SEARCH

SEARCH BY CITATION

Abstract

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Appendices

The aim of this study was to validate the expanded and revised Gross Motor Function Classification System (GMFCS-E&R) for children and youth with cerebral palsy using group consensus methods. Eighteen physical therapists participated in a nominal group technique to evaluate the draft version of a 12- to 18-year age band. Subsequently, 30 health professionals from seven countries participated in a Delphi survey to evaluate the revised 12- to 18-year and 6- to 12-year age bands. Consensus was defined as agreement with a question by at least 80% of participants. After round 3 of the Delphi survey, consensus was achieved for the clarity and accuracy of the descriptions for each level and the distinctions between levels for both the 12- to 18-year and 6- to 12-year age bands. Participants also agreed that the distinction between capability and performance and the concept that environmental and personal factors influence methods of mobility were useful for classification of gross motor function. The results provide evidence of content validity of the GMFCS-E&R. The GMFCS-E&R has utility for communication, clinical decision making, databases, registries, and clinical research.

The Gross Motor Function Classification System1 (GMFCS) was developed to provide a simple method for classifying children with cerebral palsy (CP) aged 12 years or less on the basis of functional abilities and limitations. The GMFCS includes five levels and four age bands. Distinctions between levels represent differences in gross motor function that are thought to be meaningful in the daily lives of children with CP. The age bands account for age-related differences in gross motor function. The GMFCS is intended to enhance communication between families and professionals when describing a child’s gross motor function, setting goals, and making management decisions. The GMFCS was developed for use in clinical practice and as a grouping variable for databases, registries, program evaluation, and clinical research. Research on the GMFCS supports interrater reliability and stability, as well as content, construct, discriminative, and predictive validity.1–6 Morris and Bartlett7 performed a systematic review and concluded that the GMFCS has been widely used around the world as a common language to describe gross motor function of children with CP. Versions of the GMFCS are available in at least 10 languages. According to a recent report the ISI Web of Science records almost 400 citations of the GMFCS in published articles.8

Several factors influenced the decision to develop a 12- to 18-year age band and revise the 6- to 12-year age band of the original GMFCS. When development of the GMFCS began in 1994, knowledge of gross motor development of youth with CP was limited. CanChild’s recently completed prospective longitudinal Adolescent Study of Quality of life, Mobility, and Exercise (ASQME) (P L Rosenbaum, unpublished material) provided an opportunity to create an adolescent age band by using observational data. We also wanted to expand on the conceptual framework of the expanded and revised version of the GMFCS (GMFCS-E&R) to coincide with the International Classification of Functioning, Disability and Health.9 We were interested in (1) the distinction between capability (what an individual can do in a natural environment) and performance (what a person does in his or her current environment), and (2) the perspective that environmental and personal factors influence performance of gross motor function. Research completed after publication of the GMFCS indicates that environmental setting influences methods of mobility of children with CP in important ways.10–12 The 12- to 18-year age band was developed on the basis of the concept that performance of gross motor function is influenced by the physical, social, and attitudinal environment and personal factors such as preferences, interests, and motivation. The GMFCS-E&R enabled us to incorporate new knowledge, clarify questions we have received throughout the years, and provide a better definition of terms.

The purpose of this study was to validate the content of the 12- to 18-year age band and revised 6- to 12-year age band of the GMFCS-E&R using nominal group technique and Delphi survey consensus methods. A 6-year age band was selected to coincide with the adolescent period of development and the potential effect of changes associated with puberty. Consensus was defined as agreement with a question by at least 80% of participants. Nominal group technique and Delphi survey consensus methods were previously used successfully to develop and validate the GMFCS.1 Both use a mixed-methods approach that combines quantitative and qualitative analysis.13,14

Method

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Appendices

Participants

The study was approved by the McMaster University Research Ethics Board and all participants provided informed consent. A characteristic of group consensus methods is the selection of expert participants. In this study, participants were health professionals who were knowledgeable about youth with CP and the GMFCS.

The nominal group technique typically involves five to nine participants.13 Thirty-five physical therapists, who were trained therapist assessors for the ASQME study, were invited to participate in the nominal group technique. Eighteen consented to participate in one of the three group sessions.

