Manual Ability Classication System for Children With

Cerebral Palsy in a School Setting and Its Relationship

to Home Self-Care Activities
M. A. Kuijper, G. J. van der Wilden, M. Ketelaar, J. W. Gorter
KEY WORDS
activities of daily living
cerebral palsy
motor skills
reproducibility of results
self care
task performance and analysis
M. A. Kuijper, MD, is Pediatric Rehabilitation Physician,
Rehabilitation Center De Hoogstraat, Rembrandtkade 10,
3583TM Utrecht, The Netherlands, and Department of
Rehabilitation, Nursing Science and Sports, University
Medical Centre, Utrecht, The Netherlands;
MAKuyper@dehoogstraat.nl
G. J. van der Wilden, MD, is Pediatric Rehabilitation
Physician, Rehabilitation Centre het Roessingh, Enschede,
The Netherlands.
M. Ketelaar, PhD, MD, is Associate Professor,
Rehabilitation Center De Hoogstraat, Utrecht, The
Netherlands; Department of Rehabilitation, Nursing
Science and Sports, Rudolf Magnus Institute of
Neuroscience, University Medical Centre, Utrecht, The
Netherlands; and Partner of NetChild, Network for
Childhood Disability Research in The Netherlands.
J. W. Gorter, PhD, is Associate Professor, CanChild
Centre for Childhood Disability Research, McMaster
University, Hamilton, Ontario, Canada, and Partner of
NetChild.
OBJECTIVE. Our aimin this study was to investigate the relationship between (a) the manual abilities of children
with cerebral palsy (CP), assessed with the Manual Ability Classication System (MACS) in a school rehabilitation
setting, and (b) the childrens performance of self-care activities at home, assessed with the Pediatric Evaluation of
Disability Inventory (PEDI). In addition, we assessed the interobserver reliability of the MACS.
METHOD. Sixty-one children with CP were included (mean age 5 10.3 yr, range 5 514). The MACS
was classied by 2 independent raters. The PEDI was scored in a structured interview.
RESULTS. The Spearman correlation coefcient between the MACS and the self-care domain of the PEDI
Caregiver Assistance Scale was high and statistically signicant (r 5.72). The interobserver reliability of the
MACS was good (weighted k 5 .86).
CONCLUSION. The MACS is a reliable instrument in a school environment and is related to the per-
formance of daily life self-care activities at home.
Kuijper, M. A., van der Wilden, G. J., Ketelaar, M., & Gorter, J. W. (2010). Manual ability classication system for children
with cerebral palsy in a school setting and its relationship to home self-care activities. American Journal of
Occupational Therapy, 64, 614620. doi: 10.5014/ajot.2010.08087
C
erebral palsy (CP) is a well-dened neurodevelopmental condition begin-
ning in infancy and persisting throughout life. CP encompasses a group of
disorders in the development of movement and posture that cause activity
limitations and are attributed to nonprogressive disturbances occurring in the
developing fetal or infant brain (Rosenbaum, Paneth, Leviton, Goldstein, &
Bax, 2007). The need for functional systems to classify the severity of a het-
erogeneous condition such as CP was recognized in the 1990s. The purpose of
a classication system in a clinical setting is twofold: (1) to describe the con-
sequences of CP in a consistent and meaningful way and (2) to enhance the
communication between professionals and parents to determine a childs cur-
rent needs. Moreover, a classication system with predictive validity can
help parents to anticipate their childs future function (Palisano, Cameron,
Rosenbaum, Walter, & Russell, 2006; Rosenbaum et al., 2002). Other possible
purposes of functional classication systems include education or research,
provided that the instruments can be shown to be reliable and valid for these
purposes (Morris & Bartlett, 2004).
Since 1997, two classication systems have been created and validated to
classify children with CP on the basis of their functional abilities: the Gross
Motor Function Classication System (GMFCS; Palisano et al., 1997, 2006)
and the Manual Ability Classication System (MACS; Eliasson et al., 2006).
