Exercise guide
Being active is good for people with cerebral palsy (CP) at every age and every level of ability, and strength training is safe: it makes muscles stronger and doesn't make spasticity worse. This guide is for adults with CP and for parents and carers of children with CP, whether you walk on your own, use a walking aid or use a wheelchair.
It follows guidance from the National Institute for Health and Care Excellence (NICE) and the research on exercise in CP, including where the evidence is weaker than many people expect: strength training improves strength more reliably than walking, and stretching on its own does little to prevent tightness.
You'll find how much activity to aim for, how to start strength and fitness training, honest information on stretching, help with falls, pain and fatigue in adulthood, sports to try, and a follow-along workout.
NICE asks professionals to talk with adults with CP about physical activity for fitness and for physical and mental health, and to point them to accessible local activities and sport. Children's services should tell families about local sports clubs.
Disabled children and young people: about 20 minutes of activity a day, in bite-size chunks if needed, plus challenging but manageable strength and balance activities 3 times a week. Adults: the same guidelines as everyone, adapted to what you can do.
It makes muscles stronger and doesn't make spasticity worse. Its effect on walking and everyday tasks is smaller and less certain.
A few weeks of light, simple exercises twice a week, then functional moves such as step-ups and sit-to-stands, 1 to 4 sets of 6 to 15, for at least 12 to 16 weeks.
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On its own, stretching makes little difference to how far a joint moves. Staying active and strong, positioning, splints and specialist treatment do more to prevent tightness.
Walking gets harder earlier than for other people in at least a quarter of adults who walk, falls recorded in GP records are about 6 times as common as in other adults, about 7 in 10 adults have pain, and fatigue is common. Staying active and strong is the main tool for all four, though trials are few.
A group of lifelong conditions that affect movement and co-ordination, caused by a problem with the brain that develops before, during or soon after birth. The brain problem doesn't get worse, but the condition can put strain on the body and cause problems such as painful joints later in life. It's the most common physical disability in childhood.
Spastic (stiff, tight muscles), dyskinetic (movements you can't control), ataxic (problems with balance and co-ordination) and mixed. It can affect one side of the body (hemiplegia), mainly the legs (diplegia) or all four limbs (quadriplegia). About 85% of children with CP have spasticity as the main type.
About 1 in 400 children in the UK. In high-income countries it affects about 1.6 in every 1,000 babies born, and the rate is falling.
Doctors and therapists describe movement with the Gross Motor Function Classification System (GMFCS), from level I to level V. People at levels I and II walk without a walking aid, people at level III walk with a hand-held aid, and levels IV and V are described as non-ambulant. In high-income countries about 3 in 4 children with CP now walk.
About half of children with CP have a learning disability. Others include epilepsy, sleep, vision, hearing, eating and swallowing problems, a curved spine (scoliosis) and hips that dislocate easily. One in 3 children with CP in high-income countries develop hips that gradually move out of place, which is why regular hip checks are recommended.
Muscle weakness is part of CP itself, not just a result of inactivity: children with CP are significantly weaker than other children. Children and adults with CP spend 76% to 99% of their waking hours sitting or lying down, and only those at levels I to III reach any moderate to vigorous activity, 2% to 7% of waking hours.
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At least a quarter of adults who walk find walking gets harder earlier than other people do. Pain and fatigue are common, and adults with CP have more depression and anxiety, high blood pressure, diabetes, heart disease, stroke, osteoarthritis and osteoporosis than adults without it. In England, deaths from heart and circulation disease were about 3 times the rate in the general population.
Your GMFCS level, which parts of your body are affected, and your age shape exercise more than anything. Over 16 years, walking speed fell in adults with CP affecting both sides of the body but held in those with one side affected. Women reported pain more often than men; this doesn't change the exercise advice.
A Cochrane review (29 trials, 926 people, mostly children, all at high risk of bias) found resistance training increased muscle strength in the short term, though not clearly at the intermediate term. In people aged 8 to 25 at GMFCS levels I to III, progressive resistance training increased leg strength (6 trials, 232 people, moderate certainty), more with gym-based programmes. A 2019 review of reviews rates strength training as effective for strength, and in adults (6 studies, 111 people) strength rose consistently.