A Delphi survey typically involves 15 to 30 participants.14 Fifty-one health professionals were invited to participate in the Delphi Survey; 30 participated in at least one round of the Delphi Survey and 19 participated in all three rounds. Twenty-seven individuals were involved in round 1, 26 in round 2, and 24 in round 3. The participants included 19 physical therapists, six physicians, three occupational therapists, one nurse, and one orthotist. Participants had an average of 17 years (SD 8, range 5 to 35) of experience working with individuals with CP. They were from seven countries: Australia, Canada, Greece, Norway, Sweden, the UK, and the USA. The names of the participants are listed in Appendix I.

Draft versions of the 12- to 18-year and revised 6- to 12-year age bands

Data from the ASQME study were used to develop the draft version of the 12- to 18-year age band. Participants included 230 youth with CP (126 males and 104 females), who ranged from 11 to 18 years of age (mean 14.7 [SD 1.7]) at the time of the first assessment. Participants previously participated in a population-based study of development of gross motor function.5 The participants consisted of 74% of the original sample who met the eligibility criteria for the ASQME study, and who were 11 years of age or older in 2002. We initially stratified participants by age and GMFCS (based on criteria for the 6- to 12-year band) and examined the data from two assessments, taken 1 year apart. The data examined included selected items on the Gross Motor Function Measure (GMFM-66)15 (therapist administered), the Activity Scales for Kids – Performance Version16 (completed by adolescent self-report), and usual mobility methods at home, at school, out of doors, and in the community (completed by parent report). Youth completed the Activity Scales for Kids – Performance Version by indicating how often they had performed each activity by themselves during the previous week. The results of research on methods of mobility at home, in school, and in the community of children aged 6 to 12 years with CP10–12 were used to make minor revisions to the 6- to 12-year age band.

Nominal group technique

A modified nominal group technique was used to obtain an external appraisal of the draft version of the 12- to 18-year age band before the Delphi survey. The nominal group technique is a procedure to facilitate effective group decision-making that involves the statement of a question, the facilitation of structured discussion, and voting after discussion.13 Participants resided throughout the Province of Ontario; group sessions, therefore, took place via three teleconferences involving four to nine therapists. The draft version of the 12- to 18-year age band and the questions for discussion were distributed before the teleconferences. To prepare for the teleconferences, participants were asked to read the questions and record their thoughts. The seven questions for discussion are listed in Table I.

Table I.   Questions for nominal group technique and Delphi survey consensus methods
QuestionNominal groupDelphi survey
  1. X indicates whether a question was included in the Nominal or Delphi group consensus method. GMFCS, Gross Motor Function Classification System.

Is there a need for a 12–18-year age band?X 
Are the concepts of environmental and personal factors useful for understanding differences in methods of mobility?XX
Is the distinction between capability and performance useful for classification of gross motor function?XX
Is the description for each GMFCS level of the 12–18-year (6–12-year) age band clear?12–18y12–18y 6–12y
Is the description for each GMFCS level of the 12–18-year (6–12-year) age band accurate?12–18y12–18y 6–12y
Do the distinctions among GMFCS levels of the 12–18-year (6–12-year) age band represent meaningful differences in gross motor function?12–18y12–18y 6–12y
Is the wording of the Introduction and User Instructions clear? X
Are the operational definitions clear? X
Is the title for each level clear and accurate? X
Overall, the descriptions are clear and accurate X

Four physical therapy students assisted the authors in each teleconference. Each teleconference began with an overview of the objectives, a description of how the draft version was developed, and a review of the teleconference agenda. Participants and study team members were introduced. Roles of the study team members were identified as: facilitator, non-voting discussants, timer, audiotape recorder, and vote-caller/recorder. Each question was read by the facilitator and was followed by open discussion for an allotted time of 7 to 15 minutes. Immediately after the discussion of each question, a vote was taken and recorded. Each participant voted independently, indicating whether they agreed with the question (yes or no). Consensus was defined as agreement with a question by at least 80% of participants. The audiotapes for each teleconference were subsequently transcribed. Comments and recommendations were discussed by the study team, focusing on questions for which consensus was not achieved. The 12- to 18-year age band was revised accordingly.

