Vibration therapy in patients with cerebral palsy: a systematic review

Figures & data

Figure 1 PRISMA flow diagram of findings.

Note: Step-by-step approach for study identification, screening, and eligibility procedures, and final number of articles included.
Abbreviations: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; CP, cerebral palsy.

Table 1 Study quality on the PEDro scale: acute adaptations to vibration

PEDro scale items	1	2	3	4	5	6	7	8	9	10	11	Sum
Cannon et al^Citation30	✓			✓	✓			✓	✓		✓	5
Cheng et al^Citation38	✓	✓		✓				✓	✓	✓	✓	6
Dickin et al^Citation34	✓			✓				✓	✓		✓	4
Eklund and Steen^Citation31				✓	✓				✓			3
Krause et al^Citation32	✓			✓			✓		✓		✓	4
Leonard et al^Citation15	✓			✓				✓	✓	✓	✓	5
Park et al^Citation35	✓			✓				✓	✓		✓	4
Singh et al^Citation33	✓			✓				✓	✓	✓	✓	5
Tardieu et al^Citation37	✓			✓	✓				✓	✓	✓	5
Tupimai et al^Citation36	✓	✓		✓						✓	✓	4
Score per item/average score	9 (10)	2 (10)	0 (10)	10 (10)	3 (10)	0 (10)	1 (10)	7 (10)	10 (10)	5 (10)	9 (10)	5

Notes: Ten cross-section studies investigating the acute effect of vibration therapy on neuromuscular and functional parameters. The bottom line illustrates the relative number per PEDro item and the overall average score. 1, Eligibility criteria and source of participants; 2, random allocation; 3, concealed allocation; 4, baseline comparability; 5, blinded participants; 6, blinded therapists; 7, blind assessors; 8, adequate follow-up; 9, intention-to-treat analysis; 10, between-group comparisons; 11, point estimates and variability. Item 1 does not contribute to the total score.

Table 2 Study quality on the PEDro scale: long-term adaptations to vibration

PEDro scale items	1	2	3	4	5	6	7	8	9	10	11	Sum
Ahlborg et al^Citation49	✓	✓		✓				✓			✓	4
Camerota et al^Citation64											✓	CR
el-Shamy^Citation51	✓	✓	✓	✓			✓	✓	✓	✓	✓	8
Gusso et al^Citation48	✓										✓	1
Ibrahim et al^Citation59	✓	✓		✓						✓	✓	4
Ko et al^Citation58		✓						✓		✓	✓	4
Lee and Chon^Citation50	✓	✓	✓	✓			✓	✓		✓	✓	7
Reyes et al^Citation57	✓	✓		✓	✓		✓	✓	✓	✓	✓	8
Ruck et al^Citation52	✓	✓	✓	✓						✓	✓	5
Semler et al^Citation53									✓			CR
Stark et al^Citation55	✓							✓	✓		✓	3
Stark et al^Citation56	✓							✓	✓		✓	3
Stark et al^Citation54	✓	✓	✓	✓			✓	✓	✓	✓	✓	8
Tupimai et al^Citation36	✓	✓		✓						✓	✓	4
Unger et al^Citation46	✓	✓		✓			✓	✓		✓	✓	6
Myśliwiec et al^Citation47	✓						✓	✓	✓			3
Wren et al^Citation60	✓	✓	✓	✓			✓	✓		✓	✓	7
Yabumoto et al^Citation63												CR
Score per item/average score	14 (15)	11 (15)	5 (15)	10 (15)	1 (15)	0 (15)	7 (10)	11 (15)	6 (15)	10 (15)	14 (15)	4

Notes: Longitudinal experiments investigating the chronic effect of vibration therapy on neuromuscular and functional parameters, as well as muscle and bone tissue. The bottom line illustrates the relative number per PEDro item and the overall average score. Note that CRs were excluded from evaluation, as scaling and items are not applicable for these study designs. 1, Eligibility criteria and source of participants; 2, random allocation; 3, concealed allocation; 4, baseline comparability; 5, blinded participants; 6, blinded therapists; 7, blind assessors; 8, adequate follow-up; 9, intention-to-treat analysis; 10, between-group comparisons; 11, point estimates and variability. Item 1 does not contribute to the total score.

