Age of Diagnosis, Fidelity and Acceptability of an Early Diagnosis Clinic for Cerebral Palsy: A Single Site Implementation Study

Evidence-Based Infant Assessment for Cerebral Palsy: Diagnosis Timelines and Intervention Access in a Newborn Follow-up Setting

Evidence-based assessment pathways inform early detection of cerebral palsy and access to intervention. This study investigated the relationships between early evidence-based assessments, diagnosis timeline, and rehabilitation intervention access in a population of children with cerebral palsy who were seen between 2010 and 2022 at the University of Wisconsin Waisman Center Newborn Follow Up Clinic. Cerebral palsy-specific assessments were increasingly integrated after the publication of early detection guidelines by Novak et al. in 2017. Age at cerebral palsy first mention (high risk for cerebral palsy) decreased over time, although age at diagnosis remained similar. Infants who received multiple evidence-based assessments were diagnosed at a younger age. Ninety-nine percent of children were referred to rehabilitation therapies before diagnosis. Infant age at referral to outpatient therapies decreased over time. This study provides novel clinical data on diagnosis timelines and identifies remaining gaps related to implementation feasibility toward improved early diagnosis and intervention access.

Enhanced Infant Movement Analysis Using Transformer-Based Fusion of Diverse Video Features for Neurodevelopmental Monitoring

Neurodevelopment is a highly intricate process, and early detection of abnormalities is critical for optimizing outcomes through timely intervention. Accurate and cost-effective diagnostic methods for neurological disorders, particularly in infants, remain a significant challenge due to the heterogeneity of data and the variability in neurodevelopmental conditions. This study recruited twelve parent-infant pairs, with infants aged 3 to 12 months. Approximately 25 min of 2D video footage was captured, documenting natural play interactions between the infants and toys. We developed a novel, open-source method to classify and analyse infant movement patterns using deep learning techniques, specifically employing a transformer-based fusion model that integrates multiple video features within a unified deep neural network. This approach significantly outperforms traditional methods reliant on individual video features, achieving an accuracy of over 90%. Furthermore, a sensitivity analysis revealed that the pose estimation contributed far less to the model's output than the pre-trained transformer and convolutional neural network (CNN) components, providing key insights into the relative importance of different feature sets. By providing a more robust, accurate and low-cost analysis of movement patterns, our work aims to enhance the early detection and potential prediction of neurodevelopmental delays, whilst providing insight into the functioning of the transformer-based fusion models of diverse video features.

How do parents frame their engagement experience in early intervention? A grounded theory study

PURPOSE

Parent and therapist engagement and partnership are critical in early intervention physiotherapy and occupational therapy for infants with cerebral palsy to improve outcomes. The main aim of this study was to understand how parents perceive their engagement experience in early intervention over time.

METHODS

Grounded theory methodology was used. Twenty parents of diverse backgrounds participated in 22 interviews (including some repeated longitudinally) to reflect on their engagement experience within the context of early intervention community services provided in the UK NHS.

RESULTS

The findings highlight how parents' perspectives of their engagement in EI change according to critical circumstances, including their preceding neonatal trauma, the at-risk CP label, firmer diagnosis of CP and their child's response to intervention. We theorise that this disrupted transition experience to parenthood becomes part of parental framing (or sense-making) of their engagement in EI. Overlapping frames of uncertainty, pursuit and transformation capture and explain nuances in parents' engagement patterns within EI over time.

CONCLUSION

This theorising has implications for early intervention therapists in how they engage in the lives of families and partner with parents to support healthier parental transition, wellbeing and subsequent improved infant outcomes.

Effectiveness of early diagnosis of cerebral palsy guideline implementation: a systematic review

INTRODUCTION

Tailored implementation interventions are required to overcome the diagnostic research-practice gap for cerebral palsy (CP). Evaluating the impact of interventions on patient outcomes is a priority. This review aimed to summarize the established evidence for the effectiveness of guideline implementations in lowering the age of CP diagnosis.

