Development and

reliability of a system,
to classiffy gross motor
function in children
with cerebral palsy
L
Itobrrt Ai1i.w t i o
Ie fe r Hose tiOri ii ttt
Sfeplieti Iliiltrr
Diii it iic I! ii ssc 11

Ellor ilbotl
Hnr h rii (hi 1ii p p i

To address the need for a standardized system to classifs the

gross motor function of children with cerebral palsy, the
authors developed a 5vvelevel classification system analogous
to the staging and grading systems used in medicine.
Nominal group process and Delphi survey consensus methods
were used to examine content validits and revise the
classification system until consensus among 48 experts
(physical therapists, occupational therapists, and
developmental pediatricianswith expertise in cerebral palsy 1
was achieved. Interrater reliability (K) was 0.55 for children
less than 2 years of age and 0.75 for children 2 to 12 years of
age. The classification system has application for clinical
practice, research, teaching, and administration.

(erebra1palsy irfcrs t o a group of disorders in the tlevelopiiicliit of posttrire a i d motor contid. occui-i*ingas a result of a
noii-progressive lesion of the developing cent rid ner\ouss p ten1 ( U n s 1964).Thistletinit ion ent-ompassesa witle vaiiety of
pithological and clinical entities that have i n common atlevelol)inentaI iiiotoi-disorderthat can viwy in etiology, manifestat ions. stverit.y. prognosis. antl comorbitlities. Despite the best
efforts of I)rofcssionaIs.fi.oiii many disciplines, a gieat deal
iwntiins unknown about the n a t u r d liistoiy of cerebral palsy.
I t is iwognizetl that motor oiiteome is i.oughly ielatetl to
severity but to (late there has not been a genei*allyaccepted
stantlartlizetl system of classification of severity of motor tlisability for use i n clinical practice antl research.
M e t hods of classification that have been proposed are
biisetl on ( a ) pathophysiology o r neui.oanatomical location of
tIw lesion (Fay IO:TO, Perlstein 1957, Minear IN6):(b)impairments in iiiuyle tone. refles activity. and voluntary control of
movc~m(wt(Fay 1950, Perlstein 1952): (c) parts of the body
most involved (Balf and Ingram 1955, AIincar 1956): ((I)
ambulatory status (Ratlell-Ribcra 1985.Yokochi et HI. 1993),
tir (e) cl~grecof motor impailmcnt (e.g. mild. moderate.
severe) (Balf a i i t l Ingrain 1955. hliiiear 1966, Yokoclii et al.
1!)!):3).Iheseincthotls of classifiration rely heavily on clinical
j utlgment antl are primal-ily of value for tliagnosis.Th(4r reliability antl validity have not been investigated. Evans et al.
( 1989) tlevelopetl 11 recording forin to collect data on impairment n i i d disability i n children with neuroniotor dysfunction
for use i n a register on childhood impairment. The form
indutles items to rate a rhiltls head control, trunk control,
gait ,and upper limb fnnction but does not inclutlc an o v e i d
classi tication of motor ability.
\Ve have a t l o p t d an alternative approach to classification,
basetI on the concepts oftIisabiIity and h!!ctiOnaI limitation.
The International Classification of Impairments, Disabilities,
and Hantlica~k(ICIDH) developed by the World Health
Organimtion ( 1980) defines disability as the restriction or
ladr of ability to perform an activity i n the manner or within
tlir range consicleirtl normal for a human being. The concept
of functional limitation is includctl in the models of tlisableinent tlcvelol)etl by Sagi (1965) and the Sational Center for Jiedical Rehabilitation IkwwcIi in the United States ( 1993).
Sagi defiiiecl functional limitation as a limitation i n performance at the level of the whole person. We believe that classifieation of children with cerebral palsy on the basis of abilities
antl limitations in gross motor function should eilliance communication among ~irofessionalsantl families with respect t o
( 1 ) tletcimining LI chiltls needs antl making management dccisions. (2)the creation of databases describing the development
of ehildien with cerebral palsy, and (3)comparing and generalizing t h e results of program evaluations and research into the
outcome of treatment. Furthermore if t h e classification systeni is found t o have predictive validity, early classification of a
child (e.g.at age2 years) would help parents to anticipate their
cliiltlslater motor function.
The purposes of this study were (1) t o construct a gross
motor function classification system for children with cerebral
palsy, annlogous to the staging antl grading systems used for
tumours, (2) t o esamine content validity through nominal
group process and Delphisurvey consensus methods involving
tlevelopmental therapists and pediatricians with expertise in
. cerebral palsy, and (3)t o determine interrater reliability of the
classification system. We wanted a descriptive classification

system that \voultl be quick iintl easy to use. valid, and I-eliable.

Method
The Gross Motor Disability ('Iassification System was tlcvrloped i n four 1)hiiscs. First the autliors tlraftetl tlie system.
During phases two and tliive. the validity of the c-ontrnt WIS
esaminecl using nominal group process antl Delphi survey
coiiseiisus nietliotls, ant1 tlie c.liissifi,c;ltioiisystem n w revisrtl.
Iiiteri-aterreliability was esiiininetl in phiisr four.
I)E V E 1.0 IA m r ( ) P T ti I.:( 'IASSI1w-mI os sss'r E M
The classification system was initially tlraftetl usin$ sevtwl
methods ofinc(iiii.~~.Tliese
inclutlrtl a review ofcsisting rlassifi(if cliiltl~*eii
with
cation systems and reseaidi on tlevelo~~mrnt
cerebral I'alsy:esaminatioii oftlata from 275 chiltlrcn to wliorn
tlie Cross Motor Function JIeasuir: ((3IFJI) (I<ussellet HI.
1080) was administeid twice within 6 months: a ievicw of
tlevelopmental records and videotapes of children with cerebra1 p l s y iclrntifietl by thrir current therapists as having
mild, moderate. or severe involvement; and extensive tliscussionsby the study team.
Theinitial impetus tocrrateagross motor function rlassification system arose i n part from the examination of obseiviitiom on gross motor function cdlectetl by the autlioiw i n

'Severe' CP

'Moderate' CP

2b

do

'

1w

lio

lio

lb

Figure 1:Plots of total scores on the GrmsiMotor Ftittctioti illen.sicrc: (GVFM) ngaitut nge of ch illrutt nccorditig to tleyree of ttrotor
inuolue?neitt [cRiMreit withotit motor delays (iV40) atid childreit with ~ i l (X=53),
d
ttiotierntc (iV=DS) or.sc:iw~(,V=h3)creb,nl imI.syl.