Delphi survey

The Delphi survey technique uses a series of iterative questionnaires to generate comments and ultimately to achieve consensus among experts.14 The approach involves one or more rounds and continues until the criterion for consensus is achieved for all questions. Participants were e-mailed the draft version of the 6- to 12-year and the revised 12- to 18-year age band. Instructions were provided on how to access a secure website to complete the questionnaire. The 10 questions for discussion, including five of the questions used for the nominal group technique, are listed in Table I. Each question was rated on a 7-point scale (1=strongly disagree; 4=indifferent; 7=strongly agree) followed by space in which to comment on the rating and provide recommendations for revision. For each question, the criterion for consensus was a rating of 5, 6 or 7 by at least 80% of participants.

After each round, revisions were made in response to feedback for questions where consensus was not achieved. For round 2, questions were added to the survey to evaluate the clarity and accuracy of the introduction and user instructions, definitions of terms, the title for each level, and the distinctions between levels. The survey for round 3 consisted of the following three statements: (1) ‘The operational definitions are clear’, (2) ‘Overall, the descriptions for the revised 6- to 12-year age band are clear and accurate’, and (3) ‘Overall, the descriptions for the 12- to 18-year age band are clear and accurate’.

Results

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Appendices

Nominal group technique

The results of the nominal group technique are presented in Table II. The votes from the three sessions were aggregated. Consensus was achieved on the need for a 12- to 18-year age band. Consensus was also achieved for questions pertaining to the conceptual framework of the GMFCS-E&R. Participants agreed with the distinction between capability and performance and that environmental and personal factors are useful in understanding performance of mobility. The only other question for which consensus was achieved was the distinction between levels I and II.

Table II.   Results of nominal group technique for 12- to 18-year age band
General questionsResponse    
  1. Consensus was defined as agreement by at least 80% of the participants. Figures given are numbers and percentages of respondents who said ‘yes’.

There is a need for a 12–18-year age band18 (100)    
Environmental and personal factors are useful concepts18 (100)    
The distinction between capability and performance is useful15 (83)    
Specific questionsLevels I & IILevels II & IIILevels III & IVLevels IV & V 
The distinctions between each level represent meaningful differences in gross motor function18 (100)7 (39)12 (67)12 (67) 
Specific questionsLevel ILevel IILevel IIILevel IVLevel V
The wording is clear7 (39)10 (56)12 (67)1 (6)5 (28)
The descriptions are accurate6 (33)5 (28)5 (28)7 (39)5 (28)

Delphi survey

The results of the Delphi survey are presented in Tables III to V. For round 1, at least 80% of participants agreed with the questions pertaining to the conceptual framework (Table III). For the 12- to 18-year age band, consensus was achieved for the wording, accuracy of descriptions, and distinctions between levels except for the description for level III (Table IV). For the 6- to 12-year age band, consensus was achieved for the wording, accuracy of descriptions, and distinctions between levels except for wording and accuracy of level II and the distinction between levels II and III (Table V). For both age bands, consensus was not achieved for the statement ‘Overall, the descriptions are clear and accurate’.

Table III.   Results of Delphi survey for questions pertaining to both age bands
Concepts or featuresRound 1 (n=27) Round 2 (n=26)Round 3 (n=24)
  1. Figures are percentage agreement. Consensus was defined as agreement by at least 80% of the participants. aAlthough consensus was achieved in round 2, changes in wording to improve clarity were made. ICF, International Classification of Functioning, Disability and Health. GMFCS, Gross Motor Function Classification System.

ICF concepts
 concepts of environmental and personal factors are useful for understanding differences in methods of mobility100  
 distinction between capability and performance is useful for classification of gross motor function93  
Features of the GMFCS
 wording for Introduction and User Instructions is clear 96 
 operational definitions are clear 9696a
 The title for each level is clear and accurate 88 
Table IV.   Results of Delphi survey for the 12 to 18-year age band
StatementGMFCS levelPercentage agreement
Round 1 (n=27)Round 2 (n=26)Round 3 (n=24)
  1. Consensus was defined as agreement by at least 80% of the participants. aAlthough consensus was achieved in round 1, changes in wording to improve clarity were made. GMFCS, Gross Motor Function Classification System.

