General Movements in preterm infants undergoing craniosacral therapy: a randomised controlled pilot-trial.

Role of Intervention Strategies for At-risk Preterm Infants

General movement optimality score and general movements trajectories following early parent-administrated physiotherapy in the neonatal intensive care unit

The purposes of this study were to evaluate the effects of preterm birth, severe brain lesions, and postterm age on kicking movements of young infants and to compare the prognostic value of kinematic analysis of kicking with a qualitative assessment of infants' spontaneous movements. The subjects were 12 full-term infants without brain injury, 12 low-risk preterm infants without brain injury, and 11 preterm infants with severe brain lesions (periventricular leukomalacia). Videotape recordings of each infant's motor behavior in a supine position were made at 1 and 3 months postterm age. Kicking frequency, temporal organization of the kick cycle, coordination among different joints, and interlimb coordination were measured. A qualitative assessment for lower-extremity movements and a Gestalt judgment of general movement quality according to Prechtl's method were made from the same videotape recordings. Kinematic analysis showed only mild differences among the 3 groups of infants. Qualitative assessment of the lower-extremity movements, however, showed that preterm infants with brain lesions, and particularly those who later were found to have cerebral palsy, consistently had fewer segmental movements of the foot and abnormal general movements at both ages. The data suggest that the mechanisms responsible for kicking movements in newborns and young infants do not appear to be influenced by the extrauterine environment or by brain lesions, at least at the ages studied. Qualitative assessment of lower-extremity and general movements seems to be more appropriate for clinical purposes.

Preterm infants are at an increased risk for abnormalities of general movements, which predict subsequent poor neurodevelopmental outcome. The cerebral lesion that predisposes the preterm infant to abnormal general movements remains unknown. The objective of this study was to determine the association between MRI-defined cerebral abnormalities and general movements at 1 and 3 months' corrected age in infants who were born very preterm. Eighty-six preterm infants (<30 weeks' gestation) were prospectively recruited and underwent brain MRI at term-equivalent age to investigate the relationship between qualitative white and gray matter pathology and abnormality of general movements. Standardized videotaped recordings of general movements were obtained at 1 and 3 months postterm (+/-1 week) and scored without knowledge of the MRI findings. At 1 month corrected age, general movements of a writhing character were classified as normal or abnormal (poor repertoire, cramped synchronized, or chaotic). At 3 months' corrected age, fidgety general movements were classified as present or absent. At 1 month, 53 (62%) infants had abnormal general movements, 46 of whom had poor repertoire general movements and 7 of whom had cramped synchronized general movements. At 3 months, 23 (25%) infants had absent fidgety movements. At both 1 and 3 months of age, consistently abnormal general movement classifications were related to increasing white matter abnormality on MRI. In contrast, there were no significant relationships between general movement classifications and gray matter abnormalities, either individually or in total. The significant relationships between general movements at 1 and 3 months and cerebral white matter abnormalities on MRI in the very preterm infant support the concept that abnormal general movements reflect white matter injury.

Objective To compare the validity of general movements ( GM ) assessment with that of a 52 item neurological motor examination in predicting cerebral palsy among high risk neonates.Methods Eighty-four infants aged 12 months at high risk were evaluated simultaneously with GM assessment and the 52 item neurological motor examination.The utility of the two methods in predicting cerebral palsy was then compared.Results There were 4 cerebral palsy patients among the 84 high risk neonates.The GM assessment's predictive validity for Monotonous movements was 78.57％,its sensitivity was 25％,its specificity was 81.25％,its positive predictive value was 6.25％,its negative predictive value was 95.59％,and its kappa value was 0.215.The comparable values for the Cramped-synchronised scale were validity 96.43％,sensitivity 50％,specificity 98.75％,positive predictive value 66.67％,negative predictive value 97.53％,and kappa value O.553.The values for the absence of Fidgety movements were validity 98.81％,sensitivity 75％,specificity 100％,positive predictive value 100％,negative predictive value 98.77％,and kappa value 0.851.For the entire 52 items of the neurological motor examination the corresponding values were validity 51.19％,sensitivity 100％,specificity 48.75％,positive predictive value 8.89％,negative predictive value 100％,and kappa value 0.083.Conclusions GM assessment can predict the severe neurological deficits of cerebral palsy among high risk neonates by the age of 12 months.The 52-item neurological motor examination can detect mild and moderate neurological deficits.GM assessment combined with the 52-item neurological motor examination is a desirable and effective way to assess high risk infants. Key words: Neonates; Cerebral palsy; General movements assessment; Neurological motor examination

BackgroundThe General Movements Assessment is a non-invasive and cost-effective tool with demonstrated reliability for identifying infants at risk for cerebral palsy. Early detection of cerebral palsy allows for the implementation of early intervention and is associated with better functional outcomes. No review to date has summarized the utility of the General Movements Assessment to predict cerebral palsy in term and late-preterm infants diagnosed with neonatal encephalopathy.MethodsWe conducted a scoping review involving infants born greater than or equal to 34 weeks gestational age to identify all available evidence and delineate research gaps. We extracted data on sensitivity, specificity, and positive and negative predictive values and described the strengths and limitations of the results. We searched five databases (MEDLINE, Embase, PsychINFO, Scopus, and CINAHL) and the General Movements Trust website. Two reviewers conducted all screening and data extraction independently. The articles were categorized according to key findings, and a critical appraisal was performed.ResultsOnly three studies, a cohort and two case series, met all of the inclusion criteria. The total number of participants was 118. None of the final eligible studies included late-preterm neonates. All three studies reported on sensitivity, specificity, and positive predictive and negative predictive values. An abnormal General Movement Assessment at 3–5 months has a high specificity (84.6–98%) for cerebral palsy with a similarly high negative predictive value (84.6–98%) when it was normal. Absent fidgety movements, in particular, are highly specific (96%) for moderate to severe cerebral palsy and carry a high negative predictive value (98%) when normal. In the time period between term and 4–5 months post-term, any cramped synchronized movements had results of 100% sensitivity and variable results for specificity, positive predictive value, and negative predictive value.ConclusionsA normal General Movements Assessment at 3 months in a term high-risk infant is likely associated with a low risk for moderate/severe cerebral palsy. The finding of cramped synchronized General Movements is a strong predictor for the diagnosis of cerebral palsy by 2 years of age in the term population with neonatal encephalopathy. The deficit of high-quality research limits the applicability, and so the General Movements Assessment should not be used in isolation when assessing this population.Systematic review registrationTitle registration with Joanna Briggs Institute. URL: http://joannabriggswebdev.org/research/registered_titles.aspx.

ABSTRACTAbnormal general movements are among the most reliable markers for cerebral palsy. General movements are part of the spontaneous motor repertoire and are present from early fetal life until the end of the first half year after term. In addition to its high sensitivity (98%) and specificity (91%), the assessment of general movements is non-invasive and time- and cost-efficient. It is therefore ideal for assessing the integrity of the young nervous system, most notably in lowresource settings. Studies on the general movements assessment in low- and middle-income countries such as China, India, Iran, or South Africa are still rare but increasing. In Brazil, too, researchers have demonstrated that the evaluation of general movements adds to the functional assessment of the young nervous system. Applying general movements assessment in vulnerable populations in Brazil is therefore highly recommended.

Intrauterine growth retardation plays a significant role in neurodevelopmental outcome. The assessment of general movements during the first 20 weeks is a new method for early detection of brain dysfunction. General movements in 31 infants with asymmetric intrauterine growth retardation and their appropriate for gestational age-matched controls were examined. General movements were scored as normal or abnormal by sequential videotape recordings in the writhing (term to 2 weeks), early fidgety (9-11 weeks), and late fidgety (14-16 weeks) periods. Scores were compared between the groups and correlated with neurodevelopmental outcome at 2 years. The incidence of normal general movements was lower in the intrauterine growth retarded infants than in the controls (P < .001). Significant correlations were found between general movement quality and neurodevelopmental scores in the intrauterine growth retarded group. The fidgety movements were the most sensitive and specific for prediction of neurologic outcome. The general movement assessment can, therefore, serve as an additional tool for examining the neurologic status of the preterm and term intrauterine growth retarded infant.

General Movement Assessment in Babies Born Preterm: Motor Optimality Score–Revised (MOS-R), Trajectory, and Neurodevelopmental Outcomes at 1 Year

Preterm infants born before 32 weeks gestation have increased risks for neurodevelopmental impairment at two years of age. How brain function differs between preterm infants with normal or impaired development is unknown. However, abnormal spontaneous motor behavior at 12–15 weeks post-term age is associated with neurodevelopmental impairment. We imaged brain blood oxygen level-dependent signals at term-equivalent age in 62 infants born at <32 weeks gestation and explored whether resting state functional connectivity (rsFC) differed with performances on the General Movement Assessment (GMA) at 12–15 weeks, and Bayley III scores at two years of corrected age. Infants with aberrant general movements exhibited decreased rsFC between the basal ganglia and regions in parietal and frontotemporal lobes. Infants with normal Bayley III cognitive scores exhibited increased rsFC between the basal ganglia and association cortices in parietal and occipital lobes compared with cognitively impaired children. Infants with normal motor scores exhibited increased rsFC between the basal ganglia and visual cortices, compared with children with motor impairment. Thus, the presence of abnormal general movements is associated with region-specific differences in rsFC at term. The association of abnormal long-term neurodevelopmental outcomes with decreased rsFC between basal ganglia and sub-score specific cortical regions may provide biomarkers of neurodevelopmental trajectory and outcome.