the ('hair took a formal vote. The participants were asltetl t o

ulai-lyin thesroresof rhiltlren classifictl as having motleixteor
approvenr mjec-teiwh stateinent. Forriirh statement, tlie consevere cerebral palsy. After escimining the C A I FA1 data antl
sensus target speci fietl in atlviince was approval by a t least 12
viewing ttic videotapes. we tlecidetl that a three-level classifioft he 13 prticipants..
cation system (lid not atlequately represeiit the variation i i i
,
i
gross iiiotordr\~eIopnieiitof cMtlirw with ~*ei-ebraI
~):ilsp
Ev~ntuallyit five-lcvel &ssi tication SysteIiI \WS p t a p ~ ~ e d I)EI.I'HI S('l{\'lCY
Tlir Delphi conselisus met hod is an attempt to obtain espei:t
iv1iic.h i n the autl1ars'ol)iiiion iq)resentetl clinically meaningopinion i n H systematic 1iiil1111er
through qiiestionnaires. with
f d distiiwtions in motor function. I n beping with the World
the
ultimate
goal
of
generating
a group response (Fink et al.
Health Organization> const r w t oftlisiibilitp we iociisetl the
1!)84).'l'hexrii.\~yis contluctetl ovcr two or more rounds.After
classification syst6ni on self-initiatedmovement. with emphaeiieh round. the panel of experts is informed of the results.
sis 011 function i n sitting and \valking. 1)istinctioiis hctwerii
ivhirli i w e t1it.n usrtl to construct tlie cliiestioiiiiaii~fortlienest
Irvels fociisetl on fiinctioiial liniit$ ions, the need hr.assistiw
iwuntl.'I'lir process ends when the group reaches a preset level
technology inclutling mobility devices (such as n.alkers.
of agreeiiient o r . \vhen sufficient infoixiation has been
criitrhes. and canvs). wlieeletl iiioldity. and to a lesser extent
rschangecl to achieve t he goals oft he process.
quality of Inovcment. The system is ordinal. with no intivit
I n selecting a panel \ITcc)nsideredthe rec.oniinentlations of
that the distance betwen levels be coiisitlrretl eqtial or that
Fink ct nl. (Ins$).who stated that coiisensiis pal-ticipants
chilthvn with cei.ebi-alpalsy urct~~~iiali~tlisti~il~ute~larnoiig
the
shodtl Iiave c*oiitrntesiicrtise. be iq)rwentativo o f t heir profive 1evels.Thr rliissitiwtioii system was iiitcntlctl for use with
fessioiis. and hiivc the ability to implement findings. In acltlichiltlrvn 18 months to 6 p a r s of age. I n keeping with the goal
tion. we selectetl participants who we thought \voolrl provicle
that tlieclassiticatioiis~steiiibe cpiclc andeasyto usebasedon
insightfid antl critiral input antl advice. Twenty-one pliysical
Wported 01' Observed glnSs I l l o t o ~fUlIrtiol1 I'ilthPI' thHJ1 011
theixpists, occupational therapists. antl clcvelopnicntal petliastanrlartlizetl testing. brief tlesc~iptionswere piwitled for
tiicians from Sorth r\nierica. Europe. and Australia were
each level as \veil as a somimiry of the rlistinc*tionsbetweeii
nskctl t o participate and PO agreed (Appendis.A).Theparticieach pair of levels.The rlesrriptions weir broiltl and \VPIT not
pants were recognized Ieatleisintlie fieldoftlevelopmental disintent~et~
to assess iii (letail t.iie tlevelopineiit ofintlivitiual ciiilability with espertise in ceiybral palsy. Sone of tlie persons
tlien but rat hcr to tleterniine \vhic:h of t he five levth most dose~yresL'nibIesa ciiiItIs c*iri~r~nt
gi-o,ksmotor firnrtioii.
selected had participated in the nominal group consensus
meeting. The yei1l.s of professional esl)erience of the panel
S O Y I S A I . (;KoL-l' I'KO('E:SS
nicnibers varied from (i
t o 38 yeais, with 11nieilli of2O years.
IJI phase two. content v;rliOity was examinetl using a modified
The qiiestionnaii~efor round one of the Delphi survqy was
nominal group consensus mctliotl. Sominal group ~)rocess
clivitlecl into three parts antl includctl 38 statements. Many
consists of a structured meeting of il kno\vletl~abletarget
statements were followed by an open-ended question t o
group in which issiies are clisc*usseclamong piwticipants i n an
encoui-agethe experts to elaborate upon their responses. Part
attempt to Iri\ch a coi1seiisiis (Fink et HI. 1'384).TIicprocedure
A coiisistetl of nine statementsthgt acltlressetl the need for antl
was modified. in that the first draft oftlie classification system
thc c-onstrurtof the classification system. Part B consisted of
\vas developed by tlie riuthoi.s witlioiit input from the target
23 stateinelits that atltli~essedthe definition antl description
group.The initial draft oftlieclassification system antl a C~UPSfor each of the five levels and the tlistiiictioiis between levels.
tionnaire were sent to occ.upntional therapists antl physical
The experts were asked to use the clawification system to clastherapists at tliirr rliiltlivn's treatment centres in soutlierii
sify the mofor fiinrtion of rhilclirn from their clinical practice.
Ontario 3 weeks before the consens~~s
meeting. Twenty-eight
Those who did use it completed Part C'. which inrludcd a statetherapists provided feedback on the mntent antl on tlie
ment on the ease of using the c~lassificationsystem antl invited
applicability o f t he classification systeni to cIiiIclren on t Iieir
coniments. Part D consisted of five statements aclclrrssing
caseloaJ. Of the 28 participants. 14 were occupational therupotential uses of the classification system.
pists and 14 were physical therapists. The therapists' clinieal
Each statement was rated using a seven-point scale, with t i
experience rangxl from 5 to 3Oyears, with a mean ofn.6.
rating of I inrliyating 'strong disagreement'. 4 indicating
Representatives from each ofthe three centres brought the .. 'indiffeirnce', antl 7 indicating 'strong agreement' with the
feedback from their centre antl partieipatetl in tlie consensus
statement. Before mailing the questionnaires, consensiis
meeting. I n total, 13 therapists antl two developmental pediaagirement for each item was defined as 16 or more of the 20
t ricians were voting part icipants in a half-(lay consensus escresperts rating the statement as 5 or higher. Each participant
cise. The eselrise started with an open discussion by
was mailed the questionnaire for round one of the Delphi surparticipants of their general inipirssions of the classification
vey the revised (hoss Motor Function Classification System,
system and the process used to accumulate the feedback from
an explanation of why tile classification system was being
tlieircentre.The group then proreeclecl t o respond to 17 stateclevelo1)etl.and the work to date on development oftlie classifiments. One member ofthestudy train chaired thesession, two
cation system.
served as tlisrussants. H i i d a fourth member served as
The questionnaire for round two included 28 statements.
rwonler/timcr. The discussant introtlucetl each preset statcThe 23 statements from Part B o f the questionnaire used in
nient antl then facilitated discussion among the participants.
round one weit i.epeatcd.Tliese statements addressed the tlefiThe statements atltlivssetl the applicability of the classificanition and description for each of the five levels and the distinctionsystem, how thesysteni$houltl beadministeretl, thenurntions between the levels. The reinaining five statements
ber of levels. the content of each level, distinctions between
addressed how the classification system should be adminislevels, antl the ages of chiltli-eiiwho coulcl be classified. When
teird and the ages of chiltlren who could be accurately classithe time limit for discussion of each statement was rrac*hetl,
fied. These were areas where conknsus was not achieved in

216 I ~ ~ ~ P ~ ~ I ~ I cp~( 7I iIi lP

d . ~I ~~t i~
r o Il 1o:9~9~
~i y, :39:
, ~214-228
/ P ~ / ~ ~ ~ I ~ ~

ro~uiclone. .4long with thv cluestioiinaire for round two of tlir

Delphi survey the esprrts \vei*calso mailed the rwisetl (~i*oss
Motor Function C'lassificiition Systeni, a siinimary of the
responses from r m n t l onr oft liesurvcy. and a c*opyoft h c'i l'o\vn
conipletetl questionnai re froin 1.ouiitl01i(~.
I S'I'EIIl?.\Tk;II I< l~:I,IAIs1 1,I'I'Y

