Therapeutic interventions efficacy on gross motor function in children with cerebral palsy

Objective. Verify therapeutic intervention efficacy in children between the ages of 0 to 12, with cerebral palsy, evaluated by Gross Motor Function Measure. Method. PUBMed (MEDLINE), Cochrane, Web of Science, Scopus, Lilacs and PEDro. During phase 1, titles and abstracts of all identified references were independently displayed to 2 investigators. In phase 2, the same researchers applied the inclusion criteria for complete articles text. Key data from each of the included studies were extracted, such as author, year of publication, sample size, relevant characteristics, and conclusions on therapeutic interventions in children with cerebral palsy. Results. 15 articles were combined for qualitative analysis. Total scores for methodological quality ranged from 5 to 9 points. Covering the included articles for qualitative analysis, 14 studies were included in meta-analysis. Results demonstrated a significant variation when


INTRODUCTION
Cerebral palsy (CP) is a collection of clinical symptoms that affect a child's neurological and motor development throughout life 1 and which can lead to a number of negative results 1,2 . Individuals with CP present changes in tone, posture and movement, leading to daily living activity limitations, such as transportation, food and personal care.
Cerebral palsy affects about 2 children per 1000 live births worldwide, becoming the most common cause of severe physical disability during childhood 2 . There is lack of studies in Brazil that prove specific investigations of prevalence and incidence of CP in the national scenario, however, based on data demonstration from other countries, there are predominance projections 3 of CP in developing countries. In developed countries the prevalence found varies from 1.5 to 5.9/1000 live births; it is estimated that the incidence of CP in developing countries is 7/1000 live births 4 , and data shown estimates around 30,000 to 40,000 of new cases per year 5 .
However, despite being one of the most prevalent damaging conditions in most parts of the globe 2 the efficacy of therapeutic treatment in children with cerebral palsy has shown complexity when trying to be proven scientifically in result of the low methodological quality of studies 6 . Studies on therapeutic interventions in children with cerebral palsy evaluated the efficacy of treatments that applied Neurodevelopment Therapy (NDT 7 ), strength training 8 upper limbs 9 interventions 6 , orthoses 10 usage 11 , and varied interventions 12 . Sequentially, interventions were studied, such as, induced restraint therapy 13 , efficacy of physical therapy in postural control 14 , passive stretching 15 , hydrotherapy 16 , hippotherapy 17 , and orthoses 18 besides, a variety of other interventions. Most recent revisions have studied therasuit 19 , therapeutic exercises 20 , surgical interventions 21 , hipotherapy 22 , a variety of therapies focusing on gait 23 .
In such context, one of the ways of evaluating the efficacy of various therapeutic treatments applied to children with cerebral palsy has been quantitative analysis of gross motor function. Among current existing scales for such condition 18 , one of the most used is the GMFM 24  "Cerebral palsy", to the child: "Child", "Children", therapeutic intervention: "Intervention", "Interv Sch Clin" Therapeutics "," Therapeutic "," Gross "," Motor "," Function "," Physiology "associated with a sensitive list of key terms for clinical trials in March 2018.

Combination of keywords:
1 "Cerebral palsy" AND "Child OR Children" AND "Intervention OR Interv Sch Clin OR Therapeutics OR Therapeutic" 2 "Cerebral palsy" AND "Child OR Children" AND "Intervention OR Interv Sch Clin OR Therapeutics OR Therapeutic" AND "Gross Motor Function" 3 "Cerebral palsy" AND "Child OR Children" AND "Intervention OR Interv Sch Clin OR Therapeutics OR Therapeutic" AND "Gross Motor Function" AND "Physiology"

Research
EndNote software tool was used for archive management aiming on the identification and control of bibliographic references, mainly regarding the potential of duplicity of scientific articles existing in different databases.

Study Selection
Final articles were selected through a two-step process.
In phase 1, the titles and abstracts of all identified references were independently displayed for two researchers. During phase 1, they excluded articles that did not meet the inclusion criteria. In phase 2, the same researchers applied the inclusion criteria for full text articles. In cases of discrepancy the third reviewer was consulted for a final decision.

Data Extraction
The first author performed the extraction of data from included articles, and a second author checked all the collected information. Once again, in case of discrepancy the third reviewer was consulted for final decision. The authors extracted from each of the included studies key-data: author, year of publication, sample size, relevant characteristics, and conclusions on therapeutic interventions in children with cerebral palsy.

Risk Bias and Methodological Quality Assessment
Risk bias and methodological quality of included clinical trials were independently assessed by two reviewers using PEDro scale, which is based on the Delphi list developed by Verhagen et al. (1998) 27 . PEDro score ranges from 1 point (without quality) to 10 points (excellent quality).
Disagreements were resolved by consensus or a third-party review.

Measure Summary
The only studies which were considered were studies in

Statistical Analysis
The included studies were considered to have utilized the same assessment measure, the mean difference

Study Selection
Out

WOS n=260
Identification Duplicate excluded studies n=293 Screening Studies selection by title, summary for theme evaluation n=477 Excluded studies for not adopting aimed themes n=432 Articles excluded due to studies involving (n = 30): -Use of botulinum toxin (n = 1) -Participation of subjects older than 12 years (n = 6) -Use of behavioral, educational intervention, electrical stimulation, or hyperbaric oxygen (n = 5) -Participation of children without CP diagnosis (n = 1) -Non-use of control group (n = 4) -Non-use of GMFM for evaluation of gross motor function (n = 8) -Abstracts (n = 5)

Elegibility
Full text articles evaluated for eligibility n=45

Included
Qualitative synthesis included studies n=15

Study Characteristics
Of fifteen selected studies, three articles were from Training" 35,37 , a group studied "Game Therapy" 28 , one evaluated " Group Physical Therapy" 36 , one investigated "Hydrotherapy" 29 , one studied "Functional Training" 32 , one evaluated "Walking from Sitting to Standing" 30 , a group studied "Daytime Use of Orthoses" and a group studied "Vestibular Training". Table 1 summarizes the descriptive characteristics of the studies.

Risk Bias Study
The quality of included studies is summarized in Table   2. The total scores for methodological quality vary from 5 to 9 points, meaning that two scored 5 points 33

Meta-Analysis Characteristics
Fourteen studies met the meta-analysis inclusion   Figure 2).

DISCUSSION
The present study focused on verifying, through gross however, the quality assessed by PEdro scale was low 47 . In the current review, two out of three articles improved gross motor function 37,33 , and the PEdro scale ranged from 5 to 9a better score than the review stated 47 .
In two 6-scoring studies there was no difference between the groups of virtual stationary bicycle training in relation to aerobic exercises and progressive functional training associated to neuro-evolutionary physiotherapy in relation to only neuro-evolutionary physiotherapy 28 Two studies demonstrated that treadmill walking training associated with body weight support, performed three to four times a week for 12 weeks, was also proven to be significantly to movement and functional mobility capacity of children and adolescents with CP 35,50 .
Functional training, such as sit and stand up, daily life, among other trainings are considered effective on functional performance improvement in children with cerebral palsy 51 .
This can be explained based on motor learning theory; when working on replicable day to day activities, it is possible to obtain learning retention and by practicing it improves task performance.
In two 5-scoring studies, it was possible to note the superiority of objective-oriented functional training on tasks focused activities and equine therapy on conventional physiotherapy 33