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ìImplementing the General Movements Assessment into Practice: Steps to Success

VictoriaKunkel,MS,OTR/L,NTMTCMadalynnWendland,PT,DPT,PCS,ATP,CKTP/F

Disclosures

ì Wehavenothingtodiscloseandnoconflictsofinterest

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Objectives

ì ProvideanoverviewtheGeneralMovementsAssessment(GMA)asdesignedbyPrechtl,includingreviewofpsychometricpropertiesascomparedtoothercommonneurologicassessmentsusedinearlyinfancy

ì DescribehowtheGMAcanbeutilizedclinicallyforaccurateidentificationofneurologicalimpairmentsandsubsequentprovisionofearly,targetedinterventions

ì DelineatestepsforhowtoeffectivelyintegratetheGMAintotheNICUandfollowingNICUdischarge

Case Example at 2 weeks PTA

NormalWrithingGMs CrampedSynchronizedGMs

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Step 1: Understanding GMs

ì Generalmovements(GMs)arepartofthespontaneousmovementrepertoireandareamongtheearliest,mostprevalentandcomplexpatternsofmovement1

ì GMsarecharacterizedbyavariablesequenceofarm,neckandtrunkmovementswithanintensitythatwaxesandwaneswithagradualbeginningandend1-4

ì CategorizationofGMscanbeusedtodeterminetheintegrityofnervoussystemfrom26weekspostmenstrualage(PMA)to~20weekspost-termage(PTA)5,6

Categories for GMs7

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Case Example at 16 weeks PTA

AbsentFidgetyGMsNormalFidgetyGMs

Step 2: Comparing GMs to Other Common Assessment Tools2-6,8-10

AssessmentTool Sensitivity(%) Specificity(%)The GeneralMovements

Assessment93-100 82-100

MagneticResonanceImaging

60-100 89-99

CranialUltrasound 74-80 83-97

TestofInfantMotorPerformance

62.5 77.4

NeurologicalExamination(preterm/postterm age)

57-86/68-96 45-83/52-97

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Administrative Differences of the GMA

ì Non-invasive,global-visualGestaltperspectiveminimizestheneedforhandling3-5

ì Oneoftheonlyassessmentstocategorizethequalityofmovementpatternsobserved2,11

ì PredictionimproveswithlongitudinalseriesofGMassessments2

TheGMAstandsoutasoneofthemostcost-effectiveandsensitivetoolsavailableforpredictionoflong-termneurobehavioralimpairmentsthatallowsforearly

implementationoftargetedinterventions

Individual Developmental Trajectory

F- F-

AF

CS CS

Ch

PR

H

N

40 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

WeeksPost-termAge

WrithingMovements

FMs+or+/- FMs++or+éé

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Potential Implications of Abnormal GMs2

Step 3: Rationalizing the Clinical Decision to Use the GMA

ìThecentralnervoussystemendogenouslygeneratesavarietyofmovementpatternswhichcontinueafterbirth,irrespectiveofwhenbirthoccurs2,4

ìTherateofoccurrenceofGMsisnodifferentininfantswithbraindamage,howeverthequalityisdifferent2,11

ìAstrongcorrelationexistsbetweentheGMAandtheBayley ScalesofInfantandToddlerDevelopment- 3rdedition10

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Early Identification à Early Intervention =

24weekspost-conception 40weekspost-conception

MakingaDifferenceintheBaby’sBrain

Step 4: Finding Training Opportunities

GeneralMovementsTrustì Courseruns~3.5day

ì BasicCertificationì Registration:~$895

ì AdvancedCertificationì Registration:~$950

Formoreinformation:http://general-movements-

trust.info/47/dates

Hadders-Algraì Courseruns~2days

ì GeneralMovementsAssessmentCertificationì Registration:~$700

ì InfantMotorProfileCourseì Registration:~$425

Formoreinformation:www.developmentalneurology.com

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Step 5: Getting Buy In From Your NICU

ì IntroducingtheGMAtoNICUleadership:

ì PresentationofevidencetotheMedicalDirectorofNeonatology

ì PresentationtotheentireNeonatologyEnterprise

ì 3NICUsintheClevelandClinicHealthSystem

ì OrganizationofregionalpresentationbyColleenPeytonPT,DPT,PCSUniversityofChicagoMedicine,ComersChildren’sHospital

ì Over50therapists,physicians,nursepractitionersandnursesattendedthisevent

ì ReviewofprotocolduringNICUOperationsMeeting:

ì Processforobtainingvideoconsent

ì Developmentaltimeframe

ì FamilyEducation

ì Rationaleforuseinidentifyinghighriskinfants

ì Impactondischargereferralprocess

Creating a Protocol with the NICU Team

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Step 6: Preparing for Implementation

