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GMFM PPT.pdf

The document describes the Gross Motor Function Measure (GMFM) assessment tool. It was created to measure small but important changes in motor function in children with cerebral palsy (CP). The GMFM evaluates five dimensions of gross motor function: lying and rolling, sitting, crawling and kneeling, standing, and walking, running and jumping. It consists of 88 items of increasing difficulty arranged in these dimensions. Scoring is on a 4-point scale from 0 (does not initiate) to 3 (completes independently). The GMFM provides a standardized way to assess motor abilities in children with CP and can detect changes in abilities over time or after interventions.

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Gross Motor Function Measure
- we should be able to follow maturation after events that are known to slow down brain development - To measure small but important changes in motor function of CP Motor development may plateau for long or short durations of time or the movements may become atypical
Gross motor function  Basic set of movement skills  Child’s achievement
Structure of GMFM  These gross motor milestones form the basis of GMFM dimensions  Measurement - defined as the process of assigning numerals to variables to represent quantities of characteristics according to certain rules  The items are clinically relevant and show potential responsiveness to change
Nature of GMFM  Evaluative - magnitude of change in function over time or after treatment  Criterion based measures - relevant items chosen (domain of interest) and then describing the criterion by which the observer can assess whether that characteristic or functional attribute is present or not  There is no comparison with general population
Item scoring  0 – does not initiate  1 – initiates (<10 % of the task)  2 – partially completes (10% to < 100% of the task)  3 – completes the task  NT – not tested
Difficulty levels  Can viewed in item maps  The difficulty of the items can be viewed by calculation of expected scores  The expected score is the mean score of the population  The item maps show the ability at which the given score is expected
 Pic of item map
Longitudinal Motor Growth Curves for Children with Cerebral Palsy by GMFCS Level Using GMFM-66
GMFM 88 and 66  88 - for Down’s  66 for CP - Identified items which did not “fit” the uni- dimensional construct - eliminated 22 items  Items are now arranged in order of difficulty (empirical)  Response options within items are weighted according to difficulty GMFM is appropriate for children whose motor skills are at or below those of a typical 5 year old
Scoring with aids/orthotics  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
Scoring with aids/orthotics  Consider what information you are trying to obtain – is it new orthoses or a walker or both  Entire GMFM does not need to be repeated with aids and orthoses  It is assumed that aids are intended to assist in standing or ambulating in standing  Test only when standing is included in the item or where it may be a part of transition between two items
Please note !  Only following items should be considered when testing with aids – Sitting - items 35, 36, 37 Standing – All items Walking, running and jumping – All items provided criteria of each score is observed (other than arms free) e.g. – for item 69 - aid may used to assist in standing and walking but other criteria of each score should be observed “1” – child may use aid to assist in walking forward <3 steps
Testing with orthoses  Orthoses can be applied in any dimension  With some children it would good to use in some lower dimensions - that would help in knowing the positive and the negative impact on gross motor function  It is expected that orthoses would great impact on scores where the person has to stand “arms free”
Still wondering if you have to test whole GMFM – 66?
Item -1
GMFM – 66 B&C  GMFM-66 B&C used 16-17 items for testing, compared to the GMFM-66-IS, which used 32-33 items  Scores obtained from these 2 versions were highly correlated when done on the same or different occasions with the child  Fewer items - when using the GMFM-66-B&C and these items were more suitable to the individual child’s abilities  When you have difficulties in making decisions about which item set to test when using the GMFM-66-IS
Advantage ?  Using a shorter motor assessment will provide more time to assess other aspects of the child and family  Consider using a shorter version to document motor function in a more efficient manner by assessing items around a child’s ability level
GMFM - as an outcome measure  Surgery  Drugs (botulinum toxin, intrathecal baclofen)  Physical therapy (including ambulatory aids & orthoses)  Horseback riding  Strength training & physical fitness
Testing
Equipments  Need smooth floor, large firm exercise mat, toys for motivation, large bench or table for cruising  Five steps with railing  Wheeled stool  Tape  Ruler
A. Lying and rolling
SUP, HEAD IN MIDLINE: TURNS HEAD WITH EXTREMITIES SYMMETRICAL Score Description 0 Does not maintain head in midline 1 Maintains head in midline 1-3 sec 2 Maintains head in midline, turns head with extremities asymmetrically 3 Turns head with extremities symmetrical 1.
SUP: BRINGS HANDS TO MIDLINE, FINGERS ONE WITH THE OTHER Score Description 0 Does not initiate bilateral hands to midline 1 Initiates bilateral hands to midline 2 Brings hands to front of the body, does not finger one with the other 3 Brings hands to mid-line fingers one with the other 2.
SUP: LIFTS HEAD 45 degrees Score Description 0 Does not initiate neck flexion 1 Initiates neck flexion but does not lift head 2 Lifts head <45 deg 3 Lifts head 45 deg 3.
SUP: FLEXES R/L HIP & KNEE THROUGH FULL RANGE Score Description 0 Does not initiate R/L hip & knee flexion 1 Initiates R/L hip & knee flexion 2 Flexes R/L hip & knee through partial range 3 Flexes R/L hip & knee through full range 4/5.
SUP: REACHES OUT WITH R/L ARM, HAND CROSSES MIDLINE TOWARD TOY Score Description 0 Does not initiate reaching towards midline 1 Initiates reaching towards midline 2 Reaches out with R/L arm, hand does not cross midline 3 Reaches out with R/L arm, hand crosses midline toward toy 6/7.
SUP: ROLLS TO PR OVER R/L SIDE Score Description 0 Does not initiate rolling 1 Initiates rolling 2 Rolls part way to prone 3 Rolls to prone over R/L side 8/9.
PR: LIFTS HEAD UPRIGHT Score Description 0 Does not initiate reaching towards midline 1 Initiates reaching towards midline 2 Reaches out with R arm, hand does not cross midline 3 Reaches out with R arm, hand crosses midline toward toy 10.
B: Sitting
PR ON FOREARMS: LIFTS HEAD UPRIGHT, ELBOWS EXT., CHEST RAISED Score Description 0 Does not initiate head lifting 1 Initiates head lifting chin does not clear mat 2 Lifts head, does not attain up right, weight on forearms 3 Lifts head upright, elbows extended, chest raised 11.
