Gross Motor

Function Measure
- we should be able to follow maturation after events
that are known to slow down brain development

- To measure small but important changes in motor

function of CP

Motor development may plateau for long or short

durations of time or the movements may become
atypical
Gross motor function

 Basic set of movement skills

 Child’s achievement
Structure of GMFM

 These gross motor milestones form the basis of GMFM

dimensions

 Measurement - defined as the process of assigning

numerals to variables to represent quantities of
characteristics according to certain rules

 The items are clinically relevant and show potential

responsiveness to change
Nature of GMFM

 Evaluative - magnitude of change in function over

time or after treatment

 Criterion based measures - relevant items chosen

(domain of interest) and then describing the criterion
by which the observer can assess whether that
characteristic or functional attribute is present or not

 There is no comparison with general population

Item scoring

 0 – does not initiate

 1 – initiates (<10 % of the task)
 2 – partially completes (10% to < 100% of the task)
 3 – completes the task

 NT – not tested
Difficulty levels

 Can viewed in item maps

 The difficulty of the items can be viewed by

calculation of expected scores

 The expected score is the mean score of the

population

 The item maps show the ability at which the given

score is expected
 Pic of item map
Longitudinal Motor Growth Curves for Children with Cerebral Palsy by
GMFCS Level Using GMFM-66
 GMFM 88 and 66
 88 - for Down’s

 66 for CP - Identified items which did not “fit” the uni-

dimensional construct - eliminated 22 items

 Items are now arranged in order of difficulty (empirical)

 Response options within items are weighted according to

difficulty

GMFM is appropriate for children whose motor skills are at or

below those of a typical 5 year old
Scoring with aids/orthotics

 First complete the GMFM without the aid/orthosis, then

retest with aid/orthosis

 For repeat testing at a later dater, apply the same aid

at the same item number

 Aids/orthoses could have positive and negative

effects

 Mark an “A” for the aided score on the score sheet

Scoring with aids/orthotics

 Consider what information you are trying to obtain – is

it new orthoses or a walker or both

 Entire GMFM does not need to be repeated with aids

and orthoses

 It is assumed that aids are intended to assist in

standing or ambulating in standing

 Test only when standing is included in the item or

where it may be a part of transition between two
items
Please note !
 Only following items should be considered when
testing with aids –

Sitting - items 35, 36, 37

Standing – All items

Walking, running and jumping – All items provided criteria

of each score is observed (other than arms free)
e.g. – for item 69 - aid may used to assist in standing and
walking but other criteria of each score should be
observed

“1” – child may use aid to assist in walking forward <3

steps
Testing with orthoses

 Orthoses can be applied in any dimension

 With some children it would good to use in some
lower dimensions - that would help in knowing the
positive and the negative impact on gross motor
function

 It is expected that orthoses would great impact on

scores where the person has to stand “arms free”
Still wondering if you have to
test whole GMFM – 66?
Item -1
GMFM – 66 B&C

 GMFM-66 B&C used 16-17 items for testing, compared

to the GMFM-66-IS, which used 32-33 items

 Scores obtained from these 2 versions were highly

correlated when done on the same or different
occasions with the child

 Fewer items - when using the GMFM-66-B&C and

these items were more suitable to the individual child’s
abilities
 When you have difficulties in making decisions about
which item set to test when using the GMFM-66-IS
Advantage ?

 Using a shorter motor assessment will provide more

time to assess other aspects of the child and family

 Consider using a shorter version to document motor

function in a more efficient manner by assessing items
around a child’s ability level
GMFM - as an outcome
measure
 Surgery

 Drugs (botulinum toxin, intrathecal baclofen)

 Physical therapy (including ambulatory aids &

orthoses)

 Horseback riding

 Strength training & physical fitness

Testing
Equipments

 Need smooth floor, large firm exercise mat, toys for

motivation, large bench or table for cruising

 Five steps with railing

 Wheeled stool

 Tape

 Ruler
A. Lying and rolling
 SUP, HEAD IN MIDLINE: TURNS HEAD
1. WITH EXTREMITIES SYMMETRICAL
Score Description
0 Does not
maintain head in
midline
1 Maintains head
in midline 1-3 sec

2 Maintains head
in midline, turns
head with
extremities
asymmetrically
3 Turns head with
extremities
symmetrical
 SUP: BRINGS HANDS TO MIDLINE,
2. FINGERS ONE WITH THE OTHER
Score Description
0 Does not initiate
bilateral hands to
midline
1 Initiates bilateral
hands to midline

2 Brings hands to
front of the body,
does not finger
one with the
other
3 Brings hands to
mid-line fingers
one with the
other
 SUP: LIFTS HEAD 45 degrees
3.

