2151-805X/11/$35.00 2011 by Begell House, Inc.

1
Critical Reviews in Physical and Rehabilitation Medicine, 23(14), 114 (2011)
Assessment of Strength and Function
in Ambulatory Children with Cerebral
Palsy by GMFCS Level and Age: A
Cross-Sectional Study
Sahar Hassani,
a
Joseph Krzak,
a
Ann Flanagan,
a
Anita Bagley,
b

George Gorton,
c
Mark Romness,
d
Chester Tylkowski,
e

Mark Abel,
d
Barbara Johnson,
f
& Donna Oefnger
e
a
Shriners Hospitals for ChildrenChicago, Chicago, IL.
b
Shriners Hospitals for ChildrenNorthern
California, Sacramento, CA.
c
Shriners Hospitals for ChildrenSpringeld, Springeld, MA.
d
Uni-
versity of Virginia, Charlottesville, VA.
e
Shriners Hospitals for ChildrenLexington, Lexington, KY.
f
Shriners Hospitals for ChildrenSalt Lake City, Salt Lake City, UT
*Address all correspondence to: Sahar Hassani, MS, Director of Research Administration, Shriners Hospitals for
ChildrenChicago, 2211 N. Oak Park Avenue, Chicago, IL 60707; Tel.: 773-385-5457; Fax: 773-385-5459; shas-
sani@shrinenet.org
ABSTRACT: The purpose of this work is to provide comparison data for muscle strength
and measures of activity and participation stratifed by GMFCS level, age, and cerebral
palsy (CP) type. Clinicians can use the data to determine treatment goals based on the
patients matched peer group. Methods used were data were collected on 377 individuals
with hemiplegia and diplegia, GMFCS levels IIII, ages eight to18 years. Lower extrem-
ity muscle strength, Gillette gait index (GGI), one-minute walk test (1MWT), and timed
up-and-go (TUG) were collected. Results showed that strength differed among GMFCS
levels and age for both CP types. The GGI and 1 MWT discriminated among GMFCS
levels within each CP type. The TUG discriminated between GMFCS levels I and III and
levels II and III for the diplegic group. We conclude that differences in strength and mea-
sures of activity and participation were found across GMFCS levels and CP type. The
reported stratifed data can serve as an important clinical tool in determining realistic
treatment goals and clinical outcomes.
KEY WORDS: muscle strength; one-minute walk test (1MWT), timed up-and-go (TUG), Gillette
gait index (GGI), cerebral palsy
ABBREVIATIONS: CP: cerebral palsy; GMFCS: gross motor function classifcation system; 1MWT:
one-minute walk test; TUG: timed up-and-go; GGI: Gillette gait index
I. INTRODUCTION
Comparison of function in children with cerebral palsy (CP) based on severity, age,
and distribution of limb involvement is fundamental when determining appropriate
clinical care and conducting clinical research. Standardized outcome tools are rou-
tinely used to quantify body functions and structures, activities and participation
for individuals with CP.
15

Critical Reviews in Physical and Rehabilitation Medicine
2 Hassani et al
Investigators previously reported descriptive characteristics of several outcome
tools in ambulatory children with CP stratifed by severity level.
68.
Oeffnger et
al.
6,9
found a direct relationship between gross motor function classifcation system
(GMFCS) level
2
and the pediatric outcomes data collection instrument (PODCI),
4

pediatric functional independence measure (WeeFIM),
3
Gillette functional assess-
ment questionnaire (FAQ),
1
gross motor function measure (GMFM),
10
energy cost
during walking (O
2
cost), and temporal-spatial gait parameters. The study showed
a direct relationship between increasing severity and decreasing scores on outcome
tools. The results provided descriptive data, by severity level, that clinicians can use
for comparison with individual children with CP.
Age has been found to be associated with gross motor function of children with
CP.
11
Differential rates and limits of gross motor development were found among
children of different GMFCS levels.
12
Wright et al.
13
described patterns of gross
motor development of children with CP. The GMFCS was used as a predictive
measure, longitudinally tracking the rates and limits of motor function (GMFM
scores) of children with similar age and severity.
In addition to severity and age, consideration of the type of CP has been shown to
be important when assessing children using outcome tools. Damiano et al.
14
reported
descriptive characteristics of children with CP and compared those with hemiplegia
to those with diplegia by GMFCS level. Results showed that children with hemiplegia
presented differently from those with diplegia on the PODCI, WeeFIM, GMFM,
FAQ, O
2
cost

