The link between motor disorders and executive or attentional cognitive disorders in people with cerebral palsy: Scoping review

The link between motor disorders and executive or attentional cognitive disorders in people with cerebral palsy: Scoping review | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search The link between motor disorders and executive or attentional cognitive disorders in people with cerebral palsy: Scoping review Melinda Martinet , Kathrin Reichert , View ORCID Profile Juliane Schneider , View ORCID Profile Pawel J. Matusz doi: https://doi.org/10.1101/2025.01.26.25321141 Melinda Martinet 1 Physiotherapy Section, School of Health Sciences, University of Applied Sciences Western Switzerland (HES-SO) Valais-Wallis , Sion, Switzerland Find this author on Google Scholar Find this author on PubMed Search for this author on this site Kathrin Reichert 1 Physiotherapy Section, School of Health Sciences, University of Applied Sciences Western Switzerland (HES-SO) Valais-Wallis , Sion, Switzerland Find this author on Google Scholar Find this author on PubMed Search for this author on this site Juliane Schneider 2 Clinic of Neonatology and Developmental Unit, Woman-Mother-Child Department, University Hospital Center and University of Lausanne , Lausanne, Switzerland 3 The Sense Innovation and Research Center, Lausanne and Sion , Switzerland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Juliane Schneider Pawel J. Matusz 1 Physiotherapy Section, School of Health Sciences, University of Applied Sciences Western Switzerland (HES-SO) Valais-Wallis , Sion, Switzerland 3 The Sense Innovation and Research Center, Lausanne and Sion , Switzerland 4 Department of Hearing & Speech Sciences, Vanderbilt University Medical Center , Nashville, TN, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Pawel J. Matusz For correspondence: pawel.matusz{at}hevs.ch Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Introduction Cerebral palsy (CP) causes motor deficits, which are sometimes accompanied by cognitive impairment. There are models that suggest interactions between these two domains in various populations. However, for CP, there seems to be a lack of empirical research on the subject. This scoping review aims to synthesize the literature on the specific relationships between motor and executive/attentional functions in people with CP. In addition, it seeks to identify current gaps to guide future research. Method A systematic search of three databases was conducted. Articles were selected on a double-blind basis according to predefined eligibility criteria. Finally, the results were presented in the form of tables and a narrative synthesis. This scoping review was written in accordance with the JBI manual for evidence synthesis. Results Eleven studies with different methodologies were included in this review. Relationships were investigated in different ways in each of the included studies. Some articles assessed executive functions and attention in parallel, while others focused on the individual domains. Five of the included studies found significant links between motor and executive functions. Likewise, five studies reported significant relationships between motor skills and attention. However, three of the included studies found no evidence of links between certain of these domains. Discussion This work provides empirical evidence of the links between motor and executive/attentional functions in CP. For the future, there remains a need for more high-quality empirical studies to clarify and quantify the specific relationships of motor and executive/attentional abilities. 1. Introduction 1.1 Cerebral Palsy 1.1.1 Definition Cerebral palsy (CP) is the leading cause of motor disability in children ( Paul et al., 2022 ). According to Rosenbaum et al. (2007) , it describes a group of permanent deficits in movement and posture that are regularly accompanied by various secondary non-motor disorders. It results in activity limitation, which is attributed to non-progressive disturbances in brain development ( Rosenbaum et al., 2007 ). This definition highlights the many disorders and co-morbidities associated with CP. Understanding the various factors involved is important in order to grasp the different ways in which they may interact ( Rosenbaum et al., 2007 ). 1.1.2 Epidemiology The worldwide incidence of cerebral palsy is 1.6 per 1,000 births ( McIntyre et al., 2022 ). In the Swiss population, the condition affects around 3,000 children and 12,000 adults ( Belle et al., 2022 ). CP represents the largest group of patients treated in paediatrics, who require lifelong follow-up ( Beckers et al., 2020 ). It is therefore essential to advance research in this field. 1.1.3 Etiology and risk factors CP results from damage to the brain during its development and can affect different regions of the brain ( Paul et al., 2022 ). It most frequently affects the white matter, cortex or deep grey matter ( Mendoza-Sengco et al., 2023 ). The risk of CP increases considerably in children born before the 32nd week of gestation ( Sukhov et al., 2012 ). Prematurity is therefore the most common risk factor ( Paul et al., 2022 ), although other risk factors are also described in literature ( Paul et al., 2022 ). They are divided into three groups according to their period of onset : pre-, peri- and post-natal ( Paul et al., 2022 ). The prenatal period refers to the gestation period of the foetus ( Paul et al., 2022 ). Potential causes of CP during this period include genetic abnormalities, multiple pregnancies, infections or maternal substance abuse. The perinatal period refers to childbirth and presents risks such as prematurity, caesarean section, infections and asphyxia ( Mendoza-Sengco et al., 2023 ). The postnatal period runs from birth to the age of 5 and includes trauma or brain disease ( Paul et al., 2022 ). 1.1.4 Symptoms CP is mainly characterised by motor disorders, such as muscle contractures, postural changes and movement limitations ( Paul et al., 2022 ; Vitrikas et al., 2020 ). In addition to motor symptoms, other co-morbidities play an important role. These include cognitive deficits, pain, communication and behavioural difficulties, epilepsy, incontinence and sensory or perceptual disorders ( Paul et al., 2022 ; Vitrikas et al., 2020 ). Chapters 1.2.3 and 1.3.4 will look in more detail at the motor and executive/attention symptoms associated with CP. Signs indicative of CP sometimes appear as early as birth ( Gulati & Sondhi, 2018 ). These may include early hand dominance, delayed motor development, persistent primitive reflexes, increased muscle tone and postural abnormalities ( Gulati & Sondhi, 2018 ; Paul et al., 2022 ). The diagnosis of CP is largely based on clinical symptoms ( Mendoza-Sengco et al., 2023 ). 1.1.5 Classification Because of the diversity of causes and clinical manifestations of CP, its classification can be approached in different ways ( Paul et al., 2022 ). It is frequently based on clinical signs, such as the severity or type of motor impairment ( Rosenbaum et al., 2007 ). Depending on the type motor disorder, CP is regularly classified into three groups: spastic, dyskinetic and ataxic ( Cans et al., 2007 ). The spastic form is characterized by high muscle tone and increased reflexes. Dyskinetic CP presents with involuntary, repetitive movements and fluctuating muscle tone. Lastly, ataxic CP is marked by a loss of coordination and hypotonia ( Paul et al., 2022 ). The severity of motor impairment is assessed using two scales covering five levels ( Paul et al., 2022 ). The Gross Motor Function Classification System (GMFCS) determines the gross motor function (Chapter 1.2.1) of the lower limbs by assessing voluntary movements and the use of aids ( Palisano et al., 1997 ). The Manual Ability Classification System (MACS) measures upper limb function by testing object manipulation and other manual activities ( Eliasson et al., 2006 ). A description of the different levels of these two tests can be found at Appendix 2 to 4 . 