R E S E A R C H R E P O R T

The Observational Gait Scale Can Help Determine the GMFCS Level in Children With
Cerebral Palsy
Karina A. Zapata, DPT, PhD; Charter L. Rushing, PT, ScD; Mauricio R. Delgado, MD; Chanhee Jo, PhD
Scottish Rite for Children, Dallas, Texas.

Purpose: To evaluate the association between the Observational Gait Scale (OGS) and the Gross Motor Function
Classification System (GMFCS) in walking children with cerebral palsy (CP).
Methods: The charts of 512 children with CP GMFCS levels I to IV were reviewed for the OGS score and GMFCS level at
their initial visit.
Results: The OGS score decreased with increasing GMFCS levels. The average OGS for GMFCS level I was 13.1 (2.8), level
II was 11.3 (2.7), level III was 7.7 (2.7), and level IV was 6.1 (2.0). A significant negative relationship was seen between the
OGS and the GMFCS. In particular, each GMFCS level was different across all levels in a pairwise comparison. In addition,
multivariate modeling analysis confirmed that the association between the OGS and the GMFCS was still valid, after
adjusting for age and gender.
Conclusions: The OGS is a quick tool to rate gait and help confirm a child’s GMFCS level. (Pediatr Phys Ther
2022;34:23–26)
Key words: CP, Gross Motor Function Classification System, OGS

INTRODUCTION AND PURPOSE
The Observational Gait Scale (OGS) is commonly used in
clinic as an attempt to objectively rate gait in children with cere-
bral palsy (CP). The OGS evolved from the Physician’s Rating
Scale as a simple, low-technology tool to examine gait in 2
dimensions.1 Common reasons for performing the OGS include
assessing for changes before and after botulinum neurotoxin
type A injections, serial casting, orthotic use, surgery, and as part
of yearly follow-up visits.
Several variations of the OGS exist. The OGS developed
at our institution and published by Boyd has 8 subscores to
evaluate gait parameters in the following order: knee position
in midstance, initial foot contact, foot contact at midstance,
timing of heel rise, hindfoot at midstance, base of support,
assistive devices, and whether there has been a change.2
Lower OGS scores indicate more gait deviations. Boyd’s OGS
version was found to have acceptable interrater reliability
(weighted kappa [wk] range 0.43-0.86) and intrarater relia-
bility (wk range 0.53-0.91) and validity (wk range 0.38-0.94)
0898-5669/110/3401-0023
Pediatric Physical Therapy
Copyright © 2021 Academy of Pediatric Physical Therapy of the American
Physical Therapy Association
Correspondence: Karina A. Zapata, DPT, PhD, Scottish Rite for Children,
2222 Welborn St, Dallas, TX75219 (Karina.zapata@tsrh.org).
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000851
for subscores 1 to 4 and poor reliability for subscores 5 to
6. Only subscores 1 to 4 were assessed for validity com-
pared with 3-dimensional gait analysis. Interrater reliability
was provided for subscores 1 to 7, but not for the total
mean.3 We have used a modified version of the OGS con-
sisting of 7 subscores and a total score of 19 points (Figure 1).
Our subscores differ from Boyd’s in that the version used in this
study does not assess “timing of heel rise” or “change” and has a
“speed of gait” subscore. In our clinical experience, the “change”
subscore is open to varying interpretation, and should be cap-
tured by the other gait parameters. A third published version of
the OGS consists of 24 subscores and a total score that was not
reported.4,5
The Gross Motor Function Classification System (GMFCS)
is a 5-level functional classification that differentiates children
and youth with CP according to their current gross motor abili-
ties and limitations, and need for assistive technology including
wheeled mobility.6 Those with GMFCS level I can generally walk
without restrictions but tend to have some limitations in more
challenging situations. Those classified as level V are usually
very limited in their ability to move themselves about, even with
assistive technology.
In the past, the GMFCS has been found to be mildly
related to gait speed, stride length, and cadence.7 How-
ever, we are unaware of any studies that have evaluated
whether the OGS can assist in assigning the GMFCS level
according to pairwise comparisons and post hoc analysis. We
aimed to evaluate the association between the OGS and the
GMFCS in walking children with CP according to Spearman
correlations.

Pediatric Physical Therapy The Observational Gait Scale and GMFCS 23

Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.

