children with cp experience limitations in 
 their daily activities due to abnormal muscle tone , involuntary movement , unsteady gait , 
 problems with balance , and poor social functioning2 . this decreased functioning limits the ability of children with cp 
 to participate in various activities . school - aged children with cp have social and academic 
 difficulties because they have perhaps half the physical strength of normal children , which 
 limits their ability to fully mix with their peer group3 . the gross motor function measure ( gmfm ) is commonly used to assess patients with cp . the 
 gmfm is a standardized observational instrument designed and validated to measure changes in 
 gross motor function over time in children with cp4 . the world health organization ( who ) developed the international classification of 
 functioning , disability and health ( icf ) as a classification of health and health - related 
 components of well - being , including physical function and structure , activity and 
 participation , environmental factors , and personal factors . the icf child and youth 
 version ( icf - cy ) is an extended version of the icf that includes child development as an 
 additional health and health - related component . the manual ability classification system ( macs ) , which is based on the icf , is designed to 
 classify children with cp according to the extent of their ability to use their hands and 
 manipulate objects in daily activities . the macs designates 5 levels of manual function ; the 
 lowest level ( level i ) corresponds to the ability to easily handle objects , and the highest 
 level ( level v ) indicates severe restrictions in handling objects6 . therefore , the purpose of this study was to assess the functioning , activity , and 
 participation of school - aged children with cp using the icf - cy , macs , and gmfm and thereby 
 provide physical therapists , occupational therapists , patients , and families with an 
 understanding of the current functional abilities of these children and basic data for 
 establishing interventions and treatment goals . the subjects of this study were 57 school - aged children ( between 7 and 12  years old ) who 
 were diagnosed with cp and were receiving physical therapy . the specific selection criteria 
 were as follows : no orthopedic surgery within the last 6 months and no botulin or baclofen 
 treatments of the lower limbs during the previous 3 months . the present study was approved by the sahmyook university 
 institutional review board ( syuirb2012 - 021 ) . the objective of the study and its requirements 
 were explained to the subjects and their parents , and the parents of all subjects provided 
 written consent for their child to participate . the subjects were 40 males ( 70.2% ) and 17 
 females ( 29.8% ) with a mean age of 114.4 ( 18.5 ) months , a mean height of 126.6 ( 13.4 ) cm , 
 and a mean weight of 26.1 ( 7.4 )  kg . among the subjects , the type of cp was spastic in 48 
 ( 48.2% ) , the limb distribution of cp ( n = 48 ) 
 was quadriplegic in 13 ( 27.1% ) , diplegic in 24 ( 50.0% ) , and hemiplegic in 11 ( 22.9% ) . the macs can be used to describe how well children with cp use their hands to handle 
 objects during activities of daily living . the macs is effective for children between 4 and 
 18  years of age and classifies children into 5 levels of manual function . each level is 
 divided into the following categories : ability to handle objects alone in daily living , 
 degree of required assistance , and ability to adapt to perform manual activities . the macs 
 is used as an assessment of the ability to handle objects , the need for adaptation , and the 
 degree of assistance required to perform movement tasks6 , 9 . the gmfm is divided into 5 domains : a 
 ( lying and rolling ) , b ( sitting ) , c ( quadruped and kneeling ) , d ( standing ) , and e ( walking , 
 running , and jumping)10 . it contains 88 
