although school attendance provides a number of educational and social benefits to children 
 with cerebral palsy ( cp ) , the majority of these children face significant obstacles to 
 participation in activities1 .
children 
 with disabilities have less physical abilities and fitness than their able - bodied peers and , 
 as a result , have less experience in participating in play activities with their peers . 
 impairment in a child s capacity for physical movement ,
therefore , is an important factor , 
 which limits , not only activities and participation in society , but also his / her level of 
 quality of life2 .
basic ability to 
 interact with people and to adapt to environments is another factor that limits activity and 
 participation .
motor disability in children with cp causes limitation in physical activity 
 and in general experience . in the long term
, this can result in developmental delays in 
 sensory function , cognition , formation of movement pattern , as well as in the development of 
 social stages3 .
impairment in postural 
 control leads to diminished ability to adapt to sensory - motor learning in diverse 
 environments4 .
therefore , children have 
 different participation levels in daily activities depending on their level of physical 
 function5 , 6 , which limits their activities in the community to varying 
 degrees7 , 8 .
various factors influence the limitations of a child with cp in 
 participating in activities of daily living9 such as extent of impairment , age , and self - care abilities10 .
the purpose of treatment for a child with cp is to facilitate motor and functional 
 development .
the aim of our study was to investigate the association between scores on the 
 gross motor function measure ( gmfm ) and a measure of general function , assessed using the 
 international classification of functioning , disability and health - child and youth check 
 list ( icf - cy ) , on a child s activities and participation .
the international classification 
 of functioning , disability and health ( icf ) was developed by the world health organization , 
 and the icf - cy is a modified version of the icf which addresses the health , education , and 
 social participation of children and young people .
the icf - cy defines activity as a personal 
 task or behavior , while participation is defined by involvement in actual situations of 
 daily living11 .
specifically , in this 
 study , we evaluated the mediating effect of gross motor function , measured by the gmfm , and 
 of the 8 items of function on the icf - cy , on the 9 sub - items of activities and participation 
 on the icf - cy .
children were excluded 
 if they had undergone : orthopedic surgery or nerve amputation ( neurotmesis ) surgery less 
 than 6 months prior to the start of the study , if they had received botulinum - toxin or 
 baclofen treatment 3 months prior to the start , and if they suffered from epilepsy12 .
the present study was approved by 
 sahmyook university institutional review board ( syuirb2015 - 28 ) and the objective of the 
 study and its requirements were explained to the subjects , and all participants provided 
 written parental consent ; thus , the rights of human subjects were protected .
the general characteristics of the subjects , including scores on gmfm , icf - cy function 
 domain , and icf - cy activity , and participation domain , are listed in table 1table 1.the main difference of variables according to the general characteristics 
 ( n=95)variablesgmfmicf sub - itemfunctionicf sub - item activityand participationgendermale ( n=61)64.7 ( 27.3)27.9 ( 14.9)51.7 ( 39.9)female ( n=34)74.4 ( 25.5)22.3 ( 18.0)42.6 ( 42.2)types of cpspastic ( n=86 ) , a71.1 ( 24.9)**,25.3 ( 16.0)45.2 ( 39.7)*,hypotonic ( n=4 ) , b34.5 ( 31.6)29.3 ( 18.1)93.0 ( 28.9)mixed ( n=5 ) , c45.0 ( 34.3)32.4 ( 19.6)68.4 ( 47.4)paralyzed typesquadriplegia ( n=13 ) , a31.2 ( 21.9)38.9 ( 16.5)**,88.2 ( 31.4)***,diiplegia ( n=71 ) , b70.9 ( 22.8)24.8 ( 15.8)45.5 ( 39.9)hemiplegia ( n=11 ) , c94.0 ( 5.6)***,17.7 ( 9.2)20.3 ( 17.2 ) m ( sd ) ; * p<0.05 , * * p<0.01 , * * * p<0.001 means a significant 
 difference between groups ;  mean that 
a is a significant difference 
 than  b and  c ( a > b , c ) .
m ( sd ) ; * p<0.05 , * * p<0.01 , * * * p<0.001 means a significant 
 difference between groups ;  mean that 
a is a significant difference 
 than  b and  c ( a > b , c ) the gmfm was used to assess subjects gross motor function .
the gmfm consists of 5 
 dimensions : ( a ) lying and rolling , ( b ) sitting , ( c ) crawling and kneeling , ( d ) standing , and 
 ( e ) walking , running , and jumping .
it is recommended that the gmfm first be administered in 
 its entirety to patients without orthoses or mobility aids . to determine the final gmfm 
 score ,
percent scores were calculated for each dimensions and averaged to obtain a total 
 test percentage score13 .
the gmfm has 
 demonstrated intra - rater ( r=0.77 , r=0.88 ) and inter - rater ( r=0.68 ) reliability13 , 14 .
the icf - cy check list was used to evaluate the degree of disability and health of the 
 subjects .