PR ON FOREARMS: WEIGHT ON R/L FOREARM, FULLY EXTENDS OPPOSITE ARM FORWARD Score Description 0 Does not initiate supporting wt. on R/L forearm 1 Wt. on R/L forearm, opposite arm comes free does not extend forward 2 Wt. on R/L forearm, partially extends opposite arm forward 3 Wt. on R/L forearm, fully extends opposite arm forward 12/13.
PR: ROLLS TO SUP OVER R/L SIDE Score Description 0 Does not initiate rolling 1 Initiates rolling 2 Rolls part to supine 3 Rolls to supine over R/L side 14/15.
PR: PIVOTS TO R/L 90 degrees USING EXTREMITIES Score Description 0 Does not initiate pivot to R/L 1 Initiates pivot to R/L using extremities 2 Pivots to R/L <90 deg using extremities 3 Pivots to R/L 90 deg using extremities 16/17.
SUP, HANDS GRASPED BY EXAMINER: PULLS SELF TO SITTING WITH HEAD CONTROL Score Description 0 Does not initiate Head control when pulled to sitting 1 initiates Head control when pulled to sitting 2 Assists with pulling to sitting, head control present part of the time 3 Pulls self to sitting with head control 18.
SUP: ROLLS TO R/L SIDE, ATTAINS SITTING Score Description 0 Does not initiate sitting from right side lying 1 Roles to R/ L side, sitting 2 Roles to R/ L side, partially attains sitting 3 Roles to R/L side, attains sitting 19/20.
SIT ON MAT, SUPPORTED AT THORAX BY THERAPIST: LIFTS HEAD UPRIGHT, MAINTAINS 3 SECONDS Score Description 0 Does not initiate Head lift 1 Initiates head lift 2 Lifts head, does not attain upright, holds 3 seconds 3 Lifts head upright, maintains 3 seconds 21.
SIT ON MAT, SUPPORTED AT THORAX BY THERAPIST: LIFTS HEAD MIDLINE, MAINTAINS 10 SECONDS Score Description 0 Does not initiate Head lift 1 Initiates head lift, but does not attain midline 2 Lifts head to midline, maintains < 10 seconds 3 Lifts head to midline, maintains 10 seconds 22.
SIT ON MAT, ARM(S) PROPPING: MAINTAINS, 5 SECONDS Score Description 0 Does not maintains with arm(s) propping 1 Maintains < 1 second 2 Maintains 1-4 second 3 Maintains 5 second 23.
SIT ON MAT: MAINTAIN, ARMS FREE, 3 SECONDS Score Description 0 Does not maintain unless both arms propping 1 Maintain, one arm propping 2 Maintains arms free, < 3 seconds 3 Maintains arms free, 3 seconds 24.
SIT ON MAT SMALL TOY IN FRONT: LEANS FORWARD, TOUCHES TOY, RE- ERECTS WITHOUT ARM PROPPING Score Description 0 Does not initiate leaning forward 1 Leans forward, does not re-erect 2 Leans forward, touches toy, re- erects with arms propping 3 Leans forward, touches toy, re- erects without arms propping 25.
SIT ON MAT: TOUCHES TOY PLACED 45° BEHIND CHILD’S R/L SIDE, RETURNS TO START Score Description 0 Does not initiate touching toy 1 Initiates reaching does not reach behind 2 Reaches behind, does not touch toy or return to start 3 Touches toy placed 45 deg. behind child’s right / left side, returns to start 26/27.
R/L SIDE SIT: MAINTAINS, ARMS FREE, 5 SECONDS Score Description 0 Does not maintain R/L side sitting 1 Maintains, both arms propping, 5 seconds 2 Maintains, R/L arm propping, 5 seconds 3 Maintains, arm free, 5 seconds 28/29.
SIT ON MAT: LOWERS TO PR WITH CONTROL Score Description 0 Does not initiate lowering to prone 1 Initiates lowering to prone 2 Lowers to prone but crashes 3 Lowers to prone with control 30.
SIT ON MAT WITH FEET IN FRONT: ATTAINS 4 POINT OVER R/L SIDE Score Description 0 Does not initiate 4 point over R/L side 1 Initiates 4 point over R/L side 2 Partially attains 4 point over R/L side 3 Attains 4 point over R/L side 31/32.
SIT ON MAT: PIVOTS 90 degrees, WITHOUT ARMS ASSISTING Score Description 0 Does not pivoting 1 Initiates pivot 2 Pivots 90 degrees with arms assisting 3 Pivots 90 degrees without arms assisting 33.
SIT ON BENCH: MAINTAINS, ARMS AND FEET FREE, 10 SECONDS Score Description 0 Does not maintain sitting on bench 1 Maintains, arms propping and feet supported, 10 seconds 2 Maintains, arms free and feet supported, 10 seconds 3 Maintains, arms free and feet free, 10 seconds 34.
STD: ATTAINS SIT ON SMALL BENCH Score Description 0 Does not initiate sitting on small bench 1 Initiates sitting on small bench 2 Partially attains sitting on small bench 3 Attains sitting on small bench 35.
ON THE FLOOR: ATTAINS SIT ON SMALL BENCH Score Description 0 Does not initiate sitting on small bench 1 Initiates sitting on small bench 2 Partially attains sitting on small bench 3 Attains sitting on small bench 36.
STD: ATTAINS SIT ON LARGE BENCH Score Description 0 Does not initiate sitting on large bench 1 Initiates sitting on large bench 2 Partially attains sitting on large bench 3 Attains sitting on large bench 37.
C: crawling or kneeling
PR: CREEPS FORWARD 1.8m (6') Score Description 0 Does not initiate creeping forward 1 creeps forward <60cms 2 creeps forward 60cms – 1.5m 3 creeps forward 1.8 m 38.
4 POINT: MAINTAINS, WEIGHT ON HANDS AND KNEES, 10 SECONDS Score Description 0 Does not maintain weight on hands and knees 1 Maintains weight on hands and knees, < 3 sec 2 Maintains weight on hands and knees, 3 - 9 sec 3 Maintains weight on hands and knees, 10sec 39.