The GMFCS is a ve-level classication system of gross motor abilities, that is,
the ability to move around. Since the rst publication of the GMCS (Palisano
et al., 1997), it has been shown to be reliable, valid and, most important,
614 July/August 2010, Volume 64, Number 4
meaningful with respect to the daily activities and
participation of children and adolescents with CP
(Donkervoort, Roebroeck, Wiegerink, van der Heijden-
Maessen, & Stam, 2007; McCormick et al., 2007). The
GMFCS is widely accepted among researchers and pro-
fessionals in the eld of childhood disability (Morris &
Bartlett, 2004; Rosenbaum, Palisano, Bartlett, Galuppi,
& Russell, 2008).
In addition to the GMFCS, a classication of manual
ability from a functional perspective, with clear and
meaningful levels, was needed. Until recently, the classi-
cations of manual function did not describe daily per-
formance (i.e., what a child does do in daily life).
Classication systems focused on manual function, such as
the House Classication (House, Gwathmey, & Fidler,
1981), the Modied House Classication (Koman et al.,
2008), and the Zancolli classication (Zancolli & Zancolli,
1981), or focused on manual functional capacity (i.e., what
a child can do), such as the Bimanual Fine Motor Function
(Beckung & Hagberg, 2002). Hence, a need existed for
a simple and valid instrument, focusing on performance in
daily activities, to get further insight into a childs daily
activities.
On the basis of the concept of the GMFCS, Eliasson
et al. (2006) developed the MACS. The MACS is based on
the perspective of the childs typical manual performance
in daily life. The instrument focuses on the way children
with CP use both of their hands when handling objects in
daily activities. These activities should be age appropriate
and relevant, such as eating, dressing, and playing, and
should not include activities that need advanced skills
training, such as playing a musical instrument. Thus, the
MACS focuses on everyday performance, is not designed
to classify the best capacity, and does not intend to dis-
tinguish between hands in terms of capacities. Five levels
have been dened in the MACS; the distinctions (just as
in the GMFCS) are intended to be clinically meaningful
and are based on the way in which a child handles ob-
jects and the need for assistance or adaptations to per-
form manual tasks in everyday life. The ve levels and
their descriptions are presented in Figure 1. The MACS
manual denes distinctions between each pair of levels
to assist with determining the level that most closely
resembles a childs manual abilities. The scale is ordi-
nal, and the distances between levels are not considered
equal.
The MACS is an easy and quick instrument to classify
the manual ability of children with CP. In a clinical setting,
it would be useful for professionals to know what a child
actually does in daily life. What a child does can be assessed
in different ways by various instruments but can be time
consuming. Given that occupational therapists and
physicians generally see children during the daytime in
a school or treatment setting, it is important to ascertain to
what extent a childs MACS level (as classied at school) is
related to his or her performance of self-care activities at
home. Therefore, our rst aim in this study was to ex-
amine the relationship between the MACS levels of chil-
dren with CP as assessed in a school rehabilitation setting
and their performance of self-care activities at home.
In everyday practice, occupational therapists and re-
habilitation physicians evaluate children from different
perspectives. Occupational therapists see a child mostly
on a daily basis in the classroom or during a therapeutic
session, and they focus on the assessment and treatment of
upper-extremity problems in relation to a childs manual
abilities and daily functioning. Rehabilitation physicians
see a child in their ofce during a general assessment, and
functional classication is only part of the examination.
According to the Dutch guidelines for children with
spastic CP (Kwaliteitsinstituut voor de Gezondheidszorg
CBO, 2007). all childrens GMFCS and MACS levels
should be part of the diagnosis recorded in documents
and medical correspondence. It is therefore important to
know whether a rehabilitation physicians MACS classi-
cation for a particular child is in agreement with the
MACS classication established by an occupational
therapist, who has more information on the childs
functioning in the classroom and therapy settings. Our
second aim in this study was therefore to assess the in-
terobserver reliability of the MACS between occupational
therapists and rehabilitation physicians.
Figure 1. Manual Ability Classication System levels.
From Eliasson et al. (2010, p. 2).