EVIDENCE ACQUISITION

A systematic review was conducted according to PRISMA. CINAHL, Embase, PubMed and MEDLINE were searched (2017-October 2022). Inclusion criteria were studies that evaluated effect of CP guideline interventions on health professional behaviour or patient outcomes. GRADE was used to determine quality. Studies were coded for use of theory (Theory Coding Scheme). Meta-analysis was performed and a standardized metric used to summarize statistics of intervention effect estimates.

EVIDENCE SYNTHESIS

Of (N.=249) records screened, (N.=7) studies met inclusion, comprising interventions following infants less than 2 years of age with CP risk factors (N.=6280). Guideline feasibility in clinical practice was established through health professional adherence and patient satisfaction. Efficacy of patient outcome of CP diagnosis by 12 months of age was established in all studies. Weighted averages were: (1) high-risk of CP (N.=2) 4.2 months and (2) CP diagnosis (N.=5) at 11.6 months. Meta-analysis of (N.=2) studies found a large, pooled effect size Z = 3.00 (P=0.003) favoring implementation interventions lowering age of diagnosis by 7.50 months, however study heterogeneity was high. A paucity of theoretical frameworks were identified in this review.

CONCLUSIONS

Multifaceted interventions to implement the early diagnosis of CP guideline are effective in improving patient outcomes by lowering the age of CP diagnosis in high-risk infant follow-up clinics. Further targeted health professional interventions including low-risk infant populations are warranted.

Cerebral Palsy: A Current Perspective

Cerebral palsy (CP) is the most common cause of motor disability in children. Insults to the brain at different times lead to diverse injuries. As a result, CP is an extremely heterogeneous clinical diagnosis, presenting differently in each individual and at various ages. With improving survival rates of preterm newborns, increasing active resuscitation of extremely preterm newborns, and widespread availability of extensive genetic testing soon after birth, it is imperative to focus on earlier diagnosis and long-term outcomes of CP. CP is primarily classified into 4 categories based on type of motor impairment, functional ability, distribution, and etiology. As the understanding of CP has evolved significantly in the last 2 decades, the methods of early detection of CP have consequently advanced. Appropriate diagnosis is essential for proper education and counseling of affected families, and introduction of therapeutic interventions as early as possible. In this review, we focus on early brain development and provide an overview of the etiology, classification, diagnosis, early therapeutic options, and prognosis of CP.

Kids+ Parent Infant Program (PIP): a community model for supporting partnerships in early developmental follow-up and support

High-risk infants are discharged home from hospital with increased care needs and the potential for the emergence of developmental disabilities, contributing to high levels of parental stress and anxiety. To enable optimal outcomes for high-risk infants and their families, developmental follow-up programs need to continue following hospital discharge. However, current follow-up care for high-risk infants is variable in terms of type, access and equity, and there seems to be a gap in existing services such as supporting the transition home, parental support, and inclusion of all at-risk infants regardless of causality. Routine follow-up that identifies developmental delays or neuromotor concerns can facilitate timely referral and access to targeted intervention during critical periods of development. The Kids+ Parent Infant Program (PIP) is a unique model of developmental follow-up that shares some characteristics with established programs, but also includes additional key elements for a seamless, wrap-around service for all high-risk infants and their families living in a regional area of Australia. This community-based program provides integrated assessment and intervention of infants, alongside parent support and education, embracing a holistic model that accounts for the complexity and interrelatedness of infant, parent, medical and developmental factors. By prioritising the well-being of high-risk infants and their families, the Kids+ PIP paves the way for improved developmental outcomes and provides an innovative model for developmental follow-up, with the potential for reproduction in other healthcare settings.

Early Neurodevelopmental Assessments for Predicting Long-Term Outcomes in Infants at High Risk of Cerebral Palsy

Importance

Studies suggest that early neurodevelopmental assessments are beneficial for identifying cerebral palsy, yet their effectiveness in practical scenarios and their ability to detect cognitive impairment are limited.

Objective

To assess the effectiveness of early neurodevelopmental assessments in identifying cerebral palsy and cognitive and other neurodevelopmental impairments, including their severity, within a multidisciplinary clinic.

Design, Setting, and Participants

This diagnostic study was conducted at Monash Children's Hospital, Melbourne, Australia. Participants were extremely preterm infants born at less than 28 weeks' gestation or extremely low birth weight infants less than 1000 g and term encephalopathic infants who received therapeutic hypothermia, attending the early neurodevelopmental clinic between January 2019 and July 2021. Data were analyzed from December 2023 to January 2024.

Exposures

Early cerebral palsy or high risk of cerebral palsy, the absence of fidgety movements, and Hammersmith Infant Neurological Examination (HINE) scores at corrected age (CA) 3 to 4 months. Early cerebral palsy or high risk of cerebral palsy diagnosis was based on absent fidgety movements, a low HINE score (<57), and medical neurological examination.

Main Outcome and Measures

The outcomes of interest were cerebral palsy, cognitive and neurodevelopmental impairments and their severity, diagnosed at 24 to 36 months' CA.

Results

A total of 116 infants (median [IQR] gestational age, 27 [25-29] weeks; 65 [56%] male) were included. Diagnosis of early cerebral palsy or high risk of cerebral palsy demonstrated a sensitivity of 92% (95% CI, 63%-99%) and specificity of 84% (95% CI, 76%-90%) for predicting cerebral palsy and 100% (95% CI, 59%-100%) sensitivity and 80% (95% CI, 72%-87%) specificity for predicting moderate to severe cerebral palsy. Additionally, the accuracy of diagnosis of early cerebral palsy or high risk of cerebral palsy was 85% (95% CI, 77%-91%) for predicting cerebral palsy and 81% (95% CI, 73%-88%) for predicting moderate to severe cerebral palsy. Similarly, the absence of fidgety movements had an 81% (95% CI, 73%-88%) accuracy in predicting cerebral palsy, and HINE scores exhibited good discriminatory power with an area under the curve of 0.88 (95% CI, 0.79-0.97) for cerebral palsy prediction. However, for cognitive impairment, the predictive accuracy was 44% (95% CI, 35%-54%) for an early cerebral palsy or high risk of cerebral palsy diagnosis and 45% (95% CI, 36%-55%) for the absence of fidgety movements. Similarly, HINE scores showed poor discriminatory power for predicting cognitive impairment, with an area under the curve of 0.62 (95% CI, 0.51-0.73).

Conclusions and Relevance

In this diagnostic study of infants at high risk for cerebral palsy or other cognitive or neurodevelopmental impairment, early neurodevelopmental assessments at 3 to 4 months' CA reliably predicted cerebral palsy and its severity at 24 to 36 months' CA, signifying its crucial role in facilitating early intervention. However, for cognitive impairment, longer-term assessments are necessary for accurate identification.

The Knowledge Translation of Early Cerebral Palsy (KiTE CP) Study: Implementing Screening Among a High-Risk Prospective Cohort of Australian Infants

OBJECTIVE

To describe the implementation of the international guidelines for the early diagnosis of cerebral palsy (CP) and engagement in the screening process in an Australian cohort of infants with neonatal risk factors for CP.

STUDY DESIGN

Prospective cohort study of infants with neonatal risk factors recruited at <6 months corrected age from 11 sites in the states of Victoria, New South Wales, and Queensland, Australia. First, we implemented a multimodal knowledge translation strategy including barrier identification, technology integration, and special interest groups. Screening was implemented as follows: infants with clinical indications for neuroimaging underwent magnetic resonance imaging and/or cranial ultrasound. The Prechtl General Movements Assessment (GMA) was recorded clinically or using an app (Baby Moves). Infants with absent or abnormal fidgety movements on GMA videos were offered further assessment using the Hammersmith Infant Neurological Examination (HINE). Infants with atypical findings on 2/3 assessments met criteria for high risk of CP.

RESULTS

Of the 597 infants (56% male) recruited, 95% (n = 565) received neuroimaging, 90% (n = 537) had scorable GMA videos (2% unscorable/8% no video), and 25% (n = 149) HINE. Overall, 19% of the cohort (n = 114/597) met criteria for high risk of CP, 57% (340/597) had at least 2 normal assessments (of neuroimaging, GMA or HINE), and 24% (n = 143/597) had insufficient assessments.

CONCLUSIONS

Early CP screening was implemented across participating sites using a multimodal knowledge translation strategy. Although the COVID-19 pandemic affected recruitment rates, there was high engagement in the screening process. Reasons for engagement in early screening from parents and clinicians warrant further contextualization and investigation.