1.1.6 Diagnosis To diagnose CP, doctors use a combination of the child’s clinical presentation, physical assessments and imaging ( Paul et al., 2022 ). The provisional designation ‘at high risk of CP’ is used when the diagnosis cannot yet be made with certainty ( Novak et al., 2017 ). Once the diagnosis has been made, it remains important, particularly for parents, to define the severity of motor impairment in order to better understand the child’s abilities ( Novak et al., 2017 ). The GMFCS is used for this purpose ( Paul et al., 2022 ). Early diagnosis is essential in order to set up a specific intervention programme ( Mendoza-Sengco et al., 2023 ). Children with CP should be treated as early as possible in order to exploit brain plasticity and promote the development of their abilities ( Paul et al., 2022 ). 1.2 Motor functions 1.2.1 Definition Motor functions refer to the ability to perform voluntary movements in order to carry out specific activities ( Hallemans et al., 2020 ). They are generally separated into two classes: gross motor functions and fine motor functions ( Gonzalez et al., 2019 ). Gross motor functions use large muscle movements and include locomotion, balance and object control skills ( Gandotra et al., 2021 ). Fine motor skills involve the use of small muscles and describe muscle coordination during finger, hand and wrist movements ( Gandotra et al., 2021 ). 1.2.2 The development of motor functions During childhood, motor behaviour evolves considerably, moving from reflexive to voluntary actions ( Clark & Metcalf, 2002 ). Clark and Metcalf (2002) identify five periods of motor development: reflexive, preadapted, fundamental motor patterns, context-specific and skilful. The reflexive period lasts until the second week of life and is characterised by spontaneous and reflexive movements ( Clark & Metcalf, 2002 ). During the preadapted period, reflexive behaviours are inhibited, and the infant begins to voluntarily initiate movement. The infant passes through specific motor milestones such as sitting, standing and walking ( Hallemans et al., 2020 ). With the achievement of independent walking, at around 1 year of age, the child transitions to the fundamental motor patterns period ( Clark & Metcalf, 2002 ). In the following years, up to the age of 7, the child develops a repertoire of global and fine movements, such as jumping, throwing a ball or drawing ( Clark & Metcalf, 2002 ). During the context-specific period that follows, children learn to apply their movements to a variety of task and environmental contexts ( Clark & Metcalf, 2002 ). The transition to the final period occurs between the ages of 11 and 13, during which adolescents move from context-specific competence to skilful behaviour ( Clark & Metcalf, 2002 ). 1.2.3 Motor functions during PC As previously mentioned, CP is primarily characterised by impaired motor function ( Paul et al., 2022 ), ranging from independent walking to wheelchair dependence ( Van Eck et al., 2009 ). The motor milestones described above (Chapter 1.2.2) are delayed in children with CP ( Mohammad et al., 2018 ). Symptoms can affect gross motor skills such as sitting, walking or maintaining balance, as well as fine motor functions such as writing ( Paul et al., 2022 ). The severity of these deficits varies according to the type and location of the brain lesion. ( Arnfield et al., 2013 ). White matter lesions are frequently associated with mild disabilities, graded GMFCS I to II, while grey matter lesions are associated with GMFCS levels III to V ( Arnfield et al., 2013 ). Brain malformations are generally evenly distributed across the five GMFCS levels. In some individuals, normal brain imaging can be observed. This is consistently linked to mild disability, with a GMFCS I to II ( Arnfield et al., 2013 ). Physiotherapy is essential in the management of CP ( Paul et al., 2022 ). The main aim is to optimise functional abilities and prevent side effects such as muscle contractures ( MacWilliams et al., 2022 ). Treatment techniques usually include: guiding the child through normal sequences of motor development, inhibiting abnormal reflexes, strengthening normal reflexes, facilitating normal movements and strengthening muscles ( Mohammad et al., 2018 ). Early intervention minimises secondary complications and utilises the neuroplasticity of the brain to optimise patient outcomes ( Paul et al., 2022 ). 1.3 Cognitive control functions Cognitive functions group together the mental processes involved in acquiring knowledge, manipulating information and reasoning ( Kiely, 2014 ). They enable people to adapt their behaviour to new situations ( Andrianopoulos et al., 2017 ). Cognition is divided into six main domains: attention, executive functions, learning and memory, language, perceptual-motor functions and social cognition ( American Psychiatric Association, 2013 ). 1.3.1 Executive functions Executive functions encompass the cognitive processes used to perform goal-directed behaviour ( Best & Miller, 2010 ). According to the dominant theories, they comprise three main components: inhibition, working memory and cognitive flexibility ( Diamond, 2013 ; Miyake et al., 2000 ). Inhibition is the ability to suppress a dominant response in favour of a more appropriate subdominant response ( Diamond, 2013 ). Working memory refers to the ability to retain and manipulate information for short periods ( Diamond, 2013 ). Finally, cognitive flexibility represents the ability to shift attention from one object/task to another, or to switch voluntarily from one activity to another ( Diamond, 2013 ). Higher executive functions such as reasoning, problem solving and planning are built on the basis of these functions ( Diamond, 2013 ). 1.3.2 Attentional functions Attention is the cognitive process that guides the brain in prioritising and selecting relevant information ( Lodha & Gupta, 2022 ). Sohlberg and Mateer (2001) propose five components of attention: focused, sustained, selective, alternating and divided. Focused attention describes the ability to respond to specific stimuli (visual, auditory, tactile), depending on the current task ( Sohlberg & Mateer, 2001 ). Sustained attention defines the ability to maintain a coherent response during a continuous and repetitive activity ( Sohlberg & Mateer, 2001 ). Selective attention makes it possible to maintain concentration on relevant stimuli in the face of distracting or competing stimuli ( Sohlberg & Mateer, 2001 ). Alternating attention is used to shift the focus of attention between two tasks with different cognitive demands ( Sohlberg & Mateer, 2001 ). Finally, divided attention refers to the ability to respond simultaneously to multiple stimuli ( Sohlberg & Mateer, 2001 ). Deficiencies in these functions have a considerable impact on functioning in everyday life, for example in the regulation of behaviour and emotions or the ability to adapt ( Lodha & Gupta, 2022 ). 1.3.3 Developing executive and attentional functions The development of cognitive functions begins at birth and is divided into three phases: emergent (acquisition stage), developing (partially functional capacity) and established (fully mature capacity) ( Anderson, 2002 ). The three components of executive function, discussed in chapter 1.3.1, develop differently ( Anderson, 2002 ). Inhibition develops rapidly until the age of 5 to 8. It then progresses more slowly, but continues into adulthood ( Best & Miller, 2010 ). Working memory begins to develop during the first year of life. It shows a linear progression until the age of 14, then continues to be refined during adolescence ( Best & Miller, 2010 ; Diamond, 2000 ). Cognitive flexibility is the last function to emerge. It appears between the ages of 3 and 4, and continues to improve, reaching adult levels around the age of 15 ( Anderson, 2002 ; Best & Miller, 2010 ). The different components of attention also show developmental differences ( Swingler et al., 2015 ). The ability to voluntarily control focused attention begins to emerge between 3 and 6 months of age and increases drastically until the age of 4 ( Gaertner et al., 2008 ). Towards the end of their first year, infants begin to show the ability to divide their attention between different stimuli ( Swingler et al., 2015 ). This skill improves rapidly between the ages of 6 and 12 ( Talalay, 2024 ). Selective and sustained attention also improve during this period, and then continue to develop until the onset of adolescence (10 to 13 years) ( Talalay, 2024 ). Executive and attentional functions share a complex relationship ( Deodhar & Bertenthal, 2023 ). Their components are often active simultaneously during the execution of tasks and seem to play an important role in their reciprocal development ( Deodhar & Bertenthal, 2023 ). For this reason, this work analyses these two functions. 