Gross Motor Function Classification System - Expanded and Revised (GMFCS-ER): Difference between revisions

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== Introduction ==
== Introduction ==
The Gross Motor Function Classification System - Expanded & Revised (GMFCS - E&R) categorises children with cerebral palsy in terms of their self-initiated gross motor function. This 5-level classification system focuses on wheeled mobility, walking and sitting. The levels are defined based on functional abilities, the need for wheeled mobility or assistive technology (canes, crutches or walkers). Quality of movement is also looked at, but to a lesser extent.<ref name=":1" />  
The Gross Motor Function Classification System - Expanded & Revised (GMFCS - E&R) was developed in 2007. It builds on the original version of the Gross Motor Function Classification System from 1997.<ref>Morris C. [https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1469-8749.2007.00005.x Development of the gross motor function classification system (1997)]. Developmental Medicine & Child Neurology. 2008 Jan 1;50(1):5-.</ref> It categorises children with cerebral palsy in terms of their self-initiated gross motor function. This 5-level classification system focuses on wheeled mobility, walking and sitting. The levels are defined based on functional abilities, the need for wheeled mobility or assistive technology (canes, crutches or walkers). Quality of movement is also looked at, but to a lesser extent.<ref name=":1" />  


The GMFCS - E&R is focused on discovering which level best represents the child's "present abilities and limitations in gross motor function".<ref name=":1" /> It considers usual activities, such as a child's performance in school, home and community settings rather than what they can do at their best. It, therefore, distinguishes between what they do rather than their capability. Classification is based on current performance in gross motor function and should not consider judgments about prognosis or movement quality.<ref name=":1">Can Child. GMFCS - E&R
The GMFCS - E&R is focused on discovering which level best represents the child's "present abilities and limitations in gross motor function".<ref name=":1" /> It considers usual activities, such as a child's performance in school, home and community settings rather than what they can do at their best. It, therefore, distinguishes between what they ''do'' rather than their ''capability''. Classification is based on current performance in gross motor function and should not consider judgments about prognosis or movement quality.<ref name=":1">Can Child. GMFCS - E&R
 
Gross Motor Function Classification System - Expanded & Revised.  Available from: https://canchild.ca/en/resources/42-gross-motor-function-classification-system-expanded-revised-gmfcs-e-r</ref>
 
== Objective ==
The revised and expanded version of the [[Classification of Cerebral Palsy|GMFCS]] (2007) builds upon the original version of the Gross Motor Function Classification System, which was developed in 1997 to classify and describe the abilities of children and youth with [[Cerebral Palsy Introduction|cerebral palsy]]. It has 4 age bands: less than 2 years, 2-4 years, 4-6 years and 6-12 years. This newer version describes the movement ability of a child with cerebral palsy in one of five levels across five age ranges, with emphasis on the child’s functional ability and performance in different settings, particularly sitting, walking, and wheeled mobility.<ref name=":1" />


Gross Motor Function Classification System - Expanded & Revised.  Available from: https://canchild.ca/en/resources/42-gross-motor-function-classification-system-expanded-revised-gmfcs-e-r</ref>
== Intended Population ==
== Intended Population ==
This classification system is intended for children and youth with CP from 0-18 years old. The GMFCS-ER contains five age groups, those being under 2 years, 2-4 years, 4-6 years, 6-12 years, and 12-18 years of age.
This classification system is intended for children and young people with CP. The revised version (GMFCS - E&R) includes five age ranges: The age groups are: under 2 years, 2-4 years, 4-6 years, 6-12 years, and 12-18 years of age.<ref name=":1" /> The GMFCS - E&R is available in 22 languages and has been validated in many different countries.
 
The GMFCS-ER is available in 22 languages and has been validated in many different countries.


