The Importance of a Multidisciplinary Team

Cranial deformation (CD) is a distortion of the head shape resulting from mechanical forces that occur prenatally and postnatally. 1 Prenatal forces from things like intrauterine constraint and postnatal forces from things like limited tummy time; prolonged positioning in a car seat or infant carrier; and handling, feeding, and carrying patterns can contribute to CD. 2 Decreased cervical range of motion (ROM) can cause infants to develop CD or increase the severity of CD. 3 An infant’s motor development can also be impacted by limited tummy time, again contributing to CD. 4 CD occurs in just over 90 percent of infants who are diagnosed with congenital muscular torticollis (CMT). 5 CD and CMT are caused by similar underlying conditions and, not surprisingly, have similar interventions. Typically, infants with CD and CMT will be treated by an orthotist/prosthetist and a physical therapist. To optimize outcomes, these allied healthcare professionals should take a team approach when caring for patients with CD and CMT. [caption id="attachment_248498" align="alignright" width="300"] Photograph courtesy of Orthomerica.[/caption] The team should be dynamic based on the needs of the infant and the child’s caregivers. The multidisciplinary care team for infants presenting with CD could consist of orthotists/prosthetists, physical therapists, pediatricians, speech and occupational therapists, and neurosurgeon/craniofacial specialists, and, most importantly, the child’s parents. Together, the team should maintain communication and create an individualized care plan for the infant. For example, a cranial care team may have access to a pediatric neurosurgeon to consult about an infant who presents with an atypical head shape to rule out possible craniosynostosis. The neurosurgeon can then decide if a CT or MRI is required. Communicating with the infant’s physical therapist can help to determine the degree or severity of CMT, which can have an impact on the decisions regarding cranial remolding therapy. Ideally, the orthotist/prosthetist and physical therapist should communicate when evaluating an infant for the first time. The clinician may note significant head tilt or movement preference and request a referral for a physical therapy evaluation. Conversely, the physical therapist can request a cranial evaluation if the infant has signs of cranial asymmetry. According to the World Health Organization Framework for Action on Interprofessional Education & Collaborative Practice, “Collaborative practice happens when multiple health workers from different professional backgrounds work together with patients, families, caregivers and communities to deliver the highest quality of care.” 6 The multidisciplinary care model leverages professional experience, knowledge, and skills from each team member. This combined effort promotes improved patient satisfaction, reduces episodes of care, and allows for early identification if treatment is needed. It also minimizes healthcare costs. Understanding the Importance of Team-based Care Changes to healthcare insurance requirements are driving the move toward interdisciplinary care. Team-based care allows the payer to see the patient’s needs holistically, which in turn, helps them determine if a cranial remolding orthosis will be approved. The payer can see whether conservative therapy was tried for a certain number of months before authorizing a cranial remolding orthosis. 7 When caring for patients with CD or CMT, team-based care allows practitioners to connect with the infant’s caregivers regarding key clinical issues and provide a comprehensive, continuous, coordinated care program that is within the scope of the practitioners’ training and capabilities. It can also increase the efficiency and productivity of a clinical practice. Healthcare providers can collaborate in a coordinated way. 8 When the multidisciplinary team members share the infant’s health and social history as well as past and current therapies, this can help clinicians identify interventions that address the unique needs of the patient and family. Ongoing collaboration among and communication between team members result in continuous, comprehensive, coordinated care during and between visits. This approach also helps all members of the team to feel engaged in their key role in caring for the infant. 9 Ideally, a cranial clinic should include physical, occupational, and speech therapists at one location, or in close proximity, to coordinate appointments on the same day. Coordinating clinical appointments for the caregivers can also make adherence to the appointments more likely. However, coordinating appointments in rural areas can be challenging, which reinforces the importance of ongoing communication regarding the infant’s care. Children with special needs, such as infants who are diagnosed with Down syndrome, osteogenesis imperfecta, or cerebral palsy may require adaptations to cranial treatments due to the effects these conditions have on muscle tone, muscle weakness, and, possibly, cognition and development. These factors can also contribute to cranial deformities. Along with the family, the multidisciplinary care team can identify and discuss the needs of the infant and prioritize the interventions, including cranial remolding treatments. [caption id="attachment_248308" align="alignleft" width="300"] jbrown/stock.adobe.com[/caption] The Environment Is Key to Success An effective team needs to provide an environment for open discussion regardless of role. All voices and ideas should be taken into consideration for the benefit of the patient. Each team member needs to educate the others on his or her specialty. For orthotists/prosthetists, educating the team on the importance of early referrals for baseline and follow-up scans to document the symmetry and growth of the infant’s head shape growth over time is essential in determining appropriate interventions. Educating team members about each other’s roles can also help clinicians provide appropriate specialist referrals to assist with the infant’s care. Conditions like reflux, torticollis, and low muscle tone can contribute to the infant’s head shape deformity. Specific to the cranial specialists, educating the team on the different severity scales can help to ensure that the appropriate intervention is provided at the right time. The Argenta scale, for example, provides visual guidelines to determine treatment. The Children’s Healthcare of Atlanta’s Plagiocephaly Severity Scale takes into consideration measurements and quadrant involvement (presentation) to determine treatment. 11,12 Pediatricians play a vital role in educating parents about preventing CD, early treatment for repositioning and stretching, and referring infants who present with CD and movement asymmetries to the appropriate clinical specialist. Pediatricians have the opportunity to identify risk factors for torticollis and head-shape deformities during well-baby checkups. [caption id="attachment_248307" align="alignright" width="300"] jbrown/stock.adobe.com[/caption] The home and daycare settings are part of the infant’s environment and include several caregivers throughout the day. Therefore, daycare workers, nannies, grandparents, babysitters, and siblings should be considered part of the infant’s team. Educating all caregivers on tummy time, repositioning, and equal neck movements plays a key role in preventing head shape deformities or treating torticollis. Prevention of head shape deformities is the goal. Uniting for Patient Care Challenges It takes resources to start and maintain a team-based care program. A private practice may make it more challenging. Will the various disciplines have the same access to the patient’s electronic medical records (EMRs)? Access to the EMRs allows the team to see clinical information from other disciplines. When healthcare team members act independently, this can sometimes cause confusion and can erode the patient’s and the family’s trust. Staying in close communication with each member of the care team helps to best serve the patient’s needs. 13 Having scheduled group meetings helps keep all members up to date on individual cases. Or, if that is not practical, reading each other’s clinical notes and recommendations and then discussing cases is a simple way to encourage coordinated care. The Multidisciplinary Care Team Fluid team dynamics. This can be achieved by understanding and honoring the roles and responsibilities of other healthcare professions. Team members should not allow hierarchy to dictate who feels comfortable speaking up. Everyone on the team should have a voice. 14 Effective collaboration. Collaboration promotes the active participation of each discipline. All disciplines should work together and fully engage patients and caregivers. This fosters respect for the disciplinary contributions of all professionals. Patience. This level of collaboration takes time to develop. Productive and respectful relationships between and among team members makes a difference. Start small and add more disciplines as needed. Patient- and family-centered philosophy. Put the patient and family first. The power of doing so enables the team to come together for the patient. Patients notice the difference that team-based care makes. This model helps connect all of the patient’s needs for the best outcome. 15 Editor’s note: This article originally appeared in our media partner’s publication, The Academy TODAY. Jessica Corso, CO/L, FAAOP, is team leader, Cranial Program, Children’s Healthcare of Atlanta and chair of the American Academy of Orthotists and Prosthetists’ Craniofacial Scientific Society. References Rogers GF. Deformational plagiocephaly, brachycephaly, and scaphocephaly, Part II: Prevention and Treatment. J Craniofacial Surg 123:17-23,2011 de Brock F, Braun V, Renz-Polster H. Deformational plagiocephaly in normal infants: a systematic review of cases and hypotheses. Arch Dis Child. 2017: 102 535 – 542. Gonzalez-Santos J, Gonzalez-Bernal J, et.el. Infant Cranial Deformity: Cranial Helmet Therapy or Physiotherapy. Int. J. Environ. Res. Public Health 2020, 17,2612. van Vlimmeren Risk factors for deformational plagiocephaly at birth and at 7-weeks of age: a prospective study. Pediatrics 119: e408-e418. 2007 Cheng JCY et al. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants- a study of 1,086 cases. Journal of Pediatric Surgery 35:1091-1096.2000. World Health Organization (2010) Framework for action on interprofessional education and collaborative practice. Geneva, Switzerland: WHO Patient Engagement Hit; How to use team-based care to improve the patient experience. website n.d. Accessed May 29, 2021 https://www.patientengagementhit.com/news Committee on Reviewing Evidence to Identify Highly Effective Clinical Services, Board on Health Care Services. Knowing what works in health care. A roadmap for the nation. The National Academies Press; Washington, DC . H. Sox 2008 book Improving Practice Efficiency Through Team-based Care American Academy of Allergy & Immunology website n.d. Accessed May 2,2021 https://www.aaaai.org Team-based care in primary care pediatric office website n.d. Accessed May 2, 2021 https://www.paap.org Spermon J, Spermon-Marijen R, Scholten-Peeters W. Clinical classification of deformational plagiocephaly according to Argenta: A reliability study. Journal of Craniofacial Surgery. 19: 664-668, 2008. Holowka MA, Reisner A et al. Plagiocephaly Severity Scale to Aid in Clinical Treatment Recommendations. J Craniofac Surg 2017. May;28(3):717-722.

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The Importance of a Multidisciplinary Team

Prevention, Identification, Evaluation, and Management of Infants Presenting With Nonsynostotic Cranial Deformities

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