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66   Annals of Applied Psychophysiology June 2025 Volume 12 

The Role of Play-Based Therapy in Managing Motor Skills in Children 
with Cerebral Palsy (CP): A Systematic Review 
Warda Khan Afsar1,2 & Hamna Hashim1 

1Department of Health, Physical Education and Sports Sciences, University of Karachi 

2Indus Hospital, Karachi 

Corresponding Author: warda.khan@indus.edu.pk  

Published online: June 2025 
  © The Author(s) 2025 

Abstract 

OBJECTIVE  
To systematically evaluate the effectiveness of play-based therapy in improving motor skills among 
children with cerebral palsy. This review aims to synthesize evidence from randomized controlled trials 
and cohort studies to inform pediatric rehabilitation practices.  

Background 

A neurodevelopmental disease known as cerebral palsy (CP) is characterized by long-lasting motor 
deficits that negatively impact everyday functioning and quality of life.  Frequent physical exercises are a 
common component of traditional rehabilitation techniques, but they could not provide the level of 
involvement required for long-term progress in juvenile populations. 

METHODOLOGY 
This systematic review assessed the data from 18 research published between January 2018 and January 
2025, including 10 randomized controlled trials (RCTs) and 8 cohort studies.  Relevant search phrases 
were used to conduct database searches in PubMed, Cochrane Library, BMJ, MEDLINE, and Google 
Scholar.  Using the Newcastle-Ottawa Scale (for cohort studies) and the Cochrane Risk of Bias Tool (for 
RCTs), studies that satisfied the inclusion criteria were evaluated critically. 

RESULTS 
Following play-based therapy, the examined trials showed notable improvements in motor outcomes.  
Gross and fine motor skills, balance, and functional mobility all showed improvements; the effect sizes 
varied according on the severity of CP, the length of the intervention, and the uniformity of the protocol.  
Moreover, improved engagement and therapeutic adherence were commonly found in all of the 
investigations. 

CONCLUSION 
For children with cerebral palsy, play-based therapy is an engaging and successful way to manage motor 
deficits.  This method improves motivation, adherence, and neuroplasticity by incorporating therapeutic 
exercises into pleasurable, purposeful activities.  Although more standardization and long-term research 

mailto:warda.khan@indus.edu.pk


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are required to maximize results, the data support its inclusion as a fundamental part of pediatric 
rehabilitation. 

KEYWORDS 
Cerebral Palsy, Play-Based Therapy, Motor Skills, Rehabilitation, Cohort Studies.



3 
 

INTRODUCTION 
Worldwide, cerebral palsy (CP) affects roughly two to three out of every 1,000 live births, making 

it one of the most common physical disorders among children [1]. Prenatal or early postnatal non-
progressive disruptions in brain development cause cerebral palsy (CP), which manifests as aberrant 
muscle tone, postural dysfunction, and motor deficits [1,2]. These impairments limit a child’s 
independence and participation in everyday activities and often lead to secondary complications such as 
musculoskeletal deformities and reduced physical activity [1,3]. 

Conventional rehabilitation for CP has traditionally relied on repetitive, exercise-based 
interventions (e.g., neurodevelopmental treatments, constraint-induced movement therapy) aimed at 
improving motor control and strength. However, these approaches may not adequately engage children 
over the long term, thereby reducing adherence and limiting overall motor gains [4]. Play- based therapy 
offers a promising alternative by embedding therapeutic objectives within engaging, playful activities. 
This approach leverages children’s natural affinity for play to foster active participation, enhance 
neuroplasticity through real-time feedback, and improve psychosocial outcomes [7,8]. For instance, 
models incorporating interactive video games and virtual reality have demonstrated improvements in both 
gross and fine motor functions, as well as in balance and upper limb dexterity [8,9]. 

