Improved Scaling of the Gross Motor Function Measure for Children With Cerebral Palsy: Evidence of Reliability and Validity.The Gross Motor Function Measure (GMFM GMFM Gross Motor Function Measure GMFM Gauss-Markov Fading Model ) is a criterion-referenced observational measure that was developed and validated val·i·date tr.v. val·i·dat·ed, val·i·dat·ing, val·i·dates 1. To declare or make legally valid. 2. To mark with an indication of official sanction. 3. to assess children with cerebral palsy cerebral palsy (sərē`brəl pôl`zē), disability caused by brain damage before or during birth or in the first years, resulting in a loss of voluntary muscular control and coordination. (CP).[1] The original GMFM was modified in 1990 based on feedback from the clinicians involved in the validation See validate. validation - The stage in the software life-cycle at the end of the development process where software is evaluated to ensure that it complies with the requirements. study. Three items were added to the original 85-item measure in an effort to allow the skills tested by those items to be assessed bilaterally bi·lat·er·al adj. 1. Having or formed of two sides; two-sided. 2. Affecting or undertaken by two sides equally; binding on both parties: a bilateral agreement; bilateral negotiations. . Prior to re-establishing the reliability of the GMFM measurements with the 3 items added, administration and scoring guidelines guidelines, n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. were developed. The reliability of scores obtained with the 88-item GMFM was established with the revised guidelines using videotaped examples, and this reliability was sufficiently high to permit the revised guidelines to replace the original guidelines (intraclass correlation In statistics, the intraclass correlation (or the intraclass correlation coefficient[1]) is a measure of correlation, consistency or conformity for a data set when it has multiple groups. coefficient coefficient /co·ef·fi·cient/ (ko?ah-fish´int) 1. an expression of the change or effect produced by variation in certain factors, or of the ratio between two different quantities. 2. [ICC ICC See: International Chamber of Commerce ] = .90)[2] Further evidence of the reliability of measurements obtained with the 88-item GMFM has been established by several investigators for its use with children with CP[3-5] and for children with Down syndrome Down syndrome, congenital disorder characterized by mild to severe mental retardation, slow physical development, and characteristic physical features. Down syndrome affects about 1 in every 730 live births and occurs in all populations equally. .[6] The 88 items of the GMFM are measured by observation of the child and scored on a 4-point ordinal scale ordinal scale (or´d  n (0=does not initiate, 1=initiates
[is less than] 10% of activity, 2=partially completes 10% to [is less
than] 100% of activity, 3=completes activity). The items are weighted
equally and grouped into 5 dimensions: (1) lying and rolling (17 items),
(2) sitting (20 items), (3) crawling and kneeling (14 items), (4)
standing (13 items), and (5) walking, running, jumping (24 items). By
the age of 5 years, children without motor delays can generally
accomplish all of the items of the GMFM.[1] Scores for each dimension
are expressed as a percentage of the maximum score for that dimension.
The total score is obtained by averaging the percentage scores across
the 5 dimensions. The original intent of the GMFM developers was to have
one measure that could be used for children across a spectrum of ability
levels in order to make it possible for children with different gross
motor abilities to enter clinical trials and be assessed with the same
measurement tool.[2] In addition, the measure needed to be useful for
tracking individual children over time. Although items tend to increase
in difficulty within a dimension, their ordering was based on clinical
judgment and the literature, and the order had not been substantiated
with data-based adj. 1. relying on observation or experiment.Adj. 1. data-based - relying on observation or experiment; "experimental results that supported the hypothesis" observational, experimental evidence, Items were grouped into dimensions primarily for ease of administration. Evidence of construct validity construct validity, n the degree to which an experimentally-determined definition matches the theoretical definition. of the measure's capacity to detect change in motor function over time was supported by several analyses of the scores of children who were administered the GMFM twice by the same therapist over a 5- to 7-month interval.[1] For children with CP, change scores on the GMFM were correlated cor·re·late v. cor·re·lat·ed, cor·re·lat·ing, cor·re·lates v.tr. 1. To put or bring into causal, complementary, parallel, or reciprocal relation. 2. with parents' judgments of change (r=.54), the child's treating therapist's judgment of change (r =.65), and ratings of change made by therapists who were familiar with the GMFM but unfamiliar with the children by viewing pairs of videotapes, which were in random order (r=.82). As hypothesized in the original validation study,[1] the change in GMFM scores was greatest in children recovering from acute head injury, less in preschool-aged children without motor delays, and least in children with CP. For the children with CP, the amount of change in GMFM scores was related to their age and severity of motor disability. The GMFM scores of children who were young ([is less than] 3 years of age) and had "mild" CP changed more than the scores of children who were older ([is greater than] 6 years of age) and had "severe" CP. Furthermore, children who were judged by both their parents and therapists not to have changed did not demonstrate a change in GMFM scores, whereas children who were judged by both their parents and therapists to have changed demonstrated an increase in GMFM scores. Bjornson Björn·son , Björnstjerne 1832-1910. Norwegian writer who sought to revive the literary language and character of Norway. His works include the novel The Fisher Girl (1868) and the epic poem Arnljot Gelline (1870). and colleagues[7] replicated the original GMFM validation study with children with spastic diplegia spastic diplegia A feature of cerebral palsy, which affects both legs, often unequally, characterized by hip flexion and internal rotation, due to the overactivity of the iliopsoas, rectus femorus, hip adductors; knee extension, due to overactivity of hamstrings, and quadriplegia quadriplegia: see paraplegia. and provided support for the construct validity of measurements of change in motor function obtained with the GMFM over 12- and 24-month periods. The responsiveness of the GMFM for infants under the age of 24 months with CP and motor delay has also been established.[8] Researchers have used the GMFM with children with CP to assess the effectiveness of rhizotomy rhizotomy /rhi·zot·o·my/ (ri-zot´ah-me) interruption of a cranial or spinal nerve root, such as by chemicals or radio waves. percutaneous rhizotomy ,[9-11] intrathecal intrathecal /in·tra·the·cal/ (-the´k'l) within a sheath; through the theca of the spinal cord into the subarachnoid space. Intrathecal baclofen baclofen /bac·lo·fen/ (bak´lo-fen?) an analogue of ? used to treat severe spasticity. bac·lo·fen n. ,[12,13] physical therapy,[14,15] horseback riding horseback riding: see equestrianism. ,[16] therapeutic electrical stimulation,[17] orthoses,[18,19] strength training,[20,21] and muscle tendon tendon, tough cord composed of closely packed white fibers of connective tissue that serves to attach muscles to internal structures such as bones or other muscles. surgery,[22] as well as to determine the correlation between these measurements and measurements of gait and physical fitness.[23-26] As the GMFM has been used in a variety of clinical and research situations, its limitations have become more apparent. Some users of the GMFM have chosen to administer only those dimensions that are most relevant to their clients' current level of functional needs. This selective use of the GMFM allows fewer items to be administered and increases the measure's responsiveness to change by eliminating items that are not relevant to the therapeutic intervention A procedure used in a lawsuit by which the court allows a third person who was not originally a party to the suit to become a party, by joining with either the plaintiff or the defendant. or are unlikely to change as a result of intervention. However, the evidence for the reliability and the validity of the dimension scores is generally not as strong as for the measure as a whole.