The Cochrane review found low-quality evidence that resistance training doesn't improve gross motor function, walking speed, participation or quality of life in children. A later review of 27 trials (847 children and young people with spastic CP) found small improvements in balance, walking speed and gross motor function, with most trials at some or high risk of bias. In adults, walking speed improved in 2 of 6 studies, and NICE's committee found little or no improvement in mobility, function or participation from activity programmes.
Strength training was once thought to make muscles stiffer and spasticity worse. Trials found no increase in spasticity.
NICE's adult guideline committee noted that the risk of injury or other side effects wasn't increased by activities such as strength training. The Cochrane review says exercise appears to be safe, though only 55% of trials reported side effects.
The Cochrane review found aerobic exercise may improve gross motor function a little in the short term (3 studies, 65 people, low quality), but not walking speed, and fitness didn't differ from usual care in 3 small trials. Individual trials reported fitness gains of 9% to 41% after 8 weeks to 9 months of training, with no side effects, and the 2019 review rates fitness training as effective.
The 2019 review rates fitness training, strength training (for strength), treadmill training and goal-directed training as effective for children. Physical activity programmes probably improve fitness, activity, mobility, taking part and quality of life, but don't seem to improve gross motor skills.
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Across 18 studies (549 people) with neurological conditions, stretching changed joint range by about 2 degrees, which makes no real difference (high-quality evidence). In children with CP, evidence that stretching increases range, reduces spasticity or improves walking is limited, and longer stretches looked better than short ones. In a small trial, adding calf strengthening to stretching changed the calf muscle and tendon more than stretching alone. A UK trial of a tailored stretching programme for 334 children (SPELL) is expected to report in 2027.
In UK GP records of 1,705 adults with CP, 15.3% had a recorded fall compared with 5.7% of matched adults, and falls recorded in GP records were about 6 times as common (30.5 compared with 6.7 per 1,000 person-years). Because these are falls that reached the GP's records, differences in recording could push the figure either way. In 17 adults who walked, those who fell took shorter strides, and in UK interviews falls and fear of falling were a problem for over half of 26 adults.
In 16 studies, walking declined in at least 25% of adults, earlier than in other people; the risk was higher with poorer walking to begin with, CP affecting both sides, older age and more pain or fatigue. Over 16 years, walking speed fell by 0.13 metres a second and 6-minute walk distance by 84 metres in adults with CP affecting both sides, but held in those with one side affected.
Fatigue is common and fairly stable over the years. Adults who did more moderate to vigorous activity reported less fatigue, though that was a snapshot study. A 6-month programme of fitness training and coaching on activity and sport, tested in 57 young people aged 16 to 25, reduced fatigue during the programme and improved pain and mental health scores afterwards, but didn't increase measured daily activity.
About 70% of adults with CP have pain (data from 1,243 adults), mostly in the legs, and more often women and people at GMFCS levels II and IV. In a review of 63 studies, medicines and surgery didn't reduce pain in trials, while an active lifestyle and sports programme did, though the evidence is low to very low quality.
In UK GP records, adults with CP were more likely to develop depression (1.28 times) and anxiety (1.40 times) than matched adults. Across 69 studies, adults with CP more often had high blood pressure, type 2 diabetes, heart disease and stroke. In England, deaths from heart and circulation disease were about 3 times, and from lung disease about 14 times, the rates in the general population. These are observational studies.
UK guidance made with disabled children and their families: 20 minutes of activity a day for good health, built up slowly and in bite-size chunks if needed, plus challenging but manageable strength and balance activities 3 times a week; small amounts are good too. The World Health Organization's (WHO) goal for all children, including disabled children, is an average of 60 minutes a day across the week, as they're able.
150 minutes of moderate activity a week and strength (and balance) work on at least 2 days, adapted to what you can do; any activity is better than none. NICE asks for referral to physiotherapy, occupational therapy, orthotic or wheelchair services if you need help to be active.