Interratcv reliability \fils rxiuninetl iifter i * o i ~ ~ itwo

tl
of tiit>
Delphi sur*\yvwas coniplrtetl. iintl the finiil irvisions \vere
niatle to the classification system. A con\~enieiicrsiiiii~~lr
oftivr
Ailtlren's tiwatment centres in southern Ontitrio participated
i n the stutly Physical tlieixpists iiiitl occupatioiial theriipists
tit the five centres WCIP iisketl to compile i~ list of chiltlren 12
years of' ~ g oer younger with cliiignosetl or suslwdrtl c e i v l d
~)alsy.TIiechiltlren inclutletl on t lie list n ~ r on
c act iw i~iiscloatls
(seen within the past 6 months) iintl had been known to at lrast
for at least 3montlis.l'hc~lists were tlivitletl into
two tlie~~apists
t\\vo age Striiti1: untler 2 J'WI*S o f age ~ I K I 2 JYYII'S 01'o l t l ~
Seventy-seven chiltli~eii(37 i n the youngw age group and 40 in
the oltlei~agegi~orrp)
\rere i~iintloinlyselected from the lists i)rovitletl b.v the thrrapists. with the specificiltioli tlliit 110pair of
therapists woultl classitjl inore tliiin five cliildrrn.
Etdi chiltlk level of gross motor fiiiiction \vas classi tirtl
int1el)eiitlently hy two therapists who WIP fhIi1ilii\r with t hc
rhiltl. Twenty-six p11ysic.id tlicrapists aiitl 25 occ.ul)atioii;il
tlwapists paiticipatetl. 'l'lie thcl~iipists'years of cqwiciicv
varied from 3 monthsto :%Iyears (niean 10.2years).'rhc thcrapists relied on their lano\vletlge of the child's motor abilities to
classitj the child's level of gims motor function and \ v t w not
rwiuiretl to obscrve or assess each child. Once the thei.apists
hiit1 familiarized theniselves with the cl;issific.ation system.
the time required to classifk a child shoultl not have csceedetl
10 minutes.
Interrater reliability was analyzed scliaratrly for cadi tige
groui) usiiig the crutle p(weiitiigcofngi~e~nient
and the k i i p p i ~
( K) statistic, a measure of cliiiiic~c-c~ori.e~~tetl
agreement. I n
atldition to the overall level of chance-corwctctl agreenient.
category-specific K VHILWS
tlerived to determine chancrcorrected agreement on each of tlie fivr levels of tlic classiti(-titioii system. ('ategory associations were evaluated by
compiitiiig the contlitional probabilities that givrii that one
rantlomly selcctetl therapist chooses a particular level of fiinction. the second therapist will choose rarh of the five levrls of
fu nrt ion.

Results
SOlIISAI, (:lIoL*I' I'HO('ESS

Consensus or approval of a statement by a t least 12 of the 15

voting participants was reached for 13 ofthe 17 stateinents.All
of the paltiripants rejected two of the statements: ' T ~ c
classification system is sufficirnt to iclii~sentthe variation i n
motor ;lisiibility among children with cerebral palsy':and'Thc
system should focus on best ever performance.'Oiily 11 of the
15 voting partic*ipantsapproved the statement'tl child ciin be
classitied accurately from a parent/caregiver irport using a
structured iiitei.view.'Only 10 approved the statement that 18
months should be the lower age limit for the classification system, antl only five approved the statement that 12 months
should be tlie lower age limit for the classification system.
Based on discussion among the participants of the statements
where consensus was not achieved, the descriptions for each
level ofgross motor function and tlie distinctions between lev-