 items , and scores for each section are summed and divided by 5 to obtain a total score . this 
 measure is used to provide overall standards for the gross motor functioning of subjects by 
 evaluating their abilities rather than specific performance parameters4 . the gmfm possesses good intra - rater 
 ( r=0.77 , r=0.88 ) and inter - rater 
 ( r=0.68)11 . the icf - cy checklist is a summary of the core sections of the icf - cy and is used to 
 evaluate disability and health conditions in children and youth . the present study reports 
 only the data for body function , activity , and participation from the formative factors of 
 the icf - cy for the ages of 712 years given the age of the subjects and the purpose of the 
 study . eight areas of bodily function were evaluated : mental function ; sensory function and 
 pain ; voice and speech function ; functions of the cardiovascular , hematological , 
 immunological , and respiratory systems ; functions of the digestive , metabolic , and endocrine 
 systems ; genitourinary and reproductive functions ; neuromusculoskeletal and movement - related 
 functions ; and functions of the skin and related structures . the following nine areas were 
 included in the evaluation of activity and participation : learning and application of 
 knowledge ; general tasks and demands ; communication ; mobility ; self - care ; domestic life ; 
 interpersonal interactions and relationships ; major life areas ; and community , social , and 
 civic life12 . each section was scored 
 from 0 , indicating no difficulty in performance , to 4 , indicating a need for full 
 assistance . the general 
 characteristics are presented as frequencies and percentages , with average and standard 
 deviations also provided . a one - way anova was performed to assess the effect of macs level 
 on gmfm scores and the effects of function , activity , and participation scores from the 
 icf - cy . a post hoc test using scheffe s method was employed to compare each group , and the 
 significance threshold was set to p < 0.05 . a comparison of gmfm scores in the subjects by macs level is presented in table 1table 1.comparison of gmfm scores in the subjects according to macs level ( n=57)categoriestypengmfm score(%)f(p)post hocmacs leveli1592.6 ( 7.3)45.896 ( 0.000 ) i / iii / iv , vii1481.9 ( 17.5)iii1460.9 ( 21.7)iv827.3 ( 11.0)v613.8 ( 9.1)macs : manual ability classification system , gmfm : gross motor function measure . a 
 comparison of the icf - cy checklist functions by macs level is presented in table 2table 2.comparison of function list of icf - cy in the subjects according to macs level 
 ( n=57)macscodelevel i ( a)(n=15)level ii ( b)(n=14)level iii ( c)(n=14)level iv ( d)(n=8)level v ( e)(n=6)f ( p)post hocb13.3 ( 2.4)4.8 ( 2.8)5.57 ( 4.9)11.3 ( 5.7)17.5 ( 3.5)18.531 ( 0.000)a , b , c|d|eb21.0 ( 1.7)1.6 ( 2.0)1.9 ( 2.0)2.6 ( 2.3)6.0 ( 0.9)8.202 ( 0.000)a , b , c , d|eb30.3 ( 0.7)0.6 ( 0.8)0.9 ( 1.4)1.5 ( 1.6)3.7 ( 0.5)11.763 ( 0.000)a , b , c , d|eb40.6 ( 1.4)0.7 ( 0.9)1.1 ( 2.4)0.8 ( 1.4)1.3 ( 1.2)0.330 ( 0.856)b50.5 ( 1.0)0.8 ( 1.5)0.6 ( 1.3)0.3 ( 0.5)6.2 ( 2.3)23.408 ( 0.000)a , b , c , d|eb60.1 ( 0.4)0.2 ( 0.6)0.3 ( 0.6)0.0 ( 0.0)1.7 ( 1.6)6.631 ( 0.000)a , b , c , d|eb79.6 ( 4.8)10.2 ( 5.1)13.8 ( 6.9)20.9 ( 8.0)15.5 ( 6.1)5.632 ( 0.001)a , b|db80.1 ( 0.4)0.4 ( 0.7)0.4 ( 0.6)0.3 ( 0.5)0.7 ( 1.0)0.986 ( 0.423)total15.7 ( 8.3)19.4 ( 8.3)24.4 ( 12.0)37.5 ( 12.7)52.5 ( 11.3)17.755 ( 0.000)a , b|d|evalues are means ( sd ) . macs : manual ability classification system ; b1 , mental 
 function ; b2 , sensory functions and pain ; b3 , voice and speech functions ; b4 , 
 functions of the cardiovascular , hematological , immunological , and respiratory 
 systems ; b5 , functions of the digestive , metabolic , and endocrine systems ; b6 , 
 genitourinary and reproductive functions ; b7 , neuromusculoskeletal and movement- 
