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DOI: 10.1542/peds.2006-22582007;120;e880Pediatrics

Sabine Stein, Heike Weissenmayer, Rudolf Korinthenberg and Volker MallMichaela Linder-Lucht, Verena Othmer, Michael Walther, Julia Vry, Ulla Michaelis,

Adolescents With Traumatic Brain InjuriesValidation of the Gross Motor Function Measure for Use in Children and

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located on the World Wide Web at:The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2007 by the American Academypublished, and trademarked by the American Academy of Pediatrics, 141 Northwest Point

publication, it has been published continuously since 1948. PEDIATRICS is owned,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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ARTICLE

Validation of the Gross Motor Function Measure forUse in Children and Adolescents With Traumatic

Brain Injuries

Michaela Linder-Lucht, MD,Verena Othmer, MD, Michael Walther, MD, Julia Vry, MD,Ulla Michaelis, PT,Sabine Stein,PT,

Heike Weissenmayer, PT, Rudolf Korinthenberg, MD, Volker Mall, MD, and the GrossMotorFunction Measure-Traumatic Brain Injury Study

Group

Division of Neuropediatrics and Muscular Disorders, Department of Pediatrics and Adolescent Medicine, University Hospital Freiburg, Freiburg, Germany

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT

OBJECTIVES. Motor function recovery is a key goal during rehabilitation of children

and adolescents with traumatic brain injury. To evaluate how well treatment

strategies improve motor function, we need validated outcome measures that are

responsive to change in pediatric patients with traumatic brain injury. The GrossMotor Function Measure has demonstrated excellent psychometric properties in

children with cerebral palsy and Down syndrome, yet its responsiveness in pa-

tients with pediatric traumatic brain injury has not been proven irrefutably. Our

aim was to validate the Gross Motor Function Measure for this patient group.

METHODS. Seventy-three patients (mean age: 11.4 years; range: 0.8 18.9 years) with

moderate-to-severe traumatic brain injury were recruited in 12 rehabilitation

centers and assessed twice with the Gross Motor Function Measure-88 over 4 to 6

weeks. As an external standard, we used judgements of change made indepen-

dently by parents, physiotherapists, and 2 video assessors who were not familiar

with the patients. We formulated and statistically investigated a priori hypotheses

of how Gross Motor Function Measure change scores would correlate with those

judgements of change. Both Gross Motor Function Measure versions, the original

Gross Motor Function Measure-88 and the more recently developed Gross Motor

Function Measure-66, were evaluated.

RESULTS. Both Gross Motor Function Measure change scores correlated significantly

with all of the clinical judgements of change. The degree of correlation that we

postulated, that the Gross Motor Function Measure change score would correlate

highest with the video rating followed by physiotherapists and parents, was fully

confirmed by the Gross Motor Function Measure-88 and largely confirmed by the

Gross Motor Function Measure-66. Both Gross Motor Function Measure versions

revealed convincing discriminative capability. Test-retest reliability was excellent.

www.pediatrics.org/cgi/doi/10.1542/

peds.2006-2258

doi:10.1542/peds.2006-2258

KeyWords

GMFM-88, GMFM-66, GMFM, traumatic

brain injury, children, adolescents,

evaluation, motor function, validity,

rehabilitation

Abbreviations

TBItraumatic brain injury

GCSGlasgow Coma Scale

GMFMGross Motor Function Measure

CPcerebral palsy

T1baseline measure

T2measure after 4 to 6 weeks (2 days)

T1Rmeasure readministered after 2 to 3

days

VAvideo assessor

Accepted for publication Feb 19, 2007

Address correspondence to Michaela Linder-

Lucht, MD, Division of Neuropediatrics and

Muscular Disorders, Department of Pediatrics

and Adolescent Medicine, University Hospital

Freiburg, Mathildenstrasse 1, D-79106

Freiburg, Germany. E-mail: michaela.linder@

uniklinik-freiburg.de

PEDIATRICS (ISSNNumbers:Print, 0031-4005;

Online, 1098-4275). Copyright 2007by the

AmericanAcademy of Pediatrics

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CONCLUSIONS. We demonstrate convincing evidence of re-

sponsiveness and validity to support the use of both

Gross Motor Function Measure versions as evaluative

measures of gross motor function in children and ado-

lescents with traumatic brain injury.