[1] Another limitation has been the interpretation of the GMFM total score. Children with different skills and abilities within and between dimensions can receive the same total score. A further limitation is that scores of children functioning in the middle of the scale have greater potential to change than scores of children whose initial assessment is either very low or very high because more items are in the middle of the scale than at the extremes. In an effort to improve the interpretability and the clinical usefulness of the GMFM, we applied the Rasch model Rasch models are used for analysing data from assessments to measure things such as abilities, attitudes, and personality traits. For example, they may be used to estimate a student's reading ability from answers to questions on a reading assessment, or the extremity of a person's of item analysis to the GMFM.[27] Rasch analysis uses a one-parameter logistic lo·gis·tic also lo·gis·ti·cal adj. 1. Of or relating to symbolic logic. 2. Of or relating to logistics. [Medieval Latin logisticus, of calculation model to derive an equal interval measure from the raw score.[28] Rasch analysis originated in the areas of education and psychology, and during the last 5 to 10 years has been used to construct and validate To prove something to be sound or logical. Also to certify conformance to a standard. Contrast with "verify," which means to prove something to be correct. For example, data entry validity checking determines whether the data make sense (numbers fall within a range, numeric data measures used in rehabilitation rehabilitation: see physical therapy. .[29-33] There are several reasons to apply the Rasch scaling to the GMFM. First, the items can be arranged in order of relative difficulty (hierarchical structure See hierarchical. ). Second, it makes it possible to create interval scales from what are believed to be ordinal scales, because scores take into account how much more difficult one item is to accomplish than the previous item. Third, Rasch analysis allows the elimination of items that do not fit the unidimensional u·ni·di·men·sion·al adj. One-dimensional. Adj. 1. unidimensional - relating to a single dimension or aspect; having no depth or scope; "a prose statement of fact is unidimensional, its value being measured wholly in terms construct (ie, misfitting items). The unidimensionality assumption is met when the items of the test demonstrate that only one ability is being measured (in our case, gross motor ability). Fourth, Rasch analysis allows calculation of a total score when not all items are administered. All of these factors would lead to improved scoring and interpretation of the GMFM. Although Rasch scaling has potential advantages, potential challenges also needed to be considered. These challenges include the tact that the GMFM is already in widespread use and a revised measure would require modification of the manual and training materials. In addition, because Rasch analysis is used primarily to create unidimensional measures, it could identify items for removal that do not fit the model but are considered clinically relevant. Of major concern was whether the removal of items would affect the GMFM's responsiveness to change and require new validation of the modified scale. A computer program would also be necessary to analyze and interpret scores based on Rasch scaling. With these considerations in mind, our group applied the Rasch partial credit model to the GMFM.[27] The Rasch partial credit model does not make any assumptions about the difficulty of each response option, either within an item or between items. For example, it does not assume that the difficulty of going from a score of 1 to a score of 2 is the same difficulty as going from a score of 2 to a score of 3 or that the difficulty of going from a score of 1 to a score of 2 is the same for different items. Rasch modeling helped us to identify 66 items from the original 88-item GMFM that form a unidimensional hierarchical A structure made up of different levels like a company organization chart. The higher levels have control or precedence over the lower levels. Hierarchical structures are a one-to-many relationship; each item having one or more items below it. scale, the GMFM-66. Table 1 lists the original 88 GMFM items and indicates which items we removed for the GMFM-66. Table 1. Listing of Gross Motor Function Measure (GMFM) Items Indicating Items Removed, Mean Difficulty Estimates, and Standard Errors(a) Dimension A: Lying & Rolling Difficulty SE 1 - SUP, HEAD IN MIDLINE: TURNS HEAD WITH EXTREMITIES SYMMETRICAL Removed 2 - SUP: BRINGS HANDS TO MIDLINE, FINGERS ONE WITH THE OTHER 22.90 0.59 3 - SUP: LIFT'S HEAD 45 [degrees] Removed 4 - SUP: FLEXES R HIP & KNEE THROUGH FULL RANGE Removed 5 - SUP: FLEXES L HIP AND KNEE THROUGH FULL RANGE Removed 6 - SUP: REACHES OUT WITH R ARM, HAND CROSSES MIDLINE TOWARD TOY 24.66 0.59 7 - SUP: REACHES OUT WITH L ARM, HAND CROSSES MIDLINE TOWARD TOY 24.54 0.59 8 - SUP: ROLLS TO PR OVER R SIDE Removed 9 - SUP: ROLLS TO PR OVER L SIDE Removed 10 - PR: LIFTS HEAD UPRIGHT 17.25 0.71 11 - PR ON FOREARMS: LIFTS HEAD UPRIGHT, ELBOWS EXT, CHEST RAISED Removed 12 - PR ON FOREARMS: WEIGHT ON R FOREARM, FULLY EXTENDS OPPOSITE ARM FORWARD Removed 13 - PR ON FOREARMS: WEIGHT ON L FOREARM, FULLY EXTENDS OPPOSITE ARM FORWARD Removed 14 - PR: ROLLS TO SUP OVER R SIDE Removed 15 - PR: ROLLS TO SUP OVER L SIDE Removed 16 - PR: PIVOTS TO R 90 [degrees] USING EXTREMITIES Removed 17 - PR: PIVOTS TO L 90 [degrees] USING EXTREMITIES Removed Dimension B: Sitting Difficulty SE 18 - SUP, HANDS GRASPED BY EXAMINER: PULLS SELF TO SITTING WITH HEAD CONTROL 24.31 0.59 19 - SUP: ROLLS TO R SIDE, ATTAINS SITTING Removed 20 - SUP: ROLLS TO L SIDE, ATTAINS SITTING Removed 21 - SIT ON MAT, SUPPORTED AT THORAX BY THERAPIST: LIFTS HEAD UPRIGHT, MAINTAINS 3 SEC 13.07 0.88 22 - SIT ON MAT, SUPPORTED AT THORAX BY THERAPIST: LIFTS HEAD TO MIDLINE, MAINTAINS 10 SEC 18.13 0.71 23 - SIT ON MAT, ARM(S) PROPPING: MAINTAINS, 5 SEC 23.07 0.59 24 - SIT ON MAT, MAINTAINS, ARMS FREE, 3 SEC 30.08 0.53 25 - SIT ON MAT WITH SMALL TOY IN FRONT: LEANS FORWARD, TOUCHES TOY, RE-ERECTS WITHOUT ARM PROPPING 33.84 0.53 26 - SIT ON MAT: TOUCHES TOY PLACED 45 [degrees] BEHIND CHILD'S R SIDE, RETURNS TO START 37.67 0.53 27 - SIT ON MAT: TOUCHES TOY PLACED 45 [degrees] BEHIND CHILD'S L SIDE, RETURNS TO START 37.08 0.53 28 - R SIDE SIT: MAINTAINS, ARMS FREE, 5 SEC Removed 29 - L SIDE SIT: MAINTAINS, ARMS FREE, 5 SEC Removed 30 - SIT ON MAT: LOWERS TO PR WITH CONTROL 38.02 0.53 31 - SIT ON MAT WITH FEET IN FRONT: ATTAINS 4 POINT OVER R SIDE 44.20 0.47 32 - SIT ON MAT WITH FEET IN FRONT: ATTAINS 4 POINT OVER L SIDE 44.97 0.47 33 - SIT ON MAT: PIVOTS 90 [degrees], WITHOUT ARMS ASSISTING Removed 34 - SIT ON BENCH: MAINTAINS, ARMS AND FEET FREE, 10 SEC 36.55 0.53 35 - STD: ATTAINS SIT ON SMALL BENCH 47.62 0.47 36 - ON THE FLOOR: ATTAINS IT ON SMALL BENCH 45.03 0.47 37 - ON THE FLOOR: ATTAINS SIT ON LARGE BENCH 47.85 0.47 Dimension C: Crawling & Kneeling Difficulty SE 38 - PR: CREEPS FORWARD 6' Removed 39 - 4 POINT: MAINTAINS WEIGHT ON HANDS AND KNEES, 10 SEC 38.79 0.53 40 - 4 POINT: ATTAINS SIT ARMS FREE 43.20 0.47 41 - PR: ATTAINS 4 POINT, WEIGHT ON HANDS AND KNEES 39.43 0.53 42 - 4 POINT: REACHED FORWARD WITH R ARM, HAND ABOVE SHOULDER LEVEL 44.32 0.47 43 - 4 POINT: REACHED FORWARD WITH L ARM, HAND ABOVE SHOULDER LEVEL 44.67 0.47 44 - 4 POINT: CRAWLS OR HITCHES FORWARD 6' 42.44 0.47 45 - 4 POINT: CRAWLS RECIPROCALLY FORWARD 6' 46.56 0.47 46 - 4 POINT: CRAWLS UP 4 STEPS ON HANDS AND KNEES/FEET 47.32 0.47 47 - 4 POINT: CRAWLS BACKWARDS DOWN 4 STEPS ON HANDS AND KNEES/FEET Removed 48 - SIT ON MAT: ATTAINS HIGH KN USING ARMS, MAINTAINS, ARMS FREE, 10 SEC 45.44 0.47 49 - HIGH KN: ATTAINS HALF KN ON R KNEE USING ARMS, MAINTAINS, ARMS FREE, 10 SEC Removed 50 - HIGH KN: ATTAINS HALF KN ON L KNEE USING ARMS, MAINTAINS, ARMS FREE, 10 SEC Removed 51 - HIGH KN: KN WALKS FORWARD 10 STEPS, ARMS FREE 53.03 0.47 Dimension D: Standing Difficulty SE 52 - ON THE FLOOR: PULLS TO STD AT LARGE BENCH 43.14 0.47 53 - STD: MAINTAINS, ARMS FREE, 3 SEC 46.97 0.47 54 - STD: HOLDING ON TO LARGE BENCH WITH ONE HAND, LIFTS R FOOT, 3 SEC 50.68 0.47 55 - STD: HOLDING ON TO LARGE BENCH WITH ONE HAND, LIFTS L FOOT, 3 SEC 50.97 0.47 56 - STD: MAINTAINS, ARMS FREE, 20 SEC 54.56 0.47 57 - STD: LIFTS L FOOT, ARMS FREE, 10 SEC 74.81 0.59 58 - STD: LIFTS R FOOT, ARMS FREE, 10 SEC 74.63 0.59 59 - SIT ON SMALL BENCH: ATTAINS STD WITHOUT USING ARMS 52.09 0.47 60 - HIGH