1.3.4 Executive and attentional functions during CP Cognitive function in people with CP can present in a very heterogeneous way, varying from severe deficits to typical functioning ( Stadskleiv et al., 2018 ; Wotherspoon et al., 2023 ). Nevertheless, Wotherspoon et al. (2023) propose that children with CP are more likely to have executive and attentional difficulties than typically developing children. According to Fluss and Lidzba (2020) the majority of individuals with CP present mild to moderate deficits. The functions affected include sustained and divided attention, inhibition, working memory and cognitive flexibility ( Cabezas & Carriedo, 2020 ). Problems in these areas have a direct impact on daily life. For example, a person suffering from a deficit in attentional functions is more easily distracted, this can lead to learning difficulties and problems with social relationships ( Bottcher et al., 2010 ). Impaired executive functions affect a child’s ability to adapt their behaviour and control their emotions ( Swingler et al., 2015 ). Deficits in cognitive control functions have been linked to lesions of the anterior white matter, basal ganglia or thalamus, as well as infarcts of the middle cerebral artery ( Bottcher et al., 2010 ). Disturbances in these areas influence how the child reacts and interacts with various therapies. For this reason, it is essential to determine whether a child diagnosed with CP has difficulties with executive and/or attentional functions ( Wotherspoon et al., 2023 ). 1.4 Relationship between cognitive and motor control functions The relationship between motor and cognitive skills has been the subject of research for decades. One of the most common theories was proposed by Piaget in 1950. According to him, a child’s movement skills play a central role in the emergence of his or her cognitive skills ( Piaget, 1952 ). During the first few years of life, children explore objects by touching, manipulating or looking at them, which is fundamental to their cognitive development ( Piaget, 1952 ). Campos et al. (2000) note that early locomotor experiences give children more opportunities to explore and interact with their environment. Their cognitive skills, such as the ability to focus attention on objects at a distance, are thus enhanced ( Campos et al., 2000 ). Collectively, research in this area is still ongoing. This indicates that the interactions between these two functions remain a relevant subject and highlights the importance of this work. 1.4.1 Neuroanatomical level Several studies examine the link between the two domains at a neuroanatomical level (e.g. Diamond, 2000 ; Pangelinan et al., 2011 ). Diamond (2000) investigates this in people with developmental disabilities. She found activation of the cerebellum, associated mainly with motor skills, during cognitive tasks. On the contrary, the prefrontal cortex, involved in executive functions, is activated during motor tasks. In her view, this suggests that these regions are not only responsible for one function, but also influence the second ( Diamond, 2000 ). 1.4.2 At the behavioural level Numerous primary studies explore the relationships between motor and cognitive functions, which have been summarised in various literary reviews (e.g. Fogel et al., 2023 ; Gandotra et al., 2021 ). Gandotra et al. (2021) find positive associations between all components of executive functions and motor skills in typical children. A strong correlation was observed between manual dexterity, balance and executive function ( Gandotra et al., 2021 ). In a systematic review, Fogel et al. (2023) studied children with developmental coordination disorders. They found a significant relationship between gross and fine motor functions and components of executive function, such as working memory ( Fogel et al., 2023 ). 1.4.3 In interventional studies Several intervention studies provide indirect evidence of links between the two domains (e.g. Budde et al., 2008 ; Schmidt et al., 2015 ). Budde et al. (2008) examine the effect of coordination exercises on an attention task in healthy 13–16-year-old adolescents. They found an improvement in attention in the experimental group (coordination training) compared with the control group (normal sports lessons). They concluded that specific coordination exercises activated parts of the brain involved in attention. Schmidt et al. (2015) investigated the impact of various types of physical activity (with high or low cognitive engagement) on the executive functions of healthy children aged 10 to 12. They found an improvement in cognitive flexibility only in the high cognitive engagement group. Thus, cognitive integration in physical activity seems interesting for improving executive functions ( Schmidt et al., 2015 ). 1.4.4 Relationships in CP The relationship between motor and executive/attentional functions in children with CP remains poorly studied ( Babik et al., 2023 ). Although primary research is multiplying, it has not yet been synthesised in a literary review. The implication and understanding of such interactions are insufficiently explored. In a review, Babik et al. (2023) describe the relationship between motor skills and executive function in premature infants and children with CP. In their work, they mention several possible links between various motor components and executive functions ( Babik et al., 2023 ): According to Babik et al. (2023) , attention is affected in different ways by motor disorders. On the one hand, the persistence of involuntary movements increases the child’s distractibility and thus contributes to attention deficits. On the other hand, unstable posture reduces the child’s ability to explore his environment, which is essential for the development of selective, sustained and divided attention. Cognitive flexibility develops better in the presence of behavioural variability. A reduction in cognitive flexibility, due to limited opportunities for movement, contributes to deficits ( Babik et al., 2023 ). According to the evidence summarised by Babik et al. (2023) , working memory is negatively affected by atypical involuntary movements, sub-optimal postural control and delayed development of gross motor function. Inhibition appears to be negatively affected by attention disorders resulting from motor deficits or postural control disorders. Finally, Babik et al. (2023) describe a reciprocity between the two areas: it is not only motor functions that can have an effect on executive functions, but also vice versa. Progress in executive skills also promotes the development of more complex motor skills ( Babik et al., 2023 ). To improve executive functions, Babik et al. (2023) recommend interventions focusing on motor skills. In addition, they suggest the involvement of early intervention, the integration of functional activities, the encouragement of active movements and the incorporation of a wide variety of movements ( Babik et al., 2023 ). Although this article contributes to our understanding of the mechanisms underlying the relationship between the two domains, it does not quantify nor prove their relationship. Empirical research is still needed to clarify the specific links between the different components of executive/attentional and motor functions. 