the icf - cy check list is a summary version of the total icf - cy , which includes the 
 main core sections evaluating the health and disability of children and youth .
our study 
 provides results for the icf - cy domains of body function , activities , and participation for 
 children , 7 to 12  years old , with cp .
the domain of body function consists of 8 items : 
 mental function ; sensory function and pain ; voice and speech function ; function of the 
 cardiovascular , hematological , immunological , and respiratory systems ; functions of the 
 digestive , metabolic , endocrine , genitourinary , and reproductive systems ; 
 neuromusculoskeletal and movement - related functions ; and functions of the skin and related 
 structures .
the domain of activities and participation evaluates the following 9 items : 
 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 ) life .
measured outcomes were evaluated relative 
 to subjects characteristics using t - test , analysis of variance ( anova ) , and post - hoc 
 scheffe test .
the correlation between measured variables was evaluated by pearson s 
 product - moment correlation , and mediated effects were verified through 
 hierarchical regression analysis .
a stepwise regression analysis was performed to 
 investigate the effect of gmfm and sub - items of function , activities , and participation . 

the correlation between the gmfm and icf - cy function scores and the icf - cy sub - items for 
 activity and participation are reported in table 
 2table 2.the correlation among gmfm , icf function , and icf activities and participations 
 ( n=95)icf activities and participationsgmfmtotal scorestudying knowledgegeneral taskcommunicationmovementself managementfamily lifepersonal relationsliving territorycommunitygmfm1.00.8***0.7***0.7***0.6***0.8***0.8***0.7***0.5***0.6***0.8***icf function0.7***0.9***0.7***0.8***0.8***0.9***0.9***0.8***0.7***0.8***0.7***mental0.7***0.9***0.7***0.8***0.8***0.8***0.8***0.8***0.7***0.8***0.7***sensory f0.4***0.5***0.5***0.4***0.5***0.4***0.5***0.3**0.5***0.5***0.4***speech0.6***0.7***0.7***0.6***0.8***0.4***0.6***0.4**0.5***0.5***0.5***cardiovascular0.20.2 * 0.3 * 0.10.3 * 0.10.20.10.10.2 * 0.1digestive0.5***0.5***0.5***0.4***0.5***0.3**0.4***0.3 * 0.4***0.3**0.4***urinary0.3**0.3**0.3**0.2 * 0.3**0.20.2 * 0.10.20.10.2*neuromuscle0.5***0.7***0.4***0.6***0.4***0.8***0.7***0.8***0.5***0.6***0.6***skin0.10.20.20.10.2 * 0.10.10.00.10.10.1*p<0.05 , * * p<0.01 , * * * p<0.001 .
the gmfm score negatively correlated to icf - cy scores of function ( r = 0.71 , 
 p < 0.001 ) and scores of activities and participation ( r = 0.78 , p < 0.001 ) .
icf - cy 
 function was strongly correlated to icf - cy scores for activities and participation ( r = 
 0.87 , p < 0.001 ) .
* p<0.05 , * * p<0.01 , * * * p<0.001 the mediating effects of icf - cy function on the association between gmfm and icf - cy 
 activity and participation scores are reported in table 
 3table 3.mediating effects of icf sub - item function in the relationship between gmfm and 
 icf sub - item activity and participation ( n=95)stagesroutebrf1gmfm  icf function0.420.71***0.49792.047***2gmfm  icf activity and participation1.180.78***0.612146.802***3gmfm  icf activity and participation0.510.34***0.812265.019***icf function icf activity and participation1.590.63******p<0.001 . in the first step of the logistic regression ,
gross motor function was 
 identified as an independent predictor variable of icf - cy function score (  = 0.71 , p 
 < 0.001 ) . in the second step of the analysis ,
icf - cy function was found to be an 
 independent predictor variables of icf - cy activity and participation scores (  = 0.78 , p 
 < 0.001 ) .
when scores for the gmfm and icf - cy function were combined in the third step of 
 the analysis , icf - cy function was found to be a significant mediating variable of activity 
 and participation (  = 0.63 , p < 0.001 ) . in this step ,
the gmfm score was also found to 
 have a significant mediating effect on activity and participation scores , but to a lesser 
 degree than in step 2 (  = 0.34 , p < 0.001 ) .
therefore , icf - cy function is a partial 
 mediator between the gmfm and the icf - cy domain of activity and participation .
the sobel 
 test was performed to verify the strength of this partial mediation ( z - value of 6.893 , p 
 < 0.001 ) .
taking into consideration the mediating effect of icf - cy function , the direct 
 effect of gross motor function on activity and participation was 0.34 , its indirect effect , 
 0.44 , and its total effect , 0.78 .
the multi - collinearity between gmfm score and icf - cy 
 function was analyzed , with results of 1.99 indicating absence of multi - collinearity between 
 these measures . with a 2.05 durbin - watson value calculated , independence of the error terms 
 for the two measures
gmfm scores and the icf - cy function predicted scores on 
 the icf - cy activity and participation items ( r = 0.812 , f = 198.596 , p 
 < 0.001 ) .
