ORIGINAL

Niger J Paed 2015; 42 (3):204 –209

Adeniyi OF

Lagunju IA

Abdus-salam IA

Sidebotham P

Lesi FEA

Awareness and use of Gross Motor

Function Classification System

(GMFCS) by health professionals in

a developing country

DOI:http://dx.doi.org/10.4314/njp.v42i3.6

Accepted: 29th July 2013

Abstract: Introduction The

participated in the study and ma-

degree of disability in children

with Cerebral Palsy (CP) can be

evaluated with the Gross Motor

Function Classification System

jority (58.9%) were doctors. 55

(70.5%) of the study participants

were aware of the GMFCS but

only 33(42.3%) were using it. The

nurses were neither aware of the

system nor using it. A higher pro-

portion of therapists (65.4%) were

familiar with the system compared

to the doctors (54.3%).

The location of practice was sig-

nificantly associated with the use

of the GMFCS (p=0.013). More

doctors noted the merits and de-

merits of the system compared to

the therapists.

Conclusion: Though health profes-

sionals were aware of the GMFCS

only a small proportion was using

this vital tool in the clinical set-

ting. Thus, there is the need to

create more awareness on GMFCS

and its clinical utility, and the

training of nurses should be of

paramount importance in the de-

veloping country.

(

)

Adeniyi OF

Lesi FEA

Department of Paediatrics,

College of Medicine, University of

Lagos/Lagos University Teaching

Hospital, Nigeria.

(

GMFCS), a valid tool which was

designed for such purposes. How-

ever, there appears to be paucity

of data on the awareness and use

of the GMFCS particularly in the

Sub-Saharan continent where the

condition is still prevalent. Thus,

this study aims to describe aware-

ness, use, merits and demerits of

the GMFCS system as perceived

by health professionals who take

care of children with CP.

Methods: This was a cross sec-

tional study of health profession-

als from three Nigerian teaching

hospitals. Information obtained

via structured questionnaire were

demographic data, years of quali-

fication, years of experience of

working with children with CP,

awareness, use, merits and demer-

its of the GMFCS. Factors associ-

ated with use of the GMFCS were

also evaluated with the Chi-square

analysis.

Email: layo_funke@yahoo.co.uk

Lagunju IA

Department of Paediatrics,

College of Medicine, University of

Ibadan/University College Hospital,

Ibadan, Nigeria.

Abdus-salam IA

Department of Community Health,

Lagos University Teaching Hospital,

Lagos, Nigeria.

Sidebotham P

Department of Child Health,

University of Warwick, Coventry,

United Kingdom

Key words: Awareness, cerebral

palsy, gross motor function

classification system, developing

country

Results: 78 health professionals

4

,5

Introduction

strains on the carers of children who are afflicted .

In order to determine the degree of disability which is

closely related to the gross motor function in children

with cerebral palsy, different evaluation systems have

been developed for both clinical utility and epidemiol-

ogical purposes. One of such systems is the Gross Motor

Cerebral Palsy (CP), a major cause of disability in child-

hood is associated with significant morbidity and mor-

tality and is of immense clinical and public health im-

1,2

portance in the developing world . It is a disorder of

posture and movement that results in impairment of

function with the affected child failing to attain the

level of function that is considered normal for his/her

age. The motor disability in CP has been categorized as

spastic diplegia(involvement of the lower limbs), spastic

hemiplegia (weakness of the upper limb and the ipsilat-

eral lower limb, usually, with a more severe involve-

ment of the upper limbs) double Hemiplegia and spastic

quadriplegia (weakness of both upper and lower limbs)

6,7

Function Classification System (GMFCS) . This

system was developed as a response to the need to have

a standardised system for describing and classifying the

severity of movement disability among children with

7

6

cerebral palsy . It was validated by Palisano et al for

clinical use and this classification has been found to be

6

-9,10

. Some workers have

reliable and stable over time

noted that the classification done at tw₁₁o years of age

was able to predict walking by 12 years.

2,3

.

