cerebral palsy ( cp ) is a chronic , non - progressive clinical disease characterised by 
 movement and posture impairments in children which is associated with permanent brain damage 
 occurring in the perinatal or natal period1 . the patient may be affected by motor , tonus and posture disorders 
 as well as a wide spectrum of problems associated with cerebral dysfunction such as learning 
 difficulties , autonomic dysfunction , epilepsy , mental retardation , and sight and hearing 
 problems2 . the prevalence of cp in 
 turkey has been stated as 4.4 per 1,000 live births3 . the most frequently seen type of cp in the turkish population is diplegic cp , and in 71.6% 
 of these cases there is a history of prematurity3 . spastic diplegia may be seen in both term and pre - term infants . in 
 pre - term diplegic lower extremity involvement is more evident and patients have relatively 
 better hand functions . according to the severity of the effect , advanced function loss in 
 the upper extremity may be associated with the degree of spasticity , the presence of 
 contracture , sensory loss or mental level4 . , it has been reported that ophthalmological 
 problems occur more often in diplegic type spastic cp6,7,8 . refractive errors and strabismus are the most often seen 
 ophthalmological problems in cp5,6,7 . in a study 
 evaluating the relationship between cp etiology and ocular and visual diseases , it was 
 reported that particularly for patients with diplegic and triplegic cp with positive 
 neuroradiological findings together with pre - term patients with low birth - weight , there is a 
 need for an ophthalmological examination as early as possible9 . in a study which evaluated the hand functions using the manual ability classification 
 system ( macs ) and the bimanual fine motor function ( bfmf ) scale , and the severity of cp with 
 the gross motor function classification system ( gmfcs ) , it was reported that in the 
 evaluation of the hand functions of children with cp , the macs and bfmf scales are 
 consistent with each other and with the gmfcs10 . ocular diseases which develop in cp patients and the developmental 
 level can affect the functional level and quality of life of the patient . to the best of our 
 knowledge , there is no study in the literature which has researched the relationship of 
 ocular diseases or developmental level with upper extremity functions , daily living 
 activities and quality of life of diplegic cp patients . therefore this study aimed to 
 evaluate the relationships among visual loss and developmental level , and upper extremity 
 functions , daily living activities and quality of life . the study group consisted of children with spastic cp who were admitted to the physical 
 medicine and rehabilitation clinic between november 2013 and february 2014 . the children 
 included in the study were aged 415 years and were diagnosed with diplegic cp according to 
 the swedish classification11 . patients 
 with genetic or metabolic disease and those with a progressive neurological disease were 
 excluded from the study . approval for the study was granted by the institutional ethics 
 committee of harran university , and written informed consent was obtained from all the 
 parents of the patients . for the determination of the developmental levels and mental capabilities of the children 
 with cp , the ankara developmental screening inventory ( adsi ) , which has been tested for 
 validity and reliability in turkey , was used12,13,14 . the adsi is a scale which can be used to assess children aged 06 years to evaluate their 
 communication - cognitive ( cc ) , fine motor ( fm ) , gross motor ( gm ) , social skills - self care 
 ( ss - sc ) and general development ( gd ) domains . the inventory consists of 154 items which are 
 answered by the mothers , and responses are given as yes ,  no , or  do nt know. the total 
 score of the test reflects a subject s general developmental level . those with an average 
 two standard deviations below the norm are evaluated as developmentally retarded12 . children over 6  years of age were evaluated with the mental development wisc - r test . for 
 children who could not be evaluated by the age - appropriate test as they were developmentally 
 aged below 6  years , even though their chronological age was over 6  years refraction errors , fundus examination , slit - lamp biomicroscopic 
 examination , intraocular pressure measurement and oculomotor examinations were conducted . compliance with the tests could not be achieved by any patient in assessment of visual 
 acuity . it is 
 separated into 5 levels based on gross motor functions such as starting movements by 
