Remote General Movement Assessment for early detection of Cerebral Palsy in high-risk infants: A Knowledge Translational Study implementing home filming in a Norwegian cohort.

Remote General Movement Assessment for early detection of Cerebral Palsy in high-risk infants: A Knowledge Translational Study implementing home filming in a Norwegian cohort. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Remote General Movement Assessment for early detection of Cerebral Palsy in high-risk infants: A Knowledge Translational Study implementing home filming in a Norwegian cohort. Lars Adde, Toril Fjørtoft, Randi Lade, Siril Osland, Frank Piegsa, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4351070/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background General Movement Assessment (GMA) is recommended for early detection of risk for cerebral palsy but requires trained clinical experts. We aimed to implement home- and hospital-based filming for remote GMA in a Norwegian high-risk infant cohort, as well as evaluating parents’ experiences in filming their infant at home. Methods This knowledge translational study used a prospective cohort design including participants referred to neurodevelopmental follow-up across three sites in the Central Norway Regional Health Authority. Two home films of the fidgety type of general movements were collected between 12 + 1 -14 + 6 and 15 + 1 -17 + 6 weeks after term by parents. An additional film was collected at the hospital between 12 + 1 and 17 + 6 weeks after term. The instructional guide for all filming was the In-Motion App standards. Videos were transferred to a remote GMA team and classified as either “GMA scorable” or “GMA not scorable” based on Prechtl’s GMA standards. Parents responded to an online survey using a 5-point Likert scale to collect information about their perspectives, experiences, and possible worries by filming their infant at home. Results One-hundred-and-two infants from 95 families participated. Ninety-two (96.8%) families transferred 177 home-based videos. Eighty-four (92%) of these had 95 videos taken in their local hospital. All 177 home-videos were “GMA scorable” and three (3,1%) out of 95 hospital-based videos were classified as “GMA not scorable”. Eight families did not respond to the survey and two families did not receive the survey due to a technical error. Seventy-eight (91.7%) respondents agreed or strongly agreed that it was easy to perform home filming and five (5.9%) agreed that they were more worried about their child`s development after filming at home. Almost 80% of respondents agreed that a video for GMA can be taken at home instead of in hospital. Conclusion This study strengthens the clinical implementation of home filming by parents and remote GMA for early detection of CP in high-risk follow-up programs. The implementation of remote GMA has the potential to facilitate early intervention to improve function in children with CP in line with international recommendations. Trial registration: ClinicalTrials.gov ID: NCT04287166 Date of registration: 27/02/2020 cerebral palsy early detection high-risk infant general movement assessment Figures Figure 1 Background Cerebral palsy (CP) is the most common childhood disability, causing functional limitations and co-occurring impairments due to injury to the developing brain ( 1 , 2 ). Diagnosis is typically made at 12–24 months of age in high-income countries and as late as 5 years of age in low- and middle-income countries ( 3 – 5 ). Follow-up in high-risk infants has the goal to provide early identification and referral for targeted interventions to infants with CP ( 6 ). Using standardized follow-up to identify infants with increased risk of CP based on their clinical history gives opportunity to provide interventions during infancy when neuroplasticity is high. Such early identification will improve access to community health services for those who may benefit and reassure parents of those infants who are unlikely to develop CP ( 7 – 10 ). An early “high-risk of CP” warning before 5 months of age by combining results from neonatal neuroimaging, the Prechtl General Movement Assessment (GMA) and the Hammersmith Infant Neurological Examination (HINE), can decrease the age of CP diagnosis ( 5 , 11 ). A cornerstone in early detection of CP is the GMA due to the fact that it is non-invasive and cost-efficient ( 12 ). The GMA is based on visual observation of whether the fidgety type (FMs) of General Movements (GMs) are present or not between 12 to 18 weeks after term age in 3-5-minute-long video recordings ( 12 , 13 ). The GMA has shown high accuracy in detection of CP before 5 months after term and is today recommended for clinical use ( 5 , 14 – 17 ). Neurodevelopmental follow-up after discharge from the neonatal intensive care unit (NICU) is usually designed as visits to the out-patient clinic at the hospital ( 18 ). Consequently, filming for infant FMs between 12 and 18 weeks after term are typically done by trained clinicians within face-to-face clinical settings ( 19 ). Driven by the need to empower parents, reduce the need for clinical hospital appointments (augmented by both the COVID-19 pandemic and the need to reduce costs), overcome geographical travel distance, and improve the quality of video recordings by letting families choose the best timing and surroundings for filming their infant, new telehealth solutions have recently been developed ( 20 ). Smartphone apps like the Baby Moves, In-Motion and NeuroMotion, have been used successfully by parents for home-based filming of GMs ( 21 – 24 ). The app solutions enable remote GMA by trained experts located at specialized hospital centers. However, the use of smartphone apps have been limited to research settings and app production and operating expenses are costly ( 19 ). In addition, the possibility to share GMA knowledge and films between hospitals regardless of GMA expertise, and in cases where caregivers cannot film their baby at home, is often hampered by lack of legislation consensus on data storage and transfer policy. Data transfer policy often differs between research and clinical settings, and storage and transmission of digital images like GMs films need to comply to local legislation and clinical organizational policies ( 19 ). Equally important is the need for evaluation of parental experiences and perspectives in filming their infant’s spontaneous movements at home for remote CP risk assessment. Methods Acknowledging the need for increased availability of GMA in infants at risk of CP, we aimed to implement home- and local hospital-based filming of GMs for remote expert-based GMA and telehealth solutions in follow-up programs in the Central Norway Regional Health Authority. We also wanted to evaluate the proportion of hospital films and family films performed in a Norwegian high-risk infant cohort that complied with standards for GMA, as well as parents’ experiences in filming their infant at home. This knowledge translational study used a prospective cohort design and included a knowledge translation action plan developed in cooperation with user and health-care representatives ( 25 ). The study was developed based on five questions presented by Lavis et. al. ( 26 ) for the development of knowledge translation actions. An additional file shows key questions and responses (see Additional file 1). The plan was developed by addressing the needs of each hospital organization and their follow-up health-care teams. The chief investigator and investigator team performed a barrier analysis by interviewing key members of the follow-up health-care teams at the three participating hospitals. One out of three participating hospitals had GMA trained personnel available for filming. Several barriers to the implementation of hospital- and home filming and remote GMA were identified, including lack of clinical time for the remote GMA team, lack of digital apps for smartphone hospital filming, and lack of a digital healthcare solution for transfer of home-based films that complied with legislation consensus on data storage and video transfer policy. The identified barriers were met with a knowledge translation action plan to stimulate clinical uptake of the solution. An additional document shows this in more details (see Additional file 2). Participants Participants were recruited from NICU`s across three sites (St. Olavs Hospital, Ålesund Hospital and Levanger Hospital) in the Central Norway Regional Health Authority. We aimed to recruit 100 infants. Infants were included if they were admitted to one of the three participating NICUs and referred to neurodevelopmental follow-up at discharge from 1st of August 2020 to 1st of August 2022. The centers had slightly different criteria for follow-up, but all places referred neonates considered at moderate-to-high risk of adverse neurodevelopmental development (prematurity (birth weight (BW) < 1500 g and/or gestational age (GA) < 32 weeks (one hospital) or BW < 1000g and/or GA < 28 weeks (two hospitals), neonatal arterial ischemic stroke, hypoxic-ischemic encephalopathy (HIE) with- and without therapeutic hypothermia or other neonatal conditions affecting the risk for perinatal brain injury). Data collection procedure Infant demographic data and perinatal medical data were collected from medical records and stored in a web-based data retrieval solution at St. Olavs University Hospital. Two separate home films taken between 12 + 1 -14 + 6 and 15 + 1 -17 + 6 weeks after term were collected to ensure that GM videos were taken during the period for the fidgety type of GMs. After receiving home films, parents were contacted with a link to an online survey to collect information about their perspectives, experiences and possible worries due to filming their infant at home. To facilitate implementation of hospital filming if parents could not film at home, a parallel film between 12 + 1 and 17 + 6 weeks after term was taken by a physiotherapist/nurse during the scheduled appointment in the outpatient follow-up hospital program. The instruction for healthcare personnel was to record the first video between week 12 + 1 and 14 + 6 after term and a second video between week 15 + 1 and 17 + 6 after term if abnormal GMA was identified on the first video. The hospital-based film was also transferred to the remote GMA team for assessment. Information to parents/caregivers Parents were contacted by a local physiotherapist/nurse/pediatrician before discharge from the NICU. Information was given regarding home filming procedures, the use of remote GMA for early risk for CP assessment, that they would receive phone calls from the remote GMA team with more detailed information, and that they would be scheduled for an appointment with their local follow-up team when the infant was between 12 to18 weeks after term. When infants were about 10 weeks after term, the first follow-up phone from the remote GMA team was performed giving more detailed information about the home filming procedures. The use of a digital healthcare solution providing SMS-messages was explained and parents were informed that results from the GMA risk assessment would be communicated to them as part of the clinical appointment with their local follow-up team. A second follow-up phone call to the parents by the remote GMA team was performed by the end of week 14 after term or the beginning of week 15 after term to pick up any questions about the home filming procedures. Digital health care solution, hospital smartphone app and instructional guidelines For