Systematic Review and Meta-Analysis Medicine ®

Effect of task-oriented training on gross motor

function, balance and activities of daily living in
children with cerebral palsy
A systematic review and meta-analysis
Weiyi Zai, BSa , Ning Xu, PhDa,* , Wei Wu, PhDb,*, Yueying Wang, BSa, Runfang Wang, BSa

Abstract
Background: To systematically evaluate task-oriented training (TOT) on the improvement of gross motor function, balance and
activities of daily living in children with cerebral palsy (CP).
Methods: A number of randomized controlled trials (RCTs) of TOT in children with CP were searched from Pubmed, Cochrane
Library, Web of Science, EmBase, China National Knowledge Infrastructure, Chinese Biology Medicine, Chinese Scientific Journals
Database and Wanfang data from the establishment of database to March 2022. The methodological quality of the included
studies was evaluated, and meta-analysis was performed by RevMan5.4 software.
Results: A total of 16 studies were included in the systematic review (n = 893). Meta-analysis showed that the gross motor
function measure (GMFM) (MD = 11.05, 95%CI [8.26, 13.83], P < .00001), dimension D (MD = 3.05, 95%CI [1.58, 4.53],
P < .0001) of the GMFM, dimension E (MD = 7.36, 95%CI [5.88, 8.84], P < .00001) of the GMFM, the Berg Balance Scale (BBS)
(MD = 6.23, 95%CI [3.31, 9.15], P < .0001), the pediatric evaluation of disability inventory (PEDI) mobile function (MD = 6.44,
95%CI [3.85, 9.02], P < .00001) score improved significantly in the TOT group compared with the control group.
Conclusions: Current evidence shows that TOT could effectively improve gross motor function, balance and activities of daily
living in children with CP. Due to the limitations of the number and quality of the included studies, the above conclusions need to
be verified by more high-quality studies.
Abbreviations: BBS = the Berg Balance Scale, CI = confidence interval, CP = cerebral palsy, GMFM = the gross motor function
measure, MD = mean difference, PEDI = the pediatric evaluation of disability inventory, RCTs = randomized controlled trials,
TOT = task-oriented training.
Keywords: activities of daily living, balance function, cerebral palsy, gross motor function, meta-analysis, task-oriented training

1. Introduction traditional rehabilitation therapy (physical therapy, occupa-

tional therapy, speech therapy, etc), Botulinum toxin type A,
Cerebral palsy (CP) is a group of permanent motor and Traditional Chinese medicine, massage, acupuncture, fumi-
postural developmental disorders that often lead to limited gation, and other therapeutic methods has been confirmed
activity in children due to non-progressive brain damage in in clinical practice.[5] Task-oriented training (TOT) is a new
childbirth or after birth.[1] The overall median prevalence of rehabilitation training method based on motor control theory,
CP is about 2.4 per 1000 live births, which is considered to which emphasizes the task of simulating functional activities
be the most common cause of severe physical disability in and pays attention to the role of the environment.[6] According
children.[2,3] The motor development disorder caused by CP to individual abilities and training purposes, therapists design
seriously affects the quality of life of children and causes a specific tasks or activities and guide children with CP to com-
massive burden to their families and society. Improving the plete them to improve their motor skills.[7] In previous studies,
motor function in children with CP has always been an essen- TOT has been proved to be an effective method for improv-
tial subject of rehabilitation clinical and scientific research.[4] ing function in stroke patients.[8] However, the application of
Currently, the effectiveness of neurodevelopmental therapy,

Social Science Planning and Research Project of Shandong Province (e-mail: xuning7172@126.com) and Wei Wu, Qilu Hospital of Shandong
(20CZXJ06). ECCM Program of Clinical Research Center of Shandong University University, Jinan, Shandong 250012, China (e-mail: wuwei7172@126.com).
(No. 2021SDUCRCA007). Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.
The authors have no conflicts of interest to disclose. This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
All data generated or analyzed during this study are included in this published
reproduction in any medium, provided the original work is properly cited.
article [and its supplementary information files].
How to cite this article: Zai W, Xu N, Wu W, Wang Y, Wang R. Effect of task-
PROSPERO registration number: PROSPERO CRD42022328080.
oriented training on gross motor function, balance and activities of daily living in
a
School of Rehabilitation Medicine, Shandong University of Traditional Chinese children with cerebral palsy: A systematic review and meta-analysis. Medicine
Medicine, Jinan, Shandong, China, b Qilu Hospital of Shandong University, Jinan, 2022;101:44(e31565).
Shandong, China. Received: 4 August 2022 / Received in final form: 5 October 2022 / Accepted: 6
* Correspondence: Ning Xu, School of Rehabilitation Medicine, Shandong October 2022
University of Traditional Chinese Medicine, Jinan, Shandong 250355, China http://dx.doi.org/10.1097/MD.0000000000031565