The American Journal of Occupational Therapy 615
Method
Participants
Children with CP attending two schools for special ed-
ucation and rehabilitation were included in the study if
they met the following criteria: diagnosis of CP as dened
by Rosenbaum et al. (2007) and currently between ages 5
and 14. A child was excluded if his or her parents did
not speak Dutch, if the child had a past neurosurgical or
orthopedic intervention of the upper extremity, or if the
child had been treated with botulinum toxin Type A in
the upper extremity in the past 6 months.
Of 72 children with CP at the two schools, 67 met the
inclusion and exclusion criteria. All parents were informed
about the data collection, and 61 gave consent for their
child to participate in the study. We classied the subtypes
of CP, distinguished by type of motor disorder (spastic,
ataxic, or dyskinetic) and topographical distribution for
spastic CP (unilateral or bilateral), according to Surveillance
of Cerebral Palsy in Europe guidelines (Gorter et al.,
2004; Surveillance of Cerebral Palsy in Europe, 2000).
The severity of functional motor abilities was classied
using the Dutch translation of the GMFCS (Gorter,
Boonacker, & Ketelaar, 2005; Palisano et al., 1997).
Instruments
The MACS is a systematic method, consisting of ve
levels, to classify how children with CP use their hands
when handling objects in daily activities. Results of a study
by Eliasson et al. (2006) demonstrated that the MACS
was a reliable instrument (with an intraclass correlation
coefcient [ICC] between therapists of .97) and estab-
lished initial validation. In this study, we used the Dutch
translation of the MACS (which can be downloaded at
www.MACS.nu). A childs MACS classication can be
assessed by a person who knows the childs actual per-
formance; using the MACS requires no special training.
Performance in terms of a childs self-care activities at
home was studied using the self-care domain of the
Caregiver Assistance Scale of the Pediatric Evaluation of
Disability Inventory (PEDI; Haley, Coster, Ludlow,
Haltiwanger, & Andrellos, 1992). The PEDI is a judgment-
based, standardized instrument using parental reports
through a structured interview. The PEDI consists of
three scales: Functional Skills, Caregiver Assistance, and
Modications. Each scale consists of three domains: self-
care, mobility, and social function. We used the PEDI
Caregiver Assistance Scale for self-care activities. Raw
scores on the Caregiver Assistance Scale can be transformed
into scaled scores, which provide an indication of a childs
performance on relatively easy to relatively difcult items
in a particular domain. Scaled scores range from 0 to 100.
We used the Dutch version of the PEDI (Wassenberg-
Severijnen, Custers, Hox, Vermeer, & Helders, 2003). The
interinterviewer reliability of the Dutch version has been
studied and found to be good (ICC 5 .99 for all scales;
Wassenberg-Severijnen et al., 2003), and its validity has
been conrmed (Custers et al., 2002).
Procedure
Participating in the study were eight occupational ther-
apists and two rehabilitation physicians, all of whom were
familiar with each child. Each child was rst classied with
the MACS after direct observation in the school setting by
an occupational therapist and, independently, by the re-
habilitation physician, within 3 wk of each other. The
PEDI Caregiver Assistance Scale for self-care activities was
then scored in a structured interview with one of the
childs parents. For pragmatic reasons, the interview was
done by telephone either by one of the occupational
therapists or by one of the rehabilitation physicians. All
assessors were trained in the administration and scoring
of the PEDI. More than two thirds (69%; n 5 42) of the
participants were assessed by a therapist, and the other
31% (n 5 19) were assessed by one of the two re-
habilitation physicians. The MACS classication and the
PEDI assessment were performed within a 3-wk period.
The rehabilitation physician treating a child retrieved the
childs characteristics from the medical records, including
gender, CP distribution, type of CP, age, and GMFCS
(Palisano et al., 1997).
Statistical Analysis
We used Spearman rank-order correlation coefcients to
analyze the relationship between the MACS, as classied
by the therapists, and the scaled score on the self-care
domain of the PEDI Caregiver Assistance Scale. Spear-
mans rank-order correlations of .1.29 were categorized
as small; those of .3.49, medium; and those of .51.0,
large (Cohen, 1988). Linear weighted k was used for the
interobserver reliability of the MACS levels. We catego-
rized k statistics as indicating poor agreement when <.20,
as fair when .21.40, as moderate when .4.60, as good
when .61.80, and as very good when >.8 (Altman, 1997).