home-based recordings, a commercially available digital health care solution (CheckWare), already approved for transfer of patient data in the Central Norway Regional Health Authority, was used. The solution was customized with a digital “treatment plan” for the communication with parents and transfer of home-based videos to the remote GMA team at St. Olavs Hospital. Automated SMSs were generated to remind parents to film their infant and digital alerts on a desk-top application was provided to the remote GMA team whenever a film was uploaded. The SMS informed parents about where to find the video-based instructional guides on YouTube. Reminders to parents were provided every 7th day if a video was not uploaded to the hospital server. For hospital-based recordings, a solution with an existing hospital video capture app (VidiView) was implemented. The follow-up teams at each of the three participating hospitals received training in using the video capture app which was installed on hospital smart phones. The video was automatically transferred from the smart phone to the remote GMA-team’s hospital server. Healthcare personnel from two of the three participating hospitals and all parents had access to the same instructional video for GM filming through a Uniform Resource Locator (URL) link. Instructions for recording a video of 3 minutes were the same for both parents and healthcare personnel. The instructional guideline video was the same as previously published and feasibility tested in the In-Motion App study ( 22 ). Parents and healthcare personnel could observe the instructional video for information about standards for GMA (infant state, light, clothing, positioning, and duration of video) as many times as needed. The hospital with the remote GMA team had access to trained and experienced GMA personnel who did not need the instructional video. Assessment of video quality and GMs All videos were assessed by a certified GMA observer in the remote GMA team with respect to the following standards ( 13 ): 1) active movements (not hypokinetic), supine position, correct state, adequate clothing (diaper or a onesie), no disturbances during recording, sufficient light, whole body visible in video frame and correct position of smartphone camera. Videos were classified as either “GMA scorable” or “GMA not scorable” based on these standards ( 22 ). The remote GMA team had three certified and experienced GMA observers who met once a week to observe incoming videos. None of them had knowledge about the infant`s clinical history if the infant video was not from St. Olavs hospital and at least two had no knowledge about the infant`s clinical history if infant video was from St. Olavs hospital. The three GMA observers observed all videos independently, and in cases of disagreement, a majority decision was made and used as the final classification. Fidgety type of general movements was assessed according to Prechtl`s method of assessment of GMs ( 13 ). Infants were classified as having “Low risk for CP” if fidgety movements (FMs) were present (continuous (FM++) or intermittent (FM+)). Infants were classified as having “high risk for CP” if FMs were sporadic (FM+/-), abnormal (Fa) or absent (FM-) ( 12 , 13 ). The final classification was documented in the child’s medical record by a member of the remote GMA team (medical records for all children included in the study were made available to the remote GMA team for documentation). The local follow-up team was responsible for looking up the results documented in the child’s medical record. However, if the GMA result was abnormal indicating a high risk for CP, this was communicated to the local pediatrician by the remote GMA team by a phone call. Further follow-up including the GMA result was managed by the local hospital team and evaluation of possible clinical consequences for the individual child was not a part of this study. Parental survey A digital survey was developed to assess parents’ perspectives, experiences and possible worries related to filming their infant at home for remote CP risk assessment. Only one parent in the family could reply to the survey. The survey was designed with different statements, and parents indicated agreement or disagreement with the statement on a 5-point Likert scale. An additional survey file shows this in more detail (see Additional file 3). The digital survey solution provided security measures to ensure data accuracy and privacy. Statistical analysis Data were analyzed using SPSS statistics V.29.0 (IBM SPSS Statistics). Data are presented as numbers with percentages (%) or with mean with SD and range. Descriptive statistics summarizes participants characteristics and survey responses. GMA results will be presented with numbers and proportions (%). Results The recruitment and flow of participants are described in Fig. 1 . In total, 102 infants from 95 families (seven twins) were recruited. Infant and family characteristics are shown in Table 1 . Table 1: Infant/family characteristics Infants ( n = 102) Birth characteristics Gestational age, weeks, mean (SD, range) 30.6 (5.4, 23–41) Birthweight, g, mean (SD, range) 1778 (1276, 445–5920) Male gender, n (%) 55 (54%) Perinatal data Neonatal ischemic stroke, n (%) 5 (4.9) Perinatal asphyxia without therapeutic hypothermia, n (%) 5 (4.9) Perinatal asphyxia with therapeutic hypothermia, n (%) 7 (6.9) Gestational age < 28 weeks, n (%) 37 (36.3) Gestational age 28–31 weeks, n (%) 36 (35.3) Gestational age 32–41 weeks, n (%) 29 (28.4) Families ( n = 85)* Socio-demographic data, n (%) Mother relation (survey), n (%) 72 (84.7) Married/cohabiting family, n (%) 83 (97.6) Mean age years survey respondent (SD, range) 31.8 (6.2/, 21–56) Mean age years survey partner (SD, range) 32.6 (5.5, 21–48) Single child, n (%) 44 (51.7) iOS vs. Android iOS users, n (%) 51(60) *Values calculated based on survey respondents` families only Challenges to knowledge translation Most of the challenges were related to technical issues in the knowledge translation action plan. Occasionally, technical procedures updating the smartphone app (VidiView) used for hospital-based filming caused errors and made filming of the infant impossible. In these cases, a back-up smartphone was used. Also, there was an occasional problem with transfer of video recordings from parents’ smartphones to the hospital server if the video file exceeded a pre-set file size limit. In such cases, someone from the remote GMA team called the parents and asked them to transfer the video with a compressed video file resolution. Organization of weekly expert-based GMA meetings, phone call procedures with parents, SMS communication between hospital and parents and accessibility to the In-Motion instructional video progressed without noticeable negative events. Video recordings Ninety-two (96.8%) of 95 included families transferred a total of 177 home-based videos. In parallel, 84 (92%) of these had a total of 95 videos taken in their local hospital and transferred to the remote GMA team. Two hundred and eleven (77,5%) of the 272 videos taken by both parents and healthcare personnel were within the targeted length of 3 minutes ± 5 seconds. Six (2.2%) videos were shorter than this, and 12 (4.4%) videos were longer than 4 minutes. Home-based video recordings Two (1,9%) infants had no home video, 23 (22.6%) had one home video and 77 (75,5%) had two home videos transferred. Seventy-three (79,3%) and 75 (81,5%) of families recorded and transferred the first and second video within the correct time window, respectively. Three (3,2%) videos were recorded and transferred before ( 17 + 6 weeks after term). Hospital-based video recordings: Eleven (10,8%) of 102 participating infants had no video recorded from hospitals, 87 (85,3%) had one video and 4 (3,9%) had two hospital videos recorded and transferred. Ninety (94,7%) of 95 infant hospital videos were transferred correctly by healthcare personnel within first time window between week 12 + 1 and 14 + 6 after term. Video quality for remote GMA All 177 uploaded home-videos were feasible for GMA classification according to the Prechtl GMA standards ( 13 ) and the In-Motion instructional guideline ( 22 ). Three (3,1%) out of 95 hospital-based videos showed inappropriate behavioral state of the infant and could not be used for GMA, leaving 92 (96.8%) of hospital-based videos feasible for GMA classification. The additional files 4 and 5 describe details about the video quality of home-based and hospital-based videos. General Movement Assessment Out of 269 scorable videos (177 taken by parents at home and 92 taken by healthcare personnel in hospital follow-up clinic), one (0,4%) video was classified with exaggerated (Fa), 12 (4,5%) with absent (FM-) and 23 (8,5%) with sporadic (FM+/-) FMs. Two hundred and one (74,7%) and 32 (11,8%) videos were classified with intermittent (FM+) and continuous (FM++) FMs, respectively. Parental survey Eight families did not respond to the survey and two families did not receive the survey due to a technical error. Consequently, 85 (89,4%) out of the 95 included families responded to the survey. Forty-three (50.6%) families observed the In-Motion instructional video guide on YouTube once, 36 (42.4%) twice, and 6 (7.1%) three times. Thirty-eight (44.7%) families practiced filming their baby once before uploading and transferring a video, 33 (38.8%) twice, 6 (7.1%) three times, 3 (3.5%) four times and 5 (5.9%) five times or more. About half of the respondents disagreed that the information on how GMA results would be communicated to them was good and 21% disagreed that it was easy to keep the telephone still while filming. Seventy-eight (91.7%) respondents agreed or strongly agreed that it was easy to perform home filming. Five (5.9%) respondents agreed that they were more worried about their child`s development after filming at home. Almost 80% of respondents agreed that a video for GMA can be taken at home instead of in hospital during an out-patient visit. Details about parental responses are shown in Table 2 . Table 2 Details about parental responses performing home filming Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree It was easy to understand the information sent by SMS 70 (82.3%) 13 (15.3%) 2 (2.4%) 0 0 It was easy to find the instructional video 74 (87%) 8 (9.4%) 2 (2.4%) 0 1 (1.2%) The information I got about when to perform filming was easy to understand 68 (80%) 16 (18.8%) 1 (1.2%) 0 0 The number of telephone calls with information about home filming was suitable 62 (72.9%) 19 (22.3%) 2 (2.4%) 2 (2.4%) 0 It was easy to do the filming without disturbing the child 39 (45.9%) 33 (38.8%) 9 (10.6%) 4 (4.7%) 0 It was easy to understand how my child should be dressed when filmed 68 (80%) 17 (20%) 0 0 0 It was easy to understand how my child should be positioned and how the mat should be when I was going to film 62 (72.9%) 23 (27.1%) 0 0 0 It was easy to follow the instructions about how the lighting should be during the filming 55 (64.7%) 20 (23.5%) 9 (10.6%) 1 (1,2%) 0 It was easy to understand how I should stand and hold the telephone during the filming 61 (71.8%) 22 (25.8%) 2 (2.4%) 0 0 It was easy to keep the telephone still while I was filming* 26 (31%) 40 (47.6%) 16 (19%) 2 (2.4%) 0 Filming my child for 3 minutes went smoothly** 39 (46.9%) 36 (43.4% 6 (7.3%) 2 (2.4%) 0 In general, home filming was easy to perform 57 (67.1%) 21 (24.6%) 5 (5.9%) 2 (2.4%) 0 I felt safe about uploading video of my child 48 (56.5%) 32 (37.6% 5 (5.9%) 0 0 There were no technical problems with uploading and sending the videos 34 (40%) 25 (29.4%) 10 (11.8%) 13 (15.3%) 3 (3.5%) I became more worried about my child's development through filming at home 1 (1.2%) 4 (4.7% 22 (25.9%) 25 (29.4%) 33 (38.8%) Performing home filming made me more attentive to my child's development 8 (9.4%) 36 (42.4%) 31 (36.5%) 7 (8.2%) 3 (3.5%) I think parents can film at home instead of the child being filmed in hospital by healthcare personnel 27 (31.7%) 40 (47.1%) 14 (16.4%) 2 (2.4%) 2 (2.4%) I think the information on how to get the results of the assessment was good 22 (25.9%) 25 (29.4%) 20 (23.5%) 17 (20%) 1 (1.2%) Discussion This study represents as far as we know the first knowledge translational study of remote GMA for CP risk assessment in Europe. The study shows that early filming of infant spontaneous movements both at home and at hospital visits for remote GMA can be successfully implemented in high-risk follow-up programs. Almost all parents and healthcare personnel managed to film the infants correctly and there was no substantial difference between them. Parents of high-risk infants found home-filming easy to perform, for most families it did not increase worries for their child’s development, and almost 80% agreed that filming can be done at home instead of in hospital visits. More than 50% of parents agreed or strongly agreed that filming at home made them more attentive towards their child`s development. There are promising trends in the implementation of screening guidelines for early CP detection ( 20 , 27 – 30 ), and two studies from the US have shown a reduction in age of CP diagnosis after implementing guidelines using a combination of GMA, MRI and HINE suggested by Novak et al. ( 27 , 29 ). A strength in our study is that it demonstrates a sensible way forward towards equal availability for early GMA screening for at-risk infants regardless of local expertise and geographical constraints. The success of performing remote GMA shown in this study may also indicate a pathway towards more efficient resource utilization. In infants with normal GMA, follow-up may be more focused on other developmental domains, whereas infants with an abnormal GMA need closer surveillance with regards to motor function. Although GMA should always be used in combination with clinical data, imaging and other standardized testing, the negative predictive value of a normal GMA is very high ( 5 , 31 ). The knowledge translation implementation framework used in this study is its core strength. Each of the three participating sites identified their individual organization’s need to implement the remote GMA as part of their follow-up program. For example, the initial information given to parents about the follow-up program, home filming and how results about the GMA evaluation were presented for parents as a part of this, were aligned and adopted according to the local hospital organization. Hence, the individualized and specific local site implementation facilitated a successful result and was supported by knowledge translational literature headlighting identification of local barriers as highly important ( 25 ). An additional strength is the inclusion of high-risk infants typical for post-discharge NICU follow-up programs. In Norway, national guidelines recommend scheduled follow-up of high-risk infants aiming for early detection of abnormal neurodevelopment ( 32 ). The result of this study is therefore relevant beyond the regional health authority covered by this study. With geographical restrictions and sparsely populated areas at a long distance from hospitals, remote GMA based on home-filming will facilitate equality in health care services. Evidence of improvements in health care delivery processes using SMS communication supports our approach implementing remote GMA using an SMS based communication with parents for more widespread use of GMA as recommended in international guidelines ( 33 , 34 ). The findings in this study regarding challenges keeping the telephone still during recording and the need for improved communication on GMA results gives valuable insight for future improvements. Finally, we argue that the use of certified and experienced GMA observers for evaluation of video quality and GMA scoring, and a parental survey with high response rate, make the results trustworthy. The current study also has several limitations. Parents in our context are, most likely, highly used to mobile health technology. Findings may therefore not be representative for parents/families in other localizations with less experience in usage of mobile health technology. Furthermore, the study aims to implement remote GMA for early CP diagnosis. Cerebral palsy outcomes are not evaluated yet, and we cannot evaluate whether there are differences in parental satisfaction between families who have a child with a CP diagnosis or not. The limited sample size also makes it difficult to rate parental responses based on the GMA classification. In parallel, our study is limited to infants with medical high-risk factors admitted to a NICU, leaving infants in primary healthcare without risk factors for CP (but with possible occurrence of CP) outside our knowledge translation approach ( 35 ). Another limitation is the low number of included infants leaving implementation success to more densely populated areas with much higher number of follow-up patients unclear. However, it could be argued that our successful implementation based on a relatively small number of follow-up patients on each site will probably also make implementation feasible in high-volume settings. Previous studies have reported on preferences of screening, assessment tools for early CP detection, and timing of diagnosis with parents of children who are diagnosed with CP ( 20 ). Surprisingly few studies report the experiences and perspectives of families whose child is screened for CP but do not get a CP diagnosis, as well as experiences of families having an early false positive risk assessment using GMA. Qualitative interviews will be conducted in the future with families and study site healthcare personnel to document perspectives covering more details related to these important aspects. This study presents promising results implementing remote GMA in a clinical high-risk follow-up setting. The presented solution for home-based video recordings and accompanying e-health infrastructure may also be tested for upcoming machine learning techniques for early detection of CP. Conclusion This study strengthens the clinical implementation of home filming by parents to enable remote GMA for early detection of CP in high-risk follow-up programs. Consequently, it contributes to equal access to GMA independent of travel distances and local GMA competence. The implementation of remote GMA has the potential to facilitate early intervention to improve function in children with CP in line with international recommendations. Abbreviations CP Cerebral Palsy GMA General Movement Assessment GMs General Movements FMs Fidgety Movements HINE Hammersmith Infant Neurological Examination NICU Neonatal Intensive Care Unit Declarations Ethical approval and consent to participate All infant/families provided written informed consent and ethics was approved by the regional committee for medical and health research ethics (REC Central-Committee 62240) in Norway. The study sites in St. Olavs Hospital, Ålesund Hospital and Levanger Hospital also had approvals from their local Institutional Review boards. Study registration in ClinicalTrials.gov Protocol Record ID: NCT04287166. Consent for publication Consent for publication – Not applicable Availability of data and materials The video data that support the findings of this study are not available due to ethical and regulatory considerations. Other data generated during the work are included in the manuscript text with accompanying tables and figures. Competing interests The authors declare that they have no competing interests. Funding This work was supported by grants from The Liaison Committee between the Central Norway Regional Health Authority and the Norwegian University of Science and Technology, Trondheim, Norway (SO-ID: 24239). Authors' contributions Conceptualization: LA, RS, BHE, KÅ, GS, TF. Data curation: LA, TF, SO, RL, FP, PGS, GS. Funding acquisition: LA, RS, BHE, KÅ. Methodology: LA, TF, SO, RS, BHE. Project administration: LA, BHE, KÅ, PGS, RL. Resources: LA, TF, SO, RL, FP, GS, PGS. Writhing original draft: LA, RS, BHE. Writhing-review and editing: LA, RS, BHE, TF, SO, RL, FP, KÅ, PGS, GS Acknowledgements We would like to thank all the families that participated in this study. We acknowledge the support from St. Olavs Hospital, Ålesund Hospital, Levanger Hospital, The Liaison Committee between the Central Norway Regional Health Authority and the Norwegian University of Science and Technology, Trondheim, Norway. 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Prechtl's assessment of general movements: a diagnostic tool for the functional assessment of the young nervous system. Ment Retard Dev Disabil Res Rev. 2005;11(1):61–7. Stoen R, Boswell L, de Regnier RA, Fjortoft T, Gaebler-Spira D, Ihlen E et al. The Predictive Accuracy of the General Movement Assessment for Cerebral Palsy: A Prospective, Observational Study of High-Risk Infants in a Clinical Follow-Up Setting. J Clin Med. 2019;8(11). Maitre NL, Benninger KL, Neel ML, Haase JA, Pietruszewski L, Levengood K, et al. Standardized Neurodevelopmental Surveillance of High-risk Infants Using Telehealth: Implementation Study during COVID-19. Pediatr Qual Saf. 2021;6(4):e439. Kwong AK, Eeles AL, Olsen JE, Zannino D, Kariotis T, Spittle AJ. Instructional guides for filming infant movements at home are effective for the General Movements Assessment. J Paediatr Child Health. 2021. Kwong AK, Eeles AL, Anderson PJ, Badawi N, Boyd RN, Cameron KL, et al. The Knowledge Translation of Early Cerebral Palsy (KiTE CP) study: Implementing Screening among a High-risk Prospective Cohort of Australian Infants. J Pediatr. 2024;268:113949. Kwong AK, Eeles AL, Olsen JE, Cheong JL, Doyle LW, Spittle AJ. The Baby Moves smartphone app for General Movements Assessment: Engagement amongst extremely preterm and term-born infants in a state-wide geographical study. J Paediatr Child Health. 2018. Adde L, Brown A, Van den Broeck C, DeCoen K, Eriksen BH, Fjørtoft T, et al. In-Motion-App for remote General Movement Assessment: a multi-site observational study. BMJ open. 2021;11(3):e042147. Svensson KA, Örtqvist M, Bos AF, Eliasson A-C, Sundelin HE. Usability and inter-rater reliability of the NeuroMotion app: A tool in General Movements Assessments. Eur J Paediatr Neurol. 2021;33:29–35. Kukka AJ, Sundelin HE, Basnet O, Paudel P, Subedi KU, Svensson K, et al. NeuroMotion smartphone application for remote General Movements Assessment: a feasibility study in Nepal. BMJ Open. 2024;14(3):e080063. Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;7(1):1–17. Lavis JN, Robertson D, Woodside JM, McLeod CB, Abelson J. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Q. 2003;81(2):221–48. Byrne R, Noritz G, Maitre NL, Group NED. Implementation of early diagnosis and intervention guidelines for cerebral palsy in a high-risk infant follow-up clinic. Pediatr Neurol. 2017;76:66–71. Elliott C, Alexander C, Salt A, Spittle AJ, Boyd RN, Badawi N, et al. Early Moves: a protocol for a population-based prospective cohort study to establish general movements as an early biomarker of cognitive impairment in infants. BMJ Open. 2021;11(4):e041695. Maitre NL, Burton VJ, Duncan AF, Iyer S, Ostrander B, Winter S et al. Network implementation of guideline for early detection decreases age at cerebral palsy diagnosis. Pediatrics. 2020;145(5). King AR, Machipisa C, Finlayson F, Fahey MC, Novak I, Malhotra A. Early detection of cerebral palsy in high-risk infants: Translation of evidence into practice in an Australian hospital. J Paediatr Child Health. 2021;57(2):246–50. Badawi N, Novak I, Morgan C, Crowle C. Early detection of cerebral palsy using general movements assessment and MRIs–a sensible way forward. Pediatr Res. 2024:1–2. Helsedirektoratet. Nasjonal faglig retningslinje for oppfølging av for tidlig fødte barn [cited 2021 03.05.2021]. https://helsedirektoratet.no/retningslinjer/nasjonal-faglig-retningslinje-for-oppfolging-av-for-tidlig-fodte-barn . Free C, Phillips G, Watson L, Galli L, Felix L, Edwards P, et al. The effectiveness of mobile-health technologies to improve health care service delivery processes: a systematic review and meta-analysis. PLoS Med. 2013;10(1):e1001363. Sandle M, Sheppard A, Fletcher AA, Berry M, DeVries N. Early identification of infants at risk of cerebral palsy: developing the use of general movement assessment in routine clinical practice in a tertiary neonatal unit in New Zealand. New Z Med J (Online). 2020;133(1514):63–6. Stoknes M, Andersen GL, Elkamil AI, Irgens LM, Skranes J, Salvesen KÅ, et al. The effects of multiple pre-and perinatal risk factors on the occurrence of cerebral palsy. A Norwegian register based study. Eur J Paediatr Neurol. 2012;16(1):56–63. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4351070","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":300514274,"identity":"96baff20-a0e7-4297-82b5-15a7d028463c","order_by":0,"name":"Lars Adde","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYBACPgjFzNjA3kCkFja4Fp4DjMRpQmiRSCBWC/vZxx8Yaqxl+yXfHn9c2MaQx09QC0+6mQTDsXTjmbPzEptntjEUSxKyi40hDeg2tsOJG27nGDbztjEkbjhASAv/M+YPDP8OJ+6/eYZYLRJpDBKMbUBbJHiI1vKMTSKxL914xpkcw9k85yQSZxLyCz9/GvOHD9+AIdZ+xuAzT5lNYj8BHRCQgGBKEKVhFIyCUTAKRgEBAAAcTTp9CII7swAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim","correspondingAuthor":true,"prefix":"","firstName":"Lars","middleName":"","lastName":"Adde","suffix":""},{"id":300514278,"identity":"73306518-b5b0-4b18-b75a-6cf488c08c77","order_by":1,"name":"Toril Fjørtoft","email":"","orcid":"","institution":"Clinic of Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim","correspondingAuthor":false,"prefix":"","firstName":"Toril","middleName":"","lastName":"Fjørtoft","suffix":""},{"id":300514282,"identity":"1384c21d-b237-4600-b888-4fe14d8b7587","order_by":2,"name":"Randi Lade","email":"","orcid":"","institution":"Department of Pediatrics, Møre and Romsdal Hospital trust, Ålesund Hospital, Ålesund","correspondingAuthor":false,"prefix":"","firstName":"Randi","middleName":"","lastName":"Lade","suffix":""},{"id":300514285,"identity":"d16079e6-022e-4a81-953d-4e9618563907","order_by":3,"name":"Siril Osland","email":"","orcid":"","institution":"Clinic of Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim","correspondingAuthor":false,"prefix":"","firstName":"Siril","middleName":"","lastName":"Osland","suffix":""},{"id":300514288,"identity":"2c530d63-58dc-46b9-a412-446cf7710a17","order_by":4,"name":"Frank Piegsa","email":"","orcid":"","institution":"Department of Pediatrics, Møre and Romsdal Hospital trust, Ålesund Hospital, Ålesund","correspondingAuthor":false,"prefix":"","firstName":"Frank","middleName":"","lastName":"Piegsa","suffix":""},{"id":300514290,"identity":"9d1df974-9610-4d25-877b-700cbe91b8c0","order_by":5,"name":"Per Gunnar Sandstrøm","email":"","orcid":"","institution":"Nord Trondelag Hospital Trust, Habilitation Centre, Levanger","correspondingAuthor":false,"prefix":"","firstName":"Per","middleName":"Gunnar","lastName":"Sandstrøm","suffix":""},{"id":300514292,"identity":"156ed0bd-eea3-4870-b779-c258800eb1b6","order_by":6,"name":"Ragnhild Støen","email":"","orcid":"","institution":"Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim","correspondingAuthor":false,"prefix":"","firstName":"Ragnhild","middleName":"","lastName":"Støen","suffix":""},{"id":300514293,"identity":"e9aa3b7c-e8e5-4f0e-9c7b-894cd3cc69ad","order_by":7,"name":"Gunfrid V. Størvold","email":"","orcid":"","institution":"Nord Trondelag Hospital Trust, Habilitation Centre, Levanger","correspondingAuthor":false,"prefix":"","firstName":"Gunfrid","middleName":"V.","lastName":"Størvold","suffix":""},{"id":300514294,"identity":"787e1cd5-6394-40fc-97c7-43b665f68e2e","order_by":8,"name":"Kristin Bjørnstad Åberg","email":"","orcid":"","institution":"Nord Trondelag Hospital Trust, Habilitation Centre, Levanger","correspondingAuthor":false,"prefix":"","firstName":"Kristin","middleName":"Bjørnstad","lastName":"Åberg","suffix":""},{"id":300514296,"identity":"21d028ee-16b5-415f-af12-e137ad7eee73","order_by":9,"name":"Beate Horsberg Eriksen","email":"","orcid":"","institution":"Department of Pediatrics, Møre and Romsdal Hospital trust, Ålesund Hospital, Ålesund","correspondingAuthor":false,"prefix":"","firstName":"Beate","middleName":"Horsberg","lastName":"Eriksen","suffix":""}],"badges":[],"createdAt":"2024-04-30 18:54:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4351070/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4351070/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56549214,"identity":"c1a8e0ff-92a8-4c1d-b27f-8c4c24ff1ca9","added_by":"auto","created_at":"2024-05-15 15:44:50","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":343947,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4351070/v1/d001c90397d57c4b68e00a15.jpeg"},{"id":56551198,"identity":"aea8e327-ff9c-453d-9c5d-114ec4a85a38","added_by":"auto","created_at":"2024-05-15 16:00:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":999906,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4351070/v1/81d0c8e4-7c0c-487f-9932-c027937c8a71.pdf"},{"id":56550680,"identity":"161903c7-8a4b-46ac-9323-e2fe7114671f","added_by":"auto","created_at":"2024-05-15 15:52:50","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":14927,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4351070/v1/347c3216b27be8958862d496.docx"},{"id":56549212,"identity":"1908e2dc-9fc5-460b-a80f-02676640bb0a","added_by":"auto","created_at":"2024-05-15 15:44:50","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":15723,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4351070/v1/fbf26c372fb88a350adc9009.docx"},{"id":56549217,"identity":"2d689722-4d9f-48b1-a9d1-378193a841f8","added_by":"auto","created_at":"2024-05-15 15:44:50","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":21495,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-4351070/v1/6af06f58478deeeccddcfbb8.docx"},{"id":56550681,"identity":"b24a5208-ecde-4013-8e3c-552df351511d","added_by":"auto","created_at":"2024-05-15 15:52:50","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":15998,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile4.docx","url":"https://assets-eu.researchsquare.com/files/rs-4351070/v1/3926ec9e7e91fda3f4da0c1f.docx"},{"id":56549215,"identity":"a418efe9-38ae-4579-b53f-2f86f3da6631","added_by":"auto","created_at":"2024-05-15 15:44:50","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":14415,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile5.docx","url":"https://assets-eu.researchsquare.com/files/rs-4351070/v1/07c016dc05b6b482f5bb83f0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Remote General Movement Assessment for early detection of Cerebral Palsy in high-risk infants: A Knowledge Translational Study implementing home filming in a Norwegian cohort.","fulltext":[{"header":"Background","content":"\u003cp\u003eCerebral palsy (CP) is the most common childhood disability, causing functional limitations and co-occurring impairments due to injury to the developing brain (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Diagnosis is typically made at 12\u0026ndash;24 months of age in high-income countries and as late as 5 years of age in low- and middle-income countries (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Follow-up in high-risk infants has the goal to provide early identification and referral for targeted interventions to infants with CP (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUsing standardized follow-up to identify infants with increased risk of CP based on their clinical history gives opportunity to provide interventions during infancy when neuroplasticity is high. Such early identification will improve access to community health services for those who may benefit and reassure parents of those infants who are unlikely to develop CP (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). An early \u0026ldquo;high-risk of CP\u0026rdquo; warning before 5 months of age by combining results from neonatal neuroimaging, the Prechtl General Movement Assessment (GMA) and the Hammersmith Infant Neurological Examination (HINE), can decrease the age of CP diagnosis (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). A cornerstone in early detection of CP is the GMA due to the fact that it is non-invasive and cost-efficient (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The GMA is based on visual observation of whether the fidgety type (FMs) of General Movements (GMs) are present or not between 12 to 18 weeks after term age in 3-5-minute-long video recordings (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The GMA has shown high accuracy in detection of CP before 5 months after term and is today recommended for clinical use (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNeurodevelopmental follow-up after discharge from the neonatal intensive care unit (NICU) is usually designed as visits to the out-patient clinic at the hospital (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Consequently, filming for infant FMs between 12 and 18 weeks after term are typically done by trained clinicians within face-to-face clinical settings (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Driven by the need to empower parents, reduce the need for clinical hospital appointments (augmented by both the COVID-19 pandemic and the need to reduce costs), overcome geographical travel distance, and improve the quality of video recordings by letting families choose the best timing and surroundings for filming their infant, new telehealth solutions have recently been developed (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSmartphone apps like the Baby Moves, In-Motion and NeuroMotion, have been used successfully by parents for home-based filming of GMs (\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The app solutions enable remote GMA by trained experts located at specialized hospital centers. However, the use of smartphone apps have been limited to research settings and app production and operating expenses are costly (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In addition, the possibility to share GMA knowledge and films between hospitals regardless of GMA expertise, and in cases where caregivers cannot film their baby at home, is often hampered by lack of legislation consensus on data storage and transfer policy. Data transfer policy often differs between research and clinical settings, and storage and transmission of digital images like GMs films need to comply to local legislation and clinical organizational policies (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Equally important is the need for evaluation of parental experiences and perspectives in filming their infant\u0026rsquo;s spontaneous movements at home for remote CP risk assessment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAcknowledging the need for increased availability of GMA in infants at risk of CP, we aimed to implement home- and local hospital-based filming of GMs for remote expert-based GMA and telehealth solutions in follow-up programs in the Central Norway Regional Health Authority. We also wanted to evaluate the proportion of hospital films and family films performed in a Norwegian high-risk infant cohort that complied with standards for GMA, as well as parents\u0026rsquo; experiences in filming their infant at home.\u003c/p\u003e \u003cp\u003eThis knowledge translational study used a prospective cohort design and included a knowledge translation action plan developed in cooperation with user and health-care representatives (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The study was developed based on five questions presented by Lavis et. al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) for the development of knowledge translation actions. An additional file shows key questions and responses (see Additional file 1). The plan was developed by addressing the needs of each hospital organization and their follow-up health-care teams. The chief investigator and investigator team performed a barrier analysis by interviewing key members of the follow-up health-care teams at the three participating hospitals. One out of three participating hospitals had GMA trained personnel available for filming. Several barriers to the implementation of hospital- and home filming and remote GMA were identified, including lack of clinical time for the remote GMA team, lack of digital apps for smartphone hospital filming, and lack of a digital healthcare solution for transfer of home-based films that complied with legislation consensus on data storage and video transfer policy. The identified barriers were met with a knowledge translation action plan to stimulate clinical uptake of the solution. An additional document shows this in more details (see Additional file 2).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e Participants were recruited from NICU`s across three sites (St. Olavs Hospital, \u0026Aring;lesund Hospital and Levanger Hospital) in the Central Norway Regional Health Authority. We aimed to recruit 100 infants. Infants were included if they were admitted to one of the three participating NICUs and referred to neurodevelopmental follow-up at discharge from 1st of August 2020 to 1st of August 2022. The centers had slightly different criteria for follow-up, but all places referred neonates considered at moderate-to-high risk of adverse neurodevelopmental development (prematurity (birth weight (BW)\u0026thinsp;\u0026lt;\u0026thinsp;1500 g and/or gestational age (GA)\u0026thinsp;\u0026lt;\u0026thinsp;32 weeks (one hospital) or BW\u0026thinsp;\u0026lt;\u0026thinsp;1000g and/or GA\u0026thinsp;\u0026lt;\u0026thinsp;28 weeks (two hospitals), neonatal arterial ischemic stroke, hypoxic-ischemic encephalopathy (HIE) with- and without therapeutic hypothermia or other neonatal conditions affecting the risk for perinatal brain injury).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection procedure\u003c/h2\u003e \u003cp\u003eInfant demographic data and perinatal medical data were collected from medical records and stored in a web-based data retrieval solution at St. Olavs University Hospital. Two separate home films taken between 12\u003csup\u003e+\u0026thinsp;1\u003c/sup\u003e-14\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e and 15\u003csup\u003e+\u0026thinsp;1\u003c/sup\u003e-17\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e weeks after term were collected to ensure that GM videos were taken during the period for the fidgety type of GMs. After receiving home films, parents were contacted with a link to an online survey to collect information about their perspectives, experiences and possible worries due to filming their infant at home. To facilitate implementation of hospital filming if parents could not film at home, a parallel film between 12\u003csup\u003e+\u0026thinsp;1\u003c/sup\u003e and 17\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e weeks after term was taken by a physiotherapist/nurse during the scheduled appointment in the outpatient follow-up hospital program. The instruction for healthcare personnel was to record the first video between week 12\u003csup\u003e+\u0026thinsp;1\u003c/sup\u003e and 14\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e after term and a second video between week 15\u003csup\u003e+\u0026thinsp;1\u003c/sup\u003e and 17\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e after term if abnormal GMA was identified on the first video. The hospital-based film was also transferred to the remote GMA team for assessment.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eInformation to parents/caregivers\u003c/h2\u003e \u003cp\u003eParents were contacted by a local physiotherapist/nurse/pediatrician before discharge from the NICU. Information was given regarding home filming procedures, the use of remote GMA for early risk for CP assessment, that they would receive phone calls from the remote GMA team with more detailed information, and that they would be scheduled for an appointment with their local follow-up team when the infant was between 12 to18 weeks after term. When infants were about 10 weeks after term, the first follow-up phone from the remote GMA team was performed giving more detailed information about the home filming procedures. The use of a digital healthcare solution providing SMS-messages was explained and parents were informed that results from the GMA risk assessment would be communicated to them as part of the clinical appointment with their local follow-up team. A second follow-up phone call to the parents by the remote GMA team was performed by the end of week 14 after term or the beginning of week 15 after term to pick up any questions about the home filming procedures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eDigital health care solution, hospital smartphone app and instructional guidelines\u003c/h2\u003e \u003cp\u003eFor home-based recordings, a commercially available digital health care solution (CheckWare), already approved for transfer of patient data in the Central Norway Regional Health Authority, was used. The solution was customized with a digital \u0026ldquo;treatment plan\u0026rdquo; for the communication with parents and transfer of home-based videos to the remote GMA team at St. Olavs Hospital. Automated SMSs were generated to remind parents to film their infant and digital alerts on a desk-top application was provided to the remote GMA team whenever a film was uploaded. The SMS informed parents about where to find the video-based instructional guides on YouTube. Reminders to parents were provided every 7th day if a video was not uploaded to the hospital server.\u003c/p\u003e \u003cp\u003eFor hospital-based recordings, a solution with an existing hospital video capture app (VidiView) was implemented. The follow-up teams at each of the three participating hospitals received training in using the video capture app which was installed on hospital smart phones. The video was automatically transferred from the smart phone to the remote GMA-team\u0026rsquo;s hospital server.\u003c/p\u003e \u003cp\u003eHealthcare personnel from two of the three participating hospitals and all parents had access to the same instructional video for GM filming through a Uniform Resource Locator (URL) link. Instructions for recording a video of 3 minutes were the same for both parents and healthcare personnel. The instructional guideline video was the same as previously published and feasibility tested in the In-Motion App study (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Parents and healthcare personnel could observe the instructional video for information about standards for GMA (infant state, light, clothing, positioning, and duration of video) as many times as needed. The hospital with the remote GMA team had access to trained and experienced GMA personnel who did not need the instructional video.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eAssessment of video quality and GMs\u003c/h2\u003e \u003cp\u003eAll videos were assessed by a certified GMA observer in the remote GMA team with respect to the following standards (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e): 1) active movements (not hypokinetic), supine position, correct state, adequate clothing (diaper or a onesie), no disturbances during recording, sufficient light, whole body visible in video frame and correct position of smartphone camera. Videos were classified as either \u0026ldquo;GMA scorable\u0026rdquo; or \u0026ldquo;GMA not scorable\u0026rdquo; based on these standards (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe remote GMA team had three certified and experienced GMA observers who met once a week to observe incoming videos. None of them had knowledge about the infant`s clinical history if the infant video was not from St. Olavs hospital and at least two had no knowledge about the infant`s clinical history if infant video was from St. Olavs hospital. The three GMA observers observed all videos independently, and in cases of disagreement, a majority decision was made and used as the final classification. Fidgety type of general movements was assessed according to Prechtl`s method of assessment of GMs (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Infants were classified as having \u0026ldquo;Low risk for CP\u0026rdquo; if fidgety movements (FMs) were present (continuous (FM++) or intermittent (FM+)). Infants were classified as having \u0026ldquo;high risk for CP\u0026rdquo; if FMs were sporadic (FM+/-), abnormal (Fa) or absent (FM-) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe final classification was documented in the child\u0026rsquo;s medical record by a member of the remote GMA team (medical records for all children included in the study were made available to the remote GMA team for documentation). The local follow-up team was responsible for looking up the results documented in the child\u0026rsquo;s medical record. However, if the GMA result was abnormal indicating a high risk for CP, this was communicated to the local pediatrician by the remote GMA team by a phone call. Further follow-up including the GMA result was managed by the local hospital team and evaluation of possible clinical consequences for the individual child was not a part of this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eParental survey\u003c/h2\u003e \u003cp\u003e A digital survey was developed to assess parents\u0026rsquo; perspectives, experiences and possible worries related to filming their infant at home for remote CP risk assessment. Only one parent in the family could reply to the survey. The survey was designed with different statements, and parents indicated agreement or disagreement with the statement on a 5-point Likert scale. An additional survey file shows this in more detail (see Additional file 3). The digital survey solution provided security measures to ensure data accuracy and privacy.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using SPSS statistics V.29.0 (IBM SPSS Statistics). Data are presented as numbers with percentages (%) or with mean with SD and range. Descriptive statistics summarizes participants characteristics and survey responses. GMA results will be presented with numbers and proportions (%).