Asymmetry in sensory-motor function between the lower limbs in children with hemiplegic cerebral palsy: An observational study.

The objective of this study was to examine the difference in sensory-motor impairments (i.e., balance, contracture, coordination, strength, spasticity, and sensation) between legs in children with hemiplegic cerebral palsy. An observational study measured both lower limbs of children with hemiplegic cerebral palsy over one session. Six sensory-motor impairments (balance, coordination, strength, spasticity, contracture, and proprioception) were measured. The between-leg differences were analyzed using the paired t-tests and presented as the mean differences (95% confidence interval (CI)). Twenty-four participants aged 10.3 years (standard deviation: 1.3) participated. The affected leg was less than the less-affected leg in terms of the strength of dorsiflexors (mean difference (MD) -2.8 Nm, 95% CI -4.2 to -1.4), plantarflexors (MD -2.6 Nm, 95% CI -4.1 to -1.0), knee extensors (MD -5.3 Nm, 95% CI -10.2 to -0.5) as well as range of ankle dorsiflexion (MD -8 deg, 95% CI -13 to -3), and balance (median difference -11.1, 95% CI -11.6 to -10.6). There was a trend toward a difference in terms of the strength of hip abductors (MD -2.6 Nm, 95% CI -5.3 to 0.1) and coordination (MD -0.20 taps/s, 95% CI -0.42 to 0.01). The legs were similar in terms of the strength of hip extensors (MD 0.3 Nm, 95% CI -4.7 to 5.3), proprioception (MD 1 deg, 95% CI 0 to 2), and spasticity (median difference 0, 95% CI 0 to 0). Examination of the difference in sensory-motor impairments between legs in children with hemiplegic cerebral palsy has given us some insights into the deficits in both legs. Not only was balance, strength, and coordination decreased compared with the less-affected leg but also the less-affected leg was markedly decreased compared with typically developing children. Therefore, an intervention aimed at increasing muscle strength and coordination in both legs might have a positive effect, particularly on more challenging physical activities. This may, in turn, lead to successful participation in mainstream sport and recreation.

Relative contribution of sensory and motor impairments to mobility limitations in children with cerebral palsy: an observational study.

The purpose of this study was to determine the relative contribution of sensory and motor impairments to mobility limitations in cerebral palsy. An observational study was carried out in 83 children with all types of cerebral palsy with a mean age of 10.8 years (SD 1.2). Five impairments (coordination, strength, spasticity, contracture, proprioception) and three aspects of mobility (standing up from a chair, short and long distance walking) were measured. Standard multiple regression was used to determine the relative contribution of impairments to mobility as well as the relative contribution of strength of individual muscle groups (dorsiflexors, plantarflexors, knee extensors, hip abductors and hip extensors) to mobility. Five impairments accounted for 48% of the variance in overall mobility (p < 0.001): coordination independently accounted for 9%, contracture for 4% and strength for 3% of the variance. Five muscle groups accounted for 53% of the variance in overall mobility (p < 0.001): hip extensors independently accounted for 9%, knee extensors for 4%, dorsiflexors for 4% and plantarflexors for 3% of the variance. Our findings demonstrate that the impairments making a significant independent contribution to mobility in pre-adolescent cerebral palsy were loss of coordination, loss of strength and contracture.

What are the optimum training parameters of progressive resistance exercise for changes in muscle function, activity and participation in people with cerebral palsy? A systematic review and meta-regression.

OBJECTIVES: To explore the effect of progressive resistance exercise (PRE) on impairment, activity and participation of people with cerebral palsy (CP). Also, to determine which programme parameters provide the most beneficial effects. DATA SOURCES: Electronic databases searched from the earliest available time. ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) implementing PRE as an intervention in people with cerebral palsy were included. STUDIES APPRAISAL & SYNTHESIS METHODS: Methodological quality of trials was assessed with the PEDro scale. Meta-analysis and meta-regression were completed. RESULTS: We included 20 reports of 16 RCTs (n = 504 participants). Results demonstrated low certainty evidence that PRE improved muscle strength (pooled standardised mean difference (SMD)= 0.59 (95%CI: 0.16-1.01; I²=70%). This increase in muscle strength was maintained an average of 11 weeks after training stopped. Τhere was also moderate certainty evidence that it is inconclusive whether PRE has a small effect on gross motor function (SMD= 0.14 (95%CI: -0.09 to 0.36; I²=0%) or participation (SMD= 0.26 (95%CIs: -0.02 to 0.54; I²=0%). When PRE was compared with other therapy there were no between-group differences. Meta-regression demonstrated no effect of PRE intensity or training volume (frequency x total duration) on muscle strength (p > 0.5). No serious adverse events were reported. There is lack of evidence of the effectiveness of PRE in adults and non-ambulatory people with CP. CONCLUSIONS: PRE is safe and increases muscle strength in young people with CP, which is maintained after training stops. The increase in muscle strength is unrelated to the PRE intensity or dose. CONTRIBUTION OF THE PAPER.