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TOT in the rehabilitation of children with CP is still in its evaluation of disability inventory (PEDI) mobile function were
early stages, and there is a lack of relevant evidence-based used to evaluate.
medical evidence. The aim of this review was to assess the
clinical effect of TOT on improving gross motor function, bal-
ance and activities of daily living in children with CP to pro- 2.2. Exclusion criteria
vide more scientific and reliable evidence for clinical practice Reviews, case reports and repeated publications; The interven-
and treatment in the future. tion measures, outcome indicators and sample population were
not eligible for inclusion; Studies with missing and incomplete
relevant data; Non-RCTs; Full-text literature cannot be obtained.
2. Data and methods
Our study was registered at the website of International
Prospective Register of Systematic Reviews, and the 2.3. Database and retrieval strategy
meta-analysis was performed following the PRISMA A systematic search was performed through 8 databases
(Preferred Reporting Items for Systematic Reviews and Meta- from the inception of the database to March 2022, includ-
Analyses). The registration number is CRD42022328080. ing Pubmed, Cochrane Library, Web of Science, EmBase,
As it is a meta-analysis study, and no ethical approval was China National Knowledge Infrastructure, Chinese Biology
needed. Medicine, Chinese Scientific Journals Database, Wanfang data,
to collect the RCTs of TOT in children with CP. A combination
of keywords and free words were used for retrieval, and rele-
2.1. Inclusion criteria vant resources were also manually retrieved. The search terms
2.1.1. Type of studies All the randomized controlled trials included “cerebral palsy, CP, task-oriented training, repetitive
(RCTs) that TOT in children with CP were retrieved. The study task practice, task-related training, task-orientated therapy,
language is limited to Chinese and English. randomized controlled trial.” Detailed search strategy is shown
in Table 1.
2.1.2. Types of participants Children under 18 years of age
with a definite diagnosis of CP and there are no limitations on 2.4. Data collection and extraction
sex and race.
EndnoteX9 software was used for study information manage-
2.1.3. Intervention measures The control group was treated ment, and duplicate studies were excluded. Two investigators
with conventional rehabilitation therapy or combined with other read the titles and abstracts of the papers and excluded obvi-
rehabilitation therapy (not TOT). The experimental group was ous nonconformities. Then the investigators carefully examined
given TOT alone or in combination with another rehabilitation. the full text and included trials that met the inclusion criteria
according to the inclusion and exclusion criteria established ear-
2.1.4. Outcome indicators The gross motor function lier. The study screening process was carried out by 2 research-
measure (GMFM), dimension D of the GMFM, dimension E ers independently, and the results were cross-checked. If there
of the GMFM, the Berg Balance Scale (BBS), and the pediatric was any disagreement, a third arbitrator was involved.