Score Description
0 Does not initiate
neck flexion

1 Initiates neck
flexion but does
not lift head
2 Lifts head <45
deg

3 Lifts head 45 deg

 SUP: FLEXES R/L HIP & KNEE THROUGH
4/5. FULL RANGE
Score Description
0 Does not initiate
R/L hip & knee
flexion
1 Initiates R/L hip &
knee flexion

2 Flexes R/L hip &

knee through
partial range

3 Flexes R/L hip &

knee through full
range
 SUP: REACHES OUT WITH R/L ARM,
6/7. HAND CROSSES MIDLINE TOWARD TOY

Score Description
0 Does not initiate
reaching towards
midline
1 Initiates reaching
towards midline

2 Reaches out with

R/L arm, hand
does not cross
midline
3 Reaches out with
R/L arm, hand
crosses midline
toward toy
 SUP: ROLLS TO PR OVER R/L SIDE
8/9.

Score Description
0 Does not initiate
rolling

1 Initiates rolling

2 Rolls part way to

prone

3 Rolls to prone
over R/L side
 PR: LIFTS HEAD UPRIGHT
10.

Score Description
0 Does not initiate
reaching towards
midline
1 Initiates reaching
towards midline

2 Reaches out with

R arm, hand does
not cross midline

3 Reaches out with

R arm, hand
crosses midline
toward toy
B: Sitting
 PR ON FOREARMS: LIFTS HEAD
11. UPRIGHT, ELBOWS EXT., CHEST RAISED

Score Description
0 Does not initiate
head lifting

1 Initiates head
lifting chin does
not clear mat
2 Lifts head, does
not attain up
right, weight on
forearms
3 Lifts head upright,
elbows extended,
chest raised
 PR ON FOREARMS: WEIGHT ON R/L
12/13. FOREARM, FULLY EXTENDS OPPOSITE
ARM FORWARD
Score Description
0 Does not initiate
supporting wt. on
R/L forearm
1 Wt. on R/L forearm,
opposite arm
comes free does
not extend forward
2 Wt. on R/L forearm,
partially extends
opposite arm
forward
3 Wt. on R/L forearm,
fully extends
opposite arm
forward
 PR: ROLLS TO SUP OVER R/L SIDE
14/15.

Score Description
0 Does not initiate
rolling

1 Initiates rolling

2 Rolls part to supine

3 Rolls to supine over

R/L side
 PR: PIVOTS TO R/L 90 degrees
16/17. USING EXTREMITIES

Score Description
0 Does not initiate
pivot to R/L

1 Initiates pivot to
R/L using
extremities
2 Pivots to R/L <90
deg using
extremities

3 Pivots to R/L 90
deg using
extremities
 SUP, HANDS GRASPED BY EXAMINER:
18. PULLS SELF TO SITTING WITH HEAD
CONTROL
Score Description
0 Does not initiate
Head control
when pulled to
sitting
1 initiates Head
control when
pulled to sitting
2 Assists with pulling
to sitting, head
control present
part of the time
3 Pulls self to sitting
with head control
 SUP: ROLLS TO R/L SIDE, ATTAINS
19/20. SITTING

Score Description
0 Does not initiate
sitting from right
side lying

1 Roles to R/ L side,
sitting

2 Roles to R/ L side,
partially attains
sitting

3 Roles to R/L side,

attains sitting
 SIT ON MAT, SUPPORTED AT THORAX BY
21. THERAPIST: LIFTS HEAD UPRIGHT,
MAINTAINS 3 SECONDS
Score Description
0 Does not initiate
Head lift

1 Initiates head lift

2 Lifts head, does

not attain upright,
holds 3 seconds

3 Lifts head upright,

maintains 3
seconds
 SIT ON MAT, SUPPORTED AT THORAX BY
22. THERAPIST: LIFTS HEAD MIDLINE,
MAINTAINS 10 SECONDS
Score Description
0 Does not initiate
Head lift

