children with cerebral palsy experience restrictions on handwriting due to difficulties of 
 motor coordination and balance due to damage to the central nervous system and involuntary 
 movements .
one study found that 81.3% of children with cerebral palsy were found to write 
 incorrect , uneven and unrecognizable letters1 .
previous studies1,2,3,4,5 of 
 handwriting related factors of children with cerebral palsy have been carried out , but these 
 studies had limitations regarding the identification of comprehensive relevant factors and 
 the selection of efficient priorities . in the last ten years , perspectives on outcome 
 assessments of cerebral palsy have been influenced and shaped by the world health 
 organization s international classification of functioning , disability , and health 
 ( icf)6 , as a guiding principle .
icf 
 provides descriptions of three major domains of body function , body structure , and 
 activities and participation ( execution of tasks and activities and involvement in a life 
 situation ) .
these domains are further clarified with contextual factors , either personal or 
 environmental , and by applying the icf s conceptual framework , vocational evaluators can 
 systematically gather , organize , synthesize and interpret health related assessment 
 information7 .
also , icf domains have 
 been used to understand and describe the many impacts of cp on individuals and allow the 
 categorization of various cp outcome measures by the domain that is being assessed8 .
we investigated factors affecting 
 handwriting articulation of children with cerebral palsy based on the icf model to provide 
 comprehensive data for the assessment and design of interventions for effective handwriting 
 of children with cerebral palsy .
among the subjects who participated in the research , there were 54 male ( 56.3% ) and 42 
 female subjects ( 43.8% ) .
their average age was 11.16 ( 2.06 ) , average education year was 
 3.75 ( 1.97 ) .
there were 78 right - handers ( 81.3% ) and 18 left handers ( 18.8% ) .
there were 54 
 subjects with diplegia ( 56.2% ) , 30 with hemiplegia ( 31.3% ) and 12 with quadriplegia ( 12.6% ) 
 ( table 1table 1.general characteristics of the subjectscomponents of icfn ( % ) gendermale54 ( 56.3)female42 ( 43.8)age8 years14 ( 14.6)9 years13 ( 13.5)10 years13 ( 13.5)11 years7 ( 7.3)12 years14 ( 14.6)13 years23 ( 24.0)14 years12 ( 12.5)(msd)11.162.06hand dominanceright78 ( 81.3)left18 ( 18.8)education ( elementary school)first grade19 ( 19.8)second grade13 ( 13.5)third grade11 ( 11.5)fourth grade8 ( 8.3)fifth grade18 ( 18.8)sixth grade27 ( 28.1)(msd)3.751.97type of cerebral palsyspastic74 ( 77.1)athetoid5 ( 5.2)athetoid with spasticity4 ( 4.2)ataxic11 ( 11.5)flaccid2 ( 2.1)affected sidediplegia54 ( 56.2)hemiplegia30 ( 31.3)quadriplegia12 ( 12.5 ) ) .
the subjects did not have any diseases related to the hands , fractures , or 
 past histories of diseases . before the study , the principal investigator explained all 
 procedures to the subjects in detail .
all subjects signed an informed consent form , which 
 was approved by the cheonnam university college of human health science studies committee . 

based on the icf , factors related to handwriting were classified as personal factors 
 ( gender , age , education , hand dominance , type of cerebral palsy ) , environmental factors 
 ( writing aids , sitting aids , type of desk ) , body structure(affected side ) , body functions 
 ( cognitive function : orientation , visual perception , spatial perception , motor praxis , 
 visuomotor organization , thinking operation ; sensory function : proprioception , tactile ; 
 strength function : upper extremity , grasp , prehension ; motor function : bilateral 
 coordination , upper extremity speed ) , and activity and participation ( sitting balance , 
 pencil grasp posture ) . to identify the factors related to handwriting articulation , 