Table 1
Search strategy for the PubMed database.
Number Search term

#12 #3 AND #4 AND #11

#11 #5 OR #6 OR #7 OR #8 OR #9 OR #10
#10 Trial [Title/Abstract]
#9 Randomly [Title/Abstract]
#8 Placebo [Title/Abstract]
#7 Randomized [Title/Abstract]
#6 Controlled clinical trial [Publication Type]
#5 Randomized controlled trial [Publication Type]
#4 “Task-oriented training” [Title/Abstract] OR “repetitive task practice” [Title/Abstract] OR “task-related training” [Title/Abstract] OR “task-orientated therapy”
[Title/Abstract]
#3 #1 OR #2
#2 CP (Cerebral Palsy) [Title/Abstract] OR “Cerebral Palsy,” Dystonic-Rigid[Title/Abstract] OR “Cerebral Palsies,” Dystonic-Rigid[Title/Abstract] OR “Cerebral Palsy,”
Dystonic Rigid[Title/Abstract] OR “Dystonic-Rigid Cerebral Palsies” [Title/Abstract] OR “Dystonic-Rigid Cerebral Palsy” [Title/Abstract] OR “Cerebral Palsy,”
Mixed[Title/Abstract] OR “Mixed Cerebral Palsies” [Title/Abstract] OR “Mixed Cerebral Palsy” [Title/Abstract] OR “Cerebral Palsy,” Monoplegic, Infantile[Title/
Abstract] OR “Monoplegic Infantile Cerebral Palsy” OR “Infantile Cerebral Palsy,” Monoplegic OR “Cerebral Palsy,” Quadriplegic, Infantile OR “Quadriplegic
Infantile Cerebral Palsy” [Title/Abstract] OR “Infantile Cerebral Palsy,” Quadriplegic[Title/Abstract] OR “Cerebral Palsy,” Rolandic Type[Title/Abstract] OR
“Rolandic Type Cerebral Palsy” [Title/Abstract] OR “Cerebral Palsy,” Congenital[Title/Abstract] OR “Congenital Cerebral Palsy” [Title/Abstract] OR “Little
Disease” [Title/Abstract] OR “Little’s Disease” [Title/Abstract] OR “Spastic Diplegia” [Title/Abstract] OR “Diplegias,” Spastic[Title/Abstract] OR “Spastic
Diplegias” [Title/Abstract] OR “Diplegia,” Spastic[Title/Abstract] OR “Monoplegic Cerebral Palsy” [Title/Abstract] OR “Cerebral Palsies,” Monoplegic[Title/
Abstract] OR “Cerebral Palsy,” Monoplegic[Title/Abstract] OR “Monoplegic Cerebral Palsies” [Title/Abstract] OR “Cerebral Palsy,” Athetoid[Title/Abstract]
OR “Athetoid Cerebral Palsy” [Title/Abstract] OR “Cerebral Palsies,” Athetoid[Title/Abstract] OR “Cerebral Palsy,” Dyskinetic[Title/Abstract] OR “Cerebral
Palsies,” Dyskinetic[Title/Abstract] OR “Dyskinetic Cerebral Palsy” [Title/Abstract] OR “Cerebral Palsy,” Atonic[Title/Abstract] OR “Atonic Cerebral Palsy”
[Title/Abstract] OR “Cerebral Palsy,” Hypotonic[Title/Abstract] OR “Hypotonic Cerebral Palsies” [Title/Abstract] OR “Hypotonic Cerebral Palsy” [Title/Abstract]
OR “Cerebral Palsy, Diplegic,” Infantile[Title/Abstract] OR “Diplegic Infantile Cerebral Palsy” [Title/Abstract] OR “Infantile Cerebral Palsy,” Diplegic[Title/
Abstract] OR “Cerebral Palsy,” Spastic[Title/Abstract] OR “Spastic Cerebral Palsies” [Title/Abstract] OR “Spastic Cerebral Palsy” [Title/Abstract]
#1 Cerebral palsy [MeSH]

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The extracted data included: basic information of the included 2.6. Statistical analysis
study (first author, publication time), basic characteristics of the RevMan5.4 software was used for meta-analysis of outcome
study subjects (sample size, type of motor impairment, gender, indicators. The data types of outcome indexes of this meta-anal-
age), intervention methods, intervention frequency, intervention ysis were all continuous data, and the mean difference (MD) and
cycle, main data of outcome indicators and key elements of bias 95% confidence interval (CI) with fixed or random effect mod-
risk assessment. els will be used for calculation. χ2 test (α = 0.05) was used to
analyze the heterogeneity among the results and combined with
I² to quantitatively judge the heterogeneity. A random effects
2.5. Quality of evidence model was chosen if high heterogeneity was observed (P < .05,
The risk of bias for RCTs was assessed by the Cochrane I2 > 50%). Otherwise, a fixed effects model was adopted. If there
Handbook 5.1.0. Each study was objectively evaluated as “low is significant clinical heterogeneity, subgroup analysis or sensi-
risk”, “high risk”, or “unclear risk” based on the 7 domains tivity analysis are used to treat it, or descriptive analysis is per-
of quality criteria as follows: random sequence generation; formed only. The reported bias will be shown by the funnel plot.
allocation concealment; blinding of participants and person-
nel; blinding of outcome assessors; incomplete outcome data; 3. Results
selective reporting; other bias. The risk of bias was evaluated
by 2 researchers independently, and the results were cross- 3.1. Study identification
checked. In addition, disagreements were resolved by a third A total of 180 studies were obtained, including 123 Chinese
arbitrator. studies and 57 English studies. 108 studies remained after