, and gait metrics. Children with hemiplegia had worse upper extremity
function but better gait and lower extremity function than children with diplegia.
While previous studies have focused on differences by CP type, severity level, or age,
few have used all three stratifcations. Strength is important in this population. Children
with CP are weaker than their peers,
15
which could lead to decreased function on mea-
sures of activity and participation. Strength assessments are used frequently in clinical
settings to determine if specifc muscle weakness exists. Limited comparison data for
overall lower extremity strength and individual muscle strength for ambulatory children
with CP by CP type, GMFCS levels, and age are available in the literature.
15,16
Assessments used to test endurance, balance, and gait deviations in individuals
with CP include measures of activity and participation such as the one-minute walk
test (1MWT), timed up-and-go (TUG), and the Gillette gait index (GGI). The 1MWT
is a valid measure of functional mobility and endurance in children with CP.
17
TUG
measures basic mobility, dynamic balance, and function,
18
and may be used for any
population with impaired balance.
1923
TUG may serve as an accurate tool in assess-
ing the effciency of transitions and gait in children with CP. The GGI is a measure
of gait deviation that incorporates 16 kinematic and temporal-spatial parameters.
1,24

The GGI can distinguish between types of CP (hemiplegia and diplegia) as well as
between involved and uninvolved limbs of individuals with hemiplegic CP.
25,26
The purpose of this study was to assess measures of activity and participation,
and the body function and structure measurement of strength using standardized
outcome tools stratifed by CP type, GMFCS level, and age. The results provide data
Volume 23, Issue 14, 2011
Strength and Function in Ambulatory Children with Cerebral Palsy 3
to clinicians that allow for comparison of individuals with CP to others with similar
severity levels, age, and CP type, leading to better clinical decision making, posttreat-
ment follow-up, and experimental designs. This paper builds on previous work by
the Functional Assessment Research Group that evaluated multiple outcome tools
stratifed by GMFCS level and CP type in ambulatory children with CP
6,8,9,14,27,28
and
includes new measures of TUG, 1MWT, GGI, and lower extremity strength.
II. METHODS
A. Participants
This study was part of a four-year prospective multicenter study. Participants were
a convenience sample of eligible patients from seven pediatric orthopedic hospitals.
Institutional Review Board approval was obtained at each site and consent and
Health Insurance Portability and Accountability Act forms were completed.
Inclusion criteria were: patients with a diagnosis of spastic CP, in GMFCS lev-
els IIII, ages 8 to 18 years, and who were able to complete an instrumented gait
analysis with or without assistive devices. Patients were excluded if they had lower
extremity orthopedic surgery within the last year, botulinum toxin A injections in
the past four months, or a currently implanted and operating baclofen pump. A
total of 748 patients were assessed: 273 did not meet inclusion criteria; 80 declined
participation. Demographic characteristics of individuals who did not participate
were not different from those who did. Data from 18 participants were excluded for
inconsistent or missing data, resulting in 377 in the fnal analysis.
B. Data Management
Before study initiation, all coordinators attended a mandatory two-day training ses-
sion to review and standardize administration of the outcome tools and data col-
lection processes. All participant data were entered directly into a custom database
designed for study management and data collection. Encoded data from each site
were compiled for analysis. Data quality and consistency was ensured by the project
manager and site coordinators.
C. Assessment Tools
Each participant completed an assessment that included GMFCS, height, weight, and
pubertal stage measured by self-report of the Tanner scale. Patient history was collected
that included gestational age, race, limb involvement, age at walking onset, additional
diagnoses, and previous surgeries. Each participant completed an instrumented gait
analysis, 1MWT, and TUG as measures of activity and participation. Lower extremity
strength was also collected.
16
To compare current fndings with our previous work,
6,8,9,27