A prospective assessment of readiness to implement an early detection of cerebral palsy pathway in a neonatal intensive care setting using the PARIHS framework

BACKGROUND

Early detection of cerebral palsy (CP) is possible through targeted use of assessment tools. Changes in practice are needed to facilitate this shift towards earlier diagnosis of CP in New Zealand. The aim of this study was to prospectively evaluate readiness to implement an early detection of CP pathway within a level 3 neonatal intensive care unit (NICU) setting prior to any implementation taking place. The PARIHS (Promoting Action on Research Implementation in Health Services) framework was engaged to assess readiness by highlighting determinants that influence implementation outcomes as either barriers or enablers.

METHODS

A mixed methods approach was used. Firstly, an online staff survey assessed PARIHS sub-elements using Likert scores and free text with the intent to develop a baseline understanding of staff views. Secondly, focus groups were conducted to gain deeper understanding of barriers and enablers to implementation. Participants included health professionals involved in the first 6 months of life. Data were analysed to outline the barriers and enablers of implementation under the Evidence and Context constructs of the PARIHS framework.

RESULTS

Twenty-seven participants completed the survey, and 20 participants participated in eight focus groups and two individual interviews. Quantitative (survey) findings found 65% agreement around the usefulness of research evidence on early CP detection; however, ≤ 45% felt current resources (i.e. human, financial and IT) were sufficient for implementation. Qualitative findings (survey and focus groups) highlighted key staff concerns around resources, family impact (creating unnecessary stress), and equity (barriers to participation). Staff wanted information regarding how international evidence translates to the local context and availability of timely follow-up services. Sub-elements within the Evidence and Context constructs were rated as either mixed or low (except for Evidence - Research, rated as high), overall indicating that Auckland NICU is at the early stages of readiness to implement the early CP detection pathway.

CONCLUSION

This work may resonate with other neonatal services preparing to implement CP early detection pathways. Resourcing has a major role in facilitating implementation of pathways and uncertainty about resources is a barrier to implementation. Ongoing focus on building consensus and funding is required to ensure optimal uptake.

Partnering Early to Provide for Infants At Risk of Cerebral Palsy (PĒPI ARC): protocol for a feasibility study of a regional hub for early detection of cerebral palsy in Aotearoa New Zealand

Introduction

Cerebral palsy (CP) can now be diagnosed in infants with identified CP risk factors as early as three months of age; however, many barriers prevent equitable access to early detection pathways. The "Partnering Early to Provide for Infants At Risk of Cerebral Palsy" feasibility study (PĒPI ARC) seeks to trial a new approach to decrease inequitable health service in Aotearoa New Zealand for high-risk infants and their families. PĒPI ARC incorporates face-to-face clinics, an in-person and virtual Hub, and the use of telehealth to enable flexible access to CP assessments and support for health professionals in early CP detection.

Methods and analysis

A non-randomised feasibility study was conducted from a tertiary Neonatal Intensive Care Unit (NICU) in Wellington and included seven regional referral centres, servicing nearly 30% of the total population in New Zealand (NZ). The families of infants with a high risk of neurodevelopmental impairment and health professionals interacting with the Hub were invited to participate. Mixed methods were used to evaluate the (i) equitable implementation of an early detection pathway, (ii) acceptability, (iii) demand among families and health professionals, (iv) efficacy in relation to reducing the age of receipt of CP diagnosis, and (v) the experiences around communication and information sharing.

Ethics and dissemination

The NZ Health and Disability Ethics Committee approved this study (HDEC: 2022 FULL 13434). The findings will be disseminated in peer-reviewed journals, in conference presentations, and via professional networks.

Clinical trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12623000600640.