Expert recommendations drawn from the trials: 2 to 4 weeks of very light, simple exercises twice a week, then 1 to 4 sets of 6 to 15 reps including functional moves such as step-ups and sit-to-stands, 2 to 3 times a week, for at least 12 to 16 weeks. Gains fade quickly if you stop. NICE's spasticity guideline describes progressive, repeated exercises against resistance, aimed at specific goals, where weakness limits what you can do.
At least 2 to 3 times a week for at least 20 minutes, kept up for at least 8 weeks (3 times a week) or 16 weeks (twice a week). The trials used running, step-ups, stairs, cycling, arm cranking, pushing a wheelchair and swimming. Judge your effort with the talk test: you can talk but not sing.
Less than 2 hours a day of leisure screen time, and swap some sitting for light activity, little and often through the day.
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A child who walks: active play and sport most days, building towards 20 minutes a day and beyond, with strength and balance play 3 times a week. An adult who walks: 2 to 3 strength sessions and 2 to 3 sessions of 20 minutes or more of walking, cycling or swimming a week, plus balance practice at a counter. An adult who doesn't walk: seated cardio and strength with bands, supported standing or transfers as advised, and help with stretches and positioning.
Start with very light, simple exercises that move one joint and don't need balance, twice a week: 1 to 2 sets of 10 (our editorial starting point within the expert recommendations).
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Add multi-joint moves such as sit-to-stands, step-ups (forwards or sideways) and squats, which the children's trials used, holding a support for anything standing; 2 to 3 sets of 6 to 12, building up. Adult trials also used gym machines such as the leg press.
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Train for at least 12 to 16 weeks, then keep a lighter version going, because strength fades quickly when you stop. Programmes vary widely; a UK trial (ROBUST) is now testing a tailored strengthening programme in 334 adolescents with spastic CP who walk.
Weeks 1 to 4: 1 to 2 sets of 10, light, twice a week (our editorial starting point).
From week 3 to 5: 2 to 3 sets of 6 to 12, 2 to 3 times a week, holding a counter or rail for anything standing. In a gym, the leg press is the machine the adult trials used.
3D demoSit to stand, pushing on the thighsBeginner · A bench or box
3D demoSit to stand from a chairBeginner · A bench or box
3D demoLow step-upBeginner · A step
3D demoSlow calf raiseBeginner · A wall
3D demoBodyweight squatBeginner · No equipment
3D demoLeg pressBeginner · Strength machine
3D demoBand rowBeginner · A band + An anchor point
3D demoWall push-upBeginner · A wallRunning, step-ups, stairs, cycling, arm cranking, pushing a wheelchair and swimming, 2 to 4 times a week for at least 20 minutes. Treadmill training is rated effective for children.
Our suggestions, from those trial activities: at GMFCS levels I and II, walking, running, cycling, swimming, team sports and dance; at level III, cycling on a recumbent or adapted bike, frame running, swimming and wheelchair sport; at levels IV and V, arm cranking, pushing a wheelchair, frame running, supported swimming and seated boxing.
At least 20 minutes, 2 to 3 times a week, at a talk-but-not-sing effort. Hold the rails on a treadmill. The arm crank has no 3D demo yet.
With your fingertips on a counter: 3 holds of 10 to 20 seconds, building up as you get steadier (our editorial starting point), and 10 side steps each way.
In people with neurological conditions, stretching made no real difference to how far joints move, and in children with CP the evidence for stretching is limited. Strengthening the same muscle may do more than stretching it.
NICE suggests considering 24-hour postural management (positioning through the day and night) with low-load stretching built into daily life, for example standing at the sink while brushing teeth to stretch the leg muscles, and splints (orthoses) worn for at least 6 hours a day to hold a stretch. Specialists also use active movement, standing support for children at levels IV and V, botulinum toxin, serial casting for early tightness, strength training after casting, and surgery for severe, long-standing tightness.
Regular hip checks (hip surveillance) are strongly recommended for children, because hips can gradually move out of place. For adults, NICE says not to X-ray the hips or spine unless there is pain or posture or function is affected.
