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					The GMFCS and GMFM in Clinical Practice

      Dianne Russell and Peter Rosenbaum
          CanChild Centre for Childhood Disability Research
             McMaster University, Hamilton, ON. Canada
      Watch Videoconference, Friday June 6, 2008
Why use standardized measures

Purposes of measures

     • To discriminate/describe
     • To prognosticate
     • To evaluate change over time
     “Gross Motor

Palisano et al., 1997, 2008
What is it?

• 5 level classification system describing levels of
  gross motor function of children/youth with CP

• Based on their current functional abilities and
  limitations and their need for assistive technology

• Function is emphasis, not quality of movement
Why is the GMFCS important?

• Previous subjective, clinical judgment (i.e. „mild‟,
  „moderate‟, „severe‟) meaningless, unreliable, not

• Based on observation, parent report – quick and

• Functionally based, not impairment-based
  (consistent with ICF framework)

Clinically useful:

   • Communication tool (clinicians, families)

   • Goal setting/planning interventions

   • With motor centile curves, to determine how a
     child is doing compared to children of similar
     age and GMFCS level
      • consistent language
      • describing samples
      • conveying results

      • manage caseloads/ resource allocation
      Further work with the GMFCS

• Parents‟ use of the GMFCS – reliable

• The addition of an adolescent band to the GMFCS

• Dutch colleagues will be adding more detail to the
  under 2 years band (Gorter et al, in press DMCN)
                             GMFCS-E & R

             GMFCS – E & R
          Gross Motor Function
           Classification System
          Expanded and Revised
                       GMFM or GMFM-88

What is it?
• observational measure of how much of an activity
  a child with cerebral palsy can do (but not how well
  they can do it – i.e. quality or performance)

What is the purpose of the GMFM?

  evaluative & descriptive
  GMFM “Gross
 Motor Function

Russell et al., 2002
                   GMFM or GMFM-88

• 88 items

• 5 dimensions (grouped together for ease of

• Items were ordered in each dimension
  using best judgment as to difficulty
                   GMFM or GMFM-88

• Standardized 4 point ordinal scale (0-3 for
  each item)

• Raw scores for each dimension, a total
  “percent” score; goal area scores; change
           Item 36
On the floor: Attains sitting on
small bench

0 = does not initiate sitting
1 = initiates sitting
2 = partially attains sitting
3 =attains sitting
NT = Not tested

     Generic Scoring Key

     Initiates=completes less
     than 10% of task

     Partially completes=
     completes >10% to less
     than 100%

#58: Standing:lifts R foot, arms free, 10 secs.
   •   0= does not lift R foot, arms free
   •   1= lifts R foot, arms free, < 3 secs.
   •   2= lifts R foot, arms free, 3-9 secs.
   •   3= lifts R foot, arms free, 10 secs.
How is the GMFM-66 different from the GMFM-88?

  • 66 items of the original 88 items

  • The “ability continuum” ranging from 0 (low
    motor ability) to 100 (high motor ability)

  • An interval scale where change over time
    comparisons are more meaningful (difference of “x”
    points is the same at the lower and upper ends of the scale)

Requires GMAE (“Gross Motor Ability Estimator”)
  computer program to score:

• Provides an estimate of score even when not all
  items administered

• Can track scores over time (database)

• Produces item maps – arrange items by order of
Russell et al., 2002
Russell et al., 2002
Clinical Use of Item Maps and Case
• Understand/interpret change

• Identify relatively easier and more difficult „next
  steps‟ for a child

• Discuss and communicate with parents about a child‟s

• Set appropriate goals and plan interventions
      Current work with the GMFM

• GMFM Algorithms (Item sets)

  • Developed to identify subsets of the 66
    items which give a good estimate of a
    child‟s score while shortening the time
    for administration of the GMFM-66
Exploring Gross Motor Development
Prospectively (JAMA 2002; 288; 1357-63)
 • OMG study: 5 years, NIH funding, 682 kids from
   across Ontario, 2632 GMFMs

 • First study of its type in the world

 • Main findings: a series of „motor growth‟ curves
   for prognostication and treatment planning

 • Published Sept 2002 to good critical notice
Motor Growth Curves

                  Taken from
               Rosenbaum et al.
                (2002). JAMA;
                 288; 1357-63
 How can the Motor Growth Curves
                        be used?

• Describe patterns of gross motor function
  for children with cerebral palsy over time

• Estimate a child‟s future motor capabilities
                 Current work with motor

• Adding centiles to the motor growth curves
  (Hanna et al. 2008 Phys Ther 88:596-607)

• Extending the motor growth curves into
  adolescence (ASQME study)
              Current work with motor

• Development of parent educational materials
   …my child is GMFCS level III, what does that
    mean in terms of outcomes, interventions

• Qualitative study with parents
         “If I knew then what I know now”
                 Putting the measures all
• Several distinct purposes (all validated):
   • discriminative (descriptive)
   • evaluative
   • prognostic (predictive)

• Can be used together to describe, to track and
  evaluate change over time, and to determine how
  the rate of change compares to children of similar
  abilities and ages
                        Scenario of Beth

• Beth was born prematurely

• Almost 2 years old and still not walking

• Diagnosis of cerebral palsy
         Beth’s parents want to know

• How bad is it?

• Will Beth walk?

• How will we know if therapy is working?
      Beth’s therapist wants to know

• What evidence-based measures are
  available to help me answer Beth‟s
  parents‟ questions?

• How will I find the time to learn these

• How can I use these measures to assist
  with realistic goal setting and
  collaborating with Beth‟s parents?
The administrator at Beth’s treatment
               centre wants to know
 • How do we ensure that resources
   (therapy time and equipment) are

 • How can we document the effectiveness
   of our interventions to improve motor
  “Our Child Has CP…”
  Parents’ First Questions, and Ways to Respond

                                                   Classifies gross
   “How bad is it?”                                motor function in
                          GMFCS                    children with CP

                          Motor               Relates age & GMFCS
   “Will our child                              level to prognosis
      walk?”              Growth

                                                    Measures change over
 “How do we know if                               time due to treatment or
therapy is working?”   GMFM-66 &
     Our Challenge as Researchers and

• How do we improve the uptake of these
  validated measures into clinical practice?
Knowledge translation
                                Current work

• Exploring issues in knowledge translation

   • 3 year CIHR study of moving the Motor
     Measures into Clinical Practice using a
     Knowledge Broker (KB)
      Role of the Knowledge Broker
• The job of knowledge brokering is to bring people
  (researchers, decision-makers, practitioners and
  policy-makers) together and build relationships
  among them that make knowledge transfer more

      • CHSRF (2003) The practice of Knowledge
        Brokering in Canada‟s health system

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