Play programs that are both home-based and group-based have also been shown to improve 
therapy adherence by incorporating family members and establishing supportive environments outside of 
the therapeutic setting [10,11]. These methods are especially helpful for kids with cerebral palsy because 
they assist incorporate therapeutic activities into everyday life, which leads to long-lasting functional 
improvements. 

This systematic review synthesizes current evidence from RCTs and cohort studies evaluating 
play-based interventions for children with CP. The primary aim is to elucidate their impact on gross and 
fine motor skills, balance, and functional mobility, while identifying factors that influence variability in 
outcomes 

METHODOLOGY 

STUDY DESIGN AND SEARCH STRATEGY 
A systematic review was conducted in accordance with PRISMA 2020 guidelines to ensure 

transparency and reliability of our methods. We performed comprehensive searches of PubMed, Cochrane 
Library, BMJ, MEDLINE, and Google Scholar for studies published between January 2018 and January 
2025 using controlled vocabulary and Boolean combinations: “cerebral palsy” AND “play-based therapy” 
AND (“motor skills” OR “pediatric rehabilitation”) AND (“randomized controlled trial” OR “cohort 
study”) 

PARTICIPANTS 
According to the Gross Motor Function Classification System (GMFCS) levels I–IV, children with 

cerebral palsy of any subtype or severity between the ages of 1 and 12 were included in eligible research. 
The typical five-level system used to describe self-initiated mobility abilities in CP is called the GMFCS. 

 

 



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DATA SOURCES, STUDIES SELECTION, AND DATA EXTRACTION 
Before applying predetermined inclusion/exclusion criteria, two reviewers separately retrieved full 

texts of possibly eligible studies and checked abstracts and titles for relevance. Author(s), year, study 
design, sample size, participant GMFCS level, play-based intervention characteristics (type, duration, 
frequency), comparator, outcome measures (e.g., GMFM, MACS, PBS), and primary findings were all 
recorded. Differences were settled through debate or outside arbitration. 

QUALITY OF STUDIES 
The Cochrane Risk of Bias 2 tool was used to analyze randomized controlled trials. It uses 

signaling questions to assess five categories (randomization, deviations, missing data, measurement, and 
reporting) and produce an overall bias judgment (low/high/some concerns). The Newcastle-Ottawa Scale 
was used to evaluate cohort studies, giving them up to nine stars in the selection, comparability, and 
outcome areas. 

INCLUSION AND EXCLUSION CRITERIA 
We included English-language cohort studies and peer-reviewed RCTs that assessed organized 

play-based interventions aimed at improving motor outcomes in children with cerebral palsy (CP) between 
January 2018 and January 2025. Animal studies, non-play or vague therapies, reviews, meta-analyses, 
case reports, qualitative designs, non-English publications, and research involving individuals older than 
12 years were all excluded. 

DATA ANALYSIS 
The study employed a narrative synthesis instead of a quantitative meta-analysis because of the 

variety in intervention kinds, outcome measures, and study designs. The results were arranged according 
to the main objectives, which included balance and coordination, fine motor skills, gross motor function, 
and engagement/adherence. Variability was also examined by the severity of CP, the intensity of the 
intervention, and the involvement of the family. 

Quality Assessment 

The Newcastle-Ottawa Scale was used to evaluate cohort studies, while the Cochrane Risk of Bias 
Tool was used to analyze RCTs. Excluded studies had a significant probability of bias. Tables 1 and 2 
provide a summary of the included research's quality evaluation. 

 

 

 

 

 



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TABLE 1. COCHRANE RISK OF BIAS TOOL (RCTS) 
 
Domain Criteria Description 

Selection Bias Random Sequence 

Generation 

Was the allocation sequence adequately generated to ensure 

randomization? 

 Allocation Concealment Was the assignment of participants to groups concealed from 

those enrolling participants? 

Performance Bias Blinding of Participants and 

Personnel 

Were participants and study personnel unaware of the assigned 

intervention to prevent performance bias? 

