Relationship between participation across daily environments and bimanual performance in children with unilateral cerebral palsy: an ICF-based cross-sectional study

Bimanual performance is a primary rehabilitation target in unilateral cerebral palsy children, yet its relationship with real-world participation remains unclear. This study aims to examine the relationship between bimanual performance and Participation outcomes across home, school, and community environments in children with unilateral cerebral palsy within the International Classification of Functioning, Disability and Health Children & Youth Version framework. Cross-sectional observational study of 70 children with unilateral cerebral palsy (mean age 9.5 years, Manual Ability Classification System I–III). Bimanual performance was assessed using the Assisting Hand Assessment and the Children’s Hand-use Experience Questionnaire; Participation was measured using the Participation and Environment Measure for Children and Youth. Correlation analyses examined associations between bimanual performance and Participation outcomes, adjusting for demographic characteristics, with a significance α < 0.05. Despite significant differences in bimanual performance across Manua Ability Classification System levels (p < 0.001), neither Assisting Hand Assessment nor Children’s Hand-use Experience Questionnaire scores correlated significantly with Participation frequency, involvement, or environmental facilitators/barriers across any setting (all p > 0.05). Demographic factors did not confound these associations. Environmental barriers increased progressively from home (24.5%) through school (30.5%) to community (34.1%), while Participation remained high in familiar contexts despite motor limitations. Although bimanual performance is a prominent impairment in unilateral cerebral palsy due to the lateralized motor impairments, it does not appear to be directly related to Participation. Instead, daily-life Participation is probably related with factors beyond motor function, underscoring the need for more holistic, biopsychosocial approaches. NCT06073522, 10 October 2023.