Results
Table 1 shows the characteristics of the participating
children. Most of the children had CP of the spastic type.
Most participants were bilaterally affected, and as a
group, they were distributed across all GMFCS levels.
616 July/August 2010, Volume 64, Number 4
Children were classied by the therapists as follows: 23%
as MACS Level 1, 34% as MACS Level 2, 21% as
MACS Level 3, 15% as MACS Level 4, and 7% as
MACS Level 5.
Figure 2 shows box plots of the relation between the
MACS (as classied by the therapists) and the PEDI
Caregiver Assistance Scale for self-care activities (scaled
score 5 0100). Medians (25th and 75th percentiles) of
scores on the Caregiver Assistance Scale were 81 for Level
1 (range 5 7488), 70 for Level 2 (range 5 6674), 66
for Level 3 (range 55775), 42 for Level 4 (range 526
58), and 8.3 for Level 5 (range 5724). Note that a high
MACS level represents a lower level of manual ability,
implying that these children need more assistance, as
reected by a lower score on the PEDI Caregiver Assis-
tance Scale. Only 5 children of 61 (8%) had a scaled
score of 100, indicating they were fully independent in
self-care activities. Remarkably, 3 of these children were
classied at MACS Level 1, 1 at MACS Level 2, and 1 at
MACS Level 3.
The Spearman rank-order correlation coefcient be-
tween the MACS levels (as scored by the therapists) and
the scores on the PEDI Caregiver Assistance Scale for self-
care activities was 2.72, which is signicant at the .01
level (two-tailed).
Weighted k (with linear weighting) for the inter-
observer reliability of the MACS between the therapists
and physicians was found to be .86 (condence interval 5
.78.94). Fifty children (82%) were classied at the same
MACS level by the therapist and the rehabilitation phy-
sician (Table 2). Where they disagreed, the difference be-
tween the two raters was never more than one MACS level.
The therapist classied 7 children more severely than did
the rehabilitation physician, and the rehabilitation physi-
cian classied 4 children more severely than did the ther-
apist.
Table 1. Characteristics of the Study Population (N 5 61)
Characteristic n or Mean
Age (yr) 10.3 (range 5 514)
Gender, n (%)
Male 36 (59)
Female 25 (41)
Type of CP, n (%)
Ataxic 1 (2)
Dyskinetic 2 (3)
Spastic 58 (95)
Unilateral 22 (37)
Bilateral 36 (63)
GMFCS level, n (%)
1 22 (36)
2 14 (23)
3 7 (11)
4 11 (18)
5 7 (12)
Note. CP 5 cerebral palsy; GMFCS 5 Gross Motor Function Classication
System.
Figure 2. Relationship between Manual Ability Classication System (MACS; classied by therapist) and the Caregiver Assistance Scale
(CAS) of the Pediatric Evaluation of Disability Inventory (PEDI).
Note. Box plots depict median score (), interquartile range (gray), and minimum and maximum values (whiskers); s shows outliers. IV 5 MACS Levels 15.
The American Journal of Occupational Therapy 617
Discussion
This studys results show that the relatively easy classi-
cation of the manual abilities of a child with CP by means
of the MACS in a school environment is related to the
childs level of performance in terms of self-care activities
at home: With a correlation of 2.72, 52% of the variance
in the PEDI scores can be explained by the MACS clas-
sication. Moreover, the degree of assistance with self-
care activities in the home situation increases signicantly
with each MACS level assessed at school, especially for
Levels 4 and 5. The MACS levels scored by an occupa-
tional therapist in a special school setting can thus pro-
vide the team with an estimate of the level of performance
of self-care activities at home.
The second aim of this study was to examine whether
a rehabilitation physician in clinical practice, who has only
few minutes available, would classify the MACS level in
the same way as an occupational therapist in a school
setting. The interrater reliability of the MACS levels be-
tween occupational therapists and rehabilitation physicians
was good (weighted k 5 .86, condence interval 5
.78.94). Where there was less than absolute agreement,
the difference between the occupational therapist and the
rehabilitation physician was never more than one level.
The current study focused on actual clinical practice.
