R E S E A R C H R E P O R T

The Gross Motor Function

Classification System: An Update
on Impact and Clinical Utility
Laura Gray, MPT; Hennie Ng, MPT; Doreen Bartlett, PT, PhD
School of Physical Therapy, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada.

Purpose: To examine the impact and utility of the Gross Motor Function Classification System (GMFCS) for
children with cerebral palsy (CP) in research and clinical settings through a scoping review of publications from
July 2003 to December 2008. Methods: An online literature search was performed to retrieve relevant abstracts
for classification according to GMFCS use. Results: There has been a steadily increasing use of the GMFCS over
the previous decade. Ongoing research was identified on the GMFCS measurement properties, as well as its
use in validation of other tools. Observational and experimental studies continued to be the primary use of the
GMFCS. Some studies discussed the GMFCS in clinical practice with respect to examination and evaluation.
Conclusions: The GMFCS is clearly established as a principal classification system for children with CP as
demonstrated by excellent uptake in research; however, literature on its clinical use is emerging more slowly
over time. More emphasis on the clinical utility of the GMFCS in the published literature would be helpful.
(Pediatr Phys Ther 2010;22:315–320) Key words: cerebral palsy/classification, cerebral palsy/complications,
child, motor skills/classification, motor skills disorders/classification, reference values

INTRODUCTION AND PURPOSE The validity and reliability of the original GMFCS
The Gross Motor Function Classification System have been studied extensively and are well established.2-5
(GMFCS) was originally designed and published in Subsequently, in a review by Morris and Bartlett,6 a high
1997 to assist researchers and clinicians in classifying level of uptake of this classification system internationally
children with cerebral palsy (CP) based on their gross was reported; however, at that time there was a general
motor function using 5 levels.1 Level I, the highest lack of information on how the GMFCS was used in clini-
functional level in the GMFCS, describes children with cal practice and education. Since 2004, a large number of
CP who have the ability to participate in community publications making use of the GMFCS have continued.
settings with minimal functional deficits. On the op- Thus, a research question was proposed for this article:
posite end of the spectrum, children in level V are “How has the GMFCS been used in the literature since
typically fully dependent, present great difficulty with the previous review?” Using the time frame of July 2003
voluntary movements and are transported in wheelchairs.1 to December 2008, a scoping review of publications was
performed to gain further insight on the impact and utility
of this classification system. Identification of gaps will sug-
gest areas for future investigations. Clarification of misuses
0898-5669/110/2203-0315 of the GMFCS will refine the clinical utility of the system.
Pediatric Physical Therapy
Copyright c 2010 Wolters Kluwer Health | Lippincott Williams &
Wilkins and Section on Pediatrics of the American Physical Therapy METHODS
Association.
Research Design
Correspondence: Doreen Bartlett, PT, PhD, School of Physical Therapy, To present the relevant literature, a scoping review
Faculty of Health Sciences, The University of Western Ontario, Room
1588 Elborn College, London, Ontario, Canada N6G 1H1 (djbartle@
was used.7 This type of review focuses on a topic of inter-
uwo.ca). est that is wide-ranging in both purpose and study design.7
Supplemental digital content is available for this article. Direct URL The 5 stages of a scoping review leads to an organized list
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.pedpt.com).
of the literature that is comprehensive yet summarizes the
main findings in a user-friendly way. It also does not re-
DOI: 10.1097/PEP.0b013e3181ea8e52
quire critiquing the quality of all relevant literature; thus,

