimizing GMFM in persons with CP. Impacted by the limitations of the number and quality of studies, randomized controlled trials with larger sample sizes, multiple centers, and high quality should be conducted to validate the above conclusion. Further studies will be required to focus on the total duration of the intervention, duration and frequency of sessions, and intensity that are optimal for the promotion of gait ability in this population.

Systematic review registration: https://doi.org/10.37766/inplasy2022.10.0108, identifier: INPLASY2022100108.

Keywords: gait; motor skills disorders; randomized controlled trials; rehabilitation; walking speed.

Figure 1

Literature review flowchart. BWSTT, partial body weight supported treadmill training. C, conventional physical therapy; ECTT, external cues treadmill training; OGT, over ground gait training; RAGT, robot-assisted gait training; TT, treadmill training; WOS, Web of Science.

Figure 2

Individual projects of included articles that produced a risk of bias.

Figure 3

Evidence network of gait velocity analysis. BWSTT, partial body weight supported treadmill training; C, conventional physical therapy; ECTT, external cues treadmill training; OGT, over ground gait training; RAGT, robot-assisted gait training; TT, treadmill training.

Figure 4

Evidence network of GMFM-D analysis. BWSTT, partial body weight supported treadmill training; C, conventional physical therapy; OGT, over ground gait training; RAGT, robot-assisted gait training; IT, treadmill training.

Figure 5

Evidence network of GMFM-E analysis. BWSTT, partial body weight supported treadmill training; C, conventional physical therapy; OGT, over ground gait training; RAGT, robot-assisted gait training; TT, treadmill training.