ONTARIO MOTOR GROWTH (OMG) STUDY PROJECT REPORT

WHAT WAS THE OMG STUDY ABOUT?

When told that their child has cerebral palsy, many

parents first ask: How serious is it? and Will our
child walk? Until now these important questions
have been difficult to answer because we didnt have
evidence of all the facts. Through a joint venture
with the Childrens Treatment Centres in Ontario,
CanChild Centre for Childhood Disability Research at
McMaster University is in a unique position to study
issues like this. The Ontario Motor Growth (OMG)
Study - which you and your family may have been
part of - has given us more information to answer
parents questions. This report outlines what we
have learned so far and what we plan to do in the
future.
HOW DID WE START?

It is clear that cerebral palsy affects the control a

person has over body movements - sometimes the
effects are small and sometimes they are large. In
the past, service providers have talked about the
amount of movement problems in terms of mild,
moderate or severe cerebral palsy. As far as we
know no one has ever been able to agree on what
these words actually mean! We found this situation
frustrating, so we developed a system to define the
range of gross motor function of children with
cerebral palsy more clearly. This way, service
providers and families all over the world will have a
consistent and common language when we talk
about these issues.
With the help of service providers from many Ontario
childrens centres, we created the Gross Motor
Function Classification System, or GMFCS (weve
included a copy for you in this package). For the first
time, the GMFCS gives us a standard way to describe
differences in the gross motor function of children
with cerebral palsy. The GMFCS describes five
levels of motor function. Each level is different from
the other levels in ways that, we believe, are
important for daily life. Within each level there are
descriptions of motor abilities at different ages. The
system can be used easily by service providers (such
as therapists and doctors), and many parents have
also told us they find it useful. We know that when
different people classify a childs motor abilities using

the GMFCS, they very often agree exactly about

which level applies to that child. We also have
learned that most children tend to stay in the same
GMFCS level over time. This is important because it
means that we can begin to understand early in a
childs life what motor skills the child is likely to
achieve as they get older.
Since we first made the GMFCS available to people
around the world, it has been translated into at least
six languages, and is now regularly mentioned when
people write about children with cerebral palsy. We
have also put together a training videotape that
teaches service providers about using the GMFCS.
We are continuing to do more work to improve the
GMFCS. For example, we are hoping to expand the
GMFCS to include what we learn about the abilities of
teenagers with cerebral palsy in our next study.
WHAT DID WE DO TO LEARN ABOUT A CHILDS
OUTLOOK FOR MOTOR FUNCTION?

In some of our early research about motor

development in children with cerebral palsy (in the
late 1980s) we were able to show that there were
differences in motor development according to
whether the children had what was then still being
called mild, moderate or severe cerebral palsy.
We know, however, that the best way to understand
how children grow, or how their abilities change over
time, is to measure the same children many times
over several years. We can then link these
measurements together to produce a line (usually a
curved line) that, in effect, connects the dots.
When this same process is done with a large number
of children, and we use a more accurate system to
classify function (our GMFCS), it is possible to create
five separate motor growth curves. These curves
are similar to the growth charts (describing height
and weight) used by pediatricians and family doctors
to decide whether babies and children are growing as
expected.
In order to try to make our findings useful for all
children with cerebral palsy we needed to make sure
that the children who participated in the OMG Study
were typical of children with cerebral palsy across
Ontario. To do this we worked with 18 of the

CanChild Centre for Childhood Disability Research, July 2002 .......................................................................................................... Page 1 of 5

childrens treatment centres and one additional

therapy program. We found out that there were
2108 children in Ontario with cerebral palsy under
the age of 11 in 1996 when the study began. We
used random selection (which is like picking a
number out of a hat) until we ended up with 682
families of children with cerebral palsy who wanted
to participate in the research. At the start of the
study these children ranged in age from 1 to 13
years old and had a wide range of motor abilities.
Table 1 below shows the ages and the GMFCS
levels of the 657 children with cerebral palsy who
had enough study assessments to be included in the
motor growth curves weve created.
As you may remember, in the OMG Study we wanted
to measure each childs gross motor function every
6-12 months (less often as children got older). The
tool we used to measure motor activities was the
Gross Motor Function Measure (GMFM), another
measure we developed many years ago that is now
used around the world. The GMFM was designed to
assess whether, and how much, children change
their motor abilities over time. It looks at what
children do in lying and rolling, crawling and
kneeling, sitting, standing, and walking, running and
jumping. It does not look at how well children do
these things, although this is another area of ongoing research by our group.
Therapists who did the GMFM assessments were
from centres that are part of the Ontario Association
of Childrens Rehabilitation Services (OACRS). They
were all trained to use the GMFM measure correctly
and were retested every year to be sure they
continued to use the GMFM in the same way. They
were also the same people who made classifications