1.5 Current project A first attempt to fill the gaps in our understanding of the relationships between motor and executive/attentional functions was made in the study by Babik et al. (2023) . However, they highlighted questions concerning the nature of these links. In particular, the existence of specific correlations between the various motor components and those of attention or executive functions. Their work does not provide empirical data enabling these relationships to be conclusively identified or quantified. Motor and cognitive impairments have a significant impact on the daily activities and participation of children with CP ( Crichton et al., 2020 ). It is important for therapists working with these children to understand the affected functions and their interactions ( Al-Nemr & Abdelazeim, 2018 ). This understanding is essential in order to develop effective early interventions and improve outcomes for people with CP ( Babik et al., 2023 ). This review aims to address this lack of understanding by answering the following research question: "What are the links between motor disorders and executive or attentional cognitive disorders in people with cerebral palsy?" In response, this work aims to synthesise the literature on the relationships between executive/attentional and motor functions in people with CP, and more specifically, the links between the specific components of these two domains. In addition, this work seeks to identify current gaps to guide future research. 2. Method 2.1 Study design Preliminary research was carried out to assess the state of knowledge in the field of CP using keywords ( cerebral palsy; motor function; executive function; attention ). This analysis revealed a notable lack of studies on the relationship between motor and executive/attention functions in CP. In addition, the studies identified showed significant heterogeneity in terms of participant demographics (age, type of CP, severity of impairment), approach and measures used. As defined by Munn et al. (2022) , a scoping review is a synthesis method that seeks to systematically identify and organise all available data on a specific subject. It is generally characterised by its novelty, or by the fact that the subject is not the subject of much specific research. It is used to clarify key concepts in the literature, as well as to identify the current state of knowledge in a field, including gaps ( Munn et al., 2022 ). The aim of this work is to provide an overview of the existing literature concerning the relationships between specific components of motor and executive/attentional functions in CP. In addition, this work aims to serve as a reference for future empirical research and systematic reviews. This review is conducted and reported in accordance with the Joanna Briggs Institute (JBI) manual for evidence synthesis ( Peters et al., 2020 ). 2.2 Research strategy To formulate the research equation, three key concepts were identified: (1) cerebral palsy, (2) motor functions and (3) executive and attentional functions. In order to determine the relevant key terms for each concept, an analysis of the Babik et al. (2023) article, identified during the preliminary research, as well as its literary references, was carried out. The full list of key terms is given in Table 1 . View this table: View inline View popup Download powerpoint Table 1 Concepts and keywords for formulating the research equation Searches for this review were conducted on three databases: PubMed, Embase and Cochrane. The initial search equation yielded a broad selection of articles on these three platforms. By analysing the results and collaborating with faculty librarians, the search parameters were refined to develop the final search equation [ Appendix 1 ]. A filter was applied to exclude articles written in languages other than English, French or German. The last search was carried out on 14 February 2024. 2.3 Selection of studies In order to identify relevant literary research articles, inclusion and exclusion criteria were established ( Table 2 ) The criteria were chosen by analysing those used in similar articles (e.g. Fogel et al., 2023 ; Gandotra et al., 2021 ). View this table: View inline View popup Download powerpoint Table 2 Inclusion and exclusion criteria for study selection Initially, the bibliographic references of the article by Babik et al. (2023) were analysed in a double-blind fashion. The studies were sorted by title and abstract according to the predefined inclusion and exclusion criteria. The articles selected provided an initial overview of the problem and the existing literature, which contributed to the final formulation of the search equation [ Appendix 1 ]. The research equation was applied to the three databases to identify the total number of articles to be included in the selection process. Once the articles had been retrieved, they were uploaded to Zotero to remove duplicates. Zotero is a reference management tool that can be used to collect and organise research sources ( Mueen Ahmed & Dhubaib, 2011 ). The remaining studies were uploaded to Rayyan, a platform for selecting and organising articles ( Ouzzani et al., 2016 ). The first stage of the selection process involved a double-blind evaluation of article titles and abstracts by the two primary authors according to the inclusion and exclusion criteria. Any disagreements were discussed and resolved before moving on to the second stage. This stage involved a double-blind reading of the texts by the two primary authors, applying the same exclusion criteria. Any remaining disagreements were settled through discussion. 2.4 Data extraction One primary author extracted the data for the selected articles. The second primary author then corroborated the extracted results. The data extracted included: (1) title, author, and year of publication, (2) study design, (3) participant characteristics (sample size, age, gender, type of CP, and GMFCS and/or MACS scores), (4) motor functions measured and their corresponding results, (5) executive and/or attentional functions measured and their corresponding results and finally (6) type, direction and strength of the relationship observed between motor and cognitive functions. Disagreements in data extraction were again resolved through discussion and consultation with the tco-authors. Once a consensus had been reached, the extracted data were summarised in the form of a table. In addition, a second table was created to explain the measures used in the articles. 2.5 Data summary The results were presented in two ways. Firstly, a descriptive and numerical summary of the included studies was presented in table form. It describes the type of study, the characteristics of the population, the cognitive and motor measures used, and a summary of the relationships found between these factors. The organisation of the studies in a final table followed a precise methodology, established in agreement with the co-authors. Firstly, a division based on the motor skills measured was made. The first articles include both gross and fine motor skills. These are followed by those that only measured gross motor skills and finally by those that only tested fine motor functions. Following this division, a sub-division based on cognitive functions was established. The first articles assessed both executive and attentional functions, followed by those that measured only executive functions and those that examined attention exclusively. The main results concerning the population, the measures included, and the links found between cognitive control factors and motor domains have been summarised in narrative form. This text serves as an extension to the table mentioned above and is intended to highlight key points and explore certain aspects in greater depth. 