Reliability and validity of the Eating and Drinking Ability Classification System (EDACS) for children with cerebral palsy in Taiwan.

PURPOSE: The study was to assess the inter- and intra-rater reliability, construct validity and utility of the Eating and Drinking Ability Classification System (EDACS). METHODS: EDACS was translated into in Taiwan using an interactive process. Agreement between health professionals and teachers when using EDACS was assessed using Kappa and the Intraclass Correlation Co-efficient. RESULTS: Paired ratings of 4 (13%) health professionals (either speech or occupational therapists) and 26 (87%) teachers were obtained for 53 children with CP aged 6.7 years (SD 4.1 years), who worked in six education institutions. The raters used EDACS independently to classify children's eating and drinking ability and re-classified children's eating and drinking abilities after one month. Pairs of raters showed substantial agreement for the EDACS level at the first assessment (k = 0.75; absolute agreement = 81%; ICC = 0.94) and the second assessment (k = 0.70; absolute agreement = 77%; ICC = 0.95). The intra-rater reliability of EDACS level showed almost perfect agreement at rater 1 (k = 0.87; absolute agreement = 91%) and rater 2 (k = 0.87; absolute agreement = 91%). CONCLUSIONS: We conclude that the Chinese version of EDACS is valid and reliable to be easily used by health professionals and teachers to classify functional eating and drinking abilities in children with cerebral palsy.IMPLICATIONS FOR REHABILITATIONThe Chinese version of EDACS is valid and reliable to be easily used.EDACS can be used by health professionals and teachers to classify functional eating and drinking abilities in children with cerebral palsy.The EDACS is analogous to other functional classification systems (i.e., GMFCS, MACS and CFCS) and specifically represents eating and drinking ability.

Mechanically assisted walking training for walking, participation, and quality of life in children with cerebral palsy.