Pediatric Physical Therapy GMFCS Impact and Clinical Utility 315

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins and Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
 it focuses on breadth of information not depth. This is use- undertaken into whether there were any statistical tests of
ful in that it gives the reader a variety of resources to find associations between the GMFCS levels and the outcomes
articles of interest so they can critique the information pro- of interest, or whether the levels were used only to de-
vided to them, and helps to identify gaps in the literature scribe the participants. More specifically, for experimental
for both research and clinical decision-making.7 research studies, there was interest in the type of interven-
tion being examined and whether the GMFCS was used
for sample stratification prior to random allocation. Quasi-
Search Strategy experimental studies, as defined by Cook and Campbell,9
A thorough literature search was performed in OVID, were also considered as a type of experimental studies in
MEDLINE, and CINAHL with the following key words: this scoping review.
“Cerebral Palsy” and “GMFCS” or “Gross Motor Func- In addition, we were also interested in reviewing pub-
tion Classification System.” Additional limits were applied lications that commented on the use of the GMFCS in
specifically to locate literature published in English from clinical practice. These publications were classified as ei-
July 2003 to December 2008, as the previous review ended ther primary or secondary. Publications were classified as
with June 2003.6 To further identify any potential pub- primary clinical practice studies when the sole purpose of
lications for inclusion in this scoping review, a citation the publications was to investigate the use of the GMFCS
search on Morris and Bartlett6 was also performed using in clinical settings. On the other hand, when researchers
both search engines. made specific clinical practice recommendations based on
research findings and participants’ GMFCS levels, these
publications were considered as secondary clinical practice
Inclusion and Exclusion Criteria studies. Clinical practice recommendations made by re-
Specific exclusion criteria were created, and pre- searchers were subsequently classified into subcategories
screening was performed on all search results before ini- according to the Guide to Physical Therapist Practice: ex-
tiating the scoping review. Search results that contained amination, prognosis, intervention, and outcome.10 Fur-
no abstracts or abstracts that specified “comment” only thermore, the use of the GMFCS in family-centered prac-
were excluded. Doctoral dissertations and reviews were tice was also examined. Publications were reviewed that
excluded. Studies that misused the GMFCS were also ex- commented on parent-report versions or family-assessed
cluded but are commented on in the discussion. All other instruments in the context of the GMFCS.
publications were subsequently included in this scoping
review according to the classification system that was used.

RESULTS
Literature Classification Process A total of 228 unique publications were retrieved from
The selected publications were classified into various both searches. In addition, 10 publications were retrieved
categories according to the uses of the GMFCS. The 2 from the citation search of Morris and Bartlett.6 Out of the
main classification themes were research studies and clin- total of 238 results, 26 were excluded: 3 of them were doc-
ical practice. Categories under research studies included toral dissertations; 2 did not contain an abstract; 8 were
research on the measurement properties of the original reviews; and 13 misused of the GMFCS. There were 212
GMFCS, research on the validity of other measurement publications included, of which 12 of them fit into 2 sepa-
tools with the GMFCS, as well as the use of the GMFCS in rate categories for a total reported frequency count of 224
observational and experimental research studies. as illustrated in Figure 1.
For research on the measurement properties of the
original GMFCS, the research studies that evaluated in-
terrater reliability, validity, and stability of the GMFCS or
translation of the GMFCS into another language were ex- Observational Studies
amined. For research on the validity of other measurement
Experimental Studies
tools, there was an interest in publications that included
the GMFCS in the validation process of specific measure- Validity of Other Measures
ment tools. We further classified the different types of mea-
Clinical Practice
surement tools according to the components proposed by
the International Classification of Functioning Disability Original GMFCS Studies
and Health (ICF): Body structure and function, activity, Family-Centered Practice
participation, personal factors, and environmental factors.8
Quality of life was also added as the last subcategory in ad- 0 25 50 75 100 125

dition to the ICF components. Number

For observational and experimental research studies, Fig. 1. Overall frequency counts of publications in each category
there was interest in examining how researchers made use (N = 224), from July 2003 to December 2008. Each publication
of the GMFCS in research. Therefore, an investigation was may be reported under more than 1 category.

