Active upper-limb therapies for hand function, individual goal achievement, and self-care in children with cerebral palsy: A network meta-analysis.

Many included studies had a high risk of bias (22 of 48 quantitative studies). The network of comparisons was sparse, meaning some interventions were compared indirectly rather than through direct head-to-head trials. Results for some promising interventions (like CO-OP and mirror therapy) were based on single studies with small sample sizes and high risk of bias, requiring caution. There is a paucity of data for children with bilateral CP and for children under 3 years of age. Grouping different intervention protocols into broad categories (e.g., all BiM trials) may dilute specific effects or mask variations in implementation. Effect sizes for hand function (AHA) were often close to the smallest detectable change (5 units), raising questions about clinical significance despite statistical significance.

The authors declared no conflicts of interest. Funding was provided by the National Health and Medical Research Council (NHMRC), Medical Research Future Fund, Children's Hospital Foundation, Ramaciotti Health Investment Grant, and the University of Queensland.

Do not interpret the statistically significant improvements in hand function as large clinical gains for every child. The average treatment effects for mCIMT and BiM on the AHA were between 4.0 and 4.6 units, which is below or near the 5-unit threshold typically required to detect a real change beyond measurement error.