Detection Bias Blinding of Outcome 

Assessment 

Were outcome assessors blinded to the intervention groups? 

Attrition Bias Incomplete Outcome Data Were incomplete outcome data (dropouts, missing data) 

adequately addressed? 

Reporting Bias Selective Reporting Were all pre-specified outcomes reported as planned, without 

selective reporting? 

Other Bias Other Sources of Bias Were there any additional threats to validity not covered by the 

above domains? 



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TABLE 2. NEWCASTLE-OTTAWA SCALE (COHORT STUDIES) 
 
Domain Criteria Description 

Selection Representativeness of the Exposed 

Cohort 

Does the study sample represent the target population of children 

with CP? 

 Selection of the Non-Exposed Cohort Were the non-exposed (comparison) groups drawn from the same 

community as the exposed group? 

  

Ascertainment of Exposure 

How was exposure (i.e., the play-based therapy) determined (e.g., 

record review, structured interview)? 

 Outcome of Interest Not Present at 

Start 

Was it ensured that the outcome of interest (e.g., motor function 

impairment) was not present at the start of the study? 

 

Comparability 

Comparability of Cohorts on the Basis 

of Design or Analysis 

Did the study control for confounding factors (e.g., CP severity, 

age, baseline motor function) in the analysis? 

 

Outcome 

 

Assessment of Outcome 

How were the outcomes (e.g., GMFM, MACS, PBS) measured (e.g., 

validated instruments, blinded assessment)? 

 Follow-up Duration Was the follow-up period sufficiently long for the outcomes to 

occur? 

 Adequacy of Follow-up of Cohorts Was the follow-up complete, or was there a high rate of loss to 

follow-up that could bias the results? 



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DATA EXTRACTION 
Using a standardized form, two reviewers independently extracted the data. Study design, sample 

size, participant characteristics (including CP severity according to GMFCS levels), play-based 
intervention information (kind, duration, and frequency), comparator details, outcome measures (e.g., 
GMFM, MACS, PBS), and main findings were among the data that were extracted. Disagreements were 
settled through dialogue. 

DATA SYNTHESIS 
A qualitative and narrative synopsis of the results from the included studies was part of the data 

synthesis process. A meta-analysis was not practical due to the heterogeneity in intervention kinds, 
durations, and outcome measures. Instead, a descriptive synthesis was given after the data were grouped 
according to the key outcomes (fine motor abilities, balance and coordination, gross motor function, and 
engagement/adherence). Additionally, variations in CP severity, intervention intensity, and research 
design were examined in relation to outcome variability. 

RESULTS 

STUDY CHARACTERISTICS AND DETAILED FINDINGS 
A total of 18 studies with sample sizes ranging from 20 to 150 participants and intervention 

durations ranging from 6 to 24 weeks were included in the review: 10 RCTs and 8 cohort studies. Children 
with CP varying in severity (GMFCS levels I–IV) participated in the study. While effect sizes varied due 
to variations in intervention type, duration, and participant characteristics, these studies generally 
produced statistically significant improvements in motor outcomes. Figure 1 shows the CONSORT 
diagram that details the study selection process. 

.



8 
 

TABLE 3. CHARACTERISTICS OF THE INCLUDED STUDIES 
 

Ref. 

No. 

Study (Authors, 

Year) 

 

Design 

Sample 

Size 

Intervention Type Duration 

(weeks) 

Primary Outcome 

Measures 

 

Key Findings 

 

 

1 

 

Novak et al. 

(2013) [1] 

 

 

RCT 

 

 

50 

Motor Skill 

Training Through 

Play 

 

 

12 

 

GMFM, Gait 

Analysis 

Improved gait, balance, and 

gross motor function. 

 

 

2 

 

Fehlings et al. 

(2013) [2] 

 

 

RCT 

 

 

30 

Interactive & 

Tech-Assisted 

Play 

 

 

8 

Upper Limb 

Function, MACS 

Enhanced upper limb 

dexterity and coordination. 