Table I Statements for which the 20 experts did not reach

consensus after round one of the Delphi survey

age. K was 0.55 \vliile for c l i i l d i ~2~years

i
of age or oltler- K was
0.75.TIie irsiilts 1)rovitleiiiotlei.atesii~~~~ort
fortheoverall irliability of the ctiissiticiition system. I t lias been suggested tliat
r a l u r s of' K ,nir;iter t lian 0.i5 I P I ) I P W I I excellent
~
agiwinent
I)eyontl cliance. and \-;iluesi n t lie range 0.40 t o 0.75 irpresent
fiiir to good agiremeiit beyond clioiice(Fleiss 19SI).
-4ssociation and agirenient statistics tliat aiialym inter:
riitcr reliability for eiic.11 of the tive IcveIs of the cIa.ssification
d
1I1 ant1 I\: resl)rcsysteni 1)y agegroup are p ~ ~ s e n t eiiiTables
tively I n both a p gir)iip.tlir 1)roj)ortioiioftlie total number
of classiticatioiis matle was ~rasonal)l.~
evenly t1istril)uted over
t lie five ~evels. or c~iilt~irn
untler 2 years of age. t ~ i eK eoefticirnts (Table I I I ) indicate better chance-cori~ctetlagreement
for Levels I and I 1 than fortlie other t h i w levels. For instance
tlistiiiguishabilithe K f o r Level 1 is 0.841. iiic~ic~atiiigcsc~e~lent
ty of Level 1 froin tlie others. whereas that fQr Level \: is only
ten cominrnts.
For rouiitl two oftliesui~i~y.
c.oml)lctetlc ~ ~ i ~ ~ s t i o i i iivew
i ~ i i ~ e s 0.368. iiitlicoting tliat Levc.1 \' is nioir often conftisctl with the
otIiri*le\~ls.
received f i m i 18 of tlic 20 rspwts. ('onscnsIis amoiig thi. 18
chxpelts \\:isachievetl f ~ l ~ i l2!!)sti~tc11ir1its.;\II
ll
18 oftlie e s p * t s
The category association statistics (Table I V ) indicate that
foi*cIiiltlirnunderage2 theassoriation betweeii tlieclassifica~1gi.ertl
with 1.5 of the statrinrnts arid Ii agiwrl with 11 o f t h r
stiitenieiits. Sisteen of tlie expiBrts iqyrcd with the statement
tions oftlir paired therapists \ViiS ptirticularly strong for Levtlriit tllcc.l;issitici\tio~lsystem c~oultlbeiic.rurtitclyiiscd forcliilels I nntl J I.'rliat is. if the first observer selected Level I. tliere
tlren 1 to 2yeiiisofage. Fiftrrn iigrectl that tin ii~*c*tll~iitr
(*IassiW ~ I Sail 88% chu1c.e thilt the ~ e t ~ iobserver
tl
\voiiltl a p e . I n
interview with a
contrast. tlisagreement I)et\veeiipaired therapists \vas higher
tication cwultl he niiltle froin i i st ructii~~etl
parent oi*caiq$w.Siiicoftlic2Oc\-l)ertsusrtl tlie iwisctlsysfor the otlier levels, esperially for Levels IV antl L! which t i i t
tein t o eltissify thrniotor fiiiii~tioiioil)et\vecn3 tint1 16 chiltliwi
ninre tIiffic.uk to tlistinguisli from each other i n the younger
with cerebixl ~)aIsy..411 niiir e s ~ ) w tintlic*iitrtl
s
tlittt they f i y i t l
age gi*orip.For example. if Level \I was chosen by the first
the system easy to use. Based o n the r x p t ~ t sw~itteq-c!oin'
observer. tlierr wasonly a4494 chance that thesecontl obsery
t!.r
nients. irvisions \\ere niacie to ciiirif\. some of t ~ i tlcfinitions
e
er*\vouIt~
agree. witli tIir tiiscortlant ratings being pritiiari~fat
atid tl~sc*ril)tioiis.The c i i r i ~ n tversion of the (:i*ossAlotor
L e ~ I\'
l (44% chance) 0 1 ' oc~ii~io~ially
at Level I11 ( 1 I %
Function C'las~ific.ntioii
System is iii.\p~ieiidisB.
chance).
For cliiltlren above the age of 2 years, tlie patterns ively:
I STEI< I{ XTER II E 1.1 .\ 111LITs
soinrnhat reversed (Table lII).TheK coefficients were highest
Tdble I1 lists tlie tlistribution of tigr~ennentsand tlisagrec:
(all ahow 0.8) for Levcls JII to c! while agr-eement on Levels I
iiients aiiigng the five Ievrls ofthe i*lu~sifi~i\tioii
system by age
ant1 I1 was poorei: The association statistics (Table IV) intligroup. OCertill. tlir ratings \vci*e fkirly evenly tlisti~ibutecl
cate some tlifficdty in tlistinguisliing between k v e l s I ant1 11.
aniong tlie five Ievc~ls.For tlie Xi ( ~ l i i l d i ~
less
n thaii 2 years of
\\'lien Level l o r I 1 mas chosen by the first observer, thesecontl
age. paired therapists agreed on the level of gross motor fiincobserrer agreed only 67 '% antl 53% of the time respectively.
tion for%. tlisitgiretl l)y one Ie\d for 11. ant1 tlisagrwtl baytwo
There was: Iionrvrr, clear tlistinc*tionof Lcvrls I ant1 11 from
levels for 2. Of these 1.7 tlisagrc~enients.4 w i ' e I)et\veeii Levels
the other levels:tlisa,areeineiitabove and b c l o the
~ Level-I I to
I\' and 1: tiiitl 1 \vas betwren Levels I1 I ant1 \! For the 40 rhilwas only minor
IAevel-l11 b o u n d ~ r ywas rieverobscrve.tl.Tliei~e
clreti 2 to I:! yenrs of age, 1)air~tltherapists tlisagretd by one
tlisagi*cenientin tlisti~iguishingamon~
Levels I11 toVThesec1 ~ fol.oiily
~ 1 8:ofthese t l i ~ i i g ~ ' e ~ ~5i i\vei'r
~ ~ i between
ts,
1,evclu I
ontl observer agreed 92,87, aiid 89% oftlie time for categories
and I I .
I I I. I\! antl V respectively: tlie disagreements always conTlir K coefficient is ii st~uitlartlagreement statistic usetl to
cerrietl adjacent categories.
correct for clinnce apreeineiit. For c.liiltliw uiitler 2 years of
rately cliissitied I)iisecl o i i ii j)roft~asioiiiiIsf:iiiiiIiarity with tlie
cliilrl over a lieriot1 of :it leost 3 inoiit 11s. only I:! of 20 o'f't lip
experts :tgiwI tliat tlie e1assific;itiim systeiii coiiltl he iisecl fbr
itif~int?;as.?.oiiiigiis
I2 iiiont Iisnfap.
-411 o f t lit. es1;wts iiitliciitetl t hiit ;t cI;irsification systeiii for
cliiltlirn it11 c.erel)riillialsy has applicatioiis for i-esc.iiri.li aiid
te;wIiiiig. Siiirtwii of the 20 e s p r t s iiidiviited tliiit it Iiiw
prac.tice. I i iii(~ic;ite(~
t ~xitit ~iiis
iipp~i&~iciitimi for c~iiiicii~
cation fc)rntIiiiinistration. ;\nd 13 intlicatrtl that it 1insiilq)lication forsportsparticipnt'1011.
Eleven of the 20 eslierts iiscd tlie system to cliissifv tlir
w i iwe~wii~
motor functiln of betueen 2 ;inti I ( j c . ~ i j ~ t ~ rwit11
piilsy .-\I1 1 1 i q e r t s intlicatetl that they found the c*lassificiition system easy to nsr.Tlie system \\as iyvistd a sec.ontl time
based on t IieirsiiItsofthe 1 h l 1 ) h i survey and tiicesperts'\\ rit-

'

Table ll Percentages of agreement and disagreementbetween paired therapists for each level of the classificationsystem, by age
group

Discussion
c;iven the complex antl variaidr IiiitllIPof the niovenieiit disorders i n cliiltlren wit 11 cerebral palsy. we believe that consensiis
among a tliveiuc group of experts is an essential step in tlie
develoimient of a valid elassiticaltion system antl siibscqueiit
iiw oftlir system i n clinic.al practice i d irsrarc.Ii.Tlie results
of the nominal group process and Delphi survey coiiseiisus
methods provide evitlencc of the validity of tlie content oft he
Gross Notor Fuiictioii Classification System.Tlie inteniatioiial group of experts \\-ere unatiinious iii their agreement that
there isa need fora classification system for children \\-it11 ceirbra1 palsy that is 1)asetlon tlieconstruct ofdisability and fiinctional liniitiition. Although the experts initially espirssed
sonie differences ofopinion regaiding the (Iewriptioii for each
level, the distinction between each level. anti the iige of rliilclreii who rould be classified reliably. consensus agreement I\ as
ac*hievetlfor all 2!J statements after two rouiitls of the Delphi
survey
The ovei~alllevel of c1iaiic.c-coi~rectetl
agreement ( 1 ~ 0 . 7 5 )
supports the interi-aterreliiibility of the classification system
when usctl to classify the gross motor fiinc-tionof rhildren 1 to
12yearsofagr. ~ i i r g o was
a ~ to t~evc~op
a c~assih'catioAs~stclll
that is qiiick antl easy to use.Therefore. to examine reliability
the thei*apists i.ec-eiwtl no special training antl ~vei-cnot
iwluirrtl to perform any iiSSeSSliielit proceclurea. Ratllel: each
rljild's gross motor function \\-as inclrpcntlentlg classified by
two therapists who weir familiar with the child's current

Table IIE Chance-corrected interrater agreement ( K) for

each level of classification, by age of patients

I
11
111

I\'
Y

0.216
0.270
o. in9
0.203

0.841

o.w

0.3!)0

0.389

0.138

0.473

K4iI

0.163

0.413

0.1""

