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Publications on Prechtl’s Method on the Qualitative Assessment of General Movements in Preterm, Term and Young Infants

190. PeytonC, Yang E, Msall ME, Adde L, Støen R, Fjørtoft T, Bos AF, Einspieler C, Zhou Y, Schreiber MD, Marks JD, Drobyshevsky A.
White matter injury and general movements in high-risk preterm infants.
Am J Neuroradiol 2017, 38: 162-169. 

BACKGROUND AND PURPOSE: Very preterm infants (birth weight, <1500 g) are at increased risk of cognitive and motor impairment, including cerebral palsy. These adverse neurodevelopmental outcomes are associated with white matter abnormalities on MR imaging at term-equivalent age. Cerebral palsy has been predicted by analysis of spontaneous movements in the infant termed “General Movement Assessment.” The goal of this study was to determine the utility of General Movement Assessment in predicting adverse cognitive, language, and motor outcomes in very preterm infants and to identify brain imaging markers associated with both adverse outcomes and aberrant general movements. MATERIALS AND METHODS: In this prospective study of 47 preterm infants of 24–30 weeks' gestation, brain MR imaging was performed at term-equivalent age. Infants underwent T1- and T2-weighted imaging for volumetric analysis and DTI. General movements were assessed at 10–15 weeks' postterm age, and neurodevelopmental outcomes were evaluated at 2 years by using the Bayley Scales of Infant and Toddler Development III. RESULTS: Nine infants had aberrant general movements and were more likely to have adverse neurodevelopmental outcomes, compared with infants with normal movements. In infants with aberrant movements, Tract-Based Spatial Statistics analysis identified significantly lower fractional anisotropy in widespread white matter tracts, including the corpus callosum, inferior longitudinal and fronto-occipital fasciculi, internal capsule, and optic radiation. The subset of infants having both aberrant movements and abnormal neurodevelopmental outcomes in cognitive, language, and motor skills had significantly lower fractional anisotropy in specific brain regions. CONCLUSIONS: Aberrant general movements at 10–15 weeks' postterm are associated with adverse neurodevelopmental outcomes and specific white matter microstructure abnormalities for cognitive, language, and motor delays.

189. Crowle C, Galea C, Morgan C, Novak I, Walker K, Badawi N.
Inter-observer agreement of the General Movements Assessment with infants following surgery.
Early Hum Dev 2017; 104: 17-21.

BACKGROUND: The General Movements Assessment (GMA) is a validated and reliable method of identifying infants at risk of adverse neurodevelopmental outcomes, however there is minimal data available on the use of the GMA with infants following surgery. AIMS: The aim of this study was to investigate the inter-observer agreement for the GMA with this infant population. STUDY DESIGN: Reliability and agreement study. SUBJECTS: This was a prospective cohort study of 190 infants (male n=112) born at term (mean 38weeks, SD 2weeks). OUTCOME MEASURES: A GMA was conducted in the Neonatal Intensive Care Unit (NICU) following either cardiac surgery (n=92), non-cardiac surgery (n=93) or both types of surgery (n=5), and then again at three months of age. All videos were independently assessed by three advanced trained clinicians. Agreement and reliability statistics were calculated between each pair. RESULTS: We found moderate to substantial levels of agreement in the writhing period (66-77%, AC1=0.53-0.69). For fidgety general movements, agreement was classified as almost perfect, ranging from 86 to 89% (AC1=0.84-0.88). CONCLUSIONS: The GMA has high levels of inter-observer agreement when used with infants who have undergone surgery in the neonatal period, making it a valid, complementary assessment tool. Research is now underway to determine the ability of the GMA to predict neurodevelopmental outcomes in this population.

188. Setoh P, Marschik PB, Einspieler C, Esposito G. 
Autism spectrum disorder and early motor abnormalities: Connected or coincidental companions?
Res Dev Disabil 2017; 60: 13-15. 

Research in the past decade has produced a growing body of evidence showing that motor abnormalities in individuals with autism spectrum disorder (ASD) are the rule rather than the exception. The paper by Chinello and colleagues furthers our understanding of the importance of studying motor functions in ASD by testing a non-clinical population of parents-infant triads. Chinello and colleagues' findings seem to suggest that subclinical motor impairments may exist in the typical population with inherited non-clinical ASD traits. Chinello and colleagues' discovery also urges us to ask why motor abnormalities exist in typically developing infants when their parents present some subclinical ASD traits. We believe that there are at least two possibilities. In the first possible scenario, motor impairments and ASD traits form a single cluster of symptoms unique to a subgroup of individuals with autism. A second possible scenario is that motor atypicalities are the first warning signs of vulnerability often associated with atypical development. In conclusion, Chinello et al.'s findings inform us that subclinical atypical phenotypes such as sociocommunicative anomalies may be related to subclinical motor performances in the next generation. This adds to our knowledge by shedding some light on the relation of vulnerability in one domain with vulnerability in another domain.

187. Datta AN, Furrer MA, Bernhardt I, Hüppi PS, Borradori?Tolsa C, Bucher HU, Latal B, Grunt S, Natalucci G, GM Group. 
Fidgety movements in infants born very preterm: predictive value for cerebral palsy in a clinical multicentre setting.
Dev Med Child Neurol 2017 Jan 19, doi: 10.1111/dmcn.13386.

AIM: This study assessed predictive values of fidgety movement assessment (FMA) in a large sample of infants born very preterm for developmental abnormalities, in particular for cerebral palsy (CP) at 2 years in an everyday clinical setting. METHOD: This is a multicentre study of infants born preterm with gestational age lower than 32.0 weeks. FMA was performed at 3 months corrected age; neurodevelopment (Bayley Scales of Infant Development, 2nd edition) and neurological abnormalities were assessed at 2 years. Predictive values of FMA for the development of CP were calculated and combined with abnormalities at cerebral ultrasound. RESULTS: Five hundred and thirty-five infants (gestational age 28.2wks [standard deviation 1.3wks]) were included. Eighty-one percent showed normal fidgety movements and 19% atypical (82 absent, 21 abnormal) fidgety movements. Absent fidgety movements predicted CP at 2 years with an odds ratio (OR) of 8.9 (95% confidence interval [CI] 4.1-17.0), a combination of atypical fidgety movements and major brain lesion on cerebral ultrasound predicted it with an OR of 17.8 (95% CI 5.2-61.6). Mean mental developmental index of infants with absent fidgety movements was significantly lower (p=0.012) than with normal fidgety movements. INTERPRETATION: Detection of infants at risk for later CP through FMA was good, but less robust when performed in a routine clinical setting; prediction improved when combined with neonatal cerebral ultrasound.

186. Chen CY, Georgieff M, Elison J, Chen M, Stinear J, Mueller B, Rao R, Rudser K, Gillick B. 
Understanding brain reorganization in infants with perinatal stroke through neuroexcitability and neuroimaging.
Pediatr Phys Ther 2017, 29: 173-178.

PURPOSE: The primary aim of this proposed study is to evaluate brain reorganization patterns in infants with perinatal stroke between 3 and 5 months of age using transcranial magnetic stimulation and magnetic resonance imaging, with the addition of the General Movements Assessment. A secondary aim is to demonstrate feasibility and safety of infant-appropriate brain assessment protocols. METHODS: Ten infants with perinatal stroke will be enrolled. In this exploratory study, infants will first receive magnetic resonance imaging scanning during natural sleep to examine their corticospinal tract integrity. Infants will then receive transcranial magnetic stimulation to assess their corticomotor excitability. A General Movements Assessment video of at least 5 minutes will also be recorded. DISCUSSION: Study results will enhance our understanding of brain reorganization in infants with perinatal stroke. We expect these results will also guide the development of early interventions designed to mitigate maladaptive neuroplastic changes and improve long-term motor outcomes.

185. Allinson LG, Doyle LW, Denehy L, Spittle AJ.
Survey of neurodevelopmental allied health teams in Australian and New Zealand neonatal nurseries: Staff profile and standardised neurobehavioural/neurological assessment.
Journal Paediatr Child Health 2017, Mar 23, doi: 10.1111/jpc.13484. 

AIMS: The primary aim of this study was to establish how many neonatal nurseries in Australia and New Zealand had a neurodevelopmental allied health team, to ascertain the disciplines involved, their qualifications and experience. The secondary aim was to evaluate which standardised neurobehavioural/neurological assessments were currently being implemented, and the existing practice in relation to their use. METHODS: A descriptive cross-sectional survey, sampling 179 eligible public and private hospital neonatal intensive care units (NICUs) and special care nurseries (SCNs) throughout Australia and New Zealand, was purpose-developed and administered electronically from the 5th April to 23rd July 2013. RESULTS: A total of 117 units (65%) overall, and 26 of 26 (100%) NICUs responded to the survey. NICUs had more neurodevelopmental allied health staff than SCNs, with physiotherapists and speech pathologists the most common disciplines. Physiotherapists were more likely to administer standardised neurobehavioural/neurological assessments in NICUs, while medical staff were more likely to do so in SCNs. A wide variety of standardised neurobehavioural/neurological assessment tools were used, with Prechtl's General Movements Assessment the most common in the NICUs (50%) and the Hammersmith Neonatal Neurological Examination the most common in the special care units (25%). Standardised neurobehavioural assessments were not administered in 22% of SCNs. CONCLUSIONS: Although neurodevelopmental allied health teams and standardised neurobehavioural/neurological assessments are valued by many, there was little consistency across Australian and New Zealand neonatal nurseries.

184. Brown AK, Greisen G, Haugsted U, Jonsbo F. 
Formal training in general movement assessment is required to effectively evaluate infants with perinatal asphyxia in outpatient settings.
Acta Paediatr 2016, 105: 1056-1560

AIM: General movement assessment (GMA) can help to identify children with a high risk of developing neurological dysfunction, such as cerebral palsy, and certified training is provided in this specialism. The aim of this study was to investigate the feasibility and reliability of using video recordings to assess GMA, in a busy Danish outpatient clinic. METHODS: The study comprised 30-term infants born with perinatal asphyxia, who were video recorded at three months. They were assessed by two certified GMA observers and re-assessed two weeks later. Interobserver and intra-observer agreements were analysed using proportional agreement, and nominal kappa statistics were used to calculate 95% confidence intervals (95% CI). RESULTS: We found substantial and almost perfect interobserver and intra-observer reliability. Intra-observer agreement was 0.85 (95% CI: 0.65-1.00; p < 0.0001) and 0.85 (95% CI: 0.62-1.00; p < 0.0001), and interobserver agreement was 0.71 (95% CI: 0.45-0.96; p < 0.0001) at time point one and 0.85 (95% CI: 0.63-1.00; p < 0.0001) two weeks later. All video recordings were completed within our multidisciplinary outpatient clinic without delay. CONCLUSION: This study demonstrated the reliability of the GMA method in a busy multidisciplinary Danish paediatric outpatient setting, when assessors had been formally trained in the method and used it regularly.

183. Tanis, JC, Schmitz DM, Boelen MR, Casarella L, van den Berg PP, Bilardo CM, Bos, AF. 
Relationship between general movements in neonates who were growth restricted in utero and prenatal Doppler flow patterns.
Ultrasound Obstet Gynecol 2016, 48: 772-778.

OBJECTIVE: To investigate whether Doppler pulsatility indices (PIs) of the fetal circulation in cases of fetal growth restriction (FGR) are associated with the general movements (GMs) of the neonate after birth. METHODS: This was a prospective observational cohort study including pregnancies with FGR diagnosed between June 2012 and September 2014. A diagnosis of FGR was based on an abdominal circumference or estimated fetal weight < 10th percentile (in conjuction with abnormal Doppler) or declining fetal growth of at least 30 percentiles with respect to previous size measurements. Doppler parameters of the umbilical artery (UA), fetal middle cerebral artery (MCA) and ductus venosus (DV) were measured maximally 1 week prior to delivery. Cerebroplacental ratio (CPR) was calculated as MCA-PI divided by UA-PI. We assessed the quality of neonatal GMs 7 days after birth, around the due date if cases were born preterm, and at 3 months post-term. We performed a detailed analysis of the motor repertoire by calculating a motor optimality score (MOS). RESULTS: Forty-eight FGR cases were included with a median gestational age at delivery of 35 (range, 26–40) weeks. UA-PI, MCA-PI and CPR correlated strongly (ρ, −0.374 to 0.472; P < 0.01) with the MOS on day 7 after birth, but DV-PI did not. Doppler PI measurements did not correlate with MOS at 3 months post-term. CONCLUSION: Fetal arterial Doppler measurements are associated with the quality of neonatal GMs 1 week after birth, but this association is no longer evident at 3 months post-term. Brain sparing in particular is associated strongly with GMs of an abnormal quality.

182. Spittle AJ, Olsen J, Kwong A, Doyle LW, Marschik PB, Einspieler C, Cheong J.
The Baby Moves prospective cohort study protocol: using a smartphone application with the General Movements Assessment to predict neurodevelopmental outcomes at age 2 years for extremely preterm or extremely low birthweight infants. 
BMJ Open 2016; 6: e013446

INTRODUCTION: Infants born extremely preterm (EP; <28 weeks' gestation) and/or with extremely low birth weight (ELBW; <1000g birth weight) are at increased risk for adverse neurodevelopmental outcomes. However, it is challenging to predict those EP/ELBW infants destined to have long-term neurodevelopmental impairments in order to target early intervention to those in most need. The General Movements Assessment (GMA) in early infancy has high predictive validity for neurodevelopmental outcomes in preterm infants. However, access to a GMA may be limited by geographical constraints and a lack of GMA-trained health professionals. Baby Moves is a smartphone application (app) developed for caregivers to video and upload their infant's general movements to be scored remotely by a certified GMA assessor. The aim of this study is to determine the predictive ability of using the GMA via the Baby Moves app for neurodevelopmental impairment in infants born EP/ELBW. METHODS AND ANALYSIS: This prospective cohort study will recruit infants born EP/ELBW across the state of Victoria, Australia in 2016 and 2017. A control group of normal birth weight (>2500 g birth weight), term-born (≥37 weeks' gestation) infants will also be recruited as a local reference group. Parents will video their infant's general movements at two time points between 3 and 4 months' corrected age using the Baby Moves app. Videos will be scored by certified GMA assessors and classified as normal or abnormal. Parental satisfaction using the Baby Moves app will be assessed via survey. Neurodevelopmental outcome at 2 years' corrected age includes developmental delay according to the Bayley Scales of Infant and Toddler Development-III and cerebral palsy diagnosis. ETHICS AND DISSEMINATION: This study was approved by the Human Research and Ethics Committees at the Royal Children's Hospital, The Royal Women's Hospital, Monash Health and Mercy Health in Melbourne, Australia. Study findings will be disseminated via peer-reviewed publications and conference presentations.

181. Adde L, Thomas N, John HB, Oommen S, Vågen RT, Fjørtoft T, Jensenius AR, Støen R
Early motor repertoire in very low birth weight infants in India is associated with motor development at one year.
Eur J Paediatr Neurol 2016; 20: 918-924.

BACKGROUND: Most studies on Prechtl's method of assessing General Movements (GMA) in young infants originate in Europe. AIM: To determine if motor behavior at an age of 3 months post term is associated with motor development at 12 months post age in VLBW infants in India. METHODS: 243 VLBW infants (135 boys, 108 girls; median gestational age 31wks, range 26-39wks) were video-recorded at a median age of 11wks post term (range 9-16wks). Certified and experienced observers assessed the videos by the "Assessment of Motor Repertoire - 2-5 Months". Fidgety movements (FMs) were classified as abnormal if absent, sporadic or exaggerated, and as normal if intermittently or continually present. The motor behaviour was evaluated by repertoire of co-existent other movements (age-adequacy) and concurrent motor repertoire. In addition, videos of 215 infants were analyzed by computer and the variability of the spatial center of motion (CSD) was calculated. The Peabody Developmental Motor Scales was used to assess motor development at 12 months. RESULTS: Abnormal FMs, reduced age adequacy, and an abnormal concurrent motor repertoire were significantly associated with lower Gross Motor and Total Motor Quotient (GMQ, TMQ) scores (p<0.05). The CSD was higher in children with TMQ scores <90 (-1SD) than in children with higher TMQ scores (p=0.002). CONCLUSION: Normal FMs (assessed by Gestalt perception) and a low variability of the spatial center of motion (assessed by computer-based video analysis) predicted higher Peabody scores in 12-month-old infants born in India with a very low birth weight. 

180. van Iersel PA, Bakker SC, Jonker AJ, Hadders-Algra M.
Does general movements quality in term infants predict cerebral palsy and milder forms of limited mobility at 6 years?
Dev Med Child Neurol 2016; Aug 13. doi: 10.1111/dmcn.13228. [Epub ahead of print]

AIM: To evaluate in term infants associations between quality of general movements and developmental outcome in term infants at 6 years with either cerebral palsy (CP) or limited mobility without CP. METHOD: Participants of this prospective study were 145 term infants (86 male, 59 female). Their general movements quality was assessed at 'writhing' and 'fidgety' general movements age (3wks and 13wks post term). The assessment at 6 years consisted of a neurological examination, including assessment of minor neurological dysfunction (MND), evaluation of mobility with the Movement Assessment Battery for Children, and of behaviour and learning problems with questionnaires. RESULTS: Definitely abnormal general movements at writhing age were not associated with CP, whereas definitely abnormal general movements at fidgety age were (sensitivity 60%; specificity 91%; positive predictive value 19%, negative predictive value 98%). In children without CP, general movements quality was not associated with limited mobility, but it was associated to a minor extent with MND. INTERPRETATION: In term infants, definitely abnormal general movements at fidgety age do predict CP, but with lower accuracy than in preterm infants. General movements quality does not predict limited mobility in children without CP. The study supports suggestions that predictive value of general movements assessment in term infants is lower than that in preterm infants.

179. Einspieler C, Freilinger M, Marschik PB.
Behavioural biomarkers of typical Rett syndrome: moving towards early identification.
Wien Med Wochenschr 2016; 166: 333-337. 

The dynamic course of Rett syndrome (RTT) is still said to begin with a period of apparently normal development although there is mounting evidence that individuals with RTT show behavioural peculiarities and abnormalities during their infancy. Their spontaneous general movements are abnormal from birth onwards. Normal cooing vocalisation and canonical babbling (if at all required) are interspersed with abnormalities such as proto-vowel and proto-consonant alternations produced on ingressive airstream, breathy voice characteristics, and pressed or high-pitched vocalisations. The gestural repertoire is limited. Certain developmental motor and speech-language milestones are not at all acquired or show a significant delay. Besides abnormal blinking, repetitive and/or long lasting tongue protrusion, and bizarre smiling, there are already the first body and/or hand stereotypies during the first year of life. We are currently on a promising way to define a specific set of behavioural biomarkers pinpointing RTT. 

178. Miyagishima S, Asaka T, Kamatsuka K, Kozuka N, Kobayashi M, Igarashi R, Hori T, Yoto Y, Tsutsumi H.
Characteristics of antigravity spontaneous movements in preterm infants up to 3 months of corrected age.
Infant Behav Dev 2016; 44: 227-239. 

AIMS: We investigated whether spontaneous antigravity limbs movements in very low birth weight preterm infants were insufficient compared to those in term infants. The relationship between the quality of general movements (GMs) and antigravity limbs movements was also examined. METHODS: Preterm infants with very low birth weight without central nervous system disorders nor severe respiration disorders, and healthy term infants were recruited. The infants were set in a supine position. The distance between both hands and between both feet, and the height of both hands and feet from the floor were recorded at 1-3 corrected months for preterm infants, and at 1-3 months for term infants by a 3D motion capture system. The measurements were adjusted for body proportions. GMs in preterm and term infants were assessed similarly. RESULTS: Thirteen preterm and 15 term infants completed the study. In preterm infants, the distance between both hands and between both feet were longer, and the height of both hands and feet were lower than those in term infants in all measurements. In term infants, the height of both hands and feet increased as they developed, but no change was observed in preterm infants. In preterm infants with abnormal GMs, the distance between both hands was longer, and the height of both hands and feet was lower than that in those with normal GMs. There were no such differences between preterm infants with normal GMs and term infants with normal GMs. CONCLUSION: Antigravity limbs movements in preterm infants within the first 3 month of corrected age were insufficient compared with those in term infants. Furthermore, no improvement with development was observed in preterm infants. In addition, preterm infants with abnormal GMs showed worse antigravity limbs movements than preterm and term infants with normal GMs. The preterm infants with normal GMs could behave similar to the full term infants.


177. Olsen JE, Brown NC, Eeles AL, Einspieler C, Lee KJ, Thompson DK, Anderson PJ, Cheong JL, Doyle LW, Spittle AJ.
Early general movements and brain magnetic resonance imaging at term-equivalent age in infants born <30weeks' gestation. 
Early Hum Dev 2016; 101: 63-68. 

BACKGROUND: Neurodevelopmental assessments and brain magnetic resonance imaging (MRI) at term-equivalent age (TEA) predict developmental outcomes in preterm infants. However, the relationship between neurodevelopment prior to term and cerebral structure is currently unknown. AIMS: To examine the relationships between General Movements (GMs) assessed from birth to TEA and brain MRI at TEA in infants born <30weeks' gestation. STUDY DESIGN: Prospective cohort study. GMs (categorised as 'normal' or 'abnormal') were recorded weekly from birth to 32weeks, and at 34 and 36weeks' postmenstrual age. At TEA, GMs were assessed concurrently with brain MRI (using a validated scoring system). SUBJECTS: 149 infants born <30weeks' gestation were recruited from a tertiary hospital. RESULTS: 103 infants had MRI at TEA and GMs recorded. Abnormal GMs prior to term were associated with cortical grey matter abnormality (p<0.03), deep grey matter abnormality (p=0.02) and increased interhemispheric distance (p<0.02). Abnormal GMs at TEA (n=55/90) were associated with more global brain abnormality (p<0.01) and cortical grey matter abnormality (p=0.01), and decreased transcerebellar diameter (p=0.04) on concurrent brain MRI. CONCLUSIONS: Abnormal GMs both prior to term and at TEA were associated with more marked brain abnormality, and smaller brains at TEA. Abnormal GMs are an early marker of brain abnormalities in very preterm infants.

176. So S, Patterson C, Gold A, Rogers A, Kosar C, de Silva N, Burghardt KM, Avitzur Y, Wales PW.
Early neurodevelopmental outcomes of infants with intestinal failure.
Early Hum Dev 2016; 101: 11-16. 

BACKGROUND: The survival rate of infants and children with intestinal failure is increasing, necessitating a greater focus on their developmental trajectory. AIMS: To evaluate neurodevelopmental outcomes in children with intestinal failure at 0-15months corrected age. STUDY DESIGN: Analysis of clinical, demographic and developmental assessment results of 33 children followed in an intestinal rehabilitation program between 2011 and 2014. Outcome measures included: Prechtl's Assessment of General Movements, Movement Assessment of Infants, Alberta Infant Motor Scale and Mullen Scales of Early Learning. Clinical factors were correlated with poorer developmental outcomes at 12-15months corrected age. RESULTS: Thirty-three infants (17 males), median gestational age 34weeks (interquartile range 29.5-36.0) with birth weight 1.98kg (interquartile range 1.17-2.50). Twenty-nine (88%) infants had abnormal General Movements. More than half had suspect or abnormal scores on the Alberta Infant Motor Scale and medium to high-risk scores for future neuromotor delay on the Movement Assessment of Infants. Delays were seen across all Mullen subscales, most notably in gross motor skills. Factors significantly associated with poorer outcomes at 12-15months included: prematurity, low birth weight, central nervous system co-morbidity, longer neonatal intensive care admission, necrotizing enterocolitis diagnosis, number of operations and conjugated hyperbilirubinemia. CONCLUSION: Multiple risk factors contribute to early developmental delay in children with intestinal failure, highlighting the importance of close developmental follow-up.

175. Zang FF, Yang H, Han Q, Cao JY, Tomantschger I, Krieber M, Shi W, Luo DD, Zhu M, Einspieler C.
Very low birth weight infants in China: the predictive value of the motor repertoire at 3 to 5months for the motor performance at 12months.
Early Hum Dev 2016; 100: 27-32. 

BACKGROUND: Studies on motor performance and its early markers are rare in China, especially in very low birth weight (VLBW) infants. OBJECTIVE: Apart from the assessment of the inter-scorer agreement, we aimed to analyze to what extent the motor repertoire at 10 to 18weeks postterm was related to neonatal complications, and gross and fine motor performance at 12months after term. STUDY DESIGN: Exploratory prospective study. SUBJECTS: Seventy-four VLBW infants (58 males; mean gestational age=29weeks; mean birth weight=1252g). METHOD: Five-minute video recordings were performed at 10 to 18weeks after term; fidgety movements and the concurrent motor patterns (resulting in a motor optimality score) were assessed according to the Prechtl general movements assessment (GMA). The gross and fine motor performance was assessed by means of the Peabody Developmental Motor Scales, second edition, at 12months. RESULTS: Reliability was excellent. Pneumonia was associated with absent fidgety movements; the motor optimality score was lower in infants with pneumonia and/or bronchopulmonary dysplasia. Both absent fidgety movements and a lower motor optimality score were associated with a poor or very poor gross and fine motor performance at the 12-month-assessment. CONCLUSION: Both the assessment of fidgety movements and the evaluation of the concurrent motor repertoire contribute significantly to an identification of VLBW children with a poor gross and fine motor outcome at 12months. The results of this study document the need for an early identification of infants at high risk for a poor motor performance.

174. Caesar R, Boyd RN, Colditz P, Cioni G, Ware RS, Salthouse K, Doherty J, Jackson M, Matthews L, Hurley T, Morosini A, Thomas C, Camadoo L, Baer E; PREMTiME Study Group.
Early prediction of typical outcome and mild developmental delay for prioritisation of service delivery for very preterm and very low birthweight infants: a study protocol.
BMJ Open 2016; 6:e010726. 

INTRODUCTION: Over 80% of very preterm (<32 weeks) and very low birthweight (<1500 g) infants will have either typical development (TD) or mild developmental delay (MDD) in multiple domains. As differentiation between TD and MDD can be difficult, infants with MDD often miss opportunities for intervention. For many clinicians, the ongoing challenge is early detection of MDD without over servicing the population. This study aims to: (1) identify early clinical biomarkers for use in this population to predict and differentiate between TD and MDD at 24 months corrected age. (2) Determine the extent to which family and caregiver factors will contribute to neurodevelopmental and behavioural outcomes. METHODS AND ANALYSIS: Participants will be a prospective cohort of 90 infants (<32 weeks and/or <1500 g). Between 34 weeks gestational age and 16 weeks post-term, infants will have a series of 5 neurological, neuromotor, neurobehavioural and perceptual assessments including General Movement Assessment at preterm, writhing and fidgety age. Primary caregivers will complete questionnaires to identify social risk, maternal depression and family strain. Extensive perinatal data will be collected from the medical record. At 24 months, corrected age (c.a) infants will be assessed using standardised tools including the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley III). Longitudinal trajectories of early assessment findings will be examined to determine any predictive relationship with motor and cognitive outcomes at 24 months c.a. Published data of a cohort of Australian children assessed with the Bayley III at 24 months c.a will provide a reference group of term-born controls. ETHICS: Ethical approval has been obtained from the Queensland Children's Health Services Human Research Ethics Committee (HREC/13/QRCH/66), the University of Queensland (2013001019) and the Sunshine Coast Hospital and Health Service, SC-Research Governance (SSA/13/QNB/66). Publication of all study outcomes will be in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12614000480684; Pre-results.

173. Dimitrijevi? L, Bjelakovi? B, ?olovi? H, Mikov A, Živkovi? V, Koci? M, Luki? S.
Assessment of general movements and heart rate variability in prediction of neurodevelopmental outcome in preterm infants.
Early Hum Dev 2016; 99: 7-12. 

BACKGROUND: Adverse neurologic outcome in preterm infants could be associated with abnormal heart rate (HR) characteristics as well as with abnormal general movements (GMs) in the 1st month of life. AIMS: To demonstrate to what extent GMs assessment can predict neurological outcome in preterm infants in our clinical setting; and to assess the clinical usefulness of time-domain indices of heart rate variability (HRV) in improving predictive value of poor repertoire (PR) GMs in writhing period. STUDY DESIGN: Qualitative assessment of GMs at 1 and 3 months corrected age; 24h electrocardiography (ECG) recordings and analyzing HRV at 1 month corrected age. SUBJECTS: Seventy nine premature infants at risk of neurodevelopmental impairments were included prospectively. OUTCOME MEASURES: Neurodevelopmental outcome was assessed at the age of 2 years corrected. Children were classified as having normal neurodevelopmental status, minor neurologic dysfunction (MND), or cerebral palsy (CP). RESULTS: We found that GMs in writhing period (1 month corrected age) predicted CP at 2 years with sensitivity of 100%, and specificity of 72.1%. Our results demonstrated the excellent predictive value of cramped synchronized (CS) GMs, but not of PR pattern. Analyzing separately a group of infants with PR GMs we found significantly lower values of HRV parameters in infants who later developed CP or MND vs. infants with PR GMs who had normal outcome. CONCLUSIONS: The quality of GMs was predictive for neurodevelopmental outcome at 2 years. Prediction of PR GMs was significantly enhanced with analyzing HRV parameters.

172. Craciunoiu O, Holsti L.
A Systematic Review of the Predictive Validity of Neurobehavioral Assessments During the Preterm Period.
Phys Occup Ther Pediatr 2016; 17:1-16. 

AIMS: For high-risk newborns, early assessment of neurobehavior that accurately predicts neurodevelopmental outcome is the first step towards determining early intervention needs. This study reviews systematically the validity of neurobehavioral assessments administered to premature newborns before term-equivalent age to predict long-term neurodevelopmental outcome. METHODS: A systematic literature search of CINAHL, EMBASE, MEDLINE, PubMed, Web of Science, PsychInfo, Cochrane Library databases was conducted. PRISMA and COSMIN guidelines were followed. RESULTS: Five assessments and 11 studies were identified: (a) Neonatal Behavioral Assessment Scale (NBAS); (b) Test of Infant Motor Performance (TIMP); (c) General Movements (GMs); (d) Neurobehavioral Assessment of the Preterm Infant (NAPI); (e) Neonatal Oral Motor Assessment Scale (NOMAS). Predictive validity estimates were variable. The GMs and TIMP showed the strongest associations with neurodevelopmental outcome. Threats to validity included small sample size, sample bias, limited reliability testing. CONCLUSIONS: Five neurobehavioral measures have established predictive validity for the assessment of premature newborns while they reside in the NICU. Although the GMs and TIMP have the strongest evidence, further higher quality research is required. New methods of testing should be developed that provide accurate prediction and minimize the potential stress induced during developmental assessments.

171. Yeh KK, Liu WY, Wong AM, Chung CY, Lien R, Chuang YF.
Intra-observer reliability of Prechtl's method for the qualitative assessment of general movements in Taiwanese infants.
J Phys Ther Sci 2016; 28: 1588-1594. 

[Purpose] The aim of this study was to examine the intra-observer reliability for Prechtl's General Movements Assessment in Taiwanese infants. This includes the global General Movements Assessment, the Optimality List for Preterm General Movements and Writhing Movements, and the Assessment of Motor Repertoire-3 to 5 Months. [Subjects and Methods] Fifty-nine videos of 37 infants were observed and rated by one physical therapist twice. [Results] The intra-observer reliability ranged from good to very good for the global General Movements Assessment. The overall intra-observer reliabilities for the total score of the Optimality List from preterm up to postmenstrual age 46 weeks and the total score of the Assessment of Motor Repertoire for postmenstrual age 49 to 60 weeks were both good. [Conclusion] The results suggest that the intra-observer reliability of a certified physical therapist was satisfactory for Prechtl's method in Taiwanese infants. 

170. Brown AK, Greisen G, Haugsted U, Jonsbo F.
Formal training in general movement assessment is required to effectively evaluate infants with perinatal asphyxia in outpatient settings.
Acta Paediatr 2016; 105: 1056-1060. 