KN: ATTAINS STD THROUGH HALF KN ON R KNEE, WITHOUT USING ARMS 61.04 0.53 61 - HIGH KN: ATTAINS STD THROUGH HALF KN ON L KNEE, WITHOUT USING ARMS 61.57 0.53 62 - STD: LOWERS TO SIT ON FLOOR WITH CONTROL, ARMS FREE 57.39 0.53 63 - STD: ATTAINS SQUAT, ARMS FREE 58.15 0.53 64 - STD: PICKS UP OBJECT FROM FLOOR, ARMS FREE, RETURNS TO STAND 55.03 0.47 Dimension E: Walking, Running & Jumping Difficulty SE 65 - STD, 2 HANDS ON LARGE BENCH: CRUISES 5 STEPS TO R 45.50 0.47 66 - STD, 2 HANDS ON LARGE BENCH: CRUISES 5 STEPS TO L 45.50 0.47 67 - STD, 2 HANDS HELD: WALKS FORWARD 10 STEPS 40.67 0.53 68 - STD, 1 HAND HELD: 'WALKS FORWARD 10 STEPS 49.15 0.47 69 - STD: WALKS FORWARD 10 STEPS 55.44 0.53 70 - STD: WALKS FORWARD 10 STEPS, STOPS, TURNS 180 [degrees], RETURNS 57.39 0.53 71 - STD: WALKS BACKWARD 10 STEPS 61.27 0.59 72 - STD: WALKS FORWARD 10 STEPS CARRYING A LARGE OBJECT WITH 2 HANDS 57.68 0.59 73 - STD: WALKS FORWARD 10 CONSECUTIVE STEPS BETWEEN PARALLEL LINES, 8" APART 66.16 0.59 74 - STD: WALKS FORWARD 10 CONSECUTIVE STEPS ON A STRAIGHT LINE 3/4" WIDE 73.04 0.59 75 - STD: STEPS OVER STICK AT KNEE LEVEL, R FOOT LEADING 67.27 0.59 76 - STD: STEPS OVER STICK AT KNEE LEVEL, L FOOT LEADING 67.16 0.59 77 - STD: RUNS 15 FEET, STOPS AND RETURNS 65.10 0.59 78 - STD: KICKS BALL WITH R FOOT 59.68 0.59 79 - STD: KICKS BALL WITH L FOOT 60.15 0.59 80 - STD: JUMPS 12" HIGH, BOTH FEET SIMULTANEOUSLY 74.75 0.59 81 - STD: JUMPS FORWARD 12", BOTH FEET SIMULTANEOUSLY 69.45 0.59 82 - STD ON R FOOT: HOPS ON R FOOT 10 TIMES WITHIN A 24" CIRCLE 83.93 0.65 83 - STD ON L FOOT: HOPS ON L FOOT 10 TIMES WITHIN A 24" CIRCLE 83.76 0.65 84 - STD, HOLDING 1 RAIL: WALKS UP 4 STEPS, HOLDING 1 RAIL, ALTERNATING FEET 62.74 0.59 85 - STD, HOLDING 1 RAIL: WALKS DOWN 4 STEPS, HOLDING 1 RAIL, ALTERNATING FEET 66.57 0.59 86 - STD: WALKS UP 4 STEPS, ALTERNATING FEET 72.40 0.59 87 - STD: WALKS DOWN 4 STEPS, ALTERNATING FEET 77.28 0.59 88 - STD ON 6" STEP: JUMPS OFF, BOTH FEET SIMULTANEOUSLY 70.04 0.59 (a) SUP "What's up?" See digispeak. = supine supine /su·pine/ (soo´pin) lying with the face upward, or on the dorsal surface. su·pine adj. 1. Lying on the back; having the face upward. 2. , PR = prone, R = right, L = left, SIT = sitting, STD (Subscriber Trunk Dialing) Long distance dialing outside of the U.S. that does not require operator intervention. STD prefix codes are required and billing is based on call units, which are a fixed amount of money in the currency of that country. = standing, Kn = kneeling, EXT EXT Extension EXT Extended EXT External Ext Extraction EXT Exterior (screenwriting) EXT Extinguisher EXT Extruded EXT Extinguished EXT Exeter, England, United Kingdom - Exeter (Airport Code) = extended. An item's difficulty corresponds to the ability required to receive a score of 3 on that item. "Removed" refers to items that were removed from the original 88-item GMFM by the Rasch analysis and are no longer part of the GMFM-66 scoring. Following modification of the scale, we believed that it was important to assess the psychometric psy·cho·met·rics n. (used with a sing. verb) The branch of psychology that deals with the design, administration, and interpretation of quantitative tests for the measurement of psychological variables such as intelligence, aptitude, and properties of the GMFM-66. One of the key concerns in reducing the number of items in the GMFM was not to lose the measure's responsiveness to change over time. We also wanted to determine whether the GMFM-66 is stable over a short period of time, when true change in gross motor function is not expected to occur. We hypothesized that (1) test-retest reliability test-retest reliability Psychology A measure of the ability of a psychologic testing instrument to yield the same result for a single Pt at 2 different test periods, which are closely spaced so that any variation detected reflects reliability of the instrument for the GMFM-66 would not differ from the test-retest reliability of data obtained with the original 88-item GMFM, (2) children with CP would demonstrate an increase in GMFM-66 scores over 12 months, and (3) children classified as younger and having "mild" CP would demonstrate a greater change score on the GMFM-66 over 12 months compared with children classified as older and having "severe" CP. The purposes of this article are (1) to report the psychometric properties of reliability, validity, and responsiveness to change of data obtained with the GMFM-66 and (2) to discuss the research and clinical implications of the GMFM-66 for users of the measure. Method Data used for the Rasch analyses came from the cross-sectional cross section also cross-sec·tion n. 1. a. A section formed by a plane cutting through an object, usually at right angles to an axis. b. A piece so cut or a graphic representation of such a piece. 2. time 1 GMFM assessments of 537 children stratified stratified /strat·i·fied/ (strat´i-fid) formed or arranged in layers. strat·i·fied adj. Arranged in the form of layers or strata. by age and severity of motor disability using the Gross Motor Function Classification System (GMFCS GMFCS Guided Missile Fire Control System ).[34] The children were participating in a large longitudinal study longitudinal study a chronological study in epidemiology which attempts to establish a relationship between an antecedent cause and a subsequent effect. See also cohort study. of motor development in children with cerebral palsy. This group included a subset A group of commands or functions that do not include all the capabilities of the original specification. Software or hardware components designed for the subset will also work with the original. of 228 children who had had a second GMFM assessment 12 months later. Children (N=2,108) were eligible for the longitudinal study if they had a diagnosis of CP and were on the case list of 1 of 18 publicly funded children's treatment centers in the province of Ontario, Canada, as of June 1, 1996. Children were not included in the study if they had other neuromotor disorders such as spina spina /spi·na/ (spi´nah) pl. spi´nae [L.] spine. spina bi´fida a developmental anomaly marked by defective closure of the vertebral arch, through which the meninges may (s. bifida, neuromuscular disease Neuromuscular disease is a very broad term that encompasses many diseases and ailments that either directly (via intrinsic muscle pathology) or indirectly (animal muscle in general. Neuromuscular diseases are those that affect the muscles and/or their nervous control. , or musculoskeletal musculoskeletal /mus·cu·lo·skel·e·tal/ (-skel´e-t'l) pertaining to or comprising the skeleton and muscles. mus·cu·lo·skel·e·tal adj. Relating to or involving the muscles and the skeleton. disease or if they had had a selective dorsal rhizotomy Dorsal rhizotomy A surgical procedure that cuts nerve roots to reduce spasticity in affected muscles. Mentioned in: Cerebral Palsy or intrathecal baclofen prior to recruitment for the study. Information on the sample characteristics, including sex, age, type and distribution of CP, and severity of motor disability (GMFCS level), are listed in Table 2. The characteristics of the subset of 228 children whose scores were used to examine the responsiveness of the GMFM-66 are presented in Table 3. Table 2. Sample Characteristics by Mean 66-Item Gross Motor Function Measure (GMFM-66) Score and Age (N=537)
Baseline GMFM-66 Score
[bar]X SD Minimum Maximum
Type of cerebral palsy
Spastic 53.93 23.46 0.00 100.00
Dystonic/athetotic 37.35 14.96 17.01 67.75
Ataxic 60.84 11.75 41.79 74.75
Low tone-hypotonic 47.87 23.02 0.00 100.00
Mixed 40.90 21.19 0.00 100.00
Distribution
Leg dominant 62.21 16.04 14.83 100.00
Three-limb dominant 47.80 14.67 22.66 89.70
Four-limb dominant 33.57 17.00 0.00 100.00
Right hemiplegic 75.08 15.81 43.26 100.00
Left hemiplegic 78.62 16.71 34.84 100.00
Missing
GMFCS(a) level
I 78.06 13.29 45.91 100.00
II 60.92 11.16 34.84 89.70
III 49.98 7.07 29.31 67.04
IV 37.94 7.77 19.72 52.85
V 20.63 8.66 0.00 46.67
Sex
Male 52.04 23.85 0.00 100.00
Female 51.18 22.38 0.00 100.00
Age (y) at Baseline
[bar]X SD Minimum Maximum N
Type of cerebral palsy
Spastic 6.48 2.79 0.95 12.71 411
Dystonic/athetotic 5.11 2.15 1.67 9.23 32
Ataxic 6.42 2.88 2.13 10.02 14
Low tone-hypotonic 6.67 2.52 1.71 10.66 27
Mixed 6.61 2.73 1.62 11.06 53
Distribution
Leg dominant 6.41 2.69 0.95 11.74 183
Three-limb dominant 6.63 2.45 1.81 11.06 53
Four-limb dominant 6.45 2.80 1.52 12.71 215
Right hemiplegic 6.09 3.17 1.72 11.57 43
Left hemiplegic 6.52 2.80 1.59 11.82 42
Missing 1
GMFCS(a) level
I 6.52 2.83 1.59 11.82 155
II 5.89 2.77 1.69 10.78 70
