Doreen J. Bartlett

Content validity of the expanded and revised Gross Motor Function Classification System

The aim of this study was to validate the expanded and revised Gross Motor Function Classification System (GMFCS‐E&R) for children and youth with cerebral palsy using group consensus methods. Eighteen physical therapists participated in a nominal group technique to evaluate the draft version of a 12‐ to 18‐year age band. Subsequently, 30 health professionals from seven countries participated in a Delphi survey to evaluate the revised 12‐ to 18‐year and 6‐ to 12‐year age bands. Consensus was defined as agreement with a question by at least 80% of participants. After round 3 of the Delphi survey, consensus was achieved for the clarity and accuracy of the descriptions for each level and the distinctions between levels for both the 12‐ to 18‐year and 6‐ to 12‐year age bands. Participants also agreed that the distinction between capability and performance and the concept that environmental and personal factors influence methods of mobility were useful for classification of gross motor function. The results provide evidence of content validity of the GMFCS‐E&R. The GMFCS‐E&R has utility for communication, clinical decision making, databases, registries, and clinical research.

Development of the Gross Motor Function Classification System for cerebral palsy

The Gross Motor Function Classification System (GMFCS) for cerebral palsy has been widely used internationally for clinical, research, and administrative purposes. This paper recounts the ideas and work behind the creation of the GMFCS, reports on the lessons learned, and identifies some philosophical challenges inherent in trying to develop an ordered, valid, and consistent system to describe function in children and adolescents with developmental differences. It is hoped that these ideas will be useful to others who choose to expand the field with additional systems in other areas of childhood neurodisability.

Health status of school-aged children with cerebral palsy: information from a population-based sample.

In this study parents’systematic accounts of the health status of 408 school‐aged children with cerebral palsy (CP) are reported (221 males, 187 females; mean age 8 years 5 months, SD 1 year 11 months; range 5 to 13 years), as are relations between severity of functional motor impairment and eight functional health status domains. Data were collected as part of a longitudinal study of the motor development of a population‐based, stratified, random sample of children with CP from across Ontario, Canada. The Gross Motor Function Classification System (GMFCS) was used to classify severity of CP and functional health status was described with the eight‐level Health Utilities Index ‐ Mark 3. Rates of functional limitations in Mobility, Dexterity, Speech, and Vision were statistically significantly associated with GMFCS levels (all p<0.01), with correlation values (tau‐b) of 0.82,0.58,0.46, and 0.36, respectively. Functional limitations in hearing (tau‐b=0.16; p=0.04) and cognition (tau‐b=0.27;p<0.01) were both statistically significantly associated with GMFCS levels, though correlations were low. Neither emotion (tau‐b=0.03;p=0.24) nor pain (tau‐b=0.07;p=0.37) was associated with degree of functional limitation as described by the GMFCS. Clinical and epidemiological implications of findings are discussed.

Gross Motor function classification system: impact and utility

In summary, the GMFCS has had, and continues to have, a major effect on the health care of children with CP. The number of citations of the GMFCS has been increasing every year, and the classification system has had good uptake internationally and across the spectrum of health professionals for use in research design and clinical practice by providing a system for clearly communicating about childrens gross motor function. The utility of diagnostic labels such as diplegia has been questioned. However, although by definition CP is a disorder of posture and movement, the movement disability is often only one of the neurodevelopmental problems for many children with CP. When a complete description of a childs clinical presentation is required we recommend that the GMFCS be used together with the Surveillance of Cerebral Palsy in Europe classification indicating the type and topography of movement impairment. When appropriate the clinical profile will similarly be enhanced with details of other impairments and disabilities such as epilepsy or sensory, learning, feeding, or emotional disturbance. The observations in this annotation are constrained by the amount of information in the public domain. Although these sources adequately represent the effect of the GMFCS on research design, they are less likely to inform us of how the GMFCS is being used in administration, clinical practice, or education. It is not yet clear whether information is being used for these purposes or in assisting with case load management, as intended by the developers. By its localized nature, such information might remain difficult to gauge. We would therefore be interested to hear from others who are using the system for these or any other purposes.

Effect of environmental setting on mobility methods of children with cerebral palsy.

The aim of this study was to: (1) describe the usual mobility methods of children with cerebral palsy (CP) at home, school, and outdoors or in the community and (2) examine whether children with CP are more dependent on adult assistance for mobility in certain settings. The participants were a stratified random sample of 636 children with CP (355 males and 281 females; 2 to 12 years of age, mean 6.8 years SD 2.7), receiving rehabilitation services in Ontario, Canada. Children were grouped by age and Gross Motor Function Classification System (GMFCS) level. Among the five levels of the GMFCS, there were 185 children classified at level I, 81 children at level II, 113 children at level III, 132 children at level IV, and 125 children at level V. Information on childrens usual mobility was obtained by parent report. The results of logistic regression indicated that compared with the school setting, children were more dependent on adult assistance for mobility when outdoors/in the community and less dependent at home. The majority of children aged from 4 to 12 years at levels III to V used wheelchair mobility at school and outdoors or in the community, however, only a small percentage self-propelled their wheelchair or used powered mobility. Of the children aged 4 to 12 years at level V, 39% were carried at home. The findings suggest that environmental setting is an important consideration for assessment and intervention to improve mobility of children with CP. For children who do not walk, attention should be given to the needs of caregivers and factors that are important for successful powered mobility.

