What do the GMFCS levels mean in cerebral palsy?

What is the GMFCS?

The Gross Motor Function Classification System is a five-level system used worldwide to describe the gross motor function of children with cerebral palsy, focusing on sitting, walking and mobility in everyday life. It was developed through consensus among 48 experts, including physiotherapists, occupational therapists and developmental paediatricians 1.

The GMFCS describes what a child usually does, not the most they can manage on a good day, and it is not a measure of intelligence, communication or quality of life.

What do levels I and II mean?

Children at level I walk at home, school and in the community and can climb stairs without a handrail. They can run and jump, but speed, balance and coordination may be reduced.

Children at level II walk in most settings but may have difficulty walking long distances, balancing on uneven ground, in crowds or on slopes, and usually use a handrail on stairs. They may use wheeled mobility for long distances and have limited ability to run or jump.

What do levels III, IV and V mean?

Children at level III walk using a hand-held mobility device, such as a walker or crutches, indoors, and often use a wheelchair for longer distances. They usually need support to sit in some situations.

Children at level IV have limited self-mobility and may use powered mobility, and they need adapted seating. Children at level V are transported in a manual wheelchair in all settings and have limited ability to control head and trunk posture.

How reliable is the classification?

In the original development study, interrater reliability was 0.55 for children under 2 years of age and 0.75 for children aged 2 to 12 1. This means classification is less consistent in very young children, and levels may be revised as the child develops.

Separate age bands describe expected abilities before age 2, from 2 to 4, 4 to 6, 6 to 12 and 12 to 18, because abilities change with age.

How is the GMFCS used to plan care?

A longitudinal study of 657 children created motor development curves showing the typical rates and limits of gross motor development for each GMFCS level 2. These curves help families understand likely progress and help clinicians set realistic goals and plan interventions.

The level also guides monitoring. For example, children at higher GMFCS levels are at greater risk of hip displacement and need regular hip surveillance, and UK guidance on cerebral palsy covers monitoring for such complications 3.

Can a child change GMFCS level?

The GMFCS level tends to be stable, especially after age 5, although some children, particularly those classified very young, are reclassified as they develop 2.

Therapy aims to help children achieve their full potential within and beyond the typical expectations for their level, and to improve participation and independence.

How does GMFCS level relate to equipment and support?

The GMFCS level helps teams anticipate the equipment and support a child may need. Children at levels I and II may need little equipment, while children at level III often use walkers, crutches and wheelchairs for longer distances. Children at levels IV and V usually need supportive seating, standing frames, adapted car seats and powered or manual wheelchairs.

Equipment needs change as children grow and as family routines, schools and environments change. Regular reviews by therapists help make sure equipment supports comfort, posture, participation and independence.

Which changes in movement should prompt review?

Seek review if your child loses motor skills, develops new pain, has increasing stiffness or changes in hip or spine shape.

Loss of previously gained skills is not expected in cerebral palsy and needs assessment.

Frequently asked questions