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; the lower levels correspond with milder forms of CP, while the higher levels indicate increased severity. 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.
Classifying Cerebral Palsy with the GMFCS
The GMFCS classifies infants, children, and adolescents with cerebral palsy into five groups based on three important factors:
- Gross motor function: As its name implies, the GMFCS uses assessments of gross motor skills to determine how severe a given case of cerebral palsy may be. 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.
- Performance: In addition to gross motor skills, the GMFCS considers 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. Note: this measurement assesses how an individual behaves under typical settings (performance), not how he or she would behave under ideal circumstances.
- Age: The GMFCS also takes into account an individual’s age when assigning a GMFCS level. 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 to help provide a more detailed clinical picture.
The Five GMFCS Levels
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 and that each case of cerebral palsy is different; because of this, the GMFCS will not completely describe each unique person. Broadly, the five levels are described as follows:
- Level I – Has functional gross motor skills, though may struggle with speed, balance, and coordination. Moves independently without the aid of adaptive equipment.
- Level II – Can walk with limitations and 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 and 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, and are dependent on adaptive and assistive equipment.
- Level V – Typically has limitations that impair all voluntary movement and is extremely dependent on adaptive equipment, assistive technology, and other people for mobility.
GMFCS Age-Specific Levels
GMFCS Ages 0 – 2
- Level I – Infant can move between in and out of a sitting position, and can floor sit with both hands available to move objects and toys, and can crawl on hands and knees. Can pull themselves up into a standing position and take steps while holding onto something (i.e. furniture). An infant between 18 months and 2 years 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, and 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 and can roll and crawl.
- Level IV – Infant has head control, but the entire truck must be supported for floor sitting. Can roll into a supine position (lying face upward on back) and 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 in prone or supine postures. Needs assistance to roll.
GMFCS Ages 2 – 4
- Level I – Child can floor sit with both hands available to move objects and toys. Child can move between sitting and standing without assistance, and uses walking as the preferred method of mobility without adaptive equipment.
- Level II – Child can floor sit, but may struggle with balance when both hands are busy manipulating objects. Child can move between sitting and standing without assistance from others, but must pull self into standing position on a stable surface. As the preferred method of mobility, child crawls on hands and knees, moves holding onto furniture, and walks using adaptive equipment.
- Level III – Child can floor sit by “W-sitting” (sitting between flexed and inwardly rotated hips and knees) and may require assistance to move into a sitting position. Child crawls on hands and knees as the primary method of mobility, may pull themself into a standing position on a stable surface, and move short distances. Child may walk short distances with a hand-held mobility device and 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. Child requires equipment for standing and sitting. Self-mobility is possible only through rolling or crawling.
- 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. Child cannot move independently and must be moved by others. Occasionally, child can achieve self-mobility through powered wheelchairs with extensive adaptations.
GMFCS Ages 4 – 6
- Level I – Child can get into, out of, and sit in a chair without using hands for support. Child can move from floor to sitting and standing positions without the use of others or objects for balance. Child can walk indoors and outdoors, can climb stairs, and has some ability to run or jump.
- Level II – Child can sit in a chair with both hands available to move objects. Child can move from the floor to standing and from a chair to sitting to and then standing, but often needs a surface to help with balance. Child walks without mobility devices indoors, for short distances, and on even surfaces outdoors. Child 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. Child can move in and out of a chair using a surface to pull themselves up. Child can walk with hand-held devices on level surfaces, can climb stairs with others’ assistance, and is often transported across long or difficult distances.
- Level IV – Child needs adaptive seating to sit and allow hand function. Child can move in and out of a chair with help from others or with a surface to pull themself up. Child may walk short distances with a walker and help from others, but often cannot turn or balance on uneven surfaces. Child is transported in the community, but 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. Child cannot move independently and must be moved by others.
GMFCS Ages 6 – 12
- Level I – Child can walk at home, school, outdoors, and elsewhere and can walk up and down curbs or stairs without assistance. Child can run or jump, but speed, balance, and coordination are limited. Child may participate in physical activities depending on personal and environmental factors.
- Level II – Child can walk in most settings but may find it difficult to walk long distances or balance on uneven surfaces, inclines, crowded or confined spaces, or when carrying objects. Child can navigate stairs with use of the railing or a mobility device. Child has at best minimal ability to perform gross motor tasks, and adaptations may be needed to enable 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, and need physical assistance to transfer into a standing position. Child uses wheeled devices to move long distances and needs help and use of railings to move up or down stairs.
- Level IV – Child uses powered mobility or needs physical assistance to move in most settings. Requires adaptive seating for control and balance and needs help with most transfers. In the home child uses floor mobility (rolling or crawling), and walks with physical assistance or powered mobility equipment. When positioned, child can use a walker at home or school. At school, outdoors, or in the community, child uses a manual or powered wheelchair, and adaptations are needed to enable participation in physical activities.
- Level V – Child is transported in a manual wheelchair in all settings and is limited in ability to keep head and trunk upright and control arm and leg movements. Assistive technology is needed to improve head alignment, seating, standing, and mobility, but the equipment does not compensate to full function.
GMFCS Ages 12 – 18
- Level I – Individual can walk at home, school, outdoors, and elsewhere. Is able to walk up and down curbs and railings without any assistance and can run and jump. Speed, balance, and coordination are limited. Individual can participate in physical activities depending on personal and environmental factors.
- Level II – Individual can walk in most settings, but environmental and personal factors can impact mobility choices. At school or work, individual 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 – Individual 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 individual may move in a manual wheelchair or with powered mobility. Individual may need assistance walking up and down stairs, or may use the railing. Limitations in walking necessitate adaptations for physical activities.
- Level IV – Individuals 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 individual may walk short distances with physical assistance, use wheeled mobility, or when positioned, use a walker. Individuals are 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 – Individual 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 to 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.
Can a GMFCS Level Change Over Time?
A GMFCS level classification is expected to remain the same over the course of an individual’s life, even with intervention, therapy, and rehabilitation. GMFCS levels provide information for parents and practitioners about the rehabilitative potential of each person and take in to 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 unanticipated improvement is obtained. Current research indicates, however, that GMFCS levels are quite stable after two years of age.
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