Cerebral Palsy Gross Motor Classification System

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Specialists use the Gross Motor Function Classification System (GMFCS) to describe mobility and motor skills in people with cerebral palsy. Patients are diagnosed with a level on the GMFCS scale, which helps their doctors plan treatment and choose appropriate mobility aids and assistive devices.

What Is the GMFCS?

The cerebral palsy Gross Motor Function Classification System (GMFCS) categorizes different levels of mobility and motor skills. It is a way of describing how well a person with cerebral palsy moves and functions.

According to the CanChild Centre for Childhood Disability Research at McMaster University, which revised and expanded the criteria in 2007, the focus of this classification system has been to emphasize the child’s abilities rather than restrictions.[1]

Cerebral palsy is not a progressive disease, meaning it does not get worse with time. However, most children will also not get any better with respect to their GMFCS level. While treatment cannot restore motor skills, the GMFCS diagnosis can help plan therapies and mobility aids that improve a child’s functioning.

The Importance of the GMFCS

The abilities of a child with cerebral palsy are best represented by what they do regularly rather than what they might be able to do once in a while.

Correctly classifying children with cerebral palsy according to this system gives therapists, schools, and healthcare providers a clear picture of their actual level of functioning.[2]

Descriptions for Each Level

Level I Walks without limitations

Level II Walks with limitations

Level III Walks using a hand-held mobility device (canes, crutches)

Level IV Self-mobility with limitations; self-powered mobility

Level V Transported in a manual wheelchair

GMFCS Level I

Level I has the least severe cerebral palsy motor symptoms marked by the following:

Before the 2nd Birthday:

Babies can learn to sit on the floor, crawl, pull to stand and hold onto, or “cruise” along with the furniture and hold objects in both hands without assistance. They can walk between 18 months and two years without assistance.

Between the 2nd and 4th Birthday:

Children can sit easily while holding objects in both hands without assistance and walk as the preferred method of mobility.

Between the 4th and 6th Birthday:

Children can sit down and stand up without support, sit on the floor, get up without assistance, and climb stairs. They are beginning to run and jump.

Between the 6th and 12th Birthday:

Children can run, jump, climb stairs, and walk without assistance, but speed, balance, and coordination are somewhat limited.

Between the 12th and 18th Birthday:

These older youth can walk on all surfaces, indoors and outdoors. They can run and jump, but their balance, speed, and coordination are still somewhat limited. They can participate in any physical activity based on their abilities.

GMFCS Level II

Before the 2nd Birthday:

Children still require the use of their hands for balance while sitting upright on the floor. Some babies can crawl on their hands and knees or move forward while lying on their bellies. Some can even pull up to a stand and cruise along while holding onto furniture.

Between 2nd and 4th Birthday:

They can now move in and out of the sitting position without assistance. They prefer to crawl on hands and knees, cruise along while holding onto furniture, and walk with an assistive mobility device.

Between 4th and 6th Birthday:

Children should be able to sit in a chair or on the floor and use their hands freely. They move into a stand now without as much need for a stable object to hold onto or push. They can walk for short distances without assistive devices. At this level, children can climb stairs holding onto a railing but cannot skip, run, or jump.

Between 6th and 12th Birthday:

Children can now walk indoors and outdoors with little to no assistance. For distances, however, they still require assistance. Running and jumping remains minimal. They also need help carrying objects, climbing steps, and walking on a floor or an inclined surface.

Between the 12th and 18th Birthday:

Youth can walk in most settings, with mobility choices based on personal preferences. They will likely need a hand-held mobility device for school or work and a wheelchair for longer distances. They can walk upstairs with a railing. Adaptations will probably be required for sports participation.

GMFCS Level III

Prior to 2nd Birthday:

Infants need continuous lower back support and assistance to sit up but can roll and push themselves forward while on their bellies.

Between 2nd and 4th Birthday:

Crawling is generally the preferred method of moving around at this level, and children typically use their hands and knees to crawl. They can sit up unsupported but in the “W” position with their knees bent and rotated outward and their legs facing backward. They can pull to a stand and cruise short distances. Walking for brief periods can be done with a walker, with assistance needed for turning.

Between 4th and 6th Birthday:

Children can sit in a chair but need trunk support to use their hands. While holding onto something sturdy, they can push themselves to a stand and climb stairs with assistance. Walking alone also requires assistance from an adult or a mobility device.

Between 6th and 12th Birthday:

Children can walk indoors and outdoors with the assistance of a hand-held mobility device. They can also climb stairs using handrails or with help from adults. However, they cannot walk long distances and require a wheelchair or an adult who can carry them. They need a seatbelt to support them while seated.

Between the 12th and 18th Birthday:

Youth can walk upstairs with a railing as long as they have assistance. They will, however, need help with transfers and a seat belt for support and balance while sitting. A hand-held mobility device facilitates walking, but they generally use a powered or self-propelled wheelchair at school. Adaptations are needed for participation in sports and other activities.

GMFCS Level IV

Prior to 2nd Birthday:

Babies have head control and can roll back and forth on their own. Because they lack trunk control, they need adult assistance to sit up.

Between 2nd and 4th Birthday:

Children can now sit up alone but need to use their hands for support to maintain their position. Children also need adaptive equipment for sitting and standing. At this level, children use crawling as their preferred method of moving around.

Between 4th and 6th Birthday:

Children can walk short distances with a walker but should always be monitored as they have issues with balance and coordination. They also need trunk support while sitting.

Between 6th and 12th Birthday:

Mobility generally remains the same in this age group, but once children start school, they use mobility assistance devices, such as wheelchairs, more than at home.

Between the 12th and 18th Birthday:

Self-propelled wheeled mobility is required in most settings, along with adaptive seating. Generally, one to two people are needed to help with transfers, although the youth will be able to support their weight to assist with standing transfers. Youth require adaptations and physical assistance to participate in sports and other activities.

GMFCS Level V

Prior to 2nd Birthday:

Infants’ voluntary control of their limbs is limited, and they require assistance in sitting up, rolling over, and holding their heads up.

Between 2nd and 4th Birthday:

Children continue to have minimal mobility. They need assistance in all areas of movement. Adaptive equipment cannot fully compensate for their limitations, although a wheelchair with extensive adaptations can be used.

Between 4th and 6th Birthday:

There is no increase in function from the previous level. They continue to require assistance in all areas of mobility.

Between 6th and 12th Birthday:

Mobility is still minimal, although some children can use an electric wheelchair independently. Children in this age group still depend upon others for movement and need extensive adaptations to maintain head and body alignment.

Between the 12th and 18th Birthday:

A manual wheelchair with assistance is required for mobility, although self-mobility may be attained with extensive adaptations for control and stable seating. Arm and leg movements are difficult to control. Maintaining head alignment is also difficult. Youth in this age group may require a mechanical lift for transfers and physical assistance by one to two persons.

If you believe your child has cerebral palsy, talk to your pediatrician about a diagnosis and see a specialist. A thorough evaluation using the GMFCS will help direct your child’s care and therapies.