assessment tools were classified and used based on the icf model ( table 2table 2.assessment based on the icfcomponents of icf handwriting factorsassessment personal factorsgenderinterviewageeducationhand dominancetype of cerebral palsyenvironmental factorswriting aidsinterview sitting aidstype of deskbody structureaffected sideinterviewbody functionscognitive functionorientationdotcavisual perceptionspatial perceptionpraxissensory functionvisuomotor constructionproprioception testthinking operationtactile testproprioceptionmanual muscle teststrength functiontactiledynamometerupper extremitypinch metergraspb - o test ( subtest 3)motor functionprehensionb - o test ( subtest 8)bilateral coordinationupper extremity speedactivity & participationsitting balancesitting balance testpencil grasp posturesurveyhealthwriting articulationkorean alphabet writing assessment ) .
some personal factors ( age , education ) and body functions ( cognitive function : visual 
 perception , visuomotor organization ; strength function : upper extremity elbow flexion and 
 extension , wrist extension , lateral deviation and medial deviation , grasp ; and motor 
 function : bilateral coordination , upper - extremity speed , factors were related to handwriting 
 articulation . according to the backward regression analysis , wrist lateral deviation , 
 upper - extremity speed and education were significantly associated with handwriting 
 articulation ( table 3table 3.factors related to handwriting articulationcomponent of icfhandwriting factorsunstandardized coefficientsstandardized coefficientsvifbstandard errorbetabody functionstrength functionupper extremity - wrist lateral deviation1.0460.2990.3071.001*motor functionupper extremity speed0.0790.0180.3931.024**personal factoreducation0.3640.1760.1831.023**p<0.05 , * * p<0.001 ) .
cerebral palsy may involve problems in the neuromuscular system such as spasticity , 
 contracture , muscle weakness , and loss of selective movement9 .
this decreased functioning limits the ability of children with cp 
 to participate in various activities .
so , the 
 identification of factors that lead to functional impairment is of fundamental importance in 
 clinical decision making and the evaluation of the effect of therapeutic strategies11 .
this study investigated handwriting articulation among school - aged child with cerebral 
 palsy and factors related to it .
lower body function cognitive function : visual perception , visuomotor 
 organization ; strength function : upper extremity ( elbow flexion and extension , wrist 
 extension , lateral deviation , and medial deviation , grasp ; and motor function : bilateral 
 coordination , upper - extremity speed ) contributed towards poor handwriting articulation , and 
 also occurred in individuals with lower ages and education .
several studies have described 
 the influence of visual perception , visual motor organization1 , strength function of the upper extremity12 , and motor function4 .
visual perception is the ability to recognize forms , notice 
 likenesses and differences , infer the movements necessary for the production of the form . 

visuomotor organization is the ability to copy or transpose from printing material to 
 cursive or manuscript writing1 .
bilateral coordination impairment 
 negatively affects handwriting skills4 . 
 crossing the midline is an integral skill related to bilateral coordination . a child who 
 avoid midline
crossing may have difficulty coordinating both sides of the body , has 
 difficulty establishing hand dominance and tends to use alternate hands when writing .
backward regression analyses shows that wrist lateral deviation of muscle strength , 
 upper - extremity speed and education were important predictors of handwriting articulation . 

a previous study 
 reported that the muscles of the wrist stabilize and prevent unwanted wrist movements , which 
 allow the finger muscles to maintain an adequate length that is favorable for producing 
 tension and prehension13 .
upper extremity 
 mobility is a coordinated effort of the upper extremity structure and function , and poor 
 upper extremity speed can lead to functional limitation .
this study had several limitations , and 
 one of them was the small sample size , therefore these results can not necessarily be 
 generalized to all children with cerebral palsy .
it also exclusively investigated physical 
 body function and structure and personal factors but not environmental factors . in conclusion , this study comprehensively handled overall health - related factors on the 
 basis of the icf health model for intervention approaches for children with cerebral palsy , 
 therefore , it can be used as basic data in setting systematic intervention goals and plans 
 for articulation of handwriting .
comprehensive personal function and body function 
 assessments that involve cognitive function ( visual perception , visuomotor organization ) , 
 strength function ( upper extremity : elbow flexion , extension , wrist extension , lateral 
 deviation , medial deviation , grasp ) and motor function ( bilateral coordination , 
 upper - extremity speed ) must be performed .
efforts to manage and improve the handwriting 
 articulation of children with cerebral palsy should focus on wrist lateral deviation and 
 upper - extremity speed .
 [ purpose ] this study was designed to identify factors influencing handwriting 
 articulation based on the international classification of functioning , disability and 
 health ( icf ) and to recommend effective evaluation and intervention strategies to improve 
 the handwriting of children with cerebral palsy . [ subjects ] 
 the subjects were 96 
 elementary school children with cerebral palsy and the study was conducted from 04/07/2011 
 to 29/08/2011 . 
 [ methods ] factors related to handwriting articulation were investigated 
 based on the icf model . [ results ] 
 wrist lateral deviation , upper - extremity speed of body 
 function and education of personal factor were significantly associated with handwriting 
 articulation . 
 [ conclusion ] efforts to manage and improve the handwriting articulation of 
 children with cerebral palsy should focus on wrist lateral deviation , upper - extremity 
 speed , and education . 