Abbreviation: CR, case report.

Table 3 Acute adaptations to vibration

Study	Vibration characteristics (frequency, amplitude, duration)	Subjects (n), age, classification	Outcome measures	Results: significant acute effects
Cannon et al^Citation30	FV 119 Hz, 0.5 mm, 3 minutes	n=3 (one with CP), 1–3 years, grading of GMF	Head-erect behavior (observations), paraspinal muscle activity (TVR), frequency of seizures	↑Duration of head erect behavior (during vibration), ↑paraspinal muscle activation (during vibration), no effects on number of seizures
Cheng et al^Citation38	vWBV 20 Hz, 2 mm, 1 minute (5×)	n=16, 9.8±2.3 years, GMFCS I–III	Spasticity MAS, active and passive ROM (AJ and KJ), relaxation index (Wartenberg pendulum index), gait 6MWT, and functional mobility TUG	↓Spasticity score, knee extensors (MAS), ↑active ROM, no effects on passive ROM, ↑relaxation index, ↑distance for 6MWT, ↓time required for TUG
Dickin et al^Citation34	vWBV 30–50 Hz, 2 mm, 1 minute (5×)	n=8, 20–51 years, CP 5–8	Passive and dynamic ROM (AJ and KJ), gait parameters (speed, cadence, step, stride length, step and stride time, AJ and KJ angles)	↑Dynamic ROM (ankle), ↑walking speed, ↑stride length
Eklund and Steen^Citation31	FV 100–200 Hz, 1.5 mm, 30 seconds (maximum 1–2 minutes)	n>200, <18 years	Hyper- and hypotonia, acts of voluntary motor control (observations)	↑Voluntary power (agonist), ↓hypertonicity (antagonist), ↑normal patterns of movement (dystonic syndrome), ↑body image function, kinesthesia, ↑spontaneous movement of weak muscles, ↑voluntary motor control, eg, memory of motor acts, pronunciation, feeding pattern
Krause et al^Citation32	sWBV 16–24 Hz, 1.5–3 mm, 1 minute	n=44, 4–22 years, GMFCS II–IV	Stretch reflex, voluntary muscle activation, muscle coordination, aROM (AJ and KJ)	↓Muscle-spindle reflex amplitude, ↑voluntary muscle activation, ↑muscle coordination, aROM (KJ)
Leonard et al^Citation15	FV 200 Hz, amplitude NA, 3 seconds (5–10×)	n=6 (six Con), 12–16 years	Spinal excitability (H-reflex), shank-muscle activity during dorsiflexion, plantar flexion, and vibration	↑Reflex amplitude during dorsiflexion (antagonist), ↑reflex amplitude during plantar flexion (agonist), but less compared to Con, ↓H-reflex amplitude during vibration (agonist), but less inhibition compared to Con
Park et al^Citation35	sWBV 20 Hz, 2 mm, 10 minutes (2×)	n=17, 3–14 years, GMFCS I–IV	Spasticity (MAS, MTS) of plantar flexors (AJ), persistency of results	↓Spasticity score (MAS and MTS), persistent results at 1 hour (MAS) and 2 hours (MTS)
Singh et al^Citation33	Micro-impact (Juvent) 30–37 Hz, amplitude NA, 30 seconds	n=18 (10 Con), 4–12 years, GMFCS I–III	local-high intensity vibration (HLV) signal to tibia and femur, correlation of spasticity (MAS), and vibratory transmission	CP: ↑HLV in tibia, ↓HLV in femur, negative correlation with MAS Con: ↑HLV in tibia, ↑HLV in femur
Tardieu et al^Citation37	FV 70 Hz, 0.5 mm, 10 seconds (3×)	n=22 (18 Con), 8–15 years, GMFCS	Vibration illusion	↑Kinesthesia: vibration predicts reliably muscle contraction and joint movement
Tupimai et al^Citation36	Oscillating WBV 20 Hz, 2 mm, 1 minute (5×)	n=12, 6–18 years, GMFCS I–III	Spasticity (MAS), muscle strength (FTSST), balance (PBS)	↓Spasticity score (MAS), ↓time (FTSST), no effect on balance control

Note: Illustration of chronic effects in response to VT.

