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Based on a presentation by Dianne Russell, CanChild Centre for Childhood Disability Research, Knowledge Broker project co-investigator
KB study
Looking at clinical knowledge and appropriate use of: GMFCS GMFM Motor Growth Curves (MCGs): prognosis, treatment planning
Environmental Factors
Personal Factors
To answer the question: How do we measure small but important changes in motor function for children with CP? Development started in 1984
GMFM
Criterion-referenced test: evaluates performance of motor skills on that day; useful for comparison over time Measures how much of a task the child can accomplish, rather than how well the task is completed (quantity, not movement quality)
Children with CP: original validation sample included kids 5 mo- 16 yrs May be appropriate for children with other diagnoses GMFM is appropriate for children whose motor skills are at or below those of a typical 5 year old.
GMFM Formats
GMFM-88: 88 items GMFM-66: 66 items GMFM-88 with reported scores for kids with Down Syndrome
Examiner Qualifications
For use by pediatric PTs Before testing children, PTs should familiarize themselves with the scoresheet and the administration and scoring guidelines CD ROM training available
Time required
GMFM 88: approx. 45-60 minutes GMFM 66: faster, allows for some missing data (items that are not tested) Can be completed in more than 1 session (ideally complete all items within 1 week)
GMFM-88
88 items in 5 gross motor dimensions (for ease of administration): lying and rolling crawling and kneeling Sitting Standing walking, running and jumping
GMFM-66
Reliability
Test-retest (ICC = 0.99) ( dimensions ranged .92.99) Inter-rater (ICC = 0.99) (dimensions ranged .87.99)
Validity
Gradient of change: pre-school children without CP>children with ABI>children with CP Children with CP who were young & mild > older & more severe
Change over 6 months as judged by parents, therapists, and a masked video analysis was correlated with change scores on the GMFM-88
Reliability established by others outside the GMFM team (Bjornson et al. 1994;1998, Nordmark et al. 1997) Responsiveness (Bjornson et al. 1998; Kolobe et al. 1998 Discriminative validity (Palisano et al 2000)
Translated into several languages, including Dutch, French, German, Icelandic, Japanese
Surgery (rhizotomy, pallidal stimulation, muscle tendon) Drugs (botulinum toxin, intrathecal baclofen) Physical therapy (including ambulatory aids & orthoses) Horseback riding Strength training & physical fitness
Lymphoblastic leukemia (Wright et al. 1998) Down syndrome (Russell et al. 1998)
Compared the results using the standard scoring method with an alternate method of scoring using caregiver report Reported Score (for items which the therapist couldnt entice the child to demonstrate) Found stronger evidence of reliability, validity & responsiveness with reported score
Equipment
GMFM kit Need smooth floor, large firm exercise mat, toys for motivation, large bench or table for cruising Five steps with railing Wheeled stool
Environment
Room large enough to accommodate the equipment, the child and the examiner Private area Consistent environment for retesting
Clothing
Have manual, equipment, score sheet ready. Room booked, mat in place, as well as other required furniture
Testing
Items may be tested in any order, but be careful not to miss any! (esp. when using the GMFM 88) Verbal encouragement or demonstration is permitted Maximum 3 trials for each item Spontaneous performance of any item is acceptable
Non-compliance
Strategies such as follow the leader or role playing can be used Toys and incentives can be used as motivators (eg. creep through a tunnel) If a child refuses to attempt an item that you think they can do, return to the item at the end of the test, or try it again in in another session. You can also circle not tested.
Scores 0-3 or NT 0- does not intitiate task 1- intitiates task (<10%) 2- partially completes task (10-99 %) 3- completes task (100%) Sometimes generic scoring as above, other times specific criteria for each level
The score given is based on the best performance out of the 3 trials If undecided about what score to assign, choose the lower of the 2 possible scores Any item that has been omitted or that the child is unable (or unwilling) to attempt must be indicated as NT In the GMFM 88, NT items are scored 0, but in the GMFM 66, NT items are treated as missing data
GMFM-88 vs. 66 Scoring GMAE Interpretation of results Motor Growth Curves GMFCS, GMFM, MCGs: how do they
relate?
GMFM Part II
Quick review Scoring GMAE Interpretation of results GMFM-88 vs. 66 Motor Growth Curves GMFCS, GMFM, MCGs: how do they relate?
GMFM
Criterion-referenced test: evaluates performance of motor skills on that day; useful for comparison over time Measures how much of a task the child can accomplish, rather than how well the task is completed (quantity, not movement quality)
Children with CP: original validation sample included kids 5 mo- 16 yrs May be appropriate for children with other diagnoses: osteogenesis imperfecta, lymphoblastic leukemia, Down syndrome GMFM is appropriate for children whose motor skills are at or below those of a typical 5 year old.