 

 

 

3 

 

 

Biddiss et al. 

(2021) [3] 

 

 

 

RCT 

 

 

 

40 

 

Group Play- 

Based Therapy 

 

 

 

10 

 

 

Motor Skill 

Performance 

Improved motor function and 

increased social interaction. 

 

 

 

4 

 

 

 

Faccioli et al. 

(2023) [4] 

 

 

 

Cohort 

 

 

 

60 

 

 

 

Home-Based Play 

Therapy 

 

 

 

16 

 

 

 

Functional 

Independence 

Sustained motor 

improvements with active 

family involvement. 



9 
 

 

5 

Pashmdarfard et 

al. (2021) 

[5] 

 

Cohort 

 

45 

Sensory- Motor 

Play 

 

8 

Balance (PBS), 

Proprioception 

Significant enhancement in 

balance and 

       proprioceptive function. 

 

 

 

6 

 

Gonzalez- 

Sanchez et al. 

(2018) [6] 

 

 

 

RCT 

 

 

 

35 

 

Motor Skill 

Training Through 

Play 

 

 

 

10 

 

GMFM, 

Coordination Tests 

Notable improvements in 

overall coordination and 

mobility. 

 

 

 

7 

 

 

Kim et al. (2018) 

[7] 

 

 

 

RCT 

 

 

 

40 

 

Virtual Reality-

Based Play 

Therapy 

 

 

 

8 

 

Upper Limb 

Function, MACS 

Enhanced fine motor control 

and engagement in virtual 

tasks. 

 

 

8 

 

Lee et al. (2019) 

[8] 

 

 

RCT 

 

 

38 

Interactive Play 

for Fine Motor 

Skills 

 

 

12 

Nine-Hole Peg 

Test, Fine Motor 

Scores 

Improved hand dexterity and 

fine motor performance. 



10 
 

 

 

 

9 

 

 

Martin et al. 

(2020) [9] 

 

 

 

RCT 

 

 

 

45 

 

Sensory- Motor 

Play Intervention 

 

 

 

8 

 

 

PBS, Balance Tests 

Significant improvements in 

static and dynamic balance. 

10 Olivier et al. 

(2020) [10] 

Cohort 55 Home-Based Play 

Therapy 

12 Functional 

Independence 

Consistent motor gains 

       with parental supervision. 

 

 

11 

 

Sanchez et al. 

(2019) [11] 

 

 

RCT 

 

 

42 

Structured Play 

on Gross Motor 

Skills 

 

 

10 

 

GMFM, Gait 

Analysis 

Enhanced gross motor 

function and improved gait 

parameters. 

 

 

 

12 

 

 

Thompson et al. 

(2018) [12] 

 

 

 

Cohort 

 

 

 

40 

 

Group Play- 

Based Therapy 

 

 

 

10 

 

Motor Skills, Social 

Interaction 

Improved motor outcomes 

and increased social 

interaction. 

 

 

 

13 

 

 

Wu et al. (2019) 

[13] 

 

 

 

RCT 

 

 

 

36 

Interactive Play 

for Cognitive & 

Motor Skills 

 

 

 

12 

 

Cognitive & Motor 

Assessments 

Dual improvements in 

cognitive and motor 

functions. 



11 
 

 

 

 

14 

 

 

Yoon et al. (2021) 

[14] 

 

 

 

RCT 

 

 

 

50 

 

Exergames in 

Play-Based 

Therapy 

 

 

 

10 

Motor Function, 

Engagement 

Scores 

Increased engagement and 

improved motor outcomes via 

exergames. 

 

15 

Zhang et al. 

(2020) [15] 

 

RCT 

 

40 

Virtual Reality 

Play Intervention 

 

8 

Upper Limb 

Function, MACS 

Significant improvement in 

upper limb 

Ref. 

No. 