The wording is clearI8892a 
II8885a 
III8885a 
IV8896a 
V9292a 
The description is accurateI96  
II84  
III7681 
IV88  
V96  
The distinction between levels represents a meaningful difference in gross motor functionI & II96  
II & III88  
III & IV96  
IV & V100  
Overall, the descriptions are clear and accurateAll757388
Table V.   Results of Delphi survey for the 6 to 12-year age band
StatementGMFCS levelPercentage agreement
Round 1 (n=27)Round 2 (n=26)Round 3 (n=24)
  1. Consensus was defined as agreement by at least 80% of the participants. aAlthough consensus was achieved in round 1, changes in wording to improve clarity were made. GMFCS, Gross Motor Function Classification System.

The wording is clearI8596a 
II7789 
III8285a 
IV8592a 
V9389a 
The description is accurateI85  
II7385 
III81  
IV89  
V93  
The distinction between levels represents a meaningful difference in gross motor functionI & II85  
II & III78100 
III & IV89  
IV & V89  
Overall, the descriptions are clear and accurateAll628188

For round 2, consensus was achieved for the clarity of the introduction, user instructions, definitions, and title for each level (Table III). Consensus was achieved for all questions on clarity and accuracy of descriptions except for one question on the 12- to 18-year age band: ‘Overall, the descriptions are clear and accurate’ (Tables IV and V). After round 3, consensus was achieved for the three questions, indicating that, overall, the descriptions were clear and accurate for both the 12- to 18-year and 6- to 12-year age bands.

The 6- to 12-year and 12- to 18-year age bands of the GMFCS-E&R are included in Appendix II. The full GMFCS-E&R is on the CanChild website at http://www.canchild.ca/Portals/0/outcomes/pdf/GMFCS.pdf.

Discussion

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Appendices

The process of the nominal group technique and results of the Delphi survey consensus methods provide evidence of content validity of the GMFCS-E&R. We believe that the number of participants, their qualifications, and the inclusion of two consensus methods were instrumental in achieving content validity. A total of 48 health professionals knowledgeable about individuals with CP and the GMFCS participated in the study. The 18 physical therapists who participated in the nominal group technique were influential in grounding the descriptions for the 12- to 18-year age band in the observations and perspectives of clinicians experienced in assessing youth with CP. The 30 health professionals who participated in the Delphi survey constituted an international, multidisciplinary group of clinicians, educators, and researchers. They provided a broad perspective, critically appraised content validity, and offered numerous recommendations for revision.

The biggest challenge in achieving content validity of the GMFCS-E&R was reconciliation of research data and expert opinion. The draft versions of the 6- to 12-year and 12- to 18-year age bands were informed by research findings. For the nominal group technique and round 1 of the Delphi survey, the failure to achieve consensus on the clarity and accuracy of descriptions and the distinctions between levels is primarily attributed to participants’ concerns that the descriptions were too complex and that they blurred the distinctions between levels. Some participants in the Delphi survey were hesitant to revise the 6- to 12-year age band, expressing satisfaction with the existing descriptions and concerns about how a revised age band would affect the ability to compare future research with previous findings. When revising the GMFCS-E&R, a concerted effect was made to sharpen the distinctions between levels by including only the methods of mobility most representative of each level.

Clarity was improved by the inclusion of definitions of methods of mobility and by rewording statements about variability in methods of mobility. Operational definitions of terms such as ‘body support walker’ and ‘hand-held mobility device’ were refined on the basis of participant feedback. The definitions are applicable to all age bands of the GMFCS-E&R and are responsive to feedback that the authors have received over the past 10 years. Statements about variability in methods of mobility within a level were clarified by referring to what children and youth ‘may do’ (e.g. youth may use wheeled mobility) rather than making quantitative statements (e.g. most/many/some youth use wheeled mobility). These revisions were made in response to participant feedback that when classifying gross motor function, judgments are being made about individual children and youth.