1 Initiates head lift,

but does not
attain midline
2 Lifts head to
midline, maintains
< 10 seconds

3 Lifts head to
midline, maintains
10 seconds
 SIT ON MAT, ARM(S) PROPPING:
23. MAINTAINS, 5 SECONDS

Score Description
0 Does not
maintains with
arm(s) propping

1 Maintains < 1
second

2 Maintains 1-4
second

3 Maintains 5
second
 SIT ON MAT: MAINTAIN, ARMS FREE, 3
24. SECONDS

Score Description
0 Does not
maintain unless
both arms
propping

1 Maintain, one
arm propping

2 Maintains arms
free, < 3 seconds

3 Maintains arms
free, 3 seconds
 SIT ON MAT SMALL TOY IN FRONT:
25. LEANS FORWARD, TOUCHES TOY, RE-
ERECTS WITHOUT ARM PROPPING
Score Description
0 Does not initiate
leaning forward

1 Leans forward,
does not re-erect

2 Leans forward,
touches toy, re-
erects with arms
propping

3 Leans forward,
touches toy, re-
erects without
arms propping
 SIT ON MAT: TOUCHES TOY PLACED 45°
26/27. BEHIND CHILD’S R/L SIDE, RETURNS TO
START
Score Description
0 Does not initiate
touching toy

1 Initiates reaching
does not reach
behind

2 Reaches behind,
does not touch
toy or return to
start

3 Touches toy
placed 45 deg.
behind child’s
right / left side,
returns to start
 R/L SIDE SIT: MAINTAINS, ARMS
28/29. FREE, 5 SECONDS

Score Description
0 Does not
maintain R/L side
sitting

1 Maintains, both
arms propping, 5
seconds

2 Maintains, R/L
arm propping, 5
seconds

3 Maintains, arm
free, 5 seconds
 SIT ON MAT: LOWERS TO PR WITH
30. CONTROL

Score Description
0 Does not initiate
lowering to prone

1 Initiates lowering
to prone

2 Lowers to prone
but crashes

3 Lowers to prone
with control
 SIT ON MAT WITH FEET IN FRONT:
31/32. ATTAINS 4 POINT OVER R/L SIDE

Score Description
0 Does not initiate 4
point over R/L
side

1 Initiates 4 point
over R/L side

2 Partially attains 4
point over R/L
side

3 Attains 4 point
over R/L side
 SIT ON MAT: PIVOTS 90 degrees,
33. WITHOUT ARMS ASSISTING

Score Description
0 Does not pivoting

1 Initiates pivot

2 Pivots 90 degrees
with arms assisting

3 Pivots 90 degrees
without arms
assisting
 SIT ON BENCH: MAINTAINS, ARMS AND
34. FEET FREE, 10 SECONDS

Score Description
0 Does not
maintain sitting
on bench

1 Maintains, arms
propping and
feet supported,
10 seconds
2 Maintains, arms
free and feet
supported, 10
seconds

3 Maintains, arms
free and feet
free, 10 seconds
 STD: ATTAINS SIT ON SMALL BENCH
35.

Score Description
0 Does not initiate
sitting on small
bench

1 Initiates sitting on
small bench

2 Partially attains
sitting on small
bench

3 Attains sitting on
small bench
 ON THE FLOOR: ATTAINS SIT ON SMALL
36. BENCH

Score Description
0 Does not initiate
sitting on small
bench

1 Initiates sitting on
small bench

2 Partially attains
sitting on small
bench

3 Attains sitting on
small bench
 STD: ATTAINS SIT ON LARGE BENCH
37.

Score Description
0 Does not initiate
sitting on large
bench

1 Initiates sitting on
large bench

2 Partially attains
sitting on large
bench

3 Attains sitting on
large bench
C: crawling or kneeling
 PR: CREEPS FORWARD 1.8m (6')
38.

Score Description
0 Does not initiate
creeping forward

1 creeps forward
<60cms

2 creeps forward
60cms – 1.5m

3 creeps forward
1.8 m
 4 POINT: MAINTAINS, WEIGHT ON
39. HANDS AND KNEES, 10 SECONDS