TRAUMATIC BRAIN INJURY (TBI) is a key cause of spas-tic movement disorders during childhood and ado-

lescence. The estimated annual incidence of pediatric

TBI in developed countries varies according to inclusion

criteria, age, gender, and home country, ranging be-

tween 12 and 489 per 100 000 (overall rate: 235 per

100 000), with 2 peak periods of incidence in early child-

hood (age: 5 years) and between adolescence and

young adulthood (age: 1520 years). On the basis of

initial scores in the Glasgow Coma Scale (GCS) 1, 70% to

80% of patients are classified with mild TBI (GCS: 13

15). Moderate (GCS: 912) and severe (GCS: 38) TBI

are reported in similar proportions of

10%.26

Approx-imately 65% of children with severe TBI exhibit spastic-

ity resulting in functional limitations and disability.710

Hence, recovery of motor function and achieving mobil-

ity are among the primary therapy goals during the

rehabilitation of children with brain injury. The degree

of motor function recovery is an important indicator of

the rehabilitation methods efficacy. Although various

rehabilitation programs have been designed to improve

gross motor function in a pediatric population with TBI,

there is limited research evidence supporting the effec-

tiveness of these interventions.11 This might be because

of the current lack of standardized evaluative measures

with appropriate psychometric properties developed

specifically for pediatric patients with TBI to assess the

magnitude of functional change over time. Outcome

assessments for this patient group are often self-devel-

oped, modified from existing measures, or incorporating

a combination of cognitive, self-care, and physical di-

mensions without differentiation between mobility and

purely motor skills, factors that complicate the interpre-

tation of the amount of motor function recovery alone.12

The Gross Motor Function Measure (GMFM) is recog-

nized in clinical practice and international rehabilitation

research as the gold standard for evaluating quantitative

changes in gross motor function. There are 2 versions of

the GMFM available, the GMFM-8813 and GMFM-66.14

The GMFM-88 is the original criterion-referenced mea-

sure consisting of 88 items grouped in 5 dimensions of

motor function: (1) lying and rolling; (2) sitting; (3)

crawling and kneeling; (4) standing; and (5) walking,

running, and jumping. It was primarily designed to de-

tect clinically significant change in gross motor function

in children with cerebral palsy (CP),13 followed by a

comprehensive validation study for children with Down

syndrome15,16 and a recent first-validation trial for chil-

dren aged 5 to 17 years with spinal muscular atrophy.17

The responsiveness of the GMFM-88 to changes in mo-

tor function after TBI has also been partially estab-

lished,13,18,19 but no comprehensive validation study for

its application in this patient group has yet been con-

ducted. The more recently developed GMFM-66 ema-

nated from the GMFM-88 after applying the Rasch

model of item analysis20 to it in an effort to improve its

clinical usefulness. It is composed of a subset of 66 items,forming a 1-dimensional hierarchical scale. The

GMFM-66 has only proved valid for children with CP so

far, because the item difficulties were calibrated for use

with that particular patient group. Aim of this multi-

center study was to evaluate the validity of the

GMFM-66 and GMFM-88 for use as responsive mea-

sures of change in motor function in children and ado-

lescents with moderate and severe TBI during an inpa-

tient rehabilitation setting.

METHODS

Twelve rehabilitation centers in Germany (n

11) andSwitzerland (n 1) participated in this study (study

coordination center: Childrens University Hospital

Freiburg, Movement Disorders Study Group), recruiting

children and adolescents between the ages of 1 and 18

years who received inpatient rehabilitation services for

TBI. To ensure the necessary variability in population

required for a validation study, we included patients in

early and late rehabilitation phases; the interval between

the time of injury and assessment was irrelevant. A

detailed description of inclusion and exclusion criteria is

provided in Table 1. It was not the aim of this study to

evaluate therapy or early intervention services; thus, the

patients were told to continue with their therapies at

that time. The study was approved by the ethics com-

mittee of Freiburg University.

Determination of Validity

To establish a measures validity, one must compare the

measure of interest with the gold standard (criterion

measure) for the factor being investigated (ie, motor

function). There is currently no generally accepted gold

TABLE 1 Inclusionand ExclusionCriteria

Inclusion criteria

Age 118 y

Moderate (GCS 912) or severe (GCS 38) TBI

Normal psychomotor development before TBI-related hospitalization

Spastic hemiparesis or tetraparesis with functionally significant impairment of

the lower extremities

Adequate physical and mental capability to cooperate and follow GMFM

instructions

Written informed consent from parents or patients

Exclusion criteria

Initial GMFM score 97%

Peripheral injuries interfering with gross motor function at T1/T2 (ie, treatable

fractures of the lower extremities, ribcage, or vertebral column)

PEDIATRICS Volume 120, Number 4, October 2007 e881by guest on October 31, 2011pediatrics.aappublications.orgDownloaded from


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standard in pediatric TBI rehabilitation centers for as-

sessing quantitative changes in motor performance.