GMFM- 88 and 66
GMFM 88: 88 items in 5 gross motor dimensions: lying and rolling crawling and kneeling Sitting Standing walking, running and jumping
Sum the item scores within dimensions and transfer to the summary score section on the score sheet. A percent score for each of the 5 dimensions is calculated. The total percent score for each dimension is averaged to obtain the total score (round off to the nearest whole number)
Use GMFM-88 only 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 leads to an overall % score as well as dimension % scores Change scores: T2 - T1 = GMFM score Assumes that all % changes/unit of time have the same meaning ...but we dont really know what a unit of change means clinically! (Some changes might be easier to attain than others)
GMFM-88 scaling is ordinal (ordered) Cannot assume that a unit of change has the same meaning across the scale Really need interval scaling, whereby a unit of change has the same meaning throughout the scale Hence the need for Rasch (itemresponse) analysis
It is a way to analyse data to assess the fit, order and relative difficulty of items that measure a construct (e.g., GMF)
Identified items which did not fit the unidimensional constructeliminated 22 items (GMFM-66) Items are now arranged in order of difficulty (empirical) Response options within items are weighted according to difficulty Interval scaleso that a unit of change has the same meaning across the scale (thus improving the interpretability of scores)
GMFM-66
Only 66 items administered (asterixed on score sheet) Enter scores into the computer program: Gross Motor Ability Estimator (GMAE) Not possible to calculate the score with pencil and paper
User-friendly program to analyze GMFM-66 scores with a built-in tutorial Allows entry of data in two formats:
1.
2.
Research - from ASCII files or text only files (files entered into a statistical package SPSS) Individual GMFM-66 item scores for one or more children
Provides an estimate of a childs score even when not all items have been administered Provides a database to keep child information and track GMFM-66 scores over time- case summary
report
Produces item maps- arrange items by order of difficulty Its easy! No math, but graphs!
The GMFM-66 score is an interval-level measure of function where subjects are placed on an ability continuum ranging from 0 (low motor ability) to 100 (high motor ability). Interval level scoring makes comparisons of change over time more meaningful because a difference of, for example, 10 points means the same whether the child is at the lower end or the upper end of the scale.
Summarizes demographic data Summarizes score, including error (standard error and 95% confidence interval) Graphs scores over time
Item Maps
Lower Motor GMFM-66 Score with 95% Confidence Intervals Higher Motor Ability Ability
What is the childs GMFM-66 score? Are there any unexpected scores? What would you expect the child to accomplish next? What activities might you work on in PT with this child?
GMFM 88 and 66
Items are administered and scored the same, with the exception of a new category of Not Tested (NT) to differentiate a true 0 from an item not attempted
If administer the GMFM-88 with NT, the data can also be used to calculate score for GMFM66
Strengths of GMFM-88
Reliable and valid measure of change over time in children with CP and children with Down syndrome Widely used in practice and research GMFM is most responsive to change in children with CP under age 5 years
Limitations of GMFM-88
Time to administer - all items must be administered Must give a score of 0 for items if the child refuses or assessor fails to administer Score based on number of items completed regardless of difficulty
For a more detailed description of skills especially for children whose skills are primarily in Lying and Rolling activities (e.g., infants, or children classified at GMFCS Level V) No access to a computer Assessing effects of aides and orthoses Assessing children with diagnosis other than CP
Strengths of GMFM-66
Reliable and valid measure of change over time in children with CP Items are ordered by difficulty A score can be derived with a less-thancomplete assessment Item maps useful in understanding motor function and in planning goals Computer program allows tracking of individual childrens scores over time
Requires use of a computer program for scoring May need some time to learn how to interpret item maps
Assessing children with cerebral palsy where the interval properties of the scale are important (e.g. Research purposes, change over time) When you have limited time to administer all items Access to a computer and the GMAE scoring program
More graphs!
Derived from a longitudinal study 657 children, >2600 GMFM assessments Children <6 years assessed every 6 mo., older children assessed every 9-12 mo. Plotted GMFM-66 score against age
Longitudinal Motor Growth Curves for Children with Cerebral Palsy by GMFCS Level Using GMFM-66 (N=2624 observations)
Compare childs GMFM-66 score with children in the sample of a similar age and severity
GMFM-66 plateau
Does not mean therapy is not needed! Work on quality, functional goals, equipment needs, prevention of secondary problems.
Case Study
Beth
*** Most useful if used by all PTs, in both EIP and SAP