Figure 1. Flow chart of the search and study selection process.

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eliminating duplicate studies. 36 studies remained after reading P = .36, I2 = 9%), so a fixed effects model was adopted. The
the titles and abstracts and excluding those not meeting inclu- results of meta-analysis showed that GMFM score in the
sion criteria. 16 studies were finally included after reviewing TOT group was higher than that in the control group, and the
the full text. A flowchart of the retrieval process is shown in difference was statistically significant (MD = 11.05, 95%CI
Figure 1. [8.26, 13.83], P < .00001).
Subgroup analysis of GMFM score was performed accord-
3.2. Characteristics of included studies ing to the different version of the scale. The results showed that
16 studies were included in this study, including 12 Chinese GMFM-66 score in the TOT group was significantly higher than
studies[9–20] and 4 English studies.[21–24] The sample size of chil- that in the control group (MD = 10.34, 95%CI [6.16, 14.51],
dren with CP ranged from 10 to 123 cases, including 448 cases P < .00001), and GMFM-88 score in the TOT group was signifi-
in the experimental group and 445 cases in the control group. cantly higher than that in the control group (MD = 11.62, 95%CI
The baseline data of included subjects were comparable. The [7.88, 15.35], P < .00001). All the above results prove that TOT
control group received conventional rehabilitation therapy can improve gross motor function in children with CP (Fig. 3).
(traditional physical rehabilitation training, facilitation tech- 3.4.2. Dimension d of the GMFM Total 7 studies[9,10,12,14,17,21,23]
niques, traditional physical and occupational therapy, etc) or used dimension D of the GMFM score as an outcome index,
combined with other rehabilitation therapy (not TOT). On this including 395 children with CP. There was a high heterogeneity
basis, the experimental groups were given TOT with different among the studies (χ2 = 21.66, P = .001, I2 = 72%), so a random
frequencies. The treatment duration ranged from 4 weeks to effects model was used. The results of meta-analysis showed
4 months. The basic data included in the study are shown in that dimension D of the GMFM score in the TOT group was
Table 2. significantly higher than that in the control group (MD = 3.05,
95%CI [1.58, 4.53], P < .0001), which proved that TOT was
3.3. Quality of evidence helpful to improve the standing function in children with
CP. Due to a high heterogeneity, the sensitivity analysis was
Cochrane Bias risk Assessment tool was used to evaluate the performed. After excluding the studies of Wang GX[9] and
quality of the included studies, of which 1 study[23] was rated as A Zhang HX,[10] the heterogeneity among the studies decreased
and 15 studies[9–22,24] were rated as B. Total 8 studies[11–13,15,17,18,20,23] significantly (χ2 = 6.74, P = .15, I2 = 41%) (Fig. 4).
clearly described the generation process of random sequences, 5
studies[9,14,21,22,24] only mentioned random, and 3 studies[10,16,19] 3.4.3. Dimension e of the GMFM Total 8 studies[9,10,12,14,15,17,21,23]
adopted nonrandom methods. Total 2 studies[23,24] reported the used dimension E of the GMFM score as an outcome measure,
hidden process of allocation, and the rest were not mentioned. including 440 children with CP. A fixed effects model was used
Blinding was applied in 8 studies,[12,13,15,16,19,21,23,24] but most were because of a low heterogeneity (χ2 = 13.82, P = .05, I2 = 49%).
single-blind. All the research data were complete and all pre-de- The results of meta-analysis showed that dimension E of the
signed indicators were reported. No other biases were found in GMFM score in the TOT group was higher than that in the
13 studies.[9,11–15,17,18,20–24] Risk of bias assessment details is pro- control group (MD = 7.36, 95%CI [5.88, 8.84], P < .00001),
vided in Figure 2. which proved that TOT could improve the walking function in
children with CP (Fig. 5).
3.4. Meta-analysis results
3.4.4. BBS Total 5 studies[11,15,17,18,20] used the BBS score as an
3.4.1. GMFM 6 studies used GMFM score as an
[13,16,18,19,22,24]
outcome index, including 381 children with CP. The heterogeneity
outcome indicator, of which 2 studies[16,19] used GMFM-66 among the studies was high (χ2 = 22.68, P = .0001, I2 = 82%), so
score and 4 studies[13,18,22,24] used GMFM-88 score, including a random effects model was chosen. The results of meta-analysis
320 children with CP. There was a low heterogeneity (χ2 = 5.49, showed that the score of BBS in the TOT group was higher than