Abbreviations: FV, focal vibration; CP, cerebral palsy; TVR, tonic vibration reflex; vWBV, vertical whole-body vibration; GMFCS, Gross Motor Function Classification System; MAS, modified Ashworth Scale; ROM, range of motion; 6MWT, 6-minute walking test; TUG, timed up and go; sWBV, side-alternating whole-body vibration; Con, control; aROM, active ROM; AJ, ankle joint; KJ, knee joint; NA, not available; MTS, modified Tardieu Scale; WBV, whole-body vibration; FTSST, five times sit-to-stand test; PBS, pediatric balance scale.

Table 4 Long-term adaptations to vibration

Study	Intervention (duration, training protocol, exercise, control group)	Vibration characteristics (frequency, amplitude, duration)	Subjects (n), age, classification	Outcome measures	Results: significant long-term effects
Ahlborg et al^Citation49	8 weeks, three times a week Ex: 5-minute warm-up, static standing with 50° in hips and knees on platform, progressive training program (11 levels of intensity), finished with short-muscle stretching Con: resistance training on leg press, same warm-up and stretching, three sets of 10–15 reps with 2-minute rest (progressive training program)	vWBV, 25–40 Hz, 4 mm, 6 minutes (rest included)	n=14 (Con 7), 21–41 years, diplegic, GMFCS: NA	Spasticity (MAS), isokinetic muscle strength, 6MWT, TUG, GMFM88	↓Spasticity in knee extensors of stronger leg, ↑concentric and eccentric work and peak torque in the weak leg at angle speed 90°/second. Both groups improved at 30°/second, no difference between groups, no change, no change, ↑dimensions D (standing) and E (walking)
Camerota et al^Citation64	3 consecutive days, one session/day, postmeasurement 1 month later	Sinusoidal rMV on triceps surae, 100 Hz, 0.3–0.5 mm, 3×10 minutes, 1-minute break	n=1, 5 years, tetraplegic, GMFCS: II	Spatiotemporal gait parameters, kinematic gait parameters	↑Step length, ↓stance duration relative to length of gait cycle, ↑gait velocity, ↑gait symmetry, ↓pelvic tilt anteversion and hip flexion
el-Shamy^Citation51	3 months, five times a week Ex: static/dynamic (squats, lateral shifting, tilting) Con: proprioceptive training	sWBV, 12–18 Hz, 2–6 mm, 3×3 minutes	n=30 (Con 15), 8–12 years, diplegic, GMFCS I–III	Isokinetic muscle strength, balance (Biodex)	↑Knee-extension peak torque, ↑postural stability
Gusso et al^Citation48	20 weeks, four times a week Ex: standing knees slightly flexed Con: no	sWBV, 12–20 Hz, amplitude NA, 1×1–3×3 minutes	n=40, 11.3–20.8 years, GMFCS II–III	6MWT, pQCT BMD of total body, DXA BMC of total body, DXA lean (muscle) mass, chair-rise test, force plate	↑6MWT, ↑BMD, ↑BMC, ↑muscle mass, ↓chair-rising time