A Call for Early Detection of Cerebral Palsy

Cerebral palsy (CP) is the most common physical disability across the lifespan, but historically, CP has not been diagnosed before the age of 2 years. Barriers to early diagnosis ranged from lack of available biomarkers, absence of curative treatments, perceived stigma associated with a lifelong diagnosis, and a desire to rule out other diagnoses first. Most importantly, the fundamental question that remained was whether children would benefit from earlier detection and intervention given the paucity of research. However, evidence-based guidelines published in 2017 demonstrated that the General Movements Assessment, the Hammersmith Infant Neurological Examination, and neuroimaging can be combined with other elements such as a clinical history and standardized motor assessments to provide the highest predictive value for diagnosing CP as early as age 3 months in high-risk newborns. Implementation of these guidelines has been successful in decreasing the age at CP diagnosis, particularly in high-risk infant follow-up clinics with expertise in performing these assessments. Early detection of CP allows for clinical and research opportunities investigating earlier interventions during a critical period of neuroplasticity, with the goal of improving developmental trajectories for children and their families. New guidelines and research are now being developed with a focus on early, targeted interventions that continue to be studied, along with global detection initiatives.

Characteristics of Children with Cerebral Palsy and Their Utilization of Services in Saudi Arabia

The recent emergence of research on cerebral palsy (CP) in developing countries aims to improve knowledge on affected children and the utilization of the available services. This study seeks to describe children with CP in Saudi Arabia and service utilization as per Gross Motor Function Classification System (GMFCS) levels and geographic regions. A cross-sectional survey of 227 children with CP (Mean age 6.3, SD 3.9 years) was conducted. Parents reported on children's demographics, impairments, and service utilization. Half of the children (n = 113, 49.8%) had ≥3 impairments with speech, visual and learning impairments being the most frequent. The total number of impairments differed significantly by GMFCS, F (4, 218) = 8.87, p < 0.001. Most of the children (n = 86, 83.4%) used 2-5 services. Moreover, 139 (62.3%) did not attend school, 147 (65.9%) did not receive occupational therapy, and only 32 (14.3%) received speech therapy. More children in GMFCS level I did not receive neurologist services. Profiles of children and services were described by GMFCS and by regions. This was the first study to describe children with CP and service utilization in Saudi Arabia. Although many impairments affected the children, there was low utilization of related services. Data on service utilization and on unmet needs support a comprehensive approach to rehabilitation and the proper service allocation.

Redefining cerebral palsies as a diverse group of neurodevelopmental disorders with genetic aetiology

Cerebral palsy is a clinical descriptor covering a diverse group of permanent, non-degenerative disorders of motor function. Around one-third of cases have now been shown to have an underlying genetic aetiology, with the genetic landscape overlapping with those of neurodevelopmental disorders including intellectual disability, epilepsy, speech and language disorders and autism. Here we review the current state of genomic testing in cerebral palsy, highlighting the benefits for personalized medicine and the imperative to consider aetiology during clinical diagnosis. With earlier clinical diagnosis now possible, we emphasize the opportunity for comprehensive and early genomic testing as a crucial component of the routine diagnostic work-up in people with cerebral palsy.

Early Cerebral Palsy Detection and Intervention

Early identification of cerebral palsy (CP) facilitates optimal care, support, and outcomes for children and their families. Ideally, infants with risk factors or developmental deviations should be evaluated early using standardized assessments of neurodevelopment and brain imaging. If a diagnosis of CP or high risk for CP (HRCP) is established, specialized, evidence-informed therapy and family support should be initiated. With task-specific motor skill training and an enriched environment, infants with CP show greater gross motor and cognitive gains. These enhanced outcomes are only achievable with early diagnosis and subsequent intervention.

Implementation of Early Detection and Intervention for Cerebral Palsy in High-Risk Infant Follow-Up Programs: U.S. and Global Considerations

Early detection and intervention for cerebral palsy is best practice for all high-risk infants according to international guidelines, consensus statements and research-supported evidence. It allows support for families and optimization of developmental trajectories into adulthood. All phases of implementation of CP early detection can be found across the world in high-risk infant follow-up programs, demonstrating feasibility and acceptability through standardized implementation science. The largest clinical network for CP early detection and intervention in the world has now sustained an average age at detection less than 12 months corrected age for more than 5 years. Targeted referrals and interventions for CP can now be offered to patients in optimal periods of neuroplasticity, and new therapies researched as the age of detection decreases. Implementation of guidelines and incorporation of rigorous CP research studies both allow high-risk infant follow-up programs to fulfill their mission of improving outcomes of those with the most vulnerable developmental trajectories from birth.

