Title: The GMFCS and GMFM in Clinical Practice
1The GMFCS and GMFM in Clinical Practice
Dianne Russell and Peter Rosenbaum CanChild
Centre for Childhood Disability Research McMaster
University, Hamilton, ON. Canada www.canchild.ca W
atch Videoconference, Friday June 6, 2008
2Why use standardized measures anyway?
3Measurement
- Purposes of measures
- To discriminate/describe
- To prognosticate
- To evaluate change over time
4GMFCSGross Motor Function Classification System
- Palisano et al., 1997, 2008
5GMFCS
- 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
6GMFCS
- Why is the GMFCS important?
- Previous subjective, clinical judgment (i.e.
mild, moderate, severe) meaningless,
unreliable, not valid - Based on observation, parent report quick and
easy - Functionally based, not impairment-based
(consistent with ICF framework)
7GMFCS
- 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
8GMFCS
- Research
- consistent language
- describing samples
- conveying results
- Administration
- manage caseloads/ resource allocation
9Further 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)
10GMFCS-E R
- GMFCS E R
- Gross Motor Function Classification System
- Expanded and Revised
http//www.canchild.ca/Portals/0/outcomes/pdf/GMFC
S.pdf
11 12GMFM 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
13GMFM Gross Motor Function Measure
Russell et al., 2002
14GMFM or GMFM-88
- 88 items
- 5 dimensions (grouped together for ease of
administration) - Items were ordered in each dimension using best
judgment as to difficulty
15GMFM 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 scores
16GMFM-88
17GMFM-88
18GMFM-66
- 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)
19GMFM-66
20GMFM-66
- 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
difficulty
21Russell et al., 2002
22Russell et al., 2002
23Clinical Use of Item Maps and Case Summaries
- Understand/interpret change
- Identify relatively easier and more difficult
next steps for a child - Discuss and communicate with parents about a
childs progress - Set appropriate goals and plan interventions
24Current work with the GMFM
- GMFM Algorithms (Item sets)
- Developed to identify subsets of the 66 items
which give a good estimate of a childs score
while shortening the time for administration of
the GMFM-66
25 26Exploring 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
27Motor Growth Curves
Taken from Rosenbaum et al. (2002). JAMA 288
1357-63
28How can the Motor Growth Curves be used?
- Describe patterns of gross motor function for
children with cerebral palsy over time - Estimate a childs future motor capabilities
29Current work with motor measures
- Adding centiles to the motor growth curves
- (Hanna et al. 2008 Phys Ther 88596-607)
- Extending the motor growth curves into
adolescence (ASQME study)
30Current work with motor measures
- 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
31Putting the measures all together..
- 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
32 Scenario of Beth
- Beth was born prematurely
- Almost 2 years old and still not walking
-
- Diagnosis of cerebral palsy
33Beths parents want to know
- How bad is it?
- Will Beth walk?
- How will we know if therapy is working?
34Beths therapist wants to know
- What evidence-based measures are available to
help me answer Beths parents questions? - How will I find the time to learn these
measures? - How can I use these measures to assist with
realistic goal setting and collaborating with
Beths parents?
35The administrator at Beths treatment centre
wants to know
- How do we ensure that resources (therapy time and
equipment) are optimized? - How can we document the effectiveness of our
interventions to improve motor function?
36Our Child Has CPParents First Questions, and
Ways to Respond
Classifies gross motor function in children with CP
GMFCS
How bad is it?
Motor Growth Curves
Relates age GMFCS level to prognosis
Will our child walk?
Measures change over time due to treatment or maturation
GMFM-66 GMFM-88
How do we know if therapy is working?
37 38Our Challenge as Researchers and Clinicians
- How do we improve the uptake of these validated
measures into clinical practice?
39Knowledge translation
40Current work
- Exploring issues in knowledge translation
- 3 year CIHR study of moving the Motor Measures
into Clinical Practice using a Knowledge Broker
(KB)
41Role of the Knowledge Broker (KB)
- 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
effective - CHSRF (2003) The practice of Knowledge Brokering
in Canadas health system
42