0 I??

0.m
0.L'L.i

0.908
0.817
0.8.5i

motor al)ilities.Tlie i-esults sugvst that gross motor function

can lie classi tied arcurately by occupat ional t lierapists ant1
physical therapists who have knowledge o f a diildk current
motor abilities.
Written roninients by tlierapists \die participated in the
iPlialdity phase oftliestutly suggvst that interrater reIiaI)iIity
\voultl Iiave hwn higher liacl tlie t herapists received formal arientation or training in the use of the classiticatidii system.
1lan.v of tlie questions that were raised could easily haw been
atltlressrtl in a single training session. These indude concerns
allout c.Iassif?.inga child's motor function at a particular level
if eitlirr quality of movement \\'as poor or the therapist
1)eIievedt he child's fiinction \vould eventually be classified at a
higher level.Altliough the written instructions state that gross
motor fiinrtion slioultl be clasbified based on the cliiltl's usual
performance in Iionie. srliool. and community settings. some
therapists esl)iws"eIiiiirc~rtaialy&lit wlirther to classi[y on
tlic biisis of what the child can (lo at their best versus what tlir
cliild ortlinarily does. One tlieriipist provided a written
tlesrription of a c-hilti'sniotoi-abilitiesthat cleiirly irl)irsentrd
IAWI V yet rlassificd the rliilcl's motor function as Level 1V.
('oininents I).y other therapists also suggested that theiv WHS
soinc I T ~ I I C ~ ~ ~toI Iclassi[y
W
ii child i n the most seveiv (*ategorSy
\'e have attempted to atltli~ess;dl t1ie.w concerns i n tlie
and LJserInstructions guide that is distrilwteti
Inti*otluc*tioii
with the ('lassification System. Severtheless. to avoid errors
attributable to iiicoriwt interl)luetiltionof the guidelines, we
irconiniend that users establish interrater rrliiibility befor-e
rising the classification system for research. We also ~rw"iJINW~I thilt pi*ofessioiials\\.ho \\odi togethrr classifjr the ~ I W S S
niotor fiinrtion of several c*liildrenfroni their c*asrloadsintle~)entlentlyand discuss the results before using tlie c*lassification system i n c4inical practice.
;\lthough t l WIISCIISIIS
~
of the rsperts \\.as that the 01i1ssitication systibiii can bv usrtl to cblassify acwratcly the gross
motor function of chiltlren between 1 iiiitl 2 years of age. roninients niatle by sonic oft he expvrts suggested that this may be
cliffiriilt. Interrater reliability tlierefoix?,was csuniined sepalratrly forrhiltlren untler the~gc~of).yriirs.Tlic
ovrrall lcvrl of

Table IRCategory association statistics for each level of classification,by age of

patients

o.n8

I1

0.10
0.00

0.13
0.70
0.2 1

0.ou
0.00

0.07
0.00

I
I1

0.G7
0.45

0.33

111

O.(I 0

O.lH)

I\'

0.00
0.00

O.(lO
0.00

111

I\'

\'

0.55

0.00
0.15
0.5i
0.13
0.1 1

0.00
0.00
O.!PL

0.04
0.00

0.00
0.0.5
0.14

0.33
0.44

0.IH)
0.00
0.08
0.8i
0.1 1

0.lM
0.IM

0.07
0.27
0.44

0.00
0.00
O.Il0
O.O!)

0.89

Iironounced for cMtliyii iintler 2 years of age. Despite t lie

esperts'concerns that the distiiwtioii between I,e\ds I and I I
and between Levels 1I1 aiitl I \' woiiltl be tlifticolt. the t herapistswlio participated in tlie idiability I)liascofttirstritlg had
the most tlisagiwnients bt*t\veeii I ~ ~ wI\'l s and I!
Until the
idiiibiIity aiitl vditlity of the cl~i~sifi~~atioii
system are esaminetl fiirther. carit ion shaultl be eseivisetl whiw classifying t tic
grossmotor function of c*liiltIiwiintlci-2years of age.
Level I represents the c*ontinuum of chiltlirii with iieui'omotor impairnirnts \vhose fiinc*tioniilliiiiitatioiis tuv less than
what is often associated with cvri*l)ralpiilsy and chiltlren \vho
have traditionally berii tliagnosrtl a s having *niinimnl brain
palsy of niiiiiniitl severity'. The contlysfunction' oi~*iwel)raI
struct for 1,evel I is consistent with the tintlings of ('oolman
ant1 associaites ( 1985).\v~iorrporteti tilclt somc cIiiltIiwi born
I)ii*tcriii tlemonstiatr a pittern of persistent nriii~omotor
;is those assoc~iatctlwith
iibiiormalities that a w not iis s(ve1~1
ccirbral 1 ) a h ~\Ye ainticipited that the tIistinc*tion Lwtiverii
Lrwls I antl I I \\~oultlbe tlie most tiifticult \vhen classifjring the
motor function ofchildiwi untlcbi.2 yriii*sof age. its tliffrrwicrs
i n mobility :LIPnot 1)roiiounced. For the tlierapists who
prticipatetl i n the idiability phase ot'tlie study. ho\\cvt*i:tlisagrveincnts betiveen Levels I aiitl I I \ v t w moir frequont \\hen
cliissif\.ing the motor fiinctioii ofcliiltlitvi 2 to 12 yccirs ofagr.
This suggests that the tlieixpists had difficdty deciding
\vlwther ii child liiitl fiinctional limitations in the ability to
a.alk outtloors antl climb stairs and \vhether a child can perform gross motor skills such as runningantl juniping.
The therapists antl petliatric*ians who participatetl i n the
nominal group process and Delphi siirvty consensus met hods
iiitlicatetl that a t4assification system f(z. chiltlrrn with c c w brat palsy hiis applic.iltiolls for clinical practice. research,
teaching.' antl atlmiiiistration. I'articipants i n the nominal
gr-oup process suggested that a classification system \ \ o i i l t l
Iidp professionals to pwsrnt informetion on a cliilrlb current
fiinctional a1)ilitics iintl assist f;milies and pi~ofessionalsiu
planning for a c*hiltl'siieetls. in(*lii(iingtlie recommended use of
assistive technologp Part icipants also intlic.atcd t liat n classification system would be helpfill i n coiisitlering whethei- u child
would benefit from specitic treat inciits. iiicluding surgical
interrentions. antl i n providing misistency i n teriniiiology in
the tlissemination of the results of tiwitment outcome
research. Recommentletl atlininist rative appliriations of a i h s sification system included the ability to tlisti-ibute the caseloiicls antl to tleteriiiine the irsniirces neetled for particuliir
caseloatls.
An interesting philosophic*alissue has becw raised co;icerning the use of nunierical tlesigniitions for the tive levels oftlie
classification system. rather than verbal rlescril)tors such ss
'miltl':motl~~rate'. antl.wveiv~.\Ye conclutletl that on balance
the use of numbers to distinguish levels cwrietl less implied
value than for esainple the terms just ~nentionetl.\Vc assunie
that rlinicians coiinsrling piirents about a diild-s f ~ ~ i c t i o ~ i i d
classification. i n this or any other system. will always spend
time interpreting the meaning of each level. whether~itbe a
number or a tleseriptive trim. Furt1ierinoi.e. it might lie
argued that words l i k e ~ ~ e \ ~ ~ ~ e ' ~ ~ o tcarry
e i i t i far
a l l mow
y
emotional impart than a numerical designation. offered with mi
explanation of the progiiostic antl clinical implicatioiis for
that child.
Further research is aimed a t esaminiiig thr validity antl
applicationx of the (:rims Notor Fuiiction C'lassifiratioii

System. The system is being used 11s the major stratification

variablr i n a prospwtive longitutliiinl st utly of the tlevelopinent of gross motor fiinction i n chiltli*eiiwith cerebral palsy.
tlebigiirtl to ciPate'iiic~toi.gi~o\vtli
curves'of't he motor progress
of ii r;intlonily selrctetl cohort of cliiltlreii H(*I*OSSOntario. \\%
are ;dso untIei*takiiig a miislid retrospcc-tivr c-liart itview of
ittlolcscents with ceid)ral palsy followtd I)rospei+tivelyfrom
inftincy to assess how ncll chiltlrcn trark i n thesamec*liissiticittion level, a i i t l at what age their cliishitic-ationis predictive of
niotor fiiii(*tionstatus at iige 12. \\'oi~lc is nntler way t o assess
the validity of' a bricf' stiwtuiwl inteiavicw with a parent.
using algorithms t hat appear on pilot testing to Iiiivc. utility a s
11 simple meiins of classifying c4iiltlren's gross motor function.
I f t tic system proves as usefirI*asw e IwIieve it to be. clinicians
may for the first time have objective data to atltlress t l i c t n o
n i i l j o l . cluestions iislwtl by every parent ofa child with c.ercl)ral
palsy:'How 1)ad is i t ? ' antl '\\'hat i s ' t h e outlook {'or my
cli i Id !'

Appendix A:
l'z\Xk:ld

NE31I1EI<S I'OH T H E I)KLI'HI SlVKVk:S

Robwt .4rinstroiip. JID. PIID. Associate I'rofessor of

I'etliatrics. Ukiiwrsity of British ('olumbia. Sunny Hill He;ilth
( 'eiit for ('hiltlren. Vancouver. BC'.C'anatla:
I<i*istirBjoriison. JIS (PT),
Rrseafch C'oortlinatoi; Spasticity
Jlanagcmcnt C'linic. ('liiltIi*enb Hospital and ;\lettical ( 'entrv.
Sr~attle,\\'L\.us;\:
Eva Bowel: Bl('SP (IT). I'hD dissertation submitted.
Keseilrch Rllo\v. [Tniversity of Southtimpton Rehabilitiitioii
Iteseai~c*h
Unit ,Sout ham pt 011. UK :
Sirzann ('ampbell. I'hD (PT), FAPT.4, Professor. Pliysical
Therapy. Univcrsity of Illinois. Chicago. I I,. USA:
\\kntly ('ostei:
PhD (OTR/L). Assistant Profkssor:
Depart inent of Occupational 'I'hei*apy. Boston LJniwrsity.
Bostoll. M A . us.\:
Diiiiie Damiano. I'hD
( I T ) , Assistant I'rofessor,
Orthopactlics, University of Viigiiiia Jletlical ('entre.
('harlotteville, VA. USA:
.Johannii Darrah, AISc (IT).
PhysicalTIierapist. University of
Albcrtx/Gleiirosr Kelia\)ilitation Hospital. Etlmonton. .\B( 'aniltla:
Georgia 1M:angi. PIID,OTR. FAOTA. Dircctorof Research.
Iteginaltl Lowie ('enter for Infants and ('hiltlren. Rockville.
rib

31.4,USA:
Bjorg Fallang. JIA (IT)
Research
:
FeIlo\\. University of Oslo,
Petl. Research and Oslo College. Oslo. Soi.\ray:
Stephen Haley PhD (I"),
Cooidinator, Staff Develolmient,
Etlucation. antl Research. S e w Eiiglantl Rehabilitation
H&taI. \\'olmrn, a1A , US.-\:
Susan Hardy BISc (PT).
Physiotherapist, ('eirbral h l s g
Pi*ogram. Hugh JI a c M I I a n Rehabi li t tit ion ('ent i*e,To ront o,
OX. Canatla:
Susan Harris, PhD ( I T ) . Professor and Head Division.
Gracluate Studies. School of Rehabilitation Sciences,
University of British C'olumbia, \'ancouver: antl R c n l t y
Clinical Associate. Sonny Hill Health Centre for C'hiltlren.
\'ancower, RC', Cltnatla:
Valerie Ho\rdl. PT, Cliniciil Director, JIiami C'hiltlrenB
Hospital, JIianii. FL.USL\:
Eva Sortlmark. PI',Lect yrer, PhysicalTherapy University of
I m i d . LuntI. S\vetIeii:

Fretlerick Palmei: AID,Professor of Pediatrics. University of

Tennessee. Mempliis.TS, LJSA:
Dinah
Retlclihougli, MI>.
FRAC'e I)evelopmeiital
Pediatrician. Department of C'hiltl Development and
Iiehabilitation, Royal ('hiltlrenk Hospital. ,\Iclbouime.
Aiist ralia:
D1, Rosenbloom, FRC'I: Petliatiic Seurologist. Studies iii
Child Development and Handicap. Department of ('hilt1
Health. Uiiiveixity of Liverpool, I,iverpool, UK:
David Scruttoii, MSc (I")
Senior
, Lecturer. I'hysiothei~apy
and Elioenginecring.ItistituteofC'hiId Health. I ~ ~ i i t l o tUK:
i.
A1ic.e Shea, ScD (PT). Pliysicid Therapy Department,
Association for liesearch and Etlucation. C'hiltlirn's Hospital,
Boston, A I A . US.4:
i
\\raylie Stuberg. PhD. P",Associate Professor antl I)irec.tor.
PhysicalTherapy Jleyer Rehabilitation Institute. University
ofSebixska Metlical ('elitel: Omt~lia,SB.U S A .

tions for each age interval aiv intriitletl to serve ax guidelines,

are not comprehensive. and are not norms. Children below age
2 should be coasidered at their correct age.
An effort has been made to eiiiphasize children's function
rather than their limitations. Thus as ii general principle. the
gross motor function of childi~nwho are able to perform the
funetions tlesc~ibctlin any ~)artirularlevel will probably be
classified at or above that level: i n contrast. the gross motor
function of childirn \vho caniiot perform the fuiictions of a
~iai~tic~ularlevel
will likelybeclassitirtl Lelow that level.

