the major problem of 
 children with cerebral palsy is an inability to use movement control for balance as well as 
 an inability to use the hands for reaching and manipulation in daily activities2 . in daily life activities ,
therefore , children s physical capabilities must be 
 evaluated in a real occupational environment .
several well - established classification systems are used to characterize the functional 
 abilities of children with cerebral palsy as they participate in their daily activities .
the 
 classification systems are divided in two types : the gross motor function classification 
 system ( gmfcs ) and the manual ability classification system ( macs ) .
gmfcs scores range from 
 level 1 , which includes children with no disability and community mobility , to level 5 , 
 which includes children who are totally dependent on assistance for mobility4 .
the macs provides information for 
 classifying the manual abilities of children with cerebral palsy , whether they are using 
 their hands for manipulation or not4 .
both 
 classification systems are used to evaluate children s functional status in daily routine 
 activities .
the skill of performance in daily routine activities is very important in evaluating 
 children with cerebral palsy . in general ,
children s performance skill in daily activities should reflect 
 real functions while they perform real activities such as dressing and hygiene , which are 
 influenced by environmental , personal and contextual factors5 . therefore , real performance - based evaluation is important in 
 correctly assessing a child s degree of functional skill . nowadays , for performance - based 
 evaluation , the assessment of motor and process skill ( amps ) or school amps is used .
the 
 amps is used to evaluate performance skills when children and adults perform daily tasks .
it 
 comprises two main areas : adl motor skill and adl process skill6 . according to fisher ,
the amps adl motor skills refer to observable actions of performance 
 used to move oneself or task objects , such as reaching , alignment and bending .
process 
 skills refer to observable actions , such as the ability to logically organize actions in 
 time and space and the appropriate use of task tools .  motor skills
 refer in particular to 
 the gross and fine motor capability of an individual when performing a daily occupation7 .
various studies have reported on the 
 strengths of the performance - based evaluation . to date , there has been little published 
 evidence regarding the utility of performance - based evaluations in assessing functional 
 ability in children with cerebral palsy .
the aim of this study was to investigate the predictive utility of gmfcs and macs levels 
 with respect to the performance - based adl motor skills of children with cerebral palsy .
this study included 23 children with cerebral palsy , who attended a pediatric 
 rehabilitation hospital in seoul . all children and their caregivers
were informed about the 
 purpose of this study in accordance with the ethical principle of the declaration of 
 helsinki ( 1975 , revised 1983 ) .
the study subjects were children with cerebral palsy aged 
 712  years old , with mild to moderate spastic cerebral palsy , who had been categorized as 
 gmfcs and macs levels i  iii .
children with mixed diagnoses ( e.g. , severe visual and auditory 
 problems or intellectual disability ) were excluded .
the gmfcs and macs were used to assess the functional capabilities of children with 
 cerebral palsy .
notably , the gmfcs uses five levels to classify those who are being 
 evaluated .
, patients 
 classified as level i handle objects easily and successfully , while those classified as 
 level iv handle a limited selection of easily managed objects in adapted situations . those 
 classified as level v do not handle objects4 .
for the amps 
 assessment , participants were asked to complete functional tasks such as dressing , donning 
 shoes and preparing cereal and milk .
notably , motor 
 skills represent the gross and fine motor capability of a person , while process skill is 
 more related to cognitive and mental process capability .
descriptive statistics were used to 
 analyze the demographic characteristics of the children who participated in the study ( table 1table 1.general characteristics of all children ( n=23)mean  sd [ range]frequency ( % ) age ( years)9.04  1.02 [ 811]genderboys14 ( 60.9)girls9 ( 39.1)gmfc leveli2 ( 8.7)ii7 ( 30.4)iii14 ( 60.9)iv0v0macs leveli2 ( 17.4)ii13 ( 56.5)iii6 ( 26.1)iv0v0 ) .
one - way anova and the post - hoc test in combination with scheffe s method 
 were used to determine the mean difference in adl motor skills among gmfcs and macs levels . 

multiple regression analysis was used to determine the relationships among adl motor skill , 
 gmfcs level and macs level .
adl motor skills differed significantly among gmfcs ( p=0.002 ) and macs levels ( p=0.026 ) .
a 
 post - hoc test revealed a significant difference between gmfcs levels i and iii ( p=0.009 ) as 
 well as between levels ii and iii ( p=0.019 ) .
there was no significant mean difference in adl 
 motor skill between gmfcs levels i and ii . there were also significant mean differences in 
 adl motor skill between macs levels i and iii ( p=0.026 ) ( table 2table 2.mean difference of adl - motor skill among gmfc and macs levels ( n=23)level ilevel iilevel iiiaveragepost - hocadl - motor skill among gmfcs level*117.50  3.5399.85  11.3378.50  16.6388.39
 19.50a = b , a > c , b > c adl - motor skill among macs level**108.75  10.3087.76  18.1776.16  17.4788.39  19.50 a = b , a > c , b = c*significant difference at 0.002 level , * * significant difference at 0.026 level . 