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe recruitment and flow of participants are described in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. In total, 102 infants from 95 families (seven twins) were recruited. Infant and family characteristics are shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Infant/family characteristics\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInfants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;102)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBirth characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGestational age, weeks, mean (SD, range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.6 (5.4, 23\u0026ndash;41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBirthweight, g, mean (SD, range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1778 (1276, 445\u0026ndash;5920)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale gender, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerinatal data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeonatal ischemic stroke, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerinatal asphyxia without therapeutic hypothermia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerinatal asphyxia with therapeutic hypothermia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGestational age\u0026thinsp;\u0026lt;\u0026thinsp;28 weeks, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (36.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGestational age 28\u0026ndash;31 weeks, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (35.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGestational age 32\u0026ndash;41 weeks, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamilies (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;85)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocio-demographic data, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMother relation (survey), \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72 (84.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried/cohabiting family, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (97.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean age years survey respondent (SD, range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.8 (6.2/, 21\u0026ndash;56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean age years survey partner (SD, range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.6 (5.5, 21\u0026ndash;48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle child, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (51.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eiOS vs. Android\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eiOS users, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51(60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e*Values calculated based on survey respondents` families only\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eChallenges to knowledge translation\u003c/h2\u003e\n \u003cp\u003eMost of the challenges were related to technical issues in the knowledge translation action plan. Occasionally, technical procedures updating the smartphone app (VidiView) used for hospital-based filming caused errors and made filming of the infant impossible. In these cases, a back-up smartphone was used. Also, there was an occasional problem with transfer of video recordings from parents\u0026rsquo; smartphones to the hospital server if the video file exceeded a pre-set file size limit. In such cases, someone from the remote GMA team called the parents and asked them to transfer the video with a compressed video file resolution. Organization of weekly expert-based GMA meetings, phone call procedures with parents, SMS communication between hospital and parents and accessibility to the In-Motion instructional video progressed without noticeable negative events.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eVideo recordings\u003c/h2\u003e\n \u003cp\u003eNinety-two (96.8%) of 95 included families transferred a total of 177 home-based videos. In parallel, 84 (92%) of these had a total of 95 videos taken in their local hospital and transferred to the remote GMA team. Two hundred and eleven (77,5%) of the 272 videos taken by both parents and healthcare personnel were within the targeted length of 3 minutes\u0026thinsp;\u0026plusmn;\u0026thinsp;5 seconds. Six (2.2%) videos were shorter than this, and 12 (4.4%) videos were longer than 4 minutes.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eHome-based video recordings\u003c/h2\u003e\n \u003cp\u003eTwo (1,9%) infants had no home video, 23 (22.6%) had one home video and 77 (75,5%) had two home videos transferred. Seventy-three (79,3%) and 75 (81,5%) of families recorded and transferred the first and second video within the correct time window, respectively. Three (3,2%) videos were recorded and transferred before (\u0026lt;\u0026thinsp;12\u003csup\u003e+\u0026thinsp;1\u003c/sup\u003e weeks after term) and 20 (21.7%) after the correct age window (\u0026gt;\u0026thinsp;17\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e weeks after term).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eHospital-based video recordings:\u003c/h2\u003e\n \u003cp\u003eEleven (10,8%) of 102 participating infants had no video recorded from hospitals, 87 (85,3%) had one video and 4 (3,9%) had two hospital videos recorded and transferred. Ninety (94,7%) of 95 infant hospital videos were transferred correctly by healthcare personnel within first time window between week 12\u003csup\u003e+\u0026thinsp;1\u003c/sup\u003e and 14\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e after term.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eVideo quality for remote GMA\u003c/h2\u003e\n \u003cp\u003eAll 177 uploaded home-videos were feasible for GMA classification according to the Prechtl GMA standards (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e) and the In-Motion instructional guideline (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). Three (3,1%) out of 95 hospital-based videos showed inappropriate behavioral state of the infant and could not be used for GMA, leaving 92 (96.8%) of hospital-based videos feasible for GMA classification. The additional files 4 and 5 describe details about the video quality of home-based and hospital-based videos.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eGeneral Movement Assessment\u003c/h2\u003e\n \u003cp\u003eOut of 269 scorable videos (177 taken by parents at home and 92 taken by healthcare personnel in hospital follow-up clinic), one (0,4%) video was classified with exaggerated (Fa), 12 (4,5%) with absent (FM-) and 23 (8,5%) with sporadic (FM+/-) FMs. Two hundred and one (74,7%) and 32 (11,8%) videos were classified with intermittent (FM+) and continuous (FM++) FMs, respectively.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eParental survey\u003c/h2\u003e\n \u003cp\u003eEight families did not respond to the survey and two families did not receive the survey due to a technical error. Consequently, 85 (89,4%) out of the 95 included families responded to the survey. Forty-three (50.6%) families observed the In-Motion instructional video guide on YouTube once, 36 (42.4%) twice, and 6 (7.1%) three times. Thirty-eight (44.7%) families practiced filming their baby once before uploading and transferring a video, 33 (38.8%) twice, 6 (7.1%) three times, 3 (3.5%) four times and 5 (5.9%) five times or more.\u003c/p\u003e\n \u003cp\u003eAbout half of the respondents disagreed that the information on how GMA results would be communicated to them was good and 21% disagreed that it was easy to keep the telephone still while filming. Seventy-eight (91.7%) respondents agreed or strongly agreed that it was easy to perform home filming. Five (5.9%) respondents agreed that they were more worried about their child`s development after filming at home. Almost 80% of respondents agreed that a video for GMA can be taken at home instead of in hospital during an out-patient visit. Details about parental responses are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDetails about parental responses performing home filming\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStrongly agree\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAgree\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNeither agree nor disagree\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDisagree\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStrongly disagree\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt was easy to understand the information sent by SMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70 (82.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (15.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt was easy to find the instructional video\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (9.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe information I got about when to perform filming was easy to understand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe number of telephone calls with information about home filming was suitable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (72.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (22.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt was easy to do the filming without disturbing the child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (45.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (38.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt was easy to understand how my child should be dressed when filmed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt was easy to understand how my child should be positioned and how the mat should be when I was going to film\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (72.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (27.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt was easy to follow the instructions about how the lighting should be during the filming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (64.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt was easy to understand how I should stand and hold the telephone during the filming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (71.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (25.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt was easy to keep the telephone still while I was filming*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (47.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFilming my child for 3 minutes went smoothly**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (46.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (43.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn general, home filming was easy to perform\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (67.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (24.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI felt safe about uploading video of my child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (56.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (37.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThere were no technical problems with uploading and sending the videos\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (15.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI became more worried about my child\u0026apos;s development through filming at home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (25.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (38.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerforming home filming made me more attentive to my child\u0026apos;s development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (9.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (42.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (36.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (8.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI think parents can film at home instead of the child being filmed in hospital by healthcare personnel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (31.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (47.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (16.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI think the information on how to get the results of the assessment was good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (25.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study represents as far as we know the first knowledge translational study of remote GMA for CP risk assessment in Europe. The study shows that early filming of infant spontaneous movements both at home and at hospital visits for remote GMA can be successfully implemented in high-risk follow-up programs. Almost all parents and healthcare personnel managed to film the infants correctly and there was no substantial difference between them. Parents of high-risk infants found home-filming easy to perform, for most families it did not increase worries for their child\u0026rsquo;s development, and almost 80% agreed that filming can be done at home instead of in hospital visits. More than 50% of parents agreed or strongly agreed that filming at home made them more attentive towards their child`s development.\u003c/p\u003e \u003cp\u003eThere are promising trends in the implementation of screening guidelines for early CP detection (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), and two studies from the US have shown a reduction in age of CP diagnosis after implementing guidelines using a combination of GMA, MRI and HINE suggested by Novak et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). A strength in our study is that it demonstrates a sensible way forward towards equal availability for early GMA screening for at-risk infants regardless of local expertise and geographical constraints. The success of performing remote GMA shown in this study may also indicate a pathway towards more efficient resource utilization. In infants with normal GMA, follow-up may be more focused on other developmental domains, whereas infants with an abnormal GMA need closer surveillance with regards to motor function. Although GMA should always be used in combination with clinical data, imaging and other standardized testing, the negative predictive value of a normal GMA is very high (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe knowledge translation implementation framework used in this study is its core strength. Each of the three participating sites identified their individual organization\u0026rsquo;s need to implement the remote GMA as part of their follow-up program. For example, the initial information given to parents about the follow-up program, home filming and how results about the GMA evaluation were presented for parents as a part of this, were aligned and adopted according to the local hospital organization. Hence, the individualized and specific local site implementation facilitated a successful result and was supported by knowledge translational literature headlighting identification of local barriers as highly important (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). An additional strength is the inclusion of high-risk infants typical for post-discharge NICU follow-up programs. In Norway, national guidelines recommend scheduled follow-up of high-risk infants aiming for early detection of abnormal neurodevelopment (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The result of this study is therefore relevant beyond the regional health authority covered by this study. With geographical restrictions and sparsely populated areas at a long distance from hospitals, remote GMA based on home-filming will facilitate equality in health care services.\u003c/p\u003e \u003cp\u003eEvidence of improvements in health care delivery processes using SMS communication supports our approach implementing remote GMA using an SMS based communication with parents for more widespread use of GMA as recommended in international guidelines (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The findings in this study regarding challenges keeping the telephone still during recording and the need for improved communication on GMA results gives valuable insight for future improvements. Finally, we argue that the use of certified and experienced GMA observers for evaluation of video quality and GMA scoring, and a parental survey with high response rate, make the results trustworthy.\u003c/p\u003e \u003cp\u003eThe current study also has several limitations. Parents in our context are, most likely, highly used to mobile health technology. Findings may therefore not be representative for parents/families in other localizations with less experience in usage of mobile health technology. Furthermore, the study aims to implement remote GMA for early CP diagnosis. Cerebral palsy outcomes are not evaluated yet, and we cannot evaluate whether there are differences in parental satisfaction between families who have a child with a CP diagnosis or not. The limited sample size also makes it difficult to rate parental responses based on the GMA classification. In parallel, our study is limited to infants with medical high-risk factors admitted to a NICU, leaving infants in primary healthcare without risk factors for CP (but with possible occurrence of CP) outside our knowledge translation approach (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Another limitation is the low number of included infants leaving implementation success to more densely populated areas with much higher number of follow-up patients unclear. However, it could be argued that our successful implementation based on a relatively small number of follow-up patients on each site will probably also make implementation feasible in high-volume settings.\u003c/p\u003e \u003cp\u003ePrevious studies have reported on preferences of screening, assessment tools for early CP detection, and timing of diagnosis with parents of children who are diagnosed with CP (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Surprisingly few studies report the experiences and perspectives of families whose child is screened for CP but do not get a CP diagnosis, as well as experiences of families having an early false positive risk assessment using GMA. Qualitative interviews will be conducted in the future with families and study site healthcare personnel to document perspectives covering more details related to these important aspects. This study presents promising results implementing remote GMA in a clinical high-risk follow-up setting. The presented solution for home-based video recordings and accompanying e-health infrastructure may also be tested for upcoming machine learning techniques for early detection of CP.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study strengthens the clinical implementation of home filming by parents to enable remote GMA for early detection of CP in high-risk follow-up programs. Consequently, it contributes to equal access to GMA independent of travel distances and local GMA competence. The implementation of remote GMA has the potential to facilitate early intervention to improve function in children with CP in line with international recommendations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Cerebral Palsy\u003c/p\u003e\n\u003cp\u003eGMA\u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;General Movement Assessment\u003c/p\u003e\n\u003cp\u003eGMs\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;General Movements\u003c/p\u003e\n\u003cp\u003eFMs\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Fidgety Movements\u003c/p\u003e\n\u003cp\u003eHINE\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Hammersmith Infant Neurological Examination\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNICU \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Neonatal Intensive Care Unit\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll infant/families provided written informed consent and ethics was approved by the regional committee for medical and health research ethics (REC Central-Committee 62240) in Norway. The study sites in St. Olavs Hospital, \u0026Aring;lesund Hospital and Levanger Hospital also had approvals from their local Institutional Review boards. Study registration in ClinicalTrials.gov Protocol Record ID:\u0026nbsp;NCT04287166.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication \u0026ndash; Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe video data that support the findings of this study are not available due to ethical and regulatory considerations. Other data generated during the work are included in the manuscript text with accompanying tables and figures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from The Liaison Committee between the Central Norway Regional Health Authority and the Norwegian University of Science and Technology, Trondheim, Norway (SO-ID: 24239).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: LA, RS, BHE, K\u0026Aring;, GS, TF. Data curation: LA, TF, SO, RL, FP, PGS, GS. Funding acquisition: LA, RS, BHE, K\u0026Aring;. Methodology: LA, TF, SO, RS, BHE. Project administration: LA, BHE, K\u0026Aring;, PGS, RL. Resources: LA, TF, SO, RL, FP, GS, PGS. Writhing original draft: LA, RS, BHE. Writhing-review and editing: LA, RS, BHE, TF, SO, RL, FP, K\u0026Aring;, PGS, GS\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the families that participated in this study. We acknowledge the support from St. Olavs Hospital, \u0026Aring;lesund Hospital, Levanger Hospital, The Liaison Committee between the Central Norway Regional Health Authority and the Norwegian University of Science and Technology, Trondheim, Norway. We also thank The Norwegian Cerebral Palsy Organization for all support and their valuable contribution to this study as well as colleagues at St. Olavs Hospital contributing with valuable GMA knowledge and Per Henning Valderhaug at Hemit, Trondheim for valuable contributions with digital solutions.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007;109:8\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNovak I, Hines M, Goldsmith S, Barclay R. Clinical prognostic messages from a systematic review on cerebral palsy. Pediatrics. 2012;130(5):e1285\u0026ndash;312.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhandaker G, Muhit M, Karim T, Smithers-Sheedy H, Novak I, Jones C, et al. Epidemiology of cerebral palsy in Bangladesh: a population‐based surveillance study. Dev Med Child Neurol. 2019;61(5):601\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGranild-Jensen JB, Rackauskaite G, Flachs EM, Uldall P. Predictors for early diagnosis of cerebral palsy from national registry data. Dev Med Child Neurol. 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNovak I, Morgan C, Adde L, Blackman J, Boyd RN, Brunstrom-Hernandez J, et al. Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment. JAMA Pediatr. 2017;171(9):897\u0026ndash;907.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaitre NL, Chorna O, Romeo DM, Guzzetta A. Implementation of the Hammersmith Infant Neurological Examination in a high-risk infant follow-up program. Pediatr Neurol. 