BACKGROUND: Cerebral palsy is the most common physical disability in childhood. Mechanically assisted walking training can be provided with or without body weight support to enable children with cerebral palsy to perform repetitive practice of complex gait cycles. It is important to examine the effects of mechanically assisted walking training to identify evidence-based treatments to improve walking performance. OBJECTIVES: To assess the effects of mechanically assisted walking training compared to control for walking, participation, and quality of life in children with cerebral palsy 3 to 18 years of age. SEARCH METHODS: In January 2020, we searched CENTRAL, MEDLINE, Embase, six other databases, and two trials registers. We handsearched conference abstracts and checked reference lists of included studies. SELECTION CRITERIA: Randomized controlled trials (RCTs) or quasi-RCTs, including cross-over trials, comparing any type of mechanically assisted walking training (with or without body weight support) with no walking training or the same dose of overground walking training in children with cerebral palsy (classified as Gross Motor Function Classification System [GMFCS] Levels I to IV) 3 to 18 years of age. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: This review includes 17 studies with 451 participants (GMFCS Levels I to IV; mean age range 4 to 14 years) from outpatient settings. The duration of the intervention period (4 to 12 weeks) ranged widely, as did intensity of training in terms of both length (15 minutes to 40 minutes) and frequency (two to five times a week) of sessions. Six studies were funded by grants, three had no funding support, and eight did not report information on funding. Due to the nature of the intervention, all studies were at high risk of performance bias. Mechanically assisted walking training without body weight support versus no walking training Four studies (100 participants) assessed this comparison. Compared to no walking, mechanically assisted walking training without body weight support increased walking speed (mean difference [MD] 0.05 meter per second [m/s] [change scores], 95% confidence interval [CI] 0.03 to 0.07; 1 study, 10 participants; moderate-quality evidence) as measured by the Biodex Gait Trainer 2™ (Biodex, Shirley, NY, USA) and improved gross motor function (standardized MD [SMD] 1.30 [postintervention scores], 95% CI 0.49 to 2.11; 2 studies, 60 participants; low-quality evidence) postintervention. One study (30 participants) reported no adverse events (low-quality evidence). No study measured participation or quality of life. Mechanically assisted walking training without body weight support versus the same dose of overground walking training Two studies (55 participants) assessed this comparison. Compared to the same dose of overground walking, mechanically assisted walking training without body weight support increased walking speed (MD 0.25 m/s [change or postintervention scores], 95% CI 0.13 to 0.37; 2 studies, 55 participants; moderate-quality evidence) as assessed by the 6-minute walk test or Vicon gait analysis. It also improved gross motor function (MD 11.90% [change scores], 95% CI 2.98 to 20.82; 1 study, 35 participants; moderate-quality evidence) as assessed by the Gross Motor Function Measure (GMFM) and participation (MD 8.20 [change scores], 95% CI 5.69 to 10.71; 1 study, 35 participants; moderate-quality evidence) as assessed by the Pediatric Evaluation of Disability Inventory (scored from 0 to 59), compared to the same dose of overground walking training. No study measured adverse events or quality of life. Mechanically assisted walking training with body weight support versus no walking training Eight studies (210 participants) assessed this comparison. Compared to no walking training, mechanically assisted walking training with body weight support increased walking speed (MD 0.07 m/s [change and postintervention scores], 95% CI 0.06 to 0.08; 7 studies, 161 participants; moderate-quality evidence) as assessed by the 10-meter or 8-meter walk test. There were no differences between groups in gross motor function (MD 1.09% [change and postintervention scores], 95% CI -0.57 to 2.75; 3 studies, 58 participants; low-quality evidence) as assessed by the GMFM; participation (SMD 0.33 [change scores], 95% CI -0.27 to 0.93; 2 studies, 44 participants; low-quality evidence); and quality of life (MD 9.50% [change scores], 95% CI -4.03 to 23.03; 1 study, 26 participants; low-quality evidence) as assessed by the Pediatric Quality of Life Cerebral Palsy Module (scored 0 [bad] to 100 [good]). Three studies (56 participants) reported no adverse events (low-quality evidence). Mechanically assisted walking training with body weight support versus the same dose of overground walking training Three studies (86 participants) assessed this comparison. There were no differences between groups in walking speed (MD -0.02 m/s [change and postintervention scores], 95% CI -0.08 to 0.04; 3 studies, 78 participants; low-quality evidence) as assessed by the 10-meter or 5-minute walk test; gross motor function (MD -0.73% [postintervention scores], 95% CI -14.38 to 12.92; 2 studies, 52 participants; low-quality evidence) as assessed by the GMFM; and participation (MD -4.74 [change scores], 95% CI -11.89 to 2.41; 1 study, 26 participants; moderate-quality evidence) as assessed by the School Function Assessment (scored from 19 to 76). No study measured adverse events or quality of life. AUTHORS' CONCLUSIONS: Compared with no walking, mechanically assisted walking training probably results in small increases in walking speed (with or without body weight support) and may improve gross motor function (with body weight support). Compared with the same dose of overground walking, mechanically assisted walking training with body weight support may result in little to no difference in walking speed and gross motor function, although two studies found that mechanically assisted walking training without body weight support is probably more effective than the same dose of overground walking training for walking speed and gross motor function. Not many studies reported adverse events, although those that did appeared to show no differences between groups. The results are largely not clinically significant, sample sizes are small, and risk of bias and intensity of intervention vary across studies, making it hard to draw robust conclusions. Mechanically assisted walking training is a means to undertake high-intensity, repetitive, task-specific training and may be useful for children with poor concentration.

Changes in Walking Performance between Childhood and Adulthood in Cerebral Palsy: A Systematic Review.