Ibrahim et al^Citation59	12 weeks Ex: standing knees slightly flexed Con: 1-hour conventional PT	sWBV, 12–18 Hz, 2–6 mm, 3×3 minutes, 3-minute break (add-on to 1-hour conventional PT)	n=30 (Con 15), 8–12 years, diplegic, GMFCS: NA	Isometric strength, spasticity (MAS), 6MWT, balance, GMFM88	↑Isometric muscle strength of knee extensors, ↓spasticity of knee extensors in stronger leg, ↑6MWT, no change between groups in walking balance, ↑dimensions D (standing) and E (walking)
Ko et al^Citation58	3 weeks, twice a week Ex: standing knees flexed 30° Con: conventional PT	sWBV, 20–24 Hz, 1–2 mm, 3×3 minutes, 3-minute break (add-on to 30-minute conventional PT twice a week)	n=24 (Con 12), 7–12 years, diplegia, hemiplegia, GMFCS I–III	JPS (joint-position sense), balance, gait (2-D)	↑Ankle JPS, no difference between groups, ↑gait speed and step width
Lee and Chon^Citation50	8 weeks, five times a week Ex: static upright with handle bars Con: stretching, massage, sensorimotor training	sWBV, 5–25 Hz, 1–9 mm, 6×3 minutes	n=30 (Con 15), 10±2.26 years, spastic diplegia or quadriplegia, GMFCS NA	Gait test (3-D), ultrasonography	↑Gait speed, stride length, cycle time, ↑ankle dorsiflexion and plantar flexion, ↑muscle thickness musculus tibialis anterior and soleus, no change in gastrocnemii
Reyes et al^Citation57	6 months, 7 days/week Con: placebo, 60 Hz and 90 Hz (three groups)	FV on radius and femur, 60 or 90 Hz, 0.3 g, 5 minutes a day	n=61 (placebo 21, 60 Hz 22, 90 Hz 18), 6–9 years, first neuron and some second neuron and other diseases	DXA BMD, DXA BMC, dynamometric muscle-strength measure, GMFM, MFM (gross motor), Quality-of-life questionnaire (PedsQL)	↑BMD at ultradistal radius for 60 Hz group, ↑BMC at ultradistal radius for 60 Hz and 90 Hz groups, ↑muscle-force upper limb for 60 Hz group, no change in lower limb, no change, ↑in daily activity item, no change for other items
Ruck et al^Citation52	6 months, five times a week Ex: static/tilt angle (35° vertical) Con: school PT program	sWBV, 13–18 Hz, 2–6 mm, 3×3 minutes	n=20 (Con 10), 6.2–12.3 years, GMFCS II–IV	10 m gait test, GMFM88 dimensions D (standing) and E (walking), DXA BMC lumbar spine and distal femur	↑Walking speed, no significant difference, no positive treatment effect on bone
Semler et al^Citation53	6 months, five times a week at home Ex: static/tilt angle 40°	sWBV, 13–18 Hz, 0–6 mm, 4×3 minutes	n=1, 5 years, GMFCS NA	Spasticity assessment, gait tests	↓Spasticity, ↑walking ability, ↑walking distance, ↑ability to perform unassisted steps
Stark et al^Citation55	6 months, ten times a week at home Ex: individualized according to goal-setting combined with multimodal treatment concept	sWBV (with and without tilt table), 5–25 Hz, amplitude NA, 3×3 minutes	n=78, 9.76 years, spastic diplegia, GMFCS I–V	DXA BMC of whole body without head, DXA lean (muscle) mass, modified GMFM, muscle force and angle of verticalism	↑Percentage changes for BMC, ↑percentage changes for muscle mass, ↑modified GMFM, ↑percentage changes for muscle force and angle of verticalism