 oneself , sitting and walking . at level i , in mobility within the community v , mobility is totally dependent , even with the use of assistive 
 aids15 . hand functions of children with cp while they are holding objects in daily living 
 activities were evaluated using the macs scale . , the patient can easily and successfully hold the 
 objects . at level v , an object can not be held by the subject who has severely limited 
 capability for any activity16 . , one hand can be used without any restriction and there is restriction in the fine motor 
 skills of the other hand . at level v , each hand can only hold at best17 . the functional independence measure of children ( weefim ) consists of 6 sub - categories . there are a total of 18 items : 6 items of self - care , 2 items of sphincter control , 3 items 
 of transfer , 2 items of locomotion , 2 items of communication and 3 items of social 
 cognition . each item is scored from 1 to 7 , with 1 indicating full help and 7 indicating 
 full independence . the total score can range from a minimum of 18 to a maximum of 12618 . the paediatric quality of life scale ( pedsql ) is a quality of life scale developed by varni 
 et al . to measure the quality of life of chidren and adolescents aged 218 years19 . the areas of physical health , emotional 
 functionality and social functionality are surveyed as the characteristics of health status 
 defined by the world health organisation . first , the total points ( mtp ) , then the physical health 
 total ( phtp ) , and finally the psychosocial health ( pshtp ) are calculated from the item 
 scores evaluating emotional , social and school functionality20 . the pedsql is a quality of life scale consisting of 23 items which 
 is suitable for use for the general population , such as in schools or hospitals , for both 
 healthy and sick children and adolescents . the items are scored between 0100 . a response of 
 never scores 100 , rarely 75 , sometimes 50 , often 25 and always , 0 . the higher the total 
 score in the pedsql , the better the quality of life is perceived in relation to health20 . important properties of the pedsql are 
 that it is short and can be completed in 510 minutes , it can be conducted by a researcher 
 and the scoring is easy20 , 21 . in the current study , previous studies have been demonsrated on the validity and reliability of 
 the turkish version of pedsql for the 218 years age group22,23,24 . statistical analyses were carried out using spss 18.0 for windows ( pasw statistics for 
 windows , spss inc . , all demographic and quantitative data are 
 expressed as mean  standard deviation ( sd ) . differences with p values < 0.05 were 
 considered statistically significant and all results are expressed with a 95% confidence 
 interval . the overall agreement between each gmfcs , macs and bfmf values kappa values of < 0.20 show poor agreement , 0.210.40 fair , 
 0.410.60 moderate , 0.610.80 good , and > 0.80 very good agreement25 , 26 . the study included 32 patients , 16 males and 16 females with a mean age of 90.5031.60 
 months ( range , 50172 months ) . five ( 15.6% ) of the patients were pre - term and 27 ( 84.4% ) 
 were term . six ( 18.8% ) of the patients had a low birth - weight , 10 ( 32.3% ) had epilepsy and 
 14 ( 43.8% ) had a history of anoxia . twenty - two ( 68.8% ) patients were delivered by the normal 
 vaginal route , and 10 ( 31.3% ) by caesarian section . the mean time of cp diagnosis was 
 12.969.41 months and the mean time to starting rehabilitation was 21.9319.16 months . weefim , pedsql scores , developmental evaluation , and the distribution of patients according 
 to gmfcs , bfmf and macs are shown in table 
 1table 1.clinical characteristics of the patientscharacteristic total , n=32n ( % ) developmental evaluationnormal14 ( 43.8)retarded 18 ( 56.3)weefim total score , mean ( sd)77.8745.05child form of pedsql , mean ( sd)pedsql total score 40.2533.96pedsql physical score40.4033.25pedsql psychosocial score 40.4135.39parent form of pedsql , mean ( sd)pedsql total score43.4431.51pedsql physical score38.8333.48pedsql psychosocial score45.2231.89gmfcs , levels116 ( 50)25 ( 15.6)31 ( 3.1)49 ( 28.1)51 ( 3.1)macs , levels110 ( 31.3)218 ( 56.3)32 ( 6.3)41 ( 3.1)51 ( 3.1)bfmf , levels118 ( 56.3)28 ( 25)33 ( 9.4)42 ( 6.3)51 ( 3.1)bfmf : bimanual fine motor function , gmfcs : gross motor function classification 
 system , macs : manual ability classification system , pedsql : paediatric quality of life 
 scale , weefim : the functional independence measure of children . bfmf : bimanual fine motor function , gmfcs : gross motor function classification 
 system , macs : manual ability classification system , pedsql : paediatric quality of life 