AIM: General movement assessment (GMA) can help to identify children with a high risk of developing neurological dysfunction, such as cerebral palsy, and certified training is provided in this specialism. The aim of this study was to investigate the feasibility and reliability of using video recordings to assess GMA, in a busy Danish outpatient clinic. METHODS: The study comprised 30-term infants born with perinatal asphyxia, who were video recorded at three months. They were assessed by two certified GMA observers and re-assessed two weeks later. Interobserver and intra-observer agreements were analysed using proportional agreement, and nominal kappa statistics were used to calculate 95% confidence intervals (95% CI). RESULTS: We found substantial and almost perfect interobserver and intra-observer reliability. Intra-observer agreement was 0.85 (95% CI: 0.65-1.00; p < 0.0001) and 0.85 (95% CI: 0.62-1.00; p < 0.0001), and interobserver agreement was 0.71 (95% CI: 0.45-0.96; p < 0.0001) at time point one and 0.85 (95% CI: 0.63-1.00; p < 0.0001) two weeks later. All video recordings were completed within our multidisciplinary outpatient clinic without delay. CONCLUSION: This study demonstrated the reliability of the GMA method in a busy multidisciplinary Danish paediatric outpatient setting, when assessors had been formally trained in the method and used it regularly.

169. Sæther R, Støen R, Vik T, Fjørtoft T, Vågen RT, Silberg IE, Loennecken M, Møinichen UI, Lydersen S, Adde L.
A change in temporal organization of fidgety movements during the fidgety movement period is common among high risk infants.
Eur J Paediatr Neurol 2016; 20: 512-517. 

AIM: General movement assessment (GMA) at 9-20 weeks post-term, can effectively predict cerebral palsy. Our aim was to evaluate intra-individual variability of the temporal organization of fidgety movements (FMs) in high risk infants. 104 High risk infants (66 males) with at least two video recordings from the FMs period participated. 45 of the infants had GA <28 weeks and/or BW ≤800 g. Mean post-term age at first and second assessments was 11.0 (8-16) and 14.0 (11-17) weeks, respectively, and median time-difference between the assessments was 2.0 (range: three days to six weeks) weeks. Video recordings were analyzed according to Prechtl's GMA. RESULTS: 33 (32%) Infants were classified differently at first and second assessments. Six infants (6%) changed from normal to abnormal, and 10 (10%) changed from abnormal to normal FMs. Seven of the ten who changed classification from abnormal to normal were born before GA 26 weeks. A change between intermittent and continual, which are both considered normal, was observed in 17 (16%) infants. CONCLUSION: A change in temporal organization of FMs is common in high risk infants. Especially in extremely preterm infants with abnormal FMs, more than one assessment should be performed before long-term prognosis is considered.

168. Einspieler C, Bos AF, Libertus ME, Marschik PB.
The General Movement Assessment Helps Us to Identify Preterm Infants at Risk for Cognitive Dysfunction.
Front Psychol 2016; 7:406. doi: 10.3389/fpsyg.2016.00406.

Apart from motor and behavioral dysfunctions, deficits in cognitive skills are among the well-documented sequelae of preterm birth. However, early identification of infants at risk for poor cognition is still a challenge, as no clear association between pathological findings based on neuroimaging scans and cognitive functions have been detected as yet. The Prechtl General Movement Assessment (GMA) has shown its merits for the evaluation of the integrity of the young nervous system. It is a reliable tool for identifying infants at risk for neuromotor deficits. Recent studies on preterm infants demonstrate that abnormal general movements (GMs) also reflect impairments of brain areas involved in cognitive development. The aim of this systematic review was to discuss studies that included (i) the Prechtl GMA applied in preterm infants, and (ii) cognitive outcome measures in six data bases. Seven studies met the inclusion criteria and yielded the following results: (a) children born preterm with consistently abnormal GMs up to 8 weeks after term had lower intelligence quotients at school age than children with an early normalization of GMs; (b) from 3 to 5 months after term, several qualitative, and quantitative aspects of the concurrent motor repertoire, including postural patterns, were predictive of intelligence at 7-10 years of age. These findings in 428 individuals born preterm suggest that normal GMs along with a normal motor repertoire during the first months after term are markers for normal cognitive development until at least age 10. 

167. Einspieler C, Peharz R, Marschik PB.
Fidgety movements - tiny in appearance, but huge in impact.
J Pediatr (Rio J) 2016; 92(3 Suppl 1): S64-70. 

OBJECTIVES: To describe fidgety movements (FMs), i.e., the spontaneous movement pattern that typically occurs at 3-5 months after term age, and discuss its clinical relevance. SOURCES: A comprehensive literature search was performed using the following databases: MEDLINE/PubMed, CINAHL, The Cochrane Library, Science Direct, PsycINFO, and EMBASE. The search strategy included the MeSH terms and search strings ('fidgety movement*') OR [('general movement*') AND ('three month*') OR ('3 month*')], as well as studies published on the General Movements Trust website (www.general-movements-trust.info). SUMMARY OF THE DATA: Virtually all infants develop normally if FMs are present and normal, even if their brain ultrasound findings and/or clinical histories indicate a disposition to later neurological deficits. Conversely, almost all infants who never develop FMs have a high risk for neurological deficits such as cerebral palsy, and for genetic disorders with a late onset. If FMs are normal but concurrent postural patterns are not age-adequate or the overall movement character is monotonous, cognitive and/or language skills at school age will be suboptimal. Abnormal FMs are unspecific and have a low predictive power, but occur exceedingly in infants later diagnosed with autism. CONCLUSIONS: Abnormal, absent, or sporadic FMs indicate an increased risk for later neurological dysfunction, whereas normal FMs are highly predictive of normal development, especially if they co-occur with other smooth and fluent movements. Early recognition of neurological signs facilitates early intervention. It is important to re-assure parents of infants with clinical risk factors that the neurological outcome will be adequate if FMs develop normally.

166. Spittle AJ, Walsh J, Olsen JE, McInnes E, Eeles AL, Brown NC, Anderson PJ, Doyle LW, Cheong JL.
Neurobehaviour and neurological development in the first month after birth for infants born between 32-42 weeks' gestation.
Early Hum Dev 2016; 96: 7-14. 

AIMS: The objective of this study was to generate reference values for infants born moderate preterm (MPT), late preterm (LPT) and full term (FT) for three newborn neurobehavioural/neurological examinations in the first weeks after birth. STUDY DESIGN: Prospective cohort study to examine the expected range of values for MPT (born 32(+0) to 33(+6)), LPT (34(+0) to 36(+6)) and FT (born 37 to 42weeks' gestation) infants' performance on the Hammersmith Neonatal Neurological Examination (HNNE), the Neonatal Intensive Care Unit Network Neurobehavioural Scale (NNNS) and Prechtl's General Movements Assessment (GMA) in the first weeks after birth. Further, to determine the effects of sex, gestational age at birth, and postmenstrual age at assessment on the 3 different assessments within the gestational age groups. SUBJECTS: 80 MPT, 129 LPT and 201 FT infants were recruited shortly after birth from a tertiary hospital. RESULTS: The means, standard deviations and 5th, 10th, 25th, 50th, 75th, 90th and 95th centiles are presented for the HNNE and NNNS for each of the three gestational age groups. Overall, FT infants performed better than MPT and LPT infants. The rate of normal GMA within the first few weeks after birth was 25% for MPT, 32% for LPT, and 90% for FT infants. The effects of sex, gestational age at birth, and postmenstrual age at assessment varied between test and gestational age groups. CONCLUSIONS: This study provides normative data for the HNNE, NNNS, and GMA administered within the first weeks after birth in a sample of MPT, LPT and healthy FT infants.

165. Hamer EG, Bos AF, Hadders-Algra M.
Specific characteristics of abnormal general movements are associated with functional outcome at school age. 
Early Hum Dev 2016; 95: 9-13. 

BACKGROUND: Assessing the quality of general movements (GMs) is a non-invasive tool to identify at early age infants at risk for developmental disorders. AIM: To investigate whether specific characteristics of definitely abnormal GMs are associated with developmental outcome at school age. STUDY DESIGN: Observational cohort study (long-term follow-up). SUBJECTS: Parents of 40 children (median age 8.3 years, 20 girls) participated in this follow-up study. In infancy (median corrected age 10 weeks), the children (median gestational age 30.3 weeks; birth weight 1243 g) had shown definitely abnormal GMs according to Hadders-Algra (2004). Information on specific GM characteristics such as the presence of fidgety movements, degree of complexity and variation, and stiff movements, was available (see Hamer et al. 2011). OUTCOME MEASURES: A standardised parental interview (presence of CP, attendance of school for special education, Vineland Adaptive Behavior Scale to determine functional performance) and questionnaires (Developmental Coordination Disorder Questionnaire [DCD-Q] to evaluate mobility and Child Behavior Checklist to assess behaviour) were used as outcome measures. RESULTS: Six children had cerebral palsy (CP), ten children attended a school for special education, and eight children had behavioural problems. Both the absence of fidgety movements and the presence of stiff movements were associated with CP (p=0.001; p=0.003, respectively). Stiff movements were also related to the need of special education (p=0.009). A lack of movement complexity and variation was associated with behavioural problems (p=0.007). None of the GM characteristics were related to DCD-Q scores. CONCLUSIONS: The evaluation of fidgety movements and movement stiffness may increase the predictive power of definitely abnormal GMs for motor outcome--in particular CP. This study endorses the notion that the quality of GMs reflects the integrity of the infant's brain, assisting prediction of long-term outcome.

164. Bennema AN, Schendelaar P, Seggers J, Haadsma ML, Heineman MJ, Hadders-Algra M.
Predictive value of general movements' quality in low-risk infants for minor neurological dysfunction and behavioural problems at preschool age.
Early Hum Dev 2016; 94: 19-24. 

BACKGROUND: General movement (GM) assessment is a well-established tool to predict cerebral palsy in high-risk infants. Little is known on the predictive value of GM assessment in low-risk populations. AIMS: To assess the predictive value of GM quality in early infancy for the development of the clinically relevant form of minor neurological dysfunction (complex MND) and behavioral problems at preschool age. STUDY DESIGN: Prospective cohort study. SUBJECTS: A total of 216 members of the prospective Groningen Assisted Reproductive Techniques (ART) cohort study were included in this study. ART did not affect neurodevelopmental outcome of these relatively low-risk infants born to subfertile parents. OUTCOME MEASURES: GM quality was determined at 2 weeks and 3 months. At 18 months and 4 years, the Hempel neurological examination was used to assess MND. At 4 years, parents completed the Child Behavior Checklist; this resulted in the total problem score (TPS), internalizing problem score (IPS), and externalizing problem score (EPS). Predictive values of definitely (DA) and mildly (MA) abnormal GMs were calculated. RESULTS: DA GMs at 2 weeks were associated with complex MND at 18 months and atypical TPS and IPS at 4 years (all p<0.05). Sensitivity and positive predictive value of DA GMs at 2 weeks were rather low (13%-60%); specificity and negative predictive value were excellent (92%-99%). DA GMs at 3 months occurred too infrequently to calculate prediction. MA GMs were not associated with outcome. CONCLUSIONS: GM quality as a single predictor for complex MND and behavioral problems at preschool age has limited clinical value in children at low risk for developmental disorders.

163. Fjørtoft T, Evensen KA, Øberg GK, Songstad NT, Labori C, Silberg IE, Loennecken M, Møinichen UI, Vågen R, Støen R, Adde L.
High prevalence of abnormal motor repertoire at 3 months corrected age in extremely preterm infants.
Eur J Paediatr Neurol 2016; 20: 236-242. 

AIMS: To compare early motor repertoire between extremely preterm and term-born infants. An association between the motor repertoire and gestational age and birth weight was explored in extremely preterm infants without severe ultrasound abnormalities. METHODS: In a multicentre study, the early motor repertoire of 82 infants born extremely preterm (ELGAN:<28 weeks) and/or with extremely low birth weight (ELBW:<1000 g) and 87 term-born infants were assessed by the "Assessment of Motor Repertoire - 2 to 5 Months" (AMR) which is part of Prechtl's "General Movement Assessment", at 12 weeks post-term age. Fidgety movements were classified as normal if present and abnormal if absent, sporadic or exaggerated. Concurrent motor repertoire was classified as normal if smooth and fluent and abnormal if monotonous, stiff, jerky and/or predominantly fast or slow. RESULTS: Eight-teen ELBW/ELGAN infants had abnormal fidgety movements (8 absent, 7 sporadic and 3 exaggerated fidgety movements) compared with 2 control infants (OR:12.0; 95%CI:2.7-53.4) and 46 ELBW/ELGAN infants had abnormal concurrent motor repertoire compared with 17 control infants (OR:5.3; 95%CI:2.6-10.5). Almost all detailed aspects of the AMR differed between the groups. Results were the same when three infants with severe ultrasound abnormalities were excluded. In the remaining ELBW/ELGAN infants, there was no association between motor repertoire and gestational age or birth weight. CONCLUSION: ELBW/ELGAN infants had poorer quality of early motor repertoire than term-born infants. The findings were not explained by severe abnormalities on neonatal ultrasound scans and were not correlated to the degree of prematurity. The consequences of these abnormal movement patterns remain to be seen in future follow-up studies.

162. Olsen JE, Brown NC, Eeles AL, Lee KJ, Anderson PJ, Cheong JL, Doyle LW, Spittle AJ.
Trajectories of general movements from birth to term-equivalent age in infants born <30 weeks' gestation.
Early Hum Dev 2015; 91: 683-688.

BACKGROUND: General movements (GMs) is an assessment with good predictive validity for neurodevelopmental outcomes in preterm infants. However, there is limited information describing the early GMs of very preterm infants, particularly prior to term. AIMS: To describe the early GMs trajectory of very preterm infants (born <30weeks' gestation) from birth to term-equivalent age, and to assess the influence of known perinatal risk factors on GMs. STUDY DESIGN: Prospective cohort study. SUBJECTS: 149 very preterm infants born <30weeks' gestation. OUTCOME MEASURES: GMs were recorded weekly from birth until 32weeks' postmenstrual age, and then fortnightly until 38weeks' postmenstrual age. GMs were also assessed at term-equivalent age. Detailed perinatal data were collected. RESULTS: Of 669 GMs assessed, 551 were preterm and 118 were at term-equivalent age. Prior to term, 15% (n=82) of GMs were normal and 85% (n=469) were abnormal, with the proportion of abnormal GMs decreasing with increasing postmenstrual age (p for trend <0.001). By term-equivalent 30% (n=35) of GMs were normal. On univariable analysis, lower gestational age (p<0.001), postnatal infection (p<0.001) and bronchopulmonary dysplasia (p=0.001) were associated with abnormal GMs. Postnatal infection was the only independent perinatal association with abnormal GMs on multivariable analysis. All four infants with grade III/IV intraventricular haemorrhage (IVH) had persistently abnormal GMs. CONCLUSIONS: GMs were predominantly abnormal in very preterm infants, with a higher proportion of normal GMs at term-equivalent age than prior to term. Abnormal GMs were associated with postnatal infection and IVH.

161. Zahed M, Berbis J, Brevaut-Malaty V, Busuttil M, Tosello B, Gire C.
Posture and movement in very preterm infants at term age in and outside the nest.
Childs Nerv Syst 2015; 31: 2333-2340. 

OBJECTIVE: The objective of this study is to evaluate the use of nests on general movements (GM) and posture in very preterm infants at term age. METHOD: Seventeen high-risk preterm infants-less than 30 weeks of gestation (GA)-underwent a video recording, lying in supine position, with or without nest. Posture, GM quality, and movements made around the child's midline, as well as abrupt movements and frozen postures-in extension or flexion of the four limbs-were analyzed. RESULTS: Nest did not modify quality of GM. Children significantly adopted a curled-up position. The nest system was associated with an increase in movements toward or across the midline, as well as reduction of the hyperextension posture and head rotation movements. Frozen postures in flexion or extension, as well as abrupt movements of the four limbs, were reduced but not significantly. CONCLUSIONS: Nest helps very preterm infants to adopt semi-flexed posture and facilitates movements across the midline and reduces movements of spine hyperextension, without GM global quality modifications.

160. Chen N, Wen XH, Huang JH, Wang SY, Zhu YE.
[Predictive value of qualitative assessment of general movements for adverse outcomes at 24 months of age in infants with asphyxia].
Zhongguo Dang Dai Er Ke Za Zhi 2015; 17: 1322-1326.

OJBECTIVE: To investigate the predictive value of the qualitative assessment of general movements (GMs) for adverse outcomes at 24 months of age in full-term infants with asphyxia. METHODS: A total of 114 full-term asphyxiated infants, who were admitted to the neonatal intensive care unit between 2009 and 2012 and took part in follow-ups after discharge were included in the study. All of them received the qualitative assessment of GMs within 3 months after birth. The development quotient was determined with the Bayley Scales of Infant Development at 24 months of age. RESULTS: The results of the qualitative assessment of GMs within 3 months after birth showed that among 114 infants, 20 (17.5%) had poor repertoire movements and 7 (6.1%) had cramped-synchronized movements during the writhing movements’ period; 8 infants (7.0%) had the absence of fidgety movements during the fidgety movements period. The results of development quotient at 24 months of age showed that 7 infants (6.1%) had adverse developmental outcomes: 6 cases of cerebral palsy and mental retardation and 1 case of mental retardation. There was a poor consistency between poor repertoire movements during the writhing movements period and the developmental outcomes at 24 months of age (Kappa=-0.019; P>0.05). There was a high consistency between cramped-synchronized movements during the writhing movements period and the developmental outcomes at 24 months of age (Kappa=0.848; P<0.05), and the results of predictive values of cramped-synchronized movements were shown as follows: predictive validity 98.2%, sensitivity 85.7%, specificity 99.1%, positive predictive value 85.7%, and negative predictive value 99.1%. There was a high consistency between the absence of fidgety movements during the fidgety movements period and the developmental outcomes at 24 months of age (Kappa=0.786; P<0.05), and its predictive values were expressed as follows: predictive validity 97.4%, sensitivity 85.7%, specificity 98.1%, positive predictive value 75.0%, and negative predictive value 99.1%. CONCLUSIONS: Cramped-synchronized movements and absence of fidgety movements can predict adverse developmental outcomes at 24 months of age in full-term infants with asphyxia.

159. Peyton C, Yang E, Kocherginsky M, Adde L, Fjørtoft T, Støen R, Bos AF, Einspieler C, Schreiber MD, Msall ME.
Relationship between white matter pathology and performance on the General Movement Assessment and the Test of Infant Motor Performance in very preterm infants.
Early Hum Dev 2016; 95: 23-27.  

BACKGROUND: Cerebral Magnetic Resonance Imaging, the General Movement Assessment, and the Test of Infant Motor Performance are all tools that can predict neurodevelopmental outcome in preterm infants. However, how these tests relate to each other is unclear. AIMS: To examine the relationship between cerebral Magnetic Resonance Imaging measured at term age, and the General Movement Assessment and Test of Infant Motor Performance measured at 10-15weeks post-term age. STUDY DESIGN: Prospectively collected data in a sample of very preterm infants SUBJECTS: Fifty-three infants (23 female, 30 male) with a median gestational age of 28weeks (range: 23-30weeks) and a median birth weight of 1000g (range: 515-1465g). OUTCOME MEASURES: Test of Infant Motor Performance, General Movement Assessment. RESULTS: Infants with abnormal white matter were significantly more likely to have both abnormal general movements (p=0.01) and abnormal Test of Infant Motor Performance scores (p=0.001). Infants with abnormal general movements were significantly more likely to have lower Test of Infant Motor Performance Scores (p=0.01). CONCLUSIONS: Abnormal white matter is related to motor deviations as measured by the General Movement Assessment and the Test of Infant Motor Performance as early as 3months post-term age in a cohort of preterm infants.

158. Raith W, Marschik PB, Sommer C, Maurer-Fellbaum U, Amhofer C, Avian A, Löwenstein E, Soral S, Müller W, Einspieler C, Urlesberger B.
General Movements in preterm infants undergoing craniosacral therapy: a randomised controlled pilot-trial.
BMC Complement Altern Med 2016; 16: 12ff. doi: 10.1186/s12906-016-0984-5.

BACKGROUND: The objective of this study was to investigate neurological short-term effects of craniosacral therapy as an ideal form of osteopathic manipulative treatment (OMT) due to the soft kinaesthetic stimulation. METHODS: Included were 30 preterm infants, with a gestational age between 25 and 33 weeks, who were admitted to the neonatal intensive care unit of the University Hospital of Graz, Austria. The infants were randomized either into the intervention group (IG) which received standardised craniosacral therapy, or the control group (CG) which received standard care. To guarantee that only preterm infants with subsequent normal neurodevelopment were included, follow up was done regularly at the corrected age (= actual age in weeks minus weeks premature) of 12 and 24 months. After 2 years 5 infants had to be excluded (IG; n = 12; CG: n = 13). General Movements (GMs) are part of the spontaneous movement repertoire and are present from early fetal life onwards until the end of the first half year of life. To evaluate the immediate result of such an intervention, we selected the General Movement Assessment (GMA) as an appropriate tool. Besides the global GMA (primary outcome) we used as detailed GMA, the General Movement Optimality Score (GMOS- secondary outcome), based on Prechtl's optimality concept. To analyse GMOS (secondary outcome) a linear mixed model with fixed effects for session, time point (time point refers to the comparisons of the measurements before vs. after each session) and intervention (IG vs. CG), random effect for individual children and a first order autoregressive covariance structure was used for calculation of significant differences between groups and interactions. Following interaction terms were included in the model: session*time point, session*intervention, time point*intervention and session*time point*intervention. Exploratory post hoc analyses (interaction: session*time point*intervention) were performed to determine group differences for all twelve measurement (before and after all 6 sessions) separately. RESULTS: Between groups no difference in the global GMA (primary outcome) could be observed. The GMOS (secondary outcome) did not change from session to session (main effect session: p = 0.262) in the IG or the CG. Furthermore no differences between IG and CG (main effect group: p = 0.361) and no interaction of time*session could be observed (p = 0.658). Post hoc analysis showed a trend toward higher values before (p = 0.085) and after (p = 0.075) the first session in CG compared to IG. At all other time points GMOS were not significantly different between groups. CONCLUSION: We were able to indicate that a group of "healthy" preterm infants undergoing an intervention with craniosacral therapy (IG) showed no significant changes in GMs compared to preterm infants without intervention (CG). In view of the fact that the global GMA (primary outcome) showed no difference between groups and the GMOS (detailed GMA-secondary outcome) did not deteriorate in the IG, craniosacral therapy seems to be safe in preterm infants.

157. Morgan C, Crowle C, Goyen TA, Hardman C, Jackman M, Novak I, Badawi N.
Sensitivity and specificity of General Movements Assessment for diagnostic accuracy of detecting cerebral palsy early in an Australian context.
J Paediatr Child Health 2016; 52: 54-59. 

AIM: The aim of this study was to calculate the sensitivity and specificity of the General Movements Assessment (GMA) for estimating diagnostic accuracy in detecting cerebral palsy (CP) in an Australian context by a newly established NSW rater network. METHODS: A prospective longitudinal cross-sectional study was conducted. The GMA was blind-rated from conventional video by two independent certified raters, blinded to medical history. A third rater resolved disagreements. High-risk population screening for CP using the GMA during the fidgety period (12-20 weeks) was carried out in four neonatal intensive care units and one CP service over a 30-month period (2012-2013). Participants were 259 high-risk infants. Sensitivity and specificity values were calculated with true positives defined as a confirmed diagnosis of CP from a medical doctor. RESULTS: Of the 259 infants assessed, 1-year follow-up data were available for 187. Of these, n = 48 had absent fidgety (high risk for CP), n = 138 had normal fidgety (low risk for CP), and n = 1 had abnormal fidgety (high risk for a neurological disorder). Of the 48 with absent fidgety movements, 39 had received a diagnosis of CP by 18 months and another 6 had an abnormal outcome. Of the n = 138 normal fidgety cases, n = 99 cases had a normal outcome, n = 38 had an abnormal outcome but not CP, and n = 1 had CP. For detecting CP, we had a sensitivity of 98% and specificity of 94%. CONCLUSION: GMA was feasible in an Australian context and accurately identified CP with a sensitivity and specificity comparable with European standards and published neuroimaging data.

156. Lev-Enacab O, Sher-Censor E, Einspieler C, Daube-Fishman G, Beni-Shrem, S.
The Quality of Spontaneous Movements of Preterm Infants: Associations with the Quality of Mother-Infant Interaction 
INFANCY 2015; 20: 634-660.

The assessment of the quality of infants’ spontaneous movements is a diagnostic tool for the young nervous system. We examined whether it relates to the quality of the interactions between infants born preterm and their mothers. Thirty-nine healthy infants born preterm (Mage in weeks=14.59, SD=2.21; 38.46% female) and their mothers participated in the study. Infants’ quality of spontaneous movements was assessed using the General Movement Assessment according to Prechtl (Prechtl, Early Human Development 1990, 23, 151). A new measurement was employed to evaluate the following aspects of the mother–infant interaction: maternal sensitivity in the motor modality (i.e., when touching, picking up, holding, and putting down the infant), maternal sensitivity in the modalities of vocalization and eye contact, and infants’ positive engagement. Several aspects of infants’ quality of movements were associated with maternal sensitivity in the motor modality and infants’ positive engagement, but not with maternal sensitivity in the modalities of vocalization and eye contact. These findings suggest that the quality of infants’ spontaneous movements may explain some of the variability in the interactions between infants born preterm and their mothers. The results also highlight the importance of differentiating between the modalities of mothers’ behavior when assessing their sensitivity. Implications for research and practice with families of preterm infants are discussed.

155. Einspieler C, Marschik PB, Pansy J, Scheuchenegger A, Krieber M, Yang H, Kornacka MK, Rowinska E, Soloveichick M, Bos AF, et al. 
The general movement optimality score: a detailed assessment of general movements during preterm and term age.
Dev Med Child Neurol 2015; Sep 14. doi: 10.1111/dmcn.12923. 

AIM: To explore the appropriateness of applying a detailed assessment of general movements and characterize the relationship between global and detailed assessment. METHOD: The analysis was based on 783 video recordings of 233 infants (154 males, 79 females) who had been videoed from 27 to 45 weeks postmenstrual age. Apart from assessing the global general movement categories (normal, poor repertoire, cramped-synchronized, or chaotic general movements), we scored the amplitude, speed, spatial range, proximal and distal rotations, onset and offset, tremulous and cramped components of the upper and lower extremities. Applying the optimality concept, the maximum general movement optimality score of 42 indicates the optimal performance. RESULTS: General movement optimality scores (GMOS) differentiated between normal general movements (median 39 [25-75th centile 37-41]), poor repertoire general movements (median 25 [22-29]), and cramped-synchronized general movements (median 12 [10-14]; p<0.01). The optimality score for chaotic general movements (mainly occurring at late preterm age) was similar to those for cramped-synchronized general movements (median 14 [12-17]). Short-lasting tremulous movements occurred from very preterm age (<32wks) to post-term age across all general movement categories, including normal general movements. The detailed score at post-term age was slightly lower compared to the scores at preterm and term age for both normal (p=0.02) and poor repertoire general movements (p<0.01). INTERPRETATION: Further research might demonstrate that the GMOS provides a solid base for the prediction of improvement versus deterioration within an individual general movement trajectory. 

154. Zappella M, Einspieler C, Bartl-Pokorny KD, Krieber M, Coleman M, Bölte S, Marschik PB.
What do home videos tell us about early motor and socio-communicative behaviours in children with autistic features during the second year of life - An exploratory study.
Early Hum Dev 2015; 91: 569-575.

BACKGROUND: Little is known about the first half year of life of individuals later diagnosed with autism spectrum disorders (ASD). There is even a complete lack of observations on the first 6 months of life of individuals with transient autistic behaviours who improved in their socio-communicative functions in the pre-school age. AIM: To compare early development of individuals with transient autistic behaviours and those later diagnosed with ASD. STUDY DESIGN: Exploratory study; retrospective home video analysis. SUBJECTS: 18 males, videoed between birth and the age of 6 months (ten individuals later diagnosed with ASD; eight individuals who lost their autistic behaviours after the age of 3 and achieved age-adequate communicative abilities, albeit often accompanied by tics and attention deficit). METHOD: The detailed video analysis focused on general movements (GMs), the concurrent motor repertoire, eye contact, responsive smiling, and pre-speech vocalisations. RESULTS: Abnormal GMs were observed more frequently in infants later diagnosed with ASD, whereas all but one infant with transient autistic behaviours had normal GMs (p<0.05). Eye contact and responsive smiling were inconspicuous for all individuals. Cooing was not observable in six individuals across both groups. CONCLUSIONS: GMs might be one of the markers which could assist the earlier identification of ASD. We recommend implementing the GM assessment in prospective studies on ASD.

153. Valle SC, Støen R, Sæther R, Jensenius AR, Adde L.
Test-retest reliability of computer-based video analysis of general movements in healthy term-born infants.
Early Hum Dev 2015; 91: 555-558. 

BACKGROUND: A computer-based video analysis has recently been presented for quantitative assessment of general movements (GMs). This method's test-retest reliability, however, has not yet been evaluated. AIMS: The aim of the current study was to evaluate the test-retest reliability of computer-based video analysis of GMs, and to explore the association between computer-based video analysis and the temporal organization of fidgety movements (FMs). STUDY DESIGN: Test-retest reliability study. SUBJECTS: 75 healthy, term-born infants were recorded twice the same day during the FMs period using a standardized video set-up. OUTCOME MEASURES: The computer-based movement variables "quantity of motion mean" (Qmean), "quantity of motion standard deviation" (QSD) and "centroid of motion standard deviation" (CSD) were analyzed, reflecting the amount of motion and the variability of the spatial center of motion of the infant, respectively. In addition, the association between the variable CSD and the temporal organization of FMs was explored. Intraclass correlation coefficients (ICC 1.1 and ICC 3.1) were calculated to assess test-retest reliability. RESULTS: The ICC values for the variables CSD, Qmean and QSD were 0.80, 0.80 and 0.86 for ICC (1.1), respectively; and 0.80, 0.86 and 0.90 for ICC (3.1), respectively. There were significantly lower CSD values in the recordings with continual FMs compared to the recordings with intermittent FMs (p<0.05). CONCLUSION: This study showed high test-retest reliability of computer-based video analysis of GMs, and a significant association between our computer-based video analysis and the temporal organization of FMs.

152. Øberg GK, Jacobsen BK, Jørgensen L.
Predictive Value of General Movement Assessment for Cerebral Palsy in Routine Clinical Practice.
Phys Ther 2015; 95: 1489-1495. 

BACKGROUND: Early identification of children at high risk of future neurodevelopmental disability is important for the initiation of appropriate therapy. In research settings, the assessment of fidgety movements (FMs) at 3 months supports a general movement assessment (GMA) as a strong predictor for subsequent motor development, but there are few studies from routine clinical settings. OBJECTIVE: The study objective was to examine the relationship between FMs and neurodevelopmental outcome by the age of 2 years in high-risk infants in a routine hospital clinical setting. DESIGN: This was a prospective study. METHODS: A GMA was performed in 87 high-risk infants at 3 months after term age. The infants were clinically assessed for cerebral palsy (CP) at 2 years. Sensitivity, specificity, likelihood ratios, and positive and negative predictive values were computed. The relative risk of motor problems by the age of 2 years, according to the GMA, was estimated. RESULTS: Of the infants with normal FMs, 93% (50/54) had normal development and none was diagnosed with CP, whereas 75% (12/16) with abnormal or sporadic FMs had normal development. In contrast, 53% (9/17) of those without FMs had CP. When the GMA was considered to be a test for CP and absent FMs were considered to be a positive test result, the sensitivity was 90% and the specificity was 90%. The likelihood ratios for positive and negative test results were 8.7 and 0.1, respectively. The negative predictive value was 99%, and the positive predictive value was 53%. The risk of motor problems by the age of 2 years increased linearly with the extent of pathological results on the GMA and was 10 times higher when FMs were absent at 3 months than when FMs were normal. LIMITATIONS: The relatively small study sample was a study limitation.