Crossillotor Fri,icf ion Clasai&atioir Sydc~~n

LEVEL I - \I'alks without restrictions: limitations in morc
advanced gross motor skills.
Before 2nd hiithclay: Infants inooc in a nd nut of sitting and
floor sit ~vitliboth haiitls free to maiiil~ul;itrol)jrrts. Infants
crawl on hantls antl knees. 1)uIl tc)stand antl take steps holding .
onto fiirnituiv. Iiifaiits tvallc between 18 moiiths antl 2 yearsof
Appendix B:
age without the nwtl foraiiy assistive mobility tlevice.
(: I{OSS l101'0 13 lprS('T1OX ( 'LASS I FI I 'AT10s S Y W E l l
From age 2 to4th birthday: ('hiltlirn floor sit with both liantls
1,itrorlricfioti anrl User Iti.~trrictio~is
f i w to manipulate objects. Alovenients in atid out of floor sitThe (;rosx Notor Fuiiction ('lassification System fi)i*('c~.ebral
ting a11tl stiintlillg ~ I P
performed \vithout iidult a~.sistii~l(*e.
Palsy is based 011 self-initiated movement with ~ ) a r t i ( ~ l i l r ('Iiiltlreii \valk;ts the prcfertwl method of mo1)ilitywithout the
emphasis 011 sitting (truncal control) and wallring. \\'lirn
nerd for any assistive iiiobility tlcvire.
tlefiningon a 5 level C'lassitiratioiiSSsteni,our primary eritcriFrom age 4to 6th birthday: ('liiltlri~nget into imrl out of. ancl
on was thiit the tlistinrtions i n motor function between levels
sit in, a chair without the iicrtl for h i ~ ~ i s~ipport.
tl
('Iiildreii
move from the floor and from ~~liair~itti~igtostantli~ig\vitIiout
must be clinically meaningful. Distinctions between levels of
tlic iieetl for ohjects for supl)ort. ('liiltlrrn walk intlooi~iand
motor fuiiction tire based on functional limitations. the ncrtl
outtlooi.~,ant1 rlimb stairs. Emerging ability to run and jump.
for assistive technology including iiiobility devices (such as
walkeis. c~utches,antl cknes) and \vheeletl mobility. and to a
From age 6 to 12: ('liiltlreii \valk intloors and outtlooin. and
mucli lesserestent quality of movement. Level I inchdes chilclimb stairs without limitations. ('hiltli~en ~~erfi)rm
gross
motor slrills includiiig runniiig a i d juniping I,rlt speed, baltlren with neuromotor impairnients wliose functional limitations ate less than what is typically associatctl with eei~briil
a i i e ~antl
~ . rooidination arc retlucetl.
LEVEL I I - \Valks without assistivtb tlevicw: limitations
palsy antl chiltlreii \viio have tratlitionally been diagnosetl as
walking outdoois antl in thc cominiiiiity .
having"minimal brain cl~sfiinction"oi"cerebrralpalsy of minimal severity".Tlie tlistinctions between Levels I antl 11. thereBefore 2nd hiithtlay: Infants iiiaiiitiiin floor sitting but may
nwtl to use thrir haiitls for support to maintain 1).d I allcl'.
f o r ~ are
, not as ~~ro~iouiiced
as the tlistiiictioils between tlie
Infants creep on their stoinac~hor c~aivl011 liantls and kiicws.
other Levels. pai*ticularlyfor infants less tlian Zyears ofage.
Infants may pidl to stand and take steps holding onto furniThe focus is on determining what level best relmseiits the
ture.
child's present ahilities and limitations i n motor function.
From age2 to411 birthday: Cliiltlren f l o o r s i t u m y 11avedifEmphasis is on the chiltl's usual performance in home, school.
ticulty with balance when both hands IIP free to mani~)u1ate
ancl community settings. It is therefore importiuit to classify
objects. Movrnieiits i n and out of sitting ilrt' performed withon ordinary performance (not best capacity). antl not to
include judgements about prognosis. Remember the pi111)ose~ out atlult assistaure. ('hiltlren 1)1111to stand on a stable surfilce.
('l~iltlrencrawl on haiids antl Irnees with a ~ ~ c i p r opattern.
(d
is to classicv a child's p~seentg r o ~
inotor fuiirtion. not to
cruise holding onto furniture* ant1 \veIli usiiig an assistive
judge quality of movement or potential for improvement!
mobility tlevice as preferi~dmethotlsof mobility.
Tlietlesrriptionsoftlie6 levels are broad anrl are not intentlFrom uge 4 to 6th birthtllty: ('hiltlren sit i n a chair with I)otli
etl to tlescribe the function of intlividuiil chiltlren. For example.
haiirls free to manipulateobjects. Chiltliwi move from the floor
an infant with hemiplegia\vho is unable to crawl on hands antl
to standing and from chair sitting to staiiding but often
knees but otlieiivise tits the description of Level 1. ivoultl be
require a stablr sui-f~c~e
to pusli or pull up on with their arms.
cla+ietl in Level 1.Tliescale isordinal. with 110 iiiteiit that the
Children walk without the need for any assistive mobility
distance between lerels be consideiwi equal or that childirn
devic~e'intloorsantl for short distances 011 level surfaces outwith eerebral palsy are equally tlistributetl among the 5 levels.
tlooix. ('hiltlren climb stairs holding onto H railing
air
A summary of the clistinctions bet\\wn each pair of levels is
unable to run orjump.
provitlecl to assist in determining tlie level that most closely
From age 6 to 12: Chiltlreti \wlk intloor~saiitl outtloors. atitl
resembles a child's cui-rentgross motor function.
climb stairs holding onto a railing
csl)ci*iencelimitations
The title for each level represents the highest level of mobiljvalking 011 uiieven surfaces and inclines, and \\dkiiig iii
ity that a child will achieve between 6-12 yeais ofage. \Ve reccrowds or confined spaces. ('hildreii have at best only minimal
ognize that classification of motor function is dependent on
ability to perforin gross motor skills such as runiiing aiitl
ago, especially during infancy and early chiltlhood. For each'
jumping.
level, therefore, separate descriptions are provicletl for ehildreii in several age bands. The functional abilities and limita-

Uistirrctidiis between Lads I nitd 11:

C'onipnred witli rlriltlren in Lerd 1,cliildreii iit Lerel Ilhnrie lintit at io it .y i ii t Ii e rnse o j pe rfo r 111 i i i g 111 o re )ticii t t r a m it io it a; walk iny oritdoors aiid in l?te coitiiiritnily: llre t i e d f o r aasislii-e
mobility rlericea rrlwn begiiinitiy to riylk: qrrnlity of ,notwrrrnt:
aitd tire ability to ~ierfvritiyross nrotor skilla .svicli 1t.s riiiitiiiiy
atidjtrntpiii~.

maintaining balanrc on uneven siirfures. ('hildren are transported in the community. C'hildren may achieve self-mobility
wing a p o w t ~wheelchair.
Fiwn age 6 t o 12: Childrcii may muintain levels of function
arhieved before age 6 or rely mole on wheeled mobility at
home, school, antl iii the comniunity Cliiltlren niay achieve
st4f-mobility using a po\ver\vheelchair.

LEVEL 111 - \Vnlks with assistive mo1)ility (Ievicus; l h i t a tioiis \valking outdoors and i n the community.
Before l i i t l birthtltiy: infants iiiaintnin floor sitting when the
low 1)ac.k is supported. Infiriits roll i m i C . J W ~ foi~\vaidon their
st oniachs.
From age 2 to 4th birt1itl;ty: ('hiltlren maintaiii floor sitting
often by 'W-sitting (sitting brt\vt~enflesetl ant1 internally
rotated hips and knees) and may i q u i r e adult assistance tu
assunie sitting. C'hiltlrcn c.rrep on their stoniitdi or crawl 011
liaiitls antl knew (often wit hotit 1wil)rnral leg movements) as
theit primary metliotls of self-mobility ('hiltlien 11ia.y pu11 t o
stand on a stable suifiice antl cruisr short distances. ('hiltli~eii
may \vdk short clistanves inrloors using iiii assist ive mobility
clevire antl adult assistance for steering ant1 t ai~ning.
Ffoni age4 to6th birthday: ('liiltliwsit on a 'rrgulur chair but
may require pelvic. or trunk support t o inasiinize hn;irl fuiiction. ('hiltlren move in and out of clitiir sitting rising a stublr
surfare t o ])iisIi on or pd1 111) with their arms, C'hiltlrrn walk
with an assistive mobility devirc on level surf'accs antl climb
stairs with assistance from an atlult. ('hiltlrcn frequently are
transported when travelling forloag tlistanres or outdoors on
uneven terrain.
From age 6 to 12: C'hiltlren walk indoors orouttloors on a Irvel
surfaracr with an assistive mobility c1evic.e. ('hiltlren niay rlinib
stairs holding onto a railing. Depending on upper limb fuiiction. children propel a wlieelrhair ~iianuallyor are transported
when tia\~ellingfor long distances or oettloors on uneven terrain.