 scale , weefim : the functional independence measure of children developmental evaluation of 25 ( 78.1% ) patients was made using the adsi . of these 12 ( 48% ) 
 were aged below 6  years and 13 ( 52% ) could not perform the age - appropriate test even though 
 they were aged over 6  years . the distribution of the patients according to the adsi test is 
 shown in table 2table 2.distribution of the patients according to the adsi testtotal , n=25 adsi - gdadsi - ccadsi - fmadsi - gmadsi - scnormal , n ( % ) 10 ( 40)12 ( 48)9 ( 36)5 ( 20)12 ( 48)retarded , n ( % ) 15 ( 60)13 ( 52)16 ( 64)20 ( 80)13 ( 52)adsi : ankara developmental screening inventory , gd : general development , cc : 
 communication - cognitive , fm : fine motor , gm : gross motor , sc : social 
 skills - self - care . of the 7 ( 21.9% ) patients assessed using the wisc - r , 3 were evaluated as 
 retarded general development and 4 as normal development . gd : general development , cc : 
 communication - cognitive , fm : fine motor , gm : gross motor , sc : social 
 skills - self - care in the ophthalmology examination , biomicroscopy of 31 ( 96.9% ) patients was normal . in 1 
 ( 3.1% ) patient , bilateral aphakia and micro cornea were determined . bilateral mixed type 
 astigmatism was determined in 2 ( 6.3% ) patients and glaucomatous optic atrophy in 2 ( 6.3% ) 
 patients . the findings of the ophthalmology examinations are shown in table 3table 3.findings of the ophthalmology examinationsophthalmological findingstotal , n=32n ( % ) biomicroscopic examination normal31 ( 96.9)bilateral aphakia1 ( 3.1)fundus examination normal25 ( 78.1)unilateral optic atrophy2 ( 6.3)bilateral optic atrophy 3 ( 9.4)glaucomatous optic atrophy2 ( 6.3)strabismusexotropia4 ( 12.5)esotropia 1 ( 3.1)refraction errorsnormal30 ( 93.8)mixed type astigmatism2 ( 6.3)right eye intraocular pressure , meansd ( range ) , mmhg15.653.37 ( 1130)left eye intraocular pressure , meansd ( range ) , mmhg15.813.45 ( 1131 ) . a significant positive correlation was determined between the gmfcs and bfmf scores 
 ( r=0.636 , p<0.001 ) . the kappa value was calculated and the overall agreement between the 
 gmfcs and bfmf was fair ( kappa value=0.288 ) ( table 
 4table 4.distribution of gmfcs and bfmf levelsgmfcs levelsbfmf levels12345total113 ( 40.6)3 ( 9.4)---16 ( 50)23 ( 9.4)2 ( 6.3)---5 ( 15.6)3 - -1 ( 3.1 ) --1 ( 3.1)42 ( 6.3)3 ( 9.4)2 ( 6.3)1 ( 3.1)1 ( 3.1)9 ( 28.1)5 - --1 ( 3.1)-1 ( 3.1)total18 ( 56.3)8 ( 25)3 ( 9.4)2 ( 6.3)1 ( 3.1)32 ( 100)kappa : 0.288 p=0.004 . bfmf : bimanual fine motor function , gmfcs : gross motor function 
 classification system ) . bfmf : bimanual fine motor function , gmfcs : gross motor function 
 classification system a significant positive correlation was determined between the gmfcs and macs scores 
 ( r=0.553 , p=0.001 ) . the kappa value was calculated and the overall agreement between the 
 gmfcs and macs was fair ( kappa value=0.202 ) ( table 
 5table 5.distribution of gmfcs and macs levelsgmfcs levelsmacs levels12345total18 ( 25)8 ( 25)---16 ( 50)22 ( 6.3)3 ( 9.4)---5 ( 15.6)3 - -1 ( 3.1)--1 ( 3.1)4 - 6 ( 18.8)1 ( 3.1)1 ( 3.1)1 ( 3.1)9 ( 28.1)5 - 1 ( 3.1)---1 ( 3.1)total10 ( 31.3)18 ( 56.3)2 ( 6.3)1 ( 3.1)1 ( 3.1)32 ( 100)kappa=0.202 p=0.018 . gmfcs : gross motor function classification system , macs : manual 
 ability classification system ) . gmfcs : gross motor function classification system , macs : manual 
 ability classification system a significant positive correlation was determined between the macs and bfmf scores 
 ( r=0.718 , p<0.001 ) . the kappa value was calculated and the overall agreement between the 
 macs and bfmf was moderate ( kappa value=0.537 ) ( table 
 6table 6.distribution of bfmf and macs levelsbfmf levelsmacs levels12345total110 ( 31.3)8 ( 25)---18 ( 56.3)2 - 8 ( 25)---8 ( 25)3 - 1 ( 3.1)2 ( 6.3)--3 ( 9.4)4 - 1 ( 3.1)-1 ( 3.1)-2 ( 6.3)5 - ---1 ( 3.1)1 ( 3.1)total10 ( 31.3)18 ( 56.3)2 ( 6.3)1 ( 3.1)1 ( 3.1)32 ( 100)kappa= 0.537 p<0.001 . bfmf : bimanual fine motor function , macs : manual ability 
 classification system ) . bfmf : bimanual fine motor function , macs : manual ability 
 classification system the relationships between ocular and oculomotor disorders , gmfcs , bfmf and macs and daily 
 life activities and quality of life are shown in table 
 7table 7.correlation among oculomotor disorders , gmfcs , bfmf and macs , weefim and quality 
 of lifetotal cases ( n=32)weefimpedsql - mtp - cfpedsql - phtp - cfpedsql - pshtp - cfpedsql - mtp - pfpedsql - phtp - pfpedsql - pshtp - gmfcs0.802**0.788**0.836**0.789**0.788**0.844**0.710**bfmf0.769**0.693**0.661**0.685**0.729**0.712**0.668**macs0.765**0.806**0.715**0.803**0.864**0.765**0.859**fundus pathology0.1280.0080.0790.0500.1390.1090.156strabismus0.2200.2970.3120.2840.1910.3000.168**correlation is significant at the 0.01 level ( two - tailed ) . bfmf : bimanual fine 
