Gross Motor Function Classification System (GMFCS) for Cerebral Palsy

The Gross Motor Function Classification System (GMFCS) is a multi-level categorization technique that helps to describe varying levels of severity in people with cerebral palsy (CP). The GMFCS has five levels to describe the severity of cerebral palsy. Low levels indicate mild CP, and higher levels indicate more severe CP. The Gross Motor Function Classification System can be used to describe all types and severity levels of cerebral palsy. It takes into consideration an individual’s voluntary movements, age, and functional ability under a variety of circumstances.

The GMFCS classifies infants, children, and adolescents with cerebral palsy into five groups based on three important factors:

1. Gross motor function: Gross motor skills require the use of the body’s larger muscles, and include activities like standing, walking, running, catching, and throwing. Because cerebral palsy is caused by damage to brain areas necessary for balance, movement, and coordination, gross motor skills are often impaired. This measurement takes into consideration limb control, movement transition, dependence on assistive equipment, and other related factors.
2. Performance: Performance measures how independently a person functions in settings like home, school, and the community. If a child needs extensive assistance in any or all of these settings, a more severe level of cerebral palsy is often indicated. This measurement assesses how an individual behaves under typical settings (performance), not how he or she would behave under ideal circumstances.
3. Age: Different criteria are used for five different age groups: 0 to 2 years, 2 to 4 years, 4 to 6 years, 6 to 12 years, and 12 to 18 years.

For each individual, these factors are combined to generate a general idea regarding the severity of cerebral palsy. Once these determinations are made, the GMFCS level may help doctors, parents, and other caregivers determine therapy plans, lifestyle adjustments, and rehabilitation potential for the future. In addition, the GMFCS can be used alongside other classification systems like MACS or CFCS to help provide a more detailed clinical picture.

There are five levels that comprise the GMFCS, increasing in severity from level I to level V. It is important to note that this system is meant as a general guideline. Each case of cerebral palsy is different, and the GMFCS will not completely describe each unique person.

Level I

• Has functional gross motor skills
• May struggle with speed, balance, and coordination
• Moves independently without the aid of adaptive equipment.

Level II

• Can walk with limitations
• May need assistance with inclined or uneven surfaces
• Moves without the aid of adaptive equipment.

Level III

• Can walk with the use of hand-held adaptive equipment
• May need a wheelchair to move on inclined or uneven surfaces, or to travel long distances

Level IV

• Is self-mobile only with significant limitations
• Many use powered-wheelchairs
• Require significant help with transfers
• Dependent on adaptive and assistive equipment

Level V

• Typically has limitations that impair all voluntary movement
• Extremely dependent on adaptive equipment, assistive technology, and other people
• for mobility

Level I

• Infant can move in and out of a sitting position
• Can floor sit with both hands available to move objects and toys
• Can crawl on hands and knees
• Can pull themselves up into a standing position and take steps while holding onto something (i.e. furniture)
• Can walk without the help of adaptive equipment

Level II

• Infant can floor sit, but may need hands to maintain balance
• Can crawl on hands and knees
• May pull up into a standing position or take steps while holding onto something

Level III

• Infant is able to floor sit with lower back support
• Can roll and crawl

Level IV

• Infant has head control, but the entire trunk must be supported for floor-sitting
• Can roll into a supine position (lying face upward on back)
• May roll into a prone position (lying face down on stomach)

Level V

• Infant has physical impairments that limit voluntary movement
• Unable to maintain head or trunk control when sitting
• Needs assistance to roll

Level I

• Child can floor sit with both hands available to move objects and toys
• Can move between sitting and standing without assistance
• Can walk without equipment or mobility device

Level II

• Child can floor sit, but may struggle with balance when both hands are available to move objects
• Can move between sitting and standing without assistance from others, but must pull into a standing position on a stable surface
• Prefers crawling on hands and knees
• Moves holding onto furniture
• Walks using assistive equipment

Level III

• Child can floor sit by “W-sitting” (sitting between flexed and inwardly rotated hips and knees)
• May require assistance to move into a sitting position
• Crawls on hands, knees, and their stomach as the primary method of mobility
• May pull themself into a standing position on a stable surface, and move short distances
• May walk short distances with a hand-held mobility device indoors
• May need assistance from others for steering and turning

Level IV

• Child can floor sit when placed in a sitting position, but is unable to stay balanced without using hands for support
• Often requires equipment for standing and sitting
• Can only roll or crawl for self-mobility

Level V

• Physical impairments restrict movement control and the ability to maintain an upright position of the head and body
• All motor function is limited
• Adaptive equipment doesn’t fully compensate for sitting and standing abilities
• Cannot move independently and must be moved by others
• Occasionally, child can achieve self-mobility through powered wheelchairs with many adaptations

Level I

• Child can get into, out of, and sit in a chair without using their hands for support
• Can move from the floor to sitting and standing positions without the use of others or objects for balance.
• Can walk indoors and outdoors
• Can climb stairs
• Has some ability to run or jump.

Level II

• Child can sit in a chair with both hands available to move objects
• Can move from the floor to standing; from a chair to sitting and then standing
• Often needs a surface to help with balance
• Walks without mobility devices indoors, for short distances, and on even surfaces outdoors.
• Can climb the stairs holding the railing, but cannot run or jump.

Level III

• Child can sit in a chair, but may require trunk support to allow hand function
• Can move in and out of a chair using a surface to pull themselves up
• Can walk with hand-held devices on level surfaces
• Can climb stairs with assistance from others
• Often transported across long or difficult distances

Level IV

• Child needs adaptive seating to sit and allow hand function
• Can move in and out of a chair with help from others or with a surface to pull themselves up
• May walk short distances with a walker and help from others
• Often cannot turn or balance on uneven surfaces
• Needs to be transported in the community
• May achieve self-mobility with a powered wheelchair.