Thus, rehabilitation researchers commonly use a con-

struct as an external standard to validate the parameter

in question. In accordance with the Canadian GMFM

developers original validation study,13 we used the stan-

dardized appraisals of change made by parents, physio-

therapists, and independent video assessors as an exter-nal standard, assuming that this measure reflects

clinically relevant change in motor function. A priori

hypotheses were formulated concerning how change

scores on the GMFM would relate to change as judged

by parents, physiotherapists, and independent video as-

sessors.

First we postulated that changes in the GMFM scores

would demonstrate a positive and significant correlation

between the changes in motor function as rated by par-

ents, physiotherapists, and independent video assessors

(minimal correlation coefficient: 0.4) and that this de-

gree of correlation would be higher between the GMFMchange score and video rating (estimated correlation

coefficient:0.6) than between the GMFM change score

and judgements of change made by parents and physio-

therapists. We expected the lowest correlation to occur

between GMFM change scores and those of parental

appraisals. Our postulates were based on the consider-

ation that standardized videotapes of motor function

(rated by an independent assessor) would be considered

the most objective, because the patients actual perfor-

mance would be recorded and evaluated (what is done

versus what can be done). That value should correlate

most closely with the GMFM measuring quantitative

motor function. Because of their background knowledge

about patients, motor function evaluations by treating

physiotherapists are potentially biased. Parents, on the

other hand, might perceive changes in motor function as

reflecting improvement in everyday activities, a param-

eter usually differing considerably from the quantitative

changes in gross motor function detected by the GMFM.

Second, we postulated that there would be fewer

changes in gross motor function during the period be-

tween the actual injury and the first GMFM assessment.

One would anticipate higher GMFM change scores re-

flecting faster change in motor function in the earlier

rehabilitation phases.

Third, we also aimed to test and retest reliability of the

GMFM in children and adolescents with TBI, consider-

ing the GMFM as reliable, provided the intraclass corre-

lation coefficient for the total score attained .90.

Evaluation

The assessment battery consisted of the GMFM, a stan-

dardized video recording, and standardized video rater,

parent, and physiotherapist questionnaires. Evaluations

were obligatory at baseline (T1) and after 4 to 6 weeks

(2 days; T2). The rehabilitation centers had the option

of participating in an evaluation, including the GMFM

readministered after 2 to 3 days (T1R), to monitor test-

retest reliability.

GMFM

All of the physiotherapists who acted as GMFM assessors

were trained in the use of the GMFM by the coordina-tion center as a precondition for study participation. The

official German translation of the GMFM-88 was ap-

plied, which had been developed by the Freiburg Uni-

versity Movement Disorders Study Group in 1999 in

close cooperation with the GMFMs Canadian authors; it

was recently published as the German GMFM manual.21

Training consisted of a 2-day workshop for beginners

with no previous knowledge of the GMFM and a 1-day

refresher course for certified users already familiar with

the instrument. To monitor the reliability of the GMFM,

all of the assessors were tested using a criterion test

videotape to ensure that their scores achieved a mini-mum level of agreement (Somers D coefficient: 0.7).

The same physiotherapist assessed the GMFM at T1, T2,

and T1R.

To investigate the GMFM-66 validity and sensitivity,

all of the GMFM-88 raw scores were converted into the

corresponding GMFM-66 scores using the computer

software for the GMFM-66, the Gross Motor Ability

Estimator.21 Validation analysis was repeated with the

GMFM-66 values.

Video Assessments

The gross motor abilities of the study sample were vid-

eotaped during T1 and T2 according to a standardized

protocol for camera position. Videotapes were 20 min-

utes long and contained samples of motor tasks of the

lying and rolling; crawling and kneeling; sitting; stand-

ing; and walking, running, and jumping dimensions.