Moderate-late preterm infants constitute the largest segment of preterm births globally. While previously considered to have a low neurological risk, recent research has uncovered an elevated incidence of neurodevelopmental conditions in this group. This study aimed to assess the relationship between the general movement assessment and birth-related risk factor-based tools in moderate-late preterm infants. A prospective cohort study of 65 moderate-late preterm infants in a neonatal intensive care unit involved the evaluation of general movements, the Nursery Neurobiologic Risk Score, and the Perinatal Risk Inventory. Associations were analyzed using Fisher's exact test, Spearman's correlation was used for ordinal variables, and backward stepwise logistic regression was used to identify predictor variables for the assessments. The findings indicated a high prevalence of normal (41%) and poor (52%) repertoire patterns during the writhing period. While no significant associations were found between the three assessments, a slight approximation emerged between dysmorphic traits and patterns (p = 0.053). Furthermore, an extended period of ventilation correlated with a higher likelihood of developing a cramped synchronized pattern and there was a correlation between both risk factor-based tools (p < 0.001). This research enhances our understanding of the early impact on general movement assessments in moderate-late preterm infants. While no clear relationship emerged between general movement assessment and risk factor-based tools, there was a subtle connection noted with dysmorphic traits. A longer ventilation duration was linked to a higher risk of developing cramped synchronized patterns.

The quality of general movements in the first ten days of life in preterm infants

Science, Medicine, and the Anesthesiologist

Very preterm infants (VPI) < 32 weeks are at increased risk of developmental disorders detectable using the Prechtl General Movements Assessment (GMA) and the Bayley Scales of Infant and Toddler Development-Third Edition (BSID-III). The aim of this study was to investigate General Movements (GMs) trajectories from preterm to fidgety age including GMs tendencies and their association with cognitive and motor outcome. Retrospective analysis of VPI with GMA at preterm (35 ± 2 weeks postmenstrual age (PMA), T1) and fidgety age (12 ± 3 weeks corrected age CA), T2), and BSID-III (12 ± 3 months CA, T3) is performed. Data are analysed using Pearson χ2-test, Fisher-Freeman-Halton Exact test, and residual analyses. This study found significant associations between (a) GMs (T1) and (b) persistent pathological GMs (T1 + T2) with cognitive outcomes at 12 months (T3) considering the tendencies of GMs in addition to the global character (p = 0.007, p = 0.022, respectively), representing medium-sized effects. There were no significant associations between GMs or persistence of pathological GMs and gross and fine motor outcomes, regardless of GMs tendencies. Findings indicate that considering tendencies of GMs and the persistence of pathological GMs may be important in identifying children at risk of cognitive impairments early. This additional assessment parameter may have the potential for early identification of infants with milder motor and/or cognitive impairments. However, more research is needed using larger sample cohorts to generalise the results and to be able to recommend sequential GMA for clinical routine.

The increasing clinical use of combining structural MRI (sMRI) with General Movements Assessment (GMA) or Hammersmith Infant Neurological Exam (HINE) before five months corrected age (CA) for early diagnosis of cerebral palsy (CP) lacks sufficient prognostic data for children with CP, especially those with Gross Motor Function Classification System (GMFCS) I. Evaluate the predictive value of sMRI, GMA, and HINE individually and in combination for early CP diagnosis and assess accuracy across varying GMFCS levels in a regional cohort of preterm infants. We performed sMRI between 39-44 weeks postmenstrual age and GMA and HINE between 12-18 weeks CA in 395 preterm infants born at ≤32 weeks' gestation across five NICUs in Greater Cincinnati. Brain abnormalities on sMRI included white matter injuries, cortical and deep gray matter lesions, or extensive cerebellar hemorrhage. Absent fidgety movements constituted abnormal GMA; abnormal HINEs were scores <56. The primary outcome was CP diagnosis at 22-26 months CA, classified by the GMFCS. We calculated sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios for individual tests and combinations. Of 338 (86%) infants with complete follow-up, 48 (14.2%) showed sMRI abnormalities, 15 (4.6%) had abnormal GMA, and 69 (20.9%) had abnormal HINE. Thirty-nine children (11.5%) developed CP at age 2, of which 28 had GMFCS level I and 11 had GMFCS >II. The combination of sMRI and GMA achieved 100% specificity but only 22% sensitivity while the combination of abnormal sMRI and HINE demonstrated sensitivity of 32% and specificity of 98% for prediction of CP. Individual or combined tests showed far higher sensitivity (78-100%) for predicting CP in children with GMFCS levels II-V. The combination of sMRI with GMA or HINE demonstrated high specificity but low sensitivity for early CP diagnosis in a regional cohort of preterm infants. This approach appears effective for early detection of CP levels II-V but not for level I cases, the most prevalent type, underscoring the need for continued developmental follow-up for all very preterm infants and need for more sensitive diagnostic tools for early detection of CP. Questions: What is the individual and combined prognostic accuracy of sMRI, GMA, and HINE for early diagnosis of CP in preterm infants?Findings: In our prospective, regional study of preterm infants born at ≤32 weeks' gestation, we found that combining brain abnormalities on sMRI with abnormal GMA achieved 100% specificity but 22% sensitivity for diagnosing CP. Individual or combined tests showed far higher sensitivity (78-100%) for predicting CP in children with GMFCS levels II-V. Both individual and combined tests were poor predictors of GMFCS level I CP, the most common type.Meaning: While sMRI combined with GMA or HINE is effective for diagnosing CP with GMFCS levels II-V, this approach falls short for children with GMFCS level I.