Score Description
0 Does not
maintain weight
on hands and
knees
1 Maintains weight
on hands and
knees, < 3 sec

2 Maintains weight
on hands and
knees, 3 - 9 sec

3 Maintains weight
on hands and
knees, 10sec
 4 POINT: ATTAINS SIT ARMS FREE
40.

Score Description
0 Does not initiate
sitting

1 Initiates sitting

2 Attains sitting,
arm(s) propping

3 Attains sitting,
arms free
 PR: ATTAINS 4 POINT, WEIGHT ON
41. HANDS AND KNEES

Score Description
0 Does not initiate 4
point

1 Initiates 4 point

2 Partially attains 4
point

3 Attains 4 point,
weight on hands
and knees
 4 POINT: REACHES FORWARD WITH R/L
42/43. ARM, HAND ABOVE SHOULDER LEVEL

Score Description
0 Does not initiate
reaching forward
with R/L arm

1 Initiates reaching
forward with R/L
arm

2 Partially reaches
forward with R/L
arm

3 Reaches forward
with R/L arm,
hand above
shoulder level
 4 POINT: CRAWLS OR HITCHES
44. FORWARD 1.8m(6')

Score Description
0 Does not initiate
crawling or
hitching forward

1 Crawls or hitches
forward forward
<60cms

2 Crawls or hitches
forward 60cms –
1.5m

3 Crawls or hitches
forward 1.8 m
 4 POINT: CRAWLS RECIPROCALLY
45. FORWARD1.8m ( 6')

Score Description
0 Does not initiate
crawling forward
reciprocally

1 Crawls
reciprocally
forward forward
<60cms
2 Crawls
reciprocally
forward 60cms –
1.5m
3 Crawls
reciprocally
forward 1.8 m
 4 POINT: CRAWLS UP 4 STEPS ON
46. HANDS AND KNEES/FEET

Score Description
0 Does not initiate
crawling up 4
steps

1 Crawls up one
step on hands
and knees/feet

2 Crawls up two or
three step on
hands and
knees/feet
3 Crawls up four
step on hands
and knees/feet
 4 POINT: CRAWLS BACKWARDS DOWN
47. 4 STEPS ON HANDS AND KNEES/FEET

Score Description
0 Does not initiate
crawling
backwards down
steps
1 Crawls backward
down one step
on hands and
knees / feet
2 Crawls backward
down 2 or 3 step
on hands and
knees / feet
3 Crawls backward
down 4 step on
hands and knees
/ feet
 SIT ON MAT: ATTAINS HIGH KN USING
48. ARMS, MAINTAINS, ARMS FREE, 10
SECONDS
Score Description
0 When placed
does not
maintain, holding
on
1 When placed
maintains,
holding on 10 sec

2 Attains high
kneel, holding on,
maintains 10 sec

3 Attains high
kneel, using arms,
maintains arms
free for 10 sec
 HIGH KN: ATTAINS HALF KN ON R/L
49/50. KNEE USING ARMS, MAINTAINS, ARMS
FREE, 10 SECONDS
Score Description
0 When placed
does not
maintain, holding
on
1 When placed
maintains,
holding on 10 sec

2 Attains half kneel,

holding on,
maintains 10 sec

3 Attains half kneel,

using arms,
maintains arms
free for 10 sec
 HIGH KN: KN WALKS FORWARD 10
51. STEPS, ARMS FREE

Score Description
0 Does not initiate
kneel walking
forward

1 Kneel walks
forwards 10 steps,
two hands
holding on
2 Kneel walks
forwards 10 steps,
one hand holding
on
3 Kneel walks
forwards 10 steps,
arms free
D Standing
 52. ON THE FLOOR: PULLS TO STD AT
52. LARGE BENCH

Score Description
0 Does not initiate
pulling to stand

1 Initiates pulling to
stand

2 Partially pulls to
stand

3 Pulls to stand at
large bench
 STD: MAINTAINS, ARMS FREE, 3
53. SECONDS

Score Description
0 Does not
maintain standing
holding on

1 Maintains, 2
hands holding on,
3 sec

2 Maintains, one
hand holding on,
3 sec

3 Maintains, arms
free, 3 sec
 STD: HOLDING ON TO LARGE BENCH
54/55. WITH ONE HAND, LIFTS R/L FOOT, 3
SECONDS
Score Description
0 Does not initiate
lifting R/L foot

