Gross Motor Function Measure Evolution Ratio: Use as a Control for Natural Progression in Cerebral Palsy

Published:August 17, 2015DOI:



      To develop a new way to interpret Gross Motor Function Measure (GMFM-66) score improvement in studies conducted without control groups in children with cerebral palsy (CP).


      The curves, which describe the pattern of motor development according to the children's Gross Motor Function Classification System level, were used as historical control to define the GMFM-66 expected natural evolution in children with CP. These curves have been modeled and generalized to fit the curve to particular children characteristics.


      Research center.


      Not applicable.


      Not applicable.

      Mean Outcome Measures

      Not applicable.


      Assuming that the GMFM-66 score evolution followed the shape of the Rosenbaum curves, by taking into account the age and GMFM-66 score of children, the expected natural evolution of the GMFM-66 score was predicted for any group of children with CP who were <8 years old. Because the expected natural evolution could be predicted for a specific group of children with CP, the efficacy of a treatment could be determined by comparing the GMFM-66 score evolution measured before and after treatment with the expected natural evolution for the same period. A new index, the Gross Motor Function Measure Evolution Ratio, was defined as follows: Gross Motor Function Measure Evolution Ratio=measured GMFM-66 score change/expected natural evolution.


      For practical or ethical reasons, it is almost impossible to use control groups in studies evaluating effectiveness of many therapeutic modalities. The Gross Motor Function Measure Evolution Ratio gives the opportunity to take into account the expected natural evolution of the gross motor function of children with CP, which is essential to accurately interpret the therapy effect on the GMFM-66.


      List of abbreviations:

      CP (cerebral palsy), GMFCS (Gross Motor Function Classification System), GMFM-66 (Gross Motor Function Measure), PT (physical therapy)
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        • Bax M.
        • Goldstein M.
        • Rosenbaum P.
        • et al.
        Proposed definition and classification of cerebral palsy, April 2005.
        Dev Med Child Neurol. 2005; 47: 571-576
        • Russell D.J.
        • Rosenbaum P.L.
        • Cadman D.T.
        • Gowland C.
        • Hardy S.
        • Jarvis S.
        The Gross Motor Function Measure: a means to evaluate the effects of physical therapy.
        Dev Med Child Neurol. 1989; 31: 341-352
        • Russell D.J.
        • Rosenbaum P.L.
        • Avery L.M.
        • Lane M.
        Gross Motor Function Measure (GMFM-66 and GMFM-88) user’s manual.
        Wiley, 2002
        • Palisano R.
        • Rosenbaum P.
        • Walter S.
        • Russell D.
        • Wood E.
        • Galuppi B.
        Development and reliability of a system to classify gross motor function in children with cerebral palsy.
        Dev Med Child Neurol. 1997; 39: 214-223
        • Russell D.J.
        • Avery L.M.
        • Rosenbaum P.L.
        • Raina P.S.
        • Walter S.D.
        • Palisano R.J.
        Improved scaling of the Gross Motor Function Measure for children with cerebral palsy: evidence of reliability and validity.
        Phys Ther. 2000; 80: 873-885
        • Alotaibi M.
        • Long T.
        • Kennedy E.
        • Bavishi S.
        The efficacy of GMFM-88 and GMFM-66 to detect changes in gross motor function in children with cerebral palsy (CP): a literature review.
        Disabil Rehabil. 2014; 36: 617-627
        • Rosenbaum P.L.
        • Walter S.D.
        • Hanna S.E.
        • et al.
        Prognosis for gross motor function in cerebral palsy: creation of motor development curves.
        JAMA. 2002; 288: 1357-1363
        • Hanna S.E.
        • Bartlett D.J.
        • Rivard L.M.
        • Russell D.J.
        Reference curves for the Gross Motor Function Measure: percentiles for clinical description and tracking over time among children with cerebral palsy.
        Phys Ther. 2008; 88: 596-607
        • Hanna S.E.
        • Rosenbaum P.L.
        • Bartlett D.J.
        • et al.
        Stability and decline in gross motor function among children and youth with cerebral palsy aged 2 to 21 years.
        Dev Med Child Neurol. 2009; 51: 295-302
        • Rosenbaum P.
        • Eliasson A.C.
        • Hidecker M.J.
        • Palisano R.J.
        Classification in childhood disability: focusing on function in the 21st century.
        J Child Neurol. 2014; 29: 1036-1045
        • Duncan B.
        • Shen K.
        • Zou L.P.
        • et al.
        Evaluating intense rehabilitative therapies with and without acupuncture for children with cerebral palsy: a randomized controlled trial.
        Arch Phys Med Rehabil. 2012; 93: 808-815
        • Novak I.
        • McIntyre S.
        • Morgan C.
        • et al.
        A systematic review of interventions for children with cerebral palsy: state of the evidence.
        Dev Med Child Neurol. 2013; 55: 885-910
        • Anttila H.
        • Malmivaara A.
        • Kunz R.
        • Autti-Rämö I.
        • Mäkelä M.
        Quality of reporting of randomized, controlled trials in cerebral palsy.
        Pediatrics. 2006; 117: 2222-2230
        • Damiano D.L.
        Meaningfulness of mean group results for determining the optimal motor rehabilitation program for an individual child with cerebral palsy.
        Dev Med Child Neurol. 2014; 56: 1141-1146
        • Trahan J.
        • Malouin F.
        Intermittent intensive physiotherapy in children with cerebral palsy: a pilot study.
        Dev Med Child Neurol. 2002; 44: 233-239
        • Nordmark E.
        • Josenby A.L.
        • Lagergren J.
        • Andersson G.
        • Strömblad L.G.
        • Westbom L.
        Long-term outcomes five years after selective dorsal rhizotomy.
        BMC Pediatr. 2008; 8: 54
        • Worrall J.
        Evidence and ethics in medicine.
        Perspect Biol Med. 2008; 51: 418-431
        • Kelly B.
        • Mackay-Lyons M.J.
        Ethics of involving children in health-related research: applying a decision-making framework to a clinical trial.
        Physiother Can. 2010; 62: 338-346
        • Kim D.S.
        • Choi J.U.
        • Yang K.H.
        • Park C.I.
        Selective posterior rhizotomy in children with cerebral palsy: a 10-year experience.
        Childs Nerv Syst. 2001; 17: 556-562
        • Haumont T.
        • Church C.
        • Hager S.
        • et al.
        Flexed-knee gait in children with cerebral palsy: a 10-year follow-up study.
        J Child Orthop. 2013; 7: 435-443
        • Bell K.J.
        • Ounpuu S.
        • DeLuca P.A.
        • Romness M.J.
        Natural progression of gait in children with cerebral palsy.
        J Pediatr Orthop. 2002; 22: 677-682
        • Oeffinger D.
        • Bagley A.
        • Rogers S.
        • et al.
        Outcome tools used for ambulatory children with cerebral palsy: responsiveness and minimum clinically important differences.
        Dev Med Child Neurol. 2008; 50: 918-925
        • Yabunaka Y.
        • Kondo I.
        • Sonoda S.
        • et al.
        Evaluating the effect of intensive intervention in children with cerebral palsy using a hypothetical matched control group: a preliminary study.
        Am J Phys Med Rehabil. 2011; 90: 128-136