4 POINT: ATTAINS SIT ARMS FREE Score Description 0 Does not initiate sitting 1 Initiates sitting 2 Attains sitting, arm(s) propping 3 Attains sitting, arms free 40.
PR: ATTAINS 4 POINT, WEIGHT ON HANDS AND KNEES Score Description 0 Does not initiate 4 point 1 Initiates 4 point 2 Partially attains 4 point 3 Attains 4 point, weight on hands and knees 41.
4 POINT: REACHES FORWARD WITH R/L ARM, HAND ABOVE SHOULDER LEVEL Score Description 0 Does not initiate reaching forward with R/L arm 1 Initiates reaching forward with R/L arm 2 Partially reaches forward with R/L arm 3 Reaches forward with R/L arm, hand above shoulder level 42/43.
4 POINT: CRAWLS OR HITCHES FORWARD 1.8m(6') Score Description 0 Does not initiate crawling or hitching forward 1 Crawls or hitches forward forward <60cms 2 Crawls or hitches forward 60cms – 1.5m 3 Crawls or hitches forward 1.8 m 44.
4 POINT: CRAWLS RECIPROCALLY FORWARD1.8m ( 6') Score Description 0 Does not initiate crawling forward reciprocally 1 Crawls reciprocally forward forward <60cms 2 Crawls reciprocally forward 60cms – 1.5m 3 Crawls reciprocally forward 1.8 m 45.
4 POINT: CRAWLS UP 4 STEPS ON HANDS AND KNEES/FEET Score Description 0 Does not initiate crawling up 4 steps 1 Crawls up one step on hands and knees/feet 2 Crawls up two or three step on hands and knees/feet 3 Crawls up four step on hands and knees/feet 46.
4 POINT: CRAWLS BACKWARDS DOWN 4 STEPS ON HANDS AND KNEES/FEET Score Description 0 Does not initiate crawling backwards down steps 1 Crawls backward down one step on hands and knees / feet 2 Crawls backward down 2 or 3 step on hands and knees / feet 3 Crawls backward down 4 step on hands and knees / feet 47.
SIT ON MAT: ATTAINS HIGH KN USING ARMS, MAINTAINS, ARMS FREE, 10 SECONDS Score Description 0 When placed does not maintain, holding on 1 When placed maintains, holding on 10 sec 2 Attains high kneel, holding on, maintains 10 sec 3 Attains high kneel, using arms, maintains arms free for 10 sec 48.
HIGH KN: ATTAINS HALF KN ON R/L KNEE USING ARMS, MAINTAINS, ARMS FREE, 10 SECONDS Score Description 0 When placed does not maintain, holding on 1 When placed maintains, holding on 10 sec 2 Attains half kneel, holding on, maintains 10 sec 3 Attains half kneel, using arms, maintains arms free for 10 sec 49/50.
HIGH KN: KN WALKS FORWARD 10 STEPS, ARMS FREE Score Description 0 Does not initiate kneel walking forward 1 Kneel walks forwards 10 steps, two hands holding on 2 Kneel walks forwards 10 steps, one hand holding on 3 Kneel walks forwards 10 steps, arms free 51.
D Standing
52. ON THE FLOOR: PULLS TO STD AT LARGE BENCH Score Description 0 Does not initiate pulling to stand 1 Initiates pulling to stand 2 Partially pulls to stand 3 Pulls to stand at large bench 52.
STD: MAINTAINS, ARMS FREE, 3 SECONDS Score Description 0 Does not maintain standing holding on 1 Maintains, 2 hands holding on, 3 sec 2 Maintains, one hand holding on, 3 sec 3 Maintains, arms free, 3 sec 53.
STD: HOLDING ON TO LARGE BENCH WITH ONE HAND, LIFTS R/L FOOT, 3 SECONDS Score Description 0 Does not initiate lifting R/L foot 1 Holding on to large bench with 2 hands, lifts R/L foot < 3 sec 2 Holding on to large bench with 2 hands, lifts R/L foot, 3 sec 3 Holding on to large bench with 1 hand, lifts R/L foot, 3 sec 54/55.
STD: MAINTAINS, ARMS FREE, 20 SECONDS Score Description 0 Does not maintain standing, arms free 1 Maintains, arms free < 3 sec 2 Maintains, arms free 3 – 19 sec 3 Maintains, arms free 20 sec 56.
STD: LIFTS R/L FOOT, ARMS FREE, 10 SECONDS Score Description 0 Does not lift R/L foot arms free 1 Lifts R/L foot arms free < 3 sec 2 Lifts R/L foot arms free 3 – 9 sec 3 Lifts R/L foot arms free, 10 sec 57/58.
SIT ON SMALL BENCH: ATTAINS STD WITHOUT USING ARMS Score Description 0 Does not initiate sanding 1 Initiates sanding 2 Attains standing using arms 3 Attains standing without using arms 59.
HIGH KN: ATTAINS STD THROUGH HALF KN ON R KNEE, WITHOUT USING ARMS Score Description 0 Does not initiate sanding 1 Initiates sanding 2 Attains standing using arms 3 Attains standing through half kneel on R/L knee without using arms 60/61.
STD: LOWERS TO SIT ON FLOOR WITH CONTROL, ARMS FREE Score Description 0 Does not lower to floor 1 Lowers to sitting on floor, but ‘crashes’ down 2 Lowers to sitting on floor with control, using arm(s) or holding on 3 Lowers to sitting on floor with control, arms free 62.
STD: ATTAINS SQUAT, ARMS FREE Score Description 0 Does not initiate squat 1 Initiates squat 2 Attains squat, using arm(s) or holding on 3 Attains squat, arms free 63.
STD: PICKS UP OBJECT FROM FLOOR, ARMS FREE, RETURNS TO STAND Score Description 0 Does not initiate picking up object from the floor 1 Initiates picking up object from the floor 2 Picks up object from the floor using arm(s) or holding on 3 Picks up object from the floor , arms free, returns to standing 64.