Hold stretches for longer rather than shorter, build them into everyday life, and do them because they feel good and keep you moving, not as the whole plan.
Use each move's own dose: 3 holds of 45 seconds for the calf stretches and 45 to 60 seconds for the hamstring stretch, at a comfortable pull. Longer holds looked better than short ones in children with CP.
Falls recorded in GP records are about 6 times as common as in other adults, and falls tend to start earlier in life. Adults in UK interviews used their own strategies because specialist help was scarce, and the researchers suggest falls services to keep up strength and balance. Ask your GP about a falls service, and use the balance moves above with a counter to hold.
If walking, balance or other movement is getting harder, NICE says the change should be checked for treatable causes, with a referral to a musculoskeletal specialist or orthopaedic surgeon if pain or joint problems stop you being active.
Plan activity around your energy, build up gradually, and keep some activity on tired days (our suggestion). More active adults reported less fatigue, and a fitness and coaching programme reduced fatigue while it ran.
About 7 in 10 adults with CP have pain. An active lifestyle and sports programme reduced pain in one review's trials, while medicines and surgery didn't; the evidence is weak. New or worsening pain should be assessed.
Depression, anxiety, high blood pressure and heart disease are more common in adults with CP. NICE asks professionals to look after mental health alongside physical health. Activity is one tool among several.
Low bone density is common, especially in people who don't walk (GMFCS IV or V), have eating difficulties, a low weight, low vitamin D, a previous broken bone from a minor knock, or take some epilepsy medicines. For children, NICE suggests considering an active movement programme, active weight-bearing and a diet with enough calcium and vitamin D, but not standing frames or vibration therapy only to protect bones. For adults, fracture risk is assessed, with a bone density (DXA) scan if there are 2 or more risk factors.
Follow the disabled children's guidance: about 20 minutes a day, built up slowly, with strength and balance play 3 times a week. NICE suggests building therapy into daily routines, and taking into account the child's and parents' views and practical things such as the time a programme takes.
NICE asks services to tell families about local sports clubs, respite care, specialist schools and support groups.
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With epilepsy that isn't well controlled, breathing problems, a risk of food or drink going down the wrong way, or fragile bones, equipment and techniques need to be safe and appropriate: plan activity with your child's team.
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People at GMFCS levels IV and V may also benefit from strength training, though they may find moving one joint at a time harder, and pushing a wheelchair, arm cranking and swimming were among the aerobic activities in trials. Light activity while seated also breaks up time spent still.
Seated cardio and strength with bands (see our guide for wheelchair users), supported standing as your team advises, and help from a carer with stretches and positioning.
The cerebral palsy strength workout follows the trials' structure for people who walk. The stroke home exercises suit adults who walk with an aid, the seated workout suits people who don't walk or are having a tired day, and the animal moves work for children with adaptations.
A 25-minute home session for teenagers and adults with cerebral palsy who walk: simple strength moves first, then sit-to-stands, step-ups and balance.
25 minBeginner15 movesA bench or box, Something with weightA gentle 20-minute routine for home after a stroke: moves on the bed, in a chair and standing at a chair, then a short walk. Do the parts your team has agreed.
20 minBeginner12 movesA bench or box, Something with weightA 25-minute workout done sitting, in a chair or wheelchair: seated cardio intervals, light strength work, posture and stretches, with pacing and cooling built in.
25 minBeginner14 movesA bench or box, A dumbbellFifteen minutes of animal moves, jumps and balance games for children, building the muscle- and bone-strengthening activity they need, with nothing to buy.
15 minBeginner16 movesA wallA gentle leg strength routine with no jumping: sit-to-stands, step-ups, wall sits, bridges and calf raises.
20 minBeginner7 movesA bench or box, A stepCP Sport supports people with CP to take part in sport for life, with regional hubs and national athletics and swimming events. Boccia England calls boccia the most inclusive sport in England, and frame running lets people with significant movement difficulties run and compete.
WheelPower and Every Body Moves list wheelchair and inclusive sport across the UK. Choose by what you enjoy and what suits your level, and ask a physiotherapist about adaptations.