151. Soleimani F, Badv RS, Momayezi A, Biglarian A, Marzban A. 
General movements as a predictive tool of the neurological outcome in term born infants with hypoxic ischemic encephalopathy. 
Early Hum Dev 2015; 91: 479-82.

BACKGROUND: At a time of increasing high risk neonates, an assessment method is needed that can reliably predict neurological deficits at an early age. AIMS: The objective of this study was to determine whether the assessment of fidgety movements (FMs) will predict the neurological outcome of infants with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN: This study employed a prospective and descriptive plan. SUBJECTS: The study sample consisted of 15 infants (8 male and 7 female) born at term. Video recording of FMs were analyzed at 3 to 5months' infants, who identified with perinatal asphyxia and neonatal HIE. FMs were classified as present or absent. OUTCOME MEASURES: At 12-18months age, the infants' developmental outcome was classified as normal or abnormal according to the Infant Neurological International Battery test. "Abnormal outcome" was denoted as poor motor or neurological outcome such as cerebral palsy, whereas "Normal outcome" denotes normal motor and neurological outcomes. RESULTS: The predictive values of FMs were: a sensitivity 0.80 (95% CI: 0.44-0.96), a specificity 1.00 (95% CI: 0.47-1.00), and the accuracy 0.87 (0.57 to 1.00). CONCLUSIONS: FMs assessment improves our ability to predict later neurodevelopmental outcomes in term born children with neonatal HIE.

150. Einspieler C, Yang H, Bartl-Pokorny KD, Chi X, Zang FF, Marschik PB, Guzzetta A, Ferrari F, Bos AF, Cioni G.
Are sporadic fidgety movements as clinically relevant as is their absence?
Early Hum Dev 2015; 91: 247-252. 

BACKGROUND: Infants with normal fidgety movements at 3 to 5 months after term are very likely to show neurologically normal development, while the absence of fidgety movements is an early marker for an adverse neurological outcome, mainly cerebral palsy (CP). The clinical significance of so-called sporadic fidgety movements (i.e., fidgety movements occur isolated in a few body parts and are of 1- to 3-second-duration) is not yet known. AIMS: Our objective was to determine whether infants who had developed CP and had sporadic fidgety movements have a better outcome than infants who did not have fidgety movements. STUDY DESIGN: Longitudinal study. Retrospective analysis of prospectively collected data. SUBJECTS: 61 infants who developed CP (46 male, 15 female; 29 infants born preterm; videoed for the assessment of movements and postures at 9 to 16 weeks post-term age). OUTCOME MEASURES: The Gross Motor Function Classification System (GMFCS) was applied at 3 to 5 years of age. RESULTS: There was no difference between children diagnosed with CP who had sporadic fidgety movements at 9 to 16 weeks post-term age (n = 9) and those who never developed fidgety movements (n = 50) with regard to their functional mobility and activity limitation at 3 to 5 years of age. One infant had normal FMs and developed unilateral CP, GMFCS Level I; the remaining infant had abnormal FMs and developed bilateral CP, GMFCS Level II. CONCLUSIONS: There is no evidence that the occurrence of occasional isolated fidgety bursts indicates a milder type of CP.

149. Marcroft C, Khan A, Embleton ND, Trenell M, Plötz T.
Movement recognition technology as a method of assessing spontaneous general movements in high risk infants.
Front Neurol 2015; Jan 9;5: 284. doi: 10.3389/fneur.2014.00284

Preterm birth is associated with increased risks of neurological and motor impairments such as cerebral palsy. The risks are highest in those born at the lowest gestations. Early identification of those most at risk is challenging meaning that a critical window of opportunity to improve outcomes through therapy-based interventions may be missed. Clinically, the assessment of spontaneous general movements is an important tool, which can be used for the prediction of movement impairments in high risk infants. Movement recognition aims to capture and analyze relevant limb movements through computerized approaches focusing on continuous, objective, and quantitative assessment. Different methods of recording and analyzing infant movements have recently been explored in high risk infants. These range from camera-based solutions to body-worn miniaturized movement sensors used to record continuous time-series data that represent the dynamics of limb movements. Various machine learning methods have been developed and applied to the analysis of the recorded movement data. This analysis has focused on the detection and classification of atypical spontaneous general movements. This article aims to identify recent translational studies using movement recognition technology as a method of assessing movement in high risk infants. The application of this technology within pediatric practice represents a growing area of inter-disciplinary collaboration, which may lead to a greater understanding of the development of the nervous system in infants at high risk of motor impairment. 

148. Herskind A, Greisen G, Nielsen JB.
Early identification and intervention in cerebral palsy.
Dev Med Child Neurol 2015; 57: 29-36. 

Infants with possible cerebral palsy (CP) are commonly assumed to benefit from early diagnosis and early intervention, but substantial evidence for this is lacking. There is no consensus in the literature on a definition of 'early', but this review focuses on interventions initiated within the first 6 months after term age. We cover basic neuroscience, arguing for a beneficial effect of early intervention, and discuss why clinical research to support this convincingly is lacking. We argue that infants offered early intervention in future clinical studies must be identified carefully, and that the intervention should be focused on infants showing early signs of CP to determine an effect of treatment. Such signs may be efficiently detected by a combination of neuroimaging and the General Movements Assessment. We propose a research agenda directed at large-scale identification of infants showing early signs of CP and testing of high-intensity, early interventions.

147. Ma L, Yang B, Meng L, Wang B, Zheng C, Cao A.
Effect of early intervention on premature infants' general movements.
Brain Dev 2015; 37: 387-393. 

This study is to investigate the characteristics of premature infants' general movements (GMs) and the effect of early intervention on their GMs. METHODS: The survey was carried among 285 premature infants. (1) Before intervention, the correlation between the gestational age/ birth weight and the GMs was evaluated. (2) The cases were divided into early intervention group (n=145) and control group (n=140), each group was divided into <32 weeks, 32-34 weeks and >34 weeks group according to gestational age. The early intervention was begun at the 3rd day after birth to 54th week gestational age. The rate of GMs among each group was compared after intervention. RESULTS: (1) Before intervention, gestational age/birth weight was negatively correlated with the rate of cramped-synchronized (CS) (r=-0.988, r=-0.95, p<0.01), while no correlation with the rate of poor repertoire (PR) (r=0.122, r=0.168, p>0.05). (2) After intervention, for the writhing movement, there was no significant difference (χ2=0.509, 1.401, 0.519, p>0.05) between the early intervention group and the control group. Nevertheless, for the fidgety movement, there was significant difference (χ2=7.921, χ2=5.763, p<0.05) between the two groups, especially in <32 weeks group (χ2=5.578, 4.067 p<0.05) and in >34 weeks group (χ2=5.757, p<0.05). CONCLUSIONS: (1) It shows that the lower birth weight or the younger delivery gestational age, the more abnormal GMs in premature infants. (2) Early intervention could improve the fidgety movements of premature infant.

146. Hitzert MM, van Geert PL, Hunnius S, Van Braeckel KN, Bos AF, Geuze RH.
Associations between developmental trajectories of movement variety and visual attention in fullterm and preterm infants during the first six months postterm.
Early Hum Dev 2015; 91: 89-96. 

BACKGROUND: During early infancy major developmental changes, both in the variety of body movements and in visual attention, help the infant to explore its surroundings. Both behaviours depend on a gradual shift from subcortical to cortical functioning. AIMS: First, to determine whether preterms reach mature levels of movement variety (the number of different movement patterns) and visual attention earlier than fullterms. Second, to determine whether individual developmental trajectories of movement variety and visual attention were associated. Finally, we compared the associations of developmental trajectories between fullterm and preterm infants. STUDY DESIGN: In this longitudinal study, 20 fullterm and 9 low-risk preterm infants performed a visual disengagement task every four weeks from six weeks until six months postterm. For each infant we drew up developmental trajectories for movement variety, and for frequencies and latencies of looks. We analyzed the developmental trajectories by means of general linear model (GLM) repeated measures and Monte Carlo analyses. RESULTS: In comparison to fullterms, preterm infants showed a similar increase in movement variety over time (F(4,108)=0.27; partial eta(2)=0.01; P=.90). Visual attention reached mature levels four weeks earlier than movement variety. This effect was stronger in fullterm infants. Neither in fullterm nor in preterm infants did we find an association between the developmental trajectories of movement variety and visual attention. P values ranged from .37 to .99. CONCLUSIONS: During the first 6 months postterm, movement variety and visual attention developed independently. Temporarily, preterm exposure to the extrauterine environment led to shorter latencies of looks but it did not affect developmental trajectories of frequencies of looks and movement variety.

145. Crowle C, Badawi N, Walker K, Novak I.
General Movements Assessment of infants in the neonatal intensive care unit following surgery.
J Paediatr Child Health 2015; Mar 31. doi: 10.1111/jpc.12886. 

AIM: There is an identified gap in the literature regarding the use of the General Movements (GMs) Assessment to identify risk in infants post-surgery. This paper aims to examine the GMs for infants who have undergone surgery to identify common risk profiles in the writhing age. METHODS: This was a prospective cohort study of 170 infants (99 male, 58%) admitted to a neonatal surgical unit from 2012 until June 2014. Infants were born at a mean age of 38 weeks (standard deviation (SD) 2.3), and writhing GMs were conducted at term (40 weeks, SD 2.6) following either cardiac (n = 84, 49%) or non-cardiac surgery (n = 86, 51%). GMs were categorised by three trained assessors. RESULTS: Normal writhing was recorded in 64 infants (38%). The most common profile was poor repertoire (n = 80, 47%), with 14 (8%) cramped synchronised. There was no difference in scores between infants who had undergone cardiac versus non-cardiac surgery (P = 0.45).
CONCLUSION: This is the first report on the GMs assessment in an infant surgical population. Infants who have undergone surgery most commonly display poor repertoire writhing movements. Research is needed to determine the ability of the GMs to predict neurodevelopmental outcomes in this population.

144. Mehler K, Mainusch A, Hucklenbruch-Rother E, Hahn M, Hünseler C, Kribs A.
Increased rate of parental postpartum depression and traumatization in moderate and late preterm infants is independent of the infant's motor repertoire.
Early Hum Dev 2014; 90: 797-801. 

BACKGROUND: Moderately and late preterm infants represent a considerable and increasing proportion of infants cared for in neonatal departments worldwide. Parents of preterm infants are at risk of postpartal depression (PPD) and posttraumatic stress disorder (PTSD), and preterm infants are at risk of developmental impairment. AIM: This study aimed to assess (1) the incidence of parental PPD and PTSD in moderate to late preterm infants in comparison to full-term infants and (2) the influence of infants' motor repertoire assessed by Prechtl's general movements and illness severity on parental PPD and PTSD. SUBJECTS: We studied 60 mothers and 56 fathers of 69 preterm infants (born at 32 to 37 weeks of gestation) and 32 mothers and 29 fathers of 34 full-term infants. OUTCOME MEASURES: We assessed the incidence of parental PPD, PTSD and perceived social support as well as infants' illness severity and motor repertoire at birth, term and 3 months corrected age. RESULTS: Preterm mothers and fathers had significant higher depression scores after birth compared to full-term parents (p=0.033 and 0.021). Preterm fathers also had higher traumatization scores compared to full-term fathers (p=0.007). Probable or possible PPD/PTSD was not associated with infant's illness severity or quality of motor repertoire. No differences in motor development were found between preterm and full-term infants. CONCLUSION: Moderate to late preterm infants' parents are at increased risk for PPD irrespective of infants' motor repertoire or illness severity.

143. Grunewaldt KH, Fjørtoft T, Bjuland KJ, Brubakk AM, Eikenes L, Håberg AK, Løhaugen GC, Skranes J.
Follow-up at age 10 years in ELBW children - functional outcome, brain morphology and results from motor assessments in infancy.
Early Hum Dev 2014; 90: 571-578. 

BACKGROUND: Extremely-low-birth-weight (ELBW) children without severe brain injury or CP are at high risk of developing deficits within cognition, attention, behavior and motor function. Assessing the quality of an infant's spontaneous motor-repertoire included in Prechtl's General-Movement-Assessment (GMA) has been shown to relate to later motor and cognitive functioning in preterm children without CP. AIMS: To investigate functional outcome and cerebral MRI morphometry at 10 years in ELBW children without CP compared to healthy controls and to examine any relationship with the quality of infant-motor-repertoire included in the GMA. STUDY DESIGN: A cohort-study-design. SUBJECTS: 31 ELBW children (mean birth-weight: 773 g, SD 146, mean gestational age 26.1 weeks, SD 1.8) and 33 term-born, age-matched controls. OUTCOME MEASURES: GMA was performed in ELBW children at 3 months corrected age. At 10 years the children underwent comprehensive motor, cognitive, behavioral assessments and cerebral MRI. RESULTS: The non-CP ELBW children had similar full-IQ but poorer working memory, poorer motor skills, and more attentional and behavioral problems compared to controls. On cerebral MRI reduced volumes of globus pallidus, cerebellar white matter and posterior corpus callosum were found. Cortical surface-area was reduced in temporal, parietal and anterior-medial-frontal areas. Poorer test-results and reduced brain volumes were mainly found in ELBW children with fidgety movements combined with abnormal motor-repertoire in infancy. CONCLUSION: Non-CP ELBW children have poorer functional outcomes, reduced brain volumes and cortical surface-area compared with term-born controls at 10 years. ELBW children with abnormal infant motor-repertoire seem to be at increased risk of later functional deficits and brain pathology.

142. Hadders-Algra M.
Early diagnosis and early intervention in cerebral palsy.
Front Neurol 2014; Sep 24;5:185. doi: 10.3389/fneur.2014.00185. 

This paper reviews the opportunities and challenges for early diagnosis and early intervention in cerebral palsy (CP). CP describes a group of disorders of the development of movement and posture, causing activity limitation that is attributed to disturbances that occurred in the fetal or infant brain. Therefore, the paper starts with a summary of relevant information from developmental neuroscience. Most lesions underlying CP occur in the second half of gestation, when developmental activity in the brain reaches its summit. Variations in timing of the damage not only result in different lesions but also in different neuroplastic reactions and different associated neuropathologies. This turns CP into a heterogeneous entity. This may mean that the best early diagnostics and the best intervention methods may differ for various subgroups of children with CP. Next, the paper addresses possibilities for early diagnosis. It discusses the predictive value of neuromotor and neurological exams, neuroimaging techniques, and neurophysiological assessments. Prediction is best when complementary techniques are used in longitudinal series. Possibilities for early prediction of CP differ for infants admitted to neonatal intensive care and other infants. In the former group, best prediction is achieved with the combination of neuroimaging and the assessment of general movements, in the latter group, best prediction is based on carefully documented milestones and neurological assessment. The last part reviews early intervention in infants developing CP. Most knowledge on early intervention is based on studies in high-risk infants without CP. In these infants, early intervention programs promote cognitive development until preschool age; motor development profits less. The few studies on early intervention in infants developing CP suggest that programs that stimulate all aspects of infant development by means of family coaching are most promising. More research is urgently needed. 

141. Morgan C, Novak I, Dale RC, Guzzetta A, Badawi N.
GAME (Goals - Activity - Motor Enrichment): protocol of a single blind randomised controlled trial of motor training, parent education and environmental enrichment for infants at high risk of cerebral palsy.
BMC Neurol 2014, Oct 7;14:203. doi: 10.1186/s12883-014-0203-2.

BACKGROUND: Cerebral palsy is the most common physical disability of childhood and early detection is possible using evidence based assessments. Systematic reviews indicate early intervention trials rarely demonstrate efficacy for improving motor outcomes but environmental enrichment interventions appear promising. This study is built on a previous pilot study and has been designed to assess the effectiveness of a goal - oriented motor training and enrichment intervention programme, "GAME", on the motor outcomes of infants at very high risk of cerebral palsy (CP) compared with standard community based care. METHODS/DESIGN: A two group, single blind randomised controlled trial (n = 30) will be conducted. Eligible infants are those diagnosed with CP or designated "at high risk of CP" on the basis of the General Movements Assessment and/or abnormal neuroimaging. A physiotherapist and occupational therapist will deliver home-based GAME intervention at least fortnightly until the infant's first birthday. The intervention aims to optimize motor function and engage parents in developmental activities aimed at enriching the home learning environment. Primary endpoint measures will be taken 16 weeks after intervention commences with the secondary endpoint at 12 months and 24 months corrected age. The primary outcome measure will be the Peabody Developmental Motor Scale second edition. Secondary outcomes measures include the Gross Motor Function Measure, Bayley Scales of Infant and Toddler Development, Affordances in the Home Environment for Motor Development - Infant Scale, and the Canadian Occupational Performance Measure. Parent well-being will be monitored using the Depression Anxiety and Stress Scale. DISCUSSION: This paper presents the background, design and intervention protocol of a randomised trial of a goal driven, motor learning approach with customised environmental interventions and parental education for young infants at high risk of cerebral palsy. TRIAL REGISTRATION: This trial is registered on the Australian New Zealand Clinical Trial register: ACTRN12611000572965.

140. Ma L, Meng LD, Zheng CH, Zhao FQ, Cao AH.
[High-risk factors for quality of general movements in infants]. [Article in Chinese]
Zhongguo Dang Dai Er Ke Za Zhi 2014; 16: 887-891.

OBJECTIVE: To investigate the high-risk factors for the quality of general movements (GMs), which has a predictive value for brain dysfunction in infants. METHODS: A total of 618 infants in the stage of writhing movements and 539 infants in the stage of fidgety movements were selected separately for the evaluation of GMs. The high-risk factors for the quality of GMs in infants were analyzed by ANOVA, chi-square test, and multivariate logistic regression. RESULTS: Multivariate logistic regression analysis showed that the factors significantly associated with the quality of GMs in the stage of writhing movements were gestational age (OR=0.762, P<0.001), birth weight (OR=0.264, P<0.001), severe asphyxia (OR=2.445, P=0.012), and intrauterine distress (OR=4.865, P<0.001); the factors significantly associated with the quality of GMs in the stage of fidget movements were gestational age (OR=0.786, P=0.003), birth weight (OR=0.217, P<0.001), severe asphyxia (OR=3.765, P=0.001), and hyperbilirubinemia (OR=2.640, P=0.028). CONCLUSIONS: Low gestational age, low birth weight, severe asphyxia, hyperbilirubinemia and intrauterine distress are high-risk factors for abnormal GMs in infants, and early screening and intervention should be performed to reduce the incidence of abnormal nervous system sequelae. 

139. Hitzert MM, Roescher AM, Bos AF.
The quality of general movements after treatment with low-dose dexamethasone in preterm infants at risk of bronchopulmonary dysplasia.
Neonatology 2014; 106: 222-228. 

BACKGROUND: High-dose dexamethasone (DXM) treatment of preterms at risk of bronchopulmonary dysplasia leads to a deterioration in quality of their general movements (GMs). It is unknown whether low-dose DXM affects GM quality similarly. OBJECTIVES: To assess the effect of low-dose DXM treatment on the quality of GMs and fidgety GMs (FMs). METHODS: A prospective study of preterms admitted to our NICU between 2010 and 2012, and treated with DXM (starting dose 0.25 mg/kg/day). We assessed GM/FM quality and calculated their motor optimality score (MOS) before, during, and after treatment up to 3 months postterm. Neurological follow-up was performed between 12 and 36 months. We related risk factors with infants' GM trajectories and MOSs. At 3 months we compared the MOSs of low-dose DXM infants and a historical cohort of infants treated with high-dose DXM or hydrocortisone. RESULTS: 17 infants were included. GM/FM quality improved in 9 out of 13 initially abnormal infants (p = 0.004). Shorter periods of mechanical ventilation and higher birth weights were associated with better GM trajectories (p = 0.032 and p = 0.042, respectively). Infants starting treatment later had higher MOSs on day 7 (p = 0.047). Low-dose DXM infants had higher MOSs than high-dose DXM infants (β = -0.535; 95% CI -0.594 to -0.132; p = 0.003). Out of 17 infants, 2 died, 14 developed normally, and 1 developed with mild neurodevelopmental impairments. Infants whose GMs/FMs remained normal or improved had better outcomes than infants whose GMs/FMs remained abnormal (p = 0.019). CONCLUSIONS: Out of the 17 infants treated with low-dose DXM, 2 died. Of the surviving infants, neurological functioning improved with the majority having normal neurodevelopment at the age of 12-36 months.

138. Ploegstra WM, Bos AF, de Vries NK.
General movements in healthy full term infants during the first week after birth.
Early Hum Dev 2014; 90: 55-60. 

BACKGROUND: The quality of general movements (GMs) is a widely used criterion to assess neurological dysfunction in young infants. It is unknown, however, whether the birth process influences the motor repertoire of healthy full term infants during the first week after birth. AIMS: To assess the quality of GMs and to determine the motor optimality score (OS) in healthy full term infants during the first week after birth and to evaluate the influence of the mode of delivery on GM quality. STUDY DESIGN: Thirty-three healthy full term infants born either vaginally or after caesarean section (CS) under spinal anaesthesia were video recorded in the first week after birth in order to assess GM quality and to determine OS with Prechtl's method. RESULTS: Abnormal GMs were observed mainly on the early recordings: 86% on the day of birth (day 0), 94% on day 1, and 68% on day 2. On days 5 to 7 (day 5-7) all GMs were normal (P<.001). The OSs increased significantly from median 12 on day 0 to 18 on day 5-7 (P<.001). Monotonously slow movements were frequently seen during the first days but not on day 5-7 (P<.001). GM quality and OS did not differ between infants born by vaginal delivery or after CS under spinal anaesthesia. CONCLUSIONS: Healthy full term infants often showed abnormal GM quality and lower OSs during the first week after birth, irrespective of the mode of delivery. GM quality normalised during subsequent days and was normal on day 5-7.

137. Picciolini O, Porro M, Meazza A, Giannì ML, Rivoli C, Lucco G, Barretta F, Bonzini M, Mosca F.
Early exposure to maternal voice: effects on preterm infants development.
Early Hum Dev 2014; 90: 287-292. 

BACKGROUND: Preterm infants complete their development in Neonatal Intensive Care Unit being exposed to environmental stimuli that lead to the early maturation of the sensory systems. It is known that the fetus perceives sounds and reacts to them with movements since the 26th-28th week of gestational age. Maternal voice represents a source of sensory stimulation for the fetus. AIMS: To investigate the effect of the exposure to maternal voice, administered by bone conduction, on preterm infants autonomic and neurobehavioral development. STUDY DESIGN: Longitudinal, explorative, case control study. SUBJECTS: 71 preterm infants with birth weight <1500g, born adequate for gestational age. OUTCOME MEASURES: vital and neurobehavioral parameters at term, neurofunctional assessment at 3 and 6months of corrected age. RESULTS: Infants in the treatment group had lower heart rate values and a higher proportion of stable skin color at each study point as compared to the control group. The scores in the visual attention performance and in the quality of the general movements at term were better in the treatment group than in the control one. Neurofunctional assessment score at 3months of corrected age was higher in the treatment group whereas no difference between the two groups was detected at 6months of corrected age. CONCLUSIONS: Early exposure to maternal voice exerts a beneficial effect on preterm infants autonomic and neurobehavioral development. 

136. Pierrat V.
Computer-based analysis of general movements reveals stereotypies predicting cerebral palsy.
Dev Med Child Neurol 2014; 56: 922-993. 

135. Adde L, Helbostad J, Jensenius AR, Langaas M, Støen R.
Identification of fidgety movements and prediction of CP by the use of computer-based video analysis is more accurate when based on two video recordings.
Physiother Theory Pract 2013; 29: 469-475. 

This study evaluates the role of postterm age at assessment and the use of one or two video recordings for the detection of fidgety movements (FMs) and prediction of cerebral palsy (CP) using computer vision software. Recordings between 9 and 17 weeks postterm age from 52 preterm and term infants (24 boys, 28 girls; 26 born preterm) were used. Recordings were analyzed using computer vision software. Movement variables, derived from differences between subsequent video frames, were used for quantitative analysis. Sensitivities, specificities, and area under curve were estimated for the first and second recording, or a mean of both. FMs were classified based on the Prechtl approach of general movement assessment. CP status was reported at 2 years. Nine children developed CP of whom all recordings had absent FMs. The mean variability of the centroid of motion (CSD) from two recordings was more accurate than using only one recording, and identified all children who were diagnosed with CP at 2 years. Age at assessment did not influence the detection of FMs or prediction of CP. The accuracy of computer vision techniques in identifying FMs and predicting CP based on two recordings should be confirmed in future studies. 

134. Einspieler C, Sigafoos J, Bartl-Pokorny KD, Landa R, Marschik PB, Bolte S.
Highlighting the first 5 months of life: General movements in infants later diagnosed with autism spectrum disorder or Rett syndrome. 
Res Autism Spectr Disord 2014; 8: 286-291.

We review literature identifying an association between motor abnormality in the first 5 months of infancy and later diagnosis of autism spectrum disorder (ASD) or Rett syndrome (RU). The assessment of the quality of early spontaneous movements (also known as the assessment of general movements; GMs) is a diagnostic tool that has repeatedly proven to be valuable in detecting early markers for neurodevelopmental disorders. Even though the rate of occurrence of abnormal GMs is exceedingly high in infants later diagnosed with ASD, we endorse further studies using this method either based on family videos or its prospective implementation in high-risk sibling studies to evaluate the power of GM assessment as one potential marker for early maldevelopment in this cohort. 

133. Philippi H, Karch D, Kang KS, Wochner K, Pietz J, Dickhaus H, Hadders-Algra M. 
Computer-based analysis of general movements reveals stereotypies predicting cerebral palsy.
Dev Med Child Neurol. 2014; 56: 960-967.

AIM: To evaluate a kinematic paradigm of automatic general movements analysis in comparison to clinical assessment in 3-month-old infants and its prediction for neurodevelopmental outcome. METHOD: Preterm infants at high risk (n=49; 26 males, 23 females) and term infants at low risk (n=18; eight males, 10 females) of developmental impairment were recruited from hospitals around Heidelberg, Germany. Kinematic analysis of general movements by magnet tracking and clinical video-based assessment of general movements were performed at 3 months of age. Neurodevelopmental outcome was evaluated at 2 years. By comparing the general movements of small samples of children with and without cerebral palsy (CP), we developed a kinematic paradigm typical for infants at risk of developing CP. We tested the validity of this paradigm as a tool to predict CP and neurodevelopmental impairment. RESULTS: Clinical assessment correctly identified almost all infants with neurodevelopmental impairment including CP, but did not predict if the infant would be affected by CP or not. The kinematic analysis, in particular the stereotypy score of arm movements, was an excellent predictor of CP, whereas stereotyped repetitive movements of the legs predicted any neurodevelopmental impairment. INTERPRETATION: The automatic assessment of the stereotypy score by magnet tracking in 3-month-old spontaneously moving infants at high risk of developmental abnormalities allowed a valid detection of infants affected and unaffected by CP.

132. Roescher AM, Timmer A, Hitzert MM, de Vries NK, Verhagen EA, Erwich JJ, Bos AF.
Placental pathology and neurological morbidity in preterm infants during the first two weeks after birth.
Early Hum Dev 2014; 90: 21-25. 

BACKGROUND: The placenta plays a crucial role during pregnancy and dysfunction causes long-term neurological problems. Identifying placenta-related risks for neurological problems shortly after birth may provide clues for early interventions aiming to improve neurological outcome. OBJECTIVE: To determine the association between placental pathology and neurological morbidity in preterm infants during the first two weeks after birth. STUDY DESIGN: Placentas of 52 singleton, preterm infants (GA: 25-31weeks, BW: 560-2250 grammes) were examined for histopathology. The infants' neurological condition shortly after birth was determined by assessing the quality of their general movements (GMs): normal, abnormal, or hypokinetic, on days 5, 8, and 15. A motor optimality score (MOS) was also assigned. RESULTS: Examination of the placentas revealed maternal vascular underperfusion (n=29), ascending intrauterine infection (AIUI) (n=19), villitis of unknown aetiology (n=6), chronic deciduitis (n=11), foetal thrombotic vasculopathy (FTV) (n=9), and elevated nucleated red blood cells (NRBCs) as a marker for foetal hypoxia (n=7). None of the placental lesions were significantly associated with the quality of GMs or MOS. CONCLUSIONS: This study indicated that placental lesions were not associated with infants' neurological condition as measured by the quality of their general movements during the first two weeks after birth.

131. Luxwolda MF, Kuipers RS, Boersma ER, van Goor SA, Dijck-Brouwer DA, Bos AF, Muskiet FA.
DHA status is positively related to motor development in breadfed African and Dutch infants.
Nutr Neurosci 2014; 17: 97-103.

OBJECTIVES: Docosahexaenoic (DHA) and arachidonic (AA) acids are important for neurodevelopment. We investigated the relation between erythrocyte (RBC) DHA and AA contents and neurological development, by assessment of General Movements (GMs), in populations with substantial differences in fish intakes. METHODS: We included 3-month-old breastfed infants of three Tanzanian tribes: Maasai (low fish, n=5), Pare (intermediate fish, n=32), and Sengerema (high fish, n = 60); and a Dutch population (low-intermediate, fish, n=15). GMs were assessed by motor optimality score (MOS) and the number of observed movement patterns (OMP; an MOS sub-score). RBC-DHA and AA contents were determined by capillary gas chromatography. RESULTS: We found no between-population differences in MOS. OMP of Sengerema infants (high fish) was higher than OMP of Dutch infants (low-intermediate fish). MOS related to age. OMP related positively to infant age (P<0.001) and RBC-DHA (P=0.015), and was unrelated to ethnicity and RBC-AA. DISCUSSION: The positive relation between RBC-DHA and the number of observed movement patterns of 3-month old infants might reflect the connection of DHA with motor development.

130. Berghuis SA, Soechitram SD, Hitzert MM, Sauer PJ, Bos AF.
Prenatal exposure to polychlorinated biphenyls and their hydroxylated metabolites is associated with motor development of three-month-old infants.
Neurotoxicology 2013; 38: 124-130

BACKGROUND: Polychlorinated biphenyls (PCBs) are ubiquitous environmental pollutants that are potentially toxic to the developing brain. Hydroxylated metabolites of PCBs (OH-PCBs) are suggested to be even more toxic. Little is known about their short-term effects on human health. OBJECTIVES: To determine whether prenatal background exposure to PCBs and OH-PCBs was associated with the motor development of three-month-old infants. METHODS: Ninety-seven mother-infant pairs participated in this Dutch, observational cohort study. We determined the concentrations of PCBs and OH-PCBs in cord blood samples. When the infants were three months old we evaluated their motor development by assessing the presence and performance of spontaneous movement patterns from video recordings. We calculated a Motor Optimality Score (MOS). The score could range from low (5) to high (28) optimality. We explored the correlations between PCB and OH-PCB levels and MOS. Subsequently, we tested whether the levels differed between infants with a low (<26) or high (≥26) MOS and whether the levels associated with detailed aspects of their motor repertoires. RESULTS: We found several associations between PCB and OH-PCB levels and MOS, including detailed aspects of the early motor development. High 4-OH-PCB-107 levels were associated with a low MOS (P=.013). High PCB-187 levels were associated with reduced midline arm and leg movements (P=.047 and P=.043, respectively). High 4'-OH-PCB-172 levels were associated with more manipulation (P=.033). CONCLUSIONS: Prenatal exposure to high background levels of most PCBs and 4-OH-PCB-107 seems to impair early motor development, whereas only 4'-OH-PCB-172 showed the opposite.

129. de Vries NK, van der Veere CN, Reijneveld SA, Bos AF.
Early neurological outcome of young infants exposed to selective serotonin reuptake inhibitors during pregnancy: results from the observational SMOK study.
PLoS One 2013; May 28;8(5):e64654.