316 Gray et al Pediatric Physical Therapy

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Association. Unauthorized reproduction of this article is prohibited.
 Summary tables illustrate: the classifications and sub- TABLE 4
classifications of the research studies on measurement Classification of the Experimental Research Studies Making use of the
properties of the original GMFCS (Table 1), the validity of Gross Motor Function Classification System (N = 65)a
other measurement tools with the GMFCS (Table 2), ob- N %
servational (Table 3) and experimental (Table 4) research
studies making use of the GMFCS, as well as studies on the Sample descriptor 55 85
Stratification prior to RA 6 9
use of the GMFCS in clinical practice (Table 5). In addition Intervention
to the summary tables, 4 publications that examined the Medication 24 37
use of the GMFCS in family-centered practice were identi- General exercises or training 16 25
fied. To summarize the findings, overall frequency counts Rehabilitation (PT or OT) 11 17
of publications in each category as well as frequency counts Adjunctive and recreational 8 12
Assistive device 8 12
of all publications that made use of the GMFCS each year Orthopedic/neurological surgery 8 12
since its introduction in 1997 are presented in Figures 1 Sample analysis
and 2, respectively. Subgroup 6 9
To present the findings clearly and concisely, only Gross Motor Function Classification System 4 6
summary tables and figures, as described earlier, are pre- as a covariate
sented in the main context of the current publication. Abbreviations: OT, occupational therapy; PT, physical therapy; RA,
To assist readers in locating further information and random allocation.
a Each publication may be reported under more than 1 subcategory.

TABLE 1 TABLE 5
Classification of the Research Studies on the Measurement Classification of the Publications Regarding the Use of the
Properties of the Original Gross Motor Function Gross Motor Function Classification System in Clinical
Classification System (N = 5) Practice According to the “Guide to Physical Therapist
Practice” Subcategories9 (N = 13)a
N %
N %
Interrater reliability 2 40
Validity 1 20 Primary 2 15
Stability 1 20 Secondary 11 85
Translation 1 20 Examination 11 85
Prognosis 6 46
TABLE 2
Intervention 8 62
Classification of the Research Studies on the Validity of Outcome 5 38
Other Measurement Tools With the Gross Motor
Function Classification System According to ICF a Each publication may be reported under more than 1 sub-
Subcategories7 (N = 17)a category.
N %
70
Activity 10 59 60
Number of References

Body structure and function 7 41

Quality of life 3 18 50
Participation 2 12
40
Personal factors 0 0
Environmental factors 0 0 30

Abbreviation: ICF, International Classification of 20

Functioning Disability and Health. 10
a Each publication may be reported under more than

1 ICF component. 0
1998/9 2000 2001 2002 2003 2004 2005 2006 2007 2008
TABLE 3
Year
Classification of the Observational Research Studies
Making Use of the GMFCS (N = 121)a
Fig. 2. Frequency counts of all publications that made use of
the Gross Motor Function Classification System each year since its
N %
introduction in 1997. Current data (N = 212) have been combined
Sample descriptor 87 72 with the findings from Morris and Bartlett6 (total N = 287).
Association of GMFCS with outcome 60 50
With subgroup analysis 23 19
Association of GMFCS as outcome 9 7 references, a detailed alphabetized reference list of all pub-
With subgroup analysis 2 2 lications and detailed charts containing all classification
information are available as electronic appendices. The de-
Abbreviation: GMFCS, Gross Motor Function Classifica-
tion System.
tailed alphabetized reference list is located in Appendix
a Each publication may be reported under more than 1 A, http://links.lww.com/PPT/A10, followed by 5 detailed
subcategory. charts in Appendix B, http://links.lww.com/PPT/A11.

