Transcript Document

The GMFCS and GMFM in Clinical Practice
Dianne Russell and Peter Rosenbaum
CanChild Centre for Childhood Disability Research
McMaster University, Hamilton, ON. Canada
www.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 & R
Gross 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-88
Item 36
On the floor: Attains sitting on
small bench
0 = does not initiate sitting
1 = initiates sitting
2 = partially attains sitting
3 =attains sitting
NT = 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?”
GMFCS
Motor
Growth
Curves
GMFM-66 &
GMFM-88
Classifies gross
motor function in
children with CP
Relates age & GMFCS
level to prognosis
Measures change over
time due to treatment or
maturation
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?