The disease has important implications for obstetric

and paediatric services and imposes severe stresses and

The GMFCS objectively categorizes the child’s current

2

05

gross motor function with particular emphasis on sitting

and walking. There are five levels in the system ranging

from level 1 where the child has the most independent

functional skills to level 5 where there are severe limita-

tions of self-mobility even with the use of assistive tech-

Definition of terms

‘’The GMFCS is a standardized system to classify gross

motor function of children with CP aged 12 months to

12 years based on observation of a child's self-initiated

movement and need for assistive technology and/or

wheeled mobility. Classification is made based on a

child's usual performance – not best performance – at

home, school, and in the community. There are five lev-

els from level I, in which a child is able to walk and run,

but has some difficulty with more advanced skills to

level V, in which a child has very limited voluntary

movement ability. In the original system, there are four

age bands: under 2 years, 2 to < 4 years, 4 to < 6 years,

and 6 to < 12 years. More recently there is the expanded

version of the system in which the age band 12-18 years

has been introduced’’.

7

nology. The GMFCS has been found to be very useful

by health professionals and the caregivers in describing

the gross motor function of children with CP and further

complements other classification systems used to de-

scribe the status of the children with CP especially in the

8

developed countries. Other workers have also observed

that appropriate functional classification of this chil₇d_,₉r_,e₁₂n_-

aids diagnosis, treatment and prognostication.

17

Thus, in a developing country like Nigeria where there

is still a huge burden of CP as it constitutes 40-55% of

paediatric neurologic consultations in different centres

in the country it is important that affected children are

properly evaluated and classified to₁₈_,f₁a₉cilitate manage-

ment and possibly predict prognosis.

Furthermore, in

Information on the merits/advantages and demerits/

disadvantages was also obtained. The known advantages

of the GMFCS such as being evidence based, predicting

prognosis, guiding intervention and others were high-

lighted and the study participants were to choose Yes or

no responses where applicable. Options for the demerits

were also provided.

Nigeria, there is a paucity of data on the use of the

GMFCS to evaluate the children with CP. This study

aims to describe awareness and use of the GMFCS and

the merits and demerits of the system as perceived by

health professionals who take care of children with CP.

The health professionals were categorized according to

the 3 main groups: Doctors, Therapists and Nurses. The

years of qualification was also divided into 3 groups

namely: < 10 years, 10-20 years and > 20 years. The

years of experience working with children with CP were

also divided into 3 groups : < 5 years, 5-10 years and >

10 years.

Statistical analysis was performed using the Statistical

Package for the Social Sciences (SPSS) for Windows,

version 17.0). Data summarization was done using fre-

quency and proportions. The association between cate-

gorical variables was tested using the Chi-square test.

Level of significance was set at P<0.05.

Methods

This was a cross-sectional study carried out in Nigeria

between August 2011 and July 2012 at 3 different cen-

tres, namely the Paediatric Neurology Clinics at the La-

gos University Teaching hospital, University College

Hospital Ibadan, and the Lagos State University Teach-

ing Hospital, Lagos. These 3 referral centres in the

South western Nigeria were selected by simple random

sampling technique and are centres where children with

CP are seen on a regular basis. The study population

comprised of doctors (these included paediatricians,

paediatric residents and orthopaedic surgeons), thera-

pists (namely Physiotherapists and occupational thera-

pists), and nurses who are involved in the management

of children with CP.

Results

General characteristics of the study participants

Data was collected through a self administered struc-

tured questionnaire which was given to the health pro-

fessionals by hand. The questionnaire was pre-tested

among resident doctors in the LUTH prior to the com-

mencement of the study. Information collected in the

questionnaire included demographic characteristics

The general characteristics of the study participants are

shown in Table1. A total of 78 health professionals par-

ticipated in the study, 46(58.9%) were doctors, 26

(33.3%) were therapists and 6(7.8%) were nurses. The

doctors comprised 6 paediatricians, 36 paediatric resi-

dents and 4 orthopaedic surgeons. Therapists were 24

physiotherapists and 2 occupational therapists. Many of

the doctors (67.4%) in the study had basic qualification

below 10years these were mainly resident doctors in

paediatrics. The doctors with basic qualification above

(

name, sex, occupation), years of qualification, years of

experience of working with children with CP, classifica-

tion system and awareness and experience with the use

of the gross motor function classification system.

2

0 years were paediatricians. On the other hand majority

of the therapists (50%) had basic qualification between

0-20 years.