E. Walking, running and jumping
STD, 2 HANDS ON LARGE BENCH: CRUISES 5 STEPS TO R/L Score Description 0 Does not initiate cruising to R/L 1 Initiates cruising, <1 complete step to R/L 2 Cruises 1-4 steps to R/L 3 Cruises 5steps to R/L 65/66.
STD, 2 HANDS HELD: WALKS FORWARD 10 STEPS Score Description 0 Does not initiate walking forward 1 Walks forward < 3 steps 2 Walks forward 3 - 9 steps 3 Walks forward 10 steps 67.
STD, 1 HAND HELD: WALKS FORWARD 10 STEPS Score Description 0 Does not initiate walking forward 1 Walks forward < 3 steps 2 Walks forward 3 - 9 steps 3 Walks forward 10 steps 68.
STD: WALKS FORWARD 10 STEPS Score Description 0 Does not initiate walking forward 1 Walks forward < 3 steps 2 Walks forward 3 - 9 steps 3 Walks forward 10 steps 69.
STD: WALKS FORWARD 10 STEPS, STOPS, TURNS 180 deg, RETURNS Score Description 0 Walks forward 10 steps, does not stop without falling 1 Walks forward 10 steps, does not initiate turn 2 Walks forward 10 steps, stops, turns < 180 deg 3 Walks forward 10 steps, stops, turns 180 deg, returns 70.
STD: WALKS BACKWARD 10 STEPS Score Description 0 Does not initiate walking backward 1 Walks backward < 3 steps 2 Walks backward 3 - 9 steps 3 Walks backward 10 steps 71.
STD: WALKS FORWARD 10 STEPS, CARRYING A LARGE OBJECT WITH 2 HANDS Score Description 0 Does not initiate walking, carrying large object 1 Walks forward 10 steps, carrying small object with 1 hand 2 Walks forward 10 steps, carrying small object with 2 hands 3 Walks forward 10 steps, carrying large object with 2 hands 72.
STD: WALKS FORWARD 10 CONSECUTIVE STEPS BETWEEN PARALLEL LINES 20cm (8")APART Score Description 0 Does not initiate walking b/n ║lines 20 cm (8’) apart 1 Walks <3 consec utive steps b/n ║ lines 20 cm(8’) apart 2 Walks 3-9 consec utive steps b/n ║ lines 20 cm (8’) apart 3 Walks 10 consec utive steps b/n ║ lines 20 cm(8’) apart 73.
STD: WALKS FORWARD 10 CONSECUTIVE STEPS ON A STRAIGHT LINE 2cm (3/4") WIDE Score Description 0 Does not initiate walking forward on a straight line 2 cm wide 1 Walks <3 consec utive steps 2 Walks 3-9 consec utive steps 3 Walks 10 consec utive steps 74.
STD: STEPS OVER STICK AT KNEE LEVEL, R/L FOOT LEADING Score Description 0 Does not initiate stepping over stick R/L foot leading 1 Steps over sick 5- 7.5 cm high R/L foot leading 2 Steps over sick at mid-calf level R/L foot leading 3 Steps over sick at knee level R/L foot leading 75/76.
STD: RUNS 4.5m (15’), STOPS & RETURNS Score Description 0 Does not initiate running 1 Initiates running by walking quickly 2 Runs < 4.5 m (15ft) 3 Runs < 4.5 m (15ft), stops and returns 77.
STD: KICKS BALL WITH R/L FOOT Score Description 0 Does not initiate kicking 1 Lifts R/L foot, does not kick 2 Kicks ball with R/L foot but falls 3 Kicks ball with R/L foot 78/79.
STD: JUMPS 30cm (12") HIGH, BOTH FEET SIMULTANEOUSLY Score Description 0 Does not initiate Jump 1 Jumps < 5 cm high both feet simultaneously 2 Jumps 5 – 28 cm high both feet simultaneously 3 Jumps 30 cm high both feet simultaneously 80.
STD: JUMPS FORWARD 30 cm (12"), BOTH FEET SIMULTANEOUSLY Score Description 0 Does not initiate jumping forward, both feet simultaneously 1 Jumps forward <5cm both feet simultaneously 2 Jumps forward 5- 28 cm both feet simultaneously 3 Jumps forward 30 cm both feet simultaneously 81.
STD ON R/L FOOT: HOPS ON R/L FOOT 10 TIMES WITHIN A 60cm (24") CIRCLE Score Description 0 Does not initiate hopping on R/L foot 1 Hops on R/L foot < 3 times within a 60 cm circle 2 Hops on R/L foot 3 – 9 times within a 60 cm circle 3 Hops on R/L foot 10 times within a 60 cm circle 82.
STD, HOLDING 1 RAIL: WALKS UP/WALKS DOWN 4 STEPS, HOLDING 1 RAIL, ALTERNATING FEET Score Description 0 Does not initiate walking up/down steps, holding rail 1 Walks up/down 2 steps, holding rail, same foot leads consistently 2 Walks up/down 4 steps, holding rail, alternating foot inconsistently 3 Walks up/down 4 steps, holding rail alternating foot 84/85.
STD: WALKS UP/WALKS DOWN 4 STEPS, ALTERNATING FEET Score Description 0 Does not initiate walking up/down steps, arms free 1 Walks up/down 2 steps, same foot leads consistently 2 Walks up/down 4 steps, alternating foot inconsistently 3 Walks up/down 4 steps, alternating foot 86/87.
STD ON 15cm (6") STEP: JUMPS OFF, BOTH FEET SIMULTANEOUSLY Score Description 0 Does not initiate jumping off step, both feet simultaneously 1 Jumps off step, both feet simult - aneously, but falls 2 Jumps off step, both feet simult - aneously, uses hands on floor to avoid falling 3 Jumps off, both feet simultaneously 88.
GMFM PPT.pdf

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GMFM PPT.pdf

  • 1.
  • 2.
    - we shouldbe able to follow maturation after events that are known to slow down brain development - To measure small but important changes in motor function of CP Motor development may plateau for long or short durations of time or the movements may become atypical
  • 3.
    Gross motor function Basic set of movement skills  Child’s achievement
  • 5.