using the GMFCS at each visit.

WHAT HAVE WE LEARNED SO FAR?

A total of 2,781 GMFM assessments were done

between August 1996 and February 2001! We then
carried out a join the dots statistical analysis that
links all the information about each individual child,
and then links the different children in each GMFCS
level. The resulting motor growth curves are shown
in Figure 1 on page 5.
What we see is that in each GMFCS level there is a
general pattern of improvement in gross motor
development over time that is specific for that level,
and is different from each other level. From these
graphs we know the:
average amount of change children show on
the GMFM over time.
age-90 is different for each level (the age-90 is
the age when an average child reaches 90% of
their expected motor development in that
GMFCS level).
You can also see that, at the top right corner of each
graph there are two dotted lines, above and below the
end of the labeled motor growth curve. These lines
tell us that 50% of the children in that GMFCS level
will have a GMFM score within that range by the time
they are 7 or 8 years old. This also means that in any
GMFCS level some children will score higher and some
lower than others. The GMFCS level therefore tells us
a lot (but not everything) about how much or how
well a childs motor development may happen.
Factors such as a childs interests, motivation, health
and other aspects of development will also make a
difference in a childs motor development.

Table 1: Age and GMFCS level for 657 children included in the motor growth curves
Gross Motor Function Classification (GMFCS)
Age of children

Level I
(183 children)

Level II
(80 children)

Level III
(122 children)

Level IV
(137 children)

Level V
(135 children)

Total
(657 children)

1-2 years
3-4 years
5-6 years
7-8 years
9-10 years
More than 10 years

16
47
30
36
36
18

13
20
15
14
18
0

13
22
30
27
20
10

12
30
30
29
31
5

14
22
36
32
26
5

68
141
141
138
131
38

CanChild Centre for Childhood Disability Research, July 2002 .......................................................................................................... Page 2 of 5

WHAT DOES ALL THIS WORK MEAN FOR FAMILIES?

Lets get back to why we began this work in the first

place to be able to provide families with answers to
those two important questions. The work we have
done with the help of hundreds of Ontario parents
like you has provided us with a good starting point
for answering these questions.
1) How serious is our childs cerebral palsy?
The GMFCS makes it possible to give advice to
parents about the extent of their childs motor
difficulties, and thus to answer this first question.
2) Will our child walk? With the motor growth
curves we can now also begin to make a
prediction about the pattern of gross motor
development of children in the same GMFCS level,
and have a pretty good idea about what to expect
for this second question.
It is extremely important for parents, therapists,
program managers, funders, and other decision
makers not to assume that, at a time when the curves
appear to level off, further therapy is unhelpful. We
all need to continue to make every effort to find ways
to increase childrens independence in activities so
they can do as much as possible. We also need to
work to ensure that childrens movement is as efficient
and effective as possible even when things are not
achieved easily. It is equally important to make
efforts to promote participation of children with
disabilities, so that they can be part of the community
at large and use their motor and other abilities to best
advantage for social development and the
development of their own interests.
ANDThere are some other important issues to keep
in mind about this work.
First, the results of the OMG Study are based on the
therapies and treatments that are currently used for
children with cerebral palsy. We believe that services
in Ontario are up-to-date and well provided so we are
confident that what we have learned represents the
way children with cerebral palsy are likely to develop
using the therapies we presently have available to us.
As new treatments become available it is likely that
these curves may change to show better or faster
development. When that happens it may be
necessary to change these curves.