Participants in both consensus methods agreed that the distinction between capability and performance is useful for the classification of gross motor function. Some participants in the Delphi survey, however, commented that because the GMFCS-E&R is based on performance, including the word ‘capability’ in the descriptions was confusing (e.g. ‘Youth are capable of walking but might choose to use wheeled mobility when traveling long distances’). Consequently, reference to capability was removed from the descriptions.

The differences in gross motor function between the 12- to 18-year age and revised 6- to 12-year age bands are not pronounced. The implication is that most youth continue to be capable of the methods of mobility they used at younger ages but may choose other methods on the basis of environmental and personal factors. This perspective is based on the assumption that environmental and personal factors that are relevant for youth (12–18y), differ from the factors that pertain to children (6–12y). The description for level I is the same for the 12- to 18- and 6- to 12-year age bands and includes a statement on participation in physical activities. For level II, youth continue to walk in most settings but may use wheeled mobility more often than children when traveling long distances or when other environmental or personal factors are important. The descriptions of mobility methods for level III are more variable than those in the other levels for both the 12- to 18 and 6- to 12-year age bands. A statement has been added on adaptations for participation in physical activities. The descriptions for youth in levels IV and V reflect the need for greater caregiver assistance with transfers and mobility compared with children aged 6- to 12 years of age. For both age bands, a statement has been added on physical assistance and/or powered mobility for participation in physical activities.

The GMFCS-E&R was developed with the intent that a 12- to 18-year age band would have similar applications to the younger age bands including communication between youth, families, and professionals for goal setting and making management decisions.1 Although we envisage that the 12- to 18-year age band will prove useful for communication and making management decisions, the dynamics of communication should change because youth are more actively involved. During adolescence, issues pertaining to gross motor function are likely to be addressed within the context of secondary and postsecondary education, employment, social participation, and independent living. Health promotion, including physical fitness, and prevention of musculoskeletal impairments are other issues pertinent to youth with CP.

Research is needed to examine interrater reliability of the 12- to 18-year age band and the revised 6- to 12--year age band of the GMFCS-E&R. Interrater reliability of the original GMFCS was examined among 51 physical and occupational therapists, who received no formal training.1 The overall kappa coefficient was 0.75 for children 2 to 12 years of age, indicating excellent overall chance-corrected agreement.17 We expect that the definitions and modifications made in response to feedback over the past 10 years will improve the reliability of the 6- to 12-year age band.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Appendices

This study was supported by a grant awarded by the Canadian Institutes of Health Research (MOP-53258). We thank Leanna Lee, Win Ng, Andrei Pivtoran, and Luka Senk, who were Master’s Degree physical therapy students at the time this work was conducted, for their contributions in conducting the nominal group technique.