III 6.68 2.83 0.95 11.73 104
IV 6.38 2.63 1.62 11.74 105
V 6.45 2.68 1.68 12.71 103
Sex
Male 6.38 2.84 0.95 12.71 299
Female 6.49 2.65 1.52 11.82 238
(a) GMFCS = Gross Motor Function Classification System.[34] Table 3. Sample Characteristics by Mean Baseline The horizontal line to which the bottoms of lowercase characters (without descenders) are aligned. See typeface. baseline - released version 66-item Gross Motor Function Measure (GMFM-66) Score and Age of Children Used in Responsiveness Analysis (n=228)
Baseline GMFM-66 score
[bar]X SD Minimum Maximum
Type of cerebral palsy
Spastic 54.79 21.74 0.00 100.00
Dystonic/athetotic 39.47 13.78 17.01 60.39
Ataxic 66.99 8.49 54.15 74.75
Low tone-hypotonic 47.43 18.82 4.12 73.63
Mixed 46.27 22.15 21.25 100.00
Distribution
Leg dominant 61.07 15.42 31.19 100.00
Three-limb dominant 45.93 13.73 22.66 82.99
Four-limb dominant 36.35 15.75 0.00 74.75
Right hemiplegic 74.09 16.54 43.26 96.00
Left hemiplegic 76.33 17.32 35.26 100.00
GMFCS(a) level
I 76.69 14.05 46.32 100.00
II 63.49 12.03 37.14 89.70
III 50.31 7.23 31.78 67.04
IV 38.70 6.53 27.31 52.85
V 23.06 9.28 0.00 46.67
Gender
Male 52.34 22.03 0.00 100.00
Female 53.46 20.38 13.54 100.00
Age at Baseline
[bar]X SD Minimum Maximum N
Type of cerebral palsy 6.45 2.84 1.57 11.82 173
Spastic 6.04 2.41 2.31 11.02 17
Dystonic/athetotic 9.48 0.67 8.71 10.02 5
Ataxic 7.14 2.33 2.38 10.26 15
Low tone-hypotonic 7.18 2.76 2.18 10.92 18
Mixed
Distribution 6.84 2.79 1.59 11.12 74
Leg dominant 7.11 2.49 2.62 10.90 30
Three-limb dominant 6.44 2.76 1.57 11.70 82
Four-limb dominant 5.64 3.01 1.97 10.52 24
Right hemiplegic 6.62 2.85 1.75 11.82 18
Left hemiplegic
GMFCS(a) level 6.17 2.82 1.59 11.82 61
I 6.60 2.90 1.69 10.72 35
II 6.58 2.86 1.57 11.12 49
III 6.73 2.74 2.17 11.74 48
IV 7.12 2.53 2.68 11.02 35
V
Gender 6.50 2.78 1.57 11.74 142
Male 6.73 2.79 1.75 11.82 86
Female
(a) GMFCS = Gross Motor Function Classification System.[34] Reliability To determine the test-retest reliability of the GMFM-66 scores, data were used from 19 children with CP who were assessed twice, 1 week apart, by the same therapist. These data were from a previous study of the reliability of data obtained with the GMFM.[3] Each child's GMFM-88 total scores were computed according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. the GMFM guidelines[2] and were also computed using the Gross Motor Ability Estimator (GMAE GMAE Global Mobile Access ),[35] which is software that analyzes the interval level scale of the GMFM-66. Validity and Responsiveness Face validity face validity (fāsˑ v  ·liˑ·di·tē),n was assessed by examining the hierarchy of items (Tab. 4) and the GMFM-66 total scores for different groups of children to determine whether they made clinical sense (Tab. 2) based on what is known about CP. We expected that items from the lying and rolling and the sitting dimensions would be easier for children with CP to accomplish than items in standing and the walking, running, and jumping dimensions and would, therefore, have lower difficulty estimates. We also expected that children with hemiplegia hemiplegia /hemi·ple·gia/ (-ple´jah) paralysis of one side of the body.hemiple´gic alternate hemiplegia paralysis of one side of the face and the opposite side of the body. would have higher scores, on average, than children with more limbs involved (eg, children with diplegia diplegia /di·ple·gia/ (di-ple´jah) paralysis of like parts on either side of the body.diple´gic di·ple·gia n. Paralysis of corresponding parts on both sides of the body. , triplegia triplegia /tri·ple·gia/ (tri-ple´jah) paralysis of three limbs. tri·ple·gia n. 1. Paralysis of an upper and a lower extremity and of the face. 2. , or quadriplegia) and that mean GMFM-66 scores would vary systematically by GMFCS level,[34] with children in level I (mild disability) having the highest GMFM-66 scores. Construct validity of the responsiveness of GMFM-66 scores was also assessed by testing an a priori a priori In epistemology, knowledge that is independent of all particular experiences, as opposed to a posteriori (or empirical) knowledge, which derives from experience. hypothesis, similar to the method used in the construct validation of the original GMFM,[1] and centered on the measure's ability to respond to change using information about the natural history of CP.[36] The criterion for inclusion in the responsiveness analyses was that children had 2 GMFM assessments 12 months apart ([+ or -] 1 month). These 228 children were assigned as·sign tr.v. as·signed, as·sign·ing, as·signs 1. To set apart for a particular purpose; designate: assigned a day for the inspection. 2. to an expected change category based on their age ([is less than] 5 years or [is greater than or equal to] 5 years) and severity of motor disability, as assessed using the GMFCS ("mild"=levels I and II, "moderate"=level III, "severe"=levels W and V). Data Analysis Test-retest reliability data were analyzed an·a·lyze tr.v. an·a·lyzed, an·a·lyz·ing, an·a·lyz·es 1. To examine methodically by separating into parts and studying their interrelations. 2. Chemistry To make a chemical analysis of. 3. using an ICC based on the 1-way analysis of variance The discrepancy between what a party to a lawsuit alleges will be proved in pleadings and what the party actually proves at trial. In Zoning law, an official permit to use property in a manner that departs from the way in which other property in the same locality (ANOVA anova see analysis of variance. ANOVA Analysis of variance, see there ) model 1,1.[37] for both the new and the original scoring methods. To test the difference in reliability between the 2 scoring methods, 95% confidence limits for the difference in ICCs were computed.[38] To determine whether an effect of time existed and whether there were interactions of age and severity, a 3-way repeated measures ANOVA was calculated with time as the within-subject factor and age and severity as between-subject factors. Results Reliability Test-retest reliability data using the new GMAE scoring method[35] showed that the GMFM-66 has a high level of stability over time (ICC=.9932) and is only slightly different from that of the original scoring system Noun 1. scoring system - a system of classifying according to quality or merit or amount rating system classification system - a system for classifying things using the 88-item GMFM (ICC=.9944, mean difference=.0013 [95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. of -.082 to .0109]). Validity The items of the GMFM-66 in order of difficulty ascertained as·cer·tain tr.v. as·cer·tained, as·cer·tain·ing, as·cer·tains 1. To discover with certainty, as through examination or experimentation. See Synonyms at discover. 2. by Rasch analysis (ie, with an item score of 3) are presented in Table 4. To remove negative values and be more clinically interpretable, the linear estimates of difficulty expressed in logits (log-odds ratios) were transformed to a scale with values ranging from 0 to 100. The GMFM-66 has difficulty estimates ranging from 15.72 for the easiest item (item 21: "sits on mat, supported at thorax thorax, body division found in certain animals. In humans and other mammals it lies between the neck and abdomen and is also called the chest. The skeletal frame of the thorax is formed by the sternum (breastbone) and ribs in front and the dorsal vertebrae in back. by therapist, lifts head upright upright said of limb joints and bones, especially in the horse. Indicates a lack of angulation in the joint, e.g. upright hock, or slope in a bone, e.g. upright pastern. In horses, often associated with a bumpy ride and a tendency to joint injury and lameness. , maintains 3 seconds") to 88.52 for the most difficult item (item 82: "stands on right foot, hops on right foot 10 times within a 24-inch circle"). The Rasch scale is in logits (log-odds units), which runs from negative infinity infinity, in mathematics, that which is not finite. A sequence of numbers, a1, a2, a3, … , is said to "approach infinity" if the numbers eventually become arbitrarily large, i.e. to positive infinity Positive Infinity are an alternative, metal, punk, rock band from Miami, Florida. While they are a full featured studio band, Positive Infinity are generally considered to be the solo project of Living Corban's former vocalist and guitarist, Jonathan Roberts. . A linear transformation was applied to the ability scale so that the minimum ability was 0 and the maximum ability was 100.[28] In terms of the items on the GMFM-66, a score of 0 on the ability scale means that a child has a 100% probability of having a score of 0 on every item. A score of 100 means that a child has a 100% probability of having a score of 3 on every item. The item difficulty scale was transformed using the same linear transformation. This transformation placed the easiest item at a difficulty of 15.7 and the most difficult item at a difficulty of 88.52. An item's difficulty corresponds to the ability required for a score of 3 on that item. Therefore, for a child to be likely (P=.5) to have a score of 3 on the easiest item, he or she needs to have an ability estimate of 15.7. Table 4. Hierarchy of Items (From Easy to Difficult) in the 66-Item Gross Motor Function Measure (GMFM-66) for Children with Cerebral Palsy(a) Item Difficulty(b) 21-SIT ON MAT, SUPPORTED AT THORAX BY THERAPIST: LIFTS HEAD UPRIGHT, MAINTAINS 3 SEC 15.72 10-PR: LIFTS HEAD UPRIGHT 23.25 23-SIT ON MAT, ARM(S) PROPPING: MAINTAINS, 5 SEC 25.13 22-SIT ON MAT, SUPPORTED AT THORAX BY THERAPIST: LIFTS HEAD TO MIDLINE, MAINTAINS 10 SEC 25.60 2-SUP: BRINGS HANDS TO MIDLINE, FINGERS ONE WITH THE OTHER 26.84 7-SUP: REACHES OUT WITH L ARM, HAND CROSSES MIDLINE TOWARDS TOY 29.72 18-SUP, HANDS GRASPED BY EXAMINER: PULLS SELF TO SITTING WITH HEAD CONTROL 30.84 6-SUP: REACHES OUT WITH R ARM, HAND CROSSES MIDLINE TOWARD TOY 31.43 24-SIT ON MAT: MAINTAINS, ARMS FREE, 3 SEC 32.14 27-SIT ON MAT: TOUCHES TOY PLACED 45 [degrees] BEHIND CHILD'S L SIDE, RETURNS TO START 39.49 25-SIT ON MAT WITH SMALL TOY IN FRONT: LEANS FORWARD, TOUCHES TOY, RE-ERECTS WITHOUT ARM PROPPING 39.67 34-SIT ON BENCH: MAINTAINS, ARMS AND FEET FREE, 10 SEC 39.91 26-SIT ON MAT: TOUCHES TOY PLACED 45 [degrees] BEHIND CHILD'S R SIDE, RETURNS TO START 40.44 39-4 POINT: MAINTAINS, WEIGHT ON HANDS AND KNEES, 10 SEC 41.20 30-SIT ON MAT: LOWERS TO PR WITH CONTROL 41.38 41-PR: ATTAINS 4 POINT, WEIGHT ON HANDS AND KNEES 41.49 67-STD, 2 HANDS HELD: WALKS FORWARD 10 STEPS 42.26 44-4 POINT: CRAWLS OR HITCHES FORWARD 6' 43.03 40-4 POINT: ATTAINS SIT ARMS FREE 44.91 52-ON THE FLOOR: PULLS TO STD AT LARGE BENCH 45.09 31-SIT ON MAT WITH FEET IN FRONT: ATTAINS 4 POINT OVER R SIDE 45.73 42-4 POINT: REACHES FORWARD WITH R ARM, HAND ABOVE SHOULDER LEVEL 46.44 32-SIT ON MAT WITH FEET IN FRONT: ATTAINS 4 POINT OVER L SIDE 46.73 43-4 POINT: REACHES FORWARD WITH L ARM, HAND ABOVE SHOULDER LEVEL 46.91 66-STD, 2 HANDS ON LARGE BENCH: CRUISES 5 STEPS TO L 47.62 65-STD, 2 HANDS ON LARGE BENCH: CRUISES 5 STEPS TO R 47.68 45-4 POINT: CRAWLS RECIPROCALLY FORWARD 6' 48.03 46-4 POINT: CRAWLS UP FOUR STEPS ON HANDS AND KNEES/FEET 48.38 36-ON THE FLOOR: ATTAINS SIT ON SMALL BENCH 48.44 35-STD: ATTAINS SIT ON SMALL BENCH 49.03 48-SIT ON MAT: ATTAINS HIGH KN USING ARMS, MAINTAINS, ARMS FREE, 10 SEC 49.79 68-STD, 1 HAND HELD: WALKS FORWARD 10 STEPS 51.27 37-ON THE FLOOR: ATTAINS SIT ON LARGE BENCH 52.80 53-STD: MAINTAINS, ARMS FREE, 3 SEC 53.97 55-STD: HOLDING ON TO LARGE BENCH WITH ONE HAND, LIFTS L FOOT, 3 SEC 55.74 54-STD: HOLDING ON TO LARGE BENCH WITH ONE HAND, LIFTS R FOOT, 3 SEC 55.92 69-STD: WALKS FORWARD 10 STEPS 55.92 51-HIGH KN: KN WALKS FORWARD 10 STEPS, ARMS FREE 56.74 56-STD: MAINTAINS, ARMS FREE, 20 SEC 57.21 59-SIT ON SMALL BENCH: ATTAINS STD WITHOUT USING ARMS 57.56 64-STD: PICKS UP OBJECT FROM FLOOR, ARMS FREE, RETURNS TO STAND 57.62 70-STD: WALKS FORWARD 10 STEPS, STOPS, TURNS 180 [degrees], RETURNS 57.74 72-STD: WALKS FORWARD 10 STEPS CARRYING A LARGE OBJECT WITH 2 HANDS 57.98 78-STD: KICKS BALL WITH R FOOT 60.04 79-STD: KICKS BALL WITH L FOOT 60.62 71-STD: WALKS BACKWARD 10 STEPS 62.45 63-STD: ATTAINS SQUAT, ARMS FREE 65.27 62-STD: LOWERS TO SIT ON FLOOR WITH CONTROL, ARMS FREE 65.57 84-STD, HOLDING 1 RAIL: WALKS UP 4 STEPS, HOLDING 1 RAIL, ALTERNATING FEET 65.98 77-STD: RUNS 15 FEET, STOPS & RETURNS 67.22 76-STD: STEPS OVER STICK AT KNEE LEVEL, L FOOT LEADING 69.75 60-HIGH KN: ATTAINS STD THROUGH HALF KN ON R KNEE, WITHOUT USING ARMS 70.22 75-STD: STEPS OVER STICK AT KNEE LEVEL, R FOOT LEADING 70.22 88-STD ON 6" STEP: JUMPS OFF, BOTH FEET SIMULTANEOUSLY 70.81 73-STD: WALKS FORWARD 10 CONSECUTIVE STEPS BETWEEN PARALLEL LINES 8" APART 71.45 61-HIGH KN: ATTAINS STD THROUGH HALF KN ON L KNEE, WITHOUT USING ARMS 71.92 85-STD, HOLDING 1 RAIL: WALKS DOWN 4 STEPS, HOLDING 1 RAIL, ALTERNATING FEET 72.16 81-STD: JUMPS FORWARD 12", BOTH FEET SIMULTANEOUSLY 73.34 86-STD: WALKS UP 4 STEPS, ALTERNATING FEET 74.28 74-STD: WALKS FORWARD 10 CONSECUTIVE STEPS ON A STRAIGHT LINE 3/4" WIDE 80.22 87-STD: WALKS DOWN 4 STEPS, ALTERNATING FEET 81.22 58-STD: LIFTS R FOOT, ARMS FREE, 10 SEC 85.23 57-STD: LIFTS L FOOT, ARMS FREE, 10 SEC 86.23 83-STD ON L FOOT: HOPS ON L FOOT 10 TIMES WITHIN A 24" CIRCLE 88.05 80-STD: JUMPS 12" HIGH, BOTH FEET SIMULTANEOUSLY 88.11 82-STD ON R FOOT: HOPS ON R FOOT 10 TIMES WITHIN A 24" CIRCLE 88.52 (a) SUP = Supine, PR = prone, R = right, L = left, SIT = sitting, STD = standing, KN = kneeling. (b) Difficulty values correspond to the GMFM-66 score at which a child is likely to have a score of 3 on the item. Table 2 shows the mean GMFM-66 scores or "ability estimates" for the 537 children included in the Rasch analysis by age, sex, type and distribution of CP, and GMFCS level. The mean ability estimates are similar for males and females. Children with hemiplegia have the highest mean ability estimates, and children with 4-limb involvement have the lowest mean ability estimates. Children who were classified as having "mild" (ie, level I) motor impairment Impairment 1. A reduction in a company's stated capital. 2. The total capital that is less than the par value of the company's capital stock. Notes: 1. This is usually reduced because of poorly estimated losses or gains. 2. using the GMFCS had a mean ability estimate of 78.06, followed by mean ability estimates of 60.92 for children with level II motor impairment, 49.98 for children with level III motor impairment, 37.94 for children with level IV motor impairment, and 20.63 for children with level V motor impairment. As hypothesized, there was an overall change in mean GMFM-66 scores for the sample of children assessed at baseline and at 12 months, from 52.76 to 54.61 (F= 116.3; df=1,222; P [is less than] .0001). There was also a time x severity x age interaction (F= 12.6; df=2,222; P [is less than] .0001). Figure 1 shows the 3-way interaction plotted as mean change scores by severity and age category. The means and standard deviations In statistics, the average amount a number varies from the average number in a series of numbers. (statistics) standard deviation - (SD) A measure of the range of values in a set of numbers. by group are reported in Table 5. Figure 1 shows that children under 5 years of age changed more than children aged 5 years and over. This change was greater for children whose GMFCS level was I or II than for children with other GMFCS levels. The mean change for children aged 5 years and over was approximately zero regardless of GMFCS level. [Figure 1 ILLUSTRATION OMITTED] Table 5. Mean 66-Item Gross Motor Function Measure (GMFM-66) Baseline and Follow-up follow-up, n the process of monitoring the progress of a patient after a period of active treatment. follow-up subsequent. follow-up plan Scores by Severity of Motor Disability (Gross Motor Function Classification System[34] [GMFCS] Level) and Age (n = 228)
Younger Than 5 Years of Age
Baseline 12-mo Follow-up
GMFCS [bar]X SD [bar]X SD N
Levels 1 and 2 63.16 13.48 70.16 13.58 39
Level 3 47.59 6.31 50.94 6.50 16
Levels 4 and 5 31.12 9.64 34.31 10.11 24
5 Years of Age or Older
Baseline 12-mo Follow-up
GMFCS [bar]X SD [bar]X SD N
Levels 1 and 2 77.84 12.50 77.72 12.56 57
Level 3 51.62 7.36 51.82 6.88 33
Levels 4 and 5 32.50 11.54 32.81 11.50 59
Discussion Our study provides evidence of test-retest reliability and construct validity of the GMFM-66 scores. Evidence of the responsiveness of the GMFM-66 includes the findings that the mean GMFM-66 scores of the children with CP changed over 12 months and that the mean change scores were related to age and severity Of motor disability. Test-retest reliability of the GMFM-66 scores was examined using data collected on the 88-item GMFM. The magnitude of the ICCs for the GMFM-88 and for the GMFM-66 was high. The ICCs may have been different had only the items of the GMFM-66 been administered; however, there is no reason to expect that the reliability estimates would have decreased. Although we believe that the results support the construct validity of the GMFM-66 scores, the measure detected less change in the older children regardless of severity of CP. This finding suggests either that the GMFM-66 is not as sensitive to changes in motor function made by children with CP aged 5 years and over as it is to changes in motor function made by children under 5 years of age or that a smaller mean change is happening in children over age 5 years. This pattern of varying responsiveness for children over 5 years of age is similar to current findings from the models of motor growth using the 88-item GMFM.[36] The emphasis of the GMFM is on motor abilities associated with gross motor development that typically are achieved by age 5 years in children without motor impairments. For children with CP over the age of 5 years, especially those who are unable to walk without assistive mobility devices, change may be associated with performance of motor functions at home, at school, in the community, and during social participation rather than acquisition of basic gross motor skills The term gross motor skills refers to the abilities usually acquired during infancy and early childhood as part of a child's motor development. By the time they reach two years of age, almost all children are able to stand up, walk and run, walk up stairs, etc. . In our view, therefore, measures of disability such as the Pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. Evaluation Disability Inventory[29] may be more appropriate for evaluating change in older children with CP. The improvements of the GMFM-66 over the GMFM include (1) the ordering of items according to difficulty, (2) the interval properties of the scale allowing for improved interpretability of a total score and of change scores, and (3) the decrease in administration time. The difficulty estimates for each item on the GMFM-66 (Tab. 4) provide information that is unique to gross motor function of children with CP. Items for lying, rolling, and head control in supported sitting are the least difficult, whereas items for standing on one foot, jumping, and hopping are the most difficult. The difficulty estimates for items of sitting, crawling, kneeling, standing, and walking tend to overlap o·ver·lap n. 1. A part or portion of a structure that extends or projects over another. 2. The suturing of one layer of tissue above or under another layer to provide additional strength, often used in dental surgery. v. in the middle of the scale, indicating that motor abilities in these different areas may be developing simultaneously for children with CP. These findings have implications for determining outcomes and planning intervention. Interpretation of a child's GMFM-66 score should be enhanced by using the item difficulty map (Fig. 2). The item map provides a graphic presentation of items ordered along a continuum Continuum (pl. -tinua or -tinuums) can refer to:
n. 1. One who hawks about fruit, green vegetables, fish, etc. et al.[40] Transferring the GMFM-66 score onto the item map can help in the interpretation of assessment scores by presenting both the child's gross motor abilities and the difficulty of items that have not been achieved. The GMAE program[35] provides a measure of error that is useful in assessing whether an individual's change score is significant. [Figure 2 ILLUSTRATION OMITTED] The interval scale for items of the GMFM-66 also has advantages for interpretation of scores and decision making. The magnitude of change in GMFM-66 scores for individual children or groups of children can be directly compared upon retesting. For example, a child whose GMFM-66 scores increase over 2 consecutive 6-month intervals from 24 to 29 and from 29 to 39 demonstrates 5-point and 10-point changes, respectively. The child's change in GMFM-66 score for the second 6-month interval is twice as much as the change made for the first interval. The interval scale also enables a direct comparison of change among children with different functional abilities. This comparison is particularly important for program evaluation Program evaluation is a formalized approach to studying and assessing projects, policies and program and determining if they 'work'. Program evaluation is used in government and the private sector and it's taught in numerous universities. and clinical research. Profiles of 2 children with CP illustrate differences between the original method of scoring the GMFM and the Rasched interval scale for scoring the GMFM-66 (Fig. 3). John is a 3-year 8-month-old boy with a diagnosis of CP with dystonic movements and primary involvement of the legs. He is classified at level I on the GMFCS. When initially tested,John achieved a GMFM score of 59 and a GMFM-66 score of 54. Upon retesting 6 months later, John achieved a GMFM score of 77 and a GMFM-66 score of 65. [Figure 3 ILLUSTRATION OMITTED] Sara is a 3-year 8-month-old child with a diagnosis of CP (spastic diplegia). She is also classified at level I on the GMFCS. When initially tested, Sara achieved a GMFM score of 89 and a GMFM-66 score of 68. Six months later, upon retesting, Sara achieved a GMFM score of 90 and a GMFM-66 score of 80. Although John demonstrated a change score of 12% and Sara demonstrated a change score of 1% on the GMFM, they had similar change scores on the GMFM-66. Sara's larger change score on the GMFM-66 is attributable to the large spacing between certain item difficulties (Fig. 2). Although Sara did not improve on as many items as John, the items she accomplished were more spread out along the difficulty continuum. The GMFM-66 should take less time to administer with 22 fewer items and the ability of the GMAE program[35] to estimate a child's ability score even when all items have not been administered. A potential limitation of the GMFM-66 is the need for a computer program to score it. A computer program has been designed to convert the raw scores from either the GMFM-88 or the GMFM-66 into difficulty estimates.[35] It will calculate the GMAE score based on the 66 items, with a standard error. There are no longer separate scores for each dimension. One major difference in the administration and scoring of the GMFM-66 than the scoring of the 88-item GMFM is the importance of differentiating a true score of 0 (child is unable to perform) from an item that was not tested. In the original administration and scoring guidelines, a score of 0 was assigned for items that were not administered or that the child did not perform during the assessment. The new GMFM score form has been modified to include the response "not tested." Although not all 66 items have to be administered to calculate a GMAE score, the more items that are administered, the more accurate the estimate of a child's gross motor ability.[27] We believe that the GMFM-66 has applications for evaluating the effectiveness of interventions. Three studies,[9-11] for example, have been published recently with conflicting results on the effectiveness of dorsal rhizotomy surgery for children with CP. All 3 studies used common outcome measures, including the GMFM. From discussions among the 3 groups of investigators, several hypotheses arose as to why there may have been differences in the study outcomes, including the possibility that the relative difficulty of items at different intervals of the GMFM is not reflected in the total score.[9] It will be important to determine whether the results of these studies would be different using the GMFM-66, in which the change in score is interval and reflects the difficulty of items, regardless of a child's initial motor ability. Summary and Conclusions The advantages of the GMFM-66 include: (1) items are arranged in order of difficulty, (2) the interval properties of the scale allow for improved interpretability of a total score and change scores, (3) a decrease in administration time with 22 fewer items to administer and score, (4) a computer scoring system that allows calculation of a child's total score and the standard error around an individual's score and that can estimate a child's score if some items are missing, and (5) psychometric properties of reliability, validity, and responsiveness. The potential disadvantages of the GMFM-66 include: (1) many items in the lower dimensions have been removed and the GMFM-66, therefore, may be less descriptive for children functioning at low ability levels, (2) the need for the GMAE software in order to score the GMFM-66, and (3) the need to learn to interpret item maps. Recognizing that not all service providers have access to computers for scoring and that service providers use the GMFM for purposes other than measuring change (eg, for descriptive purposes), we have maintained the original 88 items on the GMFM score sheet. In this way, service providers have the option of using the version that best suits their purpose. Because the item difficulties are calibrated cal·i·brate tr.v. cal·i·brat·ed, cal·i·brat·ing, cal·i·brates 1. To check, adjust, or determine by comparison with a standard (the graduations of a quantitative measuring instrument): for use with children with CP, availability of the 88-item GMFM will allow the measure to continue to be used for clients with diagnoses other than CP. References [1] Russell DJ, Rosenbaum PL, Cadman DT, et al. The Gross Motor Function Measure: a means to evaluate the effects of physical therapy. Dev Med Child Neurol. 