Ethical considerations

1

Ethical approval was received from the research and

ethical committees of the different institutions. Informed

consent was also obtained from the study participants

before enrolment in to the study.

The years of working with CP patients was significantly

different amongst the professionals (p= 0.009) and

53.8% of the therapists had more than 5 years experi-

ence working with children with CP. 10(38.5%) of the

therapists compared to 7(19.6%) of the doctors were

2

06

also seeing more than 20 patients with CP on a monthly

basis.

Merits and demerits of the GMFCS

The merits and the demerits of the GMFCS were evalu-

ated in this study. A significant proportion of doctors

(57.7%) and therapists (42.3%) thought the GMFCS was

evidenced based. However, more doctors were

observed to report other advantages compared to the

therapists.

In terms of demerits 88% of the therapists believed the

GMFCS was more time consuming while only 11.1% of

the doctors reported this as a disadvantage. More

doctors however thought it was cumbersome and

complex.

Table 1: General characteristics of the study participants

Professions

Parameters

Doctors

Physio-

Nurses

Total

therapists

Gender

Male

Female

22

24

20

6

0

6

42

36

N (%)

26 (100)

N (%)

6(100)

N (%)

78(100)

4

6 (100)

Years of qualifica-

tion

3

12(26.1)

3 (8.7)

1(67.4)

11 (42.30)

13(50)

2 (7.7)

2 (33)

2(33)

44(56.4)

27(34.6)

7(9)

Table 2: Awareness, use and familiarity with the GMFCS

<

1

>

10 years

0-20 years

20 years

Awareness and Profes-

Use

sions

2

Doctors

Therapist

N

Nurses

N

Total

X

P value

Years of experi-

ence of working

with children with

CP

N (%)

46 (100)

26 (100)

6 (100)

<

5 years

-10 years

10 years

27(58.7)

12 (26.1)

7 (15.2)

12 (46.2)

10 (38.5)

4(15.3)

4(66.7)

2(33.3)

----

43(55.1)

24(30.8)

11(14.1)

5

Awareness

>

Yes

34(73.9)

12(26.1)

21(80.8)

5 (19.2)

55(70.6) 15.92

23(29.4)

0.000

0.055

0

Number of children

seen in one month

No

6(100)

Use of GMFCS

1

>

-10

1-20

20

25(54.3)

12(26.1)

7(19.6)

7(26.9)

9(34.6)

10(38.5)

6(100)

-----

38(48.7)

21(26.9)

17(24.4)

Yes

No

18(39.1)

15(57.7)

33(42.3) 5.76

41(52.6)

0

24 (52.2) 11(42.3)

6

(100)

Familiarity/ knowledge of

content of GMFCS

CP - Cerebral Palsy

Yes

No

25(54.3)

21(45.7)

17(65.45)

9(34.6)

0

42(53.8) 8.39

36(46.2)

0.015

6(100)

Awareness and use of the GMFCS

Awareness and use of the GMFCS is shown in Table 2.

Fifty five (70.5%) of the study participants were aware

of the GMFCS. Most of the therapists (80.8%) were

aware of the GMFCS but only 14(53.8%) used the scale

in the routine care of their patients. Similarly, the major-

ity of the doctors (73.9) were also aware but only about

half (39%) of them employed its use.

GMFCS- Gross Motor Function Classification System, P<0.05 is

considered significant

Table 3: Factors associated with the use of GMFCS

Factors

Use

N (%)

Don’t Use

N (%)

Chisquare

N (%)

P value

Location of Practice

Doctors

Knowledge of the content of the GMFCS was signifi-

cantly different amongst the professionals. (p= 0.015), A

higher proportion of the therapists were also more famil-

iar with the content of the GMFCS compared to the

doctors.