    Structure of GMFM These gross motor milestones form the basis of GMFM dimensions  Measurement - defined as the process of assigning numerals to variables to represent quantities of characteristics according to certain rules  The items are clinically relevant and show potential responsiveness to change
  • 6.
    Nature of GMFM Evaluative - magnitude of change in function over time or after treatment  Criterion based measures - relevant items chosen (domain of interest) and then describing the criterion by which the observer can assess whether that characteristic or functional attribute is present or not  There is no comparison with general population
  • 7.
    Item scoring  0– does not initiate  1 – initiates (<10 % of the task)  2 – partially completes (10% to < 100% of the task)  3 – completes the task  NT – not tested
  • 8.
    Difficulty levels  Canviewed in item maps  The difficulty of the items can be viewed by calculation of expected scores  The expected score is the mean score of the population  The item maps show the ability at which the given score is expected
  • 9.
     Pic ofitem map
  • 10.
    Longitudinal Motor GrowthCurves for Children with Cerebral Palsy by GMFCS Level Using GMFM-66
  • 11.
    GMFM 88 and66  88 - for Down’s  66 for CP - Identified items which did not “fit” the uni- dimensional construct - eliminated 22 items  Items are now arranged in order of difficulty (empirical)  Response options within items are weighted according to difficulty GMFM is appropriate for children whose motor skills are at or below those of a typical 5 year old
  • 12.
    Scoring with aids/orthotics 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
  • 13.
    Scoring with aids/orthotics Consider what information you are trying to obtain – is it new orthoses or a walker or both  Entire GMFM does not need to be repeated with aids and orthoses  It is assumed that aids are intended to assist in standing or ambulating in standing  Test only when standing is included in the item or where it may be a part of transition between two items
  • 14.
    Please note ! Only following items should be considered when testing with aids – Sitting - items 35, 36, 37 Standing – All items Walking, running and jumping – All items provided criteria of each score is observed (other than arms free) e.g. – for item 69 - aid may used to assist in standing and walking but other criteria of each score should be observed “1” – child may use aid to assist in walking forward <3 steps
  • 15.
    Testing with orthoses Orthoses can be applied in any dimension  With some children it would good to use in some lower dimensions - that would help in knowing the positive and the negative impact on gross motor function  It is expected that orthoses would great impact on scores where the person has to stand “arms free”
  • 16.
    Still wondering ifyou have to test whole GMFM – 66?
  • 17.
  • 18.
    GMFM – 66B&C  GMFM-66 B&C used 16-17 items for testing, compared to the GMFM-66-IS, which used 32-33 items  Scores obtained from these 2 versions were highly correlated when done on the same or different occasions with the child  Fewer items - when using the GMFM-66-B&C and these items were more suitable to the individual child’s abilities  When you have difficulties in making decisions about which item set to test when using the GMFM-66-IS
  • 19.
    Advantage ?  Usinga shorter motor assessment will provide more time to assess other aspects of the child and family  Consider using a shorter version to document motor function in a more efficient manner by assessing items around a child’s ability level
  • 20.
    GMFM - asan outcome measure  Surgery  Drugs (botulinum toxin, intrathecal baclofen)  Physical therapy (including ambulatory aids & orthoses)  Horseback riding  Strength training & physical fitness
  • 21.
  • 22.
    Equipments  Need smoothfloor, large firm exercise mat, toys for motivation, large bench or table for cruising  Five steps with railing  Wheeled stool  Tape  Ruler
  • 23.
    A. Lying androlling
  • 24.
    SUP, HEAD INMIDLINE: TURNS HEAD WITH EXTREMITIES SYMMETRICAL Score Description 0 Does not maintain head in midline 1 Maintains head in midline 1-3 sec 2 Maintains head in midline, turns head with extremities asymmetrically 3 Turns head with extremities symmetrical 1.
  • 25.
    SUP: BRINGS HANDSTO MIDLINE, FINGERS ONE WITH THE OTHER Score Description 0 Does not initiate bilateral hands to midline 1 Initiates bilateral hands to midline 2 Brings hands to front of the body, does not finger one with the other 3 Brings hands to mid-line fingers one with the other 2.
  • 26.
    SUP: LIFTS HEAD45 degrees Score Description 0 Does not initiate neck flexion 1 Initiates neck flexion but does not lift head 2 Lifts head <45 deg 3 Lifts head 45 deg 3.
  • 27.
    SUP: FLEXES R/LHIP & KNEE THROUGH FULL RANGE Score Description 0 Does not initiate R/L hip & knee flexion 1 Initiates R/L hip & knee flexion 2 Flexes R/L hip & knee through partial range 3 Flexes R/L hip & knee through full range 4/5.
  • 28.
    SUP: REACHES OUTWITH R/L ARM, HAND CROSSES MIDLINE TOWARD TOY Score Description 0 Does not initiate reaching towards midline 1 Initiates reaching towards midline 2 Reaches out with R/L arm, hand does not cross midline 3 Reaches out with R/L arm, hand crosses midline toward toy 6/7.
  • 29.
    SUP: ROLLS TOPR OVER R/L SIDE Score Description 0 Does not initiate rolling 1 Initiates rolling 2 Rolls part way to prone 3 Rolls to prone over R/L side 8/9.
  • 30.
    PR: LIFTS HEADUPRIGHT Score Description 0 Does not initiate reaching towards midline 1 Initiates reaching towards midline 2 Reaches out with R arm, hand does not cross midline 3 Reaches out with R arm, hand crosses midline toward toy 10.
  • 31.
  • 32.
    PR ON FOREARMS:LIFTS HEAD UPRIGHT, ELBOWS EXT., CHEST RAISED Score Description 0 Does not initiate head lifting 1 Initiates head lifting chin does not clear mat 2 Lifts head, does not attain up right, weight on forearms 3 Lifts head upright, elbows extended, chest raised 11.
  • 33.
    PR ON FOREARMS:WEIGHT ON R/L FOREARM, FULLY EXTENDS OPPOSITE ARM FORWARD Score Description 0 Does not initiate supporting wt. on R/L forearm 1 Wt. on R/L forearm, opposite arm comes free does not extend forward 2 Wt. on R/L forearm, partially extends opposite arm forward 3 Wt. on R/L forearm, fully extends opposite arm forward 12/13.