Pediatric Physical Therapy GMFCS Impact and Clinical Utility 317

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Association. Unauthorized reproduction of this article is prohibited.
 The detailed charts contain references that are first itations included the Timed Up and Go test,[A-51,203] Berg
arranged chronologically according to the year published Balance Scale,[A-51] Child Health Questionnaire[A-189] , and
year and then alphabetically according to the authors’ Shuttle Run tests.[A-195] With respect to body structure
names for those published in the same year. They contain and function, measures included the Spinal Alignment
detailed information on references and subclassifications of and Range of Motion Measure,[A-10] the Pediatric Reach
individual publications. The information contained in Ap- Test,[A-9] the Functional Reach Test,[A-51] and limb dis-
pendix B (http://links.lww.com/PPT/A11), Detailed Charts tribution and type of motor impairment,[A-60] as well as
1 to 5, respectively, correspond to Tables 1 to 5 in this ar- a measure of overall health for preschool children.[A-157]
ticle. Selected reference numbers can be identified in the Measures of quality of life were the CP Quality of Life for
Discussion section at the end of sentences in square brack- Children measurement,[A-201] the Caregiver Priorities and
ets preceded by the letter “A,” which stands for appendix. Child Health Index of Life With Disabilities,[A-124] and the
Pediatric Quality of Life Inventory.[A-192]
DISCUSSION Notably, no studies made use of the GMFCS to vali-
Publications on the various uses of the GMFCS date measurement tools on personal or environmental fac-
were reviewed. Selected publications on the measure- tors. This could indicate a potential area of future research,
ment properties of the original GMFCS, validity of other as personal and environmental factors are integral parts of
measurement tools with the GMFCS, observational and the ICF and should be examined further.8
experimental research studies, as well as on clinical prac-
tice are discussed to illustrate the major findings of the
Observational Research Studies
scoping review.
Observational studies continued to be the major type
Research on the Measurement Properties of research studies that made use of the GMFCS. These
of the Original GMFCS studies examined associations with diagnostic tools, prog-
nostic and physical factors, as well as overall quality of
The current review suggested that the research on the
life experienced by children with CP. Although numerous
measurement properties of the original GMFCS is con-
studies used only GMFCS levels to describe their partici-
tinuous in process so that the validity, reliability, and
pants, many studies made use of the GMFCS in their data
stability are further examined in different settings. Two
analyses, attempting to establish a correlation between the
publications involved the determination of interrater re-
GMFCS levels and their outcomes of interest.
liability of the GMFCS, with kappa values ranging from
Physical factors including severity of visual and
0.57 to 0.75.[A-50,109] Emphasis was on consistently bet-
motor deficits,[A-56] presence of drooling and saliva
ter agreement with children older than 2 years.[A-109]
production,[A-164] prevalence of obesity in ambula-
Also, a few publications explored the other aspects of
tory children,[A-150] and the use and impact of as-
the GMFCS. Content validity was examined on the ex-
sistive devices[A-135,137,155] were also correlated with
panded and revised version of the GMFCS using group
the GMFCS levels of their participants. Other phys-
consensus methods for the 6- to 12-year and 12- to
ical characteristics studied included hip displacement/
18-year age bands.[A-140] Another study by the original de-
dislocation,[A-63,119,171] body mass index,[A-46,52,79] , en-
velopers further supported the stability of the GMFCS,
ergy efficiency in gait,[A-83,86] , gait velocity,[A-52] mus-
concluding that children at levels I and V are least likely
cle thickness,[A-133] dysphagia,[A-21] and nutritional
to be reclassified.[A-138] Moreover, researchers also trans-
support.[A-69,173,193] Some observational studies attempted
lated the GMFCS into a Greek version and found it to be
to establish a relationship between overall quality of life of
reliable.[A-141]
children with CP and their GMFCS levels. In these studies,
The above findings further supported the use of the
GMFCS levels were correlated with health-related quality
GMFCS in research as well as in clinical settings. The
of life[A-14,153,165,186,191] as well as with the quality of life of
GMFCS has also demonstrated good reliability, validity,
mothers who take care of children with CP.[A-43,134]
and stability for children with CP between the ages of 2
Some studies also used the GMFCS as the outcome
and 12 years, as well as validity for youth between the ages
of interest, thus looking into factors that could poten-
of 12 and 18 years.11 However, investigation is needed to
tially predict GMFCS levels. For example, da Costa and
further assess the reliability and stability of the GMFCS for
colleagues[A-31] found that there was a high positive corre-
the 12- to 18-year age band.11
lation between visual acuity loss and GMFCS levels, lead-
ing to more questions about the potential cause of the
Validity of Other Measurement Tools vision problem. Furthermore, Roze and associates[A-154]
With the GMFCS identified that a highly extended form of periventricular
The GMFCS has been used to examine the validity of hemorrhagic infarction was associated with the develop-
other measurement tools for children with CP. Most stud- ment of CP, but not with the severity of it. Kulak and
ies focused on measures that quantify activity as well as Sobaniec[A-93] reported a negative correlation between cor-
body structure and function, with a few of them evaluating pus callosum surface area and the GMFCS levels of chil-
participation (Table 2). Measures that quantify activity lim- dren with CP and further noted that magnetic resonance