1989;31:341-352. [2] Russell DJ, Rosenbaum PL, Gowland C, et al. Manual for the Gross Motor Function Measure. 2nd ed. 1993. (Available from CanChild Centre for Childhood Disability Research, Room 408, Institute for Applied Health Sciences, McMaster University McMaster University, at Hamilton, Ont., Canada; nondenominational; founded 1887. It has faculties of humanities, science, social sciences, business, engineering, and health sciences, as well as a school of graduate studies and a divinity college. , 1400 Main St W, Hamilton Hamilton, city, Bermuda Hamilton, city (1990 est. pop. 3,100), capital of Bermuda, on Bermuda Island. It is a port at the head of Great Sound, a huge lagoon and deepwater harbor protected by coral reefs. , Ontario, Canada L8S 1C7.) [3] Bjornson KF, Graubert C, McLaughlin JF, et al. Test-retest reliability of the Gross Motor Function Measure in children with cerebral palsy. Physical and Occupational Therapy in Pediatrics pediatrics (pēdēă`trĭks), branch of medicine dedicated to the attainment of the best physical, emotional, and social health for infants, children, and young people generally. . 1998;18(2):51-61. [4] Nordmark E, Hagglund G, Jarnlo GB. Reliability of the Gross Motor Function Measure in cerebral palsy. Scand J Rehabil Med. 1997;29:25-28. [5] Bjornson KF, Graubert C, McLaughlin JF, Astley SJ. Inter-rater reliability Inter-rater reliability, Inter-rater agreement, or Concordance is the degree of agreement among raters. It gives a score of how much , or consensus, there is in the ratings given by judges. of the Gross Motor Function Measure. Dev Med Child Neurol. 1994;36(SUPpl 70):27-28. [6] Russell DJ, Palisano RJ, Walter S Wal·ter , Bruno 1876-1962. German conductor noted for his interpretations of Mozart and Mahler. Noun 1. Walter - German conductor (1876-1962) Bruno Walter , et al. Evaluating motor function in children with Down syndrome: validity of the GMFM. Dev Med Child Neurol. 1998;40:693-701. [7] Bjornson KF, Graubert C, Buford V, McLaughlin JF. Validity of the Gross Motor Function Measure. Pediatric Physical Therapy. 1998; 10(2):43-47. [8] Kolobe TH, Palisano RJ, Stratford PW. Comparison of two outcome measures for infants with cerebral palsy and infants with motor delay. Phys Ther. 1998;78:1062-1072. [9] McLaughlin JF, Bjornson KF, Astley SJ, et al. Selective dorsal rhizotomy: efficacy and safety in an investigator-masked randomized clinical trial randomized clinical trial, n a clinical study where volunteer participants with comparable characteristics are randomly assigned to different test groups to compare the efficacy of therapies. . Dev Med Child Neurol. 1998;40:220-232. [10] Steinbok steinbok: see antelope. P, Reiner AM, Beauchamp R, et al. A randomized clinical trial to compare selective dorsal rhizotomy plus physiotherapy physiotherapy: see physical therapy. with physiotherapy alone in children with spastic spastic /spas·tic/ (spas´tik) 1. of the nature of or characterized by spasms. 2. hypertonic, so that the muscles are stiff and movements awkward. spas·tic adj. 1. diplegic cerebral palsy. Dev Med Child Neurol. 1997;39:178-184. [11] Wright V, Sheil E, Drake drake 1. male duck. 2. loliumtemulentum. J, Wedge wedge, piece of wood or metal thick at one end and sloping to a thin edge at the other; an application of the inclined plane. It is employed in separating two objects from each other or in separating one part of a solid object from an adjoining part, as in splitting J. Evaluation of selective dorsal rhizotomy for the reduction of spasticity spasticity /spas·tic·i·ty/ (spas-tis´i-te) the state of being spastic; see spastic (2). spas·tic·i·ty n. 1. A spastic state or condition. 2. Spastic paralysis. in cerebral palsy: a randomized controlled trial A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. . Dev Med Child Neurol. 1998;40:239-247. [12] Krach L, Gilmartin R, Bruce Bruce, Scottish royal family descended from an 11th-century Norman duke, Robert de Brus. He aided William I in his conquest of England (1066) and was given lands in England. D, et al. Functional changes noted following treatment of individuals with cerebral palsy with intrathecal baclofen. Dev Med Child Neurol. 1997;39 (suppl 75): 12-13. [13] Almeida GL, Campbell SK, Girolami GL, et al. Multidimensional mul·ti·di·men·sion·al adj. Of, relating to, or having several dimensions. mul  ti·di·men assessment of motor function in a child with cerebral palsy following
intrathecal administration of baclofen. Phys Ther. 1997;77:751-764.[14] Bower E, McLellan DL, Arney J, Campbell MJ. A randomised Adj. 1. randomised - set up or distributed in a deliberately random way randomized irregular - contrary to rule or accepted order or general practice; "irregular hiring practices" controlled trial controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. of different intensities of physiotherapy and different goal-setting procedures in 44 children with cerebral palsy. Dev Med Child Neurol. 1996;38:226-237. [15] Bower E, McLellan DL. Effect of increased exposure to physiotherapy on skill acquisition of children with cerebral palsy. Dev Med Child Neurol. 1992;34:25-39. [16] MacKinnon J, Noh S, Lariviere J, et al. A study of therapeutic effects of horseback riding for children with cerebral palsy. Physical and Occupational Therapy in Pediatrics. 1995;15(1):17-31. [17] Steinbok P, Reiner A, Kestle JR. Therapeutic electrical stimulation following selective dorsal rhizotomy in children with spastic diplegic cerebral palsy: a randomized clinical trial. Dev Med Child Neurol. 1997;39:515-520. [18] Wright V, Belbin G, Slac M, et al. A pilot evaluation of the David Hart David Hart may refer to:
[19] Evans Ev·ans , Herbert McLean 1882-1971. American anatomist who isolated four pituitary hormones and discovered vitamin E (1922). C, Gowland C, Rosenbaum PL, et al. The effectiveness of orthoses for children with cerebral palsy. Dev Med Child Neurol. 1994; 36(suppl 70):26. [20] MacPhail A, Kramer JF. Effect of isokinetic isokinetic /iso·ki·net·ic/ (-ki-net´ik) maintaining constant torque or tension as muscles shorten or lengthen; see isokinetic exercise, under exercise. strength training on functional ability and walking efficiency in adolescents with cerebral palsy. Dev Med Child Neurol. 1995;37:763-775. [21] Kramer JF, MacPhail A. Relationships among measures of walking efficiency, gross motor ability, and isokinetic strength in adolescents with cerebral palsy. Pediatric Physical Therapy. 1994;6:3-8. [22] Abel MF, Damiano DL, Pannunzio M, Bush J. Role of multiple muscle-tendon recessions and releases to improve motor function in diplegic cerebral palsy. Dev Med Child Neurol. 1997;39 (suppl 75):16-17. [23] Damiano DL, Abel MF. Relation of gait analysis gait analysis Rehab medicine Evaluation of the gait of Pts with a neurologic or orthopedic condition affecting the motor control system–eg, brain injury, spinal cord injury, cerebral palsy, stroke, multiple sclerosis, musculoskeletal actuator systems, post to gross motor function in cerebral palsy. Dev Med Child Neurol. 1996;38:389-396. [24] Harris T, Damiano DL, Abel M. Gait efficiency in diplegic cerebral palsy. Dev Med Child Neurol. 1997;39(suppl 75):28-29. [25] Drouin LM, Malouin F, Richards Rich·ards , Dickinson Woodruff 1895-1973. American physician. He shared a 1956 Nobel Prize for developing cardiac catheterization. CL, Marcoux S. Correlation between the GMFM scores and gait spatiotemporal spa·ti·o·tem·po·ral adj. 1. Of, relating to, or existing in both space and time. 2. Of or relating to space-time. [Latin spatium, space + temporal1. measures in children with neurological neurological, neurologic pertaining to or emanating from the nervous system or from neurology. neurological assessment evaluation of the health status of a patient with a nervous system disorder or dysfunction. impairments. Dev Med Child Neurol. 1996;38:1007-1019. [26] Parker DF, Carriere L, Hebestreit H, et al. Muscle performance and gross motor function of children with spastic cerebral palsy. Dev Med Child Neurol. 