== Method of Use ==
== Method of Use ==
Physical therapists, occupational therapists, physicians, and other health service providers familiar with movement abilities of children with CP can use the GMFCS-ER. Parents of children with CP are able to classify their children using an adapted version known as the GMFCS Family Report Questionnaire.
Physiotherapists, occupational therapists, physicians, and other health service providers familiar with the movement abilities of children with CP can use the GMFCS - E&R. Parents of children with CP are also able to classify their children using an adapted version known as the GMFCS Family Report Questionnaire.<ref name=":1" />


Health care providers familiar with a child can typically classify him or her within 5 minutes. Those unfamiliar with the child may require 15 to 20 minutes to complete as more observation is required.
Health care providers who are familiar with a child can typically classify them using the GMFCS - E&R within 5 minutes. Those unfamiliar with the child may require 15 to 20 minutes to complete the classification as more observation is required.<ref name=":1" />


Distinctions are usually quite clear and decisions about which level most closely represents a child's functional ability can be made quite quickly. However, distinctions between two adjacent levels can sometimes be very subtle, so more careful deliberation is required before a classification can be made.
Distinguishing between levels of the GMFCS - E&R is usually quite clear. However, it is important to note that at some ages, it is more difficult to distinguish between adjacent levels, so more time may be required to classify a child.<ref name=":1" />


Generally, the higher the level the poorer the functional ability of the child. The theme of each level is as follows:
The levels are as follows:<ref>CanChild. GMFCS-ER Resources. Last Accessed July 17, 2016 from https://canchild.ca/en/resources/42-gross-motor-function-classification-system-expanded-revised-gmfcs-e-r</ref><ref>Paulson A, Vargus-Adams J. [https://www.mdpi.com/2227-9067/4/4/30 Overview of four functional classification systems commonly used in cerebral palsy]. Children (Basel). 2017 Apr 24;4(4):30. </ref>


* '''Level I''': Walks without Limitations
* '''Level I''': able to walk without limitations
* '''Level II''': Walks with Limitations
* '''Level II''': can walk with limitations (e.g. balance, endurance limitations)
* '''Level III''': Walks Using a Hand-Held Mobility Device
* '''Level III''': can walk using a hand-held mobility device (may use additional support, such as wheeled mobility, for longer distances, outdoors)
* '''Level IV''': Self-Mobility with Limitations; May Use Powered Mobility
* '''Level IV''': self-mobility is limited - may be transported in a manual wheelchair or may use powered mobility
* '''Level V''': Transported in a Manual Wheelchair
* '''Level V''': transported in manual wheelchair
Reid et al.<ref name=":0">Reid SM, Carlin JB, Reddihough DS. [https://onlinelibrary.wiley.com/doi/full/10.1111/j.1469-8749.2011.04044.x Using the Gross Motor Function Classification System to describe patterns of motor severity in cerebral palsy]. Developmental Medicine & Child Neurology, 2011 Nov 1;53(11):1007-12.</ref> note that a child classified as Level I will be able to perform the same activities as their peers but their speed, balance or coordination may be impacted. However, a child classified as Level V will have difficulty achieving voluntary control of movement and their head/trunk control is affected in many positions.<ref name=":0" />


Children classified as Level I perform the same activities as their peers but with some degree of difficulty in speed, balance, and coordination. In contrast, children classified as Level V have difficulty in most positions controlling their head/trunk posture and voluntary control of movement.
== Evidence ==
== Evidence ==
There is strong evidence for the reliability and construct validity of the GMFCS - E&R when used by both health professionals and families/caregivers,<ref name=":2">Piscitelli D, Ferrarello F, Ugolini A, Verola S. Pellicciari, L. Measurement properties of the Gross Motor Function Classification System, Gross Motor Function Classification System-Expanded & Revised, Manual Ability Classification System, and Communication Function Classification System in cerebral palsy: a systematic review with meta-analysis. Dev Med Child Neurol. 2021;63:1251-61.</ref> which indicates that it can be used in research and clinical practice.<ref name=":3">Nylén E, Grooten WJA. [https://www.tandfonline.com/doi/full/10.1080/01942638.2020.1830915 The stability of the Gross Motor Function Classification System in children with cerebral palsy living in Stockholm and factors associated with change]. Phys Occup Ther Pediatr. 2021;41(2):138-49. </ref>