Purpose: To examine the changes in walking performance between childhood and adulthood in cerebral palsy. Methods: Cohort studies were included if the participants were children with cerebral palsy at Gross Motor Function Classification System (GMFCS) Level I-IV, initial measurement of walking by 13 years of age and follow-up measurement by 30 years of age. Results: At GMFCS Level I+ II, 7% (95% CI 6-8) had declined to GMFCS Level III. At GMFCS Level III, 4% (95% CI 3-6) had declined to GMFCS Level IV and 31% (95% CI 27-34) had improved to GMFCS Level I+ II. At GMFCS Level IV, 2% (95% CI 1-4) had improved to GMFCS Level III and 3% (95% CI 2-4) had improved to GMFCS Level I+ II. Discussion: The results suggest that walking performance is stable from childhood to adulthood at either end of the spectrum of ability but is more changeable for intermediate walkers.

Activity training on the ground in children with cerebral palsy: Systematic review and meta-analysis.

Purpose: To systematically review the evidence about whether activity training on the ground is effective on activity or participation in children with cerebral palsy. Methods: Randomized controlled trials (RCTs) were searched in databases using relevant keywords. RCTs were included with children (≤18 years) with cerebral palsy who received activity training on the ground only or activity training on the ground combined with another type of physiotherapy. Outcome measures classified as measures of activity or participation according to the International Classification of Functioning, Disability, and Health were analyzed. Results: Nine RCTs (257 participants) were included in this review. Individual studies resulted in conflicting results when activity training on the ground was compared to no intervention. Based on meta-analysis, activity training on the ground was not more effective than no intervention (standardized mean difference [SMD]: 0.18; confidence interval [CI]: -1.49 to 1.86) or other therapies (SMD: -0.09; CI: -0.86 to 0.69) (I2 > 75%) on improving activity or participation. Results from a single study demonstrated that activity training on the ground combined with other physiotherapy intervention was not more effective than no intervention (SMD: -0.18 CI: -0.89 to 0.54). Conclusions: The available evidence shows little effect of activity training on the ground on activity or participation in children with cerebral palsy, suggesting that rigorous trials with larger samples and larger "dosage" of activity training on the ground are needed in the future.

Balance and mobility training at home using Wii Fit in children with cerebral palsy: a feasibility study.

OBJECTIVES: To investigate whether balance and mobility training at home using Wii Fit is feasible and can provide clinical benefits. DESIGN: Single-group, pre-post intervention study. SETTING: Participants' home. PARTICIPANTS: 20 children with cerebral palsy (6-12 years). INTERVENTION: Participants undertook 8 weeks of home-based Wii Fit training in addition to usual care. MAIN MEASURES: Feasibility was determined by adherence, performance, acceptability and safety. Clinical outcomes were strength, balance, mobility and participation measured at baseline (preintervention) and 8 weeks (postintervention). RESULTS: The training was feasible with 99% of training completed; performance on all games improved; parents understood the training (4/5), it did not interfere in life (3.8/5), was challenging (3.9/5) and would recommend it (3.9/5); and there were no injurious falls. Strength increased in dorsiflexors (Mean Difference (MD) 2.2 N m, 95% CI 1.1 to 3.2, p<0.001), plantarflexors (MD 2.2 N m, 95% CI 1.3 to 3.1, p<0.001) and quadriceps (MD 7.8 N m, 95% CI 5.2 to 10.5, p<0.001). Preferred walking speed increased (MD 0.25 m/s, 95% CI 0.09 to 0.41, p<0.01), fast speed increased (MD 0.24 m/s, 95% CI 0.13 to 0.35, p<0.001) and distance over 6 min increased (MD 28 m, 95% CI 10 to 45, p<0.01). Independence in participation increased (MD 1.4 out of 40, 95% CI 0.0 to 2.8, p=0.04). CONCLUSIONS: Balance and mobility training at home using Wii Fit was feasible and safe and has the potential to improve strength and mobility, suggesting that a randomised trial is warranted. TRIAL REGISTRATION NUMBER: ACTRN12616001362482.

Attention during functional tasks is associated with motor performance in children with developmental coordination disorder: A cross-sectional study.

This cross-sectional and exploratory study aimed to compare motor performance and electroencephalographic (EEG) attention levels in children with developmental coordination disorder (DCD) and those with typical development, and determine the relationship between motor performance and the real-time EEG attention level in children with DCD.Eighty-six children with DCD [DCD: n = 57; DCD and attention deficit hyperactivity disorder (ADHD): n = 29] and 99 children with typical development were recruited. Their motor performance was assessed with the Movement Assessment Battery for Children (MABC) and attention during the tasks of the MABC was evaluated by EEG.All children with DCD had higher MABC impairment scores and lower EEG attention scores than their peers (P < 0.05). After accounting for age, sex, body mass index, and physical activity level, the attention index remained significantly associated with the MABC total impairment score and explained 14.1% of the variance in children who had DCD but not ADHD (P = 0.009) and 17.5% of the variance in children with both DCD and ADHD (P = 0.007). Children with DCD had poorer motor performance and were less attentive to movements than their peers. Their poor motor performance may be explained by inattention.