BACKGROUND: Use of selective serotonin reuptake inhibitors (SSRI) during pregnancy is common while the effect on the infant's neurological outcome is unknown. Our objective was to determine the effects of prenatal SSRI-exposure on the infants' neurological functioning, adjusted for maternal mental health. METHODS: A prospective observational study from May 2007 to April 2010. The study groups comprised 63 SSRI-exposed infants (SSRI group) and 44 non-exposed infants (non-SSRI group). Maternal depression and anxiety were measured using questionnaires. The main outcome measures during the first week after birth and at three to four months were the quality of the infants' general movements (GMs) according to Prechtl and a detailed motor optimality score. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for abnormal GM quality in the SSRI and non-SSRI groups, and adjusted for maternal depression, anxiety, and other confounders. The study was registered under 53506435 in the ISRCTN. FINDINGS: All infants were born around term. During the first week, abnormal GMs occurred more frequently in the SSRI group than in the non-SSRI group (59% versus 33%) and the median MOS was lower (13 versus 18). The OR for abnormal GMs in the SSRI versus the non-SSRI group was 3.0 (95% CI, 1.3 to 6.9) and increased after adjustment for confounders. At three to four months, more SSRI-exposed infants had monotonous movements (48% versus 20%) with lower median MOSs (26 versus 28). The OR for monotonous movements was 3.5 (95% CI, 1.5 to 8.6) and increased after adjusting for confounders. INTERPRETATION: Prenatal exposure to SSRI had an adverse effect on early neurological functioning as reflected by GM quality, irrespective of maternal depression and anxiety, and other confounders. Physicians should take this into account in consultation with parents.

128. Waldmeier S, Grunt S, Delgado-Eckert E, Latzin P, Steinlin M, Fuhrer K, Frey U.
Correlation properties of spontaneous motor activity in healthy infants: a new computer-assisted method to evaluate neurological maturation.
Exp Brain Res 2013; 227: 433-446. 

Qualitative assessment of spontaneous motor activity in early infancy is widely used in clinical practice. It enables the description of maturational changes of motor behavior in both healthy infants and infants who are at risk for later neurological impairment. These assessments are, however, time-consuming and are dependent upon professional experience. Therefore, a simple physiological method that describes the complex behavior of spontaneous movements (SMs) in infants would be helpful. In this methodological study, we aimed to determine whether time series of motor acceleration measurements at 40-44 weeks and 50-55 weeks gestational age in healthy infants exhibit fractal-like properties and if this self-affinity of the acceleration signal is sensitive to maturation. Healthy motor state was ensured by General Movement assessment. We assessed statistical persistence in the acceleration time series by calculating the scaling exponent α via detrended fluctuation analysis of the time series. In hand trajectories of SMs in infants we found a mean α value of 1.198 (95 % CI 1.167-1.230) at 40-44 weeks. Alpha changed significantly (p = 0.001) at 50-55 weeks to a mean of 1.102 (1.055-1.149). Complementary multilevel regression analysis confirmed a decreasing trend of α with increasing age. Statistical persistence of fluctuation in hand trajectories of SMs is sensitive to neurological maturation and can be characterized by a simple parameter α in an automated and observer-independent fashion. Future studies including children at risk for neurological impairment should evaluate whether this method could be used as an early clinical screening tool for later neurological compromise.

127. Brogna C, Romeo DM, Cervesi C, Scrofani L, Romeo MG, Mercuri E, Guzzetta A.
Prognostic value of the qualitative assessments of general movements in late-preterm infants.
Early Hum Dev 2013; 89: 1063-1066.

BACKGROUND: The quality of general movements (GMs) and its predictive value have never been evaluated in late-preterm (LP) infants. AIMS: To determine the characteristics of GMs and their predictive value for neurodevelopmental outcome in a cohort of infants born between 34 and 36weeks' gestation. STUDY DESIGN AND SUBJECTS: 574 LP infants were examined using the standard methodological principles of Prechtl's method for assessing GMs both during writhing and fidgety periods. OUTCOME MEASURES: Infants were assessed at 2years of age with neuromotor and developmental scales. RESULTS: A significant correlation was found between GMs and outcome both at writhing (rs 0.68; p<0.001) and at fidgety age (rs 0.78; p<0.001). The assessment at 1month showed 100% sensitivity and 86% specificity of predicting the development of cerebral palsy (CP), that at 3months was 100% sensitivity and 97% specificity. CONCLUSIONS: During the fidgety age GMs predict CP with very high sensitivity and specificity. The qualitative assessment of GMs should be employed to help identify LP infants who require early intervention for neurological abnormalities.

126. Spittle AJ, Spencer-Smith MM, Cheong JL, Eeles AL, Lee KJ, Anderson PJ, Doyle LW.
General movements in very preterm children and neurodevelopment at 2 and 4 years.
Pediatrics 2013; 132(2): e452-458.

OBJECTIVE: Although ∼50% of very preterm (VP) children have neurodevelopmental impairments, early prediction of infants who will experience problems later in life remains a challenge. This study evaluated the predictive value of general movements (GM; spontaneous and endogenous movements) at 1 and 3 months' corrected age for neurodevelopment at 2 and 4 years of age in VP children. METHODS: At 1 and 3 months' corrected age, infants born <30 weeks' gestation had GM assessed as normal or abnormal. Motor, cognitive, and language development at 2 years was assessed by using the Bayley Scales of Infant and Toddler Development, Third Edition. At 4 years, cognitive and language outcomes were assessed by using the Differential Ability Scale-Second Edition and motor outcomes with the Movement Assessment Battery for Children-Second Edition; a diagnosis of cerebral palsy was documented. RESULTS: Ninety-nine VP infants were recruited, with 97% and 88% of survivors followed up at age 2 and 4 years, respectively. Abnormal GM at 1 month were associated with worse motor outcomes at 2 and 4 years but not language or cognitive outcomes. Abnormal GM at 3 months were associated with worse motor, cognitive, and language outcomes at both 2 and 4 years. Overall, GM at 1 month demonstrated better sensitivity to impairments at 2 and 4 years, whereas GM at 3 months had better specificity and were more accurate overall at distinguishing between children with and without impairment. CONCLUSIONS: Abnormal GM in VP infants, particularly at 3 months postterm, are predictive of worse neurodevelopment at ages 2 and 4 years.

125. Fjørtoft T, Grunewaldt KH, Løhaugen GC, Mørkved S, Skranes J, Evensen KA.  
Assessment of motor behaviour in high-risk-infants at 3months predicts motor and cognitive outcomes in 10years old children. 
Early Hum Dev 2013; 89: 787-793. 

BACKGROUND: The general movement assessment has mainly been used to identify children with cerebral palsy (CP). A detailed assessment of quality of infant motor repertoire using parts of the "Assessment of Motor Repertoire - 3 to 5 Months" which is based on Prechtl's general movement assessment can possibly identify later motor and cognitive problems in children without CP. AIMS: This study aims to determine whether analysis of quality of infant motor repertoire has predictive value for motor and cognitive outcomes at age 10 in children at risk for later neurological impairment. STUDY DESIGN: A longitudinal study design was used. SUBJECTS: Video-recordings of 40 "neurologically high-risk" infants at 14weeks post-term age were analysed with respect to motor repertoire. OUTCOME MEASURES: Fidgety movements were classified as present or absent. Quality of concurrent motor repertoire was classified as normal if smooth and fluent and abnormal if jerky, monotonous or stiff. Poor motor outcome was defined as a score ≤5th centile on the Movement-Assessment-Battery-2, while poor cognitive outcome as total IQ <85 on Wechsler Intelligence Scale-III. RESULTS: Among the high-risk children with presence of fidgety movements, poor motor and/or cognitive outcome at 10years was identified by abnormal concurrent motor repertoire at 14weeks post-term age in 86% (95% CI: 0.60-0.96) of the children. On the other hand, 71% (95% CI: 0.47-0.87) of those with normal motor and cognitive outcomes were identified by presence of fidgety movements and normal motor repertoire. CONCLUSIONS: Assessment of quality of infant motor repertoire may be a valuable early clinical marker for later impaired motor and cognitive outcomes in high-risk children who do not develop CP.

124. Einspieler C, Marschik PB.
Complementary thinking: future perspectives on the assessment of general movements.
Dev Med Child Neurol 2013; 55: 682-683.

123. Kanemaru N, Watanabe H, Kihara H, Nakano H, Takaya R, Nakamura T, Nakano J, Taga G, Konishi Y.
Specific characteristics of spontaneous movements in preterm infants at term age are associated with developmental delays at age 3 years.
Dev Med Child Neurol 2013; 55: 713-721.

AIM: The aim of this study was to investigate the relationship between the characteristics of spontaneous movements in preterm infants at term age and developmental delay at 3 years of age. METHOD: We analysed video recordings of the spontaneous movements in the supine position of 124 preterm infants (44 males, 80 females) at 36 to 44 weeks postmenstrual age (PMA). The infants were born preterm (22-36wks PMA; birthweight 489-1696g) and had not received a diagnosis of a neurological or developmental disorder by the age of 3 years. The recorded spontaneous movements were quantified using six movement indices, which were calculated from two-dimensional trajectories of all limbs. The infants were divided into three developmental groups, normal, borderline, or delayed, based on their developmental quotient as calculated using the Kyoto Scale of Psychological Development 2001 (Kyoto Scale) at 3 years of age. Group differences in the movement indices were analysed. RESULTS: In the delayed group, average velocity of arms and legs were significantly lower (p<0.05 and p<0.01 respectively), the numbers of movement units of arms and legs were significantly lower (p<0.05 and p<0.01 respectively), kurtosis of acceleration of arms and legs was significantly higher (p<0.05 in each case), and correlation between limb velocities was higher (p<0.05) than in the normal group. INTERPRETATION: In children who exhibited developmental delay at 3 years of age, the spontaneous movements at term age can be described as less active with intermittent occurrences of abrupt and synchronized movements of the limbs. Recognition of these characteristics of spontaneous movements at term age may be used as a predictor for subsequent cognitive and behavioural development in preterm infants.

122. Marschik PB, Soloveichick M, Windpassinger C, Einspieler C.
General movements in genetic disorders: A first look into Cornelia de Lange syndrome.
Dev Neurorehabil 2013; Dec 4. [Epub ahead of print]

The assessment of General Movements (GMs), i.e. age-specific motor patterns during the first months of life, has repeatedly proven to be a valuable tool to predict neurodevelopmental outcomes. Abnormal spontaneous GMs were found to be among the most reliable markers for cerebral palsy. To add to the knowledge of the abnormal early motor repertoire we analysed prospectively collected video recordings of a boy clinically diagnosed with Cornelia de Lange syndrome. The observed atypical GMs are a further step to disentangle early motor peculiarities in the light of the genetic impact on the developing brain.

121. Adde L, Helbostad J, Jensenius AR, Langaas M, Støen R.
Identification of fidgety movements and prediction of CP by the use of computer-based video analysis is more accurate when based on two video recordings.
Physiother Theory Pract 2013, 29: 469-475. 

This study evaluates the role of postterm age at assessment and the use of one or two video recordings for the detection of fidgety movements (FMs) and prediction of cerebral palsy (CP) using computer vision software. Recordings between 9 and 17 weeks postterm age from 52 preterm and term infants (24 boys, 28 girls; 26 born preterm) were used. Recordings were analyzed using computer vision software. Movement variables, derived from differences between subsequent video frames, were used for quantitative analysis. Sensitivities, specificities, and area under curve were estimated for the first and second recording, or a mean of both. FMs were classified based on the Prechtl approach of general movement assessment. CP status was reported at 2 years. Nine children developed CP of whom all recordings had absent FMs. The mean variability of the centroid of motion (C(SD)) from two recordings was more accurate than using only one recording, and identified all children who were diagnosed with CP at 2 years. Age at assessment did not influence the detection of FMs or prediction of CP. The accuracy of computer vision techniques in identifying FMs and predicting CP based on two recordings should be confirmed in future studies.

120. Skiöld B, Eriksson C, Eliasson AC, Adén U, Vollmer B.
General movements and magnetic resonance imaging in the prediction of neuromotor outcome in children born extremely preterm.
Early Hum Dev 2013, 89: 467-472.

BACKGROUND: Extremely preterm (EPT) birth is a major risk factor for brain injury and neurodevelopmental impairment. Reliable tools for early prediction of outcome are warranted. AIM: To investigate the predictive value of general movements (GMs) at "fidgety age" for neurological outcome at age 30months in EPT infants, both in comparison and in combination with structural magnetic resonance imaging (MRI) at term equivalent age (TEA). STUDY DESIGN: Fifty-three infants born <27weeks of gestation were included prospectively. MRI was performed at TEA and images were evaluated for white and grey matter abnormalities. GMs were assessed at age 3months corrected ("fidgety age"). OUTCOME MEASURES: Neuromotor outcome was assessed at age 30months corrected. Children were classified as having a normal neurological status, unspecific signs, or cerebral palsy (CP). RESULTS: Abnormal GMs were a common finding, seen in 32% (17/53) of infants. Of these, six infants (11%) had definitely abnormal GMs. Four infants (8%) had a diagnosis of CP at follow up. Definitely abnormal GMs were significantly associated to CP at 30months (Fisher's Exact test p=0.03, sensitivity 50%, specificity 92%). Moderate-severe white matter abnormalities on MRI were more strongly associated with CP (Fisher's Exact test p<0.001, sensitivity 100%, specificity 98%) than GMs. Combining GMs with MRI-findings at TEA increased the predictive specificity to 100% (Fisher's Exact test, p=0.005), whereas sensitivity remained unchanged. CONCLUSIONS: The presence of definitely abnormal GMs was predictive of CP: prediction was significantly enhanced when the GMs assessment was combined with findings from MRI obtained at TEA.

119. Palchik AB, Einspieler C, Evstafeyeva IV, Talisa VB, Marschik PB.
Intra-uterine exposure to maternal opiate abuse and HIV: the impact on the developing nervous system.
Early Hum Dev 2013, 89: 229-235. 

BACKGROUND: Both intra-uterine exposure to maternal drugs and HIV are known to adversely affect the developing central nervous system. AIMS: (1) To describe the quality of GMs in infants who were intra-uterinely exposed to maternal opiate abuse and HIV; and (2) to analyze to what extent (a) perinatal events, (b) status of HIV-infection, and (c) the quality of GMs are associated with the neurodevelopmental outcome at 2 to 3years of age. PATIENTS AND METHOD: Seventy-seven children intra-uterinely exposed to both maternal opiate abuse and HIV in utero (41 boys and 36 girls; 39 born preterm) were videoed twice: first during the first 2months after term (writhing GMs) and again at 3-5months (fidgety GMs). Neurodevelopmental outcome was assessed at 2-3years of age. RESULTS: Thirty-eight infants showed abnormal writhing GMs; 25 infants had abnormal or absent fidgety movements; 22 children had an adverse neurodevelopmental outcome. The association between GM trajectories and outcome revealed a Cramer-V=0.75 (p<0.001). Those infants with active HIV-infection (n=10) did not differ from the 67 infants who were HIV-exposed but uninfected with respect to their GM quality or outcome. CONCLUSIONS: Serial assessment of GMs in infants who were intra-uterinely exposed to maternal opiates and to HIV can be utilized for early identification of infants at a higher risk for later deficits and needing early intervention.

118. Li N, Jia FY, Du L.
[The assessment of general movements: a reliable tool for predicting the neurodevelopment of preterm infants in an very early phase]. [Article in Chinese]
Zhongguo Dang Dai Er Ke Za Zhi 2013, 15: 317-320.

Cerebral palsy (CP) is a permanent disorder in the development of movement and posture in the developing infant brain and is one of the major disabilities that result from extremely preterm birth. Early identification of possible neurodevelopmental injury offers the opportunity to deliver intervention at a very early age and thus prevent severe disability. The assessment of general movements (GMs), has emerged as a reliable and valid predictor of severe neurologic deficits in infants. This method is based on a visual Gestalt perception of the quality of GMs in the preterm and term periods, and postterm up to 5 months. The quality of "fidgety movements" is the most valuable marker for predicting neurologic outcomes.

117. Bosanquet 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: 418-426. 

AIM: This systematic review evaluates the accuracy of predictive assessments and investigations used to assist in the diagnosis of cerebral palsy (CP) in preschool-age children (<5 y). METHOD: Six databases were searched for studies that included a diagnosis of CP validated after 2 years of age. The validity of the studies meeting the criteria was evaluated using the Standards for Reporting Diagnostic Accuracy criteria. Where possible, results were pooled and a meta-analysis was undertaken. RESULTS: Nineteen out of 351 studies met the full inclusion criteria, including studies of general movements assessment (GMA), cranial ultrasound, brain magnetic resonance imaging (MRI), and neurological examination. All studies assessed high-risk populations including preterm (gestational range 23-41 wks) and low-birthweight infants (range 500-4350 g). Summary estimates of sensitivity and specificity of GMA were 98% (95% confidence interval [CI] 74-100%) and 91% (95% CI 83-93%) respectively; of cranial ultrasound 74% (95% CI 63-83%) and 92% (95% CI 81-96%) respectively; and of neurological examination 88% (95% CI 55-97%) and 87% (95% CI 57-97%) respectively. MRI performed at term corrected age (in preterm infants) appeared to be a strong predictor of CP, with sensitivity ranging in individual studies from 86 to 100% and specificity ranging from 89 to 97% There was inadequate evidence for the use of other predictive tools. SUMMARY: This review found that the assessment with the best evidence and strength for predictive accuracy is the GMA. MRI has a good predictive value when performed at term-corrected age. Cranial ultrasound is as specific as MRI and has the advantage of being readily available at the bedside. Studies to date have focused on high-risk infants. The accuracy of these tests in low-risk infants remains unclear and requires further research.

116. Hitzert MM, Bos AF, Bergman KA, Veldman A, Schwarz G, Santamaria-Araujo JA, Heiner-Fokkema R, Sival DA, Lunsing RJ, Arjune S, Kosterink JG, van Spronsen FJ.
Favorable outcome in a newborn with molybdenum cofactor type A deficiency treated with cPMP.
Pediatrics 2012, 130: e1005-1010. 

Molybdenum cofactor deficiency (MoCD) is a lethal autosomal recessive inborn error of metabolism with devastating neurologic manifestations. Currently, experimental treatment with cyclic pyranopterin monophosphate (cPMP) is available for patients with MoCD type A caused by a mutation in the MOCS-1 gene. Here we report the first case of an infant, prenatally diagnosed with MoCD type A, whom we started on treatment with cPMP 4 hours after birth. The most reliable method to evaluate neurologic functioning in early infancy is to assess the quality of general movements (GMs) and fidgety movements (FMs). After a brief period of seizures and cramped-synchronized GMs on the first day, our patient showed no further clinical signs of neurologic deterioration. Her quality of GMs was normal by the end of the first week. Rapid improvement of GM quality together with normal FMs at 3 months is highly predictive of normal neurologic outcome. We demonstrated that a daily cPMP dose of even 80 μg/kg in the first 12 days reduced the effects of neurodegenerative damage even when seizures and cramped-synchronized GMs were already present. We strongly recommend starting cPMP treatment as soon as possible after birth in infants diagnosed with MoCD type A.

115. Sustersic B, Sustar K, Paro-Panjan D.
General movements of preterm infants in relation to their motor competence between 5 and 6 years.
Eur J Paediatr Neurol 2012, 16: 724-729. 

BACKGROUND: The criteria for identification of children with high risk of cerebral palsy are well documented, but the early identification of children at highest risk of minor motor deficits remains less clear. AIM: To analyze the correlation between the quality of general movements (GMs) from term to twenty weeks postterm age and the motor competence between 5 and 6 years of age. METHODS: In the group of 45 preterm infants, the quality of GMs was assessed using Prechtl's method. The Movement Assessment Battery for Children (M-ABC) was used to test motor competence between 5 and 6 years of age. The correlations between GMs and M-ABC results were analyzed. RESULTS: During writhing period, the sensitivity of GMs to identify children with definite motor problem was 0.86 for total impairment, 0.67 for manual dexterity, 0.89 for ball skills and 0.92 for balance. During fidgety period, the sensitivity was higher than during the writhing period: 1.00 for total impairment, 1.00 for manual dexterity, 1.00 for ball skills and 0.83 for balance, respectively. The specificity was low at both ages (total scoring 0.24 at term and 0.21 at 3 months corrected age). CONCLUSION: The sensitivity of GMs to identify children with definite motor problems is higher at the fidgety than at the writhing period. The specificity of GMs at the term and fidgety age to predict later motor abilities is low.

114. Hitzert MM, Benders MJ, Roescher AM, van Bel F, de Vries LS, Bos AF.
Hydrocortisone vs. dexamethasone treatment for bronchopulmonary dysplasia and their effects on general movements in preterm infants.
Pediatr Res 2012; 71: 100-106. 

INTRODUCTION: Hydrocortisone (HC) and dexamethasone (DXM) are used to treat preterm infants at risk for bronchopulmonary dysplasia (BPD). This may, however, affect their long-term neurological development. We aimed to determine the effect of HC and DXM therapy in preterm infants on neurological functioning as assessed by the quality of general movements (GMs) until 3 months after term. RESULTS: We found no difference in the quality of GMs between HC and DXM infants until term age. At 3 months, HC infants had a higher median motor optimality score (MOS) than DXM infants (25 vs. 21, P = 0.015). In the DXM group, MOS on the first day of treatment was lower than before treatment (10 vs. 11, P = 0.030). DISCUSSION: MOS decreased in DXM infants on the first day following treatment and at 3 months after term. This was not the case in HC infants. Our study suggests that neurological functioning at 3 months after term is better in infants treated with HC than in infants treated with DXM. METHODS: We performed a longitudinal, observational study including 56 preterm infants (n = 17 HC, n = 17 DXM, n = 22 controls). GM quality, videoed before and after treatment, was assessed. In addition, a MOS was assigned to details of the GMs. 

113. Kanemaru N, Watanabe H, Taga G.
Increasing selectivity of interlimb coordination during spontaneous movements in 2- to 4-month-old infants.
Exp Brain Res 2012; 218: 49-61. 

In the field of motor development, a question exists whether spontaneous activity in early infancy serves as a precursor to later-emerging goal-directed behaviors. To answer this question, it is necessary to investigate in detail the properties of spontaneous movements in individual infants. In the current study, we longitudinally examined the spontaneous movements of the end points of the limbs in 6 infants aged 2-4 months. Examinations were carried out every week by using a motion analysis system, and the number of recordings performed for each infant varied from 6 to 9 times. Our major finding was that there was an age-related increase in the velocity and position correlation between arms and between legs, whereas there was no significant change in the velocity, duration, and amplitude of movements of individual limbs. That is, the pattern of spontaneous movements changes from a general activity involving all the limbs to an activity involving more selective interlimb coordination from 2 to 4 months of age. These findings suggest that the dissociated movements of a selective combination of arms or legs during spontaneous movements may be a precursor to functionally dissociated movements during goal-directed behaviors.

112. Einspieler C, Hirota H, Yuge M, Dejima S, Marschik PB.
Early behavioural manifestation of Smith-Magenis syndrome (del 17p11.2) in a 4-month-old boy.
Dev Neurorehabil 2012; 15: 313-316. 

Objective: There is little systematic data on early neurodevelopmental functioning of infants with Smith-Magenis syndrome, since early diagnosis is rare. Methods: A boy with cytogenetically confirmed Smith-Magenis syndrome was videotaped at 4 months and 1 week of age. His posture and spontaneous movements were analysed without knowing the diagnosis. Results: The motor repertoire appeared significantly reduced; fidgety general movements, which are typical of that age, were missing. Posture was abnormal and overall movements were jerky and monotonous. The findings indicate a severe motor impairment by no more than 4 months of age. Conclusion: It was concluded that an absence of fidgety movements that goes along with subtle dysmorphic features indicates an increased risk of maldevelopment and justifies the need to refer for genetic evaluation with the potential of facilitating earlier diagnosis.

111. Buitenhuis S, van Wijlen-Hempel RS, Pondaag W, Malessy MJ.
Obstetric brachial plexus lesions and central developmental disability.
Early Hum Dev 2012; 88: 731-734. 

AIMS: First, to assess whether children with an Obstetric Brachial Plexus Lesion (OBPL) have a higher incidence of Central Developmental Disability (CDD) compared to the general population. Second, to test the ability of General Movements (GMs) to identify CDD children already at three months of age. STUDY DESIGN: A prospective cohort study for infants referred to our tertiary nerve lesion clinic. SUBJECTS: A prospective cohort study of 38 infants with OBPL followed until 5years (mean age). OUTCOME: Measures quality of fidgety GMs at 3months; presence or absence of CDD at a mean age of 5years; severity of the brachial plexus lesion. RESULTS: Five patients (13%) had CDD: one patient had a cerebral palsy and four showed definite other motor and/or mental problems. There was no correlation between the quality of the GMs at three months and CDD. There was no correlation between the severity of the nerve lesion and CDD. We found a correlation between quality of the GMs and severity of the nerve lesion. CONCLUSION: Children with OBPL have a high incidence of CDD. In our cohort fidgety GMs had no predictive value for CDD at a later age.

110. Nieuwenhuis T, da Costa SP, Bilderbeek E, Geven WB, van der Schans CP, Bos AF.
Uncoordinated Sucking Patterns in Preterm Infants are Associated with Abnormal General Movements.
J Pediatr 2012; 161: 792-798.

OBJECTIVE: To examine the association between sucking patterns and the quality of fidgety movements in preterm infants. STUDY DESIGN: We studied the sucking patterns and fidgety movements of 44 preterm infants (gestational age <35 weeks) longitudinally from 34 weeks' postmenstrual age up to 14 weeks postterm. We used the Neonatal Oral-Motor Assessment Scale during feeding and scored the sucking patterns as normal or abnormal. Abnormal sucking patterns were categorized into arrhythmic sucking and uncoordinated sucking. At 14 weeks postterm, we scored the quality of fidgety movements from videotapes as normal, abnormal, or absent. RESULTS: The postmenstrual age at which sucking patterns became normal (median, 48 weeks; range, 34 to >50 weeks) was correlated with the quality of fidgety movements (Spearman ρ = -0.33; P = .035). The percentage per infant of normal and uncoordinated sucking patterns was also correlated with the quality of fidgety movements (ρ = 0.31; P = .048 and ρ = -0.33; P = .032, respectively). Infants with uncoordinated sucking patterns had a higher rate of abnormal fidgety movements (OR, 7.5; 95% CI, 1.4-40; P = .019). CONCLUSION: The development of sucking patterns in preterm infants was related to the quality of fidgety movements. Uncoordinated sucking patterns were associated with abnormal fidgety movements, indicating that uncoordinated sucking, swallowing, and breathing may represent neurologic dysfunction.

109. Ferrari F, Gallo C, Pugliese M, Guidotti I, Gavioli S, Coccolini E, Zagni P, Casa ED, Rossi C, Lugli L, Todeschini A, Ori L, Bertoncelli N.
Preterm birth and developmental problems in the preschool age Part I: Minor motor problems.
J Matern Fetal Neonatal Med 2012; 25: 2154-2159.

Nearly half of very preterm (VP) and extremely preterm (EP) infants suffers from minor disabilities. The paper overviews the literature dealing with motor problems other than cerebral palsy (CP) during infancy and preschool age. The term "minor motor problems" indicates a wide spectrum of motor disorders other than CP; "minor" does not mean "minimal", as a relevant proportion of the preterm infants will develop academic and behavioural problems at school age. Early onset disorders consist of abnormal general movements (GMs), transient dystonia and postural instability; these conditions usually fade during the first months. They were underestimated in the past; recently, qualitative assessment of GMs using Prechtl's method has become a major item of the neurological examination. Late onset disorders include developmental coordination disorder (DCD) and/or minor neurological dysfunction (MND): both terms cover partly overlapping problems. Simple MND (MND-1) and complex MND (MND-2) can be identified and MND-2 gives a higher risk for learning and behavioural disorders. A relationship between the quality of GMs and MND in childhood has been recently described. The Touwen infant neurological examination (TINE) can reliably detect neurological signs of MND even in infancy. However, the prognostic value of these disorders requires further investigations.

108. Noble Y, Boyd R.
Neonatal assessments for the preterm infant up to 4 months corrected age: a systematic review.
Dev Med Child Neurol 2012; 54: 129-139.
 

Aim: The aim of this study was to systematically review the clinimetric properties of longitudinal neonatal neurobehavioural and neuromotor assessments for preterm infants. Method: Twenty-seven assessment measures were identified. The following eight measures met the study inclusion criteria: Assessment of Preterm Infants' Behaviour (APIB), Neonatal Intensive Care Unit Network Neurobehavioural Scale (NNNS), Test of Infant Motor Performance (TIMP), Prechtl's Assessment of General Movements (GMs), Neurobehavioural Assessment of the Preterm Infant (NAPI), Dubowitz Neurological Assessment of the Preterm and Full-term Infant (Dubowitz), Neuromotor Behavioural Assessment (NMBA), and the Brazelton Neonatal Behavioural Assessment Scale (NBAS). The primary purposes included prediction (TIMP, GMs, Dubowitz), discrimination (all assessments), and evaluation of change (TIMP, NAPI). Measures of assessment were included in the study if they were (1) primarily neurobehavioural or neuromotor assessments that were suitable for use with preterm infants (<37 weeks gestation) up to 4 months corrected age and were discriminative, predictive, or evaluative; (2) standardized procedures designed for serial/longitudinal use; or (3) criterion or norm referenced. However, all assessment tools that were not published in English in a peer-reviewed journal or were primarily neurological assessments, one-time evaluations, screening tools, or not commercially available were not used. Results: All of the measures included in the review demonstrated adequate content and construct validity. Concurrent validity was reported for APIB, NNNS, Dubowitz, and GMs. Predictive validity was high for GMs with studies reporting up to 100% senstivity for predicting cerebral palsy at the age of 12 to 24 months. Interrater reliability was strong for the TIMP (intraclass correlation=0.95), GMs (K=0.8), and moderate for the NAPI (r=0.67-0.97). Clinical utility was variable for ease of scoring, interpretability, cost, and access. Interpretation: In the absence of a criterion standard for neonatal neuromotor assessments, the NNNS and APIB have strong psychometric qualities with better utility for research. Similarly, the GMs, TIMP, and NAPI have strong psychometric qualities but better utility for clinical settings. The GMs has best prediction of future outcome and the TIMP has best evaluative validity.

107. Manacero SA, Marschik PB, Nunes ML, Einspieler C.
Is it possible to predict the infant's neurodevelopmental outcome at 14months of age by means of a single preterm assessment of General Movements?
Early Hum Dev 2012; 88: 39-43. 

BACKGROUND: It continues to be a challenge for clinicians to identify preterm infants likely to experience subsequent neurodevelopmental deficits. The Test of Infant Motor Performance (TIMP) and the assessment of spontaneous general movements (GMs) are the only reliable diagnostic and predictive tools for the functionality of the developing nervous system, if applied before term. AIM: To determine to what extent singular preterm assessments of motor performance can predict the neurodevelopmental outcome in 14-month olds. METHODS: Thirty-seven preterm infants born <34weeks gestational age were recruited for the study at the NICU of the São Lucas University Hospital, Porto Alegre, RS, Brazil. At 34weeks, their GMs were assessed; and the Test of Infant Motor Performance (TIMP) was applied. A prospective design was used to examine (A) the association between the GM assessment and the TIMP; and (B) the relation between GMs or the TIMP and the developmental status at 14months, assessed by means of Alberta Infant Motor Scales (AIMS) and the Pediatric Evaluation of Disability Inventory (PEDI). RESULTS: Nineteen infants (41%) had abnormal GMs; only one scored within the TIMP average range. Hence, GMs and TIMP were not related. Children with cramped-synchronized GMs at 34weeks preterm had a lower AIMS centile rank than those with poor repertoire or normal GMs. There was a marginal association between cramped-synchronized GMs and a lower PEDI mobility score. CONCLUSIONS: A single preterm GM assessment is only fairly to moderately associated with the 14-month motor development. The TIMP is not suitable as a complementary assessment tool at such a young age.

106. Beccaria E, Martino M, Briatore E, Podestà B, Pomero G, Micciolo R, Espa G, Calzolari S.
Poor repertoire General Movements predict some aspects of development outcome at 2years in very preterm infants.
Early Hum Dev 2012; 88: 393-396.