terms of the activities that allow children to become

independent in their whole body movement.
However, the GMFM assessment tells us nothing
about the quality of motor control (smoothness,
efficiency, ease of movement) children use to do
things. We know from other studies that this is a part
of motor development that seems to come along later
in childhood. The motor growth curves also tell us
nothing about how children use their motor function
in daily life, for play and activity at home/at school/in
the community.
Third, the GMFM was set up to assess motor function
tasks achieved independently by the child. The GMFM
does not look at how augmentative and technical
interventions such as aids, orthoses or the use of
powered mobility may increase day-to-day
independence. What has been observed in the OMG
Study shows us, on average, the motor activity that
children with cerebral palsy can be expected to show
without any help.
WHERE DO WE GO FROM HERE?

Several activities are happening now at the CanChild

research centre:
We still have a great deal to learn about the motor
development and function of adolescents with
cerebral palsy. As you may already have heard,
CanChild has received funding from the Canadian
Institutes of Health Research to do a follow up study
with teenagers for the next 5 years. This study is
called the Adolescent Study of Quality of life, Mobility
and Exercise or the ASQME Study (pronounced ASK
ME). The ASQME Study will allow us to continue by
looking at teens with cerebral palsy and hopefully to
extend our curves to the end of the teenage years.
We also want to know more about the things that
teens with cerebral palsy do in functional activities,
participation, exercise and recreation. If your child is
currently 11 years or older well be contacting you to
see if this new study is something you and your
adolescent will want to join.
When you see this logo, youll know its about the
new study of teenagers!

Second, the GMFM looks at gross motor function in

CanChild Centre for Childhood Disability Research, July 2002 .......................................................................................................... Page 3 of 5

We are working to share the results of our OMG

Study to people all over the world. We know that
others have been waiting for these results, because
they believe that the curves will be helpful to the
families they work with. We have written articles
that we hope will be published in medical and
therapy journals to share the findings widely.
Eventually the goal is to make motor growth curves
available on the CanChild web page so that people
can download and use them directly.

You can find the CanChild website at

www.fhs.mcmaster.ca/canchild and if you click on
Whats New then Research in Progress youll
see all the research that is happening at CanChild.
Both the Ontario Motor Growth Study (OMG Study)
and the Adolescent Study of Quality of life, Mobility
and Exercise (ASQME Study) are listed there. We will
continue to update the website with study news and
information about new publications.

AND FINALLYHOW CAN WE THANK YOU!

How do we begin to thank you for contributing to this study? It must be obvious that even the best research
cannot be done unless families like you give your time and energy and interest to make it possible! This
partnership between CanChild, families of children with special needs and the childrens treatment centres in
Ontario is unique in the world. The work we have accomplished together, like this study and others, is making a
difference around the world. We are indebted to you and your children for being part of this work, and we want
to express our deep and sincere thanks for being there with us.
If you have questions about this report, or would like to know more about the OMG Study or other CanChild
work, please contact us through the CanChild web page (www.fhs.mcmaster.ca/canchild), by telephone at (905)
525-9140, ext. 27850 (ask for Dr. Rosenbaum), or by e-mail at [email protected]

CanChild Centre for Childhood Disability Research, July 2002 .......................................................................................................... Page 4 of 5

ONTARIO MOTOR GROWTH (OMG) STUDY PROJECT REPORT

Figure 1: Motor growth curves

GMFCS Level
(Level I = highest ability)

GMFCS Level I
Level I
100

Motor growth curve

90
80
70

GMFM score
(100 = highest ability)

60
50
40
30

Age-90 line

20
10

Childrens ages in years

(0 = birth)

0
0

10 11 12 13 14 15

GMFCS Level III

GMFCS Level II

Level III

Level II
100

100

90

90

80

80

70

70

60

60

50

50

40

40

30

30

20

20

10

10

10 11 12 13 14 15

GMFCS Level IV
100

90

90

80

80

70

70

60

60

50

50

40

40

30

30

20

20

10

10

0
2

10 11 12 13 14 15

Level V

100

GMFCS Level V

Level IV

10 11 12 13 14 15

10 11 12 13 14 15

CanChild Centre for Childhood Disability Research, July 2002 .......................................................................................................... Page 5 of 5