Table 2
Basic characteristics of the included studies.
Sample Intervention
Training frequency Treatment Outcome
Study Age (yr) T C T C (TOT) duration indicator

Ko EJ[21] 2020 4–7.5 9 9 TOT Traditional PT and OT 60 min/time, 2 times/wk 8 wk ③④⑥

HK Han[22] 2016 7–15 12 12 Conventional rehabilitation + TOT Conventional rehabilitation 30 min/d, 5 d/wk 4 wk ②
Salem Y[23] 2009 4–12 5 5 TOT Conventional PT 2 times/wk 5 wk ③④
Wang GX[9] 2017 3–12 25 24 Conventional rehabilitation + TOT Conventional rehabilitation 50 min/d, 5 d/wk 12 wk ③④
Zhang HX[10] 2021 3–8 48 47 Conventional rehabilitation + TOT Conventional rehabilitation 40 min/d, 5 d/wk 3 mo ③④
Zhang CY[11] 2014 2–12 25 25 Conventional rehabilitation + TOT Conventional rehabilitation 10~15 min/d, 5 d/wk 3m ⑤
Pang W[12] 2016 3–12 20 20 Conventional rehabilitation + TOT Conventional rehabilitation 40 min/d, 5 d/wk 3m ③④
Li Y[13] 2019 2–9 41 41 Traditional PT + TOT Traditional PT 20 min/d 3m ②⑥
Li X[14] 2015 3–9 30 30 Conventional rehabilitation + TOT Conventional rehabilitation 40 min/d, 5 d/wk 3m ③④⑥
Fan TL[15]2019 6–12 22 23 Conventional rehabilitation + TOT Conventional rehabilitation 40 min/d, 5 d/wk 120 d ④⑤⑥
Cheng K[16] 2010 1–3 25 25 Facilitation techniques + TOT Facilitation techniques 40 min/d, 5 d/wk 3m ①
Sah AK[24] 2019 7–15 22 22 TOT Conventional PT 60 min/d, 6 d/wk 6 wk ②
Zhang WD[17] 2021 3–6 62 61 Conventional rehabilitation + Bio- Conventional rehabilita- 40 min/d, 6 d/wk 4m ③④⑤
feedback training + TOT tion + Biofeedback training
Lyu YB[18] 2020 2–6 40 40 Conventional rehabilitation + TOT Conventional rehabilitation / / ②⑤
Chen C[19] 2009 1–3 20 20 Facilitation techniques + TOT Facilitation techniques 40 min/d 3m ①
Zhao XY[20] 2020 3–7 42 41 Conventional rehabilitation + TOT Conventional rehabilitation 30 min/d,5 d/wk 8 wk ⑤
①GMFM-66, ②GMFM-88, ③dimension D of the GMFM, ④dimension E of the GMFM, ⑤BBS, ⑥PEDI mobile function.
BBS = the Berg Balance Scale, C = control group, GMFM-66 = the gross motor function measure-66, GMFM-88 = the gross motor function measure-88, OT = occupational therapy, PEDI = the pediatric
evaluation of disability inventory, PT = physical therapy, T = treatment group, TOT = task-oriented training.