 a = level i , b = level ii , c = level iii ) .
in comparison to 
 gmfcs level i , level iii adl motor skills were 39.0 points lower ( p=0.002 ) .
this regression 
 model s explanation power was 47.6% ( table 
 3table 3.multiple regression model to predict adl - motor skill using gmfcs level 
 ( n=23)gmfcs levelbsetrconstant117.50 * 10.4611.250.476level ii17.6411.861.48level iii39.00**11.193.48*significant level at<0.0001 , * * significant level at 0.002 .
b : coefficient of 
 regression , se : standard error , t : calculated value , r : coefficient of 
 determination ) . in comparison to macs level
i , level ii adl motor skills were 20.98 points 
 lower ( p<0.0001 ) ; level iii adl motor skills were 32.58 points lower ( p=0.044 ) .
this 
 regression model s explanation power was 30.6% ( table 
 4table 4.multiple regression model to predict adl - motor skill using macs level 
 ( n=23)gmfcs levelbsetrconstant108.75 * 8.5212.760.306level ii20.98**9.742.15level iii32.58***11.002.96*significant level at<0.0001 , * * significant level at 0.044 , * * * significant level 
 at 0.008 .
b : coefficient of regression , se : standard error , t : calculated value , 
 r : coefficient of determination ) .
* significant difference at 0.002 level , * * significant difference at 0.026 level . 
 a = level i , b = level ii , c = level iii * significant level at<0.0001 , * * significant level at 0.002 .
b : coefficient of 
 regression , se : standard error , t : calculated value , r : coefficient of 
 determination * significant level at<0.0001 , * * significant level at 0.044 , * * * significant level 
 at 0.008 .
b : coefficient of regression , se : standard error , t : calculated value , 
 r : coefficient of determination
children with cerebral palsy exhibit poor participation in daily activities due to motor 
 problems such as abnormal postural tone and poor body control8 .
this study demonstrated the clinical utility of a performance - based 
 assessment based on the amps motor skill test in predicting the gross and manual functions 
 of children with cerebral palsy .
first , adl motor skills in children differed significantly 
 among gmfcs and macs levels .
this result was reported previously9 . according to james et al . , amps motor skills are related to 
 hand function in unilateral cerebral palsy9
. another previous study demonstrated correlations among gmfcs , macs 
 and wee fim scores .
. showed a significant correlation among gmfcs scores , macs 
 scores and the self - care , mobility and locomotion scores of the wee fim10 .
moreover , in this study , multiple regression showed that the adl motor skills of children 
 with gmfcs level iii scored lower than those of children categorized as gmfcs level i. also , 
 in comparison to children classified as macs level i , children labeled as macs level ii and 
 iii had inferior adl motor skills .
thus , adl motor skills differ significantly among gmfcs 
 level iii , macs level ii and macs level iii among children with cerebral palsy .
these 
 results suggest that adl motor skills can be used to predict gmfcs or macs level in children 
 with cerebral palsy .
only spastic - type cerebral palsy patients classified as 
 gmfcs or macs levels i  iii participated .
thus this study could not characterize the 
 relationship between adl motor skills and other gmfcs or macs levels .
future research is 
 necessary to involve children with various type of cerebral palsy such as hemiplegia , 
 diplegia and ataxic type .
furthermore , future research need to investigating adl motor 
 skills that correlation with other gmfcs or macs levels .
 [ purpose ] the purpose of this study was to determine effects of gross motor function 
 classification system and manual ability classification system levels on performance - based 
 motor skills of children with spastic cerebral palsy . 
 [ subjects and methods ] twenty - three 
 children with cerebral palsy were included . 
 the assessment of motor and process skills was 
 used to evaluate performance - based motor skills in daily life . 
 gross motor function was 
 assessed using gross motor function classification systems , and manual function was 
 measured using the manual ability classification system . 
 [ results ] motor skills in daily 
 activities were significantly different on gross motor function classification system 
 level and manual ability classification system level . according to the results of multiple 
 regression analysis , children categorized as gross motor function classification system 
 level iii scored lower in terms of performance based motor skills than gross motor 
 function classification system level i children . 
 also , when analyzed with respect to 
 manual ability classification system level , level ii was lower than level i , and level iii 
 was lower than level ii in terms of performance based motor skills . 
 [ conclusion ] the 
 results of this study indicate that performance - based motor skills differ among children 
 categorized based on gross motor function classification system and manual ability 
 classification system levels of cerebral palsy . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION