Editorial: Outcome Measures in Rehabilitation Medicine

Ann Rehabil Med 2024;48(5):301-304

eISSN: 2234-0653
https://doi.org/10.5535/arm.240078

Motor Function Measurement in Children: Gross Motor

Function Measure (GMFM)
Ja Young Choi, MD, PhD

Department of Physical and Rehabilitation Medicine, Chungnam National University College of Medicine, Daejeon, Korea

The assessment and management of motor function in children, particularly those with cere- Received: August 21, 2024
Accepted: September 5, 2024
bral palsy (CP) and other motor disorders, are crucial components of pediatric rehabilitation.
The Gross Motor Function Measure (GMFM) and the Gross Motor Function Classification Correspondence:
System (GMFCS) are key tools that offer structured and reliable methods to assess and classify Ja Young Choi
Department of Physical and
motor abilities, guiding therapeutic decisions and tracking progress over time. The GMFM is a
Rehabilitation Medicine, Chungnam
standardized observational measure to evaluates and monitor changes in gross motor function, National University College of Medicine,
especially in children with CP [1]. It is based on typical developmental stages, with items de- 266 Munhwa-ro, Jung-gu, Daejeon
signed to be completed by typically developing children by age 5. 35015, Korea.
Tel: +82-42-338-2460
Fax: +82-42-338-2461
GMFM-88 and GMFM-66 E-mail: [email protected]
There are two versions of GMFM: the original 88-item measure (GMFM-88) and the 66-item
measure (GMFM-66) (Table 1). The GMFM-88 consists of five dimensions: (A) lying and roll-
ing; (B) sitting; (C) crawling and kneeling; (D) standing; (E) walking, running, and jumping.
Raw and percent scores are calculated for each of the five dimensions as well as a total score.
The GMFM-88 uses an ordinal scale, which can reduce sensitivity at extreme score ranges. To
overcome this, the GMFM-66 was developed using Rasch analysis, converting ordinal data into
an interval scale, arranging items by difficulty and ensuring equal scoring intervals. This im-
proves the accuracy and sensitivity of assessing motor function changes over time. The interrat-
er and intrarater reliability of the GMFM-88 total score, assessed with the intraclass correlation
coefficient (ICC), are both 0.99, while the interrater and intrarater reliability of the GMFM-66
are 0.98 and 0.99, respectively [1,2]. Validity was confirmed by a correlation of 0.82 between
GMFM-88 scale changes and the clinical judgments of blinded assessors [1]. Both versions of
the GMFM are reliable, valid, and responsive to change in children with CP.

Administration and best practice for GMFM

Children are rated on each item using a 4-point scale with specific descriptors: 0=does not initi-
ate; 1=initiates but completes less than 10%; 2=partially completes (10% to less than 100%); and
3=fully completes the task. The GMFM-66 score can be obtained using the Gross Motor Ability
Estimator (GMAE) scoring program [1]. During the assessment, all items the child can attempt
must be tested. If an item is not attempted, it is scored as 0 in GMFM-88, whereas in GMFM-
66, it is marked as not tested (NT) and the expected score can be estimated using the GMAE

© 2024 by Korean Academy of Rehabilitation Medicine

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/
licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Ja Young Choi Gross Motor Function Measure

Table 1. Comparison between GMFM-88 and GMFM-66

Feature GMFM-88 GMFM-66
Total items 88 items, 5 dimensions 66 items
Time to administer (min) 45–60 All 66 items: 30–45
IS, B&C: 20–30
Scoring system Dimensional score (%) Score (0–100) with 95% CI
Total score (%)
Scale property Ordinal scale Interval scale
Not tested item Scored 0 point Marked NT; GMAE software can estimate the
expected scores
Target population Children with CP and wide range of motor disorders Children with CP
Use of software Scoring typically done manually or through the GMAE-2 or GMAE-3 through the GMFM App+
GMFM App+
Use of assistive devices Allowed during the assessment Not allowed during the assessment
GMFM, Gross Motor Function Measure; IS, GMFM-66-Item Sets; B&C, GMFM-66-Basal & Ceiling; CI, confidence interval; NT, not tested; GMAE, Gross
Motor Ability Estimator; CP, cerebral palsy.

program. Each item can be tried up to three times, with the function according to age. GMFCS provides a broader, predic-
best performance recorded. Demonstrations are permitted, but tive measure of motor function over time, emphasizing daily
physical assistance is not, as the GMFM is an observational tool. performance. While GMFM is an evaluative measure, GMFCS
If a child becomes uncooperative, alternative methods like role is a classification tool not designed to measure changes, and
play or toys can help. While no specific certification is required should not be used as an outcome measure.
to use the GMFM, training has been shown to significantly im-
prove scoring consistency and accuracy [3]. The GMFM user’s Which GMFM version to choose?
manual was first published in 2002, and the most recent third The choice of which GMFM version to use depends on the
edition was published in 2021 [1]. The Korean version has been purpose of the assessment and the population. Since GMFM-
translated as the K-GMFM, demonstrating construct validity 66 excludes 22 items from GMFM-88 dimensions A, B, and C,
and inter-rater reliability [4]. GMFM-88 is recommended for very young children or func-
tioning at GMFCS Level V. Additionally, GMFM-66 does not
Target population permit the use of orthoses, shoes, or mobility aids, so GMFM-
The GMFM, originally validated for children with CP aged 5 88 should be used if these are required. GMFM-88 is also better
months to 16 years, has also been found valid and reliable for suited for assessing children with motor impairments from con-
children with Down syndrome [5,6], acquired brain injuries [7], ditions other than CP, such as Down syndrome and acquired
and osteogenesis imperfecta [8], Fukuyama congenital muscular brain injuries. The items of the GMFM-66 were weighted
dystrophy [9], and spinal muscular atrophy [10]. Additionally, a according to difficulty and were validated specifically for chil-
version adapted for children with acute lymphoblastic leukemia dren with CP, and may not be appropriate for other conditions.
(GMFM-ALL) has demonstrated strong validity and reliability Therefore, it is not recommended for use with non-CP chil-
[11]. However, before using GMFM with other populations, it dren. For a briefer method of GMFM-66 scoring, either item
is crucial to establish its reliability and validity for those specific set (GMFM-66-IS) or the basal & ceiling approach (GMFM-66-
groups. B&C) can be used [13]. For children with CP and cerebral vi-
sual impairment (CVI), the adapted version known as GMFM-
GMFCS and GMFM 88-CVI is recommended [14].
The GMFCS is a classification system for children with CP, cat-
egorizing their functional mobility and need for assistive devic- Applications in clinical practice and research
es into five levels, from minimal (Level I) to severe impairment One of the key strengths of the GMFM is its sensitivity to
(Level V) [12]. Based on GMFM-66, five distinct motor devel- changes in motor function over time. It is widely used to eval-
opment curves of GMFCS were created to stratify typical motor uate the impact of various interventions, such as rehabilitation

302 www.e-arm.org
 Ann Rehabil Med 2024;48(5):301-304

programs, medications, orthoses, and orthopedic or neurosur- Reliability and validity of the GMFM-66 in 0- to 3-year-old children
gical procedures, on gross motor function. The GMFM also with cerebral palsy. Am J Phys Med Rehabil 2006;85:141-7.
helps set short-term goals and plan interventions aimed at 3. Russell DJ, Rosenbaum PL, Lane M, Gowland C, Goldsmith CH,
improving motor function. When used alongside the GMFM- Boyce WF, et al. Training users in the Gross Motor Function Mea-
66 reference curves, it allows for a comparison of a child’s devel- sure: methodological and practical issues. Phys Ther 1994;74:630-6.
opment relative to peers of the same age and GMFCS level [12]. 4. Ko J, Kim M. Inter-rater reliability of the K-GMFM-88 and the
Beyond clinical applications, the GMFM plays a critical role GMPM for children with cerebral palsy. Ann Rehabil Med 2012;36:
in research, where it is used to assess the efficacy of new treat- 233-9.
ments, compare therapeutic approaches, and explore the natural 5. Palisano RJ, Walter SD, Russell DJ, Rosenbaum PL, Gémus M,
history of motor development in children with CP. The mini- Galuppi BE, et al. Gross motor function of children with down syn-
mum clinically important difference (MCID) for the GMFM drome: creation of motor growth curves. Arch Phys Med Rehabil
has been reported vary depending on the GMFCS level and the 2001;82:494-500.
research [1,15-17]. One study reported MCID values of 1.58 for 6. Russell D, Palisano R, Walter S, Rosenbaum P, Gemus M, Gowland
the GMFM-66 score and 1.29 for the GMFM-88, indicating a C, et al. Evaluating motor function in children with Down syn-
clinically significant improvement in gross motor function [17]. drome: validity of the GMFM. Dev Med Child Neurol 1998;40:693-
In conclusion, the GMFM is an objective measure for assess- 701.
ing motor function, tracking progress over time, and support- 7. Linder-Lucht M, Othmer V, Walther M, Vry J, Michaelis U, Stein S,
ing research in children with CP and other motor disorder. et al.; Gross Motor Function Measure-Traumatic Brain Injury Study
While GMFM effectively measure the quantitative aspects of Group. Validation of the Gross Motor Function Measure for use in
motor function, evaluating the quality of movement remains a children and adolescents with traumatic brain injuries. Pediatrics
challenge. Selecting the appropriate tool based on the evalua- 2007;120:e880-6.
tion’s purpose and the characteristics of the target population is 8. Ruck-Gibis J, Plotkin H, Hanley J, Wood-Dauphinee S. Reliability of
crucial. the Gross Motor Function Measure for children with osteogenesis
imperfecta. Pediatr Phys Ther 2001;13:10-7.
CONFLICTS OF INTEREST 9. Sato T, Adachi M, Nakamura K, Zushi M, Goto K, Murakami T, et
al. The Gross Motor Function Measure is valid for Fukuyama con-
No potential conflict of interest relevant to this article was re- genital muscular dystrophy. Neuromuscul Disord 2017;27:45-9.
ported. 10. Nelson L, Owens H, Hynan LS, Iannaccone ST, AmSMART Group.
The Gross Motor Function Measure is a valid and sensitive out-
FUNDING INFORMATION come measure for spinal muscular atrophy. Neuromuscul Disord
2006;16:374-80.
This work was supported by the National Research Foundation 11. Wright BScPT M, Fairfield SM. Adaptation and psychometric
of Korea (NRF) grant funded by the Korea government (MSIT) properties of the Gross Motor Function Measure for children re-
(#2020R1C1C1010794). ceiving treatment for acute lymphoblastic leukemia. Rehabil Oncol
2007;25:14-20.
ORCID 12. Rosenbaum PL, Walter SD, Hanna SE, Palisano RJ, Russell DJ,
Raina P, et al. Prognosis for gross motor function in cerebral palsy:
Ja Young Choi, https://orcid.org/0000-0001-9829-8922 creation of motor development curves. JAMA 2002;288:1357-63.
13. Avery LM, Russell DJ, Rosenbaum PL. Criterion validity of the
REFERENCES GMFM-66 item set and the GMFM-66 basal and ceiling ap-
proaches for estimating GMFM-66 scores. Dev Med Child Neurol
1. Russell DJ, Wright M, Rosenbaum PL, Avery LM. Gross Motor 2013;55:534-8.
Function Measure (GMFM-66 & GMFM-88) user’s manual. 3rd ed. 14. Salavati M, Rameckers EA, Waninge A, Krijnen WP, Steenbergen
Mac Keith Press; 2021. p. 1-320. B, van der Schans CP. Gross motor function in children with spastic
2. Wei S, Su-Juan W, Yuan-Gui L, Hong Y, Xiu-Juan X, Xiao-Mei S. cerebral palsy and cerebral visual impairment: a comparison be-

www.e-arm.org 303
Ja Young Choi Gross Motor Function Measure

tween outcomes of the original and the cerebral visual impairment 16. Oeffinger D, Bagley A, Rogers S, Gorton G, Kryscio R, Abel M, et
adapted Gross Motor Function Measure-88 (GMFM-88-CVI). Res al. Outcome tools used for ambulatory children with cerebral palsy:
Dev Disabil 2017;60:269-76. responsiveness and minimum clinically important differences. Dev
15. Storm FA, Petrarca M, Beretta E, Strazzer S, Piccinini L, Maghini Med Child Neurol 2008;50:918-25.
C, et al. Minimum clinically important difference of gross motor 17. Wang HY, Yang YH. Evaluating the responsiveness of 2 versions of
function and gait endurance in children with motor impairment: the Gross Motor Function Measure for children with cerebral palsy.
a comparison of distribution-based approaches. Biomed Res Int Arch Phys Med Rehabil 2006;87:51-6.
2020;2020:2794036.

304 www.e-arm.org