 motor function , cf : child form , macs : manual ability classification system , gmfcs : 
 gross motor function classification system , mtp : measured total points , pf : parent 
 form , pedsql : paediatric quality of life scale , phtp : physical health total points , 
 pshtp : psychosocial health total points . the relationships between general development , adsi evaluation , ocular and 
 oculomotor disorders , gmfcs , bfmf and macs and daily living activities and quality of life 
 are shown in table 8table 8.correlation of the developmental level with oculomotor disorders , gmfcs , bfmf , 
 macs , weefim and quality of life scoresadsi - gdn=25adsi - ccn=25adsi - fmn=25adsi - gmn=25adsi - scn=25generaldevelopmentn=32gmfcs0.612**0.756**0.556**0.2620.756**0.518**bfmf0.675**0.590**0.726**0.2010.590**0.646**macs0.490 * 0.468 * 0.507**0.3000.468 * 0.537**weefim0.700**0.720**0.691**0.2790.764**0.645**pedsql- mtp - cf0.645**0.791**0.552**0.2960.762**0.669**pedsql- phtp -cf0.597**0.768**0.503**0.2130.711**0.631**pedsql- pshtp -cf0.632**0.802**0.562**0.2410.768**0.679**pedsql- mtp - pf0.691**0.789**0.659**0.2640.756**0.710**pedsql- phtp -pf0.743**0.838**0.657**0.2150.786**0.754**pedsql- pshtp -pf0.573**0.695**0.642**0.2360.651**0.629**fundus pathology0.1340.2010.3270.0550.2010.010strabismus0.0000.0800.0420.0000.0800.033**correlation is significant at the 0.01 level ( two - tailed ) . adsi : ankara 
 developmental screening inventory , bfmf : bimanual fine motor function , cc : 
 communication - cognitive , cf : child form , fm : fine motor , gd : general development , gm : 
 gross motor , gmfcs : gross motor function classification system , macs : manual ability 
 classification system , mtp : measured total points , pf : parent form , pedsql : paediatric 
 quality of life scale , phtp : physical health total points , pshtp : psychosocial health 
 total points , sc : social skills - self - care . bfmf : bimanual fine 
 motor function , cf : child form , macs : manual ability classification system , gmfcs : 
 gross motor function classification system , mtp : measured total points , pf : parent 
 form , pedsql : paediatric quality of life scale , phtp : physical health total points , 
 pshtp : psychosocial health total points * * correlation is significant at the 0.01 level ( two - tailed ) . adsi : ankara 
 developmental screening inventory , bfmf : bimanual fine motor function , cc : 
 communication - cognitive , cf : child form , fm : fine motor , gd : general development , gm : 
 gross motor , gmfcs : gross motor function classification system , macs : manual ability 
 classification system , mtp : measured total points , pf : parent form , pedsql : paediatric 
 quality of life scale , phtp : physical health total points , pshtp : psychosocial health 
 total points , sc : social skills - self - care this study found a significant relationship between developmental retardation in cp 
 patients and disease severity , hand functions , daily living activities and quality of life . we also determined that macs and bfmf conform with each other and with the severity of cp , 
 and that as cp severity increases , hand skills worsen . it has been reported that bfmf is used more to define disability and macs to evaluate 
 activity although it is stated that it is difficult to compare these two scales26 . another study reported a strong positive 
 correlation between bfmf and macs with good overall agreement10 . in the present study the overall agreement between macs and bfmf was moderate . in 
 addition , a strong correlation was found between gmfcs and bfmf , and gmfcs and macs . the 
 overall agreement was fair , a result that is consistent with previous studies10 , 26 , 27 . although the corrrelations between the 
 scales were high , the reason for low overall agreement , which was calculated using the kappa 
 statistic , is that the kappa statistic is a method which is actually used in the evaluation 
 of the same scale by two different researchers . for the evaluation of the agreement of two 
 different scales , using there is a lower rate of upper extremity involvement in 
 children with cp , so the low agreement found by the present study could be due to the 
 evaluation of only diplegic cp children . in the present study , a significant relationship was shown between all the subscales of the 
 weefim and pedsql scales with each of the gmfcs , macs and bfmf scales . in a study which 
 evaluated the relationships between weefim and gmfcs and macs in spastic cp patients , 
 significant correlations were determined between the latter two scales and weefim , similar 
 to the results of our present27 . as an 