PODCI, GMFM, gait temporal-spatial parameters, and O
2
cost were also collected.
Critical Reviews in Physical and Rehabilitation Medicine
4 Hassani et al
During the 1MWT, participants were instructed to walk using their typical
walking aids, orthoses, and shoes at their fastest pace possible, without running,
for 1 min. Total distance in meters walked were recorded. For the TUG, the length
of time (seconds) was recorded for rising from the sitting position in a chair, walk
3 m, touch the wall, turn around, walk back, and sit down while using customary
walking aids, orthoses, and shoes.
Participants were evaluated using instrumented gait analysis. All subjects walked
barefoot at self-selected walking speed. GGI was calculated for three representative
trials and averaged to obtain the GGI score. For children with diplegia, the GGI
data from the left and right limbs were averaged to give the total GGI score. For
those with hemiplegia, total GGI score and individual GGI scores of involved and
uninvolved sides were calculated.
Lower extremity muscle strength of the hip fexors, extensors, abductors and
adductors, knee fexors and extensors, and ankle plantar fexors and dorsifexors
were assessed using a standardized protocol with a handheld dynamometer (HHD)
(JTECH PowerTrack II Commander, Salt Lake City, Utah). All examiners re-
ceived training on the standardized protocol, and reliability testing was completed.
Strength scores for each individual muscle was the maximum value of three trials.
Two aggregate strength scores were collected. Total strength score was calculated
by averaging the individual strength scores for all muscles bilaterally. Total extensor
strength was the sum of hip and knee extensors, and ankle plantar fexors bilater-
ally. All strength scores were normalized to body weight.
D. Statistical Analysis
Descriptive statistics were calculated for all interval variables and were analyzed
by GMFCS level, type of CP (hemiplegia or diplegia), and age group. Participants
with hemiplegia and diplegia were analyzed separately for all analyses. Three age
groups were created: prepubescent (age group 1: 8<11 years), pubescent (age group
2: 11<14 years), and postpubescent (age group 3: 1419 years). Paired t-tests were
used to compare differences between CP types. ANOVAs were used to analyze dif-
ferences among GMFCS levels and age groups. Post hoc tests were performed to
examine signifcant main effects. Due to the large number of parallel tests, a p <
0.01 was set a priori as the signifcance level for all statistical tests.
III. RESULTS
Participant demographics are reported for the diplegic and the hemiplegic groups
(Table 1). Of the 377 subjects, 273 (72%) were diplegic and 104 (28%) were hemiplegic.
Within the diplegic group, 67 (25%) were GMFCS level I, 130 (48%) were GMFCS level
II, and 76 (28%) were GMFCS level III. Also, 72 (26%) were in age group 1, 103 (38%)
in age group 2, and 98 (36%) in age group 3. One hundred and sixty (59%) previously
had musculoskeletal surgery. Two hundred and fourteen (79%) were Caucasian, 19 (7%)
Volume 23, Issue 14, 2011
Strength and Function in Ambulatory Children with Cerebral Palsy 5
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Critical Reviews in Physical and Rehabilitation Medicine
6 Hassani et al
were African-American, 21 (8%) were Hispanic/Latino, and 16 (6%) were considered as
other. Within the hemiplegic group, 81 (78%) were GMFCS level I and 23 (22%) were
GMFCS level II. Thirty-six (35%) were in age group I, 30 (29%) in age group II, and 38
(36%) in age group III. Sixty-six (64%) previously had musculoskeletal surgery and 38
(36%) did not. Eighty-three (81%) were Caucasian, 7 (7%) were African-American, 7
(7%) were Hispanic/Latino, and 6 (5%) were considered as other.
Data were analyzed to assess site bias for all study measures. No differences
in data collected across sites were found for any measures except for strength. The
PODCI, GMFM, gait temporal-spatial, and O
2
cost data were nearly identical to
those previously published by Oeffnger et al.
6
A. Descriptive Statistics
1. Diplegia
When comparing GMFCS levels for the diplegic group, differences were observed
across all levels for 1MWT, TUG, and GGI scores (Table 2). Specifcally, 1MWT
Table 2. Diplegic descriptive data by gross motor function classication
level, mean (SD)
Instrument GMFCS level I GMFCS level II GMFCS level III
1-min walk test, m 85.8 (14.8)
,
* 70.4 (17.3)
^
48.8 (18.5)
TUG, s 7.9 (5.5)* 8.9 (2.6)
^
26.9 (19.6)
GGI total Score 182.0 (122.0)
,
* 244.7 (125.7)
^
473.1 (186.4)
Strength, normalized, N/kg
Ankle dorsiexors 2.4 (3.3) 2.1 (3.6) 2.6 (8.2)
Ankle plantarexors 3.3 (2.4)
,
* 2.5 (1.9)
^
1.4 (1.1)
Hip abductors 2.3 (1.0)
,
* 1.8 (0.8)
^
1.0 (0.7)
Hip adductors 2.6 (1.2)
,
* 2.1 (1.0)
^
1.7 (0.9)
Hip extensors 2.3 (1.4)* 2.0 (1.4)
^
1.4 (1.1)
Hip exors 2.8 (1.2)
,
* 2.3 (1.0)
^
1.5 (0.8)
Knee extensors (30 deg) 2.5 (1.5)* 2.1 (1.2)
^
1.6 (1.2)
Knee extensors (90 deg) 3.4 (1.6)* 3.0 (1.2)
^
2.3 (1.0)
Knee exors 2.7 (1.0)
,
* 2.1 (0.9)
^
1.2 (0.7)
Total extensors 8.2 (4.8)* 6.8 (4.1)
^
5.0 (4.3)
Total strength score 2.7 (1.2)
,
* 2.2 (0.9)
^
1.6 (0.7)