  • 34.
    PR: ROLLS TOSUP OVER R/L SIDE Score Description 0 Does not initiate rolling 1 Initiates rolling 2 Rolls part to supine 3 Rolls to supine over R/L side 14/15.
  • 35.
    PR: PIVOTS TOR/L 90 degrees USING EXTREMITIES Score Description 0 Does not initiate pivot to R/L 1 Initiates pivot to R/L using extremities 2 Pivots to R/L <90 deg using extremities 3 Pivots to R/L 90 deg using extremities 16/17.
  • 36.
    SUP, HANDS GRASPEDBY EXAMINER: PULLS SELF TO SITTING WITH HEAD CONTROL Score Description 0 Does not initiate Head control when pulled to sitting 1 initiates Head control when pulled to sitting 2 Assists with pulling to sitting, head control present part of the time 3 Pulls self to sitting with head control 18.
  • 37.
    SUP: ROLLS TOR/L SIDE, ATTAINS SITTING Score Description 0 Does not initiate sitting from right side lying 1 Roles to R/ L side, sitting 2 Roles to R/ L side, partially attains sitting 3 Roles to R/L side, attains sitting 19/20.
  • 38.
    SIT ON MAT,SUPPORTED AT THORAX BY THERAPIST: LIFTS HEAD UPRIGHT, MAINTAINS 3 SECONDS Score Description 0 Does not initiate Head lift 1 Initiates head lift 2 Lifts head, does not attain upright, holds 3 seconds 3 Lifts head upright, maintains 3 seconds 21.
  • 39.
    SIT ON MAT,SUPPORTED AT THORAX BY THERAPIST: LIFTS HEAD MIDLINE, MAINTAINS 10 SECONDS Score Description 0 Does not initiate Head lift 1 Initiates head lift, but does not attain midline 2 Lifts head to midline, maintains < 10 seconds 3 Lifts head to midline, maintains 10 seconds 22.
  • 40.
    SIT ON MAT,ARM(S) PROPPING: MAINTAINS, 5 SECONDS Score Description 0 Does not maintains with arm(s) propping 1 Maintains < 1 second 2 Maintains 1-4 second 3 Maintains 5 second 23.
  • 41.
    SIT ON MAT:MAINTAIN, ARMS FREE, 3 SECONDS Score Description 0 Does not maintain unless both arms propping 1 Maintain, one arm propping 2 Maintains arms free, < 3 seconds 3 Maintains arms free, 3 seconds 24.
  • 42.
    SIT ON MATSMALL TOY IN FRONT: LEANS FORWARD, TOUCHES TOY, RE- ERECTS WITHOUT ARM PROPPING Score Description 0 Does not initiate leaning forward 1 Leans forward, does not re-erect 2 Leans forward, touches toy, re- erects with arms propping 3 Leans forward, touches toy, re- erects without arms propping 25.
  • 43.
    SIT ON MAT:TOUCHES TOY PLACED 45° BEHIND CHILD’S R/L SIDE, RETURNS TO START Score Description 0 Does not initiate touching toy 1 Initiates reaching does not reach behind 2 Reaches behind, does not touch toy or return to start 3 Touches toy placed 45 deg. behind child’s right / left side, returns to start 26/27.
  • 44.
    R/L SIDE SIT:MAINTAINS, ARMS FREE, 5 SECONDS Score Description 0 Does not maintain R/L side sitting 1 Maintains, both arms propping, 5 seconds 2 Maintains, R/L arm propping, 5 seconds 3 Maintains, arm free, 5 seconds 28/29.
  • 45.
    SIT ON MAT:LOWERS TO PR WITH CONTROL Score Description 0 Does not initiate lowering to prone 1 Initiates lowering to prone 2 Lowers to prone but crashes 3 Lowers to prone with control 30.
  • 46.
    SIT ON MATWITH FEET IN FRONT: ATTAINS 4 POINT OVER R/L SIDE Score Description 0 Does not initiate 4 point over R/L side 1 Initiates 4 point over R/L side 2 Partially attains 4 point over R/L side 3 Attains 4 point over R/L side 31/32.
  • 47.
    SIT ON MAT:PIVOTS 90 degrees, WITHOUT ARMS ASSISTING Score Description 0 Does not pivoting 1 Initiates pivot 2 Pivots 90 degrees with arms assisting 3 Pivots 90 degrees without arms assisting 33.
  • 48.
    SIT ON BENCH:MAINTAINS, ARMS AND FEET FREE, 10 SECONDS Score Description 0 Does not maintain sitting on bench 1 Maintains, arms propping and feet supported, 10 seconds 2 Maintains, arms free and feet supported, 10 seconds 3 Maintains, arms free and feet free, 10 seconds 34.
  • 49.
    STD: ATTAINS SITON SMALL BENCH Score Description 0 Does not initiate sitting on small bench 1 Initiates sitting on small bench 2 Partially attains sitting on small bench 3 Attains sitting on small bench 35.
  • 50.
    ON THE FLOOR:ATTAINS SIT ON SMALL BENCH Score Description 0 Does not initiate sitting on small bench 1 Initiates sitting on small bench 2 Partially attains sitting on small bench 3 Attains sitting on small bench 36.
  • 51.
    STD: ATTAINS SITON LARGE BENCH Score Description 0 Does not initiate sitting on large bench 1 Initiates sitting on large bench 2 Partially attains sitting on large bench 3 Attains sitting on large bench 37.
  • 52.
  • 53.
    PR: CREEPS FORWARD1.8m (6') Score Description 0 Does not initiate creeping forward 1 creeps forward <60cms 2 creeps forward 60cms – 1.5m 3 creeps forward 1.8 m 38.
  • 54.
    4 POINT: MAINTAINS,WEIGHT ON HANDS AND KNEES, 10 SECONDS Score Description 0 Does not maintain weight on hands and knees 1 Maintains weight on hands and knees, < 3 sec 2 Maintains weight on hands and knees, 3 - 9 sec 3 Maintains weight on hands and knees, 10sec 39.
  • 55.