Fig. 1. Observational Gait Scale.
METHODS
Participants
The study design is a single-center retrospective study of
data collected and entered into a clinical database with a remote
intent to use the data over time. Patients and caregivers pro-
vided a blanket assent and consent for use of their information
in the database. A research coordinator entered clinical data
obtained from a childhood movement disorder clinic at a tertiary
care hospital into this institution’s movement disorder database
following each clinic visit. Entered data included participants’
names, date of birth, date seen, gender, height, weight, diag-
nosis, type of CP, GMFCS level, and OGS scores. A research
coordinator extracted previously entered data from a consecu-
tive series of 533 walking participants with CP (GMFCS levels
I-IV) presenting to the specialty clinic who had either GMFCS
levels or OGS scores recorded between 1997 and 2016. After
data were exported from the database, the research coordinator,
24 Zapata et al
Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
first author, and statistician reviewed the data of each participant
to ensure accuracy. Data from the exported files were confirmed
for accuracy through comparison with the childhood motor
disorders database and the child’s medical record. Twenty-one
children were excluded due to missing recorded OGS scores
or GMFCS levels, resulting in a total of 512 participants for
inclusion in the study. Ethical approval was obtained from the
hospital and university institutional review boards. Participants’
caregivers provided written informed consent and participants
older than 10 years also provided assent for study participation.
Children’s OGS score and GMFCS level were both recorded
at the same initial clinic visit at baseline, prior to any interven-
tion. Each child was instructed to walk barefoot with the knees
in view back and forth along a 6-m walkway at least 6 times
at a self-selected speed. A physical therapist (PT) viewed the
child’s gait 3 times in the frontal plane and 3 times in the lat-
eral plane. Children with bilateral involvement will have 2 OGS
scores reflecting their left and right sides. When there were 2
OGS total scores, the lower OGS total score was included for
data analysis. The same PT was involved in rating both the OGS
and GMFCS level. Each child’s GMFCS level was determined by
the treating physician who consulted with the multidisciplinary
study team, including the PT, family, and medical team. All OGS
scores and GMFCS levels used in this study were recorded from
the same initial clinic visit at 1 visit at 1 time point.
Each child’s OGS score was determined by any of 8 PTs
trained in neuromuscular evaluation. Since we did not for-
mally establish interrater reliability for the OGS, we reviewed
the OGS total scores for each PT tester to evaluate whether
scores were similar across testers after reviewing the exported
data. After matching for the GMFCS level and type of CP, we
used a subgroup of 9 participants to compare 8 testers. All
OGS scores across testers were within a similar range with no
significant differences between OGS scores across the testers
(P = .69).
Statistical Analysis
Means and standard deviations were used to describe
continuous variables and a Student’s t test to compare those vari-
ables. Spearman correlations along with box plots were used to
examine the relationship between the OGS scores (total and sub
scores) and GMFCS levels. A 1-way analysis of variance was used
to assess for differences in OGS total scores across GMFCS levels,
followed by Tukey’s multiple comparisons. We ran multivariate
regression analyses where OGS was the dependent variable and
the covariates were age, gender, body mass index, and GMFCS.
Statistical significance was set at a P value less than .05. Statis-
tical analyses were performed using SAS/STAT version 9.4 (SAS
Institute, Cary, North Carolina) and IBM SPSS 26 Software (IBM
Corp, Armonk, New York).
RESULTS
Participants averaged 4 years 7 months (1-18 years)
(Table 1). The most common type of CP was bilateral (65%)
Pediatric Physical Therapy
 TABLE 1
Participant Characteristics (n = 512)
Parameters Mean (SD)
Age, y 4.6 (2.7)
Gender
Girls 278
Boys 234
Height, cm 105 (16)
Weight, kg 18.2 (8.0)
BMI, kg/m2 16.2 (2.4)
Type of cerebral palsy
Bilateral 331
Unilateral 181
Abbreviations: BMI, body mass index; SD, standard deviation.
(Table 1). Participant distribution of GMFCS levels was GMFCS
I = 47%, GMFCS II = 28%, GMFCS III = 20%, and GMFCS
IV = 5%.
The OGS scores decreased as GMFCS levels increased
(Table 2 and Figure 2). A significant negative relationship was
seen between the OGS total scores and GMFCS levels according
to a Spearman correlation (r = −0.61; P < .001). In partic-
ular, each GMFCS level was different based on the OGS total
score across all levels in a pairwise comparison (P < .001)
(Table 2). Each GMFCS level was different based on the OGS
total score across all levels according to post hoc analysis (P <
.05) (Table 2). In addition, multivariate modeling analysis con-
firmed that the association between the OGS total score and the
GMFCS was still valid after adjusting for age and gender (P <
.001). In particular, the OGS total score did not differ according
to gender, age, or body mass index. Furthermore, when the OGS
total score was compared across GMFCS levels according to 2
age groups (≤5 years old vs >5 years old), no significant dif-
ferences were found according to t tests. Finally, when the 7
subscores of the OGS were compared across GMFCS levels, a
weak to moderate negative association was seen (r = −0.14
to −0.70; P < .01 for all subscores) according to Spearman
correlations (Table 3).
A subgroup analysis of participants with bilateral CP
(diparesis, quadriparesis) and unilateral CP (hemiparesis) also
demonstrated that the OGS total score decreased as the GMFCS
increased (Table 2). Participants with GMFCS I with bilateral
CP demonstrated significantly lower OGS total scores compared
with participants with GMFCS I with unilateral CP (P < .01)
Range
according to t tests, but these were not statistically significant
1.3-18.0 for participants with GMFCS II with bilateral CP compared to
participants with GMFCS II with unilateral CP (P = .15). Mul-
tivariate modeling analysis revealed that each GMFCS level was
77-171
different based on the OGS total score across all levels (P < .05)
8.6-73.4 (Table 2).
11.3-34.1
DISCUSSION
At our institution, we use the OGS as a tool to assess a child’s
gait and response to treatment at this institution since it is quick,
convenient, and easy to learn. The OGS does not substantially
lengthen a child’s clinic visit or contribute to testing fatigue. The
OGS can be performed in any space without requiring any spe-
cial equipment. Although 3-dimensional gait analysis is the gold
standard for gait, it is unavailable and impractical for most clin-
ical settings.8 Components of the OGS have been found to be
reliable and valid overall, but the reliability and validity of the
total score have not been reported.3 Not only does this study
include OGS total score findings, but we also add to the evi-
dence supporting the validity of the OGS by finding that the
OGS total score and GMFCS levels measure related constructs
according to Spearman correlations.
Occasionally, discussions arise about a child’s GMFCS level
when it falls on the border of 2 GMFCS age bands and descrip-
tors. For example, it can be difficult to define whether a child
who just turned 4 years old (when the 4 to 6 age band starts) is
GMFCS level I or II. The OGS may help establish the GMFCS
level by determining the average OGS total score according to
GMFCS level. Each GMFCS level showed significantly different
OGS total score means according to post hoc analysis, with
OGS scores decreasing more than 50% from GMFCS I to IV.
Since we found that the OGS total score is moderately associ-
ated with the GMFCS level, the distribution of the OGS within
the GMFCS level can help confirm a child’s GMFCS level if there
is uncertainty.
This study also provides expected OGS total scores based off
a child’s GMFCS level overall, by bilateral CP, and by unilateral