this study investigated the relationship of the score on the gmfm and icf - cy function of 
 school - age children with cp to that of the icf - cy scores for activity and participation , 
 with the aim of informing intervention goals , treatment strategies , and contributing , in 
 general , to improving the rehabilitation for children with cp .
the movement disorder of cp 
 leads to restriction in physical activity and experience with exercise .
in addition , cp 
 causes delays to the development of sensory or perceptual function , the formation of 
 movement concept , and social development . in the long run ,
cp produces not only a disorder 
 of movement development , but also restriction in the participation in several 
 activities7 .
it is well recognized that 
 restrictions in participation and activities vary with the extent of disability5 .
our study group included children with different types of movement disorders resulting from 
 cp : spastic type , mixed type , and hypotonic type .
it is considered that each of these 
 different levels of movement disorder would have a major impact on activities and 
 participation in daily living15 .
post - hoc analysis of our results indicated that higher scores on the gmfm and icf - cy 
 domains of activity and participation for children with a spastic type of cp , compared to 
 children with hypotonia .
this indicates that the movement disorder of spasticity supports a 
 higher participation at school and society that the movement disorder of hypotonia .
gmfm 
 scores varied by spastic cp types ( f=27.682 , p<0.001 ) , with higher scores for hemiplegia , 
 followed by diplegia and quadriplegia . in fact , scores on icf - cy items of activity ( f=6.461 , 
 p<0.01 ) and participation ( f=10.897 , p<0.001 ) were significantly lower for children 
 with quadriplegia .
icf - cy function , used in this study , includes not only motor function , 
 but also a holistic view of function that includes physical , mental , sensory , and digestive 
 system function .
again , on this holistic scale of function , outcomes were better for 
 children with hemiplegia , compared to those with hemiplegia and quadriplegia .
the limitations of children with cp to participation in activities of daily living are 
 multifactorial in nature9 .
this is why we 
 used both the gmfm and icf - cy to investigate factors that lead to limitation in 
 community - based activity and participation .
in addition , we specifically investigated the 
 relationship between the sub - domains of the gmfm16 and the 8 sub - items of icf - cy function : learning and applying 
 knowledge , general tasks and demands , communication , movement , self - care , home living , 
 interpersonal relationships , major life areas , community life , and social life to explore 
 the impact of disability on the child s civic life .
this study investigated whether the 
 icf - cy function mediated effects of gross motor function on activity and participation . 

mediating effects were evaluated through the hierarchical regression analysis ; in all three 
 steps of the analysis , we evaluated the effects of identified independent variables , as well 
 as evaluating mediating effects .
in hierarchical regression analysis , in - putting parameters 
 at the same time as the independent variable in step 3 allows us to determine the 
 significance of the direct effect of the independent variable on the dependent variables ; if 
 the effect of the independent variable is not significant , then effects are considered to be 
 mediated .
if its effect is less than step 2 , but was still significantly , the effect is 
 determined to be partial mediated . using this approach in our study
, we identified both 
 gross motor function and icf - cy function to be predictive of icf - cy activity and 
 participation .
however , the effects of gross motor function were partially mediated by 
 icf - cy function .
therefore , gmfm scores will have both a direct and an indirect relationship 
 to activity and participation . the results of this study show that icf - cy function partially mediates the effects of gross 
 motor function on activity and participation in children with cp .
a child with cp , depending 
 on the extent of damage , will experience varying levels of restrictions to participation in 
 activities of daily living5 .
all 
 components of icf - cy function will have a significant impact on a child s gross motor 
 function , activity , and participation .
therefore , intervention should target the affected 
 components of icf - cy function , rather than on gross motor function alone . therefore ,
when 
 establishing a treatment plan for a child with cp , it is important to identify , not only the 
 child s physical ability and development , but also factors restricting activity and 
 participation , using the icf - cy function as a reference .
 [ purpose ] this study aimed to evaluate the mediating effect of gross motor function , 
 measured using the gross motor function measure ( gmfm ) and of general function , measured 
 using the international classification of functioning , disability and health - child and 
 youth check list ( icf - cy ) , on the icf domains of activity and participation in children 
 with cerebral palsy ( cp ) . [ subjects ] ninety - five children with cp , from seoul , korea , 
 participated in the study . 
 [ methods ] the gmfm was administered in its entirety to patients 
 without orthoses or mobility aids . 
 the icf - cy was used to evaluate the degree of 
 disability and health of subjects . 
 [ results ] gmfm score and icf - cy function were 
 negatively correlated to icf - cy activity and participation . 
 icf - cy partially mediated the 
 effects of the gmfm on activity and participation . 
 [ conclusion ] when establishing a 
 treatment plan for a child with cp , limitations in activity and participation , as 
 described by the icf - cy , should be considered in addition to the child s physical 
 abilities and development . 
 in addition , the treatment plan should focus on increasing the 
 child s activity and participation level , as well as his / her physical level . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION