Are sporadic fidgety movements as clinically relevant as is their absence?

General Movements Assessment in Infants with High Birth Weight

BACKGROUND

High birth weight (HBW) describes fetal birth weight of more than 4000 g. Infants with HBW have a high risk of developing neurological and developmental problems. Until recently, there were no studies in the literature that investigated the quality of spontaneous movements and the integrity of the developing nervous system in infants with HBW. The aims of this study were (1) to describe age-specific detailed early spontaneous movements in infants with HBW and (2) to compare the detailed early spontaneous movements of infants with HBW and normal birth weight (NBW).

METHODS

Twenty-two infants with HBW (median birth weight = 4190 g) and 22 infants with NBW (median birth weight = 3255 g) were included at 10 to 19 weeks post-term age (median = 13 weeks). All infants were assessed according to General Movement Assessment using three- to five-minute video recordings. Video recordings of each infant were evaluated using Motor Optimality Score for three- to five-month-old infants-Revised score sheet.

RESULTS

Motor Optimality Score-Revised (MOS-R) (P < 0.001), observed postural patterns (P < 0.001), and age-adequate movement repertoire (P = 0.005) were significantly lower in the infants with HBW. Infants with HBW had more aberrant (abnormal or absent) fidgety movements (18%) than those with NBW (0%).

CONCLUSIONS

The results of this study demonstrated that the motor repertoire of infants with HBW tended to decrease more than that of those with NBW. To enable the follow-up of progression as a result of these assessments infants in need should be referred to age-adequate early intervention programs.

Inter-rater reliability and agreement of the General Movement Assessment and Motor Optimality Score-Revised in a large population-based sample

BACKGROUND

Prechtl's General Movement Assessment (GMA) at fidgety age (3-5 months) is a widely used tool for early detection of cerebral palsy. Further to GMA classification, detailed assessment of movement patterns at fidgety age is conducted with the Motor Optimality Score-Revised (MOS-R). Inter-rater reliability and agreement are properties that inform test application and interpretation in clinical and research settings. This study aims to establish the inter-rater reliability and agreement of the GMA classification and MOS-R in a large population-based sample.

METHODS

A cross-sectional study of 773 infants from birth-cohort in Perth, Western Australia. GMA was conducted on home-recorded videos collected between 12 + 0 and 16 + 6 weeks post term age. Videos were independently scored by two masked experienced assessors. Inter-rater reliability and agreement were assessed using intraclass correlation coefficient and limits of agreement respectively for continuous variables, and Cohen's Kappa and Gwet's Agreement Coefficient, and percentage agreement respectively for discrete variables.

RESULTS

The classification of GMA showed almost perfect reliability (AC1 = 0.999) and agreement (99.9 %). Total MOS-R scores showed good-excellent reliability (ICC 0.857, 95 % CI 0.838-0.876) and clinically acceptable agreement (95 % limits of agreement of ±2.5 points). Substantial to almost perfect reliability and agreement were found for all MOS-R domain subscores. While MOS-R domains with higher redundancy in their categorisation have higher reliability and agreement, inter-rater reliability and agreement are substantial to almost perfect at the item level and are consistent across domains.

CONCLUSION

GMA at fidgety age shows clinically acceptable inter-rater reliability and agreement for GMA classification and MOS-R for population-based cohorts assessed by experienced assessors.

General movements in spinal muscular atrophy type 1

PURPOSE

To investigate the motor repertoire of infants diagnosed with spinal muscular atrophy Type I (SMA Type I) without administration of any disease-modifying agent.

METHODS

Motor Optimality Score-Revised (MOS-R) was calculated from videos recorded between post-term weeks 9-17 for 22 infants with SMA Type I. The MOS-R of infants with SMA Type I was compared with those of 22 infants with cerebral palsy (CP) and 22 infants with typical development.

RESULTS

Of the infants with SMA Type I, 17 had absent fidgety movements (FMs) and 5 had sporadic FMs. Age adequate movement repertoire was absent, and the variety of movements in infants was very low. Movements were symmetrical but movements of four limbs remained on the surface level. Antigravity movements were very rare. Movement characterization was monotonous, slow speed, and small amplitude. The MOS-R of infants with SMA Type I was lower than those of infants with typical development but similar to those of infants with CP.

CONCLUSIONS

Infants with SMA Type I had a motor repertoire similar to infants with CP, while they had a poorer motor repertoire than infants with typical development in the fidgety period as evidenced by MOS-R. Central nervous system involvement in these infants with SMA Type I with absent FMs and reduced MOS-R is unknown. Further studies are needed to determine the role of problems in the afferent and efferent pathways of spinal cord and muscle atrophy in the observation of normal FMs.

Reduction in limb-movement complexity at term-equivalent age is associated with motor developmental delay in very-preterm or very-low-birth-weight infants

Reduced complexity during the writhing period can be crucial in the spontaneous movements of high-risk infants for neurologic impairment. This study aimed to verify the association between quantified complexity of upper and lower-limb movements at term-equivalent age and motor development in very-preterm or very-low-birth-weight infants. Video images of spontaneous movements at term-equivalent age were collected from very-preterm or very-low-birth-weight infants. A pretrained pose-estimation model and sample entropy (SE) quantified the complexity of the upper- and lower-limb movements. Motor development was evaluated at 9 months of corrected age using Bayley Scales of Infant and Toddler Development, Third Edition. The SE measures were compared between infants with and without motor developmental delay (MDD). Among 90 infants, 11 exhibited MDD. SE measures at most of the upper and lower limbs were significantly reduced in infants with MDD compared to those without MDD (p < 0.05). Composite scores in the motor domain showed significant positive correlations with SE measures at most upper and lower limbs (p < 0.05). The results show that limb-movement complexity at term-equivalent age is reduced in infants with MDD at 9 months of corrected age. SE of limb movements can be a potentially useful kinematic parameter to detect high-risk infants for MDD.

Automating General Movements Assessment with quantitative deep learning to facilitate early screening of cerebral palsy

The Prechtl General Movements Assessment (GMA) is increasingly recognized for its role in evaluating the integrity of the developing nervous system and predicting motor dysfunctions, particularly in conditions such as cerebral palsy (CP). However, the necessity for highly trained professionals has hindered the adoption of GMA as an early screening tool in some countries. In this study, we propose a deep learning-based motor assessment model (MAM) that combines infant videos and basic characteristics, with the aim of automating GMA at the fidgety movements (FMs) stage. MAM demonstrates strong performance, achieving an Area Under the Curve (AUC) of 0.967 during external validation. Importantly, it adheres closely to the principles of GMA and exhibits robust interpretability, as it can accurately identify FMs within videos, showing substantial agreement with expert assessments. Leveraging the predicted FMs frequency, a quantitative GMA method is introduced, which achieves an AUC of 0.956 and enhances the diagnostic accuracy of GMA beginners by 11.0%. The development of MAM holds the potential to significantly streamline early CP screening and revolutionize the field of video-based quantitative medical diagnostics.

Motor repertoire in 3- to 5- month-old infants with prenatal exposure to syphilis and toxoplasmosis

AIM

To characterize the motor repertoire of 3- to 5-month-old infants who were prenatally exposed to the infectious agents of syphilis and toxoplasmosis.

METHODS

Exploratory observational study that evaluated 15 exposed infants (34.4 ± 3.5 weeks gestation) recruited from a referral center. Age assessment ranged 12-20 (median 12) weeks post-term. General Movement Assessment, including the Motor Optimality Score-Revised (MOS-R), was used to assess the global quality of fidgety movements (FMs) and to quantify and detail coexisting motor patterns. Clinical variables were also collected. Later motor outcomes were obtained from medical reports when possible.

RESULTS

MOS-R ranged 10-26 (median 24). There was a higher proportion of infants with normal (80.0 %) than aberrant FMs, but the proportion of infants with reduced MOS-R (80.0 %) was higher compared to optimal MOS-R. One infant with aberrant FMs was later diagnosed with cerebral palsy. Only 13.3 % of the infants showed smooth and fluent movement character. All observed tongue movements were abnormal.

CONCLUSION

Infants had predominantly normal FMs, but with reduced MOS-R and abnormalities in the coexisting motor repertoire.

Mobile Solutions for Clinical Surveillance and Evaluation in Infancy-General Movement Apps

The Prechtl General Movements Assessment (GMA) has become a clinician and researcher toolbox for evaluating neurodevelopment in early infancy. Given that it involves the observation of infant movements from video recordings, utilising smartphone applications to obtain these recordings seems like the natural progression for the field. In this review, we look back on the development of apps for acquiring general movement videos, describe the application and research studies of available apps, and discuss future directions of mobile solutions and their usability in research and clinical practice. We emphasise the importance of understanding the background that has led to these developments while introducing new technologies, including the barriers and facilitators along the pathway. The GMApp and Baby Moves apps were the first ones developed to increase accessibility of the GMA, with two further apps, NeuroMotion and InMotion, designed since. The Baby Moves app has been applied most frequently. For the mobile future of GMA, we advocate collaboration to boost the field's progression and to reduce research waste. We propose future collaborative solutions, including standardisation of cross-site data collection, adaptation to local context and privacy laws, employment of user feedback, and sustainable IT structures enabling continuous software updating.

Early detection of developmental delay in infants born very preterm or with very low birthweight

AIM

This study aimed to identify early clinical biomarkers from birth to 16 weeks corrected age to predict typical outcome and developmental delay in infants born very preterm or with very low birthweight.

METHOD

A prospective cohort of infants on the Sunshine Coast, Australia, was assessed using the Premie-Neuro Examination, the General Movement Assessment (GMA), the Alberta Infant Motor Scale, and the Infant Sensory Profile 2. At 24 months corrected age, delay was identified using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) and Neurosensory Motor Developmental Assessment (NSMDA).

RESULTS

One hundred and four infants were recruited; 79 completed outcome assessments (43 females, 36 males; mean gestational age 30 weeks [SD 1 week 6 days], mean birthweight 1346 g [SD 323]). The incidence of developmental delay (motor or cognitive) was 6.3%. Suboptimal quality of fidgety general movements (temporal organization) at 16 weeks corrected age demonstrated the best predictive accuracy (Bayley-III motor: sensitivity 100% [95% confidence interval {CI} 3-100], specificity 75% [95% CI 63-84], area under the curve [AUC] 0.87); Bayley-III cognitive: sensitivity 100% [95% CI 3-100], specificity 75% [95% CI 64-84], AUC 0.88); NSMDA motor: sensitivity 100% [95% CI 40-100], specificity 81% [95% CI 70-90], AUC 0.91 [95% CI 0.86-0.95]). GMA trajectories that combined abnormal writhing general movements at 4 to 5 weeks corrected age with suboptimal quality of fidgety movement at 16 weeks corrected age were strongly predictive of developmental delay, superior to all other clinical tools, and perinatal and demographic variables investigated (p = 0.01, Akaike information criterion method 18.79 [score corrected for small sample size], accounting for 93% of the cumulative weight).

INTERPRETATION

Only the GMA had sufficient predictive validity to act as a biomarker for both conditions: typical outcome and developmental delay (motor or cognitive). GMA trajectories that assessed both writhing general movements at 4 to 5 weeks corrected age and quality of fidgety movement at 16 weeks corrected age predicted adverse neurodevelopmental outcome, accurately differentiating between infants with typical outcomes and those at increased risk for motor or cognitive delay.

Relationship between fidgety movement and frequency of movement toward midline: An observational study

BACKGROUND

Infants show other movements and posture patterns during the fidgety movement period, including movement toward midline (MTM). Few studies have quantified MTM occurring during the fidgety movement period.

