Combining the International Classification of Functioning (ICF) with Standardized Testing: An In-Depth Look at Squatting

Devin likes to go fishing; it’s his favorite hobby.  He is a five-year old boy with a diagnosis of bilateral cerebral palsy, GMFCS level 1.  Devin perches at the river’s edge in a deep squat in order to catch a glimpse of the trout beneath him.

Deep squatting is useful for a variety of reasons, like getting close to the floor to see something clearly, or to rest without getting on knees or bottom.  It requires adequate hip flexion range, ankle range, and postural control.  It is a developmental milestone.

When I look at the drawing of Devin, I wonder why:

  • Devin has an inverted foot position on right.
  • His low back position shows excessive lumbar flexion during a deep squat.
  • His pelvis is posteriorly tilted.
  • He is stabilizing, or limiting his degrees of freedom, by bracing his right elbow on his right knee and resting his chin firmly on his left knee.

Continue reading “Combining the International Classification of Functioning (ICF) with Standardized Testing: An In-Depth Look at Squatting”

Using the Gross Motor Function Classification System- Expanded & Revised Version (GMFCS-E&R)

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. Continue reading “Using the Gross Motor Function Classification System- Expanded & Revised Version (GMFCS-E&R)”

How to Use the Timed Floor to Stand-Natural Test (TFTS-N)

Alina loves going to school and spending time with her classmates. She is a first grader with hemiplegic cerebral palsy (GMFCS level 1).   Alina’s typical school day involves getting up and down from circle time, getting in and out of chairs at various stations, and moving to get supplies.  As a PT coming into the classroom for the first time, you are pleased with the number of activities she joins.  However, her teacher shares concern that Alina struggles to keep up with the movement pace of the classroom.   How can you compare Alina’s classroom mobility to that of her peers?  Is there a test with norms that you can use?

TFTS-N Quick Facts:

  • 5-14 years
  • Stand-alone test for children in school environments
  • Walking at a natural pace
  • Timing begins at “go,” not when movement is initiated
  • Tape 3m apart on floor
  • Face validity:  activity of transitioning to/from floor and walking short distance.
  • Test-retest reliability: 0.871
  • Intertester reliability: 0.988

The Timed Floor to Stand-Natural (TFTS-N) test measures time as a child transitions from floor sitting to standing, walks 3m at a natural pace, turns around, walks back to the starting point and then returns to floor sitting.   The sitting position is tailor (criss-cross).   Continue reading “How to Use the Timed Floor to Stand-Natural Test (TFTS-N)”

How to Use the 30-Second Walk Test (30sWT)

Walking from class to the school library, Josh falls to the back of the line.   Shortly thereafter, a gap forms between Josh and the rest of his class.  He is last to arrive and gets the half-functioning computer that everyone else avoids.   As his PT,  you are there to observe, problem-solve and treat.   The computer lab is a half-minute walk from class.    His teacher comments “Is that really as fast as Josh can walk? Has it always been that way?”.  Do you have an answer for this question?

30sWT Quick Facts:

  • Age 5-17
  • natural environment
  • walking at natural pace

Josh’s slow walking speed was a major concern at the begining of the school year.  At that time you did the thirty-second walk test (30sWT) and the result was clear; he was below the 5th percentile for boys his age and off the low-end of the chart.   Although you are having this conversation right now, you think he has improved because he has propulsion and a more efficient gait. Continue reading “How to Use the 30-Second Walk Test (30sWT)”

How to Use the Pediatric Balance Scale

Elise is constantly falling during her school day.   She often has skinned knees and bruises.  Although she is 10,  she walks down stairs one step at a time.    As Elise’s physical therapist, what observational measure will you use to measure her functional balance skills?  How will you document her progress?  

Balance is defined as the ability to keep the center of mass over the base of support.

Postural control is the act of maintaining, achieving or restoring a state of balance during an activity.  

Link to Pediatric Balance Scale Score Sheet

Pediatric physical therapists informally evaluate balance and postural control in every movement.   Multiple body systems contribute to balance, and this makes measurement of functional balance somewhat challenging.

Continue reading “How to Use the Pediatric Balance Scale”

How to Use the Gross Motor Function Measure (GMFM-66)

Freya is a 6-year-old girl with ataxic cerebral palsy.   She moved to California from Iowa last month and has been prescribed six months of physical therapy.   Freya’s parents are concerned; she has been having difficulty going down the front stairs of their new home.  As her physical therapist, do you have a standardized test that will measure her initial gross motor function?   In six months, how will you determine whether Freya has made progress?  

GMFM-66 Quick Facts:

  • 5mo-16 years
  • Cerebral palsy or Down Syndrome
  • Test re-test reliability GMAE-scoring method: 0.9932
  • Most sensitive to change in children 5 years and younger

My Gross Motor Function Measure User’s Manual is tattered.  I could not work without the GMFM!    Like all things that are well designed, the creators have taken a complex concept and made it logical and simple.   The GMFM is an evaluative measure that assesses change in motor function over time.  I can test Freya in January,  provide PT 1x/week and then retest in July to determine if she has made significant progress.  In addition, I won’t overlook Freya’s inability to reach across midline while I am heavily focused on her stair skills; the test covers all domains from lying and rolling  up to running and jumping, with each skill being incrementally harder than the last (in the GMFM-66). Continue reading “How to Use the Gross Motor Function Measure (GMFM-66)”