2016;65:31\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuttmann K, Flibotte J, DeMauro SB. Parental perspectives on diagnosis and prognosis of neonatal intensive care unit graduates with cerebral palsy. J Pediatr. 2018;203:156\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson V, Spencer-Smith M, Wood A. Do children really recover better? Neurobehavioural plasticity after early brain insult. Brain. 2011;134(8):2197\u0026ndash;221.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorgan C, Fetters L, Adde L, Badawi N, Bancale A, Boyd RN et al. Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews. JAMA Pediatr. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaird G, McConachie H, Scrutton D. Parents' perceptions of disclosure of the diagnosis of cerebral palsy. Arch Dis Child. 2000;83(6):475\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim F, Maitre N, Foundation CP. A Call for Early Detection of Cerebral Palsy. NeoReviews. 2024;25(1):e1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEinspieler C, Peharz R, Marschik PB. Fidgety movements - tiny in appearance, but huge in impact. J Pediatr (Rio J). 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEinspieler C, Prechtl HF, Bos A, Ferrari F, Cioni G. Prechtl`s method on the qualitative assessment of general movements in preterm, term and young infants. London: Mac Keith; 2004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrechtl HF, Einspieler C, Cioni G, Bos AF, Ferrari F, Sontheimer D. An early marker for neurological deficits after perinatal brain lesions. Lancet. 1997;349(9062):1361\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBosanquet M, Copeland L, Ware R, Boyd R. A systematic review of tests to predict cerebral palsy in young children. Dev Med Child Neurol. 2013;55(5):418\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEinspieler C, Prechtl HF. Prechtl's assessment of general movements: a diagnostic tool for the functional assessment of the young nervous system. Ment Retard Dev Disabil Res Rev. 2005;11(1):61\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStoen R, Boswell L, de Regnier RA, Fjortoft T, Gaebler-Spira D, Ihlen E et al. The Predictive Accuracy of the General Movement Assessment for Cerebral Palsy: A Prospective, Observational Study of High-Risk Infants in a Clinical Follow-Up Setting. J Clin Med. 2019;8(11).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaitre NL, Benninger KL, Neel ML, Haase JA, Pietruszewski L, Levengood K, et al. Standardized Neurodevelopmental Surveillance of High-risk Infants Using Telehealth: Implementation Study during COVID-19. Pediatr Qual Saf. 2021;6(4):e439.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwong AK, Eeles AL, Olsen JE, Zannino D, Kariotis T, Spittle AJ. Instructional guides for filming infant movements at home are effective for the General Movements Assessment. J Paediatr Child Health. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwong AK, Eeles AL, Anderson PJ, Badawi N, Boyd RN, Cameron KL, et al. The Knowledge Translation of Early Cerebral Palsy (KiTE CP) study: Implementing Screening among a High-risk Prospective Cohort of Australian Infants. J Pediatr. 2024;268:113949.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwong AK, Eeles AL, Olsen JE, Cheong JL, Doyle LW, Spittle AJ. The Baby Moves smartphone app for General Movements Assessment: Engagement amongst extremely preterm and term-born infants in a state-wide geographical study. J Paediatr Child Health. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdde L, Brown A, Van den Broeck C, DeCoen K, Eriksen BH, Fj\u0026oslash;rtoft T, et al. In-Motion-App for remote General Movement Assessment: a multi-site observational study. BMJ open. 2021;11(3):e042147.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSvensson KA, \u0026Ouml;rtqvist M, Bos AF, Eliasson A-C, Sundelin HE. Usability and inter-rater reliability of the NeuroMotion app: A tool in General Movements Assessments. Eur J Paediatr Neurol. 2021;33:29\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKukka AJ, Sundelin HE, Basnet O, Paudel P, Subedi KU, Svensson K, et al. NeuroMotion smartphone application for remote General Movements Assessment: a feasibility study in Nepal. BMJ Open. 2024;14(3):e080063.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;7(1):1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLavis JN, Robertson D, Woodside JM, McLeod CB, Abelson J. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Q. 2003;81(2):221\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eByrne R, Noritz G, Maitre NL, Group NED. Implementation of early diagnosis and intervention guidelines for cerebral palsy in a high-risk infant follow-up clinic. Pediatr Neurol. 2017;76:66\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElliott C, Alexander C, Salt A, Spittle AJ, Boyd RN, Badawi N, et al. Early Moves: a protocol for a population-based prospective cohort study to establish general movements as an early biomarker of cognitive impairment in infants. BMJ Open. 2021;11(4):e041695.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaitre NL, Burton VJ, Duncan AF, Iyer S, Ostrander B, Winter S et al. Network implementation of guideline for early detection decreases age at cerebral palsy diagnosis. Pediatrics. 2020;145(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKing AR, Machipisa C, Finlayson F, Fahey MC, Novak I, Malhotra A. Early detection of cerebral palsy in high-risk infants: Translation of evidence into practice in an Australian hospital. 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Nasjonal faglig retningslinje for oppf\u0026oslash;lging av for tidlig f\u0026oslash;dte barn [cited 2021 03.05.2021]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://helsedirektoratet.no/retningslinjer/nasjonal-faglig-retningslinje-for-oppfolging-av-for-tidlig-fodte-barn\u003c/span\u003e\u003cspan address=\"https://helsedirektoratet.no/retningslinjer/nasjonal-faglig-retningslinje-for-oppfolging-av-for-tidlig-fodte-barn\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFree C, Phillips G, Watson L, Galli L, Felix L, Edwards P, et al. The effectiveness of mobile-health technologies to improve health care service delivery processes: a systematic review and meta-analysis. PLoS Med. 2013;10(1):e1001363.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandle M, Sheppard A, Fletcher AA, Berry M, DeVries N. Early identification of infants at risk of cerebral palsy: developing the use of general movement assessment in routine clinical practice in a tertiary neonatal unit in New Zealand. New Z Med J (Online). 2020;133(1514):63\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStoknes M, Andersen GL, Elkamil AI, Irgens LM, Skranes J, Salvesen K\u0026Aring;, et al. The effects of multiple pre-and perinatal risk factors on the occurrence of cerebral palsy. A Norwegian register based study. Eur J Paediatr Neurol. 2012;16(1):56\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cerebral palsy, early detection, high-risk infant, general movement assessment","lastPublishedDoi":"10.21203/rs.3.rs-4351070/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4351070/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGeneral Movement Assessment (GMA) is recommended for early detection of risk for cerebral palsy but requires trained clinical experts. We aimed to implement home- and hospital-based filming for remote GMA in a Norwegian high-risk infant cohort, as well as evaluating parents\u0026rsquo; experiences in filming their infant at home.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e This knowledge translational study used a prospective cohort design including participants referred to neurodevelopmental follow-up across three sites in the Central Norway Regional Health Authority. Two home films of the fidgety type of general movements were collected between 12\u003csup\u003e+\u0026thinsp;1\u003c/sup\u003e-14\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e and 15\u003csup\u003e+\u0026thinsp;1\u003c/sup\u003e-17\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e weeks after term by parents. An additional film was collected at the hospital between 12\u003csup\u003e+\u0026thinsp;1\u003c/sup\u003e and 17\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e weeks after term. The instructional guide for all filming was the In-Motion App standards. Videos were transferred to a remote GMA team and classified as either \u0026ldquo;GMA scorable\u0026rdquo; or \u0026ldquo;GMA not scorable\u0026rdquo; based on Prechtl\u0026rsquo;s GMA standards. Parents responded to an online survey using a 5-point Likert scale to collect information about their perspectives, experiences, and possible worries by filming their infant at home.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOne-hundred-and-two infants from 95 families participated. Ninety-two (96.8%) families transferred 177 home-based videos. Eighty-four (92%) of these had 95 videos taken in their local hospital. All 177 home-videos were \u0026ldquo;GMA scorable\u0026rdquo; and three (3,1%) out of 95 hospital-based videos were classified as \u0026ldquo;GMA not scorable\u0026rdquo;. Eight families did not respond to the survey and two families did not receive the survey due to a technical error. Seventy-eight (91.7%) respondents agreed or strongly agreed that it was easy to perform home filming and five (5.9%) agreed that they were more worried about their child`s development after filming at home. Almost 80% of respondents agreed that a video for GMA can be taken at home instead of in hospital.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study strengthens the clinical implementation of home filming by parents and remote GMA for early detection of CP in high-risk follow-up programs. The implementation of remote GMA has the potential to facilitate early intervention to improve function in children with CP in line with international recommendations.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eClinicalTrials.gov ID: NCT04287166 Date of registration: 27/02/2020\u003c/p\u003e","manuscriptTitle":"Remote General Movement Assessment for early detection of Cerebral Palsy in high-risk infants: A Knowledge Translational Study implementing home filming in a Norwegian cohort.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-15 15:44:45","doi":"10.21203/rs.3.rs-4351070/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-03T05:04:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-31T08:04:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-23T09:54:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106839837020717796806767400773058077658","date":"2024-05-08T20:55:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224027456612327177848053136781915660972","date":"2024-05-08T13:13:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-08T13:02:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-08T12:56:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-07T23:55:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-07T10:01:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-04-30T18:46:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"52d8617b-e4f1-4714-9000-91e4d45c7530","owner":[],"postedDate":"May 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-07-02T06:00:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-15 15:44:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4351070","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4351070","identity":"rs-4351070","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}