BACKGROUND: Observation of the quality of endogenously generated "General Movements" has been proved to be a reliable and sensitive tool in the assessment of fragile neonates. The absence of fidgety movements at 2-4months post-term is highly predictive of Cerebral Palsy. On the contrary, the presence of a poor repertoire pattern during the writhing period is not reliable in predicting motor or neurobehavioral disorders at any stage of development. AIM: To examine if the presence of a PR pattern at 1month post-term was associated with lower neurodevelopmental quotients at 2years. STUDY DESIGN: General Movements evaluation at 1 and 3months and the Griffiths Scales of Mental Development at 2years were administered to a sample of very preterm infants. Infants were divided into two groups: poor repertoire pattern group and normal pattern group. Student's t Test and Chi squared test and ANOVA were used to compare neonatal variables and results between the two groups. SUBJECTS: 79 very preterm infants (birthweight≤1500g or gestational age≤32weeks), born January 2003 to December 2006 who had a follow-up at 2years. OUTCOME MEASURE: Griffiths developmental quotient at 2years. RESULTS: The Poor Repertoire group had lower Gestational Age, lower Birth Weight, lower Apgar scores at birth and lower Developmental Quotient at 2years. Eye and Hand Coordination (subscale D) was the domain mostly responsible for such a difference. Quality of fidgety movements (normal or abnormal fidgety) at 3months did not show any correlation with outcome measures at 2years. CONCLUSION: The presence of a PR pattern at 1month post-term seems to predict lower neurodevelopmental scores at 2years especially in the domain of eye and hand coordination. Longer follow-up is necessary in order to ascertain if such difference will continue to persist at older ages.

105. Zuk L.
Fetal and infant spontaneous general movements as predictors of developmental disabilities.
Dev Disabil Res Rev 2011, 17: 93-101. 

The challenge of identifying infants who are at risk for developmental delay and possible adverse neurodevelopmental outcome demands methods of evaluation that will lead to early intervention to minimize developmental disability and to maximize the infant's potential. A qualitative assessment of spontaneous general movements (GMs) in the preterm, term, and young infant at risk is a valid and reliable tool for evaluation (Prechtl [1990] Early Hum. Dev. 23:151-158). The aim of this review is to describe the theoretical and clinical bases for the assessment of GMs and its relationship to developmental delay and brain dysfunction. Thirty-seven studies related to the predictive validity of GMs were included in this review. Results suggested that consistent cramped synchronized GMs are highly predictive of later development of cerebral palsy. The fidgety movement quality that appears at the age of 2 to 3 months was found to be a most sensitive predictor of neurodevelopmental outcome in different populations of infants.

104. Spittle A
How do we use the assessment of general movements in clinical practice?
Dev Med Child Neurol 2011; 53: 681-682.

103. De Vries N, Bos A.
The motor repertoire of extremely low-birthweight infants at term in relation to their neurological outcome.
Dev Med Child Neurol 2011; 53: 933-937. 

AIM: The aim of this study was to assess the motor repertoire of extremely low-birthweight infants at term-equivalent age (TEA), in relation to their neurological outcome. METHOD: Using Prechtl's method, we assessed both the quality of general movements and a detailed motor optimality score in 13 extremely low-birthweight infants (four males; nine females; mean gestational age 27.9wks, SD 2.9wks; mean birthweight 798g, SD 129g) at TEA, and related them to general movements at the age of 3 months after term and neurological outcome at the age of 2 years 6 months. RESULTS: At TEA, 10 of the 13 infants had abnormal general movements. All infants showed abnormal leg lifting with extended legs; nine showed stiff movements, three showed cramped movements, and two showed cramped synchronized general movements. At 3 months, three infants still had abnormal general movements. Concurrent movements were abnormal in nine infants owing to monotony and jerkiness. Abnormal posture was seen in seven infants. None developed cerebral palsy; one infant showed cognitive and motor delay. Neurological outcome was not related to general movement quality and optimality score at TEA. INTERPRETATION: Abnormal general movements at TEA are common in extremely low-birthweight infants. General movements often appear stiff and cramped with extended legs. At the age of 3 months after term, general movements are mostly normal, but concurrent movements are not. Nevertheless, these abnormalities do not imply an impaired neurological outcome such as cerebral palsy.

102. Hamer EG, Bos AF, Hadders-Algra M.
Assessment of specific characteristics of abnormal general movements: does it enhance the prediction of cerebral palsy?
Dev Med Child Neurol 2011; 53: 751-756.

AIM: Abnormal general movements at around 3 months corrected age indicate a high risk of cerebral palsy (CP). We aimed to determine whether specific movement characteristics can improve the predictive power of definitely abnormal general movements. METHOD: Video recordings of 46 infants with definitely abnormal general movements at 9 to 13 weeks corrected age (20 males; 26 females; median gestational age 30wks; median birthweight 1200g) were analysed for the following characteristics: presence of fidgety, cramped synchronized, stiff, or jerky movements and asymmetrical tonic neck reflex pattern. Neurological condition (presence or absence of CP), gross motor development (Alberta Infant Motor Scales), quality of motor behaviour (Infant Motor Profile), functional mobility (Pediatric Evaluation of Disability Inventory), and Mental Developmental Index (Bayley Scales) were assessed at 18 months corrected age. Infants were excluded from participating in the study if they had severe congenital anomalies or if their caregivers had an insufficient knowledge of the Dutch language. RESULTS: Of the 46 assessed infants, 10 developed spastic CP (Gross Motor Function Classification System levels I to V; eight bilateral spastic CP, two unilateral spastic CP). The absence of fidgety movements and the presence of predominantly stiff movements were associated with CP (Fisher's exact test, p=0.018 and p=0.007 respectively) and lower Infant Motor Profile scores (Mann-Whitney U test, p=0.015 and p=0.022 respectively); stiff and predominantly stiff movements were associated with lower Alberta Infant Motor Scales scores (Mann-Whitney U test, p=0.01 and p=0.004 respectively). Cramped synchronized movements and the asymmetrical tonic neck reflex pattern were not related to outcome. None of the movement characteristics were associated with Pediatric Evaluation of Disability Inventory scores or the Mental Developmental Index. INTERPRETATION: The assessment of fidgety movements and movement stiffness may improve the predictive power of definitely abnormal general movements for developmental outcome. However, the presence of fidgety movements does not preclude the development of CP.

101. Darsaklis V, Snider LM, Majnemer A, Mazer B.
Predictive validity of Prechtl's Method on the Qualitative Assessment of General Movements: a systematic review of the evidence.
Dev Med Child Neurol 2011; 53: 896-906. 

AIM: The aim of this systematic review was to examine the evidence for the predictive validity of Prechtl's Method on the Qualitative Assessment of General Movements (GMsA) with respect to neurodevelopmental outcomes. METHOD: Six electronic databases (PsychINFO, Embase, Health and Psychosocial Instruments, PubMed, and AMED) were searched using the following keywords to identify all studies that examined the predictive validity of the GMsA: 'general movements', 'assessment', 'movement', 'child development', 'infant', and 'predictive value of test'. Only English- and French-language studies were included, whereas studies that focused on spontaneous mobility in preterm infants, but not necessarily the GMsA, or which did not report on the predictive value of the GMsA were excluded. A total of 39 studies were included in the final analysis. RESULTS: Studies were separated according to the age at follow-up: 12 to 23 months, 2 to 3, 4 to 11, and 12 to 18 years. All used a longitudinal cohort study design; however, the outcome measures differed greatly amongst the studies. Values for sensitivity, specificity, positive predictive value, and negative predictive value varied amongst studies. The overall trend indicated that the presence of abnormalities in the quality of fidgety movements at 12 weeks adjusted age is more predictive of adverse outcomes than abnormal writhing movements. INTERPRETATION: The GMsA demonstrates potential as a cost-effective, non-intrusive means of infant examination. However, current studies include important sources of bias. Future methodologically rigorous studies with functional outcomes are suggested.

100. Burger M, Frieg A, Louw QA.
General movements as a predictive tool of the neurological outcome in very low and extremely low birth weight infants--a South African perspective.
Early Hum Dev 2011; 87: 303-308.  

BACKGROUND: At a time of increasing demands on South African limited healthcare resources, there is a need for an assessment method that can reliably predict neurological deficits in high-risk infants at an early age. OBJECTIVE: The objective of the study is to determine whether the qualitative assessment of fidgety movements will predict the neurological outcome of very low birth weight and extremely low birth weight infants admitted to Tygerberg Children's Hospital (TCH), Cape Town, South Africa. METHODOLOGY: A prospective descriptive study was conducted using Prechtl's method of qualitative assessment of fidgety movements at three months corrected age (CA). The study sample consisted of 115 infants, with a birth weight of ≤1250 g each. At 12 months CA, the infants' final motor outcome was classified as normal, abnormal or suspect according to assessments undertaken in line with those of Amiel-Tison and Gosselin, the Peabody Developmental Motor Scale and the Alberta Infant Motor Scale (AIMS). RESULTS: A significant relationship was found (ρ<0.01) between fidgety movement outcome and the infants' final motor outcome at 12 months corrected age, with a sensitivity of ≥71%, a specificity of ≥89%, a positive predictive value of ≥80%, and a negative predictive value of ≥96%. CONCLUSIONS: The results of the study indicated that Prechtl's qualitative method of fidgety movement assessment, as used in a clinical setting, is a highly sensitive and specific predictor of neurological outcome in preterm infants, which might effectively be used at TCH.

99. Yuge M, Marschik PB, Nakajima Y, Yamori Y, Kanda T, Hirota H, Yoshida N, Einspieler C.
Movements and postures of infants aged 3 to 5 months: to what extent is their optimality related to perinatal events and to the neurological outcome?
Early Hum Dev 2011; 87: 231-237. 

BACKGROUND: The quality of spontaneous general movements (GMs), assessed in the individual infant, has emerged as one of the most reliable and valid predictors especially of severe neurological impairments. AIMS: To implement a more detailed assessment of GMs and co-existing movements and postural patterns in a rehabilitation clinic, and to examine to what extend is the optimality of movements and postures of infants aged 3 to 5 months related to perinatal events and the neurological outcome. STUDY DESIGN: Prospective study of 41 infants (15 boys and 26 girls; 11 infants born preterm) admitted to the Department of Paediatric Neurology and Rehabilitation of the St. Joseph's Hospital in Kyoto (Japan). OUTCOME MEASURES: Clinical, neurological and psychological status at age 5. RESULTS: Motor optimality at age 3 to 5 months correlated positively with neonatal optimality (r=0.48, p<0.01), especially regarding factors associated with hypoxic events. A non-optimal motor performance (lowest possible scores) predicted cerebral palsy with 100% accuracy. Other adverse outcomes such as developmental delays, developmental coordination disorders, pervasive developmental disorder or attention deficit hyperactivity disorder turned out not to be associated with early motor performance. In 13% of cases absence of fidgety movements proved to be false positives, but their normal appearance along with a smooth concurrent motor performance was solely found in infants with a normal neurological development. CONCLUSION: Assessing the quality of motor performance at age 3 to 5 months considerably improves our ability to identify infants at risk for maldevelopment.

98. Berthouze L, Mayston M.
Design and validation of surface-marker clusters for the quantification of joint rotations in general movements in early infancy.
J Biomech 2011, 44: 1212-1215.

Lack of complexity in general movements in early infancy is an important marker of potential motor disorders of neurological origin, such as cerebral palsy. Quantitative approaches to characterising this complexity are hampered by experimental difficulties in recording from infants in their first few months of life. The aim of this study was to design and validate bespoke surface-marker clusters to facilitate data acquisition and enable full quantification of joint rotations. The clusters were validated by recording the controlled movements of a soft-body dummy doll simultaneously with an optical (Qualisys) and inertial (XSens) motion capture system. The angles estimated from the optical system were compared with those measured by the inertial system. We demonstrate that the surface-marker based approach compares well with the use of an inertial system to obtain "direct" readings of the rotations whilst alleviating the issues associated with the use of an optical motion capture system. We briefly report use of this technique in 1-5 month old infants. By enabling full quantification of joint rotation, use of the custom made markers could pave the way for early diagnosis of movement disorders.  

97. Zahed-Cheikh M, Brévaut-Malaty V, Busuttil M, Monnier AS, Roussel M, Gire C.
Comparative analysis of perinatal and postnatal factors, and general movement in extremely preterm infants.
Brain Dev 2011; 33: 656-665. 

STUDY AIM: To describe general movement in extremely premature infants and examine correlations with risk factors for antenatal, perinatal, and postnatal morbidity. STUDY TYPE: Prospective, single-center study. Nineteen patients were followed up. METHODOLOGY: The infants' general movement was analyzed using video recordings. Qualitative and quantitative assessments were performed during the writhing movement (WM) period and fidgety movement (FM) period. The quality of the general movements (GMs) and the scores achieved were then correlated with antenatal, perinatal, and postnatal factors. RESULTS: Infants' motor activity fluctuated during the WM period, especially in extremely premature infants where poor repertoire is often observed. No correlations were found between WMs and obstetric factors. Gestational age correlated with WMs' quality (p=0.023). WMs correlated with factors of postnatal morbidity such as chronic lung disease (CLD) (p=0.034) and nosocomial infections (p=0.05). At 3 months corrected age, the spontaneous movement quality are correlated with neurological explorations such as US brain (p=0.032), MRI (p=0.039), EEG (p=0.036), and neurological follow-up assessments (p=0.015). CONCLUSION: Prudence must be used when performing the analysis of general movement in extremely preterm infants. WMs may be influenced by perinatal morbidity, and possibly by the severe brain immaturity of these infants. WMs correlate with CLD and nosocomial infections. Analysis of general movement in infants of 3 months corrected age is a valuable means to detect neurological disorders.

96. Bernhardt I, Marbacher M, Hilfiker R, Radlinger L.
Inter- and intra-observer agreement of Prechtl's method on the qualitative assessment of general movements in preterm, term and young infants.
Early Hum Dev 2011; 87: 633-639.

BACKGROUND: Prechtl's method on the qualitative assessment of general movements (GMs) has been shown to be a good predictor of neurological outcome. There is substantial evidence that this method has good inter- and intra-observer agreement. AIMS: We wanted to find out whether this high agreement is reproducible in the clinical setting. STUDY DESIGN: Reliability study (inter- and intra-observer agreement). SUBJECTS: Twenty video-sequences of children at the age of preterm and writhing movements (31-41 weeks postmenstrual age) and 10 video-sequences of children at the fidgety movements age (49-54 weeks postmenstrual age) were rated by five physiotherapists. OUTCOME MEASURES: Intra- and inter-observer agreements were analyzed with percentage agreement and with nominal kappa statistic with bootstrapped bias corrected 95% confidence intervals. RESULTS: We found fair to substantial inter-observer reliability for the six response categories (time-point 1(t1): median kappa 0.44, range 0.27 to 0.59, time-point 2 (t2): median kappa 0.55, range 0.41 to 0.77) and fair to almost perfect for the normal/abnormal ratings (t1: median kappa 0.53, range 0.29 to 0.61, t2: median kappa 0.63, range 0.29 to 0.85). There was statistically significant improvement from t1 to t2 for the six response categories. The intra-observer reliability for the 9-week interval was moderate to almost perfect (median kappa 0.68, range 0.41 to 0.86). CONCLUSIONS: We were not able to exactly reproduce the generally very good results. In our clinical setting now videos are evaluated by at least two trained therapists and the results are discussed, if necessary, to reach a consensus.

95. Ferrari F, Todeschini A, Guidotti I, Martinez-Biarge M, Roversi MF, Berardi A, Ranzi A, Cowan FM, Rutherford MA.
General movements in full-term infants with perinatal asphyxia are related to Basal Ganglia and thalamic lesions.
J Pediatr 2011; 158: 904-911. 

OBJECTIVE: To correlate the site and severity of brain lesions seen on magnetic resonance imaging (MRI) with the quality of general movements in term infants with hypoxic-ischemic encephalopathy (HIE) and compare the prognostic value of general movements and MRI for motor outcome. STUDY DESIGN: Early brain MRI scans in 34 term infants with HIE not treated with hypothermia were reviewed and scored for site of injury and lesion pattern by an experienced neuroradiologist. General movement quality and trajectories at 1 and 3 postnatal months were evaluated. Motor outcome was assessed at 24 months. RESULTS: MRI scores for the basal ganglia and thalami, posterior limb of the internal capsule, white matter, and cortex and lesion patterns were correlated with 1-month and 3-month general movements and general movement trajectories; central gray matter scores were correlated most strongly with cramped-synchronized general movements and abnormal motor outcome. MRI scores were 100% sensitive and 72.2% specific for motor outcome, and cramped-synchronized general movements were 100% specific and 68.7% sensitive for motor outcome. CONCLUSIONS: In term infants with HIE, the site and severity of brain lesions seen on early MRI are highly correlated with general movements. Central gray matter damage leads to cramped-synchronized general movements and poor motor outcome. Early MRI scans and general movements are complementary tools for predicting motor outcome.

94. Kodric J, Sustersic B, Paro-Panjan D.
Assessment of general movements and 2.5 year developmental outcomes: pilot results in a diverse preterm group.
Eur J Paediatr Neurol 2010; 14: 131-137.

BACKGROUND: While the predictive value of general movements for later cerebral palsy is well known, its value to predict minor neurological and developmental impairments is less clear. AIM: To analyze the results of the assessment of general movements in relation to the developmental outcome measured by the Bayley scales of infant development in a group of preterm infants. METHODS: Twenty-six preterm infants (gestational age from 23 weeks to 36 weeks) were included. The results of the assessment of general movements at term age and at 3 months corrected age were compared to the results of the mental and psychomotor developmental index of the Bayley scales assessed between two and three years of chronological age. RESULTS: Infants with normal writhing general movements achieved the highest scores on the mental and psychomotor developmental index, and those with cramped-synchronized general movements had the lowest scores. Infants with normal general movements during the fidgety period achieved the highest scores on both scales; those with an absence of fidgety movements achieved the lowest scores. We found the sensitivity of general movements to predict cognitive impairments to be 1.00 during the writhing period and 0.83 during the fidgety period; and 0.85 and 0.54, respectively, to predict motor impairments. The differences in the mental developmental index score between the groups with different qualities of general movements were significant in the writhing period and approached significance in the fidgety period, while for the psychomotor developmental index the differences between the groups with different qualities of general movements were not significant. CONCLUSION: The quality of general movements may be predictive of later development.

93. Mutlu A, Livanelioglu A, Korkmaz A.
Assessment of "general movements" in high-risk infants by Prechtl analysis during early intervention period in the first year of life.
Turk J Pediatr 2010; 52: 630-637.

This study was performed to assess the neurological status of high-risk infants by "general movements" (GMs) method and to compare it with the findings of standard clinical neurological examination and neuroimaging findings during the early rehabilitation period. Neurodevelopmental examination was performed by a neonatologist at the corrected ages of 40 weeks, and 3, 6 and 12 months. Assessment of the physiotherapist included video recording of "Prechtl Analysis of GMs" from the first week of life to the corrected age of 5 months. All infants underwent an early physiotherapy program, and follow-up examinations continued until 12 months. A percentage of agreement of 0.86 was found between cranial ultrasound imaging results and GMs and of 0.78 between neurological examination and GMs. Prechtl analysis was found to be important for detecting neurological dysfunction and differentiating normal neurological development in high-risk infants during the early intervention period. This analysis can be used complementary to other diagnostic and imaging techniques in the follow-up of preterm infants.

92. de Vries NK, Bos AF.
The quality of general movements in the first ten days of life in preterm infants.
Early Hum Dev 2010; 86: 225-229. 

BACKGROUND: The assessment of the quality of general movements (GMs) in preterm infants early in life has been used mainly to determine temporary or permanent neurological dysfunction and not to predict outcome. AIM: Assessing the quality and evolution of GMs during the first ten days of life in preterm infants, and relating them to clinical factors and neurological outcome at 24months' post-term. METHODS: Using Prechtl's method, the GM quality was assessed in 45 preterm infants on days 2, 4, 6 and 10. They were related to clinical factors and outcome. After GM assessment, an extra item was scored: chaotic features (ChF). ChF was defined as chaotic GMs or poor repertoire GMs+chaotic movements. RESULTS: Abnormal GMs were seen mostly in early recordings. A better GM trajectory correlated with a higher birth weight, a higher gestational age and a lower Nursery Neurobiologic Risk Score (NBRS). Predictive value for normal outcome of at least one normal GM was 94%. Predictive value for abnormal outcome of only abnormal GMs was 21%. ChF were seen mostly in early recordings. Occurrence of ChF on day 2 correlated with lower serum calcium. CONCLUSIONS: Preterm infants often showed abnormal GMs during the first few days. This was related mostly to a higher NBRS. Normalization of GMs during the first ten days was associated with a lower NBRS and was a reliable predictor for neurological outcome. ChFs could be a GM quality that is associated to lower calcium, indicating hyperexcitability of the nervous system.  

91. Bruggink JL, Van Braeckel KN, Bos AF.
The early motor repertoire of children born preterm is associated with intelligence at school age.
Pediatrics 2010; 125: 1356-1363

OBJECTIVE: The goal was to determine whether the quality of general movements (GMs) for preterm children had predictive value for cognitive development at school age. METHODS: In this prospective cohort study, 60 preterm infants (gestational age, median: 30.0 weeks [range: 25-33 weeks]; birth weight, median: 1130 g [range: 595-1800 g]) without cerebral palsy were studied. The quality of GMs was assessed prospectively as normal or abnormal, from video recordings that were made at regular intervals until 17 weeks after term. At 7 to 11 years, intelligence was tested by using the Wechsler Intelligence Scale for Children III, Dutch version. Total IQ (TIQ), verbal IQ (VIQ), and performance IQ (PIQ) scores were calculated. RESULTS: The median TIQ was 93 (range: 67-113), VIQ 96 (range: 68-117), and PIQ 92 (range: 65-119). Fifteen children (25%) had low TIQ scores (<85). When the quality of GMs normalized before 8 weeks after term, TIQ, VIQ, and PIQ scores were in the normal range. Consistently abnormal GMs to 8 weeks after term were associated with lower TIQ, VIQ, and PIQ scores. With correction for male gender and the educational levels of the parents, the likelihood ratio of consistently abnormal GMs for a low TIQ was 4.9 (95% confidence interval: 1.3-17.6). The model explained 22.4% of the variance. CONCLUSIONS: The quality of GMs during the early postterm period is a marker for intelligence at school age. Abnormal GMs during the early postterm period may reflect injury or developmental disruptions of brain areas involved in cognitive development.

90. Adde L, Helbostad JL, Jensenius AR, Taraldsen G, Grunewaldt KH, Støen R.
Early prediction of cerebral palsy by computer-based video analysis of general movements: a feasibility study.
Dev Med Child Neurol 2010; 52: 773-778. 

AIM: The aim of this study was to investigate the predictive value of a computer-based video analysis of the development of cerebral palsy (CP) in young infants. METHOD: A prospective study of general movements used recordings from 30 high-risk infants (13 males, 17 females; mean gestational age 31wks, SD 6wks; range 23-42wks) between 10 and 15 weeks post term when fidgety movements should be present. Recordings were analysed using computer vision software. Movement variables, derived from differences between subsequent video frames, were used for quantitative analyses. CP status was reported at 5 years. RESULTS: Thirteen infants developed CP (eight hemiparetic, four quadriparetic, one dyskinetic; seven ambulatory, three non-ambulatory, and three unknown function), of whom one had fidgety movements. Variability of the centroid of motion had a sensitivity of 85% and a specificity of 71% in identifying CP. By combining this with variables reflecting the amount of motion, specificity increased to 88%. Nine out of 10 children with CP, and for whom information about functional level was available, were correctly predicted with regard to ambulatory and non-ambulatory function. INTERPRETATION: Prediction of CP can be provided by computer-based video analysis in young infants. The method may serve as an objective and feasible tool for early prediction of CP in high-risk infants.

89. Rosier-van Dunné FM, van Wezel-Meijler G, Bakker MP, de Groot L, Odendaal HJ, de Vries JI.
General movements in the perinatal period and its relation to echogenicity changes in the brain.
Early Hum Dev 2010; 86: 83-86.
BACKGROUND: In preterm born infants abnormal general movements (GMs) generally normalize before three months post term, but may persist when perinatal brain injury is present. AIMS: To assess the continuity of GM quality from fetal to early neonatal period and its relation to brain echogenicity changes. STUDY DESIGN: Prospective study examining GMs and three vulnerable brain areas before and 7days after birth. The quality of GMs was classified as normal or abnormal by Gestalt-perception. The brain was examined for moderate echogenicity changes (periventricular: brighter than choroid plexus, intraventricular: filling equal or more than 50% of the ventricle, and locally increased basal ganglia/thalami). SUBJECTS: 94 fetuses from pregnancies complicated by preterm hypertensive disorders or labour at a gestational age between 26 and 34weeks. OUTCOMES MEASURES: Correlations of fetal GMs, echogenicity changes, and clinical parameters (e.g. gestational age, parity, hypertensive disorders or preterm labour, oligohydramnios and fetal growth restriction) with neonatal GMs. RESULTS: Fetal GMs were abnormal in 64%, normalizing in 68% within 7days after birth. Fetal GMs were significantly related to postnatal GMs (p=0.045). Moderate fetal brain echogenicity changes and clinical parameters were not significantly related to neonatal GM. CONCLUSIONS: In this population of pregnancies compromised by hypertensive disorders or preterm labour fetal GMs correlated with neonatal GMs. Presence of moderate echogenicity changes in the fetal brain was not related to neonatal GMs.
  
88. Spittle AJ, Doyle LW, Anderson PJ, Inder TE, Lee KJ, Boyd RN, Cheong JL.
Reduced cerebellar diameter in very preterm infants with abnormal general movements.
Early Hum Dev 2010; 86: 1-5.

BACKGROUND: Abnormal General Movements (GMs) early in life are predictive of later neuromotor deficits and are related to white matter abnormalities on magnetic resonance imaging (MRI). However, other structural correlates of abnormal GMs have not been defined. AIMS: The objective of this study was to explore brain-metrics (linear brain measurements on MRI representative of 3-D brain volumes) at term as a predictor of abnormal GMs at 1 and 3months' corrected age in preterm infants. It was hypothesized that abnormal GMs would be related to reduced brain-metrics in primary motor areas, namely the cerebellum and parietal lobes. STUDY DESIGN: Eighty three preterm infants (<30weeks' gestational age) were scanned at term-equivalent age. MRI was assessed for white matter abnormality and brain-metrics in six predefined brain regions (i.e. bifrontal, biparietal, lateral ventricles and transverse cerebellar diameters, and inter-hemispheric distance). OUTCOME MEASURES: At 1 and 3months' corrected age infants' GMs were assessed from video-taped footage and rated as normal or abnormal using standardized methodology. RESULTS: At 1month, 63% (n=52) of infants had abnormal GMs with no association between any of the brain-metrics and abnormal GMs. At 3months, 23% (n=18) of infants had abnormal GMs (absent fidgety movements n=18; abnormal fidgety movements n=0). Reduced bifrontal, biparietal, and cerebellar transverse diameters, along with an increase in lateral ventricle sizes were associated with an increased risk of abnormal GMs at 3months' corrected age. After controlling for white matter abnormality and grade III/IV intraventricular haemorrhage, only the cerebellar transverse diameter was predictive of abnormal GMs at 3months. CONCLUSIONS: Reduced cerebellar diameter at term equivalent age is related to abnormal GMs at 3months' corrected age, independent of white matter abnormality and intraventricular haemorrhage.

87. Bruggink JL, Einspieler C, Butcher PR, Stremmelaar EF, Prechtl HF, Bos AF.
Quantitative aspects of the early motor repertoire in preterm infants: do they predict minor neurological dysfunction at school age?
Early Hum Dev 2009; 85: 25-36. 

BACKGROUND: Qualitative aspects of the motor repertoire, at 11-16 weeks post-term are predictive for minor neurological dysfunction (MND) at 7 to 11 years of age. Predictive value of quantitative aspects is unknown so far. AIM: To investigate whether quantitative aspects of the motor repertoire between 6 and 24 weeks post-term also have predictive value for neurological outcome at 7 to 11 years of age. STUDY DESIGN: Prospective cohort study. SUBJECTS: Preterm infants from whom several quantitative aspects of the motor repertoire were assessed between 6 and 24 weeks post-term. OUTCOME MEASURES: Neurological outcome at 7-11 years of age was assessed according to Touwens' neurological examination. Children were classified as neurologically normal, or as having complex MND or cerebral palsy (CP). RESULTS: Eighty-two children were included. At 7 to 11 years of age 15 children (18%) had developed CP, 49 (60%) were neurologically normal, and 18 (22%) had MND. Multiple logistic regression analysis showed that, when the qualitative aspects of the motor repertoire known to predict neurological outcome were taken into account, only the asymmetric tonic neck (ATN) posture provided additional predictive value. In case of normal fidgety movements (FMs) accompanied by an abnormal concurrent motor repertoire, the presence of an obligatory ATN increased the risk for developing complex MND to 75%; absence of an obligatory ATN reduced the risk to 15% (p<0.05). CONCLUSIONS: Quantitative aspects of the motor repertoire at 11-16 weeks post-term, in particular the presence of an obligatory ATN posture, contribute to the prediction of neurological outcome at 7 to 11 years of age.

86. Adde L, Helbostad JL, Jensenius AR, Taraldsen G, Støen R.
Using computer-based video analysis in the study of fidgety movements.
Early Hum Dev 2009; 85: 541-547. 

OBJECTIVE: Absence of fidgety movements (FM) in high-risk infants is a strong marker for later cerebral palsy (CP). FMs can be classified by the General Movement Assessment (GMA), based on Gestalt perception of the infant's movement pattern. More objective movement analysis may be provided by computer-based technology. The aim of this study was to explore the feasibility of a computer-based video analysis of infants' spontaneous movements in classifying non-fidgety versus fidgety movements. METHOD: GMA was performed from video material of the fidgety period in 82 term and preterm infants at low and high risks of developing CP. The same videos were analysed using the developed software called General Movement Toolbox (GMT) with visualisation of the infant's movements for qualitative analyses. Variables derived from the calculation of displacement of pixels from one video frame to the next were used for quantitative analyses. RESULTS: Visual representations from GMT showed easily recognisable patterns of FMs. Of the eight quantitative variables derived, the variability in displacement of a spatial centre of active pixels in the image had the highest sensitivity (81.5) and specificity (70.0) in classifying FMs. By setting triage thresholds at 90% sensitivity and specificity for FM, the need for further referral was reduced by 70%. CONCLUSION: Video recordings can be used for qualitative and quantitative analyses of FMs provided by GMT. GMT is easy to implement in clinical practice, and may provide assistance in detecting infants without FMs.  

85. Butcher PR, van Braeckel K, Bouma A, Einspieler C, Stremmelaar EF, Bos AF.
The quality of preterm infants' spontaneous movements: an early indicator of intelligence and behaviour at school age.
J Child Psychol Psychiatry 2009; 50: 920-930.

BACKGROUND: The quality of very preterm infants' spontaneous movements at 11 to 16 weeks post-term age is a powerful predictor of their later neurological status. This study investigated whether early spontaneous movements also have predictive value for the intellectual and behavioural problems that children born very preterm often experience. METHODS: Spontaneous movement quality was assessed, using Prechtl's method, at 11 to 16 weeks post-term in 65 infants born at <or= 33 weeks of gestation in a single centre. Intelligence and behaviour were assessed with standardised tests at 7 to 11 years of age. Neurological status was assessed with Touwen's test. Multiple regression was used to determine the predictive value of movement quality for intelligence and behavioural problems. The Sobel test was used to determine if neurological status mediated associations found between early movement quality and outcome. RESULTS: Spontaneous movement quality at 11 to 16 weeks post-term was significantly, positively associated with later intelligence. The number of normal postural patterns displayed contributed most strongly to the association, which was not mediated by neurological status. Fidgety movements, strong predictors of later neurological dysfunction, were not associated with intelligence. Spontaneous movement quality was not associated with internalising or externalising problems but showed a trend to an association with attention problems. CONCLUSION: These findings suggest that, in children born preterm, early spontaneous movement quality has clear prognostic value for neurological and intellectual outcome, and to a lesser extent, for attentional outcome. However, cognitive outcome was associated with the presence of specific, age-appropriate postural patterns, while neurological outcome has been associated with the presence of global movement abnormalities. The presence of specific, age-appropriate postural patterns may reflect the integrity of areas of the brain involved in cognitive processing and the regulation of attention later in childhood. Alternately, it may facilitate cognitive and attentional development.

84. Bruggink JL, van Spronsen FJ, Wijnberg-Williams BJ, Bos AF.
Pilot use of the early motor repertoire in infants with inborn errors of metabolism: outcomes in early and middle childhood.
Early Hum Dev 2009; 85: 461-465.

BACKGROUND: Predicting later outcome in neonates presenting with severe inborn errors of metabolism (IEM) is difficult. The assessment of the early motor repertoire is a reliable method of evaluating the integrity of the central nervous system in young infants. This method is based on an age-specific qualitative assessment of general movements (GMs, 0-8 weeks of age), fidgety movements (FMs) and the concurrent motor repertoire (9-20 weeks of age). AIM: To determine the quality of the early motor repertoire (at 0-20 weeks post term age) in relation to later neurological outcome in infants with severe IEM. STUDY DESIGN: Prospective cohort study. The quality of the motor repertoire was assessed from serial videotape recordings. SUBJECTS: Five infants with IEM. Four presented with a severe IEM in the neonatal period: an undefined gluconeogenesis defect, propionic acidemia, arginosuccinate synthetase and arginosuccinate lyase deficiency. One neonate was antenatally diagnosed with arginosuccinate synthetase deficiency. OUTCOME MEASURES: Outcome at the age of at least 18 m was determined by neurological examination and developmental tests. RESULTS: All infants initially had abnormal GMs: hypokinesia, followed by GMs of a poor repertoire. The quality of the early motor repertoire normalised in 3 infants, and remained abnormal in 2. The more severe and persistent abnormalities of the motor repertoire were considered with the more abnormal neurological and developmental scores, later on. CONCLUSIONS: The quality of the early motor repertoire might be related to later neurological outcome in infants with inborn errors of metabolism.
  
83. Spittle AJ, Boyd RN, Inder TE, Doyle LW.
Predicting motor development in very preterm infants at 12 months' corrected age: the role of qualitative magnetic resonance imaging and general movements assessments.
Pediatrics 2009; 123: 512-517. 

OBJECTIVE: The objective of this study was to compare the predictive value of qualitative MRI of brain structure at term and general movements assessments at 1 and 3 months' corrected age for motor outcome at 1 year's corrected age in very preterm infants. PATIENTS AND METHODS: Eighty-six very preterm infants (<30 weeks' gestation) underwent MRI at term-equivalent age, were evaluated for white matter abnormality, and had general movements assessed at 1 and 3 months' corrected age. Motor outcome at 1 year's corrected age was evaluated with the Alberta Infant Motor Scale, the Neuro-Sensory Motor Development Assessment, and the diagnosis of cerebral palsy by the child's pediatrician. RESULTS: At 1 year of age, the Alberta Infant Motor Scale categorized 30 (35%) infants as suspicious/abnormal; the Neuro-Sensory Motor Development Assessment categorized 16 (18%) infants with mild-to-severe motor dysfunction, and 5 (6%) infants were classified with cerebral palsy. White matter abnormality at term and general movements at 1 and 3 months significantly correlated with Alberta Infant Motor Scale and Neuro-Sensory Motor Development Assessment scores at 1 year. White matter abnormality and general movements at 3 months were the only assessments that correlated with cerebral palsy. All assessments had 100% sensitivity in predicting cerebral palsy. White matter abnormality demonstrated the greatest accuracy in predicting combined motor outcomes, with excellent levels of specificity (>90%); however, the sensitivity was low. On the other hand, general movements assessments at 1 month had the highest sensitivity (>80%); however, the overall accuracy was relatively low. CONCLUSION: Neuroimaging (MRI) and functional (general movements) examinations have important complementary roles in predicting motor development of very preterm infants.  

82. Fjørtoft T, Einspieler C, Adde L, Strand LI.
Inter-observer reliability of the "Assessment of Motor Repertoire--3 to 5 Months" based on video recordings of infants.
Early Hum Dev 2009; 85: 297-302. 
OBJECTIVE: A detailed analysis of infant motor behaviour can show up indicators for later neurological impairment. The "Assessment of Motor Repertoire--3 to 5 Months", which is part of Prechtl's general movement assessment, could potentially be used for this purpose. The aim of the present study was to investigate inter-observer reliability in this instrument. METHOD: Video recordings of 24 infants (corrected ages 3 to 5 months, gestational ages 24 to 42 weeks) were analysed by four observers. Kappa and ICC statistics were applied in the reliability analysis. RESULTS: High to very high inter-observer reliability was found in the assessment of "Fidgety Movements" (kappa 0.75-0.91). Agreement on the "Movement Character" was also high (kappa 0.54-0.84), while the assessment of the "Posture" showed the lowest inter-observer reliability (kappa 0.39-0.56). Moderate to high inter-observer reliability (kappa 0.51-0.84) was achieved in the field "Quality of Other Movements", and moderate in "Repertoire of Co-Existent Other Movements" (kappa 0.51-0.69). Inter-observer reliability in the assessment of the total "Motor Optimality Score" was very high between all four observers as intraclass correlation coefficient (2,1) was 0.87, and ICCs for the pairwise analyses ranged between 0.80 and 0.94. CONCLUSION: Inter-observer reliability in the "Assessment of Motor Repertoire - 3 to 5 Months" was satisfactory in respect of the subcategories and in case of high and low total optimality scores in pairwise assessments. In the total optimality scores, however, there was some inconsistency in the middle range of the scale.

81. Burger M, Louw QA.
The predictive validity of general movements--a systematic review.
Eur J Paediatr Neurol 2009; 13: 408-420. 

BACKGROUND: The assessment of general movements (GMs), introduced by Professor Heinz Prechtl and his co-workers in the early 1990s, may offer the opportunity to identify infants with neurological deficits at a very early age. AIM: The aim of this review was to systematically assess available data in order to determine the evidence of general movements in early infancy to predict the neurodevelopmental outcome in 12- and 24-month-old infants. METHOD: A systematic literature search was performed using the following computerised databases: Medline, CINAHL, Pedro, The Cochrane Library, Science Direct, ProQuest: Science Journals, Medical Library & Social Science Journals, Journals @ OVID and PsycINFO. The following key terms were used: general movements, spontaneous motor activity, nervous system diseases [MeSH] and developmental disabilities [MeSH]. A comprehensive author search was also conducted. The methodological quality of eligible studies was critically appraised by two reviewers using the Critical Review Form for Quantitative Studies of the McMaster University Occupational Therapy Evidence-Based Practice Research Group. RESULTS: Seventeen studies were eligible for this review. The average score of the studies was 8.82 (73.5%) from a total of 12 (SD 0.73). Fifteen of the 17 studies found a high relationship (sensitivity > or =92%; specificity > or =82%; p<0.01) between the quality of general movements at 8-20 weeks postterm (fidgety movements' period) and the infants' neurodevelopmental outcome. CONCLUSION: The results of this systematic review indicate that the qualitative assessment of general movements, especially during the fidgety movements' period, can be used as a prognostic tool to identify infants with neurodevelopmental disabilities.

80. Gaboli M, Aguilera S, Azcona C, Alzina V, Narbona J.
Normal neurological outcome after congenital thyrotoxicosis: prognostic value of observation of general movements.
Neuropediatrics 2008; 39:351-353.

We followed up a patient born preterm with congenital thyrotoxicosis by observing her general movements (GMs) in accordance with Prechtl's method. Initially a chaotic pattern was observed. Along with the normalization of thyroid hormones, the GM pattern changed to a poor repertoire at four weeks of life, full-blown writhing movements at six weeks and fidgety movements at the age of four months. This is the first report of chaotic GMs in a neonate reflecting transient neurological dysfunction related to congenital thyrotoxicosis, with subsequent normal neurological and cognitive outcome.

79. Sustersic B, Paro-Panjan D.
Assessment of general movements in relation to neurologic signs at age two years.
Pediatr Neurol 2008; 39: 108-112.

Abnormal movement patterns during the fidgety period, as identified by Prechtl's method for qualitative assessment of general movements, and the presence of minor neurologic and cranial signs at age 2 years, as defined by Amiel-Tison, are related to minor developmental disorders. Our study analyzed the relationship between the two assessment methods in 45 preterm infants. Cerebral palsy was identified in 4, minimal cerebral palsy in 2, and the Amiel-Tison triad in 4 children; in all, continuously abnormal patterns of general movements were present. In the intermediate group with 2 signs of the triad, one child exhibited normal movements in the writhing period, and all were abnormal in the fidgety period. The intermediate group, with one sign of the triad, comprised 9 children: abnormal findings in the writhing period were present in 8, and in the fidgety period in 7. Among 16 children without neurologic signs, normal general movements were present in 7 children during the writhing period, and in 5 during the fidgety period. We confirmed good correlation between general movements and neurologic outcome at age 2 years (Pearson's R at term age, 0.51; at fidgety period, 0.62). 

78. Santos RS, Araújo AP, Porto MA.
Early diagnosis of abnormal development of preterm newborns: assessment instruments.
J Pediatr (Rio J) 2008; 84: 289-299. 

OBJECTIVE: To review the literature regarding screening psychomotor tests for the early identification of developmental problems. SOURCES: A search on SciELO, PubMed and Google Scholar was performed using the terms "prematurity," "developmental delay," "cerebral palsy," "early diagnosis" and "evaluation tests." SUMMARY OF THE FINDINGS: A total of 455 references were listed, and 174 studies were selected for this review based on title, relevance, and abstract. Only original and electronically available material, from 1985 forward, with information on design, applicability, and psychometric properties of those tests was included. CONCLUSIONS: Screening tests are important to speed the beginning of treatment measures in order to allow for better developmental outcome. Among the many tests that can be employed for this purpose, the DENVER II and the Alberta Infant Motor Scale are the most often used in Brazilian studies. The Movement Assessment of Infants is starting to be used in our country. Two other tests are recommended in the literature due to their high sensibility and specificity: the Test of Infant Motor Performance and the General Movements. 

77. de Vries NK, Erwich JJ, Bos AF.
General movements in the first fourteen days of life in extremely low birth weight (ELBW) infants.
Early Hum Dev 2008; 84: 763-768. 

 OBJECTIVE: To assess the quality of general movements (GMs) in the first fourteen days of life in relation to obstetric and postnatal risk factors and neurodevelopmental outcome in extremely low birth weight (ELBW) infants. STUDY DESIGN: The GMs of nineteen infants were assessed on days 2, 4, 6, 10 and 14 with Prechtl's method. Additionally, detailed GM assessment produced optimality scores (OSs). GMs and the OSs were related to obstetric and postnatal data and to neurodevelopmental outcome at 18 months. RESULTS: GMs and OSs fluctuated substantially during the first fourteen days of life. Most infants had abnormal GMs, especially poor repertoire (PR) GMs. No relation was found between GMs and obstetric factors. Regarding postnatal factors, septicaemia correlated to hypokinesia (H) and artificial ventilation correlated to a lower OS. CONCLUSIONS: Due to physiological disturbances the quality of GM in ELBW infants fluctuates substantially during the first fourteen days of life. Abnormal GMs, especially PR GMs, are mostly seen for the same reason. Septicaemia and artificial ventilation are associated with deterioration of the GMs (lower OSs), and in case of septicaemia also with hypokinesia.  

76. van Schie PE, Rep A, Ganzevoort W, de Groot L, Wolf H, van Wassenaer AG, de Vries JI; PETRA-Investigators.
General movements in infants born from mothers with early-onset hypertensive disorders of pregnancy in relation to one year's neurodevelopmental outcome.
Early Hum Dev 2008; 84: 605-611. 

BACKGROUND: Assessment of general movements (GMs) at three months is considered useful for prediction of adverse neurological outcome in high risk infants.AIMS: To study the prevalence of abnormal GMs in infants born from women with early-onset hypertensive disorders of pregnancy and the association of GMs with neurodevelopmental outcome at one year. STUDY DESIGN: Prospective study, part of a randomised controlled trial of pre-birth management strategies. SUBJECTS: Infants born from women with early-onset hypertensive disorders of pregnancy. OUTCOME MEASURES: GMs observation and neurological examination at term and three months corrected age; at one year neurological examination and Bayley Scales of Infant Development. RESULTS: From 216 women included, 175 of 178 surviving infants (mean gestational age 31.6 weeks [SD 2.3], mean birth weight 1346 grams [SD 458]), were examined at three months. At term age normal, mildly abnormal and definitely abnormal GMs were observed in 54%, 36% and 10% respectively; and at three months in 47%, 40% and 13%. Mildly or definitely abnormal GMs at three months were not associated with abnormal neurological examination at one year, however, they were associated with delayed psychomotor development at one year (p = 0.01). CONCLUSIONS: In this prospective study, including small for gestational age, preterm infants about half of them did not have normal GMs at term and three months. There was no association of GMs at term nor three months with neurological outcome at one year, but there was a significant association of GMs at three months with one year psychomotor development.

75. Spittle AJ, Doyle LW, Boyd RN.
A systematic review of the clinimetric properties of neuromotor assessments for preterm infants during the first year of life.
Dev Med Child Neurol 2008; 50: 254-66. 75. 

This systematic review evaluates assessments used to discriminate, predict, or evaluate the motor development of preterm infants during the first year of life. Eighteen assessments were identified; nine met the inclusion criteria. The Alberta Infant Motor Scale (AIMS), Bayley Scale of Infant and Toddler Development -- Version III, Peabody Developmental Motor Scales -- Version 2, Test of Infant Motor Performance (TIMP), and Toddler and Infant Motor Examination have good discriminative validity when examined in large populations. The AIMS, Prechtl's Assessment of General Movements (GMs), Neuro Sensory Motor Development Assessment (NSMDA), and TIMP were designed for preterm infants and are able to detect more subtle changes in movement quality. The best predictive assessment tools are age dependent: GMs, the Movement Assessment of Infants, and TIMP are strongest in early infancy (age 4 mo or less) and the AIMS and NSMDA are better at older ages (8-12 mo). The TIMP is the only tool that has demonstrated a difference between groups in response to intervention in two randomized controlled trials. The AIMS, TIMP, and GMs demonstrated the highest levels of overall reliability (interrater and intrarater intraclass correlation coefficient or kappa>0.85). Selection of motor assessment tools during the first year of life for infants born preterm will depend on the intended purpose of their use for discrimination, prediction, and/or evaluation.

74. Einspieler C.
Early markers for unilateral spastic cerebral palsy in premature infants.
Nat Clin Pract Neurol 2008; 4: 186-187.

73. Phagava H, Muratori F, Einspieler C, Maestro S, Apicella F, Guzzetta A, Prechtl HF, Cioni G.
General movements in infants with autism spectrum disorders.
Georgian Med News 2008; 156: 100-105.

General movements (GMs) are a distinct movement pattern carried out spontaneously without external stimulation and seen in fetuses of 9 weeks gestational age till 21 weeks postterm. GMs are helpful in the early diagnosis of an impaired central nervous system and the specific prediction of later neurological deficits. Autism spectrum disorder (ASD) is a neurodevelopmental disorder involving a life-long deficit in several aspects of the social and communicative behavior. Recently there appeared studies proving that children with ASD demonstrate disorders of motor development. The aim was: to detect whether abnormalities in spontaneous motor activity can be observed already in the first months of life in infants with ASD. A retrospective study was performed by analyzing the family videos provided by parents of 20 children (male 17, female 3) later diagnosed as ASD. Home videos provided by parents of a control group of healthy children (n=20; male 10, female 10) matched for age with the ASD subjects and recorded in similar conditions were also analysed. In total 70 sequences were studied. Two independent observers, blind of the infants' outcome (ASD or normal), assessed the cases applying a global and a more detailed assessment of GMs. Hence, the age-specific GM pattern (normal or abnormal) as well as the motor optimality scores were determined for each video sequence. Cohen kappa was 0.614. During the writhing movement period 70.0% sequences of infants with ASD showed poor repertoire GMs. In the control group, poor repertoire GMs were only seen in 12.5% of the sequences. In the fidgety movement period 20.8% of sequences were assessed as absent fidgety movements, 29.2% as abnormal fidgety movements. The large majority of the videos for the control cases were scored as normal (88.9%), 11.1% had no fidgety movements. According to the Mann-Whitney U test there were significant differences between the ASD and the control groups' optimality scores. The optimality scores were lower in the ASD group. The reduced optimality scores were mainly due to a lack of variable sequences, amplitude and speed of writhing GMs and an altered quality of fidgety and other spontaneous movements in the ASD group. Infants with ASD had more often poor repertoire writhing GMs as well as abnormal or absent fidgety movements than control infants. These data encourage further studies involving a larger number of family videos.

72. Spittle AJ, Brown NC, Doyle LW, Boyd RN, Hunt RW, Bear M, Inder TE.
Quality of General Movements Is Related to White Matter Pathology in Very Preterm Infants.
Pediatrics 2008; 121: 1184-1189.

OBJECTIVE. 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. METHODS. 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. RESULTS. 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. CONCLUSION. 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.

71. Mutlu A, Einspieler C, Marschik PB, Livanelioglu A.
Intra-individual consistency in the quality of neonatal general movements.
Neonatology 2008; 93: 213-216. 

BACKGROUND: The qualitative assessment of general movements (GMs) proved to be a highly sensitive and specific diagnostic tool for the assessment of the integrity of the young nervous system. It is essential that the quality of GMs remains consistent in an individual during a given recording at a certain date. OBJECTIVES: The aim of the study was to investigate the intra-individual consistency of the quality of GMs during one recording. METHODS: 39 preterm infants were recorded at least twice; some were recorded three times. In all, 88 recordings were available but three recordings were excluded due to frequent crying, seizures or hypokinesia. Three scorers assessed 2-3 sequences of these 85 GM recordings. RESULTS: The inter-scorer agreement was high (kappa 0.85-0.94). Intra-individual consistency revealed a kappa of 0.90 with a 95% CI (0.51, 1.00) for preterm GMs, 0.96 with a 95% CI (0.57, 1.00) for writhing GMs, and 0.92 with a 95% CI (0.53, 1.00) for fidgety GMs. CONCLUSIONS: The individual quality of GMs remains consistent for a neonate or young infant at a certain date.

70. Romeo DM, Guzzetta A, Scoto M, Cioni M, Patusi P, Mazzone D, Romeo GM.
Early neurologic assessment in preterm-infants: Integration of traditional neurologic examination and observation of general movements.
Eur J Pediatr Neurol 2008; 12: 183-189.  

OBJECTIVE: To evaluate the possible additional benefit in terms of prognostic accuracy of an integrated application of a traditional scorable method of neurologic examination and the Prechtl's method of qualitative assessment of general movements (GMs) in a large population of 903 consecutive preterm infants. STUDY DESIGN: Infants were enrolled from the Intensive Care Unit of the University of Catania. Inclusion criteria were a gestational age below 37 weeks and the absence of genetic disorders. All infants underwent serial ultrasound and at 3 months performed both the GMs assessment and the Hammersmith Infant Neurologic Examination (HINE). Outcome was assessed at 2 years by the Touwen neurologic examination and the Clinical Adaptive Test/Clinical, Linguistic and Auditory Milestone Scale. RESULTS: The integration of the two methods was shown to be more effective than the single assessments in predicting neurologic outcome. The additional benefit of combining the two approaches was particularly clear for the discrimination between unilateral and bilateral cerebral palsy. CONCLUSIONS: The integrated use of a scorable neurological examination and Prechtl's assessment of GMs can improve early prediction of neurodevelopmental outcome in preterm infants and should complement other clinical and instrumental exams in follow-up programs.

69. Snider LM, Majnemer A, Mazer B, Campbell S, Bos AF.
A comparison of the general movements assessment with traditional approaches to newborn and infant assessment: Concurrent validity.
Early Hum Dev 2008; 84: 297-303 

BACKGROUND: Assessment of the quality of general movements (GMs) is an early clinical marker for prediction of cerebral palsy. AIMS: To explore how the General Movements Assessment (GMsA) relates to traditional newborn and infant measures currently in use. STUDY DESIGN: A prospective cohort design was used to examine concurrent validity of the GMsA in Neonatal Intensive Care (NICU) survivors (n=100) at three age points: preterm (34 weeks gestational age GA), term (38-40 weeks GA), and post term (12 weeks adjusted age [AA]) with traditional assessments (see below). Correlation analysis was used to determine the strength of the associations between tests at each age point. SUBJECTS: Preterm infants born at </=32 weeks gestational age and birth weight <1500 g (n=108) were recruited sequentially from the NICU of a large teaching hospital and referral centre. Infants with diagnoses of metabolic disorders, cardiac, chromosomal, or congenital abnormalities were excluded. OUTCOME MEASURES: Test of Infant Motor Performance (TIMP), Einstein Neonatal Neurobehavioral Assessment Scale (ENNAS), Alberta Infant Motor Scales (AIMS). RESULTS: A low-strength relationship (r=<0.25) was found between the GMsA and the traditional tests which increased across age points (r=0.25-0.50). Relationships between the traditional tests over time was characterized by stronger associations (r=0.50-0.75). CONCLUSIONS: Evidence of concurrent validity of the GMsA with traditional assessments was not found. These early findings support Prechtl's suggestion that GMs reflect a unique neurologic construct, different from traditional tests and reinforce the complementary perspective which the GMsA brings to neonatal assessment.

68. Seme-Ciglenecki P.
Predictive values of cranial ultrasound and assessment of general movements for neurological development of preterm infants in the Maribor region of Slovenia.
Wien Klin Wochenschr 2007; 119: 490-496.

OBJECTIVE: The aim of the study was to assess the predictive values of cranial ultrasound (US) scans and assessment of general movements of fidgety character (GMs) for the later neurological development of preterm infants in the Maribor region of Slovenia. METHODS: Results of cranial US scans done longitudinally from the day of birth until the end of three months of chronologic age and results of GMs at three months of corrected age were compared with traditional neurological examination and evaluation of psychomotor development of the same children at the corrected age of six years. RESULTS: A total of 112 preterm infants (gestational age 37 weeks and below) were included in the study. The infants were classified as low-risk or high-risk for neurological impairment on the basis of cranial US scans. The scans classified as low-risk were followed by a normal neurological outcome in 74 (89%) of 83 infants; those classified as high-risk for neurological impairment were followed by abnormal neurological outcome in 21 (72%) of 29 infants. Of 77 infants with normal fidgety movements, 73 (95%) had a normal neurological outcome and 4 (5%) had an abnormal neurological outcome; of 35 infants with abnormal or absent fidgety movements, 26 (74%) had an abnormal neurological outcome and 9 (26%) had a normal neurological outcome. Of 30 children with abnormal outcome, cerebral palsy was diagnosed in 16, mental retardation in one, nine children had both of these, and four had complex minor neurological dysfunction. The validity of the scans was 85%, sensitivity 70%, specificity 90%, positive predictive value 72% and negative predictive value 89%; the validity of the GMs was 88%, sensitivity 87%, specificity 89%, positive predictive value 74% and negative predictive value 95%. CONCLUSIONS: The sensitivity of the cranial US scans was clearly lower than that of assessment of general movements of a fidgety character. The specificities of the two methods were almost the same.

67. Stahlmann N, Härtel C, Knopp A, Gehring B, Kiecksee H, Thyen U.
Predictive value of neurodevelopmental assessment versus evaluation of general movements for motor outcome in preterm infants with birth weights <1500 g.
Neuropediatr 2007; 38: 91-99.

PURPOSE: The aim of this study was to make a comparison of predictive values of neurodevelopmental assessment and evaluation of videotaped spontaneous movements of premature infants for motor outcome. METHODS: We performed a prospective longitudinal study of 103 VLBW infants, 96 (455-1490 g, 24-35 weeks gestational age) including (a) a neurodevelopmental assessment based on criteria by Amiel-Tison/Grenier at 40 weeks postconceptional age, 3 and 20 months corrected age; (b) an evaluation of general movements with fidgety character, based on criteria by Prechtl, at 3 months; and (c) a standardized testing using the Griffiths Developmental Motor Scale at 20 months. We calculated sensitivity, specificity and predictive values for each method. RESULTS: For predicting motor outcome, the assessment of general movements (GM) had a positive predictive value of 89% and negative predictive value of 84%; neurodevelopmental assessment (NA) at 40 weeks had a positive predictive value of 33% and negative predictive value of 88%, respectively, with similar results for neurodevelopmental assessment at age 3 months. CONCLUSIONS: Normal motor outcome of VLBW infants may be accurately predicted by clinical neurodevelopmental assessment, but for adverse outcomes, evaluation of general movements (fidgety movements) is superior. GM assessment has a high predictive value, especially for CP, but it needs to be complemented by NA for non-CP outcomes. It is a simple, repeatable and non-intrusive technique, and may be a valuable method for the early detection of central nervous system impairment in VLBW infants in routine follow-up.

66. Hadders-Algra M.
Putative neural substrate of normal and abnormal general movements.
Neurosci Biobehav Rev 2007, 31: 1181-1190.

During the last decade it has become clear that the assessment of the quality of general movements (GMs) in foetus and young infant is a sensitive tool to evaluate the integrity of the young nervous system. GMs are movements in which all parts of the body participate. The hallmark of typical GMs is movement complexity and variation; in abnormal GMs movement complexity and variation is reduced or absent. Abnormal GMs may predict developmental outcome. Prediction on the basis of longitudinal series of GM assessments is best. Second best is prediction on the basis of an assessment at 'fidgety' GM age, i.e. at 2-4 months post-term. Definitely abnormal GMs at 'fidgety' age are related to cerebral palsy, mildly abnormal GMs to minor neurological dysfunction at school age. In the present paper the hypothesis is advanced that GM complexity and variation are brought about by the transiently present cortical subplate and that abnormal GMs are the result of damage or dysfunction of the subplate and its efferent motor connections in the periventricular white matter.

65. Guzzetta A, Belmonti V, Battini R, Boldrini A, Paolicelli PB, Cioni G.
Does the assessment of general movements without video observation reliably predict neurological outcome?
Eur J Paediatr Neurol 2007, 11: 362-367.

OBJECTIVE: To assess the clinical value of a modified version, not employing video recording, of Prechtl's method on the qualitative assessment of general movements (GMs) in preterm, term and young infants at neurological risk. MATERIALS AND METHODS: One-hundred and fifteen infants consecutively enrolled in our follow-up program were selected for the study (103 preterm and 12 term infants). While being video recorded, each infant’s spontaneous motor activity was directly observed and documented using a written proforma. An evaluation of the video was later performed by a different assessor blind to the infant’s clinical history. RESULTS: The correlation between the two techniques was significant both at writhing age (birth to 6 weeks post-term age) and at fidgety age (9-15 weeks post-term age). Both methods showed a very high sensitivity for the prediction of cerebral palsy, as no false negatives were observed. The direct assessment showed a lower specificity, particularly during the writhing period. CONCLUSIONS: These results support the use of the direct assessment of GMs when the full application of the standard video observation cannot be routinely applied, restraining the use of video recordings to the abnormal or doubtful cases. This may facilitate the wished integration of the assessment of spontaneous motility into more general protocols of neurological examination and into clinical follow-up programs.

64. Ferrari F, Bertoncelli N, Gallo C, Roversi MF, Guerra MP, Ranzi A, Hadders-Algra M.
Posture and movement in healthy preterm infants in supine position in and outside the nest.
Arch Dis Child Fetal Neonatal Ed. 2007, 92: F386-F390.

OBJECTIVE: To evaluate whether lying in a nest affects the posture and spontaneous movements of healthy preterm infants. METHOD: 10 healthy preterm infants underwent serial video recording in the supine position, when lying in a nest and outside it, at three ages: 30-33 weeks postmenstrual age (PMA) (early preterm), 34-36 weeks PMA (late preterm) and 37-40 weeks PMA (term). The nest was shell-shaped, made by putting two rolled blankets in a form of an oval. Posture was assessed both before and after general movements by scoring the predominant postural pattern. Movements towards and across the midline, elegant wrist movements, abrupt hand and/or limb movements, rolling to side, and frozen postures of the arms and legs were assessed during four general movements. All data relating to motor and postural items were normalised into frequencies of events per minute because the general movements varied in duration. RESULTS: When lying in the nest, the infants more often displayed a flexed posture with shoulder adduction and elbow, and hip and knee flexion, and the head was frequently in the midline. The nest was also associated with an increase in elegant wrist movements and movements towards and across the midline and a reduction in abrupt movements and frozen postures of the limbs. The nest did not affect the occurrence of asymmetrical tonic neck posture. CONCLUSIONS: A nest promotes a flexed posture of the limbs with adduction of shoulders, facilitates elegant wrist movements and movements towards and across the midline and reduces abrupt movements and frozen postures of the arms and legs.

63. Constantinou JC, Adamson-Macedo EN, Mirmiran M, Fleisher BE.
Movement, imaging and neurobehavioral assessment as predictors of cerebral palsy in preterm infants.
J Perinatol 2007; 27: 225-229.

OBJECTIVE: To study the relative efficacy of three early predictors of cerebral palsy. METHOD: One Hundred and thirty infants with birth weight <1500 g were recruited. Video recordings of spontaneous general movements were made at 36 and 52 weeks postconceptional age. Magnetic resonance imaging and the neurobehavioral assessment of the preterm infant were done at 36 weeks postconceptional age. Follow-up neurological examination and Bayley assessments were made at 18 months corrected age to make early identification of cerebral palsy. RESULTS: Magnetic resonance imaging gave the best specificity and accuracy of 91 and 84% respectively. General movements at 52 weeks showed an improved specificity and accuracy over performance at 36 weeks postconceptional age. The negative predictive value for all methods tested was between 90 and 97%. Combining the results of magnetic resonance imaging and the neurobehavioral assessment improved the sensitivity of prediction to 80%, suggesting that a holistic approach to early detection of cerebral lesions is preferable to a single test. CONCLUSIONS: The majority of infants who appeared to behave within normal limits and exhibit normal brain structure in the newborn period were classified as neurologically intact at follow-up.

62. Einspieler C, Marschik PB, Milioti S, Nakajima Y, Bos AF, Prechtl HF.
Are abnormal fidgety movements an early marker for complex minor neurological dysfunction at puberty?
Early Hum Dev 2007; 83: 521-525.

BACKGROUND: Prechtl's method on the qualitative assessment of general movements (GMs) is a powerful tool for early and specific prediction of cerebral palsy. However, it is uncertain whether the GM assessment can be used to predict mild neurological impairment. AIMS: To determine whether the quality of GMs from the age of 3 to 5 months, i.e. fidgety movements, is related to the presence of complex minor neurological dysfunctions (MND) 13 to 15 years later. STUDY DESIGN: Prospectively collected data on the quality of GMs during infancy were retrospectively analysed on the basis of MND at puberty. SUBJECTS: Twenty-eight participants (14 girls and 14 boys) with a median gestational age of 40 weeks (range: 35 to 42 weeks) and an appropriate birth weight (median 3390 g; range 1900 to 4200 g). OUTCOME MEASURES: Touwen's neurological examination. RESULTS AND CONCLUSIONS: Abnormal fidgety movements were not related to later complex MND, but to fine manipulative disabilities (p<0.05). Normal fidgety movements, which are continually present in the whole body, might be required for optimal calibration of the proprioceptive system.
PMID: 17129688 [PubMed - indexed for MEDLINE]

61. Adde L, Rygg M, Lossius K, Oberg GK, Støen R.
General movement assessment: predicting cerebral palsy in clinical practise.
Early Hum Dev 2007; 83: 13-18.
 