ì Equipmentpurchase:ì Videocameras(2)ì Tripod(2)ì Memorycardreader(2)

ì Costs:PTandOTbudgets

ì Storage:ì Physicalanddigital

ì Space

ì Documentationtemplates

ì Billing

Step 7: Implementing GMA Protocol

ì GMAProtocolforNICU:

ì Atypicalmovementpatternsidentified

ì Videoconsentobtained

ì Educationwithnursing

ì Educationwithmultidisciplinaryteam

ì 1st videoinpretermwrithingstage34-39weeksPMA

ì 2nd videointermwrithingstage40-46weeksPMA

ì Billing

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Videotaping Parameters2,10

Requirements Age ConditionsDuration of

Video<36weeksPMA 3-5minute recording36weeks PMA –6weeksPTA

3-5minute recording

14-20 weeksPTA 1-2 minuterecordingPreferredBehavioral

State

Anyage No crying,noNNS<36weeks PMA Quietalert state> 36weeksPMA Quiet alertstate

Position Anyage SupineonflatsurfaceClothing Anyage Noclotheswithsmalldiaper

Environment Anyage Neutraltemperature,sound,lighting. Avoidengagingwith

babyduringrecording

Educating Families on GMA

ì Baselineassessmentofmovementpatterns

ì DescribeusingGMAlanguage:

ì Varietyandvariability,fluency,complexity,connectionbetweenupperandlowerbody

ì Allowstrackingofprogressoverthefirst3-4monthsafterdischarge

ì ExplanationofNICUTransitionandNICUFollowUpClinics

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Discharge Referral Process

ì CreationofNICUTransitionClinicusingGMAasprimaryassessmenttool

ì OrderwrittenforOT/PTinNICU- referralformforintake

ì FirstappointmentinNICUTransitionClinicpriorto6weeksPTAfortermwrithingvideo

ì FamiliesleaveNICUwithappointmentinhandà improvedcompliancewithkeepingappointments

ì ContinuityofcarebetweenNICUandNICUTransitionClinicwithNICUtherapists

NICU Transition Clinic

ì GMAProtocolforNICUTransitionClinic:

ì PatientServicesRepresentativescriptforappointmentconfirmation

ì Rotatingscheduleofevaluatingtherapist/considerationofdisciplinespecificneeds

ì 2nd/3rd videointermwritingstage(priorto6weeksPTA)

ì 3rd/4th videoinfidgetystage(14-20weeksPTA)

ì Smallpartofoverallassessmentintermsoftime:first5minutesofvisit,completeevaluation,familyeducation

ì BilledasOTorPTevaluation/treatment

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Referrals for Ongoing Outpatient Services

ì Whentorefertooutpatienttherapy?

ì Manyreferralsmadeafter13-15weeksPTA(fidgetystage)

ì NICUTransitionClinicheldinoutpatienttherapysatellite

ì Clinicallymaypresentwithneedforearlierreferral,fidgetyvideothendoneduringoutpatientvisitincoordinationwithTransitionClinicTeam

Clinical Usage of GMA at Cleveland Clinic Children’s Hospital

ì GMAperformedin:1. HillcrestHospital36bedLevelIIINICU:OTandPTreceive

referralsforhigh-riskinfants/infants<34weeksGA2. Children’sHospitalforRehabilitationBeachwoodSatellite:

a. NICUTransitionClinicwithOTorPTb. OutpatientServices

ì GMAcurrentlyperformedbycertifiedPTsandOTsì ResultsofGMsconveyedtoneurologists,neonatologistsand

pediatriciansì AbilityforMDsandNNP’stoalsobecomecertifiedtoassess

withouttherapistevaluation

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Step 8: Dealing with Roadblocks

ì ITissues

ì Videouploading

ì Storageofequipment

ì Researchvs.clinicalapplication

ì Needtostreamlinereferralprocess

Step 9: Assessing if it is Making a Difference

ì Howmanypatientsarewereferring?

ì Howisthischangingourpractice?