From guidelines to practice: A retrospective clinical cohort study investigating implementation of the early detection guidelines for cerebral palsy in a state-wide early intervention service

OBJECTIVES

To report on knowledge translation strategies and outcomes from the implementation of the early detection guidelines for cerebral palsy (CP) in a state-wide tertiary early intervention (EI) service and investigate the impact of social determinants on clinical services.

DESIGN

Retrospective longitudinal cohort study.

SETTING

The Western Australia tertiary paediatric EI service.

PARTICIPANTS

EI clinicians, consumers and children using the EI service.

OUTCOME MEASURES

Knowledge translation strategies including consumer perspectives, clinician training and Communities of Practice (CoP) guided implementation. We measured changes in referral number and age, delivery of early detection and intervention following the implementation of the guidelines. Exposure to adverse childhood experiences (ACEs), appointment non-attendance (DNA) rates, remoteness and socioeconomic quintiles were used to measure social determinants of health using negative binomial (Incidence Rate Ratios, IRR) and logistic regression (Odds Ratios, ORs).

RESULTS

Ten consumers participated in Focus Groups, 100 clinicians were trained and 22 clinicians established a monthly CoP. Referrals increased fourfold to 511 children. Corrected gestational age at referral decreased from a median of 16.1 to 5.1 months (p<0.001) and at first appointment from 18.8 to 6.8 months (p<0.001). Children living in social disadvantage had the highest DNA risk (quintile 1 vs 5: IRR 2.2, 95% CI 1.1 to 4.6, p=0.037). Children exposed to ACEs had higher odds of living in social disadvantage (quintile 1 vs 5, OR=3.8, 95% CI 1.4 to 10.0, p=0.007). No significant association was found between remoteness and DNA rate or ACE score.

CONCLUSIONS

Implementation strategies reduced referral age and improved the delivery of early detection assessments. Further investigation of the association between social disadvantage, DNA risk and ACE score is required in the development of a state-wide early detection network.

Can web-based implementation interventions improve physician early diagnosis of cerebral palsy? Protocol for a 3-arm parallel superiority randomised controlled trial and cost-consequence analysis comparing adaptive and non-adaptive virtual patient instructional designs with control to evaluate effectiveness on physician behaviour, diagnostic skills and patient outcomes

INTRODUCTION

Cerebral palsy (CP) is the most common childhood physical disability. Accurate diagnosis before 6 months is possible using predictive tools and decision-making skills. Yet diagnosis is typically made at 12-24 months of age, hindering access to early interventions that improve functional outcomes. Change in practice is required for physicians in key diagnostic behaviours. This study aims to close the identified research-practice gap and increase accurate CP diagnosis before 6 months of age through tailored web-based implementation interventions. This trial will determine whether adaptive e-learning using virtual patients, targeting CP diagnostic behaviours and clinical decision-making skills, effectively changes physician behaviour and practice compared with non-adaptive e-learning instructional design or control.

METHODS AND ANALYSIS

This study is a 3-arm parallel superiority randomised controlled trial of two tailored e-learning interventions developed to expedite physician CP diagnosis. The trial will compare adaptive (arm 1) and non-adaptive (arm 2) instructional designs with waitlist control (arm 3) to evaluate change in physician behaviour, skills and diagnostic practice. A sample size of 275 paediatric physicians enables detection of small magnitude effects (0.2) of primary outcomes between intervention comparators with 90% power (α=0.05), allowing for 30% attrition. Barrier analysis, Delphi survey, Behaviour Change Wheel and learning theory frameworks guided the intervention designs. Adaptive and non-adaptive video and navigation sequences utilising virtual patients and clinical practice guideline content were developed, integrating formative key features assessment targeting clinical decision-making skills relative to CP diagnosis.Physician outcomes will be evaluated based on postintervention key feature examination scores plus preintervention/postintervention behavioural intentions and practice measures. Associations with CP population registers will evaluate real-world diagnostic patient outcomes. Intervention costs will be reported in a cost-consequence analysis from funders' and societal perspectives.

ETHICS AND DISSEMINATION

Ethics approved from The University of Sydney (Project number 2021/386). Results will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry: ACTRN 12622000184774.