The Role of Cognitive Functioning in the ICF Framework: A Systematic Review of Its Influence on Activities and Participation and Environmental Factors in People with Cerebral Palsy

Abstract

Background/Objectives: Cerebral palsy (CP) is the most common cause of motor disability in childhood and is frequently associated with cognitive impairments that limit autonomy and participation. While motor function is a known predictor of functional outcomes, the specific contribution of cognitive domains within the International Classification of Functioning, Disability and Health (ICF) framework remains unexplored. This systematic review examines the relationship between cognitive domains and the ICF components of Activities and Participation, and Environmental Factors in people with CP. Methods: Following PRISMA guidelines, a systematic search was conducted across six databases (PubMed, PsycINFO, CENTRAL, CINAHL, ERIC, and WOS) for studies published between 2002 and 2025. Eligible studies included participants with CP (n = 3056) and analyzed associations between cognitive functions and ICF domains using standardized tools and statistical methods. Risk of bias was evaluated using the Oxford Centre for Evidence-Based Medicine criteria. Results: Forty-four studies met inclusion criteria, involving mostly children and adolescents with spastic CP and mild to moderate motor impairment. General intellectual functioning, language, and visual perception were the most studied domains, showing consistent associations with ICF chapters such as Learning and applying knowledge, Communication, and Mobility. Although fewer studies examined Environmental Factors, relevant associations emerged with support systems, attitudes, and services. Heterogeneity in assessment methods and participant profiles was observed, and adult representation was limited. Conclusions: Cognitive functioning is significantly associated with multiple ICF domains in CP. Environmental Factors remain insufficiently addressed. Further research should consider CP heterogeneity and promote standardized assessments to support ICF-based intervention planning.