Gross Motor Function Classification System - Expanded and Revised (GMFCS-ER)

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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