AIMS

This study aimed to examine the relationship between fidgety movements (FMs) and MTM frequency and occurrence rate per minute, from two video data sets (video attached to Prechtl video manual and accuracy data from Japan).

STUDY DESIGN

Observational study.

SUBJECTS

It encompassed 47 videos. Of these, 32 were deemed normal FMs. The study amalgamated FMs that were sporadic, abnormal, or absent into a category of aberrant (n = 15).

OUTCOME MEASURES

Infant video data were observed. MTM item occurrences were recorded and calculated for occurrence percentage and MTM rate of occurrence per minute. The differences between groups for the upper limbs, lower limbs, and total MTM were statistically analysed.

RESULTS

Twenty-three infant videos of normal FMs and seven infant videos of aberrant FMs showed MTM. Eight infant videos of aberrant FMs showed no MTM, and only four with absent FMs were included. There was a significant difference in the total MTM rate of occurrence per minute between normal FMs versus aberrant FMs (p = 0.008).

CONCLUSIONS

This study presented MTM frequency and rate of occurrence per minute in infants who showed FMs during the fidgety movement period. Those who showed absent FMs also demonstrated no MTM. Further study may need a larger sample size of absent FMs and information on later development.

Smartphone application links severity of retinopathy of prematurity to early motor behavior in a cohort of high-risk preterm infants

PURPOSE

To evaluate the General Movement Assessment (GMA) with the Motor Optimality Score-Revised (MOS-R) as a neurodevelopmental marker in infants with retinopathy of prematurity (ROP).

METHODS

Infants screened prospectively for ROP were evaluated at 3 months' post-term age using a smartphone application to complete the GMA and MOS-R. Results were analyzed by ROP severity.

RESULTS

Of 105 enrolled infants, 83 completed the study. Of these, 54 (65%) had any ROP, 32 (39%) had severe ROP, and 13 (16%) had type 1 ROP. The proportion with aberrant GMA was significantly higher in infants with severe ROP (14/32 [44%]) compared with infants who had milder ROP (8/51 [16%]; P = 0.006). Of those with severe ROP, there was no significant difference comparing infants with type 1 ROP treated with bevacizumab (7/13 [54%]) to infants with type 2 ROP without treatment (7/19 [37%]; P = 0.47). Although the presence of any ROP, stage of ROP, and severe ROP each predicted lower MOS-R scores on univariate analyses, only severe bronchopulmonary dysplasia and markers of brain injury remained significant in the multivariate analysis.

CONCLUSIONS

The GMA was a convenient, short-term method of data collection with low attrition. Although severe ROP initially appeared linked to poor early motor scores, this association is likely confounded by neurological and respiratory complications, which frequently accompany severe ROP.

Motor Optimality Scores are significantly lower in a population of high-risk infants than in infants born moderate-late preterm

BACKGROUND

The Motor Optimality Score-Revised (MOS-R) is a detailed scoring of the General Movement Assessment (GMA), measuring the spontaneous behaviors of infants. Infants born moderate-late preterm are not traditionally followed in high-risk clinics, but have increased risk of neurodevelopmental disability.

AIMS

Compare MOS-R at 3 months corrected age (CA) in high-risk (HR; very preterm or abnormal neuroimaging) infants to infants born moderate-late preterm (MLP).

STUDY DESIGN

In this prospective cohort study, parents of enrolled infants created video recordings using an app at 3 months CA. Videos were scored with the General Movement Assessment (GMA) and MOS-R. MOS-R scores were divided into "higher-risk" (≤19) and "lower-risk" (≥20).

SUBJECTS

181 infants born MLP or categorized as HR.

RESULTS

Among enrolled infants, 68 (38 %) were in the MLP group, and 113 infants were in the HR group. The HR group had 3.8 increased odds of having an aberrant GMA score compared to the MLP group (p < 0.01, 95 % CI 1.38-10.52). The HR group had significantly lower MOS-R scores (mean 20) than the MLP group (mean 24; p < 0.001; 95%CI 3.3-7.3). The HR group had 11.2 increased odds of having a higher-risk MOS-R score (95%CI 2.5-47.6, p < 0.001) than MLP group. Infants were most likely to have a lower MOS-R score if they had any of the following: VP shunt placement, periventricular leukomalacia, or bronchopulmonary dysplasia.