: p < 0.01 between GMFCS levels I and II

*: p < 0.01 between GMFCS levels I and III
^
: p < 0.01 between GMFCS levels II and III
Volume 23, Issue 14, 2011
Strength and Function in Ambulatory Children with Cerebral Palsy 7
distances decreased and GGI scores increased (indicating more gait deviations) with
increasing severity (GMFCS level). Time required to perform the TUG increased
between GMFCS levels I and III and levels II and III. For the individual and ag-
gregate normalized strength values, all were different across GMFCS levels with the
exception of ankle dorsifexors. Monotonic decreases in strength were found with
increasing GMFCS levels for ankle plantar fexors, hip abductors and adductors,
hip fexors, knee fexors, and total strength.
When comparing strength across age groups for the diplegic group (Table 3), the
prepubescent group (age group 1) was the strongest, based on normalized strength.
They were stronger than the pubescent group (age group 2) for hip adductors, knee
extensors, knee fexors, total extensors, and total strength, and stronger than the
postpubesent (age group 3) for all muscle groups except ankle dorsifexors and hip
extensors. There were no differences in strength identifed between the pubescent
(age group 2) and postpubescent groups (age group 3). No differences in the scores
on the activity and participation measures were observed among age groups.
Table 3. Diplegic descriptive data for pediatric outcome tools by
age group, mean (SD)
Instrument
Age group I
(8.010.9)
Age group II
(11.013.9)
Age group III
14.019.0)
1-min walk test, m 66.9 (19.3) 66.7 (22.2) 70.5 (23.0)
TUG, s 12.0 (9.5) 13.9 (13.7) 14.5 (15.6)
GGI total score 273.8 (157.0) 315.0 (205.4) 279.1 (174.8)
Strength, normalized, N/kg
Ankle dorsiexors 1.8 (1.4) 2.5 (4.4) 2.4 (6.9)
Ankle plantarexors 3.1 (2.4)* 2.3 (1.8) 2.0 (1.9)
Hip abductors 2.1 (1.0)* 1.7 (0.9) 1.5 (1.0)
Hip adductors 2.7 (1.0)
,
* 2.1 (1.0) 1.8 (1.0)
Hip extensors 2.3 (1.6) 1.9 (1.2) 1.7 (1.3)
Hip exors 2.6 (1.1)* 2.3 (1.1) 2.0 (1.1)
Knee extensors (30 deg) 2.9 (1.5)
,
* 1.9 (1.1) 1.7 (1.1)
Knee extensors (90 deg) 3.6 (1.4)
,
* 2.9 (1.2) 2.5 (1.2)
Knee exors 2.4 (1.0)
,
* 2.0 (1.0) 1.7 (1.0)
Total extensors 8.5 (4.9)
,
* 6.6 (3.9) 5.7 (4.4)
Total strength normalized 2.7 (1.0)
,
* 2.2 (.9) 1.9 (1.0)

: p < .05 between age groups I and II

*: p < .05 between age groups I and III
^
: p < .05 between age groups II and III
Critical Reviews in Physical and Rehabilitation Medicine
8 Hassani et al
2. Hemiplegia
For the hemiplegic group (Table 4), distances walked in 1MWT decreased between
levels I and II and total GGI scores increased. Differences in GGI scores were seen
between GMFCS levels I and II for both the involved and uninvolved sides. Strength
decreased with increasing severity for the involved sides hip abductors, knee exten-
sors (30 deg), knee fexors, and total extensors. For the uninvolved side, GMFCS
level II were weaker than level I for hip abductors, hip extensors, knee extensors
(30 deg), and total extensors. No differences in strength or outcome measure scores
were identifed when age groups were compared.
Table 4. Hemiplegic descriptive data by gross motor function classication
level (GMFCS) and involved/uninvolved sides, mean (SD)
Instrument GMFCS level I GMFCS level II
1-min walk test, m 89.0 (17.7)

