The GMFCS and GMFM in Clinical Practice

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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 www.canchild.ca W
atch Videoconference, Friday June 6, 2008
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Why use standardized measures anyway?
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Measurement

• Purposes of measures
• To discriminate/describe
• To prognosticate
• To evaluate change over time

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GMFCSGross Motor Function Classification System

• Palisano et al., 1997, 2008

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GMFCS

• 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

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GMFCS

• 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)

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GMFCS

• 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

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GMFCS

• Research
• consistent language
• describing samples
• conveying results
• Administration
• manage caseloads/ resource allocation

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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)

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GMFCS-E R

• GMFCS E R
• Gross Motor Function Classification System
• Expanded and Revised

http//www.canchild.ca/Portals/0/outcomes/pdf/GMFC
S.pdf
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• Questions?

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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

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GMFM Gross Motor Function Measure
Russell et al., 2002
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GMFM 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

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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 scores

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GMFM-88
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GMFM-88
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GMFM-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)

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GMFM-66
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GMFM-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

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Russell et al., 2002
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Russell et al., 2002
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Clinical 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

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Current 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

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• Questions?

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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

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Motor Growth Curves
Taken from Rosenbaum et al. (2002). JAMA 288
1357-63
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How 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

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Current 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)

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Current 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

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Putting 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

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Scenario of Beth

• Beth was born prematurely
• Almost 2 years old and still not walking
• Diagnosis of cerebral palsy

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Beths parents want to know

• How bad is it?
• Will Beth walk?
• How will we know if therapy is working?

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Beths 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?

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The 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?

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Our 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?
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• Questions?

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Our Challenge as Researchers and Clinicians

• How do we improve the uptake of these validated
  measures into clinical practice?

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Knowledge translation
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Current work

• Exploring issues in knowledge translation
• 3 year CIHR study of moving the Motor Measures
  into Clinical Practice using a Knowledge Broker
  (KB)

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Role 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

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• Questions?