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JPHYS-334; No. of Pages 1

Journal of Physiotherapy xxx (2017) xxx–xxx

Journal of
PHYSIOTHERAPY
journal homepage: www.elsevier.com/locate/jphys

Appraisal Clinimetrics

The Gross Motor Function Measure (GMFM)

Summary

Description and administration: The Gross Motor Function Measure
(GMFM) is a tool that has been developed to assess change in gross
motor function in children with cerebral palsy aged 5 months to 16 years
of age.1 The GMFM measures ‘activity’ as defined within the Interna-
tional Classification of Functioning, Disability and Health.2 To administer
the GMFM, a trained therapist observes the child completing a number
of gross motor tasks in a standardised environment, and the child’s best
ability is measured. The tool measures capacity (what a person can do in
a standardised, controlled environment) rather than performance (what
a person actually does do in his/her daily environment).3 The assessment
typically takes 45 to 60 minutes to complete and only requires ‘usual
therapy equipment’.
The original GMFM version has 88 items each scored on a 4-point
ordinal scale of 0 to 3, where 0 indicates that the child does not initiate
the task; 1 indicates that the child initiates the task (completes < 10% of
the activity); 2 indicates that the child partially completes the task
(completes from 10 to 99% of the activity); 3 indicates that the child
completes the task (100%); and NT indicates that the child was not
tested. The 88 items are grouped into five dimensions: 1) lying and
rolling, 2) sitting, 3) crawling and kneeling, 4) standing, and 5) walking,
running and jumping. A maximum of three trials is allowed for each
item and the best trial is recorded. Scores for each dimension are
expressed as a percentage of the maximum score for that dimension
and the total score is obtained by averaging the percentage scores across
the five dimensions.4
Rasch analysis was applied to the GMFM-88 in order to improve its
interpretability and clinical usefulness, which resulted in a unidimen-
sional interval-measure hierarchical scale – the GMFM-66 – consisting
of 66 items from the original 88.4 The GMFM-66 is only valid for use with
children with cerebral palsy, while there is some evidence that the
GMFM-88 is valid for use with children with Down syndrome and
acquired brain injury.5
Shortened versions of GMFM-66 have been developed more recently.
The GMFM-66 Items Sets (IS)6 uses a scoring algorithm, whereby a
number of decision items guide the therapist toward a predetermined
set of items relevant to a child functioning at that level, and the child is
then tested on that ‘item set’. The GMFM- 66 Basal and Ceiling (B&C)7
approach establishes the ‘basal’ score of three successes in a row as the
start of the test and testing ends when the ‘ceiling’ is reached, which
is indicated by scoring three zeros in a row. However, if the primary
goal of assessment is to measure change, the full GMFM-66 should be
used.8
The GMFM user’s manual for all versions can be purchased from Wiley
Blackwell Publishing5 and the GMFM score sheets are freely available for
personal and non-commercial use. In addition, the Gross Motor Ability
Estimator (GMAE-2) Scoring Software for the GMFM-66 can be down-
loaded from the CanChild website (https://www.canchild.ca/).9
Reliability, validity and responsiveness to change: Studies have reported
excellent interrater and test-retest reliability and internal consistency in
children with cerebral palsy and Down syndrome,10 as well as supporting
content, concurrent, construct, and discriminative validity in the same
populations.10,11 Responsiveness to change has been tested using various
statistical methods, including comparison of parental and clinician
responses, investigating minimum clinically important difference, effect
size, receiver operating curves and standardised response means.10,11 The
minimum clinically important difference is 0.8 to 1.6 for medium effect
size and 1.3 to 2.6 for larger effect size.12 Different versions of the GMFM are
responsive in children with cerebral palsy, Down syndrome and traumatic
brain injury.10

Commentary

The GMFM is a reliable, valid and responsive measure of gross motor Provenance: Invited. Not peer reviewed.
function for children with cerebral palsy. It is frequently utilised in
clinical and research practice to measure change over time or following
interventions. With a reasonably lengthy administration time, the tool is
best suited for yearly or half yearly longitudinal clinical assessments or
for research studies. It is strongly recommended that testers be familiar
with use before administering the tool.
Limitations of the GMFM include: it is not well suited for children with References
higher functioning gross motor ability13 because of ceiling effects; it 1.
measures capacity and therefore does not consider the environmental 2.
influence on the child’s functioning in their everyday activities; and the 3.
4.
GMFM-66 version requires access to a computer and software.
5.
In summary, the GMFM is a psychometrically sound measure for children 6.
7.
with cerebral palsy. It measures one aspect of activity only and therefore 8.
should be used where the clinical or research outcome of interest is gross 9.
motor ability. For a comprehensive assessment of a child with cerebral
10.
palsy, the GMFM should be part of a suite of measures with other
11.
psychometrically sound tools to ensure that all aspects of the International 12.
Classification of Functioning, Disability and Health are covered. 13.
Adrienne R Harvey
Developmental Disability and Rehabilitation Research,
Murdoch Children’s Research Institute, Australia
Russell DJ, et al. Dev Med Child Neurol. 1989;31:341–352.
World Health Organisation. WHO; 2001.
Holsbeeke L, et al. Arch Phys Med Rehabil. 2009;90:849–855.
Russell DJ, et al. Phys Ther. 2000;80:873–885.
Russell DJ, et al. Mac Keith Press; 2013.
Russell DJ, et al. Dev Med Child Neurol. 2010;52:e48–e54.
Brunton LK, Bartlett DJ. Phys Ther. 2011;91:577–588.
Avery LM, et al. Devl Med Child Neurol. 2013;55:534–538.
Gross Motor Ability Estimator (GMAE-2) Scoring Software for the GMFM-66;
2012. Viewed 28 December 2016 from https://www.canchild.ca/.
Adair B, et al. Dev Med Child Neurol. 2012;54:596–605.
Harvey A, et al. Devl Med Child Neurol. 2008;50:190–198.
Oeffinger D, et al. Dev Med Child Neurol. 2008;50:918–925.
Vos-Vromans. et al. Disab Rehabil. 2005;27:1245–1252.

http://dx.doi.org/10.1016/j.jphys.2017.05.007
1836-9553/© 2017 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Harvey AR. The Gross Motor Function Measure (GMFM). J Physiother. (2017), http://dx.doi.org/10.1016/
j.jphys.2017.05.007