1 Holding on to
large bench with
2 hands, lifts R/L
foot < 3 sec
2 Holding on to
large bench with
2 hands, lifts R/L
foot, 3 sec

3 Holding on to
large bench with
1 hand, lifts R/L
foot, 3 sec
 STD: MAINTAINS, ARMS FREE, 20
56. SECONDS

Score Description
0 Does not
maintain
standing, arms
free

1 Maintains, arms
free < 3 sec

2 Maintains, arms
free 3 – 19 sec

3 Maintains, arms
free 20 sec
 STD: LIFTS R/L FOOT, ARMS FREE, 10
57/58. SECONDS

Score Description
0 Does not lift R/L
foot arms free

1 Lifts R/L foot

arms free < 3 sec

2 Lifts R/L foot

arms free 3 – 9
sec

3 Lifts R/L foot

arms free, 10 sec
 SIT ON SMALL BENCH: ATTAINS STD
59. WITHOUT USING ARMS

Score Description
0 Does not initiate
sanding

1 Initiates sanding

2 Attains standing
using arms

3 Attains standing
without using
arms
 HIGH KN: ATTAINS STD THROUGH HALF
60/61. KN ON R KNEE, WITHOUT USING ARMS

Score Description
0 Does not initiate
sanding

1 Initiates sanding

2 Attains standing
using arms

3 Attains standing
through half kneel
on R/L knee
without using
arms
 STD: LOWERS TO SIT ON FLOOR WITH
62. CONTROL, ARMS FREE

Score Description
0 Does not lower to
floor

1 Lowers to sitting
on floor, but
‘crashes’ down
2 Lowers to sitting
on floor with
control, using
arm(s) or holding
on
3 Lowers to sitting
on floor with
control, arms free
 STD: ATTAINS SQUAT, ARMS FREE
63.

Score Description
0 Does not initiate
squat

1 Initiates squat

2 Attains squat,
using arm(s) or
holding on

3 Attains squat,
arms free
 STD: PICKS UP OBJECT FROM FLOOR,
64. ARMS FREE, RETURNS TO STAND

Score Description
0 Does not initiate
picking up object
from the floor
1 Initiates picking
up object from
the floor
2 Picks up object
from the floor
using arm(s) or
holding on
3 Picks up object
from the floor ,
arms free, returns
to standing
E. Walking, running and
jumping
 STD, 2 HANDS ON LARGE BENCH:
65/66. CRUISES 5 STEPS TO R/L

Score Description
0 Does not initiate
cruising to R/L

1 Initiates cruising,
<1 complete step
to R/L
2 Cruises 1-4 steps
to R/L

3 Cruises 5steps to
R/L
 STD, 2 HANDS HELD: WALKS FORWARD
67. 10 STEPS

Score Description
0 Does not initiate
walking forward

1 Walks forward < 3

steps

2 Walks forward 3 -
9 steps

3 Walks forward 10
steps
 STD, 1 HAND HELD: WALKS FORWARD
68. 10 STEPS

Score Description
0 Does not initiate
walking forward

1 Walks forward < 3

steps

2 Walks forward 3 -
9 steps

3 Walks forward 10
steps
 STD: WALKS FORWARD 10 STEPS
69.

Score Description
0 Does not initiate
walking forward

1 Walks forward < 3

steps

2 Walks forward 3 -
9 steps

3 Walks forward 10
steps
 STD: WALKS FORWARD 10 STEPS,
70. STOPS, TURNS 180 deg, RETURNS

Score Description
0 Walks forward 10
steps, does not
stop without
falling
1 Walks forward 10
steps, does not
initiate turn
2 Walks forward 10
steps, stops, turns
< 180 deg
3 Walks forward 10
steps, stops, turns
180 deg, returns
 STD: WALKS BACKWARD 10 STEPS
71.