If someone with CP has a seizure, follow their own seizure plan and our epilepsy guide's first aid.
Stop if something hurts sharply, or for chest pain, dizziness or unusual breathlessness (our advice). You may take a splint or brace (orthosis) off if it causes pain that doesn't ease after repositioning the limb in it or adjusting the straps, and tell the team if it causes discomfort, sleep problems or sores.
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Scope's helpline is 0808 800 3333.
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It was once thought to, but trials found no increase in spasticity, and strength training makes muscles stronger.
On its own, stretching makes almost no difference to joint range (about 2 degrees in a high-quality review), and the evidence in children with CP is limited. Preventing tightness takes a combination: staying active and strong, positioning, splints, casting and specialist treatment.
There's no evidence for this popular claim. Strength training builds strength without a stretching phase first, and in one small trial adding calf strengthening to stretching changed the calf muscle and tendon more than stretching alone.
The brain problem itself doesn't get worse, but many adults find walking harder over time, and pain and fatigue are common. Staying active and strong is part of managing them, and changes should be checked for treatable causes.
NICE asks services to tell families about local sports clubs. CP Sport supports people with CP in sport for life, Boccia England calls boccia the most inclusive sport in England, and frame running lets people with significant movement difficulties compete.
CP is lifelong. Exercise and physiotherapy help keep and, hopefully, improve movement, strength and fitness, which is worth a lot, but they don't remove the condition.
People at GMFCS levels IV and V may also benefit from strength training, and pushing a wheelchair and arm cranking were among the aerobic activities in trials. Light activity while seated counts too.
Strength training, aerobic exercise such as walking, cycling, swimming or pushing a wheelchair, balance work and active play, chosen for your level and goals. NICE recommends physiotherapy programmes aimed at specific goals, with strengthening where weakness limits what you can do.
UK guidance for disabled children is about 20 minutes a day, in bite-size chunks if needed and built up slowly, plus challenging but manageable strength and balance activities 3 times a week. The WHO's goal for all children, including disabled children, is an average of 60 minutes a day, as they're able.
Yes. Trials found no increase in spasticity, and NICE's adult guideline committee noted no increase in injury or other side effects. Start with a few weeks of light, simple exercises.
It makes muscles stronger, but its effect on walking speed and everyday tasks is smaller and less certain. In adults, walking speed improved in 2 of 6 studies.
On its own, stretching makes little difference to how far joints move, and the evidence in children with CP is limited. It can still feel good, but positioning, splints, staying active and strong, and specialist treatment do more to prevent tightness.
Fatigue is common in adults with CP and fairly stable over the years. Adults who did more moderate to vigorous activity reported less fatigue, and a programme of fitness training and coaching reduced fatigue while it ran. Build up gradually and plan activity around your energy.
Falls recorded in GP records are about 6 times as common in adults with CP as in other adults. Strength and balance training, a referral to a falls service, and the NHS advice on falls can help.
The brain problem doesn't get worse, but many adults find walking harder over time, and pain and fatigue are common. NICE says changes should be checked for treatable causes.
Yes, adapted to your level. CP Sport runs athletics and swimming events and regional hubs, Boccia England calls boccia the most inclusive sport in England, and frame running lets people with significant movement difficulties compete.
People at GMFCS levels IV and V may also benefit from strength training, and pushing a wheelchair, arm cranking and swimming can all be aerobic exercise. Breaking up long spells of sitting with light activity helps too.
About 7 in 10 adults with CP have pain. In one review, an active lifestyle and sports programme reduced pain while medicines and surgery didn't, though the evidence is low quality.
NICE says not to offer standing frames only to prevent low bone density, but to consider an active movement programme, active weight-bearing and a good diet. Standing may still be used for other reasons, as your child's team advises.
Exercise education, not a diagnosis or treatment plan, and clinical review of these guides is pending. Stop and get advice for chest pain, unusual breathlessness, dizziness or fainting, or new pain, and check with your doctor or midwife first if they have told you to limit activity. Health disclaimer.
