gmfm: gross motor function classification measure
TRANSCRIPT
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GMFM: Gross Motor Function Measure, Part I
Kathy McKellar, “Knowledge Broker” January 2007
Based on a presentation by Dianne Russell, CanChild Centre for Childhood Disability Research, Knowledge Broker project co-investigator
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KB study Looking at clinical knowledge and
appropriate use of: GMFCS GMFM Motor Growth Curves (MCG’s):
prognosis, treatment planning
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Health Condition Health Condition ((disorder/diseasedisorder/disease))
Interaction of ConceptsInteraction of ConceptsICF 2001ICF 2001
Environmental Environmental FactorsFactors
Personal Personal FactorsFactors
Body Body function&structurefunction&structure (Impairment(Impairment))
ActivitiesActivities(Limitation)(Limitation)
ParticipationParticipation(Restriction)(Restriction)
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GMFM: Why was it developed? To answer the question: “How do
we measure small but important changes in motor function for children with CP?”
Development started in 1984
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GMFM Criterion-referenced test:
evaluates performance of motor skills on that day; useful for comparison over time
Measures how much of a task the child can accomplish, rather than how well the task is completed (quantity, not movement quality)
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Who is the GMFM appropriate for? Children with CP: original validation
sample included kids 5 mo- 16 yrs May be appropriate for children
with other diagnoses GMFM is appropriate for children
whose motor skills are at or below those of a typical 5 year old.
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GMFM Formats GMFM-88: 88 items GMFM-66: 66 items GMFM-88 with reported scores for
kids with Down Syndrome
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Examiner Qualifications For use by pediatric PT’s Before testing children, PT’s should
familiarize themselves with the scoresheet and the administration and scoring guidelines
CD ROM training available
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Time required GMFM 88: approx. 45-60 minutes GMFM 66: faster, allows for some
missing data (items that are not tested)
Can be completed in more than 1 session (ideally complete all items within 1 week)
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GMFM-8888 items in 5 gross motor dimensions
(for ease of administration): lying and rolling crawling and kneeling Sitting Standing walking, running and jumping
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GMFM-66 Same dimensions, but 22 items
eliminated (mostly in lying position)
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Validation of the GMFM-88 Reliability
• Test-retest (ICC = 0.99) ( dimensions ranged .92-.99)• Inter-rater (ICC = 0.99) (dimensions ranged .87-.99)
•Validity• Gradient of change: pre-school children without
CP>children with ABI>children with CP
• Children with CP who were young & mild > older & more severe
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Validation of the GMFM-88 Change over 6 months as judged by
parents, therapists, and a “masked” video analysis was correlated with change scores on the GMFM-88
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Further evidence of reliability & validity Reliability established by others outside the
GMFM team (Bjornson et al. 1994;1998, Nordmark et al. 1997)
Responsiveness (Bjornson et al. 1998; Kolobe et al. 1998
Discriminative validity (Palisano et al 2000)
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Why use the GMFM? Reliable, valid Internationally accepted: Translated
into several languages, including Dutch, French, German, Icelandic, Japanese
Considered best practice Used as an outcome measure
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Used as an outcome measure Surgery (rhizotomy, pallidal stimulation, muscle
tendon)
Drugs (botulinum toxin, intrathecal baclofen)
Physical therapy (including ambulatory aids & orthoses)
Horseback riding
Strength training & physical fitness
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Use of the GMFM in other populations Osteogenesis imperfecta (Ruck-Gibis
et al. 2001)
Lymphoblastic leukemia (Wright et al. 1998)
Down syndrome (Russell et al. 1998)
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Validation for children with Down syndrome Compared the results using the
standard scoring method with an alternate method of scoring using caregiver report “Reported Score” (for items which the therapist couldn’t entice the child to demonstrate)
Found stronger evidence of reliability, validity & responsiveness with “reported score”
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Equipment GMFM kit Need smooth floor, large firm
exercise mat, toys for motivation, large bench or table for cruising
Five steps with railing Wheeled stool
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Environment Room large enough to
accommodate the equipment, the child and the examiner
Private area Consistent environment for
retesting
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Clothing Shorts and Tshirt are ideal Testing is done without shoes
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Preparing for Testing Have manual, equipment, score
sheet ready. Room booked, mat in place, as
well as other required furniture
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Testing Items may be tested in any order,
but be careful not to miss any! (esp. when using the GMFM 88)
Verbal encouragement or demonstration is permitted
Maximum 3 trials for each item Spontaneous performance of any
item is acceptable
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Non-compliance Strategies such as “follow the leader” or
role playing can be used Toys and incentives can be used as
motivators (eg. creep through a tunnel) If a child refuses to attempt an item that
you think they can do, return to the item at the end of the test, or try it again in in another session. You can also circle “not tested”.