UCH

LUTH

LASUTH

Therapists

UCH

5(71.4)

13(35.1)

0

2(28.2)

24(64.9)

2(100)

4.599

8.678

0.100

0.013

5(100)

3(23.1)

7(50)

0

10(76.9)

7(50)

LUTH

LASUTH

Factors associated with the use of GMFCS

Years of experience

Doctors

<

5

>

Therapists

5 years

-10 years

10 years

13(48.1) 14(51.9)

1(10.0) 9(90.0)

4 (57.1) 3(42.9)

The factors associated with the use of GMFCS are

shown in Table 3. The use of the GMFCS was signifi-

cantly associated with location of practice especially for

the therapists. (p=0.013). All the therapists in UCH

were using the GMFCS while only 50% and 23.1% of

the therapists in LASUTH and LUTH respectively were

using the system. Similarly, majority of the doctors

6.724

0.804

0.175

0.849

<5 years

8(47.1)

2(33.3)

2(50.0)

9(52.9)

4(66.7)

2(50.0)

5

-10 years

>

10 years

(

71.4%) in UCH were using the system compared to

UCH- University College Hospital Ibadan, LUTH- Lagos University

Teaching Hospital, LASUTH- Lagos State University Teaching

Hospital, P<0.05 is significant

only 35.1% in LUTH. The years of experience of work-

ing with children with CP was not significantly associ-

ated with the use of the GMFCS.

2

07

Table 4: Merits and Demerits of the GMFCS as perceived by

the health professionals

capability of a group of CP patients with the GMFCS

and compared it to the gross motor performance deter-

mined by the parents using the and Gross Motor Func-

tion Classification System Family Questionnaire

Merits

Professionals

Doctors

Physio-

therapist

N(%)

Total

N(%)

p value

(

GMFCSFQ) . There was a strong correlation between

4

15 (57.7)

11(61.11)

6

26

14(42.3)

7(38.89)

72

29 (100)

18

the GMFCS scores and the GMFCSFQ scores. The

study outcome suggested that both the caregivers and

the care providers of children with hemiplegic and quad-

riplegic CP would turn in similar judgment while assess-

ing motor function in this group of patients. In another

Evidence based

Easy to remember

0.395

0.728

Internationally

recognized

Convenient

19(73.1)

7(26.9)

26

0.820

2

14(63.6)

17(94.4)

Guides Intervention 21(67.7)

8(36.4)

1(5.6)

10(32.3)

22

18

31

0.975

0.50

0.619

study, Lagunju et a1 used the GMFCS to determine the

Predicts prognosis

severity of functional impairment in CP patients and

association with neurocongitive deficits. Forty four

(14.5%) of the children were classified as class I, 32

Demerits

Cumbersome

12(80)

10(83.3)

1(11.1)

3(20)

15

12

9

0.677

0.385

0.847

(

10.6%) class II, 24(7.9%) – class III, 48(15.8%) –class

Complex

2(16.7)

8(88.9)

IV and 155(51.2%) –class V. The GMFCS provided an

objective means of assessing the severity of disability

and this showed a significant correlation with the pres-

ence of associated neurocognitive deficits and the over-

all burden of care of the child with CP.

Time consuming

P value of chi-square statistic, GMFCS- Gross Motor Function

Classification System, P<0.05 is significant.

In this present study, the nurses were neither aware of

the system nor using it, the reason for this finding is not

clear but plausible reasons may be that clinical evalua-

tion of children with disability especially with the use of

GMFCS may not be part of the schedule of duties of the

nurses. In a developing country like Nigeria, there is

poor access to health care facilities and about 60% of the

population including children with CP would seek medi-

cal help from a nearby nurse before reporting to the hos-

pital. Thus it might be of immense benefit if nurses were

trained to evaluate children with CP with the GMFCS

and to identify other deficits especially at the commu-

nity level. These trained nurses can assess such children

and refer them to the appropriate centre for comprehen-

Discussion

The GMFCS was developed in response to the need to

have a standardized system to measure the severity of

movement disability in children with cerebral palsy

(

CP). It has been established as a valid system for as-

sessing the functional status of the cerebral palsied child

and its impact and utility has been described₁₅_,i₂n₀_-₂l₂iterature

especially for caucascian children with CP

. In this

study, the health professionals who participated in the

study were at different levels of qualification and years

of experience of working with children with CP, the

nurses had the lowest experience with working with

children with CP. 73.9% of the doctors and 80.8% of

the therapists respectively were aware of the GMFCS.