CONCLUSIONS

Aberrant GMA and higher-risk MOS-R scores were more common in infants at high-risk, reflecting history of brain lesions and younger gestational age at birth.

The predictive ability of the Lacey Assessment of Preterm Infants (LAPI), Cranial Ultrasound (cUS) and General Movements Assessment (GMA) for Cerebral Palsy (CP): A prospective, clinical, single center observational study

BACKGROUND AND AIM

The LAPI, cUS and GMA are assessments used clinically in the UK to identify preterm infants at high risk of neurodevelopmental disabilities such as cerebral palsy. This study investigated the ability of these assessments to predict cerebral palsy at 2 years corrected gestational age.

METHODS

Design: Prospective longitudinal cohort study including infants born <30 weeks' gestation from a single tertiary neonatal intensive care unit. The LAPI and cUS were undertaken as part of routine care before term equivalent age and the GMA was undertaken at 11-18 weeks corrected gestational age.

RESULTS

There were 123 eligible infants and 95 infants (77.2%) were included. Thirteen infants (13.7%) had a diagnosis of CP at 2 years. There was no significant difference in gestational age, gender, or birth weight between the groups with and without a diagnosis of CP. The highest accuracy of prediction of CP was achieved by an aberrant, absent fidgety general movements classification with a sensitivity of 92.3% and specificity of 98.9%. Combining the GMA to include the cUS or LAPI did not increase the predictive accuracy.

CONCLUSION

The GMA when undertaken in clinical practice had high accuracy for predicting CP at 2 years corrected age in infants born <30 weeks gestation; LAPI and cUS did not improve this accuracy.

Development and Validation of a Deep Learning Method to Predict Cerebral Palsy From Spontaneous Movements in Infants at High Risk

Importance

Early identification of cerebral palsy (CP) is important for early intervention, yet expert-based assessments do not permit widespread use, and conventional machine learning alternatives lack validity.

Objective

To develop and assess the external validity of a novel deep learning-based method to predict CP based on videos of infants' spontaneous movements at 9 to 18 weeks' corrected age.

Design, Setting, and Participants

This prognostic study of a deep learning-based method to predict CP at a corrected age of 12 to 89 months involved 557 infants with a high risk of perinatal brain injury who were enrolled in previous studies conducted at 13 hospitals in Belgium, India, Norway, and the US between September 10, 2001, and October 25, 2018. Analysis was performed between February 11, 2020, and September 23, 2021. Included infants had available video recorded during the fidgety movement period from 9 to 18 weeks' corrected age, available classifications of fidgety movements ascertained by the general movement assessment (GMA) tool, and available data on CP status at 12 months' corrected age or older. A total of 418 infants (75.0%) were randomly assigned to the model development (training and internal validation) sample, and 139 (25.0%) were randomly assigned to the external validation sample (1 test set).

Exposure

Video recording of spontaneous movements.

Main Outcomes and Measures

The primary outcome was prediction of CP. Deep learning-based prediction of CP was performed automatically from a single video. Secondary outcomes included prediction of associated functional level and CP subtype. Sensitivity, specificity, positive and negative predictive values, and accuracy were assessed.