 related functions ; b8 , functions of the skin , and related structures . the results indicated significant differences by macs level in mental 
 functions ( b1 ) ; sensory function and pain ( b2 ) ; voice and speech functions ( b3 ) ; functions 
 of the digestive , metabolic and endocrine systems ( b5 ) ; genitourinary and reproductive 
 functions ( b6 ) ; and neuromusculoskeletal and movement - related functions ( b7 ) . however , 
 functions of the cardiovascular , hematological , immunological , and respiratory systems ( b4 ) 
 and the functions of the skin and related structures ( b8 ) were not significantly different 
 across macs levels . macs : manual ability classification system , gmfm : gross motor function measure values are means ( sd ) . macs : manual ability classification system ; b1 , mental 
 function ; b2 , sensory functions and pain ; b3 , voice and speech functions ; b4 , 
 functions of the cardiovascular , hematological , immunological , and respiratory 
 systems ; b5 , functions of the digestive , metabolic , and endocrine systems ; b6 , 
 genitourinary and reproductive functions ; b7 , neuromusculoskeletal and movement- 
 related functions ; b8 , functions of the skin , and related structures a comparison of the activity and participation data from the icf - cy checklist by macs level 
 is presented in table 3table 3.comparison of activity and participation list of icf - cy in the subjects according 
 to macs level ( n=57)macscodelevel i ( a)(n=15)level ii ( b)(n=14)level iii ( c)(n=14)level iv ( d)(n=8)level v ( e)(n=6)f ( p)post hocd12.9 ( 3.9)7.9 ( 5.6)9.8 ( 9.9)18.4 ( 8.8)26.2 ( 2.4)15.523 ( 0.000)a , b|ed21.4 ( 1.8)2.7 ( 3.0)4.3 ( 4.3)10.4 ( 6.1)15.3 ( 1.0)22.401 ( 0.000)a , b , c|d , ed31.1 ( 2.6)4.2 ( 4.1)5.4 ( 6.7)10.0 ( 6.4)18.5 ( 2.1)15.964 ( 0.000)a|d|ed44.0 ( 2.5)9.4 ( 5.2)11.6 ( 6.2)21.3 ( 2.8)20.0 ( 4.9)24.725 ( 0.000)a|c|d , ed52.7 ( 3.1)5.8 ( 4.0)9.2 ( 5.5)16.5 ( 3.5)19.5 ( 0.8)28.894 ( 0.000)a|c|d , ed60.5 ( 0.8)1.2 ( 1.1)1.3 ( 1.4)2.9 ( 1.6)3.7 ( 0.5)11.088 ( 0.000)a , b|ed70.5 ( 0.7)0.9 ( 0.7)0.9 ( 1.5)2.1 ( 1.3)3.3 ( 1.0)9.961 ( 0.000)a|ed81.2 ( 1.4)2.0 ( 1.5)2.2 ( 2.4)5.6 ( 2.7)6.3 ( 2.4)11.709 ( 0.000)a , b , c|d , ed90.5 ( 0.5)1.2 ( 1.0)1.8 ( 1.2)3.4 ( 0.7)4.0 ( 0.0)27.219 ( 0.000)a|d , etotal14.8 ( 13.1)35.3 ( 15.4)46.5 ( 31.7)90.5 ( 22.8)116.8 ( 12.4)34.917 ( 0.000)a|d , evalues are means ( sd ) . macs : manual ability classification system ; d1 , learning and 
 apply knowledge ; d2 , general tasks and demands ; d3 , communication ; d4 , mobility ; d5 , 
 self care ; d6 , domestic life ; d7 , interpersonal interactions and relationships ; d8 , 
 major life areas ; d9 , community , social , and civic life . the overall activities and participation section of the icf - cy checklist was 
 significantly different across macs levels . values are means ( sd ) . macs : manual ability classification system ; d1 , learning and 
 apply knowledge ; d2 , general tasks and demands ; d3 , communication ; d4 , mobility ; d5 , 
 self care ; d6 , domestic life ; d7 , interpersonal interactions and relationships ; d8 , 
 major life areas ; d9 , community , social , and civic life the current study assessed the functioning , activity , and participation of school - aged 
 children with cp based on the icf - cy . this study not only provides basic data that can be 
 used to establish actual treatment goals and interventions but can also enhance our general 
 understanding of rehabilitation for children with cp . this study also used the gmfm and the 
 icf - cy checklist to compare the functioning , activity , and participation across macs levels 
 in school - aged children with cp . the macs can be used to assess a range of functional restrictions in children with cp . the macs is divided into 5 levels indicating 
 ( from lowest to highest ) the degree of difficulty in handling , and manipulating objects6 , 9 . in 
 this study , the gmfm scores declined significantly when compared by macs level : 92.6  7.3 