However, only 57.7% of the therapists and 39.1% of the

doctors were using it respectively. Thus, it appears that

there is a gap or bridge between the knowledge of this

tool of assessment and its use in clinical practice or of-

fice setting in a developing c₅ountry like Nigeria.

s

i

v

e

t

h

e

r

a

p

y

.

Thirty two (41%) of the 78 health professionals who

participated in this study used the GMFCS and 18 of

these were doctors and 14 were therapists. It is not quite

clear what factors influenced the use of the GMFCS by

the professionals but knowledge of the content of the

system may play a role. In addition, it was observed that

the location of practice of the health professionals was

significantly associated with the use of the system espe-

cially for the therapists. This implies that for any classi-

fication system to be utilized by a professional adequate

knowledge of such a system and the centre where the

professional practices may influence the use of such a

system. It appears that in centres where there is a stan-

dardized protocol of evaluating of children with CP the

1

In a review by Morris et al on the impact and utility of

the GMFCS, it was observed that the GMFCS has been

used in observational research and experimental re-

search by various workers. It was also noted that the

uptake of the system by researchers had been rapid as

several workers found it useful and this justified its ex-

tensive use by various researchers in the developed

countries.

2

use of the GMFCS plays a significant role . However,

reports on the use of standardized clinical tools of as-

sessment indicate a possible gap between the develop-

ment of any tool of assessment and its use in the clinical

setting as observed in this study. Thus, other proposi-

tions which may enable the use of such tools have been

related to the known advantages or merits or demerits of

However, in Nigeria, there are only few studies in which

the GMF₂_,₂C₃_,S₂₄ have been used to evaluate the children

with CP

. In a study conducted by therapists in La-

23

gos, Tella et al while evaluating the health related

quality of life of 54 children with CP at Lagos used the

GMFCS to evaluate the severity of motor disability in

these patients. The severity of disability was observed to

have a negative impact on the health related quality of

25

the tool .

24

In this present study, majority (67.7%) of the doctors

believed that the GMFCS could guide intervention while

life of the children. Hamzat et al , another group of

physiotherapists in Ibadan, evaluated the gross motor

2

08

only 32.3% of the therapists acknowledged this as an

advantage of the system. Other workers have also ob-

served that th₆e GMFCS may also guide intervention.

with high academic qualification are likely to be the best

target for training purposes. This group of nurses can

then go on to even train other community health workers

in issues pertaining to CP.

2

Dumas et al reported that functional ability, defined

broadly by classifying hypothetical children as ‘more

mobile’ (GMFCS levels I to IV) and ‘less mobile’ (level

V), influenced therapists’ intervention choices. In a

study on the effectiveness of h₇orseback riding on the

Limitation

The limitation of this study may be the small number of

the health professionals it would have been more desir-

able to document the perspective of more health profes-

sionals from other centres but this was not possible for

logistic reasons.

2

functional ability of CP Sterba and workers also high-

lighted variation in treatment schedule between children

categorized as GMFCS levels I, II, or III compared to

levels IV and V. Even in terms of response to therapy

some workers have observed a better response in

younger children who were in GMFCS levels I- IV,

25 28

compared to level V , . Other merits noted by the

health professionals in this study such as prediction of

prognosis has also been noted by other workers. How-

ever it was quite striking that only one of the therapists

compared to 17 doctors thought that GMFCS was able

to predict prognosis. The reason for this is not quite

clear. Other merits observed in this present study were

seen more by the doctors than the therapists. The demer-

its/disadvantages of the system mainly being cumber-

some and complex were also observed more by the doc-

tors than the therapists. Nevertheless, the observed ad-

vantages in this study still support the need to train

nurses who are likely to be the first contact of children

with CP in the community in evaluating such children in

terms of functionality. However, in view of the observed

disadvantages the more experienced nurses and those

Conclusion

In conclusion, there appears to be a gap in the awareness

and use of this valid tool in the assessment of children

with CP. Knowledge of the content of the system and

location of practice may influence the use of the

GMFCS and thus standardized protocol for evaluating

these children incorporating the GMFCS should be

available in the centres where these children are being

evaluated. There is a need to train nurses in the use of

GMFCS as they play a key role in the management of

such children. Known merits and demerits as observed

by previous workers were also noted in the study.

Further large multicentre studies are advocated.

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