3. Results 3.1 Selection of studies The article identification and selection processes are illustrated as a flow diagram in Figure 1 . The search was performed on three databases using the research equation, resulting in the identification of a total of 465 articles. After excluding the 153 duplicates, 312 articles were retained for the selection process. In the first stage of this screening, the titles and abstracts of the identified articles were evaluated, and 270 articles were discarded. Subsequently, 32 articles were excluded after a full reading of the article texts. At this stage, one article was added. It corresponds to the entire article of a conference extract that had been excluded for its study design. In the end, a total of 11 articles were retained for this review. Download figure Open in new tab Figure 1: Flow diagram of article selection for this scoping review Several types of studies are included in this review, including six cross-sectional studies ( Forsman & Eliasson, 2016 ; Soriano & Hustad, 2021 ; Stadskleiv et al., 2018 ; Van Rooijen et al., 2012 , 2016; Wang et al., 2020 ), a cohort study ( Wotherspoon et al., 2023 ), a case-control study ( Ballester-Plané et al., 2018 ), an observational study ( Al-Nemr & Abdelazeim, 2018 ), a non-randomised clinical study ( Reilly et al., 2008 ), and a pre-post interventional study ( Surkar et al., 2015 ). The most recent study is by Wotherspoon et al. (2023) , while the oldest is by Reilly et al. (2008) . The articles included in this review span a period of 17 years. Table 3 presents a description of all the relevant information from the included studies to meet the objectives of this scoping review. View this table: View inline View popup Table 3 Relevant information from included studies 3.2 Population The studies included a total population of 543 participants, aged between 22 months and 62 years. Given the wide age range of participants tested among these articles, a subdivision by age group was carried out. This enabled a more homogeneous and therefore more informative analysis of the relationships between motor functions and cognitive control. The three age groups are divided as follows: under 4 years, 4-18 years old and a mixed-age group. They are divided in this way to best reflect the key periods of human development. One article deals with infants under 4 years of age. Nine articles concern children aged 4 to 18 and one article concerns a mixed population aged 7 to 62 ( Table 3 , Population characteristics). Six studies included a mixed sample containing participants with spastic, dyskinetic or ataxic CP, while four articles focused specifically on a single type. Only one search did not include information on the form of CP ( Table 3 , Type of CP). Three studies use both the GMFCS and the MACS to classify the severity of CP impairment. Five employ only the GMFCS and one adopts only the MACS ( Forsman & Eliasson, 2016 ). Two articles do not report a classification system ( Surkar et al., 2015 ; Wang et al., 2020 ) ( Table 3 , GMFCS and MACS). Of the eight articles that apply the GMFCS, six include a sample representing all five classification levels. As a result, they cover all levels of motor impairment. This makes it possible to explore the relationships between motor and executive/attentional functions across the full range of abilities, from so-called normal motor functions to the need to use aids such as a wheelchair. One study is limited to stages I to III ( Reilly et al., 2008 ), while another confines itself to stages II and III ( Al-Nemr & Abdelazeim, 2018 ). Thus, these two articles exclude individuals with more severe impairments who need help in most situations. Of the four articles using the MACS scale, three include a sample representing all five levels. In this way, they cover the whole range of manual skills, from independent manipulation of objects to severe limitation. While one study focuses solely on stages I to III ( Forsman & Eliasson, 2016 ), it excludes people with more severe impairments, who are very limited or require total assistance when handling objects. 3.3 Motor and cognitive measurements 3.3.1 Motor measures Three articles measure both gross and fine motor functions, while eight assess only one of these functions. Taking this into account, a total of ten articles focus on gross motor functions and four on fine motor functions. Most of the studies assessed global domains of motor function. However, some measure components such as postural control, standing or walking. A description of all motor tests can be found in Table 4 , Section a. The two tests most frequently used to measure the two types of motor function are the GMFCS and the MACS. They are already partially explained in the introduction (1.1.5) and their classification system can be found in Appendix 2 to 4 respectively. View this table: View inline View popup Table 4 Explanation of the tests used 3.3.2 Cognitive measures Three articles measured executive functions and attention simultaneously, while eight others assessed only one of these two functions. Executive functions were reported in a total of eight studies and attention in six. In order to study executive function and attention, most of the articles tested the following components: working memory, cognitive flexibility and various types of attention (focused, selective, spatial, visual and verbal). Other research examines the global domains of these functions. A description of all the cognitive tests can be found in Table 4 , Section b. The test most regularly used to measure executive functions is the Wisconsin Card Sorting Test. In this test, the subject is given cards to sort according to an unknown rule. During the task, they have to recognise rule changes and adapt their approach accordingly ( Greve, 2001 ). For attentional functions, each article uses a different test. To determine the most commonly used measure in practice, a list was sent to a neonatologist at the CHUV, who mentioned the Conners-3 as the most widespread. This is a questionnaire completed by parents, based on observations of behaviour, school work and social life ( Conners et al., 2011 ). 3.4 Relationship between cognitive and motor functions The diversity of tests used to assess motor and cognitive control reflects the multiple approaches adopted to explore the relationship between these two domains ( Table 3 ). Although a brief summary of the approaches and results of each study is developed in the text below, the following trends can be observed: Eight articles explore executive functions, with three investigating their relationship with both gross and fine motor skills, four examining only gross motor functions, and one only fine motor functions. Positive relationships were found in five studies, while three did not find significant relationships ( Table 3 , Relationships). Six of the studies included explored attention all examining its link to gross motor skills. Five studies reported positive correlations, while only one found no evidence of links. The research included in this review is discussed in the following chapters, organising the results according to the age groups defined in Table 3 . The first category (under 4 years) includes one study, the second (4 to 18 years) contains nine studies and the last category (mixed ages) contains one study. For correlations, Pearson’s or Spearman’s coefficients are reported. 3.4.1 Children with CP under the age of 4 Surkar et al. (2015) examine whether the focused attention of children under 4 years of age with CP changes as their postural control in sitting improves. An initial GMFM Section B assessment of sitting ( Table 4 , GMFM) and focused attention is performed. Focused attention is determined by measuring the duration of periods of concentration on specific objects, using a video assessment ( Table 4 , Video assessment). The children then receive interventions over a period of 8 to 12 weeks, with varying approaches, but all aimed at improving seated postural control. At the end of the intervention period, the measures are reassessed. In their study, focused attention increased linearly as the child moved from supported to independent sitting. Surkar et al. (2015) assume that the independent sitting position allows the child to direct more resources towards exploring his environment and thus an increase in focused attention can be observed. 