References

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Appendices
  • 1
    Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and validation of a gross motor function classification system for children with cerebral palsy. Dev Med Child Neurol 1997; 39: 21423.
  • 2
    Palisano R, Cameron D, Rosenbaum PL, Walter SD, Russell D. Stability of the Gross Motor Function System. Dev Med Child Neurol 2006; 48: 42428.
  • 3
    Palisano R, Hanna S, Rosenbaum P, et al. Validation of a model of gross motor function for children with cerebral palsy. Phys Ther 2000; 80: 97485.
  • 4
    Wood E, Rosenbaum P. The Gross Motor Function Classification System for Cerebral Palsy: a study of reliability and stability over time. Dev Med Child Neurol 2000; 42: 29296.
  • 5
    Rosenbaum PL, Walter SD, Hanna SE, et al. Prognosis for gross motor function in cerebral palsy: creation of motor development curves. JAMA 2002; 288: 135763.
  • 6
    Morris C, Galuppi BE, Rosenbaum PL. Reliability of family report for the Gross Motor Function Classification System. Dev Med Child Neurol 2004; 46: 45560.
  • 7
    Morris C, Bartlett D. Gross Motor Function Classification System: impact and utility. Dev Med Child Neurol 2004; 46: 6065.
  • 8
    Morris C. Development of the Gross Motor Function Classification System. Dev Med Child Neurol 2008; 50: 45560.
  • 9
    World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization, 2001.
  • 10
    Palisano RJ, Tieman BL, Walter SD, et al. Effect of environmental setting on mobility methods of children with cerebral palsy. Dev Med Child Neurol 2003; 45: 11320.
  • 11
    Tieman B, Palisano RJ, Gracely EJ, Rosenbaum PL. Gross motor capability and performance of mobility in children with cerebral palsy: a comparison across home, school, and outdoors/community settings. Phys Ther 2004; 84: 41929.
  • 12
    Tieman BL, Palisano RJ, Gracely E, Rosenbaum P, Chiarello L, O’Neil M. Changes in mobility of children with cerebral palsy over time and across environmental settings. Phys Occup Ther Pediatr 2004; 24: 10928.
  • 13
    Potter M, Gordon S, Hamer P. The nominal group technique: a useful consensus methodology in physiotherapy research. NZ J Physiother 2004; 32: 12630.
  • 14
    DeVilliers MR, DeVilliers PJ, Kent AP. The Delphi technique in health sciences education research. Med Teach 2005; 27: 63943.
  • 15
    Russell D, Rosenbaum PL, Avery L, Lane M. The Gross Motor Function Measure. GMFM-66 and GMFM-88 (Users’ Manual). Clinics in Developmental Medicine No. 159. London: Mac Keith Press, 2002.
  • 16
    Young NL. The Activities Scale for Kids Manual. Toronto, Ontario: The Hospital for Sick Children, 1994.
  • 17
    Fleiss JL. Statistical Methods for Rates and Proportions. New York: John Wiley & Sons, 1981.

Appendices

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Appendices

Appendix I: Participants

Nominal group technique

Lindsay Bray, Marie Brien, Keri Burgess, Gillian Davis, Nicole Giftopoulos, Nicole Graham, Kelly Holy, Linda Kealey, Paula Mooney, Lesley Morton, Andrea Norton, Rosemary Perlman, Heather Schiffler, Wendy Schrader, Karen Suave, Linda Wallman, Mary Weerdenburg, and Sharon White.

Delphi survey

Catherine Arndell (PT), Mitch Barr (PT), Kristie Bjornson (PT), Johanna Darrah (PT), Adrienne Fosang (PT), Deborah Gaebler-Spira (MD), Ellen Godwin (PT), H Kerr Graham (MD), Adrienne Harvey (PT), Reidun Jahnsen (PT), Dace Johnson (PT), Gayatri Kembhavi (PT), Annika Lundkvist (PT), Anna McCormick (MD), Brona McDowell (PT), Sarah McIntyre (OT), Catherine Morgan (PT), Christopher Morris (Orthotist), Shubhra Mukherjee (MD), Unni Narayanan (MD), Eva Nordmark (PT), Iona Novak (OT), Sigrid Ostensjo (PT), Antigone Papavasiliou (MD), Jackie Parkes (Nursing), Jillian Rodda (PT), Karin Sandstrom (PT), Pamela Thomason (PT), Laura Vogtle (OT), and Lesley Wiart (PT).

Appendix II: 6- to 12-year and 12- to 18-year age bands of GMFCS-E&R

Between 6th and 12th birthdays
Level I

Children walk at home, school, outdoors, and in the community. Children are able to walk up and down curbs without physical assistance and stairs without the use of a railing. Children perform gross motor skills such as running and jumping but speed, balance, and coordination are limited. Children may participate in physical activities and sports depending on personal choices and environmental factors.

Level II

Children walk in most settings. Children may experience difficulty walking long distances and balancing on uneven terrain, inclines, in crowded areas, confined spaces or when carrying objects. Children walk up and down stairs holding onto a railing or with physical assistance if there is no railing. Outdoors and in the community, children may walk with physical assistance, a hand-held mobility device, or use wheeled mobility when traveling long distances. Children have at best only minimal ability to perform gross motor skills such as running and jumping. Limitations in performance of gross motor skills may necessitate adaptations to enable participation in physical activities and sports.