 explanation for these results , we consider that as cp severity increases , hand functions are 
 impaired with deteriorations in daily living activities and quality of life . the visual process is a complex cerebral activity which involves a large part of the 
 central nervous system28 . it can be 
 considered , therefore that visual deficits are often seen in the neurodevelopmental 
 disabilities which are observed in cp . in cp patients with hypoxic ischaemia encephalopathy , 
 not only the motor pathways , but fundus pathologies associated with the trans - synaptic 
 degeneration mechanism may develop in such patients30 . in support of this view , a mri study of cp children with visual 
 problems showed trans - synaptic degeneration of the lateral geniculate body31 . studies have also shown there is a 
 relationship between the severity of visual sensory problems in children with cp and mental 
 motor deficits6 , 8 , 32 . therefore , early 
 referral of cp children to an ophthalmologist can be an important factor in increasing 
 mental and motor capacity . in the present study , fundus pathology was determined in 21.9% , 
 strabismus in 15.6% and refractive error in 6.3% of patients . however , no significant 
 correlations were determined between the functional status , quality of life and 
 developmental level of cp patients with fundus pathology or strabismus . cerebral visual 
 impairment is defined as the involvement of the retrogeniculate pathways in symptoms such as 
 reduced visual field and visual acuity . it has been determined in 6070% of children with 
 cp33 . in the present study , cerebral 
 visual impairment in children with cp therefore , a significant 
 corrrelation may not have been revealed between oculomotor dysfunction and functional 
 status , quality of life and developmental level in children without oculomotor dysfunction 
 who may have visual problems . in the present study , significant correlations were determined between general 
 developmental level and the functional status and quality of life of the children . in 
 children evaluated with the adsi , significant relationships were also determined between 
 functional status and quality of life and all the subscales of adsi except the adsi - gm 
 subscale . therefore , when there is a poor functional status in children with good general 
 development and high capacity expectations , motivational factors can be considered to be 
 exerting an effect and different treatment strategies should be defined . limitations of the present study were the inclusion of only diplegic type spastic cp 
 patients , and the lack of evaluation of cerebral visual impairment , visuocognitive 
 dysfunction or visuoperceptual diseases in the ophthalmology examination . in conclusion , gmfcs , macs and bfmf can be useful in the determination of the functional 
 status of children with cp as they are easy , practical and simple classification scales 
 which are consistent with each other . ophthalmological examination of children with cp in 
 the early period and early treatment strategies may enhance the possibility of increasing 
 the mental and motor development of these children . however , there is a need for further 
 larger studies with detailed neuro - ophthalmological evaluation including cp patients with 
 different clinical characteristics .
[ purpose ] the aim of this study was to evaluate the relationships among vision problems , 
 developmental levels , upper extremity functions , and qualities of life of children with 
 cerebral palsy ( cp ) . [ subjects ] the study included 32 children , aged 415 years , diagnosed 
 with diplegic type cp . 
 [ methods ] hand function was evaluated using the manual ability 
 classification system ( macs ) and the bimanual fine motor function ( bfmf ) scale , and the 
 severity of cp was assessed using the gross motor function classification system ( gmfcs ) . 
 the developmental and mental capabilities of the children were evaluated using the ankara 
 developmental screening inventory ( adsi ) or the wisc - r test . 
 an oculomotor examination was 
 conducted for all patients . 
 [ results ] positive correlations were found between gmfcs and 
 bfmf , gmfcs and macs , and macs and bfmf scores ( r=0.636 ; r=0.553 ; r=0.718 , respectively ) . 
 significant correlations were found between upper extremity function , the severity of cp , 
 the quality of life , and the general developmental level . 
 there was no significant 
 correlation between ocular disorders and clinical characteristics . 
 [ conclusion ] gmfcs , 
 macs , and bfmf may be useful for defining the functional status of children with cp , as 
 they are easy , practical , and simple classification scales that conform to each other .