3.4.2 Children with CP aged 4 to 18 Nine articles examine executive and/or attentional functions in a population aged between 4 and 18 with CP. 3.4.2.1 Executive functions Seven studies analysed executive functions. Of these, two cross-sectional studies examined the influence of various factors on arithmetic. Arithmetic abilities include early skills such as understanding and using numbers or counting, as well as more advanced skills such as addition and subtraction ( Van Rooijen et al., 2016 ). Van Rooijen et al. (2012) examined the addition and subtraction skills of 7-year-olds, while Van Rooijen et al. (2016) focused on early arithmetic skills in 6-year-olds. In the latter study, they chose to investigate foundational skills, as more advanced arithmetic abilities build upon these ( Van Rooijen et al. 2016 ). The influencing factors studied were working memory, gross and fine motor functions ( Van Rooijen et al., 2012 ) and working memory and fine motor skills ( Van Rooijen et al. 2016 ). In both studies researchers gathered data from the sample population and then analysed the correlations between various factors to explore potential relationships. The results confirm significant links between working memory and fine motor skills ( Van Rooijen et al., 2012 , 2016) and between working memory and gross motor skills ( Van Rooijen et al., 2012 ). Both studies obtained similar results regarding the relationships between fine motor skills and working memory. Significant correlations, of moderate size, r = 0.41, p < 0.01 ( Van Rooijen et al., 2012 ) and r = 0.35, p < 0.01 ( Van Rooijen et al. 2016 ) are observed. Correlations between gross motor skills and working memory are also significant and moderate, with r = 0.40, p < 0.01 ( Van Rooijen et al., 2012 ). Forsman et Eliasson (2016) seek to describe, with a cross-sectional study, the motor and non-motor challenges faced by school-aged children with CP. The domains included are, among others, fine and gross motor skills, as well as executive functions. To assess these functions, they used a questionnaire providing information on general domains ( Table 4 , FTF Questionnaire). They found significant and moderate relationships between gross motor skills and executive functions ( r = 0.43, p < 0.01). In addition, significant and strong correlations were observed between fine motor skills and executive functions ( r = 0.70, p < 0.01). A non-randomised clinical study, conducted by Reilly et al. (2008) , analysed the effect of a dual task on postural control in children aged 10 to 14. A primary postural control task was performed simultaneously with a secondary task involving working memory. The children with CP showed both a lower working memory capacity and greater postural instability than the comparison group comprising only healthy individuals. In the dual task setting, the children with CP showed a reduction in postural stability, compared with performing the postural task alone. According to the authors, this relationship indicates strong links between working memory and postural control in children suffering from CP. Reilly et al. (2008) state that with the addition of a cognitive task, these children do not have sufficient capacity to allocate their resources to both tasks. This indicates that children with CP, aged between 10 and 14, have not developed their postural control to the same level as healthy children of the same age ( Reilly et al., 2008 ). Three studies found no evidence of correlations between executive and motor functions. In a cross-sectional study, Soriano et Hustad (2021) examined the relationships between non-verbal cognition, language comprehension, speech, executive function and fine and gross motor skills in children aged 10 to 12. Executive function is not broken down into its components but is measured in a general way using a questionnaire ( Table 4 , BRIEF). Motor skills were assessed using the GMFCS and MACS scales ( Table 4 , GMFCS, MACS). After data collection, correlation analyses were applied to all the factors included to determine interrelationships. This analysis revealed weak non-significant correlations between executive function and gross motor function ( r = 0.001, p > 0.05) and fine motor function ( r = 0.209, p > 0.05). The cohort study by Wotherspoon et al. (2023) assesses executive capacity and attention in school-age children with CP. Executive functions were assessed globally using a questionnaire completed by parents ( Table 4 , BRIEF). They then studied the impact of GMFCS level on these measures. The GMFCS level was not significantly associated with executive ability, as shown by the results of the multivariate analysis of covariance (MANCOVA) ( p = 0,81). Stadskleiv et al. (2018) conducted a cohort study to explore factors contributing to variability in cognitive functioning in children with CP aged 5-17 years. They investigate factors such as gross motor function, focused attention, working memory and cognitive flexibility. Working memory was assessed using the Leiter-R’s Backward Memory ( Table 4 , Leiter-R) and cognitive flexibility using the Wisconsin Card Sorting Test ( Table 4 , WCST). Motor functions were measured using the GMFCS ( Table 4 , GMFCS). The authors found that neither working memory ( p = 0,3) nor cognitive flexibility ( p = 0,66) varied with GMFCS level, as shown by the results of the analysis of variance (ANOVA). 3.4.2.2 Attentional functions The relationships between motor and attentional functions are explored in four studies. An observational study was conducted by Al-Nemr et Abdelazeim (2018), to better understand the relationships of selective attention with standing and walking abilities in children with CP aged 6-12 years. They separated the participants into three age groups (6 to 8 years, 8 to 10 years and 10 to 12 years) to analyse the development of these relationships through the individual’s growth. Selective attention was measured using the RehaCom system ( Table 4 , RehaCom Attention/ Concentration Program) and motor skills using sections D and E of the GMFM ( Table 4 , GMFM). The results reveal strong and significant correlations for the three age categories (6 to 8; 8 to 10; 10 to 12) between attention and standing ( r = 0.87, p < 0.01; r = 0.73, p < 0.01; r = 0.71, p < 0.01), as well as with walking ( r = 0.79, p < 0.01; r = 0.77, p < 0.01; r = 0.64, p < 0.01). This relationship remained constant for all three age groups, suggesting, according to the authors, stable links throughout childhood. In a cross-sectional study, Wang et al. (2020) studied children aged between 5 and 12 with unilateral CP. They explored the relationship between the use of the more affected hand in daily activities and asymmetry in spatial attention. By quantifying the differences in performance between the more and less affected sides, they demonstrated the presence of asymmetry in spatial attention in children with CP. They then carried out a correlation analysis to assess whether the asymmetry in spatial attention was linked to the use of the hand of the side more affected in daily activities. They found a significant and moderate to strong correlation of r = 0.50, p < 0.05. The researchers speculate that asymmetric development between the more and less affected limbs has a negative impact on the development of various domains, including cognitive domains. One example is the ability to direct and focus attention between the two sides of the visual field. The study by Stadskleiv et al. (2018) , already discussed in the previous chapter, also investigates the relationships between focused attention and GMFCS level in children with CP. Focused attention is measured using the Leiter-R Forward Memory ( Table 4 , Leiter-R). Using an ANOVA test, the authors found that focused attention varied significantly with GMFCS level ( p = 0.002). Only one study included in this review found no evidence of links between attention and motor skills. As described in the previous chapter, Wotherspoon et al. (2023) assessed executive functions and attention in school-age children with CP. Attentional functions were assessed globally using a questionnaire ( Table 4 , Conners-3). They then explored the impact of GMFCS level on attention. The GMFCS stage was not significantly associated with attention, as indicated by the MANCOVA results ( p = 0.089). 