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Scoring the GMFM Scores 0-3 or NT 0- does not intitiate task 1- intitiates task (<10%) 2- partially completes task (10-99 %) 3- completes task (100%) Sometimes generic scoring as
above, other times specific criteria for each level
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Scoring the GMFM, cont. The score given is based on the best
performance out of the 3 trials If undecided about what score to assign,
choose the lower of the 2 possible scores Any item that has been omitted or that
the child is unable (or unwilling) to attempt must be indicated as NT
In the GMFM 88, NT items are scored 0, but in the GMFM 66, NT items are treated as missing data
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Item 36On the floor: Attains sitting on small bench
0 = does not initiate sitting1 = initiates sitting 2 = partially attains sitting 3 =attains sittingNT = Not tested
Generic Scoring Key
Initiates=completes less than 10% of task
Partially completes= completes >10% to less than 100%
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#58: Standing:lifts R foot, arms free, 10 secs.• 0= does not lift R foot, arms free• 1= lifts R foot, arms free, < 3 secs.• 2= lifts R foot, arms free, 3-9 secs.• 3= lifts R foot, arms free, 10 secs.
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GMFM Part II… to follow GMFM-88 vs. 66 Scoring GMAE Interpretation of results Motor Growth Curves GMFCS, GMFM, MCG’s: how do
they relate?
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Knowledge Broker studyCanChild research project looking at
clinical knowledge and appropriate use of:
GMFCS GMFM Motor Growth Curves (MCG’s)
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GMFM Part II Quick review Scoring GMAE Interpretation of results GMFM-88 vs. 66 Motor Growth Curves GMFCS, GMFM, MCG’s: how do they
relate?
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GMFM Criterion-referenced test:
evaluates performance of motor skills on that day; useful for comparison over time
Measures how much of a task the child can accomplish, rather than how well the task is completed (quantity, not movement quality)
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Who is the GMFM appropriate for? Children with CP: original validation
sample included kids 5 mo- 16 yrs May be appropriate for children with
other diagnoses: osteogenesis imperfecta, lymphoblastic leukemia, Down syndrome
GMFM is appropriate for children whose motor skills are at or below those of a typical 5 year old.
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GMFM- 88 and 66GMFM 88: 88 items in 5 gross motor
dimensions: lying and rolling crawling and kneeling Sitting Standing walking, running and jumpingGMFM-66: Same dimensions, but 22 items
eliminated (mostly in lying position)
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Scoring of the GMFM 88/66 Math or no math Graph or no graph Computer or no computer
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GMFM-88 score: math! Sum the item scores within dimensions
and transfer to the summary score section on the score sheet.
A percent score for each of the 5 dimensions is calculated.
The total percent score for each dimension is averaged to obtain the total score (round off to the nearest whole number)
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Scoring with aids/orthotics Use GMFM-88 only First complete the GMFM without the
aid/orthosis, then retest with aid/orthosis For repeat testing at a later dater, apply
the same aid at the same item number Aids/orthoses could have positive and
negative effects Mark an “A” for the aided score on the
score sheet
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GMFM-88 - scoring issues (i)
Scoring leads to an overall % score as well as dimension % scores
Change scores: T2 - T1 = GMFM score Assumes that all % changes/unit of time
have the same meaning… ...but we don’t really know what a ‘unit’
of change means clinically! (Some changes might be easier to attain than others)
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GMFM-88 - scoring issues (ii) GMFM-88 scaling is ‘ordinal’ (ordered) Cannot assume that a unit of change
has the same meaning across the scale
Really need ‘interval’ scaling, whereby a ‘unit’ of change has the same meaning throughout the scale
Hence the need for Rasch (item-response) analysis
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What is Rasch Analysis? It is a way to analyse data to
assess the ‘fit’, order and relative difficulty of items that measure a construct (e.g., GMF)
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RASCH SCALING OF THE GMFM Identified items which did not “fit” the
unidimensional construct- eliminated 22 items (GMFM-66)
Items are now arranged in order of difficulty (empirical)
Response options within items are weighted according to difficulty
Interval scale…so that a unit of change has the same meaning across the scale (thus improving the interpretability of scores)
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GMFM-66 Only 66 items administered
(asterixed on score sheet) Enter scores into the computer
program: Gross Motor Ability Estimator (GMAE)
Not possible to calculate the score with pencil and paper
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Gross Motor Ability Estimator (GMAE)
User-friendly program to analyze GMFM-66 scores with a built-in tutorial
Allows entry of data in two formats:1. Research - from ASCII files or text only
files (files entered into a statistical package –SPSS)
2. Individual GMFM-66 item scores for one or more children
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Why use a computer program to score?