=== Reliability ===
* Various studies have shown that its intra- and inter-reliability is "almost excellent".<ref name=":3" />
The inter-tester reliability between physiotherapists and parents has been determined to have an ICC value of 0.96 (95% CI, 0.95-0.97). This indicates that parents and clinicians can use the same terms and understand each other when determining the motor functional classification of their child if the GMFCS-ER is carefully administered.
* Palisano et al.<ref name=":4">Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH. [https://onlinelibrary.wiley.com/doi/full/10.1111/j.1469-8749.2008.03089.x Content validity of the expanded and revised Gross Motor Function Classification System]. Developmental Medicine & Child Neurology. 2008 Oct 1;50(10):744-50.</ref> used Delphi survey consensus methods (where consensus was defined as "agreement with a question by at least 80% of participants"<ref name=":4" />) to confirm the content validity of the GMFCS - E&R.
 
* However, it has been found that the GMFCS - E&R cannot be used to detect change over time,<ref name=":2" /> and while it was previously considered a stable measure, some authors have shown that a child's GMFCS can change.<ref name=":3" />
=== Validity ===
* Towns et al.<ref>Towns M, Rosenbaum P, Palisano R, Wright FV. [[Should the Gross Motor Function Classification System be used for children who do not have cerebral palsy?]]. Developmental Medicine & Child Neurology. 2018 Feb;60(2):147-54.</ref> note that it cannot be used as an outcome measure to check progression or changes after treatment and it is not intended for conditions other than cerebral palsy.
The GMFCS-ER has been evidenced with the content validity of 80% by consensus process in a Delphi study. The content has been validated for clarity and accuracy of the descriptions for each level and the distinctions between levels of 6 to 12 years and 12-18 years age bands. The GMFCS-ER has utility for communication related to the condition between the various health professionals, therapists and parents etc. and also for clinical decision making, databases, registries and clinical research.The study published in the Europian journal of Physiotherapy "suggests that the GMFCS-E&R, if administered carefully, can be used as when comparing longitudinal data with the GMFCS."
 
=== Responsiveness ===
In a study conducted where 18 Physical therapists participated to evaluate the draft version of the 12-18 years age band and a Delphi survey where 30 health professionals from 7 countries participated to evaluate the revised 12-18 years and 6-12 years age band and consensus was gained by 80% of participants.It has been agreed as useful tool for classification of gross motor function.
 
The GMFCS or the GMFCS-ER is a classification system. It has been developed for the purpose of classification alone. It is just to determine the type of cerebral palsy. It is neither to be used as an outcome measure for checking the progression over time or after treatment nor to be used for conditions other than CP unless there is an evidenced research saying so for a condition.


== Resources  ==
== Resources  ==

Revision as of 01:01, 22 May 2023

Original Editor - Evan Thomas

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Introduction[edit | edit source]

The Gross Motor Function Classification System - Expanded & Revised (GMFCS - E&R) was developed in 2007. It builds on the original version of the Gross Motor Function Classification System from 1997.[1] It categorises children with cerebral palsy in terms of their self-initiated gross motor function. This 5-level classification system focuses on wheeled mobility, walking and sitting. The levels are defined based on functional abilities, the need for wheeled mobility or assistive technology (canes, crutches or walkers). Quality of movement is also looked at, but to a lesser extent.[2]

The GMFCS - E&R is focused on discovering which level best represents the child's "present abilities and limitations in gross motor function".[2] It considers usual activities, such as a child's performance in school, home and community settings rather than what they can do at their best. It, therefore, distinguishes between what they do rather than their capability. Classification is based on current performance in gross motor function and should not consider judgments about prognosis or movement quality.[2]

Intended Population[edit | edit source]

This classification system is intended for children and young people with CP. The revised version (GMFCS - E&R) includes five age ranges: The age groups are: under 2 years, 2-4 years, 4-6 years, 6-12 years, and 12-18 years of age.[2] The GMFCS - E&R is available in 22 languages and has been validated in many different countries.