3.4.3 People with CP of mixed ages The article by Ballester-Plané et al. (2018) is the only one included in this review that studies a mixed-age population. The study population includes individuals with dyskinetic CP aged between 7 and 60 years. The aim of the study was to describe the cognitive profile, including verbal attention, working memory and cognitive flexibility, of individuals with CP. To do this, they considered motor severity as measured by the GMFCS. Their results show more severe impairments in working memory, cognitive flexibility and verbal attention when motor impairment increases. The authors hypothesise that this association between GMFCS and cognitive functioning can be explained by the severity of the brain injury. According to Ballester-Plané et al. (2018) , the literature associates greater brain injury not only with more severe motor problems, but also with greater cognitive impairment. 4. Discussion 4.1 Summary of main results This scoping review summarises what is currently known about the relationship between motor functions and executive and attentional cognitive control functions in people with CP. More specifically, the links between the specific components of these two domains. A total of 11 studies were analysed in this study. The population studied in all the articles included proved to be very heterogeneous. For example, substantial variations in CP type, age, GMFCS level and MACS level were observed. The majority of the studies in this review involve a paediatric population. This trend is probably attributable to early diagnosis in childhood ( Mendoza-Sengco et al., 2023 ). This leads to a predominantly paediatric representation in the population receiving therapies. Only one study included participants over the age of 18. There is also considerable heterogeneity in the measures of motor function and cognitive control. The tests most frequently used to measure motor skills are the GMFCS for gross motor skills and the MACS for fine motor skills. For executive functions, the Wisconsin Card Sorting Test is the most regularly used. However, attention is assessed differently in each integrated article. The relationships observed throughout this work are as follows. For executive functions, statistically significant relationships are shown in five studies. Working memory is significantly related to gross motor skills ( Ballester-Plané et al., 2018 ; Reilly et al., 2008 ; Van Rooijen et al., 2012 ) as well as fine motor skills ( Van Rooijen et al., 2012 , 2016). Cognitive flexibility is significantly correlated with gross motor skills ( Ballester-Plané et al., 2018 ). Furthermore, executive functions show, overall, significant relationships with gross and fine motor functions ( Forsman & Eliasson, 2016 ). Only three studies found no evidence of relationships between motor and executive domains ( Soriano & Hustad, 2021 ; Stadskleiv et al., 2018 ; Wotherspoon et al., 2023 ). Specifically, gross motor with general executive functions ( Soriano & Hustad, 2021 ; Wotherspoon et al., 2023 ), but also with the components of working memory and cognitive flexibility ( Stadskleiv et al., 2018 ). As well as fine motor skills with general executive functions ( Soriano & Hustad, 2021 ). Concerning attention, five studies found positive and statistically significant relationships with gross motor skills. This concerns links with focused attention ( Stadskleiv et al., 2018 ; Surkar et al., 2015 ), selective attention ( Al-Nemr & Abdelazeim, 2018 ), spatial attention ( Wang et al., 2020 ) and verbal attention ( Ballester-Plané et al., 2018 ). Only one study does not mention any relational evidence between attention, as a whole, and gross motor function ( Wotherspoon et al., 2023 ). Overall, the results suggest positive relationships between motor and executive/attentional functions. Motor domains and cognitive control abilities appear to interact during their development in people with CP. It is not clear from these results whether these are simultaneous or cascading phenomena. Experimental studies are still needed to understand the direction of the relationships between each component of motor and executive/attentional functions. The presence of relationships between motor and executive/attentional functions suggests that one domain may be influenced by the other. This seems important for the development of better management of the population with CP. 4.2 Comparison with the literature Positive relationships between motor function and cognitive control abilities have also been found in various populations (e.g. Fogel et al., 2023 ; Gandotra et al., 2021 ; Van der Fels et al., 2015 ; Van der Veer et al., 2024 ). In the following sections, the results for these populations will be discussed in more detail. 4.2.1 Population with typical development The results of this review are consistent with the established links between motor skills and executive functions in typical children (e.g. Bao et al., 2024 ; Gandotra et al., 2021 ; Van der Fels et al., 2015 ). In a systematic review, Gandotra et al. (2021) assess the specific associations between motor and executive functions and their components in typically developing children aged 3 to 12. They describe significant associations between the global domains of these two functions. In addition, fine motor functions are significantly correlated with all components of executive function (inhibition, working memory, cognitive flexibility) ( Gandotra et al., 2021 ). The systematic review and meta-analysis by Bao et al. (2024) summarises the associations between motor and executive skills in children aged 5 to 18. Their results show significant but weak associations between all motor (general motor skill, locomotion, object control, stability) and executive (inhibition, working memory and cognitive flexibility) components ( Bao et al., 2024 ). Furthermore, there is no indication that the strength of the relationships between these two domains differs significantly from childhood to adolescence. This suggests that these associations remain stable during this period ( Bao et al., 2024 ; Gandotra et al., 2021 ). Van der Fels et al. (2015) highlight, in a systematic review, insufficient evidence of the relationships between motor and executive functions in children aged 4 to 16. In particular between gross and fine motor skills and general executive skills as well as with working memory. This finding is contrary to trends observed throughout this work, however it is consistent with some included studies ( Soriano & Hustad, 2021 ; Stadskleiv et al., 2018 ; Wotherspoon et al., 2023 ). 4.2.2 Population with developmental coordination disorder In a systematic review, Fogel et al. (2023) examine the relationship between motor skills and executive functions in children with developmental coordination disorder. Their results show significant relationships between these two abilities, in particular for fine and gross motor skills with working memory ( Fogel et al., 2023 ). These findings are consistent with the results of several studies included in this work ( Ballester-Plané et al., 2018 ; Reilly et al., 2008 ; Van Rooijen et al., 2012 , 2016). 4.3 Strengths and limitations To the authors’ knowledge, this is the first study to systematically analyse the relationship between motor skills and executive and/or attentional functions in people with CP. It followed the guidelines described in the JBI manual for evidence synthesis ( Peters et al., 2020 ). This provided a systematic and transparent process for searching and selecting articles. Different study designs were included, reflecting the heterogeneity of the literature and ensuring that relevant literature in this field was not overlooked. Most of the studies (9/11) were published within the last decade, making the results of this work relevant to current knowledge. This scoping review improves our understanding of the relationship between motor skills and executive and/or attentional functions during CP. However, there are certain limitations to be considered when interpreting these results. To begin with, there is considerable heterogeneity among the 11 studies included. They used a wide variety of tests, making it difficult to compare and summarise the results. In addition, the population studied showed considerable variability across the studies, including factors such as age, type of CP or level of disability. For example, while some studies focused on a specific type of CP, others included different types. Consequently, the results do not apply to a specific sub-population of people with CP. Overall, the heterogeneity of the included studies limits the interpretation and generalisability of the results. In addition, only seven articles had as their main objective to examine the links between motor skills and executive/attentional functions. As a result, these links are not discussed in depth in these articles and few interpretations by the authors are provided. Finally, the lack of a control group in the articles also proves to be a limiting factor. Of the 11 studies included, only three incorporated typical children as a comparison group. 