Before the start of the study, physiotherapists were in-

structed in how to properly record the videotapes. The 2

video assessors were asked to rate the gross motor abil-

ities observed and to judge any changes in overall and

specific gross motor function dimensions using a stan-

dardized questionnaire. Motor abilities were rated using

a 5-point Likert scale varying from 1 (no impairment) to

5 (very severe impairment). A 7-point Likert scale was

applied to quantify the magnitude of change at the T2

assessment, ranging from 3 (much less) to 3 (much

more), with 0 representing no change. They were ex-

plicitly instructed not to score the GMFM from video-

tape. Both assessors were blinded to the complete case

histories of the patients, meaning they had no back-

ground information regarding rehabilitation phase, in-

terval between brain injury and GMFM assessment, se-

verity of TBI, motor and mental impairment, therapy

goals, or other personal data.



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Parentand PhysiotherapistQuestionnaires

The parent and physiotherapist questionnaires were

identical to those of the video raters regarding the rating

of current motor abilities and the magnitude of change

at T2. In addition, information about the relevance of

the observed change on everyday activities was obtained

by parents and physiotherapists using a 7-point Likert

scale ranging from 3 (severe negative impact) to 3(highly positive impact). The questionnaires were ad-

ministered by telephone by medical staff at the coordi-

nation center (2 pediatricians and 1 physiotherapist)

according to a standardized protocol. The telephone in-

terview took 8 to 10 minutes.

StatisticalAnalysis

All of the statistical computations were performed with

SPSS 13.0 software (SPSS Inc, Chicago, IL). The criterion

for determining significance was a Pvalue of.05 for all

of the statistical tests. A Spearmans correlation coeffi-

cient was used for correlation analysis (hypothesis 1);the Mann-Whitney U test for independent samples was

used to determine any gradient of change over time and

whether the change in gross motor function decreased as

the interval between brain injury and first GMFM as-

sessment increased (hypothesis 2). Test-retest reliability

(hypothesis 3) was evaluated using the Bland-Altman

plot. Correlation between functional change and activi-

ties of daily living was examined by the Kruskal-Wallis

test for k independent samples.

RESULTS

Patient Characteristics

Of the 78 patients recruited in 12 study centers in Ger-

many (n 11) and Switzerland (n 1) between Octo-

ber 2003 and August 2005, 5 failed to complete the

study and had to be excluded from the analysis. A de-

tailed description of the subject population is summa-

rized in Table 2. The mean interval between the GMFM

assessments was 5 weeks and 5 days (SD: 7 days).

Hypothesis1

Change scores for the GMFM, parent and physiothera-

pist questionnaires, and video ratings were derived by

comparing total scores from T1 with those obtained at

T2. Both GMFM version change rates and changes as

judged by parents, physiotherapists, and video assessors

correlated significantly, indicating parallel alterations (P

.0001). Correlations between the total GMFM-88

change score and video rating were best, meeting the

hypothesized criterion of0.6 (video assessor 1 [VA1]: r

0.737; VA2: r 0.657), followed by those between

physiotherapists (r 0.555) and parents (r 0.531). In

accordance with those results, we observed the highest

correlation between the GMFM-66 change score and

VA1 (r 0.679), followed by those between physiother-

apists (r 0.609) and parents (r 0.563). However,

VA2 correlated much weaker than expected, with the

GMFM-66 change score (r 0.536) not achieving the

hypothesized criterion of 0.6. We also assessed the

reliability of the judgements of change made by the 2

independent video raters who were experienced phys-

iotherapists. Interrater reliability was high, with r at

0.704 for the 9 overall judgements of change, ranging

from 0.24 (sitting) to 0.726 (walking, running, and

jumping) for the individual dimensions.

Hypothesis2

As hypothesized, changes in gross motor function be-

came fewer as the interval between brain injury and T1

increased. The total GMFM-88/-66 change scores in chil-

dren and adolescents with date of injury1 year before

the first GMFM assessment (n 10) was only 1.8% (SD:

4.8%)/2.1% (SD: 3.0), whereas it was 12.8% (SD:

14.5)/11.6% (SD: 10.3) in patients for whom the

TABLE 2 BaselineCharacteristics of 73 ChildrenWithModerate-to-

Severe TBI EnteredOntoa ProspectiveMulticenter Study

to Evaluate theValidity of theGMFM-66 andGMFM-88

Parameter Subjects

Female, n (%) 32 (43.8)

Male, n (%) 41 (56.2)

Age at T1

Mean (SD), y 11.4 (

5.1)Range, y 0.818.9

Age at injury

Mean (SD), y 10.5 (4.9)

Range, y 0.818.8

Time between injury and T1

Mean (SD), y 0.86 (2.0)

Range, y 0.011.4

Cause of TBI, n (%)

Traffic accidents 62 (84.9

Falls 7 (9.6)