Method of Use[edit | edit source]

Physiotherapists, occupational therapists, physicians, and other health service providers familiar with the movement abilities of children with CP can use the GMFCS - E&R. Parents of children with CP are also able to classify their children using an adapted version known as the GMFCS Family Report Questionnaire.[2]

Health care providers who are familiar with a child can typically classify them using the GMFCS - E&R within 5 minutes. Those unfamiliar with the child may require 15 to 20 minutes to complete the classification as more observation is required.[2]

Distinguishing between levels of the GMFCS - E&R is usually quite clear. However, it is important to note that at some ages, it is more difficult to distinguish between adjacent levels, so more time may be required to classify a child.[2]

The levels are as follows:[3][4]

  • Level I: able to walk without limitations
  • Level II: can walk with limitations (e.g. balance, endurance limitations)
  • Level III: can walk using a hand-held mobility device (may use additional support, such as wheeled mobility, for longer distances, outdoors)
  • Level IV: self-mobility is limited - may be transported in a manual wheelchair or may use powered mobility
  • Level V: transported in manual wheelchair

Reid et al.[5] note that a child classified as Level I will be able to perform the same activities as their peers but their speed, balance or coordination may be impacted. However, a child classified as Level V will have difficulty achieving voluntary control of movement and their head/trunk control is affected in many positions.[5]

Evidence[edit | edit source]

There is strong evidence for the reliability and construct validity of the GMFCS - E&R when used by both health professionals and families/caregivers,[6] which indicates that it can be used in research and clinical practice.[7]

  • Various studies have shown that its intra- and inter-reliability is "almost excellent".[7]
  • Palisano et al.[8] used Delphi survey consensus methods (where consensus was defined as "agreement with a question by at least 80% of participants"[8]) to confirm the content validity of the GMFCS - E&R.
  • However, it has been found that the GMFCS - E&R cannot be used to detect change over time,[6] and while it was previously considered a stable measure, some authors have shown that a child's GMFCS can change.[7]
  • Towns et al.[9] note that it cannot be used as an outcome measure to check progression or changes after treatment and it is not intended for conditions other than cerebral palsy.

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ Morris C. Development of the gross motor function classification system (1997). Developmental Medicine & Child Neurology. 2008 Jan 1;50(1):5-.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Can Child. GMFCS - E&R Gross Motor Function Classification System - Expanded & Revised. Available from: https://canchild.ca/en/resources/42-gross-motor-function-classification-system-expanded-revised-gmfcs-e-r
  3. ↑ CanChild. GMFCS-ER Resources. Last Accessed July 17, 2016 from https://canchild.ca/en/resources/42-gross-motor-function-classification-system-expanded-revised-gmfcs-e-r
  4. ↑ Paulson A, Vargus-Adams J. Overview of four functional classification systems commonly used in cerebral palsy. Children (Basel). 2017 Apr 24;4(4):30.
  5. ↑ 5.0 5.1 Reid SM, Carlin JB, Reddihough DS. Using the Gross Motor Function Classification System to describe patterns of motor severity in cerebral palsy. Developmental Medicine & Child Neurology, 2011 Nov 1;53(11):1007-12.
  6. ↑ 6.0 6.1 Piscitelli D, Ferrarello F, Ugolini A, Verola S. Pellicciari, L. Measurement properties of the Gross Motor Function Classification System, Gross Motor Function Classification System-Expanded & Revised, Manual Ability Classification System, and Communication Function Classification System in cerebral palsy: a systematic review with meta-analysis. Dev Med Child Neurol. 2021;63:1251-61.
  7. ↑ 7.0 7.1 7.2 Nylén E, Grooten WJA. The stability of the Gross Motor Function Classification System in children with cerebral palsy living in Stockholm and factors associated with change. Phys Occup Ther Pediatr. 2021;41(2):138-49.
  8. ↑ 8.0 8.1 Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH. Content validity of the expanded and revised Gross Motor Function Classification System. Developmental Medicine & Child Neurology. 2008 Oct 1;50(10):744-50.
  9. ↑ Towns M, Rosenbaum P, Palisano R, Wright FV. Should the Gross Motor Function Classification System be used for children who do not have cerebral palsy?. Developmental Medicine & Child Neurology. 2018 Feb;60(2):147-54.
  10. ↑ Gorter JW, Ketelaar M, Rosenbaum P, Helders PJ, Palisano R. Use of the GMFCS in infants with CP: the need for reclassification at age 2 years or older. Developmental Medicine & Child Neurology. 2009 Jan 1;51(1):46-52. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1469-8749.2008.03117.x
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