All study participants' demographic characteristics and prognostic variables, and mean ages of participants classified into different GMFCS, MACS, and CFCS levels were shown in Table I. Children at each of the three levels of the classification systems demonstrated similarity in the age (p>0,05). Among the 98 enrolled children, 57 (% 58,2) were in good functioning levels in MACS (level I-II), whereas 41 (% 41,8) were in moderate functioning level (MACS level III). On average, % 55,1 could walk independently in all environments (GMFCS I), % 38.1 could walk with some limitations (GMFCS II), and only % 6.1 required a hand-held device for mobility. Considering that the MACS is a classification system of disabled children's hand function in five levels (a lower value describes higher manual ability), most of the children in this study had effective hand use (MACS I-II). For communication skills, the predominant levels were level I (% 56.1) and level II (% 29.6) respectively, while fewer participants had a moderate score (level III; %14.3). That is, most of the study participants could independently and effectively communicate with people in most environments. Finally, except for hearing impairment, vision, speech, and cognition impairment was reported in 9 (% 9.2), 11 (%11,2), and 12 (% 12,2) of study participants, respectively.
The distribution of children at different MACS levels within GMFCS levels was demonstrated in Table II. As indicated, most children in MACS level I (89,3%) were qualified with GMFCS I; on the other hand, a very few percent (10,7%; 3 children) presented GMFCS II. Of children in MACS II, 55,2% had the best mobility level on GMFCS (level I); whereas 44,8% relatively had a lower mobility level on GMFCS (level II). Finally, children with MACS III demonstrated greater variability in mobility level on GMFCS than those with MACS I and II, with a majority part representing GMFCS II (53,7%).
Table III demonstrates comparison of participants’ upper limb functions and participation in different life situations scaled scores on ABILHAND-Kids and CASP questionnaires according to MACS levels. Analysis of one-way ANOVA showed that the upper limb functions and participation in different life situations outcomes exhibited variability in participants at each of the three MACS levels (p= 0,000). In other words, children’s s both upper limb functions and participation scaled scores on ABILHAND-Kids and CASP questionnaires were found clearly to increase with higher functioning levels of MACS (Post-Hoc: a>b>c). Moreover, Figures 1 and 4 illustrated the range of scaled scores of upper limb functions and participation in different life situations by MACS levels. According to Figure 1, children in MACS I demonstrated greater variability as to upper limb functions than children in MACS II and III.
Children in level I, II, and III at GMFCS differed greatly for upper limb functions and participation in different life situations outcomes (p=0,000) (Table IV). Furthermore, results of pairwise post-hoc tests suggested that participants in a higher functioning GMFCS level had more remarkable outcomes in both upper limb functions and participation in different life situations than those with a lower GMFCS level (Post-Hoc: a>b>c). That is, the higher GMFCS levels were found to be associated with greater mean scores on both the ABILHAND-kids and CASP-subtests. Children in GMFCS I presented greater variability for upper limb function (ABILHAND-Kids) than those in GMFCS II and III. In contrast, children in GMFCS III demonstrated greater variability in scaled scores on CASP-community participation subdomains than those in GMFCS I and II (Figures 2 and 5)
Table V shows upper limb functions and participation in different life situation outcomes by communication skills on CFCS. Results of one-way ANOVA displayed statistical meaningful differences among three levels related to both manual ability and participation in different life situation outcomes (p=0,000). However, isolated comparisons (pairwise post-hoc tests with Tukey) revealed a statistically significant difference only between high and moderate levels (CFCS I-III), whereas it was not found out statistically meaningful differences between level I and II, and between level II and III (Post-Hoc: a>c, a=b, b=c). In other words, the mean upper limb functions and participation scaled scores obtained by children qualified with one of three levels of CFCS differed significantly only between those qualified with levels I and III. In contrast, a significant difference could not be found between children classified into levels closer to each other for upper limb functions and participation in different life situations. Furthermore, as demonstrated in Figures 3 and 6, children qualified with CFCS III displayed greater variability in scaled scores on both upper limb functions and participation in different life situations than those characterized as CFCS I and II.
As demonstrated in Table VI, MACS levels were found to be moderately correlated with GMFCS levels (r=0,491, p=0,000), whereas, weakly correlated with the CFCS levels (r=0.247, p=0,014). Finally, a moderate relationship was observed between GMFCS and CFCS levels (r=0,574, p=000).
Table VII demonstrate the findings of regression models. For the upper limb functions, MACS, GMFCS, and CFCS explained % 65, % 23, and % 8 of variance, respectively. Also, it was found out that the MACS was the strongest predictor of participation in home, school, and home and community, explaining % 62, % 56, and % 48 of variance. On the other hand, the MACS and GMFCS contribute equally to the scaled score of community participation, with a % 48 variance. As a result, the manual ability level as defined by MACS is the strongest predictor of upper limb functions and participation in home and school environments compared to both gross motor and communication performance on GMFCS and CFCS (R2 of MACS > R2 of GMFCS and CFCS). At the same time, GMFCS is an identical predictor to MACS for participation in community environment where mobility would be more needed.