Michaela is a five-year-old girl who loves ballet. She has a diagnosis of diplegic cerebral palsy, GMFCS level III. What does this mean?
GMFCS Level III (Between 4th & 6th Birthday)
Children walk using a hand-held mobility device in most indoor settings. They may climb stairs holding onto a railing with supervision or assistance. Children use wheeled mobility when traveling long distances and may self-propel for shorter distances.
From the GMFCS E&R instruction guide
GMFCS-E&R Quick facts:
- Five-level classification system
- Based on the child’s self-initiated, regular movement
- For use with children with cerebral palsy only
- Used to classify children with CP from 1-18 years
- Not for use to classify infants under 1 year of age
- Not for use as an outcome measure
The Gross Motor Function Classification System (GMFCS) levels I-V are gross motor function categories for children with cerebral palsy. This post describes what GMFCS levels I through V mean, how they are used, and some of the controversy around them.
Children in level I are able to walk independently whereas level V children require high levels of postural management because they are not able to move themselves. Here are the general levels as described in the CanChild GMFCS E&R instruction guide:
LEVEL I – Walks without limitations
LEVEL II- Walks with limitations
LEVEL III- Walks using a hand-held mobility device
LEVEL IV- Self mobility with limitations; may used powered mobility
LEVEL V- Transported in a manual wheelchair
In the past, it was difficult to efficiently relay a child’s level of functioning during a collaborative conversation. A lengthy description painted a picture of daily mobility. With the GMFCS-E&R one can easily say “Michaela is a five-year old girl in GMFCS level III” and we are immediately on the same page with how Michaela is getting around in home, school and community. Furthermore, there are established guidelines for best practices with her care, such as evidence-based hip surveillance protocols for each GMFCS level.
How do we find out the GMFCS classification of a child with cerebral palsy? Michaela, in the example above, is five years old. She uses a walker for home and classroom mobility and a wheelchair to move on the kindergarten playground. She is pushed in her chair on field trips. Going to the GMFCS-E&R instruction guide and looking at the section that is labeled “Between 4th and 6th birthdays”, see which category fits Michaela’s regular level of performance in her daily environments. In this case, she clearly fits into GMFCS level III.
The GMFCS was, in part, created to assist with clear communication between health care professionals, so the level is often discussed in the introductory narrative of PT, orthopedic, physiatrist and other health-related reports. Which International Classification of Functioning, Health & Disability- Children & Youth (ICF-CY) domain would a therapist document Michaela’s level III? It is generally contained in the activity limitation section, but do remember that it is explicitly a categorization tool, not an outcome measure.
Will Michaela be classified as a GMFCS level III forever? Not necessarily. Although often stable through time, sometimes the classification level does change. I have several children who straddle level III and a IV. Some years they are a III and some years a IV. In my experience, it has a lot to do with spasticity management, participation in activities, positioning programs, growth spurts, maintaining motivation as well as physical therapy. Additionally, if you are following the Australian Hip Surveillance Guidelines for children with Cerebral Palsy, the instructions are to retest the GMFCS level at regular intervals to confirm that it has not changed. The classification only takes a few minutes. Research has shown that parents can accurately classify their 6-12 year old children with CP with the GMFCS Family Self Report Questionnaire.
There are GMFCS controversies, all with good points. The stated level is, in effect, a label and it is important to see the person first. Michaela is a little girl who loves everything about ballet and this incorporates her personal interests and her participation first and foremost in her care. Additionally, the categorizations could be used to unfairly predict a child’s potential, blinding therapists to signs of readiness to make significant gross motor change. I enjoy Dr. Karen Pape’s blog, which discusses these issues in much greater detail.
- Use of the Gross Motor Function Classification System to Optimize Rehabilitation Management of Children with Cerebral Palsy
- Should the Gross Motor Function Classification System Be Used Outside of Cerebral Palsy?
- Gross Motor Function Classification System – Expanded & Revised (GMFCS – E&R)
- Reliability of family report for the Gross Motor Function Classification System
- What Constitutes Cerebral Palsy in the 21st Century?