Constraint-induced movement therapy improves upper limb activity and participation in hemiplegic cerebral palsy: a systematic review.

QUESTIONS: Does constraint-induced movement therapy improve activity and participation in children with hemiplegic cerebral palsy? Does it improve activity and participation more than the same dose of upper limb therapy without restraint? Is the effect of constraint-induced movement therapy related to the duration of intervention or the age of the children? DESIGN: Systematic review of randomised trials with meta-analysis. PARTICIPANTS: Children with hemiplegic cerebral palsy with any level of motor disability. INTERVENTION: The experimental group received constraint-induced movement therapy (defined as restraint of the less affected upper limb during supervised activity practice of the more affected upper limb). The control group received no intervention, sham intervention, or the same dose of upper limb therapy. OUTCOME MEASURES: Measures of upper limb activity and participation were used in the analysis. RESULTS: Constraint-induced movement therapy was more effective than no/sham intervention in terms of upper limb activity (SMD 0.63, 95% CI 0.20 to 1.06) and participation (SMD 1.21, 95% CI 0.41 to 2.02). However, constraint-induced movement therapy was no better than the same dose of upper limb therapy without restraint either in terms of upper limb activity (SMD 0.05, 95% CI -0.21 to 0.32) or participation (SMD -0.02, 95% CI -0.34 to 0.31). The effect of constraint-induced movement therapy was not related to the duration of intervention or the age of the children. CONCLUSIONS: This review suggests that constraint-induced movement therapy is more effective than no intervention, but no more effective than the same dose of upper limb practice without restraint. REGISTRATION: PROSPERO CRD42015024665. [Chiu H-C, Ada L (2016) Constraint-induced movement therapy improves upper limb activity and participation in hemiplegic cerebral palsy: a systematic review.Journal of Physiotherapy62: 130-137].

Upper limb training using Wii Sports Resort for children with hemiplegic cerebral palsy: a randomized, single-blind trial.

OBJECTIVE: To investigate whether Wii Sports Resort training is effective and if any benefits are maintained. DESIGN: Randomized, single-blind trial. PARTICIPANTS: Sixty-two hemiplegic children with cerebral palsy (6-13 years). INTERVENTION: Experimental group undertook six weeks of home-based Wii Sports Resort training plus usual therapy, while the control group received usual therapy. MAIN MEASURES: Outcomes were coordination, strength, hand function, and carers' perception of hand function, measured at baseline, six, and 12 weeks by a blinded assessor. RESULTS: There was a trend of mean difference (MD) for the experimental group to have more grip strength by six (MD 4.0 N, 95% confidence interval (CI) -0.8 to 8.8, p = 0.10) and 12 (MD 4.1 N, 95% CI -2.1 to 10.3, p = 0.19) weeks, and to have a higher quantity of hand function according to carers' perception by six (MD 4.5 N, 95% CI -0.7 to 9.7, p = 0.09) and strengthened by 12 (MD 6.4, 95% CI 0.6 to 12.3, p = 0.03) weeks than the control group. There was no difference between groups in coordination and hand function by six or 12 weeks. CONCLUSION: Wii training did not improve coordination, strength, or hand function. Beyond the intervention, carers perceived that the children used their hands more.

Effect of functional electrical stimulation on activity in children with cerebral palsy: a systematic review.

PURPOSE: To determine whether functional electrical stimulation (FES) is effective and whether it is more effective than activity training alone. METHOD: MEDLINE, CINAHL, EMBASE, Cochrane, Web of Science, and PEDro databases were searched for randomized trials. Studies of randomized trials were included if the participants were children (<18 years old) with spastic cerebral palsy, who underwent a program of FES that involved electrical stimulation during practice of an activity. Measures of activity that best reflected the activity trained were examined. RESULTS: Five randomized trials were included. Three trials reported statistically significant between-group differences in favor of FES compared with no FES. Two trials reported no statistically significant between-group differences of FES compared with activity training alone. CONCLUSION: The available evidence suggests that FES is more effective than no FES but that it has a similar effect as activity training alone in cerebral palsy.