71.6 (13.6)
TUG, s 6.7 (1.6) 7.6 (1.8)
GGI total score 150.0 (102.2)

346.6 (260.5)
Instrument Involved side Involved side Involved side Involved side
GGI score 200.0 (146.5)

101.7 (74.6)

461.8 (419.1) 231.4 (176.0)

S t r e n g t h ,
normalized, N/kg
A n k l e
dorsiexors
2.0 (4.1) 3.0 (3.5) 1.6 (4.2) 1.9 (0.9)
A n k l e
plantarexors
2.3 (1.7) 3.8 (2.2) 1.5 (1.5) 2.8 (2.1)
Hip abductors 2.4 (0.9)

2.6 (0.9)

1.7 (0.7) 2.0 (0.8)

Hip adductors 2.4 (1.0) 2.6 (1.1) 2.0 (1.0) 2.1 (0.9)
Hip extensors 2.6 (1.5) 2.7 (1.5)

1.8 (1.2) 1.8 (1.1)

Hip exors 3.0 (1.2) 3.1 (1.2) 2.5 (1.1) 2.5 (1.0)
Knee extensors
(30 deg)
2.5 (1.1)

3.0 (1.2)

1.6 (1.1) 2.0 (1.0)

Knee extensors
(90 deg)
3.2 (1.6) 3.5 (1.8) 2.9 (1.3) 3.4 (1.2)
Knee exors 2.5 (1.0)

3.0 (1.0) 1.9 (0.7) 2.4 (0.8)

Total extensors 7.4 (3.4)

9.5 (4.0)

4.9 (3.2) 6.6 (3.4)

Total strength,
normalized
2.6 (1.0) 3.0 (1.0) 2.0 (0.8) 2.4 (0.8)