OBJECTIVE: The general movement assessment (GMA) method is used to predict cerebral palsy (CP) in infants with high risk of developing neurological dysfunctions. Most of the work on GMA has been performed from the same group of researchers. The aim of this study was to demonstrate to what extent GMA predicted CP in our hands. METHOD: A prospective study was performed using the Prechtl classification system for GMA in the fidgety period to predict later cerebral palsy. The study population consisted of 74 term and preterm infants at low and high risk of developing neurological dysfunction. The absence or presence of CP was reported at 23 months median-corrected age by the child's physician and the parents. RESULTS: The GMA identified all 10 infants that later were classified as having CP. GMA also identified all the infants that did not develop CP except for one infant with abnormal GMA and no CP. Three infants had uncertain CP status at follow-up. The sensitivity of GMA with regard to later CP was 100% with 95% CI (0.73, 1.00) and the specificity was 98% with 95% CI (0.91, 0.99) when the three uncertain cases were excluded. CONCLUSION: Our study indicates that the GMA used in a clinical setting strongly predicts the development of CP. The work supports the results of previous studies and contributes to the validation of GMA. The qualitative nature of this method may be a problem for inexperienced observers. Larger clinical studies are needed.

60. Bouwstra H, Dijck-Brouwer DJ, Decsi T, Boehm G, Boersma ER, Muskiet FA, Hadders-Algra M.
Relationship between umbilical cord essential fatty acid content and the quality of general movements of healthy term infants at 3 months.
Pediatr Res 2006; 59: 717-722.

Prenatal essential fatty acid (EFA) status might be an important factor in the development of the central nervous system (CNS). The aim of the present study was to evaluate the relationship between the fatty acid compositions of the umbilical blood vessels at birth, used as a proxy of prenatal EFA status, and quality of general movements (GMs) at 3 mo. Umbilical artery and vein fatty acid compositions were investigated in a mixed group of breastfed infants and infants fed with formula with or without long-chain polyunsaturated fatty acid (LCPUFA) supplementation. At the age of 3 mo, video assessment of the quality of GMs was performed to evaluate neurologic condition. The quality of GMs was scored by assessing the degree of variation, complexity, and fluency. Outcomes were classified as normal-optimal, normal suboptimal, mildly abnormal, and definitely abnormal movements. Information on potential confounders, including the type of postnatal feeding, was collected prospectively. Associations between fatty acid status at birth and quality of GMs were investigated, and multinomial logistic regression analyses were carried out. None of the infants showed definitely abnormal movements. Infants with mildly abnormal GMs had a lower EFA index, lower arachidonic acid (AA) content, higher total n-9 fatty acid, and higher total monounsaturated fatty acid (MUFA) content in the umbilical artery compared with infants with normal GMs. Multivariate analyses confirmed these findings. We conclude that mildly abnormal GMs are associated with a less favorable EFA status in the umbilical artery.

59. Ivanov IS, Shukerski KG, Chepisheva EV.
Spontaneous motor activity three months after birth in comparison with clinical and ultrasound studies.
Folia Med (Plovdiv) 2005; 47: 18-23.

The introduction of the general movement assessment into pediatric practice as a prognostic method (HFR Prechtl, et al., 1997) has prompted the necessity of further, more extended study of spontaneous motor activity. Possible correlations of this method with the well-established diagnostic and prognostic methods in the neonatal and early post-neonatal period need also more extensive study. Fidgety movements seem to be considered the most convenient to study and of the greatest prognostic value. OBJECTIVE: To study prospectively the spontaneous motor activity in the period of fidgety movements and compare it with the results of the clinical and ultrasound methods of investigation. MATERIAL AND METHODS: Thirty five infants aged 0 to 3 months (7 preterm infants) referred to the Pediatric Neurology Service at Plovdiv University Clinic of Pediatrics and Medical Genetics for consultation or hospitalisation were prospectively followed up to one year of age. Fidgety movements were examined from six to 20 weeks corrected age; neurologic examination and transfontanel ultrasonography were conducted on the day of an infant’s inclusion into the study, during the period of fidgety movements and between 12 to 18 months of age. The clinical and ultrasonographic findings from the neonatal period were analysed. RESULTS: Normal fidgety movements were observed in 31 infants; four infants were with absent fidgety movements. The rate of agreement of the results was high (more than 91%, p<0.05) when presence of normal fidgety movements was correlated with absent or mild neonatal and postneonatal neurologic and ultrasonographic abnormalities, and absent fidgety movements with severe clinical and ultrasonographic abnormalities. CONCLUSION: Abnormal fidgety movements are statistically significantly correlated with the grade of neonatal neurologic and ultrasonographic abnormalities and with the clinical and imaging findings during their investigations.

58. Sival DA, Brouwer OF, Bruggink JL, Vles JS, Staal-Schreinemachers AL, Sollie KM, Sauer PJ, Bos AF.
Movement analysis in neonates with spina bifida aperta.
Early Hum Dev 2006, 82: 227-234.

INTRODUCTION: In neonates with spina bifida aperta (SBA), leg movements by myotomes caudal to the meningomyelocele (MMC) are transiently observed. It is unclear whether these leg movements relate to functional neural conduction through the MMC. For optimal therapeutical intervention, pathophysiological insight in these transient leg movements seems relevant. If leg movements by myotomes caudal to the MMC concur with the execution of general movements (GMs), functional neural conduction through the MMC is implicated. OBJECTIVE: In neonates with SBA, we aimed to determine whether the transiently present leg movements caudal to the MMC indicate functional neural conduction through the MMC. METHODS: During the perinatal period, fetuses and neonates with SBA (n = 7 and n = 13, respectively) were longitudinally analysed for concurrency between leg movements caudal to the MMC and GMs. To address the integrity of the reflex arc in spinal segments (at, or) caudal to the MMC, tendon leg reflexes were assessed during the first postnatal week. RESULTS: At postnatal day 1, leg movements caudal to the MMC concurred with GMs in 12 of 13 infants. Isolated leg movements were observed in only 3 of these 12 infants (isolated vs. concurrent; p < 0.005). Leg movements concurring with GMs lasted longer than isolated leg movements (median duration = 11 s vs. 2 s; p < 0.05). Between days 1 and 7, tendon leg reflexes (at, or) caudal to the MMC had disappeared in all but 1 neonate. However, leg movements caudal to the MMC remained concurrently present with GMs in all five neonates available for follow-up after day 7. Comparing these leg movements between days 1 and 7 indicated a decreased duration (-44%, p < 0.05). CONCLUSIONS: In neonates with SBA, leg movements caudal to the MMC concur with GMs, indicative of functional neural conduction through the MMC. The disappearance of these leg movements is caused by lower motor neuron dysfunction at the reflex arc, whereas neural conduction through the MMC is still functional.

57. Paro-Panjan D, Sustercic B, Neubauer D
Comparison of two methods of neurologic assessment in infants.
Pediatr Neurol 2005, 33:317-324.

Information provided by the neonatal neurologic assessment is important for identifying infants with neurologic abnormalities at a very early age. The aim of this study was to compare two distinct approaches to the neurologic assessment of newborns: the Amiel-Tison neurologic assessment, and Prechtl's qualitative assessment of general movements. The results of both assessments were studied in a group of 45 preterm infants with different risk factors for brain damage that were compared at term age and at a corrected age of 3 months. The predictive power of the two methods regarding the neurologic and developmental outcome at a corrected age of 12-15 months was analyzed. The agreement of the two methods was excellent at term (kappa = 0.87) and good at 3 months (kappa = 0.54). The sensitivity of both methods for detecting children with neurologic abnormalities was high both at term and at 3 months (0.92, 1.0 for the Amiel-Tison assessment and 0.96, 1.0 for general movements). The specificity of both techniques was low at both ages (0.45, 0.75 for the Amiel-Tison assessment and 0.40, 0.35 for general movements). The agreement of the neurologic and developmental outcome was better with the Amiel-Tison assessment (kappa = 0.39, 0.77) than with the observation of general movements (kappa = 0.38, 0.37).

56. Groen SE, de Blécourt AC, Postema K, Hadders-Algra M.
General movements in early infancy predict neuromotor development at 9 to 12 years of age.
Dev Med Child Neurol 2005, 47: 731-738

Assessment of the quality of general movements (GMs) in early infancy is a powerful instrument to predict cerebral palsy (CP). The aim of the present study is to explore the value of GM assessment in predicting minor neurological dysfunction (MND) at 9 to 12 years of age. Two groups of infants were studied prospectively: 28 low-risk full-term infants (11 females, 17 males) and 24 high-risk infants, mostly born preterm (<37 weeks; 11 females, 13 males). In each group the quality of GMs (normal or abnormal) was assessed during two developmental periods: the age at which 'writhing' GMs occur (36 weeks' postmenstrual age to 7 weeks' postterm) and the age at which 'fidgety' GMs occur (8 to 17 weeks' postterm). Eight of 24 high-risk infants were diagnosed as having CP at 4 to 9 years of age. The remaining 44 children were followed-up at 9 to 12 years. In children without CP, quality of GMs at 'fidgety age' was related to neurological condition (normal, simple MND, complex MND) at follow-up (rho=0.46, p<0.01). Abnormal GMs at 'fidgety-GM age' showed a specific relationship to the development of coordination problems (chi2=6.1, p=0.01) and fine manipulative disability (Fisher, p<0.05) at 9 to 12 years. This finding supports the notion that the quality of GMs may provide information on the integrity of complex supraspinal circuitries.

55. Einspieler C, Kerr AM, Prechtl HFR.
Abnormal general movements in girls with Rett disorder: The first four months of life.
Brain Dev 2005, 27: Suppl 1 S8-S13

An apparently normal early development was one of the initial criteria for classical Rett syndrome. However, several investigators considered Rett syndrome to be a developmental disorder manifesting very soon after birth. Videos of 14 infants with Rett disorder were carefully assessed for their spontaneous movements, in particular general movements (GMs), during the first 4 months of life. A detailed analysis clearly demonstrated that none of the infants had normal GMs. However, a specific abnormal GM pattern could not be detected for Rett disorder. The abnormal GMs described here, and their individual developmental trajectories are different from the abnormal GMs described in infants with acquired brain lesion. Our study is the first to apply specific standardised measures of early spontaneous movements to infants with Rett syndrome, proving conclusively that the disorder is manifest within the first weeks of life.

54. Nakayima Y, Einspieler C, Marschik PB, Bos AF, Prechtl HFR.
Does a detailed assessment of poor repertoire general movements help to identify those infants who will develop normally?
Early Hum Dev 2006, 82: 53-59.

BACKGROUND: The assessment of the quality of general movements (GMs) in young infants is a reliable and valid diagnostic tool for detecting brain dysfunction early in life. Poor repertoire GMs are the most frequently observed abnormal GMs during the preterm, term and early postterm period. However, their predictive value for the neurological outcome is low. AIM: To find out whether a detailed scoring of poor repertoire GMs might lead to a better prediction of the neurological outcome. SUBJECTS: We studied 18 preterm infants who were repeatedly videoed from birth to 22 weeks postterm age, including several recordings assessed as poor repertoire GMs. At 8 to 10 years, six children were neurologically normal, six had mild neurological abnormalities, and the remaining six were classified as cerebral palsy. STUDY DESIGN: Each GM globally assessed as poor repertoire was scored in details according to several aspects of neck and trunk, arm and leg movements applying Prechtl's optimality concept. RESULTS: By and large, the detailed score of poor repertoire GMs was not related to the neurological outcome. CONCLUSION: For the clinical application of the GM assessment, it remains important to assess the fidgety movements of those infants with poor repertoire GM trajectories in order to predict their outcome.

53. Valentin T, Uhl K, Einspieler C.
The effectiveness of training in Prechtl’s method on the qualitative assessment of general movements .
Early Hum Dev 2005, 81: 623-627.

BACKGROUND: Prechtl's method on the qualitative assessment of general movements (GMs) is a highly sensitive and specific diagnostic tool for the assessment of the integrity of the young nervous system. AIM: To find out whether the ability to assess GMs correctly could be gained after receiving a few days' standardised training. STUDY DESIGN: We evaluated 700 scoring sheets (containing a total of 8019 assessments) from the final tests of 18 training courses held between 1997 and 2002. RESULTS: Eighty-three per cent of the assessments were correct after completing a 4- to 5-day training course. The correct discrimination between normal and abnormal GMs was 92%. It proved more difficult to assess infants correctly if they had been recorded around term age. CONCLUSION: Standardised training courses enable professionals in the field of infant and child neurology to apply Prechtl's method of GM assessment accurately.

52. Einspieler C, Prechtl HFR.
Prechtl’s assessment of general movements: a diagnostic tool for the functional assessment of the young nervous system.
MRDD Research Reviews 2005, 11: 61-67.

General movements (GMs) are part of the spontaneous movement repertoire and are present from early fetal life onwards until the end of the first half a year of life. GMs are complex, occur frequently, and last long enough to be observed properly. They involve the whole body in a variable sequence of arm, leg, neck, and trunk movements. They wax and wane in intensity, force and speed, and they have a gradual beginning and end. Rotations along the axis of the limbs and slight changes in the direction of movements make them fluent and elegant and create the impression of complexity and variability. If the nervous system is impaired, GMs loose their complex and variable character and become monotonous and poor. Two specific abnormal GM patterns reliably predict later cerebral palsy: 1) a persistent pattern of cramped-synchronized GMs. The movements appear rigid and lack the normal smooth and fluent character. Limb and trunk muscles contract and relax almost simultaneously. 2) The absence of GMs of fidgety character. So-called fidgety movements are small movements of moderate speed with variable acceleration of neck, trunk, and limbs in all directions. Normally, they are the predominant movement pattern in an awake infant at 3 to 5 months. Beside a sensitivity and specificity of 95% each, the assessment of GMs is quick, noninvasive, even nonintrusive, and cost-effective compared with other techniques, e.g., magnetic resonance imaging, brain ultrasound, and traditional neurological examination.

51. Einspieler C, Prechtl HFR, Bos AF, Ferrari F, Cioni G.
Prechtl’s Method on the Qualitative Assessment of General Movements in Preterm, Term and Young Infants (incl. CD-Rom).
London: Mac Keith Press; distributed by Cambridge University Press.
Clin Dev Med 2004, 167: pp 1-91.

50. Sival DA, Brouwer OF, Meiners LC, Sauer PJJ, Prechtl HFR, Bos AF.
The influence of cerebral malformations on the quality of general movements in spina bifida aperta.
Eur J Pediatr Surg 2003; 13: S29-S30.

49. Mazzone L, Mugno D, Mazzone D.
The General Movements in children with Down syndrome.
Early Hum Dev 2004, 79:119-130.

OBJECTIVE: Aim of our study was to describe the character of General Movements (GMs) in children with Down Syndrome (DS). MATERIAL AND METHODS: GMs of 23 children with DS and of 30 healthy full-term infants were assessed from birth to 6th month corrected age. A qualitative and a semi-quantitative evaluation of GMs were achieved for each child. Data were graphically displayed to obtain growth curves of motor optimality scores. RESULTS: GMs in children with DS are characterised by low-low/moderate speed, large-large/moderate amplitude, partially creating impression of fluency, smoothness and complexity, abrupt beginning and end, few other concurrent gross movements. During the 6 months, all children showed an improvement of qualitative and semi-quantitative evaluation, but it was possible to observe great heterogeneity among children in the evolutionary course. GMs evaluation of children with no known motor problems was normal, showing only slight and transient abnormalities at first months. CONCLUSION: GMs character of children with DS could be related to central nervous system and peripheral abnormalities characterizing this syndrome. The evaluation of GMs in children with DS could be an early marker of motor impairment and help in early management decisions making.

48. Garcia JM, Gherpelli JL, Leone CR.
The role of spontaneous general movement assessment in the neurological outcome of cerebral lesions in preterm infants..
J Pediatr (Rio J) 2004, 80: 296-304.

OBJECTIVE: To study the relationship among the quality, type, and trajectory of general movements in preterm infants and neonatal cranial ultrasonography findings and neurological outcome. METHOD: Forty preterm newborn infants, with gestational ages under 35 weeks, had their general movements recorded through video-tape during the preterm, term (37th - 42nd postconceptional weeks of age) and post-term (49th - 56th postconceptional weeks of age) periods, and were prospectively followed up to one-year conceptional age. RESULTS: Our results showed that the quality of general movements, particularly in the post-term period (p = 0.009), were related with the presence of severe cerebral lesions in the neonatal cranial ultrasonography and the neurological outcome. While the presence of severe ultrasonography lesions was associated with an adverse neurological outcome (p = 0.01), the finding of normal general movements patterns was associated with a normal neurological outcome, with negative predictive values of 100%, for the preterm, and 80%, for both term and post-term periods. CONCLUSIONS: When concurrently used, these evaluation methods may increase the specificity and sensitivity in detecting the group of preterm infants at high risk for neurological disturbances in long-term follow-up.

47. Palmer FB.
Strategies for the early diagnosis of cerebral palsy.
J Pediatr 2004, 145: S8-S11.

Strategies for the early detection and diagnosis of cerebral palsy include multiple measures of the underlying brain abnormalities and their neurodevelopmental consequences. These measures can be grouped into the categories of pathogenesis, impairment, and functional limitation. Neuroimaging techniques are the most predictive measures of pathogenesis of cerebral palsy in both the preterm and term infant. Measures of neurological impairment focusing on muscle tone, reflexes, and other features of the neurological examination are poorly predictive in the first months of life. Detection of functional limitations manifested by motor developmental delay is sensitive and specific for later cerebral palsy, but not until well into the second 6 months of life. Abnormal spontaneous general movements in the infant 16 to 20 weeks postterm and earlier reflect functional limitations in the first months of life and have been shown to predict later cerebral palsy. Recognition of abnormal spontaneous general movements may improve early detection and diagnosis of cerebral palsy if these techniques can be successfully incorporated into organized follow-up programs and developmental surveillance. Copyright 2004 Elsevier Inc.

46. Hadders-Algra M.
General movements: A window for early identification of children at high risk for developmental disorders.
J Pediatr 2004, 145: S12-S18.

Detection of children with a developmental disorder, such as cerebral palsy, at an early age is notoriously difficult. Recently, a new form of neuromotor assessment of young infants was developed, based on the assessment of the quality of general movements (GMs). GMs are movements of the fetus and young infant in which all parts of the body participate. The technique of GM assessment is presented and the features of normal, mildly abnormal, and definitely abnormal GMs discussed. Essential to GM assessment is the Gestalt evaluation of movement complexity and variation. The quality of GMs at 2 to 4 months postterm (so-called fidgety GM age) has been found to have the highest predictive value. The presence of definitely abnormal GMs at this age--that is, GMs devoid of complexity and variation--puts a child at very high risk for cerebral palsy. This implies that definitely abnormal GMs at fidgety age are an indication for early physiotherapeutic intervention. Copyright 2004 Elsevier Inc.

45. Zuk L, Harel S, Leitner Y, Fattal-Valevski A.
Neonatal general movements: an early predictor for neurodevelopmental outcome in infants with intrauterine growth retardation.
Child Neurol 2004, 19: 14-18.

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.

44. Sival DA, Brouwer OF, Meiners LC, Sauer PJ, Prechtl HF, Bos AF.
The influence of cerebral malformations on the quality of general movements in spina bifida aperta.
Eur J Pediatr Surg 2003, 13: S29-S30.

43. Takaya R, Yukuo K, Bos AF, Einspieler C.
Preterm to early postterm changes in the development of hand-mouth contact and other motor patterns.
Early Hum Dev 2003, 75:S193-S202.

Hand-mouth contacts (HMCs) and other spontaneous movements of five low-risk preterm infants were studied longitudinally after their birth until 60 weeks postmenstrual age. For all infants, HMCs that emerged in the preterm period could not be observed transiently after 45 weeks, however, they re-emerged after 50 weeks postmenstrual age. In actograms of the infants' behaviors, the frequency of other spontaneous movements, such as head rotation, showed the same re-emerging pattern. Movements such as cloni, which were also observed in the preterm period, decreased after the term period, with no subsequent increase. Only general movements were continuously present throughout the entire observation period; these changed from writhing to fidgety in nature around the third month. These findings clarify which spontaneous movements of preterm infants are important for later behavioral development.

42. Dibiasi J, Einspieler C.
Load perturbation does not influence spontaneous movements in 3-month-old infants.
Early Hum Dev 2004, 77:37-46.

BACKGROUND: The assessment of the quality of general movements (GMs) in young infants is a reliable and valid diagnostic tool for detecting brain dysfunction early in life. Of special interest is a type of GMs called fidgety movements (FMs) characteristic for 3- to 5-month-old infants. GMs are part of an infant's spontaneous motor repertoire and as such endogenously generated by the nervous system. Visual, acoustic and social stimuli hardly had any influence on FMs. AIM: Our main purpose was to find out whether FMs are sensitive to load perturbation. STUDY DESIGN: Spontaneous motility in supine position, with and without weighting was recorded on video and the data were semiquantitatively analysed. Weights were attached to the ankles and wrists of all four limbs; on one side of the body only; or without visual feedback of the weighted arm. SUBJECTS: We studied 29 healthy infants with normal FMs at the age of 12 weeks. RESULTS: Spontaneous motility remained symmetrical during all the experimental trails. Weighting had no influence on the quality or temporal organisation of FMs. CONCLUSION: This study demonstrated that the mechanisms responsible for FMs in 3-month-old infants are all but impervious to weight perturbation, at least not with the loads studied. FMs is the stable and predominant motor pattern of this age.

41. Guzzetta A, Mercuri E, Rapisardi G, Ferrari F, Roversi MF, Cowan F, Rutherford M, Paolicelli PB, Einspieler C, Boldrini A, Dubowitz L, Prechtl HF, Cioni G.
General movements detect early signs of hemiplegia in term infants with neonatal cerebral infarction.
Neuropediatr 2003, 34:61-66.

Background. Studies have reported that infants with hemiplegia of congenital origin may have a period between birth and up to 12 months when clinical signs of hemiplegia are not evident. The aim of this study was to establish whether the assessment of general movements (GMs) may help in the earlier detection of signs of hemiplegia. Subjects and Methods. Eleven infants with cerebral infarction on brain MRI, and eleven normal controls were enrolled in the study. Quality of GMs was assessed from videotapes between 3 and 6 weeks and between 9 and 16 weeks. Neurological outcome was evaluated at least at two years. Results. Seven of the 11 infants had an assessment performed between 3 and 6 weeks: abnormal GMs were observed in all the infants who developed hemiplegia, but one child had abnormal GMs and a normal outcome. All 11 infants had a scorable assessment between 9 and 16 weeks. In all a specific type of GMs, fidgety movements (FMs), were predictive of neurological outcome. The presence of early asymmetries at both 3 - 6 and 9 - 16 weeks was also significantly associated with later signs of hemiplegia. Conclusions. The assessment of GMs after the neonatal period appears to be very useful in the early identification of hemiplegia in infants with cerebral infarction. Whilst the prediction of hemiplegia should be possible from early neonatal MRI brain scans, this facility is not always available. Observation of GMs is a bedside clinical approach that allows confirmation of early prediction from MRI, early rehabilitation if needed and reassurance that neurological outcome will be good where that is appropriate.

40. Parisi P, Francia A, Vanacore N, Fiore S, Giallonardo AT, Manfredi M.
Psychomotor development and general movements in offspring of women with epilepsy and anticonvulsant therapy.
Early Hum Dev 2003, 74:97-108.

While the role of antiepileptic drug (AED) therapy in teratogenesis has widely been investigated, there are few prospective studies on later postnatal development in offspring of epileptic women in utero exposed. The aim of this study was a prospective investigation of the psychomotor development in a selected population of infant born to women with epilepsy on AED therapy during pregnancy. PATIENTS AND METHODS: Children were assessed at various times until 30 months of age by general movement (GMs) observation (at 7 days and 4 and 13 weeks), traditional neurologic examination (at 7 days and 4 and 13 weeks, 6, 9 and 12 months) and Brunet-Lezine (B-L) administration (at 30 months). We present the preliminary results of our study conducted on 11 children. RESULTS: Psychomotor delay in children was confirmed by traditional neurological examinations scores at 7 days, 4 weeks, 13 weeks and 6 months and by B-L score at 30 months. Between 9 and 12 months of age, traditional neurologic examination became "silent". GM assessment was found to be a better predictor of psychomotor development. In fact, GM analysis, particularly at 4 weeks, was strongly correlated with the Brunet-Lezine score at 30 months. In conclusion, on the basis of these data we suggest a psychomotor delay in the offspring of epileptic women and that GMs and neurologic evaluation provide complementary information concerning psychomotor development and later outcome of these children.

39. Bos AF, Dibiasi J, Tiessen AH, Bergman KA.
Treating preterm infants at risk for chronic lung disease with dexamethasone leads to an impaired quality of general movements.
Biol Neonate 2002, 82:155-158.

Mortality rates do not decline markedly after postnatal corticosteroid therapy and concern has been raised about its neurological sequelae. We studied 37 preterm infants with Prechtl's method for the qualitative assessment of general movements before, during and after dexamethasone therapy and found that the quality of general movements was impaired in 9 of 13 initially normal infants (p = 0.004, McNemar test). The quality of fidgety movements at 3 months was abnormal in the majority of the infants and correlated strongly with neurological abnormalities at 2 years (Spearman r = 0.785, p < 0.001). Prechtl's method may prove useful for the early neurological evaluation of alternative corticosteroid treatment strategies for the treatment of chronic lung disease.

38. Einspieler C, Cioni G, Paolicelli PB, Bos AF, Dressler A, Ferrari F, Roversi MF, Prechtl HFR.
The early markers for later dyskinetic cerebral palsy are different from those for spastic cerebral palsy.
Neuropediatr 2002, 33: 73-78.

Qualitative abnormalities of spontaneous motor activity in newborns and young infants are early predictive markers for later spastic cerebral palsy. Aim of this research was to identify which motor patterns may be specific for later dyskinetic cerebral palsy. In a large, prospectively performed longitudinal study involving four European hospitals we identified twelve cases with the relatively rare condition of dyskinetic cerebral palsy and compared their early motor development with twelve spastic cerebral palsy cases and twelve controls. From birth to the fifth month post-term, all infants were repeatedly videoed and their spontaneous motor patterns, including general movements, were assessed. Until the second month post-term, the infants that later became dyskinetic displayed a poor repertoire of general movements, "arm movements in circles" and finger spreading. Abnormal arm and finger movements remained until at least five months and were then concurrent with a lack of arm and leg movements towards the midline. Later dyskinetic infants share with later spastic infants the absence of fidgety movements, a spontaneous movement pattern that is normally present from three to five months. Qualitative assessment of spontaneous motor patterns enabled us to identify infants at high risk for dyskinetic cerebral palsy early in life. Additionally, we were able to discriminate them from those infants at high risk for later spastic cerebral palsy. This is a matter of significant clinical relevance because the two types of cerebral palsy ask for different management and early intervention.

37. Ferrari F, Cioni G, Einspieler C, Roversi F, Bos AF, Paolicelli PB, Ranzi A, Prechtl HFR. Cramped synchronised general movements in preterm infants as an early marker for cerebral palsy.
Arch Pediatr Adolesc Med 2002, 156:460-467

OBJECTIVE: To ascertain whether specific abnormalities (ie, cramped synchronized general movements [GMs]) can predict cerebral palsy and the severity of later motor impairment in preterm infants affected by brain lesions. DESIGN: Traditional neurological examination was performed, and GMs were serially videotaped and blindly observed for 84 preterm infants with ultrasound abnormalities from birth until 56 to 60 weeks' postmenstrual age. The developmental course of GM abnormalities was compared with brain ultrasound findings alone and with findings from neurological examination, in relation to the patient's outcome at age 2 to 3 years. RESULTS: Infants with consistent or predominant (33 cases) cramped synchronized GMs developed cerebral palsy. The earlier cramped synchronized GMs were observed, the worse was the neurological outcome. Transient cramped synchronized character GMs (8 cases) were followed by mild cerebral palsy (fidgety movements were absent) or normal development (fidgety movements were present). Consistently normal GMs (13 cases) and poor repertoire GMs (30 cases) either lead to normal outcomes (84%) or cerebral palsy with mild motor impairment (16%). Observation of GMs was 100% sensitive, and the specificity of the cramped synchronized GMs was 92.5% to 100% throughout the age range, which is much higher than the specificity of neurological examination. CONCLUSIONS: Consistent and predominant cramped synchronized GMs specifically predict cerebral palsy. The earlier this characteristic appears, the worse is the later impairment.

36. Dibiasi J, Einspieler C.
Spontaneous movements are not modulated by visual and acoustic stimulation in three months old infants.
Early Human Dev 2002, 68: 27-37.

Background: The assessment of the quality of general movements (GMs) in infants proves to be a reliable and valid diagnostic tool for detecting brain dysfunction early in life. Of special interest, particularly for the prediction of cerebral palsy, is the fidgety kind of GMs, the so-called fidgety movements (FMs) observable in 3- to 5-month-old infants. GMs are part of an infant's spontaneous motor repertoire and as such endogenously generated by the nervous system itself. Aim: The question was raised as to what extent the temporal organisation of FMs can be modulated by visual and acoustic stimulation. Study design: Spontaneous motility in supine position with and without stimulation was recorded on video and the data were semiquantitatively analysed. We studied the effect of visual stimulation (red ring, red puppet), unanimated acoustic stimulation (68, 77, 88 dB) and of the mother, approaching her infant in a talkative manner after an absence of a quarter of an hour. Subjects: Twenty-nine healthy infants at the age of 12 weeks who all showed normal FMs. Results: Visual stimulation demonstrated that only the presentation of a red puppet elicited a significant level of focussed attention and led to a decrease of FMs. A red ring, unanimated acoustic stimulation as well as the interaction with the mother had no influence on the temporal organisation of FMs. Conclusion: This study demonstrated that in 3-month-old infants, FMs is a predominant motor pattern and that it is possible to assess FMs during (playful) social interaction.

35. Prechtl HF, Cioni G, Einspieler C, Bos AF, Ferrari F.
Role of vision on early motor development: lessons from the blind.
Dev Med Child Neurol 2001 Mar;43(3):198-201

For a better understanding of the contribution vision makes to the development of other sensory systems and to movement and posture, we studied effects of early blindness by examining video recordings of 14 totally blind infants. Infants were born at term or preterm and showed no evidence of brain damage. During preterm and term periods no noticeable changes in motor activity were observed. Around 2 months postterm all infants showed clear delay in head control and abnormal, exaggerated type of 'fidgety movements'. Later, postural control was characterized by a prolonged period of ataxic features. Results indicate a lack of normal calibration exerted by vision on proprioceptive and vestibular systems. Early visuomotor coordination such as coordinated eye-head scanning and head orientating were present but disappeared after several weeks.

34. Prechtl HFR.
General movement assessment as a method of developmental neurology: new paradigms and their consequences. The 1999 Ronnie MacKeith Lecture.
Dev Med Child Neurol 2001; 43: 836-842.

33. Bos AF, Einspieler C, Prechtl HFR.
Intrauterine growth retardation, general movements, and neurodevelopmental outcome: a review.
Dev Med Child Neurol 2001; 43: 61-68.

32. Bos AF, Venema IMJ, Bergervoet M, Zweens MJ, Pratl B, van Eykern LA.
Spontaneous motility in preterm infants treated with indomethacin.
Biol Neonate 2000; 78: 174-180.

Objective: To determine in preterm infants with a patent ductus arteriosus (PDA) the effect of indomethacin treatment on spontaneous motor activity. Study Design: Motor activity was assessed from repeated videotape recordings in 32 preterm infants (less than or equal to 33 weeks gestation). Sixteen infants required indomethacin therapy for treatment of PDA, 16 were control infants, matched for gestational age. Indomethacin (0.2 mg/kg i.v. in 5 min) was given thrice, with an interval of 12 h. One-hour recordings were made immediately before and immediately after the first dose of indomethacin and 24 h later before and after the third dose. The same recording schedule was used for the control infants. The effects of indomethacin on quantity and quality of spontaneous motor activity were examined. Results: A significant reduction in the quantity of several spontaneous movement patterns and an increase in the occurrence of rest periods were found following the first indomethacin administration (p < 0.01). Concerning the quality of general movements, a reduction in the speed was found (p < 0.05). Both effects were not found after the third indomethacin administration. Conclusion: In preterm infants with a PDA, treatment with indomethacin leads to a transient reduction in the quantity of spontaneous movement patterns and to a decrease in the speed of general movements. We recommend a cautious use of bolus indomethacin for the treatment of PDA.

