Effects of the combination of exercise with noninvasive brain stimulation on motor function and spasticity in children with cerebral palsy: A systematic review and meta-analysis.

Cerebral palsy (CP) includes persistent movement impairments that affect posture or mobility. Noninvasive brain stimulation (NIBS) results in structural and, consequently, functional changes. In this review, the effects of exercise with and without NIBS on gross motor function (MF) and muscle spasticity in children with CP were evaluated through a meta-analysis. Systematic searches of six databases for eligible studies were performed, with a subsequent screen of the retrieved studies. The inclusion criteria were as follows: 1) children with CP; 2) randomized controlled trials; 3) children received exercise and NIBS therapy; 4) the study conducted pre- and posttests, which included tests of MF and muscle spasticity; and 5) publications in English or Chinese. The Cochrane risk of bias assessment tool was used to evaluate the quality of the selected studies. The standardized mean difference (SMD) was selected as the appropriate index for determining the effect, and RevMan 5.4 software was used to analyze the mean differences in the selected studies. (Registration number: CRD420251021673). The effects of the intervention on MF and muscle spasticity in children with CP in the experimental group (EG) and control group (CG) were analyzed in seven and four selected studies, respectively. Consequently, compared with the CG, the EG demonstrated greater improvement in MF [SMD, 1.25 (0.89, 1.62), p < 0.05; I2 = 61%; τ2 = 0.13]. The subgroup analyses revealed that exercise combined with transcranial direct-current stimulation (tDCS) [SMD, 1.74 (1.17, 2.31), p < 0.05, I2 = 39%, τ2 = 0.10] and combined with repetitive transcranial magnetic stimulation (rTMS) [SMD, 1.05 (0.76, 1.34), p < 0.05, I2 = 26%, τ2 = 0.03] resulted in significant improvements in MF. Compared with the CG, the EG of children with CP also exhibited a notable reduction in muscle spasticity [SMD, -0.99 (-1.44, -0.55), p < 0.05; I2 = 36%; τ2 = 0.12].Conclusions The intervention combining exercise with NIBS may improve MF in children with CP. This result may be associated with a reduction in muscle spasticity. What is Known: • Cerebral palsy is associated with impaired gross motor function and muscle spasticity. • An exercise intervention can improve physical function, reduce spasticity, and improve gross motor function. What is New: • This systematic review and meta-analysis showed that the combination of exercise with NIBS can significantly improve MF, which may be related to reduced spasticity. • Compared with interventions lacking NIBS, the combination of NIBS with exercise may be related to improved balance, lower limb strength, and walking speed, rather than social living ability.