the gmfcs and gmfm in clinical practice dianne russell and peter rosenbaum canchild centre for...

The GMFCS and GMFM in Clinical The GMFCS and GMFM in Clinical PracticePractice

Dianne Russell and Peter Rosenbaum CanChild Centre for Childhood Disability Research

McMaster University, Hamilton, ON. Canadawww.canchild.ca

Watch Videoconference, Friday June 6, 2008

Why use standardized measures anyway?

Measurement

Purposes of measures

•To discriminate/describe•To prognosticate•To evaluate change over time

GMFCS“Gross Motor

Function Classification

System”

Palisano et al., 1997, 2008

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

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)

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

GMFCS

Research:

•consistent language•describing samples•conveying results

Administration:

•manage caseloads/ resource allocation

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)

GMFCS-E & R

GMFCS – E & RGross Motor Function Classification System

Expanded and Revised

http://www.canchild.ca/Portals/0/outcomes/pdf/GMFCS.pdf

Questions?

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

GMFM “Gross Motor

Function Measure”

Russell et al., 2002

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

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

GMFM-88Item 36

On 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%

GMFM-88

#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.

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)

GMFM-66

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

Russell et al., 2002

Russell et al., 2002

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 child’s progress

• Set appropriate goals and plan interventions

Current work with the GMFM

• GMFM Algorithms (Item sets)

• Developed to identify subsets of the 66 items which give a good estimate of a child’s score while shortening the time for administration of the GMFM-66

Questions?

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

Motor Growth Curves

Taken from Rosenbaum et al. (2002). JAMA; 288;

1357-63

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

Current work with motor measures

• Adding centiles to the motor growth curves(Hanna et al. 2008 Phys Ther 88:596-607)

• Extending the motor growth curves into adolescence (ASQME study)

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”

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

Scenario of Beth

• Beth was born prematurely

• Almost 2 years old and still not walking

• Diagnosis of cerebral palsy

Beth’s parents want to know

• How bad is it?

• Will Beth walk?

• How will we know if therapy is working?

Beth’s therapist wants to know

• What evidence-based measures are available to help me answer Beth’s 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 Beth’s parents?

The administrator at Beth’s 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?

“Our Child Has CP…”Parents’ First Questions, and Ways to Respond

“How bad is it?”

“Will our child walk?”

“How do we know if therapy is working?”

Classifies gross motor function in children with CP

Relates age & GMFCS level to

prognosis

Measures change over time due to treatment

or maturation

GMFCS

Motor Growth Curves

GMFM-66 &

GMFM-88

Questions?

Our Challenge as Researchers and Clinicians

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

Knowledge translation

Current work

• Exploring issues in knowledge translation

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

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 Canada’s health system

Questions?