Stark et al^Citation56	6 months, ten times a week at home Ex: individualized according to goal setting combined with a multimodal treatment concept	sWBV (with and without tilt table), 5–25 Hz, amplitude NA, 3×3 minutes	n=356, 8.6±4.2 years	GMFM66 and GMFM88	↑GMFM66 total score, ↑All GMFM-88 dimensions
Stark et al^Citation54	14 weeks, ten times a week at home Ex: standing (if possible in squatting), sitting and four-point position with hands on platform Con: treatment as usual	sWBV (with and without tilt table), 12 and 22 Hz, maximum 2.5 mm, 3×3 minutes	24 (Con 12), 12–24 months, GMFCS II–IV	GMFM66, PEDI (motor function)	Training was safe, developmental motor changes were similar in both groups
Tupimai et al^Citation36	6 weeks, five times a week Ex: standing with handle bar if necessary Con: prolonged passive-muscle stretching (PMS) on a tilt table for 40 minutes, PMS + WBV vs PMS alone	Oscillating WBV (Aiko), 20 Hz, 2 mm, 1×5 minutes, 1-minute break	n=12, 6–18 years, spastic, GMFCS I–III	Spasticity (MAS), FTSST, balance (PBS)	↓Spasticity, ↓time in FTSST, ↑balance on the PBS
Unger et al^Citation46	4 weeks, twice a week in week 1, three times a week in week 2, four to five times a week in weeks 3 and 4 Ex: trunk-oriented (sit-up variation, hip and lumbar extensions, plank) Con: inactive – groups switched after 4 weeks	vWBV, 35–40 Hz, 2–4 mm, 8×30 seconds (progression 45 seconds and 60 seconds)	n=27, 6–13 years, spastic diplegic, GMFCS I–III	1MWT, posture (2-D photographic), ultrasound resting abdominal thickness, number of sit-ups (strength)	↑Distance walked, ↑upright posture, ↑resting thickness of all four abdominal muscles (transversus abdominis, obliquus internus, obliquus externus, rectus abdominis), ↑sit-ups executed in 1 minute
Myśliwiec et al^Citation47	4 weeks, three times a week	vWBV, 20 Hz, 2 mm, 2×1 minute, 10-minute break	n=3, 22–30 years, spastic quadriplegic, GMFCS NA	ROM	↑ROM in knee joint, no change in hip joint
Wren et al^Citation60	6 months, daily at home Ex: standing not specified Con: standing without WBV, groups switched after 6 months	Micro-impact (Juvent), 30 Hz 0.3 g, 10 minutes	n=31, 6–12 years, spastic hemi-, di-, tri-, quadriplegia, GMFCS I–IV	CT vertebral CBD, cross-sectional area, CBD tibia and geometry, plantar flexor strength	↑Cortical bone area and moments of inertia, no difference in CBD or muscle, no correlation between compliance and outcome, similar in all GMFCS levels, no differences between vibration and standing for any muscle or strength variables
Yabumot et al^Citation63	5 weeks, PT twice a week + WBV for standing Ex: standing	vWBV, 30 Hz, 1–3 mm	n=1, 8 years, spastic diplegic, GMFCS III	5 m walk test, spasticity (MAS), GMFM88, ROM with MTS (Tardieu)	↑Number of steps, no change in spasticity, ↑GMFM88 dimension C (sitting) and D (standing), trend for increased ROM after intervention