318 Gray et al Pediatric Physical Therapy

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins and Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
 imaging findings and GMFCS classifications were signifi- and it was found that the higher the GMFCS level, the
cantly correlated in children with diplegic and tetraplegic lower the probability of fulfillment of needs and functional
CP.[A-94] The same researchers also found that children improvements.[A-129]
with spastic diplegia were more likely to be at levels I or
II, while those with spastic tetraplegia were more likely to Clinical Practice
be at levels IV or V. Therefore, the reported GMFCS levels
The GMFCS is becoming increasingly important in
could reflect the severity of functional limitation.[A-95] A
clinical practice and the clinical decision-making pro-
large multicenter study also reached similar conclusions,
cess. Two publications primarily investigated the use of
as they found that the children with more limb involve-
the GMFCS in clinical practice. Hanna et al[A-65] devel-
ment had higher GMFCS levels, but indicated that the
oped cross-sectional reference percentiles for the Gross
GMFCS was a better indicator of gross motor functional
Motor Function Measure-66 within the GMFCS levels to
impairment than the traditional indicator of the number of
improve normative interpretation of scores, thus improv-
limbs involved.[A-198]
ing clinical utility. Also, Ketelaar et al[A-87] examined the
Experimental or Quasi-experimental challenges and possible strategies to incorporating
Research Studies evidence-based measures like the GMFCS into clinical
practice in the Netherlands.
Experimental studies mainly focused on examining
In addition, specific clinical practice recommenda-
the effect of specific interventions on children with CP, and
tions were made in research studies secondarily to assist
the GMFCS primarily played a role in participant descrip-
clinicians in examination, as well as determining prog-
tions or stratification prior to random allocation. Experi-
nosis, intervention, and outcome. Recommendations from
mental studies mainly examined the application of med-
these studies were condition-specific and provided clin-
ication, general exercise training, rehabilitational services
icians with insights on decision making in their clinical
(occupational therapy or physical therapy), adjunctive and
practice. For example, it was found that the GMFCS and
recreational activities, assistive devices as well as orthope-
Manual Ability Classification System worked well together
dic/neurological surgeries. Medical interventions for CP
in clinical practice.[A-23] Also, a correlation was found be-
identified in this review included botulinum toxin type A
tween hip dislocation and GMFCS levels; therefore, a hip
injection,[A-4,12,13,35,58,100,101,107,127,158,159,160,210] intrathe-
surveillance program with x-rays for children with CP was
cal Baclofen,[A-16,77,120,161,163] hyoscine skin patches for
recommended on the basis of GMFCS levels.[A-63] GMFCS
drooling,[A-156] and muscle release surgery.[A-91] Assistive
levels were also found to be important for assessing the
devices mainly included dynamic ankle foot orthoses for
risk of hip displacement.[A-171] Moreover, children with
gait and spasticity management.[A-112,125,188] Studies also
GMFCS levels of lower gross motor function may be pre-
examined the benefits of intermittent versus continuous
disposed to worsening of hip subluxation after selective
physiotherapy for children with CP.[A-27] General exer-
dorsal rhizotomy.[A-71] For self-care and mobility, it was
cises included hippotherapy,[A-64] robotic-assisted locomo-
found that children with GMFCS levels II to V will need
tor training,[A-112] a static bicycling program for nonam-
increased physical assistance during the day. Furthermore,
bulant CP,[A-204] partial body-weight–supported treadmill
the classification has implications on the role of physio-
training,[A-26,38,43] reach performance,[A-125] as well as pe-
therapy in transition planning.[A-139] Selective muscle re-
diatric endurance and limb strengthening.[A-49] Adjunctive
lease surgery appears to be the most beneficial for children
recreational training included conductive education (ef-
at GMFCS levels III and IV based on research findings.[A-91]
fects on hand motor functions),[A-17] massage on mechan-
In addition, GMFCS levels are also helpful in determining
ical behavior of muscles,[A-102] therapeutic taping,[A-47]
the energy costs or the metabolic demands, which are im-
application of a novel pointing-device apparatus,[A-25]
portant in the treatment selection process.[A-83]
gastrostomy feeding,[A-142,178] comparison of efficacy of
Adeli suit and neurodevelopmental treatments,[A-6] func-
tional therapy,[A-1] balance training on muscle activity and Family-Centered Practice
stability,[A-168,207] a school-based conductive education Some studies were done on a parent-report version
program,[A-209] and neurodevelopmental treatment.[A-6,185] of the GMFCS to examine the possibility of expanding
Similar to the findings in some observational studies, its use in clinical practice; however, further research is
associations were identified among the GMFCS levels and still needed. It was found that these parent-report in-
the outcomes of interest in some studies. For example, struments are useful for classifying children’s activities
Macgregor and colleagues[A-102] found that children can and participation.[A-116] However, discrepancies still ex-
have sustained improvements in GMFM-66 scores post- isted between families and professionals for GMFCS level
massage of calf muscles for children who were in GM- classifications, and these discrepancies could be a result
FCS levels I or II only. Bar-Haim and associates[A-6] found of variations seen in children’s performance in different
that Adeli suit treatment may improve mechanical effi- environments.[A-118] McDowell et al[A-109] also found that
ciency in children with GMFCS levels II and III but not agreement with parent report increased with the thera-
IV and V. One research group also looked into parents’ pists’ experience with the GMFCS, as well as how knowl-
perceived perception of 2 intensive training programs, edgeable the therapist was about the child. Regardless,