Results

Among 557 infants (310 [55.7%] male), the median (IQR) corrected age was 12 (11-13) weeks at assessment, and 84 infants (15.1%) were diagnosed with CP at a mean (SD) age of 3.4 (1.7) years. Data on race and ethnicity were not reported because previous studies (from which the infant samples were derived) used different study protocols with inconsistent collection of these data. On external validation, the deep learning-based CP prediction method had sensitivity of 71.4% (95% CI, 47.8%-88.7%), specificity of 94.1% (95% CI, 88.2%-97.6%), positive predictive value of 68.2% (95% CI, 45.1%-86.1%), and negative predictive value of 94.9% (95% CI, 89.2%-98.1%). In comparison, the GMA tool had sensitivity of 70.0% (95% CI, 45.7%-88.1%), specificity of 88.7% (95% CI, 81.5%-93.8%), positive predictive value of 51.9% (95% CI, 32.0%-71.3%), and negative predictive value of 94.4% (95% CI, 88.3%-97.9%). The deep learning method achieved higher accuracy than the conventional machine learning method (90.6% [95% CI, 84.5%-94.9%] vs 72.7% [95% CI, 64.5%-79.9%]; P < .001), but no significant improvement in accuracy was observed compared with the GMA tool (85.9%; 95% CI, 78.9%-91.3%; P = .11). The deep learning prediction model had higher sensitivity among infants with nonambulatory CP (100%; 95% CI, 63.1%-100%) vs ambulatory CP (58.3%; 95% CI, 27.7%-84.8%; P = .02) and spastic bilateral CP (92.3%; 95% CI, 64.0%-99.8%) vs spastic unilateral CP (42.9%; 95% CI, 9.9%-81.6%; P < .001).

Conclusions and Relevance

In this prognostic study, a deep learning-based method for predicting CP at 9 to 18 weeks' corrected age had predictive accuracy on external validation, which suggests possible avenues for using deep learning-based software to provide objective early detection of CP in clinical settings.

The Subject Construction and Role Mental Model Construction of Erotic Movies Based on Lacan's Desire Theory

Jacques Lacan is a famous French psychoanalyst, but his influence has long gone beyond the scope of psychoanalysis and has affected almost all fields of "human science." Film and psychoanalysis coincided almost simultaneously and influenced each other. But with the development of film, researchers found that film studies in the period of classic film and film semiotics have come to an end. It has certain theoretical value to explore the construction of the subject and the mental model of the erotic film based on Lacan's desire theory. Method. The body in the film and video described in this paper includes both the material body as an aesthetic object and the spiritual body with aesthetic consciousness. The so-called artistic presentation of the body element means that the beauty of the body form displayed by the actor's body in the film video is perceived by the audience, and the desire to stare is captured by the audience, thereby completing the audience's entire body composed of eyes, body, and mind. The body is not only an aesthetic object but also an aesthetic subject, and the human cognitive system is not just a closed brain. Because the nervous system, body, and environment are constantly changing and interacting, true cognition is a unified system of all three. The main part of this paper uses Lacan's psychoanalytic theory to deeply analyze the relationship between the characters shown in the film. From the cognitive impairment of the self to the failure of communication between characters, the language of uncertainty entangled by desire is removed, and the behavior and facial expressions of the movie characters are used as the analysis basis to fully interpret the inner world of the characters. This includes love, hatred, pain, struggle, and many other contradictory emotions. In addition, this paper also analyzes the metaphor of the relationship between the characters from the perspective of semiotics and discusses the description of the relationship between the characters from the lens language from the perspective of cinematography. The special meaning conveyed by the recurring elements in the film is emphasized, and the correlation between the pictures is explained from the less mentioned photographic aspect of the film. Results/Discussion. Looking at Lacan's theory, the subject, the other, and desire are linked by the subject spirit, which is the core of the connection between the three, and only through the resistance and struggle of the subject spirit can the illusion of the subject be broken. Bewilderment and the suppression of the other and desire finally become the self. And the embodiment of this true self is particularly prominent in film art. Lacan's purpose is not merely to dissolve the subject but to seek a stand in the midst of destruction, pursuing the ultimate transcendence of man's desire for the external other and internal desire.