Note: Chronic effects in response to VT.

Abbreviations: Ex, exercise; vWBV, vertical whole-body vibration; GMFCS, Gross Motor Function Classification System; 1MWT, 1-minute walking test; MAS, modified Ashworth Scale; 6MWT, 6-minute walking test; TUG, timed up and go; GMFM, Gross Motor Function Measure; rMV, repeated muscle vibration; sWBV, side-alternating whole-body vibration; Con, control; pQCT, peripheral quantitative computed tomography; BMD, bone-mineral density; DXA, dual-energy X-ray absorptiometry; BMC, bone-mineral content; PT, physiotherapy; FV, focal vibration; MFM, motor-function measure; PEDI, Pediatric Evaluation of Disability Inventory; WBV, whole-body vibration; FTSST, five-time sit-to-stand test; PBS, pediatric balance scale; 2-D, two dimensional; ROM, range of motion; CT, computed tomography; CBD, cancellous bone density; MTS, modified Tardieu Scale.

Table 5 Conclusive effects of vibration therapy

Clustering of parameters	Acute adaptations: effects of VT after a single bout	Chronic adaptations: effects of VT after weeks and months of application
Neuromuscular parameters
Spasticity, reflex activation, muscle tone, cocontraction of antagonists	Reduced spasticity in dorsal extensors, plantar flexors,^Citation35 knee flexors,^Citation31,Citation36 knee extensors,^Citation36,Citation38 and hip adductors^Citation36 assessed in static and dynamic measures, reduced H-reflex^Citation15 and muscle-spindle stretch reflex amplitude^Citation32 in muscles vibrated, reduced muscle hypertonicity of antagonists,^Citation31,Citation38 reduced cocontraction of ankle and knee muscles^Citation32	Reduced spasticity in dorsal extensors, plantar flexors,^Citation36,Citation53 knee extensors,^Citation36,Citation49,Citation53,Citation59 and hip adductors^Citation36 assessed in static and dynamic measures
Voluntary activation	Increased voluntary activation of ankle and knee muscles,^Citation32 spontaneous activation of weak muscles,^Citation31 and paraspinal muscle activation,^Citation30 improvements in voluntary motor control^Citation31,Citation32 and coordination^Citation32 approaching normative values of healthy subjects^Citation31
Kinesthesia	Improved joint-position sense,^Citation31,Citation37 awareness of level of muscle contraction,^Citation31,Citation37 body image,^Citation31 and awareness of body segments^Citation31	Improved segmental position sense in the ankle joint^Citation58
Functional parameters
GMFM, total score, particular dimensions, particular tasks	Increased movement speed,^Citation31 edurance,^Citation30 precision,^Citation31 and spontaneous movement of weak musculature,^Citation31 improved recognition of body parts,^Citation31 pronunciation,^Citation31 and feeding patterns,^Citation31 increased memory of motor acts^Citation31 and repeatability after breaks^Citation31 of VT	Increased GMFM66 total score,^Citation55,Citation56,Citation58 improvement in all GMFM88 dimensions:^Citation56 C (sitting),^Citation63 D (standing),^Citation49,Citation59,Citation63 and E (walking)^Citation49,Citation59
Strength, torque, work, force, power, particular tasks	Increase in voluntary muscle power in upper and lower extremities,^Citation31 increased duration for head-erect behavior,^Citation30 reduced time to accomplish a sit-to-stand test^Citation36	Increased concentric peak torque,^Citation49,Citation51 eccentric peak torque,^Citation49 concentric^Citation49 and eccentric work,^Citation49 and increased muscle force^Citation55,Citation57,Citation59 (in upper and lower limb musculature), chair-rising: reduced time to accomplish the required number of repetitions^Citation48
Gait, spatiotemporal characteristics, joint kinematics, complex locomotor movements	Increased gait speed^Citation34 and walking distance,^Citation38 augmented stride length,^Citation34 increased angular excursion in the limb joints,^Citation34 reduced time to accomplish TUG^Citation38	Increased gait speed^Citation48,Citation50,Citation52,Citation54,Citation58 walking distance,^Citation46,Citation48,Citation53,Citation59 walking abilty,^Citation53 walking agility,^Citation53 and number of steps,^Citation63 augmented stride length,^Citation50 increased step length^Citation54 and width,^Citation58 reduced relative stance time,^Citation64 cycle time,^Citation50 and gait symmetry,^Citation54 increased dorsiflexion and plantar flexion,^Citation50 reduced hip flexion,^Citation64 and pelvic tilt anteversion^Citation64
Posture control and balance	No effects of VT^Citation36	No effects of VT,^Citation36,Citation58 improved postural stability,^Citation51 increased verticality in upright stance^Citation55
Mobility	Increased active and passive range of motion in the ankle^Citation34,Citation38 and knee joints^Citation32,Citation38	Increased active and passive range of motion in the ankle,^Citation50 knee,^Citation49 and hip joints^Citation64
Quality of life	Increased well-being^Citation31	Increased daily activity^Citation57
Structural components
Muscle thickness, lean body mass		Increased muscle thickness of shank thigh muscles^Citation48,Citation50 and lean mass of limbs,^Citation48 trunk,^Citation48 and whole body without head^Citation48,Citation55
BMD, BMC		Increased BMD in vertebral bodies,^Citation48,Citation60 limbs,^Citation57,Citation48 and total body^Citation48 and BMC in lumbar spine,^Citation48 limb,^Citation48,Citation57 and whole body without head^Citation48,Citation55

Note: Note that table sums up positive effects of VT only, without considering insignificant study results manifesting no effects.

Abbreviations: VT, vibration therapy; GMFM, Gross Motor Function Measure; TUG, timed up and go; BMD, bone-mineral density; BMC, bone-mineral content.

Figure 2 Overview of results.

Note: Overview of mechanisms underlying vibration therapy and resulting short- and long-term effects.

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