 ( macs level i ) , 81.9  17.5 ( macs level ii ) , 60.9  21.7 ( macs level iii ) , 27.3  11.0 ( macs 
 level iv ) , and 13.8  9.1 ( macs level v ) . this indicates that the higher the functional 
 ability of children with cp , the greater their gross motor functions . similarly , lower 
 functional ability is associated with lower mobility . in this study , the following functions from the icf - cy checklist were significantly 
 different when compared by macs level : mental functions ( b1 ) ; sensory function and pain 
 ( b2 ) ; voice and speech functions ( b3 ) ; functions of the digestive , metabolic , and endocrine 
 systems ( b5 ) ; genitourinary and reproductive functions ( b6 ) ; and neuromusculoskeletal and 
 movement - related functions ( b7 ) . however , functions of the cardiovascular , hematological , 
 immunological , and respiratory systems ( b4 ) and functions of the skin and related structures 
 ( b8 ) did not show significant differences by macs level . this suggests that the functional 
 differences of children with cp depend on whether or not the functional motions are 
 voluntary . arnaud et al.13 reported that physical 
 activity is closely related to not only social activities but also social function . in this 
 study , the activity and participation data from the icf - cy checklist significantly differed 
 by macs level . this suggests that the degree of functioning , which depends on the degree of 
 the disability , significantly influences the activity and participation of children in 
 society and school and at home . altogether , these findings suggest that in school - aged children with cp , the extents of 
 functioning , activity , and participation all depend on the ability of the children to handle 
 and manipulate objects ( macs level ) . furthermore , the functioning of such children affects 
 their activity level and degree of participation . however , because of our small sample size , 
 it can not be assumed that this sample is representative of the general population . this 
 study only compared gmfm scores , function , standards of activity , and participation using a 
 cross - sectional design . in addition , each macs level had a different number of subjects , 
 with some better represented than others . therefore , we hope that future studies will use 
 macs level groups of similar size , conduct correlation analyses for each of the items , and 
 further attempt to identify effective intervention methods for functional improvement .
[ purpose ] the purpose of this study was to evaluate the functioning , extent of activity , 
 and participation of school - aged children with cerebral palsy ( cp ) using the manual 
 ability classification system ( macs ) . 
 [ subjects and methods ] the subjects were 57 
 school - aged children ( 712 years old ) with cp . 
 the macs , gross motor function measure 
 ( gmfm ) , international classification of functioning , disability and health for children 
 and youth ( icf - cy ) checklist , and a questionnaire were used to measure children s 
 functioning , activity , and participation . 
 [ results ] gmfm scores differed significantly 
 across the macs levels . 
 the following differed significantly according to macs level when 
 assessed with the icf - cy function section : mental functions ; sensory function and pain ; 
 voice and speech functions ; functions of the digestive , metabolic , and endocrine systems ; 
 genitourinary and reproductive function ; and neuromusculoskeletal and movement related 
 function . the data from the activities and participation section of the icf - cy also showed 
 statistically significant differences across macs levels . 
 [ conclusion ] these results 
 suggest that the functioning , activity , and participation of school - aged children with cp 
 depend on their macs level and that the functioning of children with cp affects their 
 activities and participation .