    4 POINT: ATTAINSSIT ARMS FREE Score Description 0 Does not initiate sitting 1 Initiates sitting 2 Attains sitting, arm(s) propping 3 Attains sitting, arms free 40.
  • 56.
    PR: ATTAINS 4POINT, WEIGHT ON HANDS AND KNEES Score Description 0 Does not initiate 4 point 1 Initiates 4 point 2 Partially attains 4 point 3 Attains 4 point, weight on hands and knees 41.
  • 57.
    4 POINT: REACHESFORWARD WITH R/L ARM, HAND ABOVE SHOULDER LEVEL Score Description 0 Does not initiate reaching forward with R/L arm 1 Initiates reaching forward with R/L arm 2 Partially reaches forward with R/L arm 3 Reaches forward with R/L arm, hand above shoulder level 42/43.
  • 58.
    4 POINT: CRAWLSOR HITCHES FORWARD 1.8m(6') Score Description 0 Does not initiate crawling or hitching forward 1 Crawls or hitches forward forward <60cms 2 Crawls or hitches forward 60cms – 1.5m 3 Crawls or hitches forward 1.8 m 44.
  • 59.
    4 POINT: CRAWLSRECIPROCALLY FORWARD1.8m ( 6') Score Description 0 Does not initiate crawling forward reciprocally 1 Crawls reciprocally forward forward <60cms 2 Crawls reciprocally forward 60cms – 1.5m 3 Crawls reciprocally forward 1.8 m 45.
  • 60.
    4 POINT: CRAWLSUP 4 STEPS ON HANDS AND KNEES/FEET Score Description 0 Does not initiate crawling up 4 steps 1 Crawls up one step on hands and knees/feet 2 Crawls up two or three step on hands and knees/feet 3 Crawls up four step on hands and knees/feet 46.
  • 61.
    4 POINT: CRAWLSBACKWARDS DOWN 4 STEPS ON HANDS AND KNEES/FEET Score Description 0 Does not initiate crawling backwards down steps 1 Crawls backward down one step on hands and knees / feet 2 Crawls backward down 2 or 3 step on hands and knees / feet 3 Crawls backward down 4 step on hands and knees / feet 47.
  • 62.
    SIT ON MAT:ATTAINS HIGH KN USING ARMS, MAINTAINS, ARMS FREE, 10 SECONDS Score Description 0 When placed does not maintain, holding on 1 When placed maintains, holding on 10 sec 2 Attains high kneel, holding on, maintains 10 sec 3 Attains high kneel, using arms, maintains arms free for 10 sec 48.
  • 63.
    HIGH KN: ATTAINSHALF KN ON R/L KNEE USING ARMS, MAINTAINS, ARMS FREE, 10 SECONDS Score Description 0 When placed does not maintain, holding on 1 When placed maintains, holding on 10 sec 2 Attains half kneel, holding on, maintains 10 sec 3 Attains half kneel, using arms, maintains arms free for 10 sec 49/50.
  • 64.
    HIGH KN: KNWALKS FORWARD 10 STEPS, ARMS FREE Score Description 0 Does not initiate kneel walking forward 1 Kneel walks forwards 10 steps, two hands holding on 2 Kneel walks forwards 10 steps, one hand holding on 3 Kneel walks forwards 10 steps, arms free 51.
  • 65.
  • 66.
    52. ON THEFLOOR: PULLS TO STD AT LARGE BENCH Score Description 0 Does not initiate pulling to stand 1 Initiates pulling to stand 2 Partially pulls to stand 3 Pulls to stand at large bench 52.
  • 67.
    STD: MAINTAINS, ARMSFREE, 3 SECONDS Score Description 0 Does not maintain standing holding on 1 Maintains, 2 hands holding on, 3 sec 2 Maintains, one hand holding on, 3 sec 3 Maintains, arms free, 3 sec 53.
  • 68.
    STD: HOLDING ONTO LARGE BENCH WITH ONE HAND, LIFTS R/L FOOT, 3 SECONDS Score Description 0 Does not initiate lifting R/L foot 1 Holding on to large bench with 2 hands, lifts R/L foot < 3 sec 2 Holding on to large bench with 2 hands, lifts R/L foot, 3 sec 3 Holding on to large bench with 1 hand, lifts R/L foot, 3 sec 54/55.
  • 69.
    STD: MAINTAINS, ARMSFREE, 20 SECONDS Score Description 0 Does not maintain standing, arms free 1 Maintains, arms free < 3 sec 2 Maintains, arms free 3 – 19 sec 3 Maintains, arms free 20 sec 56.
  • 70.
    STD: LIFTS R/LFOOT, ARMS FREE, 10 SECONDS Score Description 0 Does not lift R/L foot arms free 1 Lifts R/L foot arms free < 3 sec 2 Lifts R/L foot arms free 3 – 9 sec 3 Lifts R/L foot arms free, 10 sec 57/58.
  • 71.
    SIT ON SMALLBENCH: ATTAINS STD WITHOUT USING ARMS Score Description 0 Does not initiate sanding 1 Initiates sanding 2 Attains standing using arms 3 Attains standing without using arms 59.
  • 72.
    HIGH KN: ATTAINSSTD THROUGH HALF KN ON R KNEE, WITHOUT USING ARMS Score Description 0 Does not initiate sanding 1 Initiates sanding 2 Attains standing using arms 3 Attains standing through half kneel on R/L knee without using arms 60/61.
  • 73.
    STD: LOWERS TOSIT ON FLOOR WITH CONTROL, ARMS FREE Score Description 0 Does not lower to floor 1 Lowers to sitting on floor, but ‘crashes’ down 2 Lowers to sitting on floor with control, using arm(s) or holding on 3 Lowers to sitting on floor with control, arms free 62.
  • 74.
    STD: ATTAINS SQUAT,ARMS FREE Score Description 0 Does not initiate squat 1 Initiates squat 2 Attains squat, using arm(s) or holding on 3 Attains squat, arms free 63.
  • 75.
    STD: PICKS UPOBJECT FROM FLOOR, ARMS FREE, RETURNS TO STAND Score Description 0 Does not initiate picking up object from the floor 1 Initiates picking up object from the floor 2 Picks up object from the floor using arm(s) or holding on 3 Picks up object from the floor , arms free, returns to standing 64.