Violent blows 4 (5.5)

Severity of TBI, n (%)

Moderate (GCS 912) 9 (12.3)

Severe (GCS 38) 64 (87.7)

Type of spasticity, n (%)Hemiparesis 41 (56.2)

Tetraparesis

PEDI mobility level, n (%)

I. Limited capability 10 (13.7)

II. Early movement 10 (13.7)

III. Early mobility 21 (28.8)

IV. Home mobility 10 (13.7)

V. Limited community capability 11 (15.1)

VI. Advanced transfers 4 (5.5)

VII. Advanced community mobility 7 (9.6)

Severity of cognitive impairment, n (%)

No impairment 2 (2.7)

Learning disabilities 28 (38.4)

Moderate mental retardation 22 (30.1)

Severe mental retardation 21 (28.8)

Toclassifythe childrenaccording to their current functional status, thePEDI MobilityClassifica-

tion System20 was used. PEDI indicates Pediatric Evaluation of Disability Inventory.



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interval between brain damage and T1 was 1 year (n

63). That correlation was statistically significant (P

.002/P .001).

Hypothesis3

Test-retest reliability of the GMFM-88/-66 was deter-

mined in a subsample of 10 children. The interval be-

tween T1 and T1R was 3.8 days (SD: 1.1). The intra-class correlation coefficient for the total GMFM-88 and

GMFM-66 score amounted to .99 (Fig 1).

Correlation Between Functional ChangeandActivities of Daily

Living

To investigate whether the functional changes observed

in both GMFM versions were at all relevant to the pa-

tient vis-a-vis activities of daily living, we also compared

parents and physiotherapists subjective judgments of

the relevance of change with the GMFMs change score.

Parallel alterations between GMFM change scores and

parent and physiotherapist judgements regarding theimpact of motor change on activities of daily living could

be demonstrated (Table 3).

DISCUSSION

We evaluated the validity of the GMFM-66 and GMFM-88

for use as responsive measures of change in motor func-

tion in children and adolescents with TBI in this study,

using 3 a priori hypotheses, as described below.

First, change scores of the GMFM-66 and the

GMFM-88 strongly correlated with all of the clinical

judgments of change. For the degree of correlation, we

postulated that the GMFM change score would correlate

highest with the 2 video raters (VA1 and VA2) followed

by physiotherapists and parents. This was fully con-

firmed with the GMFM-88 (r VA1 and r VA2 r phys-

iotherapists r parents) and largely confirmed with the

GMFM-66 (r VA1 r physiotherapists r parents r

VA2).Second, change scores of the GMFM-66 and the

GMFM-88 were higher during the first year of rehabil-

itation after brain injury than during later rehabilitation

phases, reflecting the clinical observation that patients

with TBI show the largest motor recovery during the

first year of rehabilitation.2224

Third, test-retest reliability in a small subsample of

patients was high, indicating that both versions of the

GMFM are consistent over a short period of time when

no significant change in function occurred.

Using a priori construct hypotheses in the absence of

a gold standard is a well-accepted validation strate-gy.13,15,25 The definition of a video rater as an objective

observer is a crucial point in this validation method. In

accordance with previous GMFM validation studies,13,15

the video assessors were physiotherapists blinded to the

medical history of the patient, covering treatment, as

well as statements from parents or therapists and/or

medical professionals. They were not informed about the

interval between the time point of brain injury and first

GMFM evaluation. Because the video rater had to eval-

uate the question of change in motor function over time,

and it was not our aim to investigate the impact of

therapy or early intervention services, we did not blind

the video raters to the time point (T1 or T2) of the

assessments. Certainly, one could argue that an observer

blinded for the time point of evaluation might be even

more objective. However, we believe that we have elim-

inated the most serious confounders, and our video rat-

ers fulfilled the criterion of being highly objective and

independent assessors.

This study did not evaluate interrater reliability in the

administration of the GMFM. Taking into account that

interrater reliability in children with CP and in those

with Down syndrome has been excellent for trained

users in the GMFM, it seemed reasonable to assume that

the interrater reliability of trained users assessing pedi-

atric TBI patients would be comparatively high.