: p < .01 between GMFCS level I and II

Volume 23, Issue 14, 2011
Strength and Function in Ambulatory Children with Cerebral Palsy 9
3. Diplegia versus Hemiplegia
Differences were seen between the subset of the diplegic group (GMFCS levels I
and II) and hemiplegic groups for the 1MWT (diplegia: 68.6 21.7 m, hemiplegia:
85.0 18.5 m) and TUG (diplegia: 13.1 13.1 s, hemiplegia: 6.9 1.7 s), with the
hemiplegic group having greater function. For total GGI score at GMFCS level II
(diplegia: 244.7 125.7, hemiplegia: 461.8 419.1), diplegics had less gait devia-
tion than hemiplegics (involved side). Strength scores were similar between those
with hemiplegia and those with diplegia. Differences were seen in normalized hip
abductors (diplegia: 2.0 .9, hemiplegia: 2.3 .9) and hip fexors (diplegia: 2.3
1.1, hemiplegia: 2.9 1.2), as well as normalized plantarfexor strength at GMFCS
level I (diplegia: 3.3 2.4, hemiplegia: 2.3 1.7).
IV. DISCUSSION
The fndings from this study are part of a broader multicenter study to identify factors
that help explain the variance in measures of activity and participation accounting for
CP type, severity level, and age. The descriptive statistics reported are representative
of a group of ambulatory children with CP ranging from eight to 18 years of age.
The 1MWT is quick and easy, and requires minimal space to measure functional
mobility and endurance. Our results are consistent with previous fndings
17
that the
1MWT can differentiate among severity levels and CP type. However, previous re-
searchers did not stratify by CP type, and assessed only 34 participants among the four
GMFCS levels.
17
Based on our fndings, clinicians can quickly assess and compare
their patients to the mean distance of the 1MWT based on severity level and CP type.
While the TUG is a valid tool to assess balance in children with CP,
18
it only
detected differences between GMFCS levels I and III and levels II and III in the
diplegic group. The TUG did not differentiate by severity level for the hemiplegic
group. These fndings are consistent with Gan et al.,
29
who reported that the TUG
and Berg balance scale (BBS) were unable to distinguish between GMFCS levels I
and II in children with CP. However, in their study, the sample of 30 children was
not stratifed by CP type, and included children with diplegia, hemiplegia, quad-
riplegia, ataxia, and athetosis. Although Williams et al.
18
reported that the TUG
can differentiate among GMFCS levels when stratifed by CP type, only a small
sample size was tested. Based on our fndings, a more discriminative or more physi-
cally challenging tool is necessary to measure differences in functional mobility in
children with GMFCS levels I and II.
The GGI was able to differentiate among severity levels for children with diplegia,
as well as between GMFCS levels, and the uninvolved and involved sides for children
with hemiplegia. While these fndings were consistent with Schutte et al.,
26
the GGI only
differentiated between individuals with hemiplegia and diplegia at GMFCS level II, but
not for the less involved GMFCS level I group. Overall, the GGI is an accurate and reli-
able tool to provide a global assessment of a patients gait deviations compared to peers.
Critical Reviews in Physical and Rehabilitation Medicine
10 Hassani et al
Surprisingly, activity and participation scores in this study did not differ by age.
Previous studies reported that age is associated with gross motor function, activ-
ity, and participation when stratifed by GMFCS level.
13,30
The GMFM has been
reported to differentiate among age groups, showing that function deteriorates as a
child with CP gets older primarily in levels III, IV, and V.
30
Strength measures differed among age groups for both CP types. Specifcally, the
prepubescent group exhibited higher normalized strength values for several muscle
groups when compared to the pubescent and postpubescent age groups. No previ-
ous studies have stratifed normalized strength values by age group, GMFCS level,
and CP type. Muscle strength has been directly correlated with motor function in
children with CP.
3134
Based on these fndings, strength training may be indicated for
children as they progress into puberty and adulthood.
In addition to age, muscle strength varied by GMFCS level for the hemiple-
gic and diplegic groups. Participants exhibited greater muscle weakness as their
GMFCS level increased. Wiley et al.
16
reported lower extremity muscle weakness
in ambulatory children with hemiplegia and diplegia compared to age-matched
peers using the HHD, but did not stratify by GMFCS levels. To our knowledge,
no study to date has stratifed lower extremity muscle strength by both GMFCS
level and CP type. The data reported from this study could assist therapists in
baseline assessment and treatment goals. For example, if a child with diplegic
CP (GMFCS level II) who ambulates 40 m for the 1MWT walks a signifcantly
shorter distance than their peers (70 17.3 m). Based on this comparison, a physi-