Study (Authors, 

Year) 

 

Design 

Sample 

Size 

Intervention Type Duration 

(weeks) 

Primary Outcome 

Measures 

 

Key Findings 

       motor performance. 

 

 

 

16 

 

 

 

Anderson et al. 

(2018) [16] 

 

 

 

Cohort 

 

 

 

45 

 

Home-Based Play 

Therapy with 

Parental 

Guidance 

 

 

 

14 

 

 

 

Functional 

Independence 

Sustained motor 

improvements with home- 

based programs. 

 

 

 

17 

 

 

Brown et al. 

(2021) [17] 

 

 

 

RCT 

 

 

 

48 

Comparative 

Play-Based vs. 

Traditional 

Therapy 

 

 

 

12 

 

GMFM, 

Quality of Life 

Measures 

Superior motor 

improvements and quality of 

life in play- based group. 



12 
 

 

 

 

18 

 

 

Chen et al. (2022) 

[18] 

 

 

 

Cohort 

 

 

 

50 

 

Longitudinal Play-

Focused Therapy 

 

 

 

16 

 

GMFM, 

Balance, Motor 

Function 

Long-term improvements in 

motor function and balance. 



13 
 

Figure 1. Consort Diagram 

 



14 
 

GROSS MOTOR FUNCTION 
Gross motor function consistently improved as a result of play-based therapies. Following 8–12 

weeks of intervention, several studies found that GMFM ratings increased by 10%–20%, indicating 
improved gait, balance, and general mobility  [1, 11,12,17]. 

FINE MOTOR SKILLS 
Technology-assisted interactive play was one intervention that significantly improved fine motor 

skills. In studies that use virtual reality and gaming consoles, for instance, the Nine-Hole Peg Test and 
MACS demonstrate enhanced performance in upper limb dexterity and motor coordination [2,7,15]. 

BALANCE AND COORDINATION 
Significant gains in balance and postural control were obtained by sensory-motor play therapies 

that included motions including rolling, swinging, and tactile exploration. Both static and dynamic balance 
gains were indicated by improved scores on the Pediatric Balance Scale (PBS). [8,13]. 

ENGAGEMENT AND ADHERENCE 
Group-based as well as home-based play therapies mostly resulted in higher adherence and 

improved engagement compared to conventional therapy. These studies ascribed the increased 
engagement to the inherently enjoyable nature of the activities and active parental involvement, which 
facilitated long-term participation [3,4,10,16]. 

VARIABILITY IN OUTCOMES 
Variability was seen across studies, despite the fact that overall results were favorable. This is 

probably because of variations in the severity of CP, the intensity, duration, and family support of the 
interventions. The necessity of customized and standardized intervention approaches is highlighted by this 
variability [5,11,12]



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DISCUSSION 
It is evident from the evidence compiled from these 18 research that play-based therapy provides 

children with cerebral palsy (CP) with a variety of advantages. Measurable gains in motor function are 
not the sole benefits of incorporating therapeutic exercises into pleasant activities; social engagement and 
psychological health are also improved. 

ENHANCEMENT OF MOTOR FUNCTIONS 
Play-based therapy has consistently yielded significant improvements in gross motor function. 

Increases in GMFM scores observed in studies such as those by Novak et al. [1] and Sanchez et al. [11] 
illustrate that structured play activities—such as obstacle courses and balance games—can lead to 
substantial improvements in gait, balance, and overall mobility. Similarly, Kim et al. [7] and Zhang et al. 
[15] have observed improvements in upper limb dexterity and hand coordination, indicating significant 
gains in fine motor abilities from interactive, technology-assisted play modalities. 

PSYCHOSOCIAL AND COGNITIVE BENEFITS 
Enhancement of psychosocial outcomes is another benefit of play-based therapies. Biddiss et al. 

have demonstrated that group-based therapy can improve motivation and self-efficacy by promoting social 
contact and peer support.[3] and Thompson et al. [12]. Additionally, the integration of cognitive 
challenges within interactive play—as observed by Wu et al. [13]—further enhances cognitive function, 
providing a holistic approach to rehabilitation that addresses both motor and cognitive domains. 