31. Cioni G, Bos AF, Einspieler C, Ferrari F, Martijn A, Paolicelli PB, Rapisardi G, Roversi MF, Prechtl HFR.
Early neurological signs in preterm infants with unilateral intraparenchymal echodensity.
Neuropediatrics 2000; 31: 240-251.

The aim of the study was to document the early developmental course of neurological signs in a group of preterm infants at risk for hemiplegia, due to unilateral intraparenchymal echodensity (UIPE). Sixteen preterm infants with UIPE and sixteen controls were given serial neurological examinations, according to the protocols currently adopted in the different NICUs of the project. Moreover, the quality assessment of their general movements (GMs) was assessed subsequently from videotapes, from birth until around four months postterm. At two years, 12 of the UIPE infants showed hemiplegia and one suffered from asymmetrical diplegia. The findings of the traditional neurological examination were abnormal for the large majority of the UIPE group, although normal findings were also recorded, especially during the preterm period. Asymmetries were found after term age in nine UIPE and in two control infants. From the first observation onwards, all infants with UIPE showed bilaterally abnormal GMs and in those with unfavourable outcome fidgety movements (FMs) were absent. At the FMs period (9-16 weeks postterm), all infants with subsequent hemiplegia showed asymmetry of distal segmental movements which were reduced or absent on the side contralateral to the lesion.
Conclusions: Unilateral brain lesions induce clear neurological signs and abnormal GMs in particular, although these abnormalities are not initially asymmetrical. A reduction of segmental movements on one side of the body during the third month postterm is highly predictive of hemiplegia.

30. Bos AF, Einspieler C, Prechtl HFR, Touwen BCL, Okken-Beukens MD, Stremmelaar AF.
The quality of spontaneous motor activity in preterm infants as early predictive signs for minor neurological abnormalities at 2 years.
Newsletter Neonatal Neurology 1999; 8: 4-5.

Objective: To determine in preterm infants with a patent ductus arteriosus (PDA) the effect of indomethacin treatment on spontaneous motor activity. Study Design: Motor activity was assessed from repeated videotape recordings in 32 preterm infants (less than or equal to 33 weeks gestation). Sixteen infants required indomethacin therapy for treatment of PDA, 16 were control infants, matched for gestational age. Indomethacin (0.2 mg/kg i.v. in 5 min) was given thrice, with an interval of 12 h. One-hour recordings were made immediately before and immediately after the first dose of indomethacin and 24 h later before and after the third dose. The same recording schedule was used for the control infants. The effects of indomethacin on quantity and quality of spontaneous motor activity were examined. Results: A significant reduction in the quantity of several spontaneous movement patterns and an increase in the occurrence of rest periods were found following the first indomethacin administration (p < 0.01). Concerning the quality of general movements, a reduction in the speed was found (p < 0.05). Both effects were not found after the third indomethacin administration. Conclusion: In preterm infants with a PDA, treatment with indomethacin leads to a transient reduction in the quantity of spontaneous movement patterns and to a decrease in the speed of general movements. We recommend a cautious use of bolus indomethacin for the treatment of PDA.

29. Bos AF. Analysis of movement quality in preterm infants.
Europ J Obstet Gynecol Reprod Biolog 1998; 76: 117-119.

28. Bos AF, Martijn A, van Asperen RM, Hadders-Algra M, Okken A, Prechtl HFR.
Qualitative assessment of general movements in high risk preterm infants with chronic lung disease requiring dexamethasone therapy.
J Ped 1998; 132:300-306.

OBJECTIVE: The objective of this study was to determine in preterm infants at risk for severe chronic lung disease (1) the quality of general movements (GMs) and (2) the effect of dexamethasone treatment on spontaneous motor activity. STUDY DESIGN: In 15 very low birth weight infants the quality of GMs was assessed from repeated videotape recordings. Recordings were made at weekly intervals during the preterm period until term age and thereafter three times until the twentieth postterm week. All infants required dexamethasone therapy, and additional recordings were made a few hours before and 24 hours, 48 hours, and 7 days after dexamethasone was started. The relationship among movement quality, brain ultrasonographic abnormalities, and long-term outcome was explored. Acute effects of dexamethasone on motor activity were examined. RESULTS: After dexamethasone therapy was started, a significant transient reduction of the quantity of most spontaneous movements (p < 0.05) and a reduction of speed and amplitude of GMs was found (p < 0.05). A significant relationship was found between the severity of brain ultrasonographic abnormalities and the extent to which developmental trajectories of GMs were abnormal (p < 0.001). The development of cerebral palsy was related to the presence of cramped-synchronized movements near term (p < 0.02) and to the absence of fidgety movements at the age of 3 months after term (p < 0.05). CONCLUSION: In preterm infants with severe chronic lung disease and brain lesions, dexamethasone treatment leads to an acute reduction in motility and changes in the speed and amplitude of GMs. Until more is known about long-term neurologic sequelae, a cautious use of systemic dexamethasone therapy in preterm infants is recommended.

27. Bos AF, Martijn A, Okken A, Prechtl HFR. Quality of general movements in preterm
infants with transient periventricular echodensities.
Acta Paediatr 1998; 87: 328-335.

By means of sequential videotape recordings, the relevance of the quality of general movements for neurological outcome was determined in a group of 21 appropriate-for-gestational-age preterm infants with transient periventricular echodensities of variable localization and duration and in 6 infants without echodensities. Echodensities, especially in the parieto-occipital area, affected the quality of general movements. Echodensities persisting beyond 14d were associated with abnormal general movements; infants with echodensities up to 14 d had either normal or abnormal general movements. The developmental course of movement quality was correlated to neurological outcome (p < 0.005): normal outcomes were found in 11/12 infants with normal general movements throughout and in 9/11 infants with transient abnormal general movements; all 4 infants with persistent abnormal general movements had impaired outcomes. In infants with transient echodensities, longitudinal assessment of the quality of general movements helps to determine if there is brain dysfunction, either transient or persistent, and identifies infants at risk for impaired neurological outcomes.

26. Bos AF, van Asperen R M, de Leeuw DM, Prechtl HFR The influence of septicaemia on spontaneous motility in preterm infants.
Early Hum Dev 1997, 50: 61-70.

The qualitative assessment of general movements (GMs) in preterm infants is a sensitive method to investigate the integrity of the central nervous system. The question arises whether systemic infections affect the quality of GMs in a similar fashion to brain lesions. We were able to provide an answer to this problem in six infants (gestational age 24.4-32.4 weeks, birth weight 600-1660 grams), who had initially normal GMs as analyzed from sequential video-recordings. All infants sustained a proven septicaemia (Candida albicans in two, Staphylococcus aureus in three, a coagulase-negative staphylococcus in one infant). Unintentionally, recordings were also made during the acute phase. The complexity and variability of the GMs remained largely intact in five of the six infants; only one infant had transiently abnormal GMs. Compared with 1 week before the acute phase, the speed and amplitude of the GMs were diminished, giving the GMs a sluggish appearance. One to two weeks after the acute phase of septicaemia, the quality of GMs, i.e. speed and amplitude, had normalized in all infants. This study demonstrates that it is possible to discriminate between abnormal GMs due to cerebral lesions and sluggish GMs due to severe systemic infections, when the complexity of the GMs is considered as the main characteristic for judgement of normality of GM-quality.

25. Bos AF, van Loon A J, Hadders-Algra M, Martijn A, Okken A, Prechtl HFR. Spontaneous motility in preterm, small for gestational age infants. II. Qualitative aspects.
Early Hum Dev 1997, 50: 131-147.

In order to document in detail the developmental course of qualitative aspects of early spontaneous motility in intrauterine growth-retarded infants, sequential videotape recordings were made in 19 preterm infants with a birth weight below the 5th percentile. The quality of general movements (GMs) was studied longitudinally during the preterm and postterm period until approximately 20 weeks corrected age, using Prechtl's method of quality assessment. An abnormal quality of GMs was present in 15 out of 19 infants. Compared to a low-risk group, consisting of appropriate-for-gestational age preterm infants, the proportion of infants with normal findings on brain scans who had an abnormal quality of GMs was high. The presence of 'abrupt chaotic' GMs was related to late fetal heart-rate decelerations and ischaemic alterations of the placenta. The quality of GMs normalized before or during the third month postterm in most infants with abnormal GMs. In four infants, the GMs did not normalize during the study period. The quality of fidgety movements was, in particular, a marker for neurological outcome at 24 months. This study demonstrates that intrauterine growth retardation may cause prolonged, but in most cases transient brain dysfunction; the qualitative assessment of GMs may help to identify infants at increased risk for neurodevelopmental abnormalities.

24. Cioni G, Ferrari F, Einspieler C, Paolicelli PB, Barbani MT, Prechtl HFR.
Comparison between observation of spontaneous movements and neurological examination in preterm infants.
J Ped 1997; 130: 704-711.

OBJECTIVE: The Prechtl method of qualitative assessment of general movements (GMs) has been shown to be a good predictor of neurologic outcome in fetuses, preterm infants, and term infants. The aim of this study was to compare the results of this new technique with those of traditional neurologic examination and of cranial ultrasonography in preterm infants. METHODS: Serial videotape recordings (with off-line assessment of GMs), ultrasound examination of the brain, and neurologic examinations were performed from birth until about 6 months of corrected age, on a group of 66 preterm infants whose gestational age ranged from 26 to 36 weeks (mean 30.7 weeks). The agreement between the two techniques and their predictive power, with respect to the neurologic outcome at 2 years of corrected age, were evaluated for five different age groups from preterm age to 65 weeks of postmenstrual age. RESULTS: Overall agreement of the neurologic and GM findings was 80.3% and strongly age related (lower during the preterm and term periods and higher thereafter). At all ages the results of GM observation correlated highly with neurologic outcome; they showed higher sensitivity and specificity than the neurologic examination. This held true in particular before term age, when poor neurologic responses might be related to transient complications, and at term age, mainly because of infants with normal neurologic examination results but unfavorable outcome. During the preterm period the ultrasound results showed a better specificity and a lower sensitivity to outcome than GM findings. CONCLUSIONS: The results of this study indicate that quality assessment of GMs should be added to traditional neurologic assessment, neuroimaging, and other tests of preterm infants for diagnostic and prognostic purposes.

23. Cioni G, Prechtl HFR, Ferrari F, Paolicelli PB, Einspieler C, Roversi MF. Which
better predicts later outcome in fullterm infants: quality of general movements or neurological examination?
Early Hum Dev 1997, 50: 71-85.

The qualitative assessment of general movements (GMs) has been shown to be a better predictor of neurological outcome than the traditional neurological examination in brain-damaged preterm infants. The aim of this study was to compare the results of the two techniques in term infants. Off-line assessment of GMs from videorecordings and neurological examinations were carried out, from birth till about 6 months of postterm age, in a group of 58 term infants, the majority of which were affected by mild to severe hypoxic-ischaemic encephalopathy. The agreement between the two techniques and their predictive power, with respect to the neurological outcome at 2 years, were evaluated for four age groups. The range of agreement between neurological and GM findings was between 78 and 83%. At all ages the results of GM observation correlated highly with the neurological outcome; their sensitivity and specificity with respect to outcome were consistently slightly superior to those of neurological examination. In infants normalize after an initial period of transient abnormalities, GMs normalize earlier than the neurological results.

22. Einspieler C, Prechtl HFR, Ferrari F, Cioni G, Bos AF. The qualitative assessment of general movements in preterm, term and young infants - review of the methodology.
Early Hum Dev 1997, 50: 47-60.

We describe the state of the art of Prechtl's method for the qualitative assessment of general movements as a diagnostic tool for early detection of brain dysfunction. After discussing the optimal technique for video recording general movements in preterm, term and young infants, attention is focused on the proper analysis of this spontaneous motor pattern. Recently, a group of active researchers in the field reached consensus on the various qualities of normal and abnormal general movements. These definitions are reported here in full. Since it is a newly introduced method careful investigation into its reliability is required. Various groups of investigators have obtained data which demonstrate the robust character of the method (interscorer agreement: 78-98%). Finally, we discuss the validity of this early assessment method on the basis of the reports published so far. While the method's sensitivity is similar in all age groups studied (preterm, term, first month, second month, and third month age epochs), and averages 94.5%, the specificity of the method is age-dependent. It is low during the early ages, increases gradually and reaches 82 to 100% at 3 months post-term. This phenomenon is explained by spontaneous recovery of early dysfunction. In contrast, consistent abnormalities of general movements are linked to neurological deficits found at the 2 year follow-up.

21. Ferrari F, Prechtl HFR, Cioni G, Roversi MF, Einspieler C, Gallo C. Paolicelli PB,
Cavazutti GB. Behavioural states, posture and spontaneous movements in infants affected by brain malformation.
Early Hum Dev 1997, 50: 87-113.

Posture, quantity of spontaneous movement patterns, quality of general movements (GMs), and behavioural state organisation were studied in nine infants affected by documented brain malformations. A single 1 h video recording of five infants and two or more serial video recordings of another four infants were performed after birth. The graphic representation of single movement patterns (actogram) and of behavioural states of one video recording was performed in eight out of nine infants. The quality of GMs was assessed according to Prechtl's method in all video recordings. All nine infants showed a less variable posture than normal newborn infants and an unusual resting posture was detected in seven infants. Poor behavioural state organisation without sleep cycles was common to the nine infants and excessive wakefulness was observed in six infants. As for the quantity of single movement patterns, six infants lacked one or two movement patterns normally present in healthy newborn infants. An abnormal quality of GMs was noted in all nine infants and distinct motor abnormalities were observed in single infants. A monotonous and sometimes stereotyped sequence of different body parts involved in the movement (i.e. poor repertoire GMs) was common to all infants. In the four infants of whom two or more video recordings were available, initial poor repertoire GMs were followed by a further deterioration in movement quality. No relationship was found between the quantity of defective brain tissue, lack of a specific part of the brain, type and severity of GM and posture abnormalities.

20. Kainer F, Prechtl HFR, Engele H, Einspieler C. Prenatal and postnatal assessment of the quality of general movements in infants of women with type-I diabetes mellitus.
Early Hum Dev 1997, 50: 13-25.

The effect of type-I diabetes on the quality of general movements (GMs) was studied longitudinally in 12 human fetuses. GMs were analysed at two-weekly intervals from 16 weeks until delivery. A pregnancy optimality-score and a diabetes optimality-score were used to cover the course of the pregnancy and delivery and the severity of diabetes. GMs of infants were analysed 1, 4-6, and 12-18 weeks after birth and the Bayley developmental test was performed at 10 months. All fetuses showed normal GMs at 16 weeks. From 20 weeks onwards until delivery five fetuses developed abnormal GMs. The diabetes optimality-score was significantly lower in the group with abnormal GMs (P = 0.018) whereas the pregnancy optimality-score did not differ between fetuses with normal and abnormal GMs. Our results indicate that type-I diabetes can have a negative impact on prenatally observed GMs. Consistently normal GMs indicate normal neurodevelopmental outcome at 10 months whereas in the group with abnormal GMs reduced Bayley-scores may occur.

19. Prechtl H.F.R. (ed). Spontaneous Motor Activity as a Diagnostic Tool. Functional
Assessment of the Young Nervous System.
Early Hum Dev, Special Issue, 1997, Vol. 50 (1), pp:148.

18. Prechtl H.F.R. State of the art of a new functional assessment of the young nervous
system. An early predictor of cerebral palsy.
Early Hum Dev 1997, 50: 1-11.

The paper provides a survey of the state of the art of a new neurological diagnostic procedure in fetuses, preterm and term infant as well as in young infants. This method consists of a judgement of the movement quality of a particular type of spontaneous movements, the so-called general movements. At a very early age normal and abnormal general movement quality predicts the neurological outcome over 2 years, in particular cerebral palsy. The reliability of this method turned out to be very robust. Recent animal experiments on isolated parts of the central nervous system provide convincing evidence of endogenously generated neural activity. Similar neural mechanisms must provide the basis for spontaneous movements seen in the human at early ages. Those neural defects leading to qualitative changes of general movements are described in detail.

17. Prechtl HFR, Einspieler C. Is neurological assessment of the fetus possible?
Eur J Obstet Gynecol Reprod Biol 1997; 75: 81-84.

The possibility to assess the functional condition of the fetal nervous system is of great importance to the obstetrician, since a considerable part of early brain damage is of prenatal origin. Several attempts to develop such a technique are reviewed. In addition, a new method, the qualitative assessment of fetal general movements, is described as a successful tool to obtain reliable data on the fetal brain dysfunction. This new method is robust, non-intrusive and cost-effective. There is also the advantage that the same criteria for the diagnostic assessment can be used for the fetus as well as for the young infant.

16. Prechtl HFR, Einspieler C, Cioni G, Bos AF, Ferrari F, Sontheimer D. An early
marker for neurological deficits after perinatal brain lesions.
Lancet 1997; 349: 1361-1363

BACKGROUND: In normal awake infants, fidgety movements are seen from the age of 6 weeks to 20 weeks. The aim of the study was to test the predictive value of absent or abnormal spontaneous movements in young infants for the later development of neurological deficits. METHODS: In a collaborative study involving five hospitals we collected data on the normal and abnormal quality of fidgety movements of 130 infants and compared it with assessments of neurological development done longitudinally until the age of 2 years. On the basis of ultrasound scans infants were classified as at low-risk or at high-risk of neurological deficits. Infants were videoed for 1 h every week from birth to discharge and then for 15 min every 3 to 4 weeks; quality of general movements was assessed. Repeated neurological assessments were also done until 24 months of corrected age. FINDINGS: 67 (96%) of 70 infants with normal fidgety movements had a normal neurological outcome. Abnormal quality or total absence of fidgety movements was followed by neurological abnormalities in 57 (95%) of the 60 infants (49 had cerebral palsy and eight had developmental retardation or minor neurological signs). Specificity and sensitivity of fidgety movement assessment were higher (96% and 95%, respectively) than of ultrasound imaging of the infants' brain (83% and 80%, respectively). INTERPRETATION: Our technique of assessing spontaneous motor activity can identify and distinguish between those infants who require early intervention for neurological abnormalities and those who do not. Our technique is simple, non-intrusive, reliable, quick, and can be done on very young infants.

15. Albers S, Jorch G. Prognostic significance of spontaneous motility in very immature
preterm infant under intensive care treatment.
Biol. Neonate 1994; 66: 182-187.

Qualitative analysis of spontaneous motility was performed in 22 preterm infants (gestational age 25-31 weeks) on the intensive care unit. The infants were videorecorded once a week in the late afternoon during 1 h until 36 weeks of gestation. Quality of movement was analyzed by 8 observers using visual 'Gestalt perception' and compared with the neurological outcome 1 year after term. A normal quality of movement consistently predicted a normal neurological outcome with a probability of 90-100%. An abnormal quality of movement predicted an abnormal outcome with a probability of only 56% in the first, but with a probability of 82% in the third postnatal week. The average interobserver agreement was 78%. The analysis of spontaneous motility for the early diagnosis of neurological dysfunctions can reliably be applied on very immature preterms under intensive care conditions from the 3rd postnatal week on.

14. Einspieler C. Abnormal spontaneous movements in infants with repeated sleep apnoaes.
Early Hum Dev 1994; 36: 31-49.

Infants with repeated apnoea during sleep have received great attention for the assumed reason of being at-risk for sudden infant death. The present paper reports findings which indicate a different risk, namely for neurological impairment during infancy due to repeated hypoxia. A very strong correlation exists between the respiratory measurements based on a polygraphic all-night recording (PtcO2 drops and apnoea incidence and duration) and the impairment of the spontaneous movement repertoire in 114 infants, aged between 3 and 26 weeks. All infants have been video recorded at the same day as the registration of the sonogram. As there was a gradient of respiratory abnormalities from absent to severe, a similar gradient was present in the degree of motor deviations in these infants. A variety of qualitative changes in the spontaneous movement patterns was found which was similar to those previously described in cases with documented brain damage. These abnormalities could not be attributed to pre- and perinatal complications. It is concluded that infants with repeated sleep apnoea need special attention for prevention of neurological impairment irrespective of the supposed risk for sudden infant death.

13. Einspieler C. Prechtl HFR, van Eykern L, de Roos B. Observation of movements during sleep in ALTE and apnoeic infants.
Early Hum Dev 1994; 40, 39-50.

Fourteen infants of 2 months or 6 months of age were video-recorded during polysomnography. Four were normal infants, five had a history of ALTE (apparent life threatening event) and five had repeated and prolonged apnoea during sleep. Two ALTE infants have been recorded at 2 months as well as at 6 months of age. Movements during sleep could be classified into general movements, isolated movements of the upper extremity, startles, head rotations, and trunk rotations. In the ALTE cases at 2 months of age, the motility was quantitatively not different from the control infants but was markedly reduced at 6 months of age. (All cases had their event before 8 weeks of age.) In contrast to these findings, infants with repeated apnoea did not show a clear change in the quantity of their movements. With the exception of one ALTE case at 2 months, all observed cases of ALTE and apnoeic infants showed an abnormal quality of their spontaneous movements during sleep. As reported in a previous study, all these cases had also been found moving abnormally during wakefulness. It is suggested that the abnormal motility is a sequelae of the event (ALTE or repeated apnoeas) with as a consequence, an impairment of neural functions.

12. Prechtl HFR. Abnormal movements are a marker of brain impairment in fetuses and
preterm and fullterm infants. In: HC Lou, G Greisen, J Falck-Larsen (eds). Brain Lesions in the Newborn.
Copenhagen: Munksgaard. Alfred Benzon Symp 1994; 37: 314-321.

11. Prechtl HFR, Ferrari F, Cioni G. Predictive value of general movements in asphyxiated fullterm infants.
Early Hum Dev 1993; 35: 91 - 120.

The developmental course of spontaneous motility was investigated in a group of 26 fullterm infants, affected by mild to severe hypoxic-ischaemic encephalopathy. Serial 1-h videorecordings were carried out from birth to 15-22 weeks and a quality assessment of general movements (GMs) was made from a replay of the videos. Neurological follow-up of the infants were continued until at least 18 months of age; neonatal EEG and neuro-imaging techniques (US-scan, CT or MRI) were also carried out in all cases. The results indicate that perinatal asphyxia has important effects on the spontaneous motility of fullterm infants. Hypokinesis occurred very frequently during the first days of life, followed by a transient or prolonged (lasting longer than 15-22 weeks) abnormal quality of GMs. In the first 2 weeks the results of GM assessment did not correlate with the simultaneous findings of neurological examination, neuro-imaging and EEG, whereas they did when the results at 15-22 weeks were considered. The changes in spontaneous motility and especially GM developmental trajectories were good predictors of the neurological outcome. The predictive value of GM assessment was found to be similar to that of EEG and neuro-imaging, and better than neurological examination.

10. Hadders-Algra M, Prechtl HFR. Developmental course of general movements in early infancy. I. Descriptive analysis of change in form.
Early Hum Dev 1992; 28: 201-213.

In order to describe the developmental changes of general movements (GM) in early infancy and to relate them to changes in other aspects of the neurological repertoire, the spontaneous motility in supine position was recorded on video tape at 4-week intervals in a group of twenty-two full-term healthy infants aged 2-18 weeks. Each follow-up session included a neurological examination. In newborn infants GM have a 'writhing' quality. The movements are characterized by a tight appearance, a relatively slow speed and a limited amplitude. The 'writhing' character of the GM is gradually broken down into a so-called 'fidgety' quality. These GM are typified by an ongoing flow of small movements occurring irregularly all over the body. The transformation of GM from a 'writhing' character into a 'fidgety' character was related more closely to postmenstrual than to postnatal age. 'Fidgety' GM were almost constantly present at the age of 8-12 weeks. In the third month very rapid arm movements ('swipes' and 'swats') occurred. The developmental changes in the form of the GM and those of the neurological repertoire showed no significant correlation. This demonstrates that within the normal CNS the various functional modules develop autonomously.

9. Hadders-Algra M, van Eykern LA, Klip van den Nieuwendijk AW, Prechtl HFR.
Developmental course of general movements in early infancy. II. EMG correlates.
Early Hum Dev 1992; 28: 231-251.

In order to study developmental changes in muscle co-ordination during the first postnatal months, simultaneous polymyographic recordings and video-recordings were made during spontaneous movements of 22 healthy infants, who were followed from birth onwards. During the first 2 months general movements (GM) change from movements with a so-called 'writhing' character, which have a tight appearance, a relatively slow speed and a limited amplitude, into GM with a 'fidgety' character, which consist of an ongoing flow of small, elegant movements. We hypothesized that this transformation would coincide with a change from a pattern of co-contraction of antagonistic muscle groups into a pattern of reciprocal activation. This was not the case, a pattern of co-activation of antagonistic muscle groups remained the prevailing pattern. With increasing age, we found shorter burst durations of phasic activity, an attenuation of burst amplitude and a decrease of tonic background activity. These changes were attributed to a reduction of the sensitivity of the motor units due to spinal and supraspinal reorganization. It is hypothesized that the so-called 'bistable' properties of motoneurones play a central role in the observed phenomena: in neonates motor units are apt at displaying sustained activity, at 2 months of age the threshold for reaching this maintained activity increases, resulting in a low level of excitation of motor units during spontaneous movements. In the third month rapid arm movements ('swipes' and 'swats') develop. The 'swats' are characterized by a consistent pattern of reciprocal activity of antagonistic (shoulder) muscles.

8. Cioni G, Prechtl HFR. Preterm and early postterm motor behaviour in low-risk premature infants.
Early Hum Dev 1990; 23: 159-193.

The development of spontaneous motility and posture was studied longitudinally in 14 carefully selected low-risk preterm infants. The aim of this investigation was to provide a set of data suitable for comparison with fetuses and with neurologically abnormal preterm infants. The infants were videorecorded weekly, for one hour in a supine position, from birth until their discharge from the hospital. Ten of them were thereafter also observed at home at 3-week intervals from 3 to 18 weeks of corrected age, together with 10 healthy fullterm infants. Occurrence and duration of motor patterns and postures in periods of rest and activity were obtained by off-line analysis of the videotapes. Few significant changes were found from birth until term age in the composition and quantity of the spontaneous movement patterns. Only twitches and stretches during activity periods showed a small decline approaching term age. However, notable inter-individual differences and intra-individual fluctuations from week to week were observed. Postterm development of preterm infants was similar to that of the fullterms. Both showed considerable changes in the qualities of general movements after the first postterm weeks. Only fidgety character movements occur earlier in preterm infants. No age-specific preference postures of the limbs were found in the preterm period. Midline position of the head in supine was observed at about the same postterm age in preterm and fullterm groups. Asymmetrical tonic neck postures were very inconsistently present before term age and rapidly disappeared after term, earlier so in preterm infants.

7. Ferrari F, Cioni G, Prechtl HFR Qualitative changes of general movements in
preterm infants with brain lesions.
Early Hum Dev 1990; 23: 193-233.

The aims of the study were (1) to replicate previous quantitative studies of motor activity in low-risk and high-risk preterm infants and (2) to apply a new method of systematic analysis of the qualitative characteristics of general movements in these two groups of infants. Sequential one-hour videorecordings of the unstimulated infants in the incubator were made during the preterm period and then continued during the postterm period until about 20 weeks. The high-risk group consisted only of infants with signs of haemorrhage and/or leucomalacia in the repeated ultrasonograms of the brain. The neurological follow-up continued up to a minimum of one and a maximum of three years of corrected age. The quantification of the various motor patterns in 12 matched pairs of low-risk and high-risk preterm infants revealed a slight but significant (P = 0.05) excess of isolated arm movements in the low-risk cases during the activity phase. No other movement pattern differed significantly. The qualitative assessment of general movements during the preterm period resulted in all but one of the 14 low-risk cases having a normal quality of general movements. In the lesion-group (N = 29) all the infants had an abnormal quality during the preterm period. Eight cases later became neurologically normal although 1 of them had strabism. In addition, one infant was blind (ROP) and retarded and one other had mental retardation. Nineteen infants later developed cerebral palsy (two monoplegia of a leg, three hemiplegia, 5 diplegia and 9 quadriplegia). Strabism was present in 48.3% of the whole group of 29 cases. A semi-quantitative estimation of various aspects of the abnormal general movements made a typology of abnormal patterns possible. A graphic display of developmental trajectories of individual cases, depicting the course of abnormal aspects along the time axis, helps document the evolution of abnormal signs. Their course is a better predictor of the neurological outcome than the nature and localization of the lesion, detected by imaging techniques. The qualitative assessment of general movements from videorecordings is a reliable, quick, cheap and totally non-intrusive method in neonatology for the early detection of functional impairment of the nervous system.

6. Prechtl HFR. Qualitative changes of spontaneous movements in fetus and preterm infants are a marker of neurological dysfunction.
Early Hum Dev 1990; 23: 151-159.

5. Cioni G, Ferrari F, Prechtl HFR. Posture and spontaneous motility in fullterm infants.
Early-Hum Dev 1989; 18: 247-262

Posture and spontaneous motor patterns during the first days of life were studied in ten healthy fullterm infants by direct observation and videorecording. The aim of the study was to provide a description of motor and postural characteristics of normal newborns. The infants were recorded for 1 h on their first and fourth day of life, when unstimulated in an incubator. Incidence and duration of the different body postures and motor patterns were scored during the replay of the videorecordings. The preference for the fully flexed posture of arms and legs described in the literature could not be confirmed. There was a large intra- and inter-individual variability in the postural repertoire. No particular posture, characteristic for each behavioural state, existed. Similar postures rarely occurred in the same infant on the first and fourth day. Extended postures more often occurred on the fourth day. Spontaneous motility consisted of several distinct movement patterns, the occurrence of which in states 1 and 2 was computed for day 1 and day 4. Motor patterns were differently related to the states. No differences were noted in the motor activity between the first and fourth days. Large inter-individual differences, but an intra-individual consistency, were found in the rates of specific motor patterns: infants who showed a low or high rate of particular movements on day 1 maintained the same characteristic on day 4. There was no overall low or high motor activity.

4. Prechtl HFR. New perspectives in early human development.
Eur J Obstet Gynecol Reprod Biol 1986; 21: 347-355

A new hypothesis is presented concerning the maturation of the human nervous system and the duration of pregnancy. It has been found that many neural functions characteristic of the fetus continue after birth until a major transformation takes place at the end of the second postnatal month. From a comparative perspective the duration of pregnancy in man is relatively short among primates. An explanation may be found in metabolic constraint. The special energy demands of a large fetal nervous system and the build-up of a subcutaneous fat deposit may have prevented a proportional prolongation of pregnancy during evolution of hominids.

3. Prechtl HFR, Hopkins B. Developmental transformations of spontaneous movements in early infancy.
Early Hum Dev 1986; 4: 233-238.

One component of the major transformation of neural functions at the end of the second postnatal month is concerned with a change in the appearance of general movements. These endogenously generated complex movements lose their writhing character and are replaced by a transient form, termed 'fidgety' movements. There are individual differences in the age of onset and duration as revealed by longitudinal observations. It is speculated that 'fidgety' movements may be related to a postnatal calibration of the proprioceptive system.

2. Prechtl HFR. (ed.) Continuity of Neural Functions from Prenatal to Postnatal Life.
Oxford: Blackwell Scientific Publications. Clin Dev Med 1984; 94.

1. Hopkins B, Prechtl HFR A qualitative approach to the development of movements during early infancy. In: HFR Prechtl (ed.) Continuity of Neural Functions from Prenatal to Postnatal Life.
Oxford: Blackwell Scientific Publications. Clin Dev Med 1984; 94: 179-197.

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