cal therapist would focus on endurance and speed training to help the child reach
their full potential.
A. Limitations
A potential limitation of the study was that there may have been differences be-
tween evaluators for strength measurements despite standardization of the protocol
and training of all assessors. Some difference may be due to the individual evalua-
tor strength. Despite the signifcant differences in magnitude of the measurements
among examiners, the study trends were the same for all evaluators. Isokinetic ma-
chines could provide more accurate, reliable readings, but can be expensive and not
always easily accessible or practical in a clinical setting. While the sample size was
large, when the data were stratifed by both CP type and GMFCS levels, the fndings
may be limited by the small sample size in GMFCS level II for the hemiplegic group.
V. CONCLUSION
Differences in strength and measure of activity and participation were found across
GMFCS levels and CP type. For the diplegic group, strength data and the activity
and participation measures of 1MWT, TUG, and GGI differed by severity level.
For the hemiplegic group, the 1MWT and GGI differed by GMFCS level. The
Volume 23, Issue 14, 2011
Strength and Function in Ambulatory Children with Cerebral Palsy 11
1MWT, a simple, quick measure of endurance, proved to be discriminative among
GMFCS levels and between CP types. The GGI was discriminative among GMFCS
levels within each CP type.
This study enhanced our previous work by assessing strength and additional
outcome tools to measure activity and participation across GMFCS levels, age, and
CP type. Comparison data for lower extremity strength, 1MWT, TUG, and GGI
by GMFCS level and CP type is provided. By comparing a childs score to the
reported data stratifed by severity, age, and CP type, clinicians can use the data to
determine treatment goals and assess long-term follow-up based on the patients
matched peer group. Future work from this study includes analyzing relationships
among the tools. Also, the longitudinal component of the study will allow us to
measure changes in these tools over time in ambulatory children with CP.
ACKNOWLEDGMENTS
The Functional Assessment Research Group (FARG) acknowledges the funding of
this work by the Shriners Hospitals for Children Grant No. 9158; the contribution
of statistical consultant Dick Kryscio, PhD, Department of Biostatistics at the Uni-
versity of Kentucky; Sylvia unpuu, M.Sc., coinvestigator, Connecticut Childrens
Medical Center; and the research coordinators and motion analysis laboratory staff
at all participating facilities for their roles in data collection, as well as the partici-
pants and their families.
REFERENCES
1. Novacheck TF, Stout JL, Tervo R. Reliability and validity of the Gillette Func-
tional Assessment Questionnaire as an outcome measure in children with walk-
ing disabilities. J Pediatr Orthop. 2000 Jan-Feb;20(1):7581.
2. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Develop-
ment and reliability of a system to classify gross motor function in children with
cerebral palsy. Dev Med Child Neurol. 1997 Apr;39(4):21423.
3. McCabe MA, Granger CV. Content validity of a pediatric functional indepen-
dence measure. Appl Nurs Res. 1990;3(3):1202.
4. Daltroy LH, Liang MH, Fossel AH, Goldberg MJ. The POSNA pediatric mus-
culoskeletal functional health questionnaire: report on reliability, validity, and
sensitivity to change. Pediatric Outcomes Instrument Development Group. Pe-
diatric Orthopaedic Society of North America. J Pediatr Orthop. 1998 Sep-
Oct;18(5):56171.
5. Ottenbacher KJ, Msall ME, Lyon NR, Duffy LC, Granger CV, Braun S. In-
terrater agreement and stability of the Functional Independence Measure for
Children (WeeFIM): use in children with developmental disabilities. Arch Phys
Med Rehabil. 1997;78(12):130915.
Critical Reviews in Physical and Rehabilitation Medicine
12 Hassani et al
6. Oeffnger DJ, Tylkowski CM, Rayens MK, Davis RF, Gorton GE 3rd, DAstous
J, Nicholson DE, Damiano DL, Abel MF, Bagley AM, Luan J. Gross Motor
Function Classifcation System and outcome tools for assessing ambulatory ce-
rebral palsy: a multicenter study. Dev Med Child Neurol. 2004 May;46(5):3119.
7. Sullivan E BD, Calmes J, Linton J, Damiano D, Oeffnger D, Tylkowski C, Abel
M, Bagley A, Gorton G, Nicholson D, Rogers S. Relationships among pediatric
measures utilized for assessment of functional outcomes in ambulatory chil-
dren with cerebral palsy. Dev Med Child Neurol. 2007;49(5):33844.
8. Bagley A, Gorton G, Oeffnger D, Barnes D, Calmes J, Nicholson D, Damiano
D, Abel M, Kryscio R, Rogers S, Tylkowsk C. Outcome assessments in children
with cerebral palsy, part II: discriminatory ability of outcome tools. Dev Med
Child Neurol. 2007 Mar;49(3):1816.
9. Oeffnger D, Gorton G, Bagley A, Nicholson D, Barnes D, Calmes J, Abel M,
Damiano D, Kryscio R, Rogers S, Tylkowsk C. Outcome assessments in chil-
dren with cerebral palsy, part I: descriptive characteristics of GMFCS Levels I