TABLE 2
Observational Gait Scale Total Score Mean Across Gross Motor Function Classification System Levela

OGS Total Score

Overall Bilateral Unilateral
GMFCS Level n Mean (SD) Range n Mean (SD) Range n Mean (SD) Range

I 240 13.1 (2.8) 4-19 111 12.7 (2.9) 4-19 129 13.5 (2.6) 6-18
II 143 11.4 (2.7) 5-18 91 11.1 (2.7) 5-17 52 11.8 (2.7) 5-18
III 103 7.7 (2.7) 1-16 103 7.7 (2.7) 1-16
IV 26 6.1 (2.0) 2-9 26 6.1 (2.0) 2-9
P value <.001 <.001 <.001
Multiple comparisons
I vs II <.001 <.001 <.001
II vs III <.001 <.001
III vs IV .030 .031

Abbreviations: GMFCS, Gross Motor Function Classification System; OGS, Observational Gait Scale; SD, standard deviation.
a The lower total OGS score was included.

Pediatric Physical Therapy The Observational Gait Scale and GMFCS 25

Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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Fig. 2. Box plot with actual values of OGS total scores across GMFCS levels. GMFCS indicates Gross Motor Function Classification System; OGS, Observational Gait Scale.
TABLE 3
Observational Gait Scale Subscore Associations Across Gross Motor
Function Classification System Levels (n = 415)
GMFCS Level
OGS Subscore Spearman Correlation (r)
Initial foot contacta −0.19
Foot at midstancea −0.26
Knee position at midstancea −0.21
Base of supporta −0.48
Hindfoot at midstancea −0.14
Speed of gaita −0.47
Assistive devicea −0.70
Abbreviations: GMFCS, Gross Motor Function Classification System; OGS,
Observational Gait Scale.
a Statistical significance (P < .05).
CP. Participants with GMFCS level I with unilateral CP may have
higher OGS scores compared with participants with bilateral CP
since they can compensate with their unaffected leg. Clinicians
can use these expected scores as a reference.
This study is limited in several ways. First, the OGS ver-
sion used in this study is based on a modified version of Boyd’s
OGS. Therefore, the expected OGS total scores are specific to
this version only. Another limitation is that numerous raters
performed the OGS without establishing intrarater or interrater
reliability since this is clinical retrospective data. However, this
reflects the reality of clinical care. Raters were trained under
direct supervision to perform the OGS to minimize interrater
inconsistencies. Furthermore, standardization among raters also
occurred during frequent discussions between the physical ther-
apist rater and the interdisciplinary team in clinic regarding the
OGS subscores regarding a child’s possible or previous man-
agement. Future research should evaluate the reliability of this
OGS version and whether the OGS total score for each par-
ticipant changes over time. In conclusion, this study supports
the OGS as another tool to help determine a child’s GMFCS
26 Zapata et al
Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
level, and provides expected total OGS scores based off a child’s
GMFCS level. The OGS is a clinically useful tool to quickly and
objectively rate a child’s gait.
ACKNOWLEDGMENTS
P Value
The authors would like to acknowledge Deanna Carman
<.001 and Blanch Carpenter for assisting in the development of the
<.001
OGS, Debbie Baldwin and Jonathan VanPelt for assisting with
<.001
<.001 the database, and Kim Kaipus, Stephanie Cone, Darla Kalb, Tony
<.01 Hageman, Carol Chambers, and Hun Epps for performing the
<.001 OGS.
<.001
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