Score Description
0 Does not initiate
walking
backward
1 Walks backward
< 3 steps

2 Walks backward
3 - 9 steps

3 Walks backward
10 steps
 STD: WALKS FORWARD 10 STEPS,
72. CARRYING A LARGE OBJECT WITH 2
HANDS
Score Description
0 Does not initiate
walking, carrying
large object
1 Walks forward 10
steps, carrying
small object with
1 hand
2 Walks forward 10
steps, carrying
small object with
2 hands
3 Walks forward 10
steps, carrying
large object with
2 hands
 STD: WALKS FORWARD 10
73. CONSECUTIVE STEPS BETWEEN
PARALLEL LINES 20cm (8")APART
Score Description
0 Does not initiate
walking b/n ║lines
20 cm (8’) apart

1 Walks <3 consec

utive steps b/n ║
lines 20 cm(8’)
apart
2 Walks 3-9 consec
utive steps b/n ║
lines 20 cm (8’)
apart
3 Walks 10 consec
utive steps b/n ║
lines 20 cm(8’)
apart
 STD: WALKS FORWARD 10
74. CONSECUTIVE STEPS ON A STRAIGHT
LINE 2cm (3/4") WIDE
Score Description
0 Does not initiate
walking forward
on a straight line
2 cm wide
1 Walks <3 consec
utive steps

2 Walks 3-9 consec

utive steps

3 Walks 10 consec
utive steps
 STD: STEPS OVER STICK AT KNEE LEVEL,
75/76. R/L FOOT LEADING

Score Description
0 Does not initiate
stepping over
stick R/L foot
leading
1 Steps over sick 5-
7.5 cm high R/L
foot leading
2 Steps over sick at
mid-calf level R/L
foot leading

3 Steps over sick at

knee level R/L
foot leading
 STD: RUNS 4.5m (15’), STOPS & RETURNS
77.

Score Description
0 Does not initiate
running

1 Initiates running
by walking
quickly

2 Runs < 4.5 m (15ft)

3 Runs < 4.5 m

(15ft), stops and
returns
 STD: KICKS BALL WITH R/L FOOT
78/79.

Score Description
0 Does not initiate
kicking

1 Lifts R/L foot, does

not kick

2 Kicks ball with R/L

foot but falls

3 Kicks ball with R/L

foot
 STD: JUMPS 30cm (12") HIGH, BOTH
80. FEET SIMULTANEOUSLY

Score Description
0 Does not initiate
Jump

1 Jumps < 5 cm
high both feet
simultaneously
2 Jumps 5 – 28 cm
high both feet
simultaneously

3 Jumps 30 cm high
both feet
simultaneously
 STD: JUMPS FORWARD 30 cm (12"),
81. BOTH FEET SIMULTANEOUSLY

Score Description
0 Does not initiate
jumping forward,
both feet
simultaneously

1 Jumps forward
<5cm both feet
simultaneously
2 Jumps forward 5-
28 cm both feet
simultaneously
3 Jumps forward 30
cm both feet
simultaneously
 STD ON R/L FOOT: HOPS ON R/L FOOT
82. 10 TIMES WITHIN A 60cm (24") CIRCLE

Score Description
0 Does not initiate
hopping on R/L
foot
1 Hops on R/L foot
< 3 times within a
60 cm circle
2 Hops on R/L foot
3 – 9 times within
a 60 cm circle

3 Hops on R/L foot

10 times within a
60 cm circle
 STD, HOLDING 1 RAIL: WALKS
84/85. UP/WALKS DOWN 4 STEPS, HOLDING 1
RAIL, ALTERNATING FEET
Score Description
0 Does not initiate
walking up/down
steps, holding rail
1 Walks up/down 2
steps, holding rail,
same foot leads
consistently
2 Walks up/down 4
steps, holding rail,
alternating foot
inconsistently
3 Walks up/down 4
steps, holding rail
alternating foot
 STD: WALKS UP/WALKS DOWN 4 STEPS,
86/87. ALTERNATING FEET

Score Description
0 Does not initiate
walking up/down
steps, arms free
1 Walks up/down 2
steps, same foot
leads consistently
2 Walks up/down 4
steps, alternating
foot inconsistently

3 Walks up/down 4
steps, alternating
foot
 STD ON 15cm (6") STEP: JUMPS OFF,
88. BOTH FEET SIMULTANEOUSLY

Score Description
0 Does not initiate
jumping off step,
both feet
simultaneously
1 Jumps off step,
both feet simult -
aneously, but falls
2 Jumps off step,
both feet simult -
aneously, uses
hands on floor to
avoid falling
3 Jumps off, both
feet
simultaneously