Provides an estimate of a child’s score even when not all items have been administered
Provides a database to keep child information and track GMFM-66 scores over time- case summary report
Produces item maps- arrange items by order of difficulty
It’s easy! No math, but graphs!
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The GMFM-66 score is an interval-level measure of function where subjects are placed on an ability continuum ranging from 0 (low motor ability) to 100 (high motor ability).
Interval level scoring makes comparisons of change over time more meaningful because a difference of, for example, 10 points means the same whether the child is at the lower end or the upper end of the scale.
What is the GMFM-66 score?
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Case Summary Report Summarizes demographic data Summarizes score, including error
(standard error and 95% confidence interval)
Graphs scores over time
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Item Maps By item order or by difficulty order-
by difficulty order is the most useful
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Lower Motor GMFM-66 Score with 95% Confidence Intervals Higher Motor Ability Ability
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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 a child’s progress
• set appropriate goals and plan interventions
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Interpretation of GMAE print-outs
Group exercise
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Questions for groups: What is the child’s GMFM-66
score? Are there any unexpected scores? What would you expect the child to
accomplish next? What activities might you work on
in PT with this child?
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GMFM 88 and 66 Good reasons to choose one or the
other.
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GMFM-88 & GMFM-66General Issues Items are administered and scored the
same, with the exception of a new category of ‘Not Tested’ (NT) to differentiate a true “0” from an item not attempted
If administer the GMFM-88 with NT, the data can also be used to calculate score for GMFM-66
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Strengths of GMFM-88 Reliable and valid measure of change
over time in children with CP and children with Down syndrome
Widely used in practice and research GMFM is most responsive to change
in children with CP under age 5 years
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Limitations of GMFM-88 Time to administer
- all items must be administered
Must give a score of “0” for items if the child refuses or assessor fails to administer
Score based on number of items completed regardless of difficulty
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When should I use the GMFM-88? For a more detailed description of skills
especially for children whose skills are primarily in Lying and Rolling activities (e.g., infants, or children classified at GMFCS Level V)
No access to a computer Assessing effects of aides and orthoses Assessing children with diagnosis other
than CP
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Strengths of GMFM-66 Reliable and valid measure of change
over time in children with CP Items are ordered by difficulty A score can be derived with a less-than-
complete assessment Item maps useful in understanding
motor function and in planning goals Computer program allows tracking of
individual children’s scores over time
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Possible Limitations of GMFM-66 Requires use of a computer
program for scoring
May need some time to learn how to interpret item maps
No longer able to calculate dimension scores
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When should I use the GMFM-66? Assessing children with cerebral palsy
where the interval properties of the scale are important (e.g. Research purposes, change over time)
When you have limited time to administer all items
Access to a computer and the GMAE scoring program
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Motor Growth Curves More graphs!
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Motor Growth Curves Derived from a longitudinal study 657 children, >2600 GMFM
assessments Children <6 years assessed every
6 mo., older children assessed every 9-12 mo.
Plotted GMFM-66 score against age
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Longitudinal Motor Growth Curves for Children with Cerebral Palsy by GMFCS Level Using GMFM-66 (N=2624 observations)
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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 child’s future motor capabilities (prognosis)
• Compare child’s GMFM-66 score with children in the sample of a similar age and severity
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GMFM-66 plateau Does not mean therapy is not
needed!
Work on quality, functional goals, equipment needs, prevention of secondary problems.
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Putting the measures all together…..• Several different purposes :
discriminative (descriptive) evaluative prognostic (predictive)
• Can be used together to track and evaluate change over time and determine how the rate of change compares to children of similar abilities and ages
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Case Study
• Beth
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Use of Motor Measures at QA How could these measures work
for us?
*** Most useful if used by all PT’s, in both EIP and SAP