Associated reactions during a visual pursuit position tracking task in hemiplegic and quadriplegic cerebral palsy.

Most previous studies of associated reactions (ARs) in people with cerebral palsy have used observation scales, such as recording the degree of movement through observation. The sensitive quantitative method can detect ARs that are not amply visible. The aim of this study was to provide quantitative measures of ARs during a visual pursuit position tracking task. Twenty-three hemiplegia (H) (mean +/- SD: 21y 8m +/- 11y 10m), twelve quadriplegia (Q) (21y 5m +/- 10y 3m) and twenty-two subjects with normal development (N) (21y 2m +/- 10y 10m) participated in the study. An upper limb visual pursuit tracking task was used to study ARs. The participants were required to follow a moving target with a response cursor via elbow flexion and extension movements. The occurrence of ARs was quantified by the overall coherence between the movements of tracking and non-tracking limbs and the amount of movement due to ARs was quantified by the amplitude of movement the non-tracking limbs. The amplitude of movement of the non-tracking limb indicated that the amount of ARs was larger in the Q group than the H and N groups with no significant differences between the H and N groups. The amplitude of movement of the non-tracking limb was larger during non-dominant than dominant tracking in all three groups. Some movements in the non-tracking limb were correlated with the tracking limb (correlated ARs) and some movements that were not correlated with the tracking limb (uncorrelated ARs). The correlated ARs comprised less than 40% of the total ARs for all three groups. Correlated ARs were negatively associated with clinical evaluations, but not the uncorrelated ARs. The correlated and uncorrelated ARs appear to have different relationships with clinical evaluations, implying the effect of ARs on upper limb activities could be varied.

Characteristics of associated reactions in people with hemiplegic cerebral palsy.

PURPOSES: To investigate the relationship between associated reactions and a) spasticity, b) contracture and c) coordination. METHODS: Associated reactions were measured as magnitude of muscle activity in the affected limb during a 50% maximum voluntary contraction of muscles in the unaffected limb. Spasticity was measured as hyper-reflexia during passive muscle stretch, coordination as performance during a tracking task, and contracture as loss of range of motion. Chi-square analysis was used to examine the association between associated reactions and spasticity, and linear regression to examine the relationship between associated reactions and spasticity, coordination and contracture. RESULTS: Twenty-three people with hemiplegic cerebral palsy aged from 15 to 47 years (mean [SD]: 29 years [9]) participated. Thirteen participants exhibited spasticity, and six participants exhibited associated reactions. Five of the six participants with associated reactions also had spasticity (χ2=2.37, p=0.12). Associated reactions were highly correlated with spasticity (r=0.77, p=0.001), but not with contracture (r=0.35, p=0.29) or coordination (r=-0.31, p=0.30). CONCLUSIONS: Although 27% of participants exhibited associated reactions, and these were mostly small, associated reactions appear to be an expression of spasticity in hemiplegic cerebral palsy.

Relative contribution of motor impairments to limitations in activity and restrictions in participation in adults with hemiplegic cerebral palsy.

OBJECTIVE: To determine which motor impairments make a significant relative contribution to upper limb activity limitations, and whether activity limitations are related to participation restrictions in people with hemiplegic cerebral palsy. DESIGN: An observational study. SETTING: Neurological Rehabilitation Research Group at Faculty of Health Sciences, The University of Sydney. SUBJECTS: Twenty-three people with hemiplegic cerebral palsy participated. MAIN MEASURES: Four motor impairments (strength, coordination, spasticity and contracture), upper limb activity and participation were measured. Multiple regression was used to determine the relative contribution of motor impairments to activity limitations. Linear regression was used to determine the correlation between activity and participation. RESULTS: The four motor impairments accounted for 63% of the variance in upper limb activity with coordination independently accounting for 21% (P<0.01). Upper limb activity accounted for 13% of the variance in participation (P=0.10). CONCLUSIONS: The findings imply that coordination of four motor impairments makes the largest independent relative contribution to activity limitations, whereas upper limb activity makes less contribution to participation in people with mild and moderate hemiplegic cerebral palsy.