Although our results indicate that both versions of

the GMFM are valid and sensitive tools to assess change

in motor function in pediatric patients with TBI, some

differences are revealed between the 2 versions of the

GMFM, however. In the GMFM-66, 1 objectivity crite-

rion failed regarding the correlation between the

GMFM-66 change score and VA2, indicating that the

GMFM-66 might be less accurate in detecting clinically

significant change than the GMFM-88. This finding

might be explained by the development of the

100.080.060.040.020.00.0

Total GMFM score T1R, %

6.0

4.0

2.0

0.0DifferenceoftotalGMFM

scoreT1andT1R

,

%

GMFM-88

GMFM-66

GMFM-66 (n = 10)

GMFM-88 (n = 10)

FIGURE 1

Bland-Altman plot for describing test-retest reliability with reference line to x-axis for

doubled uncorrected SDs of GMFM-88 (upper continuous line) and GMFM-66 (upper

interrupted line).



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GMFM-66 representing a kind of concentration on the

specific motor development pattern of patients with CP,

which certainly differs from children with TBI. Because

these differences between the 2 versions of the GMFM

are nonetheless small and tend to be of merely theoret-

ical interest, the potential advantages of the GMFM-66,

namely its quicker administration and improved calcu-

lation of total scores (even when some items have been

omitted), may enhance its clinical efficacy.

CONCLUSIONS

This multicenter trial has provided sufficient evidence of

responsiveness and the validity to support the use of the

GMFM-88 and GMFM-66 in clinical and research set-

tings as an evaluative measure of gross motor function in

children and adolescents with TBI. A standardized ther-

apy evaluation method is a precondition for a better

understanding of therapeutic effects on motor outcome

and for optimizing rehabilitative strategies in pediatric

patients with TBI.

ACKNOWLEDGMENTS

This study was financially supported by ZNS-Hannelore-

Kohl-Stiftung grant 200 300 1.

The Gross Motor Function Measure-Traumatic Brain

Injury Study Group participating in this trial included

rehabilitation centers in Germany and Switzerland: Uni-

versity Childrens Hospital Zurich, Rehabilitation Center,

Affoltern (CH): B. Knecht, MD; Fachklinik Hohen-

stucken, Brandenburg: M. Kohler, MD; Neurologisches

Rehabilitationszentrum Friedehorst, Bremen: M.

Spranger, MD; HUMAINE Klinik, Geesthacht: A. Nolte,

MD; Hegau-Jugendwerk Gailingen GmbH: D.

Schmalohr, MD; Klinik Holthausen, Hattingen: W.

Boksch, MD; Kinderkrankenhaus Park Schonfeld, Kas-

sel: F. K. Tegtmeyer, MD; Klinik Bavaria, Kreischa: W.

Deppe, MD; St Mauricius Therapieklinik, Meerbusch: K.

Muller, MD; Fachkrankenhaus Neckargemund: W. Die-

ner, MD; Kinderklinik Schomberg: Ch. Seilacher, MD;

and Behandlungszentrum Vogtareuth: S. Lutjen, MD.

We thank the children, adolescents, and their parents

for participation. We especially thank the physiothera-

pists and pediatricians at all of the 12 participating reha-

bilitation centers for their invaluable assistance with data

collection. We also thank Carole Curten for editorial

assistance.

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TABLE 3 Correlations BetweenGMFMChange Scores andParent/Physiotherapist Judgements

Regardingthe Impactof theObserved Changeon Activities of Daily Living(n70)

Judgement on Impact on

Activities of Daily Living

n GMFM-88 Change

Score, % (SD)

GMFM-66 Change

Score, % (SD)

Parent judgement

High positive impact 51 12.6 (14.6) 11.4 (10.6)

Mean positive impact 10 9.8 (11.1) 10.3 (7.5)

Low positive impact 4 5.7 (6.8) 3.6 ( 8.5)

No change 5 1.4 (3.6) 0.5 (2.2)

P P 0.094 P .05

Physiotherapist judgement

High positive impact 30 17.0 (16.2) 13.9 (11.7)

Mean positive impact 18 10.7 (11.3) 8.3 (7.3)

Low positive impact 15 4.7 (5.4) 8.5 (8.6)

No change 6 0.1 (1.7) 1.3 (2.0)

Low negative impact 0

Mean negative impact 0

High negative impact 1 0.7(0.0) 1.7(0.0)

P P .05 P .05

indicates none.



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DOI: 10.1542/peds.2006-22582007;120;e880Pediatrics

Sabine Stein, Heike Weissenmayer, Rudolf Korinthenberg and Volker MallMichaela Linder-Lucht, Verena Othmer, Michael Walther, Julia Vry, Ulla Michaelis,

Adolescents With Traumatic Brain InjuriesValidation of the Gross Motor Function Measure for Use in Children and

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