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

The Gross Motor Function Classification System - Expanded & Revised (GMFCS - E&R) is a 5-level classification system that describes the gross motor function of children and youth with cerebral palsy on the basis of their self-initiated movement with particular emphasis on sitting, walking, and wheeled mobility. Distinctions between levels are based on functional abilities, the need for assistive technology, including hand-held mobility devices (walkers, crutches, or canes) or wheeled mobility, and to a much lesser extent, quality of movement.

The focus of the GMFCS - E&R is on determining which level best represents the child's or youth's present abilities and limitations in gross motor function. Emphasis is on usual performance in home, school, and community settings (i.e., what they do), rather than what they are known to be able to do at their best (capability). It is therefore important to classify current performance in gross motor function and not to include judgments about the quality of movement or prognosis for improvement.

Children who have motor problems similar to those classified in "Level I" can generally walk without restrictions but tend to be limited in some of the more advanced motor skills. Children whose motor function has been classified at "Level V" are generally very limited in their ability to move themselves around even with the use of assistive technology.

The GMFCS - E&R includes an age band for youth 12 to 18 years of age and emphasizes the concepts inherent in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). We encourage users to be aware of the impact that environmental and personal factors may have on what children and youth are observed or reported to do. The descriptions for the 6 to 12 year and 12 to18 year age bands reflect the potential impact of environment factors (e.g., distances in school and community) and personal factors (e.g., energy demands and social preferences) on methods of mobility.

GMFCS Family Report Questionnaire

The GMFCS - E&R is a widely used method for classifying the movement ability of children with cerebral palsy. To date, use of the GMFCS - E&R has relied upon a health professional to classify a child. The newly developed GMFCS Family and Self Report Questionnaire presents an option for parent involvement in classifying children's motor abilities. The questionnaire is available for four age groups of children and youth: 2 to < 4 years, 4 to < 6 years, 6 to < 12 years, and 12 to 18 years.

Translations of measures and materials on the CanChild website are performed by individuals who are fluent in both English and their own language. CanChild requires a "back translation" of the document by a different person than the original translator to ensure accuracy. The customs and culture of various regions may not be reflected accurately unless a validation study has been conducted.

GMFCS - E&R Descriptors and Illustrations

Our colleagues have developed illustrations based on the GMFCS E&R level descriptions and have shared these with us. Currently, these illustrations have been developed for the upper age bands only (6 to 12 years, 12 to 18 years). These illustrations may be helpful to share with parents and when communicating with others.

Translations of measures and materials on the CanChild website are performed by individuals who are fluent in both English and their own language. CanChild requires a ‘back translation’ of the document by a different person than the original translator to ensure accuracy. The customs and culture of various regions may not be reflected accurately unless a validation study has been conducted.

Frequently Asked Questions

Q. What is the GMFCS - E&R?

The GMFCS, or Gross Motor Function Classification System, is a five-level classification that differentiates children with cerebral palsy based on the child’s current gross motor abilities, limitations in gross motor function, and need for assistive technology and wheeled mobility. The GMFCS - E&R contains 5 age bands (under 2 years, 2-4 years, 4-6 years, 6-12 years, and 12-18 years).

Q. Who can use the GMFCS - E&R?

Physical therapists, occupational therapists, physicians, and other health service providers familiar with movement abilities of children with cerebral palsy can use the GMFCS - E&R. Parents of children with cerebral palsy aged 6 to 12 years have been shown to be accurate in classifying their children using an adapted version of the GMFCS - E&R.

Q. How long does it take to learn the GMFCS - E&R?

Therapists and physicians can reliably use the GMFCS - E&R with no training simply by reading the criteria.

Q. How long does it take to classify a child using the GMFCS - E&R?

Service providers familiar with a child can complete the GMFCS - E&R in less than 5 minutes. Those unfamiliar with the child (and therefore requiring an observation session), may require 15 to 20 minutes to complete the GMFCS - E&R. Most distinctions are fairly clear and decisions about which level most closely resembles the child’s current gross motor function can be made quite quickly. Sometimes (i.e., at certain ages), the distinctions between two adjacent levels are more subtle and require more careful deliberation before making a classification.

Q. Do I need to observe the child in order to complete the GMFCS - E&R?

A classification can be made based on general familiarity with a child’s current gross motor abilities without necessitating an observation. Information about the child’s usual performance and limitations in gross motor function in home, school and community settings can be obtained by parent/caregiver interview or by review of recent clinic notes that describe gross motor function.

Q. How can I obtain a copy of the GMFCS - E&R?

The GMFCS - E&R brochure can be downloaded at no cost for personal, non-commercial use. Distribution of the GMFCS - E&R has been made possible through a grant from the United Cerebral Palsy Research and Education Foundation in the United States. If wishing to license the GMFCS - E&R and it's variations for commercial clinical trials, industry sponsored research, or integration into electronic health records, please contact us at ccstore@mcmaster.ca

Q. How can the GMFCS - E&R information be used?

The GMFCS - E&R has application for clinical practice, research, teaching, and administration (have interactive link/”hot” buttons to each of the words: clinical practice, research, teaching, administration).

In clinical practice, knowledge of a child’s GMFCS - E&R level is very useful for communicating with parents and setting the stage for collaborative goal setting.

For example, the probability of ambulation for a child classified at level V is extremely low and very different from children in levels I, II, or III. As a result, the system is extremely useful in terms of intervention planning at the levels of impairment and activity. An emphasis in intervention for children in levels IV and V might be health promotion, prevention of secondary impairments, and use of technology and adapted equipment, whereas intervention for children in levels I, II, and III might be focused more on achievement of gross motor abilities.

In research, the GMFCS - E&R is useful in:

  1. sample selection (i.e. identifying a more homogeneous subset of children with cerebral palsy with similar gross motor abilities);
  2. sample description (thereby facilitating communication between researcher and consumers), and
  3. stratification (to assist in ensuring that groups in experimental research studies are comparable).

In teaching, the GMFCS - E&R is a very useful tool to introduce students and service providers in all disciplines to the complexities of cerebral palsy relating to the extremely wide variation in gross motor abilities of children with this diagnosis.

In administration, the GMFCS - E&R is useful in terms of caseload management and resource allocation in health, recreation, and education settings for children with cerebral palsy.

Q. How frequently should a child be classified using the GMFCS - E&R?

A child should first be classified when referred for rehabilitation services to assist with realistic goal setting and appropriate intervention planning. Children might also be classified during interdisciplinary or special clinic visits or when a child is in an older age band. The most recent information indicates that GMFCS - E&R levels are quite stable after 2 years of age and children are not likely to change levels even following intervention. This is currently being studied in more depth.