Association between General Movements Assessment and Later Motor Delay (excluding Cerebral Palsy) in Low-Birth-Weight Infants

The general movements (GMs) assessment is useful for the prediction of cerebral palsy (CP) and other developmental disorders. Developmental coordination disorder (DCD) is highly prevalent in low-birth-weight (LBW) infants. We investigated the association between aberrant GMs during early infancy and later motor development in LBW infants. The study included infants who fulfilled the following criteria: GMs assessed at 9–20 weeks post-term age; developmental quotient (DQ) assessed at 3 years of age using the Kyoto Scale; intelligence quotient (IQ) assessed at 6 years of age. Participants with normal IQs at 6 years of age without a diagnosis of CP (14 males and 37 females, 23–36 weeks gestation with birth weights of 492–1498 g) were categorized into normal (n = 39) and aberrant (n = 12) groups based on GMs assessment; DQ was compared between the groups. We investigated the items in the DQ assessment and found that the infants in the aberrant group were more frequently unable to perform. Infants in the aberrant group showed a significantly lower DQ in the ‘postural-motor domain’, and were more frequently unable to ‘climb the stairs with alternating legs’ and ‘Jump from a 15–20 cm platform’. This study highlights that GMs aberrancy in early infancy is associated with a delayed gross motor development, even in children with a typical development. The GMs assessment may be useful for the prediction of DCD.

Spontaneous movements, motor milestones, and temperament of preterm-born infants: Associations with mother-infant attunement

Preterm-born infants and their mothers are at higher risk of showing less attuned interactions. We sought to identify characteristics of preterm-born infants associated with the attunement of mother-infant interactions at the corrected ages of 3-4 months, looking specifically at motor behaviors. We focused on infants' spontaneous movements, achievement of motor milestones, and temperament, which at this young age is often manifested via movement. Sixty preterm-born infants (Mdn_{gestation age in weeks}  = 33, 57.38% male, corrected age Mdn = 14 weeks, interquartile range = 13-16) and their mothers participated. Independent observers rated mother-infant attunement, infants' spontaneous movements, and infants' achievement of motor milestones. Mothers reported infant temperament. We found infants' smooth and fluent movement character and continual fidgety movements were associated with better attunement in terms of higher maternal sensitivity and non-intrusiveness and higher infant responsiveness and involvement. Unexpectedly, infants' achievement of motor milestones was not significantly associated with mother-infant attunement, and maternal reports of infants' higher soothability were associated with lower maternal sensitivity. The study illustrates the value of including the assessment of infants' spontaneous movements, designed for early detection of neurological deficiencies, in research and in clinical practice with parents and preterm-born infants.

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

BACKGROUND

The Prechtl General Movement Assessment (GMA) is a reliable tool for the functional assessment of the young nervous system. It is based on a global assessment of the quality of infants' movements. In addition, detailed steps of assessment have been developed - one for preterm and term age, and one for use between 3 and 5 months. One potential benefit of such a detailed analysis is the documentation of subtle changes in the infants' spontaneous movements caused by early intervention.

AIM

To present detailed scores of the infants' general movements (GMs) at preterm age, and of the infants' motor repertoire at 3 months' postterm age (PTA), for infants having participated in a randomized controlled trial (RCT) of early intervention, and to examine possible group differences. In addition, the aim is also to present the GMA from preterm to 3 months' PTA, comparing the intervention and the control group.

STUDY DESIGN

A retrospective study on infants who had participated in an RCT of parent-administered early intervention.

SUBJECTS

141 infants born very preterm.

OUTCOME MEASURES

GMA, "Detailed Assessment of General Movements During Preterm and Term Age" and "Assessment of Motor Repertoire at 3 to 5 months".

RESULTS

The GMA and the detailed assessments of GMs conducted at 36 weeks' post menstrual age (PMA) showed the same distribution of normal and abnormal movements in both the intervention and in the control group, as did the assessment of motor repertoire at 3 months' PTA.

CONCLUSION

Neither the GMA nor the detailed assessments of GMs at 36 weeks' PMA and of the motor repertoire at 13 weeks' PTA suggest that early intervention, performed before term, changes the GMs of very preterm-born infants.