Reference Curves for the Gross Motor Function Measure: Percentiles for Clinical Description and Tracking Over Time Among Children With Cerebral Palsy

Background and Purpose: Physical therapists frequently use the 66-item Gross Motor Function Measure (GMFM-66) with the Gross Motor Function Classification System (GMFCS) to examine gross motor function in children with cerebral palsy (CP). Until now, reference percentiles for this measure were not available. The aim of this study was to improve the clinical utility of this gross motor measure by developing cross-sectional reference percentiles for the GMFM-66 within levels of the GMFCS. Subjects and Methods: A total of 1,940 motor measurements from 650 children with CP were used to develop percentiles. These observations were taken from a subsample, stratified by age and GMFCS, of those in a longitudinal cohort study reported in 2002. A standard LMS (skewness-median-coefficient of variation) method was used to develop cross-sectional reference percentiles. Results: Reference curves were created for the GMFM-66 by age and GMFCS level, plotted at the 3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th, and 97th percentiles. The variability of change in childrens percentiles over a 1-year interval also was investigated. Discussion and Conclusion. The reference percentiles extend the clinical utility of the GMFM-66 and GMFCS by providing for appropriate normative interpretation of GMFM-66 scores within GMFCS levels. When interpreting change in percentiles over time, therapists must carefully consider the large variability in change that is typical among children with CP. The use of percentiles should be supplemented by interpretation of the raw scores to understand change in function as well as relative standing.

Early identification and risk management of children with developmental coordination disorder.

Purpose The purpose of this study was to determine the motor control issues, motor learning differences, and secondary impairments of children with developmental coordination disorder (DCD) and to explore physical therapists’ contribution to their early management. Summary of Key Points DCD is a condition involving limitations in gross motor, postural, and/or fine motor performance that is not attributable to other neurological disorders. Manifestation is varied across children and depends, in part, on their level of anticipatory motor control, response to specific task demands, and ability to attend to feedback to obtain flexible, adaptive movement solutions. Children with DCD rely primarily on vision for feedback, frequently use “fixing” strategies, and exhibit limited motor repertoires. As a result of their movement problems, they tend to avoid physical activity and are prone to secondary impairments, including decreased strength and power. Clinical Implications and Recommendations Physical therapists can 1) use their keen observational skills to identify children with DCD earlier in life and 2) use their knowledge of the secondary impairments and movement difficulties to work with families to engage children in continuous movement activities to maintain strength and power and thus obtain the physical, social, and psychosocial benefits of physical activity.

Validity and reliability of a pediatric reach test.

Purpose: The purpose of this study was to develop and evaluate the validity and reliability of a Pediatric Reach Test (PRT). Methods: The Functional Reach Test was modified to incorporate side reaching in addition to forward reaching in both sitting and standing. Nineteen children developing typically (age 3.0 to 12.5 years) completed the standing section of the PRT as well as laboratory force platform tests of standing balance. On two separate occasions, two different raters evaluated 10 children with cerebral palsy (age 2.6 to 14.1 years) in both the sitting and standing sections of the PRT. Results: Concurrent validity was supported with the observation of moderate‐to‐high correlations between the standing section of the PRT and laboratory tests of limits of stability (r = 0.42 to 0.77). Construct validity was supported with the observation of high correlations between the standing section of the PRT and a laboratory test of steadiness in quiet stance (r = ‐0.79) and age (r = 0.83). Construct validity was also supported with a high correlation between the total PRT score and Gross Motor Function Classification System level (rs = ‐0.88) among the sample of children with cerebral palsy. Test‐retest reliability and intertester reliability with children with cerebral palsy ranged from intraclass correlation coefficients of 0.54 to 0.88 and 0.50 to 0.93, respectively. Conclusions: This study provides evidence that the PRT is a simple, valid, and reliable measure with potential for use with children. (Pediatr Phys Ther 2003; 15:84‐92)

The development of expertise in pediatric rehabilitation therapists: Changes in approach, self-knowledge, and use of enabling and customizing strategies

Purpose: To examine the clinical decision making of novice, intermediate, and expert pediatric rehabilitation therapists from various disciplines. Methods: Two qualitative studies were conducted. Thirteen therapists took part in a study using the critical incident interview technique and 11 therapists took part in a study using the ‘think aloud’ technique. Therapists were classified as novice, intermediate, or expert in developmental level based on a cluster analysis of data collected using a multifaceted battery of assessment tools. Data were analyzed using a grounded theory approach. Results: Expert and intermediate therapists differed from novices with respect to content, self-, and procedural knowledge. Conclusion: With increasing expertise, therapists use a supportive, educational, holistic, functional, and strengths-based approach; have heightened humility yet increased self-confidence; and understand how to facilitate and support client change and adaptation by using principles of engagement, coherence, and manageability. Expert therapists use enabling and customizing strategies to ensure a successful therapeutic session, optimize the childs functioning in the mid-term, and ensure child and family adaptation and accommodation over the longer-term.

Exploring Assessment Tools and the Target of Intervention for Children with Developmental Coordination Disorder

Purpose: We reviewed current practice for children with Developmental Coordination Disorder (DCD) using research evidence and the International Classification of Functioning, Disability and Health (ICF). Characteristics of children with DCD can be described at the levels of body function (impairments), whole body movements (activities) and involvement in life situations (participation). Summary of Key Points: Descriptive instruments measuring the extent of motor impairments or activity limitations can be used to: (1) identify children who might benefit from intervention; and (2) determine the optimal type of intervention and model of service delivery. Evaluative tools that measure activities or participation, but not primary impairments, should be used to determine change over time. Commonly used measures for describing children with DCD and evaluating outcomes are reviewed and discussed in the context of the ICF framework. Intervention approaches are then outlined for children with DCD that are targeted to the levels of ativity, participation, and prevention of secondary impairments. Conclusions: Outcomes of children with DCD will be optimized with the use of current research evidence and the appropriate ICF level guiding both assessment and intervention.