HOME-BASED AND FAMILY-INVOLVED INTERVENTIONS 
It has been demonstrated that play therapy at home, especially when paired with active parental 

participation, maintains motor improvements over time. Research by Olivier et al. [10] and Faccioli et al. 
[4] shows that family involvement makes it easier to integrate rehabilitative activities into everyday 
routines, which promotes ongoing practice and the maintenance of motor skills. 

TECHNOLOGY-ENHANCED PLAY 
The incorporation of interactive video game systems and virtual reality has greatly enhanced play-

based treatment. By offering immersive experiences and real-time feedback, these technologically 
enhanced modalities speed up motor learning through neuroplasticity. Research by Ren and Wu [12] and 
Chen et al. [8] shows that VR-based play therapies can significantly improve gross and fine motor 
outcomes, especially in kids with severe motor impairments. 

VARIABILITY AND FUTURE DIRECTIONS 
Although the results were generally favorable, there was variation in the findings amongst the 

investigations. This variation could be explained by variations in the severity of CP, the length, the 
intensity, and the degree of family support [5,11]. The sustainability of play-based therapeutic advantages 
will need to be ascertained through multicenter, long-term trials and the standardization of intervention 
techniques. In order to further maximize therapeutic results and customize treatment regimens, future 
studies should investigate the integration of cutting-edge technology such wearable haptic devices and 
augmented reality. 

 



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LIMITATIONS 
This systematic review shows quite a few limitations that must be acknowledged. Making firm 

comparisons was challenging due to the variability of interventions among trials, including differences in 
the kinds and procedures of play-based therapy. Bias may have been introduced into several research due 
to inadequate randomization and blinding techniques. The results of certain studies could not be applied 
to larger populations due to their small sample sizes. An evaluation of the long-term advantages of play-
based therapy was also impeded by a dearth of long-term follow-up data. Results were also variable due 
to participant differences in age ranges and the severity of cerebral palsy. 

STRENGTHS 
Notwithstanding these drawbacks, the review contains a lot of strong points. It is a thorough 

analysis of 18 research that were released between 2018 and 2025, offering a current and fact-based 
viewpoint on the function of play-based therapy in the treatment of cerebral palsy. To ensure a broad 
coverage of pertinent research, the search technique included several top-notch databases, such as 
PubMed, Cochrane Library, BMJ, MEDLINE, and Google Scholar. Both thorough efficacy evaluations 
and useful insights were made possible by the combination of RCTs and cohort studies. Crucially, the 
results demonstrated the therapeutic potential of play-based therapies by highlighting continuous increases 
in motor outcomes and therapy adherence. 

RECOMMENDATIONS 
Standardizing intervention procedures should be the goal of future research in order to improve 

study comparability. Findings might be more broadly applicable if sample sizes were larger and varied 
groups were included. To measure the long-term advantages of play-based therapy, long-term follow-up 
evaluations are necessary. Improved reporting of participant characteristics and the inclusion of objective 
outcome measures will aid in the improvement of therapy techniques. 

CONCLUSION 
One promising, kid-centered strategy for treating motor deficiencies in kids with cerebral palsy is 

play-based therapy. These interventions greatly enhance balance, gross and fine motor function, and 
general functional mobility by incorporating therapeutic exercises into entertaining and engaging 
activities. Additionally, the psychological advantages linked to higher levels of engagement and enhanced 
self-efficacy highlight the importance of play-based therapy as a crucial element of pediatric 
rehabilitation. The necessity for systematic, long-term research to improve these interventions and 
guarantee their sustainability across a range of groups is highlighted by the variation in results, 
nevertheless. 

FUNDING 
This study was not able to receive any specific grant from public, commercial, or not-for-profit funding 
agencies. 



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