Pediatric Physical Therapy GMFCS Impact and Clinical Utility 319

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins and Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
 reliability of parent-report versions of the GMFCS was publication on the use of the GMFCS in clinical education
found to be high.[A-118] There was also an excellent agree- has been identified, reflecting a need for further exami-
ment between family reports of the GMFCS and GMFCS nation and documentation of this use. Anecdotally, one
classifications from professionals.[A-115] Family assessment therapist’s report indicates that the GMFCS training DVD
tools are indicated for future use in research and clinical is very useful in assisting physical therapy students in un-
practice.[A-115,118] derstanding the wide range of functional ability levels of
children with CP.
Misuses of GMFCS
It is important to examine researchers’ knowledge on CONCLUSIONS
the use of the GMFCS in this scoping review. Thirteen This scoping review demonstrates that the GMFCS is
studies were found to have misused the GMFCS. Three clearly established as a classification system to describe re-
studies inappropriately used the GMFCS in adults with CP search participants and to investigate the variation in gross
and were thus excluded. The GMFCS was designed to clas- motor functional level for a variety of research purposes.
sify children on the basis of their gross motor functional Most recently, the system has been expanded to include
level in childhood, originally younger than 12 years and youth with CP aged 12 to 18 years.11 It appears that the
now up to 18 years of age.11 One study used the GMFCS use of the GMFCS is increasing in family-centered prac-
to classify gross motor function of children with traumatic tice and education, but this remains to be documented.
brain injuries, and another with children with Down syn- It is anticipated that the use of the GMFCS will further
drome; however, the GMFCS has been validated for use expand over time, including its use in clinical practice,
only in children with CP. Many researchers used the GM- family-centered practice, and education.
FCS as an outcome measure with the inappropriate inter-
pretation that GMFCS levels would change in response to
interventions over time. This does not reflect the true in- ACKNOWLEDGMENT
tention of the measure, as the GMFCS level typically does This work was completed in fulfillment of the require-
not change. Stability of the GMFCS was previously stud- ments of the MPT degree for Ms Gray and Ms Ng at the
ied and found to be satisfactory, despite the fact that there University of Western Ontario.
were still some children being reclassified over time.[A-138]
These reclassifications could reflect situations such as a
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320 Gray et al Pediatric Physical Therapy

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