Percy Hedley Foundation

The Percy Hedley Foundation Speaks Out

"The Problem of Assessment"

"Many children with Cerebral Palsy need an assessment of their movement and function to provide a basis for their developmental programme and to identify their progress. However this presents a challenge to many therapists or practitioners who may be unfamiliar with specialist assessment scales or who work in isolation from the schools who teach the children. This may also become an issue to many parents when their child is placed, for sound educational reasons, in mainstream school. This article suggests an approach to the problem of assessment of the complex needs of these children and presents evidence of the successful use of a specialist assessment procedure, pioneered at Percy Hedley School".

Dr Tony Best, Chief Executive of Percy Hedley Foundation

The Use of the Gross Motor Function Measure and The Gross Motor Classification System in a Special School

A paper presented at Conductive Education Higher Education Group Conference in March 2008 at Ingfield Manor School, in Sussex

The measurement of movement and function in children with Cerebral Palsy has always been problematic and a multi-facetted approach has been used in the past using standard scales of joint range, spasticity and qualitative descriptions of function. In recent years Physiotherapists are increasingly being asked to provide data to evaluate the effectiveness of their interventions and to put the data on learning required for OFSTED, into context.

The Percy Hedley School uses the Conductive Education approach and employs conductors and therapists who work together in a collaborative way.

Since 1997, physiotherapists have been using the Gross Motor Function Measure (GMFM) and the Gross Motor Classification System (GMFCS) in a range of ways to measure outcomes for individual children and for an overall comparison of groups of children. It has therefore been possible to use this small amount of data to investigate trends and differences between different classification groups, as well as keeping an individual record of a child's motor progress.

The GMFM was developed in Canada at the Canchild centre for Childhood disability research at McMaster University and first published in Developmental Medicine and Child Neurology in June 1989 and the current manual was published in 2002.

The test takes between 45-90 minutes to perform and is easy to set up and administer. There are 5 dimensions to measure, lying and rolling, sitting, crawling and kneeling, standing, walking, running and jumping and a score is given for each dimension.

The use of the data

For an individual child the GMFM can be used to

• Inform changes in gross motor function
  The results can be plotted on a simple graph and changes in the dimensions can be seen at a glance. For children with a more severe disability very small changes can be measured. The results can be displayed as an overall score or by itemising out each dimension. This is an easy and clear way for parents and other professionals to be kept informed of a child's motor progress.
• Evaluate interventions
  If a child has had surgery, new orthosis or a treatment such as Botox it is possible to gain a clear idea of whether these interventions have had some impact on the child's gross motor function.
• Monitors change
  When measurements are done regularly over time it is possible to monitor changes in function, which may be an indicator for a specific intervention i.e. Botox
• Goal setting
  The test gives therapists a possibility of using the tasks as goals which are measurable.
• Evaluate use of aids/orthosis
  As the test can be performed with or without orthosis, it is possible to determine whether the intervention has been effective.

The Gross Motor Classification System has been developed alongside the GMFM by examining the relationship between the severity of physical disability and gross motor function. The classification system offers:

• An objective classification
• A prognosis of expected change over time and development
• A tool by which to describe children with CP according to motor development

The GMFCS consists of 5 levels.

• Level I - Walks without restriction; limitations in more advanced motor skills.
• Level II - Walks without assistive devices; limitations walking outdoors and in the community.
• Level III - Walks with assistive mobility devices; limitations in walking outdoors and in the community.
• Level IV - Self-mobility with limitations; children are transported or use power mobility.
• Level V - Self-mobility is severely limited even with use of assistive technology.

Graph of Total Population at Percy Hedley School in 2008

Chart 1: Graph of Total Population at Percy Hedley School in 2008.

Case Study

Chart 2: Case Study.

The above chart shows a child who has a GMFCS 3 and how the progress of each dimension of the GMFM is plotted to show the changes in skills over time. Although the test does not measure quality, it is clear that some skills such as crawling and kneeling, standing and walking are starting to dip down. The child has had increasing difficulty with tightness of the hamstrings and has since had surgery. The challenge now will be plan a programme of rehabilitation to help him to regain skills to his previous level.

The chart below shows the progress of children in school with a GMFCS 3 and their PIVATS scores over time for Science, Literacy, Numeracy, PSD, and ICT.

Chart 3: Progress

Conclusion

The GMFM and the GMFCS are useful tools. They can ...

• Establish a baseline of motor skills on entry to school.
• Track a child's progress and set new targets that are measurable.
• Monitor physical skills and report to statutory annual review.
• To monitor effectiveness of interventions.
• To relate changes and difficulties to the evidence of the severity of the C.P.
• Identify the relationship between physical difficulties and cognitive ability.
• Provide a source of evidence for OFSTED that is clear and thorough for all aspects of a child's learning.

References
Russell D.J, Rosenbaum P.L, Avery L.M, Lane M, Gross Motor Function Measure (GMFM-66 & GMFM-88) User's Manual. Mac Keith Press 2002.

Anne Coates MSc. M.C.S.P
Head Physiotherapist

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