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

Original Editor - Evan Thomas

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Objective[edit | edit source]

The revised and expanded version of the GMFCS (2007) builds upon the original version of the Gross Motor Function Classification System developed in 1997[1] to classify and describe the abilities of children and youth with cerebral palsy. It has 4 age bands namely, 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.[2][3]

Intended Population[edit | edit source]

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.

The GMFCS-ER is available in 22 languages and has been validated in many different countries.[3]

Method of Use[edit | edit source]

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.[3]

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.[3]

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.[3]

Generally, the higher the level the poorer the functional ability of the child. The theme of each level is as follows:

  • Level I: Walks without Limitations
  • Level II: Walks with Limitations
  • Level III: Walks Using a Hand-Held Mobility Device
  • Level IV: Self-Mobility with Limitations; May Use Powered Mobility
  • Level V: Transported in a Manual Wheelchair

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.[2]


Evidence[edit | edit source]

Reliability[edit | edit source]

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.[5]

Validity[edit | edit source]

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.[6]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."[7]

Responsiveness[edit | edit source]

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.[6]

The GMFCS or the GMFCS-ER is a classification system.[8] 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.[9]

Resources[edit | edit source]

References[edit | edit source]

  1. 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 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.
  3. 3.0 3.1 3.2 3.3 3.4 CanChild. GMFCS-ER Resources. Last Accessed July 17, 2016 from
  4. Freedom Concepts. GMFCS for Cerebral Palsy. Available from: [last accessed 28/08/16]
  5. Mutlu A, Kara OK, Gunel MK, Karahan S, Livanelioglu A. Agreement between parents and clinicians for the motor functional classification systems of children with cerebral palsy. Disabil Rehabil, 2011; 33(11): 927-32.
  6. 6.0 6.1 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.
  7. Gudmundsson C, Nordmark E. The agreement between GMFCS and GMFCS-E&R in children with cerebral palsy. The European Journal of Physiotherapy. 2013 Sep 1;15(3):127-33.
  8. Oeffinger DJ, Tylkowski CM, Rayens MK, Davis RF, Gorton Iii GE, D'Astous J, Nicholson DE, Damiano DL, Abel MF, Bagley AM, Luan J. Gross Motor Function Classification System and outcome tools for assessing ambulatory cerebral palsy: a multicenter study. Developmental medicine and child neurology. 2004 May;46(5):311-9.
  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.