ì ReplicatingtheGMAProtocolforadditionalNICUsinoursystem

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0

5

10

15

20

25

30

35

40

45

50

55

Sep2013-Aug2014 Sep2014-Aug2015 Sep2015- Feb2016

MonthlyNICUAdmissionRatesandNumberofGMAVisits

NICUGMA OutpatientGMA NICUAdmissions

Developing a Program for NICU Graduates

ì GMACertificationforoutpatienttherapists

ì DevelopmentofclinicalskillsspecifictotreatingNICUgraduates:ì Targetedcontinuingeducation,

mentoring,collaborationwithNICUtherapists

ì NICUFamilySupportGroup:HighestriskinfantsbeingfollowedinNICUTransitionClinicorOutpatientTherapy

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Case Example at 2 ½ years of age

Case Example Summary

ì DischargedfromNICUafter39days

ì Termwrithingvideotakenat2weeksPTAwithsubsequentreferraltooutpatientPTandHelpMeGrow

ì Fidgetyvideotakenat16weeksPTA(aspartofoutpatientPTvisit)withsubsequentreferraltoOT

ì Currentmedicalteamincludes:Neurology,PediatricPhysiatry,OT,PTandEarlyInterventionProviders

ì Currentmedicalmanagementincludes:ì Oralbaclofenì Botoxinjectionsì Equipmentì Microcurrent

ì Currentfunctionalabilities:ì Beganwalkingat29monthsì Stilllimitedinplay,self-care

anddressingskills

ì ExpectedtoparticipateinastructuredConstraintInducedMovementTherapyprogramthissummer

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Step 10: Seeking out Additional Resources

ì Whenpossible,havemorethanonepersononyourteamtrained

ì Findoutwhoinyourregioniscertified

ì GMAPow-Wowstomaximizereliabilitypost-certification

ì Seekoutadvancedtrainingonceyouhavesomepractice2,3

ì Utilizeeagertherapystudentstohelpmanagesomeoftheadministrativelogistics

ì ExploreusingtheGMAfortrackingoutcomes/research

In Summary:

ì TheGMAisacost-effective,objectiveassessmenttoolthatcanaccuratelyidentifyneonatesatriskforneurobehavioralsequelae

ì StepsexisttohelpstreamlineimplementationoftheGMAasaclinicalstandardofcare

ì Thebabiesyouseewillthankyou,asinitiatingearly-targetedinterventionscanmaximizelong-termfunctionandminimizedisability

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References

1. Einspieler CSigafoos J,Bartl-Pokorny KD,Landa R,Marschik PB,Bolte S.Highlightthefirst5monthsoflife:GeneralmovementsininfantslaterdiagnosedwithautismspectrumdisorderorRett syndrome.ResearchinAutismSpectrumDisorders.2015;8:286-291.

2. Einspieler C,Prechtl HFR.Prechtl’s assessmentofgeneralmovements:Adiagnositic toolforthefunctionalassessmentoftheyoungnervoussystem.MRDDResearchReviews. 2005;11:61-67.doi:10.1002/mrdd.20051

3. Einspieler C,Marschik PB,Prechtl HFR.Humanmotorbehavior.Prenataloriginandearlypostnataldevelopment.JPsychol. 2008;216(3):148-154.doi:10.1027/0044-3409.216.3.148

4. ByrneE,CampbellSK.Physicaltherapyobservationandassessmentintheneonatalintensivecareunit.Phys Occup Ther Pediatr.2013;33(1):39-74.

5. BurgerM,Louw Q.Thepredictivevalidityofgeneralmovements- asystematicreview.EuropeanJournalofPaediatric Neurology.2009;13:408-420. doi:10.1016/j.ejpn.2008.09.004

6. Einspieler C,Marschik P,Bos A,Cioni F,Prechtl HFR.Earlymarkersforcerebralpalsy:insightsfromtheassessmentofgeneralmovements.FutureNeurol.2012;7(6):709-717.doi:10.2217/FNL.12.60

References - continued

7. FerrariF,Cioni G,Einspieler C,etal.Crampedsynchronizedgeneralmovementsinpreterminfantsasanearlymarkerforcerebralpalsy.ArchPediatr Adolesc Med.2002;156:460-467.

8. Bosanquet M,CopelandL,WareR,BoydR.Asystematicreviewofteststopredictcerebralpalsyinyoungchildren.DevelopmentalMedicineandChildNeurology. 2013;55:418-426.

9. NobleY,BoydR.Neonatalassessmentforthepreterminfantupto4monthscorrectedage:asystematicreview.DevelopmentalandChildNeurology.2012:54(2):129-239.doi:10.111/j.1469-8749.2010.03903.x

10. SpittleAJ,Spencer-SmithMM,CheongJLY,Eeles AL,LeeKJ,AndersonPJ,DoyleLW.Generalmovementsinverypretermchildrenandneurodevelopmentat2and4years.Pediatrics. 2013;132:e452-458.doi:10.1542/peds.2013-0177

11. Hadders-Algra M.Variationandvariability:Keywordsinhumanmotordevelopment.PhysicalTherapy.2010;90:1823-1837.doi:10.2522ptj.20100006

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Questions?