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Figure 2. Risk of bias graph and summary. (A) Risk of bias graph. (B) Risk of bias summary.

that in the control group (MD = 6.23, 95%CI [3.31, 9.15], studies (χ2 = 2.07, P = .56, I2 = 0%), so a fixed effects model was
P < .0001), which proved that TOT helped improve the balance used. The results of meta-analysis showed that PEDI mobility
function in children with CP. Due to a high heterogeneity, the function score in the TOT group was higher than that in the
sensitivity analysis was performed. After excluding the study of control group (MD = 6.44, 95%CI [3.85, 9.02], P < .00001),
Zhang WD,[17] the heterogeneity among the studies decreased indicating that TOT can improve the ability of daily living
significantly (χ2 = 5.55, P = .14, I2 = 46%) (Fig. 6). activities in children with CP (Fig. 7).
3.4.5. PEDI mobile function Total 4 studies[13–15,21] used PEDI 3.4.6. Publication bias The “dimension E of the GMFM” was
mobility function score as an outcome index, including 205 selected as an indicator to analyze the publication bias of the
children with CP. There was a low heterogeneity among the included studies, and the results showed that studies were mainly
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Figure 3. Forest plot of the effect of TOT on GMFM. GMFM = the gross motor function measure, TOT = task-oriented training.

Figure 4. Forest plot of the effect of TOT on dimension D of the GMFM and dimension D of the GMFM after sensitivity analysis. (A) Forest plot of the effect of
TOT on dimension D of the GMFM. (B) Forest plot of the effect of TOT on dimension D of the GMFM after sensitivity analysis. GMFM = the gross motor function
measure, TOT = task-oriented training.

Figure 5. Forest plot of the effect of TOT on dimension E of the GMFM. GMFM = the gross motor function measure, TOT = task-oriented training.

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Figure 6. Forest plot of the effect of TOT on BBS and BBS after sensitivity analysis. (A) Forest plot of the effect of TOT on BBS. (B) Forest plot of the effect of
TOT on BBS after sensitivity analysis. BBS = the Berg Balance Scale, TOT = task-oriented training.

Figure 7. Forest plot of the effect of TOT on PEDI mobile function. PEDI = the pediatric evaluation of disability inventory, TOT = task-oriented training.

Figure 8. Funnel plot of dimension E of the GMFM. GMFM = the gross motor function measure.