to III. Dev Med Child Neurol. 2007 Mar;49(3):17280.
10. Russell D, Rosenbaum, P., Avery, L., Lane, M. Gross motor function measure
(gmfm-66 & gmfm-88) users manual. Clinics in Developmental Medicine No.
159. London: MacKeith Press; 2002.
11. Palisano RJ, Cameron D, Rosenbaum PL, Walter SD, Russell D. Stability of
the gross motor function classifcation system. Dev Med Child Neurol. 2006
Jun;48(6):4248.
12. Rosenbaum PL, Walter SD, Hanna SE, Palisano RJ, Russell DJ, Raina P, E. Wood
E, Bartlett DJ, Galuppi BE. Prognosis for gross motor function in cerebral palsy:
creation of motor development curves. Jama. 2002 Sep 18;288(11):135763.
13. Wright F, Rosenbaum, P, Goldsmith, C., Law, M., Fehlings, D. How do changes
in body functions and structures, activity, and participation relate in children
with cerebral palsy. Dev Med Child Neurol. 2008;50:2839.
14. Damiano D, Abel M, Romness M, Oeffnger D, Tylkowski C, Gorton G, Bagley
A, Nicholson D, Barnes D, Calmes J, Kryscio R, Rogers S. Comparing func-
tional profles of children with hemiplegic and diplegic cerebral palsy in GMF-
CS Levels I and II: are separate classifcations needed? Dev Med Child Neurol.
2006 Oct;48(10):797803.
15. Stackhouse SA B-MS, Lee SC. Voluntary muscle activiation, contractile prop-
erties, and fatigability in children with cerebral palsy: effects on gait character-
istics and muscle strength. Muscle Nerve. 2005;31:594601.
16. Wiley ME, Damiano DL. Lower-extremity strength profles in spastic cerebral
palsy. Dev Med Child Neurol. 1998 Feb;40(2):1007.
17. McDowell BC, Kerr C, Parkes J, Cosgrove A. Validity of a 1 minute walk test
for children with cerebral palsy. Dev Med Child Neurol. 2005 Nov;47(11):7448.
Volume 23, Issue 14, 2011
Strength and Function in Ambulatory Children with Cerebral Palsy 13
18. Williams EN, Carroll SG, Reddihough DS, Phillips BA, Galea MP. Investiga-
tion of the Timed Up & Go test in children. Dev Med Child Neurol. 2005
Aug;47(8):51824.
19. Andersson C, Grooten W, Hellsten M, Kaping K, Mattsson E. Adults
with cerebral palsy: walking ability after progressive strength training.
Dev Med Child Neurol. 2003 Apr;45(4):2208.
20. Eekhof JA, De Bock GH, Schaapveld K, Springer MP. Short report:
functional mobility assessment at home. Timed up and go test using
three different chairs. Can Fam Physician. 2001 Jun;47:12057.
21. Geiger RA, Allen JB, OKeefe J, Hicks RR. Balance and mobility fol-
lowing stroke: effects of physical therapy interventions with and without
biofeedback/forceplate training. Phys Ther. 2001 Apr;81(4):9951005.
22. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability
for falls in community-dwelling older adults using the Timed Up & Go
Test. Phys Ther. 2000 Sep;80(9):896903.
23. Westcott SL, Lowes LP, Richardson PK. Evaluation of postural stabil-
ity in children: current theories and assessment tools. Phys Ther. 1997
Jun;77(6):62945.
24. Schwartz MH, Rozumalski A. The Gait Deviation Index: a new compre-
hensive index of gait pathology. Gait Posture. 2008 Oct;28(3):3517.
25. Romei M, Galli M, Motta F, Schwartz M, Crivellini M. Use of the nor-
malcy index for the evaluation of gait pathology. Gait Posture. 2004
Feb;19(1):8590.
26. Schutte LM, Narayanan U, Stout JL, Selber P, Gage JR, Schwartz MH.
An index for quantifying deviations from normal gait. Gait Posture. 2000
Feb;11(1):2531.
27. Oeffnger D, Tylkowski C, Gorton G, Bagley A, Nicholson D, Barnes D, Calmes
J, Abel M, Damiano D, Kryscio R, Rogers S. Outcome tools commonly used
in ambulatory children with cerebral palsy: Part Idescriptive characteristics.
Dev Med Child Neurol. 2007;49:17280.
28. Gorton GE 3rd, Abel MF, Oeffnger DJ, Bagley A, Rogers SP, Damiano
D, Romness M, Tylkowski C. A prospective cohort study of the effects of
lower extremity orthopaedic surgery on outcome measures in ambulato-
ry children with cerebral palsy. J Pediatr Orthop. 2009 Dec;29(8):9039.
29. Gan S, Tung L, Tang Y, Wang C. Psychometric properties of functional
balance assessment in children with cerebral palsy. Neurorehab Neural
Repair. 2008;22(6):74553.
30. Hanna S, Rosenbaum,PL, Bartlett, DJ, Palisano RJ, Walter SD, Avery L,
Russell DJ. 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(4):295302.
Critical Reviews in Physical and Rehabilitation Medicine
14 Hassani et al
31. Kramer J, MacPhail H. Relationships among measures of walking ef-
fciency, gross motor ability, and isokinetic strength in adolescents with
cerebral palsy. Pediatr Phys Ther. 1994;6:38.
32. MacPhail HE, Kramer JF. Effect of isokinetic strength-training on functional
ability and walking effciency in adolescents with cerebral palsy. Dev Med Child
Neurol. 1995 Sep;37(9):76375.
33. Russell DJ, Rosenbaum PL, Cadman DT, Gowland C, Hardy S, Jarvis S. The
gross motor function measure: a means to evaluate the effects of physical ther-
apy. Dev Med Child Neurol. 1989 Jun;31(3):34152.
34. Damiano DL, Kelly LE, Vaughn CL. Effects of quadriceps femoris muscle
strengthening on crouch gait in children with spastic diplegia. Phys Ther. 1995
Aug;75(8):65867; discussion 6871.