  • 76.
  • 77.
    STD, 2 HANDSON LARGE BENCH: CRUISES 5 STEPS TO R/L Score Description 0 Does not initiate cruising to R/L 1 Initiates cruising, <1 complete step to R/L 2 Cruises 1-4 steps to R/L 3 Cruises 5steps to R/L 65/66.
  • 78.
    STD, 2 HANDSHELD: WALKS FORWARD 10 STEPS Score Description 0 Does not initiate walking forward 1 Walks forward < 3 steps 2 Walks forward 3 - 9 steps 3 Walks forward 10 steps 67.
  • 79.
    STD, 1 HANDHELD: WALKS FORWARD 10 STEPS Score Description 0 Does not initiate walking forward 1 Walks forward < 3 steps 2 Walks forward 3 - 9 steps 3 Walks forward 10 steps 68.
  • 80.
    STD: WALKS FORWARD10 STEPS Score Description 0 Does not initiate walking forward 1 Walks forward < 3 steps 2 Walks forward 3 - 9 steps 3 Walks forward 10 steps 69.
  • 81.
    STD: WALKS FORWARD10 STEPS, STOPS, TURNS 180 deg, RETURNS Score Description 0 Walks forward 10 steps, does not stop without falling 1 Walks forward 10 steps, does not initiate turn 2 Walks forward 10 steps, stops, turns < 180 deg 3 Walks forward 10 steps, stops, turns 180 deg, returns 70.
  • 82.
    STD: WALKS BACKWARD10 STEPS Score Description 0 Does not initiate walking backward 1 Walks backward < 3 steps 2 Walks backward 3 - 9 steps 3 Walks backward 10 steps 71.
  • 83.
    STD: WALKS FORWARD10 STEPS, CARRYING A LARGE OBJECT WITH 2 HANDS Score Description 0 Does not initiate walking, carrying large object 1 Walks forward 10 steps, carrying small object with 1 hand 2 Walks forward 10 steps, carrying small object with 2 hands 3 Walks forward 10 steps, carrying large object with 2 hands 72.
  • 84.
    STD: WALKS FORWARD10 CONSECUTIVE STEPS BETWEEN PARALLEL LINES 20cm (8")APART Score Description 0 Does not initiate walking b/n ║lines 20 cm (8’) apart 1 Walks <3 consec utive steps b/n ║ lines 20 cm(8’) apart 2 Walks 3-9 consec utive steps b/n ║ lines 20 cm (8’) apart 3 Walks 10 consec utive steps b/n ║ lines 20 cm(8’) apart 73.
  • 85.
    STD: WALKS FORWARD10 CONSECUTIVE STEPS ON A STRAIGHT LINE 2cm (3/4") WIDE Score Description 0 Does not initiate walking forward on a straight line 2 cm wide 1 Walks <3 consec utive steps 2 Walks 3-9 consec utive steps 3 Walks 10 consec utive steps 74.
  • 86.
    STD: STEPS OVERSTICK AT KNEE LEVEL, R/L FOOT LEADING Score Description 0 Does not initiate stepping over stick R/L foot leading 1 Steps over sick 5- 7.5 cm high R/L foot leading 2 Steps over sick at mid-calf level R/L foot leading 3 Steps over sick at knee level R/L foot leading 75/76.
  • 87.
    STD: RUNS 4.5m(15’), STOPS & RETURNS Score Description 0 Does not initiate running 1 Initiates running by walking quickly 2 Runs < 4.5 m (15ft) 3 Runs < 4.5 m (15ft), stops and returns 77.
  • 88.
    STD: KICKS BALLWITH R/L FOOT Score Description 0 Does not initiate kicking 1 Lifts R/L foot, does not kick 2 Kicks ball with R/L foot but falls 3 Kicks ball with R/L foot 78/79.
  • 89.
    STD: JUMPS 30cm(12") HIGH, BOTH FEET SIMULTANEOUSLY Score Description 0 Does not initiate Jump 1 Jumps < 5 cm high both feet simultaneously 2 Jumps 5 – 28 cm high both feet simultaneously 3 Jumps 30 cm high both feet simultaneously 80.
  • 90.
    STD: JUMPS FORWARD30 cm (12"), BOTH FEET SIMULTANEOUSLY Score Description 0 Does not initiate jumping forward, both feet simultaneously 1 Jumps forward <5cm both feet simultaneously 2 Jumps forward 5- 28 cm both feet simultaneously 3 Jumps forward 30 cm both feet simultaneously 81.
  • 91.
    STD ON R/LFOOT: HOPS ON R/L FOOT 10 TIMES WITHIN A 60cm (24") CIRCLE Score Description 0 Does not initiate hopping on R/L foot 1 Hops on R/L foot < 3 times within a 60 cm circle 2 Hops on R/L foot 3 – 9 times within a 60 cm circle 3 Hops on R/L foot 10 times within a 60 cm circle 82.
  • 92.
    STD, HOLDING 1RAIL: WALKS UP/WALKS DOWN 4 STEPS, HOLDING 1 RAIL, ALTERNATING FEET Score Description 0 Does not initiate walking up/down steps, holding rail 1 Walks up/down 2 steps, holding rail, same foot leads consistently 2 Walks up/down 4 steps, holding rail, alternating foot inconsistently 3 Walks up/down 4 steps, holding rail alternating foot 84/85.
  • 93.
    STD: WALKS UP/WALKSDOWN 4 STEPS, ALTERNATING FEET Score Description 0 Does not initiate walking up/down steps, arms free 1 Walks up/down 2 steps, same foot leads consistently 2 Walks up/down 4 steps, alternating foot inconsistently 3 Walks up/down 4 steps, alternating foot 86/87.
  • 94.
    STD ON 15cm(6") STEP: JUMPS OFF, BOTH FEET SIMULTANEOUSLY Score Description 0 Does not initiate jumping off step, both feet simultaneously 1 Jumps off step, both feet simult - aneously, but falls 2 Jumps off step, both feet simult - aneously, uses hands on floor to avoid falling 3 Jumps off, both feet simultaneously 88.