Level V

• Physical impairments restrict movement control and the ability to maintain an upright position of the head and body
• All areas of motor function are limited
• Sitting and standing abilities are not fully compensated for through the use of adaptive equipment
• Cannot move independently and must be moved by others
• May be able to use a powered wheelchair with many adaptations

Level I

• Child can walk at home, school, outdoors, and elsewhere
• Can walk up and down curbs or stairs without assistance
• Can run or jump, but speed, balance, and coordination are limited.
• May participate in physical activities depending on personal and environmental factors

Level II

• Child can walk in most settings
• May find it difficult to walk long distances or balance on uneven surfaces, inclines, crowded or confined spaces, or when carrying objects
• May require physical assistance or a mobility device to navigate outdoors, or a wheelchair for long distances
• Can navigate stairs with the use of the railing or adult assistance.
• Minimal ability to perform gross motor tasks
• Adaptations may be needed to enable their ability to perform physical activities.

Level III

• Child can walk using hand-held mobility devices indoors
• When seated, the child may require a seatbelt for balance
• May need physical assistance to transfer into a standing position
• Uses wheeled devices to move long distances
• May need adult help or supervision while using railings to move up or down stairs.

Level IV

• Child uses powered mobility or needs physical assistance to move in most places.
• Requires adaptive seating for control and balance
• Needs help with most transfers.
• In the home, the child uses floor mobility (rolling or crawling)
• Walks at home with physical assistance or powered mobility equipment
• When positioned, can use a walker at home or school
• At school, outdoors, or in the community, child uses a manual or powered wheelchair
• Adaptations are needed to participate in physical activities.

Level V

• Child is transported in a manual wheelchair
• Has limited ability to keep head and trunk upright and to control arm and leg movements
• Assistive technology is required to improve head alignment, seating, standing, and mobility, but the equipment does not compensate for full function.

Level I

• Teen can walk in any setting
• Able to walk up and down curbs and stairs without assistance
• Can run and jump.
• Speed, balance, and coordination are limited
• Depending on personal and environmental factors, they can participate in physical activities.

Level II

• Can walk in most settings, but environmental and personal factors can impact mobility choices.
• At school or work, they may use handheld devices for safety.
• Outdoors and in the community, a wheeled device may be used when moving long distances.
• Can walk up and down stairs using the railing or with assistance.
• Limitations in gross motor skills may mean that adaptations are needed to participate in physical activities.

Level III

• Can walk with handheld devices and show variability in modes of mobility depending on physical, environmental, and personal factors.
• May need a seatbelt for alignment and balance.
• Transfers require physical assistance from others.
• At school, the student may move in a manual wheelchair or with powered mobility.
• May need assistance walking up and down stairs, or may use the railing.
• Limitations in walking necessitate adaptations for physical activities.

Level IV

• Use wheeled mobility in most settings and require adaptive seating for pelvic and trunk control.
• Physical assistance (often requiring one or two people) is needed for transfers, but may be able to support weight with their legs.
• Indoors, they may walk short distances with physical assistance, use wheeled mobility, or when positioned, use a walker.
• Capable of operating a powered wheelchair and may also use a manual wheelchair.
• Limitations in mobility make adaptations necessary for participation in physical activities, including physical assistance or powered mobility.

Level V

• Uses a manual wheelchair in all settings and is limited in his or her ability to keep head and trunk upright and control arms and legs.
• Assistive technology is needed to improve head alignment, seating, standing, and mobility, but the equipment does not compensate for full function.
• Physical assistance (from one or two people) or a mechanical lift is required for transfers.
• Powered mobility may be used with extensive adaptations for seating.
• Limitations in mobility make adaptations necessary for participation in physical activities, including physical assistance or powered mobility.

A GMFCS level classification is expected to remain the same for an individual’s entire life. Intervention, therapy, and rehabilitation can improve the quality of life, but they will not change the GMFCS classification.
GMFCS levels provide information for parents and practitioners about the rehabilitative potential of each person, and the categories take into account any expected improvement in gross motor performance over time. While this is the intended goal, it is not always the case.
Sometimes, a new GMFCS level can be assigned if the child unexpectedly improves. Research indicates, however, that GMFCS levels are quite stable after two years of age.

As a parent, it’s difficult to witness your child navigating settings that do not accommodate their special needs. While assistive devices can help children move independently, they can be costly. Modifications to your home may not be financially accessible. However, if you believe your child’s cerebral palsy was due to malpractice at birth, a successful legal case can help cover the costs of care and equipment your child needs.

If your child had a traumatic birth, it can be stressful to recall the events that led to their injury. It may seem intimidating to pursue a lawsuit against the negligent doctor or hospital. Here are a few considerations to help you weigh your options:

• Choosing a firm that focuses only on birth injury cases means you will be working with lawyers who have experience with cerebral palsy cases. Birth injury medical malpractice is a very complex field of law and requires the right knowledge and resources.
• Choosing a firm that offers free consultations will allow you to learn more about your options without making a commitment. Some firms don’t require you to pay any costs unless they settle or win your case. If you’re unsure, it’s important to ask before signing any agreements.
• A cerebral palsy lawyer will do the work to investigate malpractice so you can have more time to take care of your child.
• A lawyer may help provide additional resources that allow you to advocate and care for your child.
• Checking reviews and testimonials for each firm can help you see what to expect from other parents and caregivers.
• The financial recovery from a successful case can provide even more for your child beyond assistive equipment and modifications. Adaptive recreation, alternative or additional therapies, and a dedicated care manager can make a difference in your child’s well-being and yours.