The effects of stretching, strengthening and combined interventions on lower-limb spasticity in spastic cerebral palsy: a systematic review

Background: Spastic cerebral palsy (CP) is a common childhood neurological condition that results in abnormal muscle tone, motor dysfunction, and gait impairments. While stretching is widely used to reduce muscle stiffness, strengthening exercises are increasingly incorporated to improve functional mobility. Concerns remain, however, regarding whether strengthening may increase spasticity. Method: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of studies published between 2004 and 2024 was conducted across major databases. Eligible studies included those evaluating stretching, strengthening, or combined interventions targeting lower-limb spasticity in individuals with spastic CP. Risk of bias was assessed using the Cochrane Risk-of-Bias tool (ROB-2).Results:Twelve studies met the inclusion criteria. Intervention categories comprised stretching alone (n = 2), strengthening alone (n = 2), and combined stretching–strengthening programmes (n = 8). Findings indicated that stretching alone and strengthening alone do not consistently reduce lower-limb spasticity, although both may help preserve muscle and joint properties. Combined exercise programmes demonstrated mixed outcomes: some studies reported improvements in tendon stiffness, fascicle length, and clinical spasticity scores, while others showed no significant effects. Despite inconsistent spasticity outcomes, several studies noted functional gains, including better gait performance,enhanced muscle morphology, and improved movement efficiency.Conclusion: Overall, the evidence suggests that while combined interventions may offer selective benefits, reductions in spasticity are not uniformly observed.Current evidence does not support stretching, strengthening, or combined exercise programmes as consistently effective in reducing lower-limb spasticity in spastic CP, although functional improvements are frequently reported. Future research should prioritise spasticity as a primary outcome, standardise intervention parameters, and incorporate larger, methodologically robust samples to inform clinical practice.