At schools, children are often seen by an occupational
therapist in the classroom or in therapy sessions without
parents being present. For health professionals, however, it
is important to have an idea about a childs performance at
home. Ideally, a full PEDI assessment with the parent
would provide the therapist with the most complete in-
formation about the childs needs and functioning, but
the full PEDI can be time consuming (Wassenberg-
Severijnen et al., 2003) and cannot always be completed
in a single session. Therefore, a single MACS classication
that correlates with the PEDI score can provide in-
formation about areas requiring extra attention in therapy.
If necessary, a therapist could always decide to assess
a childs functioning in more detail by means of a full
PEDI or a home visit.
A limitation of the current study was that the children
were classied only by health professionals. Although
Morris, Kurinczuk, Fitzpatrick, and Rosenbaum (2006)
demonstrated that, when used by families to assess their
childs manual ability, the MACS reliability is high
(albeit a little lower than the reliability among pro-
fessionals), families and professionals observe the child in
different environments and thus from different per-
spectives. The developers of the MACS emphasize that
the MACS classication should be based on information
from the parents (Eliasson et al., 2006). We realize that
MACS classication based on parents reports might
provide a better indication of self-care activities at home,
but our data show that therapists MACS classications
provide a useful indication.
Another limitation of the current study is that we do
not have detailed information regarding the arguments
used by therapists and physicians for their classications.
Hence, we do not knowin cases in which the two
disagreedwhat the reasons behind the disagreement
were. The MACS manual states that the MACS should
be used by someone who knows the child well. It might
be helpful to dene what is meant by someone who
knows the child well.
Although this study provides some information about
the relation between the MACS and daily self-care ac-
tivities at home, longitudinal studies are needed to learn
more about the development of self-care activities at home
in relation to the MACS. The GMFCS has proved to be an
important predictor of development in terms of gross
motor functioning. It is conceivable that the MACS could
have the same value for the description of self-care ac-
tivities.
Our study included a sample of children in the age
range of 514 yr at a school for special education. The
distribution of GMFCS levels across the study population
is comparable with that found in the Himmelmann,
Hagberg, Beckung, Hagberg, and Uvebrant (2005) study.
It is noteworthy that most children were classied at
MACS Level 2 (34%); Eliasson et al. (2006) found the
same pattern (Level 2 5 40%). Disagreements in our
study were distributed across Levels 14, but not Level 5,
whereas Eliasson et al. found disagreements across all
levels. In both studies, differences between observers did
not exceed one level.
To our knowledge, no studies on the MACS exist that
are comparable to the current study in a school setting. We
anticipate that the use of the MACS in everyday practice
will enhance the communication between professionals
with different backgrounds and between professionals and
parents and children, in much the same way that
Table 2. Number of Children at Each Level of the Manual Ability
Classication System (MACS)
MACS Level (Therapist)
MACS Level (Physician)
1 2 3 4 5 Total
1 12 2 0 0 0 14
2 1 20 0 0 0 21
3 0 5 6 2 0 13
4 0 0 1 8 0 9
5 0 0 0 0 4 4
Total 13 27 7 10 4 61
618 July/August 2010, Volume 64, Number 4
the GMFCS currently does (Morris & Bartlett, 2004).
The MACS can be used in research to describe the
characteristics of the study sample, to compare groups, or
as a stratication variable in prospective studies. In clin-
ical practice, the MACS might help professionals to de-
scribe a childs functional abilities and to guide treatment
options.
Summary
The MACS focuses on manual ability in daily life. We
found that the MACS, as scored in a school environment
by a therapist or rehabilitation physician who knows the
child well, is related to everyday self-care activities at
home. The MACS is therefore a reliable and useful
classication system in a special school setting to provide
the team with an estimate of the level of performance in
terms of self-care activities at home. If more detailed
information on a childs capability and performance of
self-care activities at home is required, the PEDI should
be regarded as the measure of rst choice, taking into
account the amount of time it will take. s
Acknowledgments
We acknowledge the children, parents, and therapists of
the two schools for special education and rehabilitation in
Enschede and Utrecht, The Netherlands, for participating
in this study.
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