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concentrated in the upper 1/3 of the funnel plot, indicating that is concluded that heterogeneity comes from the study of Zhang
there was little possibility of significant publication bias (Fig. 8). WD,[17] which may be related to different intervention measures.
In this study, the intervention measures in the experimental
group were a combination of 2 treatments and TOT.
4. Discussion PEDI mobility function is used to evaluate the mobility of
daily life in children with CP. Meta-analysis results showed
CP is a neurodevelopmental disease characterized by abnormal
that TOT could effectively improve limb motor function and
muscle tone, movement and motor skills, which seriously limits
the ability to independently perform daily activities in children
children’s activity and social participation.[25] Although modern
with CP, and there was a low heterogeneity among the studies.
medical technology has made significant progress, the rehabili-
GMFM can only reflect the best completion of motor function
tation of children with cerebral palsy remains a huge challenge.
in children with CP after receiving corresponding instructions
Currently, the existing rehabilitation methods in clinical practice
in a specific assessed environment. In contrast, PEDI focuses on
mainly aim at motor problems, such as abnormal muscle tone,
the evaluation of the level of activity and participation in the
abnormal reflexes, abnormal movement patterns, etc., while
ICF framework, which can reflect the performance of motor
functional movement is often ignored.[26] The International
function in children with CP in daily life.[34,35] The above results
Classification of Functioning, Disability and Health (ICF)
proved that TOT could improve the motor function and activ-
recommends that rehabilitation should focus on activity and
ities of daily living in children with CP, enabling them to better
participation limitations.[27] TOT attaches importance to the
integrate into school and society.
interaction between individuals, tasks and the environment
In the retrieval process, researchers found that many studies
in which tasks are performed and emphasizes the establish-
combined with other treatment methods basis on TOT, such as
ment of “functional tasks.” Children with CP can actively try
head low frequency electrical stimulation,[36] biofeedback train-
to solve problems in functional tasks, adapt to environmental
ing,[28] and hydrotherapy,[37] had better efficacy than TOT alone
changes, and apply the functions acquired in training to the real
in improving the motor function in children with CP. In addition,
environment.[28]
emphasizing the participation of families of children with CP in
Neural plasticity is a piece of strong evidence that TOT can
the treatment of TOT can further enhance their confidence in
improve the function in children with CP. The brain can recon-
rehabilitation and contribute to completing the task.[38,39] These
struct cortical motor maps by constantly establishing new neu-
results suggest that further research should focus on the com-
ral connections and neural networks.[29,30] It is important to note
bination of TOT with other therapies and further research on
that adaptive cortical recombination in both intact and injured
“home-based” task-oriented exercise to play a more significant
central nervous system (CNS) is not induced by generic use or
role in the rehabilitation of children with CP.
activation but requires task specific training protocols.[31] The
The study found that the 16 included studies had the follow-
combination of a rich environment and task-specific rehabili-
ing deficiencies: The subjects of the RCTs were not completely
tation can enhance the plasticity of inherent neurons in non-in-
uniform in the types of disease, age, treatment plan, etc., leading
jured and functionally connected brain regions and achieve the
to a high heterogeneity among the studies. The methodologi-
result of improving function.[32] The actual operation of TOT
cal representation of the included studies was vague, some of
involves the brain’s judgment of information and the innervation
the studies did not specify the randomization method, and most
of nerves to motion. After repeated practice and constant modes
did not mention the allocation concealment and blinding, lead-
adjustment, an optimized neural network and motion program
ing to a particular publication bias. There are many domestic
can be formed to innervate relevant muscles to complete spe-
and foreign studies on improving gross motor function, balance
cific tasks. If the upper limb is flexing and extending without
function and activities of daily living in children with CP, but
a particular goal, the integration and input of the above com-
the evaluation indicators are not the same. In this study, only
prehensive information will be lost, and the motion mechanics
GMFM, BBS, and PEDI mobile function were selected, and the
characteristics will become an empty joint activity.[33] TOT is
limited number of included studies may affect the evaluation
a controlled exercise training emphasizing the active participa-
results to some extent.
tion of children with CP, which has prominent advantages in the
In conclusion, current evidence suggests that TOT can sig-
rehabilitation of children with CP.
nificantly improve gross motor function, balance function, and
GMFM is an international index to evaluate the gross motor
activities of daily living in children with CP compared with con-
development in children with CP, with 2 versions: GMFM-66
ventional rehabilitation techniques. However, due to the limited
and GMFM-88. The higher GMFM scores indicate an excellent
number and quality of included studies, more high-quality RCTs
effect on children with CP. The subgroup analysis of GMFM
are needed to provide a more scientific basis for applying TOT
outcome indicators showed no significant difference in the
in clinical practice.
score of GMFM-66 and GMFM-88 between the 2 groups, sug-
gesting that TOT can improve gross motor function in children
with CP. Dimension D of the GMFM is mainly used to evalu-
Author contributions
ate the standing level of children. Meta-analysis results showed
that TOT could improve the standing function in children with Conceptualization: Weiyi Zai, Ning Xu, Wei Wu.
CP, but there was a high heterogeneity. The sensitivity analy- Data curation: Weiyi Zai, Ning Xu, Wei Wu.
sis showed that the heterogeneity came from Wang GX[9] and Funding acquisition: Ning Xu, Wei Wu.
Zhang HX.[10] However, the specific reasons for a high hetero- Methodology: Weiyi Zai, Ning Xu, Wei Wu, Runfang Wang.
geneity have not been found, which may be due to methodolog- Resources: Weiyi Zai, Yueying Wang, Runfang Wang.
ical deficiencies in both studies. These 2 studies have unclear Software: Weiyi Zai, Yueying Wang, Runfang Wang.
risk and high risk in the random sequence generation, alloca- Visualization: Ning Xu.
tion concealment and blinding. Dimension E of the GMFM is Writing – original draft: Weiyi Zai.
used to evaluate the walking function of the children. Meta- Writing – review & editing: Ning Xu, Wei Wu.
analysis showed that TOT could improve the walking function
in children with CP.
BBS is mainly used to evaluate the recovery of balance func- References
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