1993;35:17-23. [27] Avery A·ver·y , Oswald 1877-1955. American bacteriologist noted for establishing (1944) that DNA is responsible for the transmission of heritable characteristics. LM, Russell DJ, Raina PS, et al. Rasch analysis of an established health outcome measure: a case study of the Gross Motor Function Measure (GMFM). Manuscript manuscript, a handwritten work as distinguished from printing. The oldest manuscripts, those found in Egyptian tombs, were written on papyrus; the earliest dates from c.3500 B.C. submitted for publication. [28] Wright B, Masters G. Rating Scale Analysis. Chicago, Ill: MESA Press; 1980. [29] Haley SM, Coster W, Ludlow L, et al. Pediatric Evaluation of Disability Inventory (PEDI PEDI Pediatric Evaluation of Disability Inventory PEDI Protocol for Electronic Data Interchange ): Version 1.0. Boston, Mass: New England New England, name applied to the region comprising six states of the NE United States—Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut. The region is thought to have been so named by Capt. Medical Centre Hospitals Inc; 1992. [30] Campbell SK, Osten E, Kolobe TH, Fisher A. Development of the Test of Infant Motor Performance. Phys Med Rehabil Clin N Am. 1993;4:541-550. [31] Fisher W, Fisher A. Application of Rasch analysis to studies in occupational therapy. Phys Med Rehabil Clin N Am. 1993;4:551-569. [32] Haley SM, McHorney CA, Ware JE Jr. Evaluation of the MOS (1) (Metal Oxide Semiconductor) See MOSFET. (2) (Mean Opinion Score) The quality of a digitized voice line. It is a subjective measurement that is derived entirely by people listening to the calls and scoring the results from SF-36 physical functioning scale (PF-10), I: unidimensionality and reproducibility reproducibility Lab medicine The degree of agreement among repeated measurements of a particular parameter, presented in terms of a standard deviation or coefficient of variation of the results in a set of measurements of the Rasch item scale. J Clin Epidemiol. 1997;47:671-684. [33] McHorney CA, Haley SM, Ware JE Jr. Evaluation of the MOS SF-36 physical functioning scale (PF-10), II: comparison of relative precision using Likert and Rasch scoring methods. J Clin Epidemiol. 1997; 50:451-461. [34] Palisano RJ, Rosenbaum PL, Walter S, et al. Development and reliability of a system to classify clas·si·fy tr.v. clas·si·fied, clas·si·fy·ing, clas·si·fies 1. To arrange or organize according to class or category. 2. To designate (a document, for example) as confidential, secret, or top secret. gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214-223. [35] Burrows Burrows is a provincial electoral division in the Canadian province of Manitoba. It was created by redistribution in 1957, and formally came into existence in the provincial election of 1958. The riding is located in the northern part of Winnipeg. L. Gross Motor Ability Estimator [software]. Hamilton, Ontario, Canada: CanChild Centre for Childhood Disability Research, McMaster University; 1999. (Software available from the CanChild website at: http://www.fhs.mcmaster.ca/canchild). [36] Palisano RJ, Hanna SE, Rosenbaum PL, et al. Validation of a model of gross motor function for children with cerebral palsy. Phys Ther. In press. [37] Shrout PE, Fleiss J. Intraclass correlations: uses in assessing rater rat·er n. 1. One that rates, especially one that establishes a rating. 2. One having an indicated rank or rating. Often used in combination: a third-rater; a first-rater. reliability. Psychol Bull. 1979;86:420-428. [38] Olkin E. Correlations revisited. In: Stanley Stanley, town (1991 pop. 1,557), capital of the Falkland Islands, S Atlantic Ocean, on East Falkland island. It is the main port and trading center of the islands. The name is sometimes written as Port Stanley. JC, ed. Improving Experimental Design and Statistical Analysis. Chicago, Ill: Rand McNally Rand McNally & Company is the preeminent American publisher of maps, atlases, and globes for travel, reference, commercial, and educational uses. It also provides online consumer street maps and directions, as well as commercial transportation routing software and mileage data. ; 1967. [39] Coster W, Beeney T, Haltiwinger J, Haley SM. School Function Assessment. San Antonio San Antonio (săn ăntō`nēō, əntōn`), city (1990 pop. 935,933), seat of Bexar co., S central Tex., at the source of the San Antonio River; inc. 1837. , Tex: The Psychological Corporation/Therapy Skill Builders; 1998. [40] Coster W, Ludlow L, Mancini M. Using IRT IRT Item Response Theory IRT In Regard To IRT Incident Response Team IRT In Reference To IRT In Regards To IRT Icing Research Tunnel (wind tunnel) IRT Interborough Rapid Transit variable maps to enrich understanding of rehabilitation data. J Outcome Meas. 1999;3:23-133. DJ Russell, MSc, is Assistant Professor, School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, and Research Coordinator, CanChild, Centre for Childhood Disability Research, Room 408, Institute for Applied Health Sciences, McMaster University, 1400 Main St W, Hamilton, Ontario, Canada L8S 1C7 (russelld@fhs.mcmaster.ca). Address all correspondence to Ms Russell. LM Avery, BEng, is Research Assistant, CanChild, Centre for Childhood Disability Research, McMaster University. PL Rosenbaum, MD (FRCP FRCP Fellow of the Royal College of Physicians. FRCP abbr. Fellow of the Royal College of Physicians ), is Professor, Department of Pediatrics, McMaster University, Co-Director, CanChild, Centre for Childhood Disability Research, McMaster University, and Chief of Medical Staff, Bloorview MacMillan Centre, Toronto, Ontario, Canada. PS Raina, PhD, is Assistant Professor, Department of Health Care and Epidemiology epidemiology, field of medicine concerned with the study of epidemics, outbreaks of disease that affect large numbers of people. Epidemiologists, using sophisticated statistical analyses, field investigations, and complex laboratory techniques, investigate the cause , Centre for Community Health and Health Evaluation Research, BC Research Institute for Children's and Women's Health Women's Health Definition Women's health is the effect of gender on disease and health that encompasses a broad range of biological and psychosocial issues. , University of British Columbia Locations Vancouver The Vancouver campus is located at Point Grey, a twenty-minute drive from downtown Vancouver. It is near several beaches and has views of the North Shore mountains. The 7. , Vancouver, British Columbia British Columbia, province (2001 pop. 3,907,738), 366,255 sq mi (948,600 sq km), including 6,976 sq mi (18,068 sq km) of water surface, W Canada. Geography , Canada. SD Walter, PhD, is Professor, Clinical Epidemiology and Biostatistics biostatistics /bio·sta·tis·tics/ (-stah-tis´tiks) biometry. bi·o·sta·tis·tics n. The science of statistics applied to the analysis of biological or medical data. , McMaster University, and Investigator, CanChild, Centre for Childhood Disability Research, McMaster University. RJ Palisano, PT, ScD, is Professor, Department of Rehabilitation Sciences, MCP (1) See Microsoft certification. (2) (MultiChip Package) A chip package that contains two or more chips. It is essentially a multichip module (MCM) that uses a laminated, printed-circuit-board-like substrate (MCM-L) rather than ceramic (MCM-C). Hahnemann Hah·ne·mann , (Christian Friedrich) Samuel 1755-1843. German physician and founder of homeopathy. He postulated that medicine produces symptoms in healthy people that are similar to those that it relieves in sick people. University, Philadelphia, Pa, and Co-investigator, CanChild, Centre for Childhood Disability Research, McMaster University. All authors provided concept/research design, writing, and consultation (including review of manuscript before submission). Ms Avery, Dr Walter, and Dr Raina provided data analysis. Ms Russell and Ms Avery provided project management, and Ms Russell and Dr Rosenbaum provided fund procurement The fancy word for "purchasing." The procurement department within an organization manages all the major purchases. . The study was approved by the McMaster University Research Ethics Research ethics involves the application of fundamental ethical principles to a variety of topics involving scientific research. These include the design and implementation of research involving human participants (human experimentation); animal experimentation; various aspects of Board. This research was supported by grant R01 HD34947 from the National institute for Child Health and Human Development, National Institutes of Health. This article was submitted June 22, 1999, and was accepted May 10, 2000. |
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