1)istinctiony I h t i i ~ e t Levels
i
111 and 11':
Uvfereiices i n sitling ability and mobility exiat, ei)eii alloiiv'ny
f o r e.rtensive w e of assist iiJetechioloqy. Cliildren i n Level I11 sit
intlependently, have independent poor mobility, a n d walk with
nssislirye iiio6iIity rlecicrs. C'lrildren i n Level I V ftrncfioii i n sittiiiy (~rstrnllystrp1wrled) birt indepeilrlent mobility i s aery liniited.PIiildreii iii Lerel Il'are more likelyto6etrcitisportzrlor use
p o w r mobility.

l h t i i i c l i o i i s 6ctrr.erii Lerd.s I n i i d 111:

Uiffretlre.s nre .see)i i n /lie rlryrec! of nclrieretite,i/ of jrrnc!ioiiul
i1106iIity.C'liildreii iti Lerel I l l irrerl rmistiiie niobility clerices
nrtd jreqt(ertt1y ortho.w to tr*nlk,tcJile ch ilrlreii iii L e d I1 do tiot
require nssistit.e iiiobility (Iwices uftler age 4.

LEVEL 1V - Self-mobility with limitations; children are

transpoi-tcd or usel)ower niobilit youtcloow antl in the community.
Before2ntl birthday: Infants have head control but trunk support is iwliiiretl for floor sitting. Iiifants can roll to supine and
niay roll to prone.
From age 2 t o l t h birthday: C'hiltli*eiifloor sit when plared, but
are unable t o maintain alignment and bidance without use of
their hands for support. Children frequently require adaptive
equipment for sitting antl standing. Self-mobility for short
distances (within a room) is achieved through rolling, creeping
on stomach, or cvwvling on hands and knees without reriproral leg movement.
From age 4to 6th birthday: ('hiltlren sit on a chair but need
atlaptiveseating for trunk control and to maximize halid function. ChiltlreJi move in antl out ofrhair sitting with assistance
from an adult or a stable surface to push or pull u p on with
their arms. Chiltliwi niay at best walk short distances with a
walker and adult supervision but have difficulty turning.antl
I

'

I,EVEL\~-Self-mol~ilityisseverclylimitetleveiiwith theuse
ofassistivr tec-hnology.
Before h i t i biithday: Physical impairments limit voluntary
control ofinovement. Infants are uqable t o maintain antigravity head and trunk postiires in prone antl sitting. Infants
rrqiiiir atliilt assistanre to roll
From age 2 to 12: Physical impairments restrict voluntary
control of movement antl the abi1it.y t o maintain antigravisy
head aiitl trunk postures.Al1 areasofmotorfuiictioii arelimitctl. Func.tionaI limitations in sitting ant1.standing are not fully
compensated for through the use of adaptive equipment antl
assistive technology A t Level I! children have no meiiiis of
intle1)enclent mobility and are transported. Some cliiltlren
achieve sclf-niobility using a power wheelchair with extensive
athptations.
Uistinctiotis Iletir*ernLeilels I V and :1' ,
Cliildreii in Level Vlack independence eaen i n basic antigravity
posttrral control. Self inability is acliieced only ifthe child can
lenrn Iioici to operate un electrically poirered wheelchaiz

Appentlis B copyright
Research Unit, 1995.

Seurodevelop~rntal C'linical

drrrptedfor piildirittiutr !Nr Jliry 19.W.

.-I
rktr o ic'lrtlymrr ti tx

greatly appreciate the contributioiis of the following inclivitluals us voting partiripants i n the iioniinal group process:
Sandy Caik, Heather McCavin, AnnahIaria Tancretli, ('oleen
Toal, AIarilyn Wright
(Children's
Developmental
Kehabilitation Centre, C'hetloke Division, Chetloke-BIcMaster
Hospitals, Hamilton, Ontario): Julie C'hiba-Branson,
Elizabeth Kzrajbcr, KaKei Yeung (Hugh Macblillan
Rehabilitation Centis, Toronto, Ontario): Jennifer BergC'arnegie. Kelly Cahill, Patti hIcGillivray. Shelley Potter
(Siagara Peninsula Children's Centre, St Catharines,
Ontario).
\Ve owespecial thanks to ourcolleagiies in the occupational
therapy and physiotherapy departments at five Ontario chiltlwn's treatment centres, who gave of their time t o help us
examiiie the reliability of the Gross Motor Function
Classification System. These five centres are the Children's
Developmental Rehabilitation Program, ChetlokeMrhIaster
Hospitals, C'hedoke Division, Hamilton, Ontario: Chiltlren's
e'\

Kehabilitation Centre of Essex C'ounty, \Vintlsor, Ontario:

Hugh 1\IacbIillan Rehabilitation C'entir, Toronto. Ontario;
Siagara Peninsula Children's ('entre, S t C'atharines, Ontario:
and Ottawa Cliildren'sTreatment Centre. Ottawa, Ontario. We
also wish to acknowledge specifically the contributions of the
respective coordinators i n each of these five eentres: Heather
hlcOavin, Laurie Lessarct. Virginia Wright, Shelley Potter.
and Diana JIcI ntosh.
The authors wish to express their thanks to Dawn
\Vhitu~Il,our i.eseareh clerk throughout the period of the
studies reported here.
Funding for these stritlics \\'as provided in part by griults
from tho Easter Seals Remarch Institute antl Xational Health
Research and Developinent Program. Dr Palisano's work was
supported by a Career Scientist Amartl, Ontario Ministry of
Hea1th.The work of Dr Rosenbauin antl Dr \Valter was supported by a Sational Health SeientistAwai~tl,Health Canada.
This research was contluctrtl within the Seurotlevelopme~ltal
Clinical Research Unit, \vhich is funded by the Ontiwio
hlinistry of Health through its Health Syste~n-I~iiiketl
Research Unit program.
~ U f l 1 0 I ' U' ~ L ] J ~ ~ ~ t l / / / l P l l / S

*Robert Palisano, ScD,Associnte Professor, Uepurtnient of I'liysiciil

Therapy,Allegheny University oftlir tIraltli Scictires. Pliiladrlphia.
PA, us.-\;
Peter Rouenbauin. i\I D.PKC'P Profcvisnr, Depurtnient of Pcdiiitrics:
Steplien "alter, PIi D.Professor. Depurtlnrnt of('linical
Epi&niinlngy and Biostutistics;
Dianne Russell, MSc, Research Cooidinator, Seurorlevelopliientti1
Clinical Research Unit;
Ellen \\'ootl. AID, FRC'PAssistant Profewor, Drpartinent of
Petliat rirs;
Barbura Galuppi. BA. Seurotlevelopiiieiital Clinical 1iesc.arcli Unit,
AlrAlaster Universits Hamilton. OX, C'anntla.
r/it/korat Seurotlevelo~imetitnlc'liniciil
Research Unit, i\lcl\lristcr University Furultg of Health Sciences,
BuildingT-16. Room 126.1280 Main Stipet West, Hamilton. OX.
Crnatln I S 4K 1.
f l o r r e s l w t r r l o r r e /ojfir;uf

Gross Motor Function Clas..ifiratioliSystem in C'P liobrr/ I'ttlisrrtro

P / nl.

223