Level III

Children walk using a hand-held mobility device in most indoor settings. When seated, children may require a seat belt for pelvic alignment and balance. Sit-to-stand and floor-to-stand transfers require physical assistance of a person or support surface. When traveling long distances, children use some form of wheeled mobility. Children may walk up and down stairs holding onto a railing with supervision or physical assistance. Limitations in walking may necessitate adaptations to enable participation in physical activities and sports including a self-propelling manual wheelchair or powered mobility.

Level IV

Children use methods of mobility that require physical assistance or powered mobility in most settings. Children require adaptive seating for trunk and pelvic control and physical assistance for most transfers. At home, children use floor mobility (roll, creep, or crawl), walk short distances with physical assistance, or use powered mobility. When positioned, children may use a body support walker at home or school. At school, outdoors, and in the community, children are transported in a manual wheelchair or use powered mobility. Limitations in mobility necessitate adaptations to enable participation in physical activities and sports, including physical assistance and/or powered mobility.

Level V

Children are transported in a manual wheelchair in all settings. Children are limited in their ability to maintain antigravity head and trunk postures and control arm and leg movements. Assistive technology is used to improve head alignment, seating, standing, and and/or mobility but limitations are not fully compensated for by equipment. Transfers require complete physical assistance of an adult. At home, children may move short distances on the floor or may be carried by an adult. Children may achieve self-mobility using powered mobility with extensive adaptations for seating and control access. Limitations in mobility necessitate adaptations to enable participation in physical activities and sports including physical assistance and using powered mobility.

Between 12th and 18th birthdays
Level I

Youth walk at home, school, outdoors, and in the community. Youth are able to walk up and down curbs without physical assistance and stairs without the use of a railing. Youth perform gross motor skills such as running and jumping but speed, balance, and coordination are limited. Youth may participate in physical activities and sports depending on personal choices and environmental factors.

Level II

Youth walk in most settings. Environmental factors (such as uneven terrain, inclines, long distances, time demands, weather, and peer acceptability) and personal preference influence mobility choices. At school or work, youth may walk using a hand-held mobility device for safety. Outdoors and in the community, youth may use wheeled mobility when traveling long distances. Youth walk up and down stairs holding a railing or with physical assistance if there is no railing. Limitations in performance of gross motor skills may necessitate adaptations to enable participation in physical activities and sports.

Level III

Youth are capable of walking using a hand-held mobility device. In comparison with individuals in other levels, youth in Level III demonstrate more variability in methods of mobility depending on physical ability and environmental and personal factors. When seated, youth may require a seat belt for pelvic alignment and balance. Sit-to-stand and floor-to-stand transfers require physical assistance from a person or support surface. At school, youth may self-propel a manual wheelchair or use powered mobility. Outdoors and in the community, youth are transported in a wheelchair or use powered mobility. Youth may walk up and down stairs holding onto a railing with supervision or physical assistance. Limitations in walking may necessitate adaptations to enable participation in physical activities and sports including self-propelling a manual wheelchair or powered mobility.

Level IV

Youth use wheeled mobility in most settings. Youth require adaptive seating for pelvic and trunk control. Physical assistance from one or two persons is required for transfers. Youth may support weight with their legs to assist with standing transfers. Indoors, youth may walk short distances with physical assistance, use wheeled mobility, or, when positioned, use a body support walker. Youth are physically capable of operating a powered wheelchair. When a powered wheelchair is not feasible or available, youth are transported in a manual wheelchair. Limitations in mobility necessitate adaptations to enable participation in physical activities and sports, including physical assistance and/or powered mobility.

Level V

Youth are transported in a manual wheelchair in all settings. Youth are limited in their ability to maintain antigravity head and trunk postures and control arm and leg movements. Assistive technology is used to improve head alignment, seating, standing, and mobility but limitations are not fully compensated for by equipment. Physical assistance from one or two persons or a mechanical lift is required for transfers. Youth may achieve self-mobility using powered mobility with extensive adaptations for seating and control access. Limitations in mobility necessitate adaptations to enable participation in physical activities and sports including physical assistance and using powered mobility.

GMFCS-E&R, Expanded and Revised Gross Motor Function Classification System.