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What is the Quality FM?

The Quality FM is an observational clinical assessment that captures the quality of movement of the Stand and Walk/Run/Jump skills (items) in the Gross Motor Function Measure (GMFM-66). It was designed for use by physical therapists with children who have cerebral palsy (CP) and are age 5 years and up, able to walk (i.e., in GMFCS Level I, II or III), and can actively follow the GMFM’s administration instructions.

The Quality FM assesses five quality of movement attributes: alignment, co-ordination, dissociated movement, stability and weight-shift. For each GMFM-66 Stand/Walk item, the three most appropriate quality attributes have been pre-selected for scoring. Each quality attribute is scored on a 4-point response scale using item-specific response options described on the Quality FM score form.

Scoring is done from review of the child’s GMFM Stand and Walk/Run/Jump item video that has been made with use of the Quality FM's start/finish position and camera angles. For a therapist who is familiar with the Quality FM, it takes about 60 to 90 minutes to score the video. Instead of coming up with a total quality score, each of the five attributes has its own final score. This allows us to see where the child's relative strengths and challenges are (e.g., a child might have good stability but issues with alignment and dissociated movement.) This information can be used in goal setting and intervention planning.

The Quality FM needs to be scored by a pediatric physical therapist who has experience with administering the GMFM-66, and has taken the Quality FM training course and also passed the Quality FM criterion test. It is also fine for occupational therapists who use the GMFM to learn the Quality FM.

Why do we need the Quality FM?

Gross motor interventions for children/youth who have cerebral palsy (CP) are focused on optimizing the child’s functional skills ('what they can do') and their movement quality '(how they do it'). Both are important components of motor skill performance that allow a child to participate in gross motor activities. We think that improving quality of movement may be an important foundation for acquiring new gross motor skills. If we do not include a measurement of quality of movement in our gross motor assessments, quality changes can only be inferred from improvements in other aspects of function such as greater walking speed, acquisition of new skills, or greater functional skill independence.

How was the Quality FM developed?

The story of the development of the Quality FM began with the creation of  the Gross Motor Performance Measure (GMPM) 15 years ago by the Gross Motor Measures group at CanChild. The GMPM was created to address a notable lack of suitable measures to assess quality of movement. It was linked directly to the Gross Motor Function Measure (GMFM-88) to permit the dual assessment of the skills the child could do and the way they were done. The GMPM measures five quality of movement attributes (Alignment, Co-ordination, Dissociated movement, Stability, and Weight-shift) on 20 of the GMFM’s items (4 per GMFM dimension). Specifically, three quality attributes were linked via an expert consensus process to each GMFM item.

While the GMPM was a strong beginning to the clinical measurement of movement quality, there were three key concerns about the GMPM: i) its lack of item-specific response option descriptions, ii) and the small representation of motor skills (20 GMFM-88 items), and  iii) the need for highly experienced physical therapist raters.

As a result, two of the GMPM development team members (Wright and Rosenbaum) decided to create a new version of the GMPM that would focus on a thorough assessment of movement quality related to just the Stand and Walk items of the GMFM. This new focus meant that the quality of movement test would be directed towards use with children in GMFCS levels I, II, and III, i.e., children who are ambulatory and have movement based goals. We renamed this test the Quality Function Measure (Quality FM or QFM for short). The rationale for moving away from measurement of movement quality in the GMFM’s Lie/Roll, Crawl and Sit dimensions is that for most children, knowing about the ability to complete those skills is likely far more important that the quality of the performance.

How is the Quality FM administered?

The GMFM Stand and Walk Dimensions are the foundation for the Quality FM. The child's performance of the GMFM Stand and Walk items that they are able to attempt is videotaped. The Quality FM is  scored from the GMFM video. This video scoring is necessary since Quality FM is too detailed to be scored during live performance. There are item by item guidelines in the Quality FM manual on the video-camera position that should be used.

Each GMFM Stand and Walk item that the child is able to at least attempt should performed three times.The first trial of the item MUST always be done without performance cues. Then, the item is repeated twice more with the physical therapist giving the child any cues that that she/he thinks will optimize the child's quality of movement. An average of the scores from three trials is used to  allow  combined consideration of the child’s natural and best performances  in the Quality FM score. For many of the items, it is important to use specified start and finish positions to give the best demonstration of the child's quality of movement. These positions are outlined in the Quality FM manual. It is important to always refer to these test details when administering the GMFM for the study.

When scoring the Quality FM it is also absolutely essential to use the Quality FM manual. Each GMFM item has its own Quality FM  score descriptions that help to make the scoring easier. Ideally it is recommended that all five of the  Quality FM attributes be scored so that a full picture of quality of movement is obtained. There may be occasional circumstances in which you decide to do score one or two of the attributes (e.g., might focus on just Alignment and Stability). Since the attributes have been validated separately, this is permissible although you risk losing a full understanding of the way the child moves by doing this abbreviated assessment.

What do Quality FM items look like?

Each GMFM Stand and Walk item has its own set of 3 quality attributes to rate. The ratings are done using 4-point response options that have very specific criteria designed for each item. These are outlined in the Quality FM manual. The response sets are based on the following general guidelines:

0 = a lot of difficulty (markedly atypical)                                                                                   

1 = a lot of difficulty (moderately atypical                                                                                 

2 = a little difficulty (slightly atypical)                                                                                         

3 = no difficulty (i.e., looks fine!)  

What participants have said...

"I enjoyed how the course was facilitated. The videos and discussions were very useful. Thank you once again for the training"

"I like going through the Quality FM scoring with children’s videos and discussing their strengths and areas of needs"

"Great tools - well done! I found myself looking at the Challenge through "Quality" eyes following previous training!"

"Really fantastic course. Love all analyses. Fits in to our way of clinical reasoning but gives more structure which is great"

"Personally used to find GMFM a good assessment on relevant children but feel much more equipped to accurately do and score both GMFM and QFM now. Just need practice at this now."

"I felt at ease and learning material was given in a relaxed but efficient manner (if that makes sense!!). Good that we get to practice it ourselves before being actually certified. QFM was demonstrated as very effective tool that will without a doubt add an extra dimension to my therapy. It does seem timely to implement, however, I am looking forward to putting it into practice!"

"So refreshing to have a measure that is more meaningful than the GMFM in terms of change post intervention (that has potential to be more sensitive and responsive to change)."

"I like the opportunity to discuss and clarify scoring with videos and share wealth of practical experience. The last session was very good - how to use the information."

"Excellently presented. Very engaging. Useful extension of GMFM. ... I liked the live demonstration of how to video and cue the GMFM with the child with CP."

"I like the discussion arising from videos that weren't so conclusive, and the willingness of Virginia and Blythe to allow open discussion."

"I now feel able to complete the Quality FM and am keen to complete online aspect of the course and certification."

"Just the tool I missed … this is a useable tool for "rating" quality. Liked your engagement and finding the child's resources as well. The best parts were the videotraining, seeing a kid do some of the test, and scoring the sheets myself then discussing videos in groups and together.”