4.4 Implications 4.4.1 For research This review identifies gaps in research on the relationships between cognitive control functions and motor skills. Overall, for the population with CP, there appears to be a lack of studies systematically analysing these relationships. The reasons for this gap are described by several researchers. Firstly, Pereira et al. (2018) highlight the complexity of assessing attention and executive abilities due to the diversity of processes involved. In addition, motor and speech impairments complicate this assessment ( Soriano & Hustad, 2021 ; Stadskleiv et al., 2018 ). The diversity of people with CP also makes it difficult to set up studies on a homogeneous population ( Soriano & Hustad, 2021 ). The studies included in this review show a wide variety of assessment tools. To be able to compare the results of different studies, the measures used to assess people with CP need to be standardised. There is also considerable heterogeneity in the population included in the studies. CP manifests itself in different forms and displays a variety of symptoms, making it difficult to establish a homogenous sample ( Rethlefsen et al., 2010 ). However, to allow better interpretation and generalisation of results, research should include more uniform subjects. This is particularly necessary for the type of CP (spastic, dyskinetic, ataxic), age or severity of motor impairment. It would also be interesting to conduct more longitudinal studies to explore the effects of age on the links between motor functions and control skills. Finally, systematic reviews appear to be essential for quantifying the specific relationships between motor and executive/attentional functions. They thus provide a global understanding of these complex interactions. Systematic reviews offer higher quality evidence thanks to their rigorous methods, particularly those involving randomised controlled trials ( Wallace et al., 2022 ). To carry out systematic reviews, it would first seem essential to conduct more randomised controlled trials. 4.4.2 For practical use The presence of interactions between motor and cognitive factors has several clinical implications. In the past, research has focused mainly on motor performance in children with CP. However, the role of the cognitive aspect is now increasingly recognised and studied ( Wang et al., 2020 ). In order to establish a complete profile of people with CP, it is necessary to assess motor deficits and cognitive control ( Ballester-Plané et al., 2018 ). Children with severe motor impairments are not frequently assessed, which leads to an underestimation of their cognitive abilities ( Soriano & Hustad, 2021 ; Stadskleiv et al., 2018 ). Correctly characterising children’s abilities remains relevant in order to improve therapists’ understanding of how motor skills and cognitive control functions interact ( Surkar et al., 2015 ). Understanding the complex interrelationships between cognitive control functions and motor skills helps to develop appropriate intervention programmes ( Gandotra et al., 2021 ). The relationships between these factors support the idea that improvement in one area facilitates the development of the other ( Gandotra et al., 2021 ). Thus, motor interventions strengthen attentional/executive functions and improvements in cognitive control functions facilitate the subsequent development of more complex motor skills ( Babik et al., 2023 ; Surkar et al., 2015 ). 5. Conclusion This scoping review provides evidence of the interrelationships between motor function and executive and/or attentional abilities in people with CP. It is based on a systematic review of the existing literature. The aim of this study was to improve understanding of the relationship between these various functions for people with cerebral palsy. The results of this research suggest the presence of positive relationships between motor skills and executive and/or attentional skills. Significant links between global functions and between their components were observed. This work identifies gaps in research on the relationships between cognitive control functions and motor skills in people with CP. It highlights the need for further systematic reviews to specifically quantify the relationships between the components of motor and executive/attentional functions. This would provide a comprehensive understanding of these complex interactions. To carry out these systematic reviews, more randomised controlled trials are still needed. Relationships between motor factors and cognitive control skills are also of practical interest. They suggest that interventions in one area can promote the development of the second. This makes it possible to provide appropriate care, with relevant and achievable treatment goals. 6. Conflicts of interest For this work, we affirm that there is no known conflict of interest. Furthermore, no financial support was received. This had no influence on the results. Data Availability This is a systematic review paper and as such the paper did not produce original data that could be shared. 8. Supplementary material View this table: View inline View popup Appendix 1: Research equation View this table: View inline View popup Download powerpoint Appendix 2: Motor Function Classification System (GMFCS) - 6 to 12 years View this table: View inline View popup Download powerpoint Appendix 3: Gross Motor Function Classification System (GMFCS) - 12 to 18 years Download figure Open in new tab Download figure Open in new tab Appendix 4: Manual Ability Classification System (MACS) Acknowledgements This study is based on work submitted in June 2024 by MM and KR for a Bachelor’s degree in Physiotherapy at the Physiotherapy Section of School of Health Sciences, HES-SO Valais, under the direction of PJM. This project was conducted as part of a collaboration conducted with JS. The authors have no funding sources to report. List of abbreviations ANOVA Analysis of Variance/analyse de variance AWMA Automated Working Memory Assessment BRIEF Behaviour Rating Inventory of Executive Function CHUV Centre hospitalier universitaire vaudois F Female FTF Five-to-Fifteen GMFCS Gross Motor Function Classification System GMFM Gross Motor Function Measure m Male JBI Joanna Briggs Institute m Month MACS Manual Ability Classification System MANCOVA Multivariate analysis of covariance/analyse multivariée de la covariance n Number (of participants or studies) N/A Not available OTCPDD Observatory Test of Capacity, Performance, and Developmental Disregard CP Cerebral palsy RVDST Random Visual Stimuli Detection Task SCPE Surveillance of Cerebral Palsy in Europe SD Standard deviation ADHD Attention deficit hyperactivity disorder WAIS Wechsler Adult Intelligence Scale WCST Wisconsin Card Sorting Test WISC Wechsler Intelligence Scale for Children WNV Wechsler Nonverbal Scale y Year 7. 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Share The link between motor disorders and executive or attentional cognitive disorders in people with cerebral palsy: Scoping review Melinda Martinet , Kathrin Reichert , Juliane Schneider , Pawel J. Matusz medRxiv 2025.01.26.25321141; doi: https://doi.org/10.1101/2025.01.26.25321141 Share This Article: Copy Citation Tools The link between motor disorders and executive or attentional cognitive disorders in people with cerebral palsy: Scoping review Melinda Martinet , Kathrin Reichert , Juliane Schneider , Pawel J. 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