Technology-assisted quantification of movement to predict infants at high risk of motor disability: A systematic review

AIM

To systematically review the scientific literature to determine the predictive validity of technology-assisted measures of observable infant movement in infants less than six months of corrected age (CA) to identify high-risk of motor disability.

METHOD

A comprehensive search for randomised and non-randomised controlled trials, cohort studies and cross-comparison trials was performed on five electronic databases up to Feb 2021. Studies were included if they quantified infant movement before 6 months CA using some method of technology-assistance and compared the instrumented measure to a diagnostic clinical measure of neurodevelopment. Studies were excluded if they did not report a technology-assisted measure of infant movement. Methodological quality of the included studies was assessed using the Downs and Black scale.

RESULTS

23 studies met the full inclusion and exclusion criteria. Methodological quality of the included papers ranged from 9 to 24 (out of 26) on the Downs and Black scale. Infant movement assessments included the General Movements Assessment (GMA) and domains of the Hammersmith Infant Neurological Assessment (HINE). Studies used 2D video recordings, RGB-Depth recordings, accelerometry, and electromagnetic motion tracking technologies to quantify movement. Analytical approaches and movement features of interest were individual and varied. Technology assisted quantitative assessments identified cases of later diagnosed CP with sensitivity 44-100 %, specificity 59-95 %, Area under the ROC Curve 82-93 %; and typical development with sensitivity range 30-46 %, specificity 88-95 %, Area under the ROC Curve 68 %.

INTERPRETATION

Technology-assisted assessments of movement in infants less than 6 months CA using current technologies are feasible. Validation of measurement tools are limited. Although methods and results appear promising clinical uptake of technology-assisted assessments remains limited.

Inter-observer reliability using the General Movement Assessment is influenced by rater experience

OBJECTIVE

To describe the inter-observer reliability of the General Movement Assessment (GMA) among a sample of infants at high-risk of cerebral palsy (CP) among raters with various levels of experience.

METHODS

Video assessments of 150 high-risk infants at 10-15 weeks corrected age were rated by three Prechtl GMA-certified observers with varied experience using the assessment. Videos were scored based on temporal organization of fidgety movements (FMs), presence of abnormal FMs, or absence of FMs. Inter-observer agreements were analyzed with Gwet's AC1 statistic.

RESULTS

We found fair to moderate agreement when subcategories of normal FMs (continuous and intermittent) were included (AC₁ = 0.32-0.57) and moderate to near perfect agreement when normal categories of FMs were combined (AC₁ = 0.60-0.95). Reliability was higher among observers with more experience using the GMA (AC₁ = 0.57-0.98) than the observer with less experience (AC₁ = 0.32-0.61).

CONCLUSIONS

Caution may be warranted when the GMA is used to differentiate "continuous and intermittent" FMs temporal organization. The GMA is highly reliable among experienced raters when comparing normal FMs to other FMs categorizations.

The assessment of general movements in term and late-preterm infants diagnosed with neonatal encephalopathy, as a predictive tool of cerebral palsy by 2 years of age-a scoping review

BACKGROUND

The General Movements Assessment is a non-invasive and cost-effective tool with demonstrated reliability for identifying infants at risk for cerebral palsy. Early detection of cerebral palsy allows for the implementation of early intervention and is associated with better functional outcomes. No review to date has summarized the utility of the General Movements Assessment to predict cerebral palsy in term and late-preterm infants diagnosed with neonatal encephalopathy.

METHODS

We conducted a scoping review involving infants born greater than or equal to 34 weeks gestational age to identify all available evidence and delineate research gaps. We extracted data on sensitivity, specificity, and positive and negative predictive values and described the strengths and limitations of the results. We searched five databases (MEDLINE, Embase, PsychINFO, Scopus, and CINAHL) and the General Movements Trust website. Two reviewers conducted all screening and data extraction independently. The articles were categorized according to key findings, and a critical appraisal was performed.

RESULTS

Only three studies, a cohort and two case series, met all of the inclusion criteria. The total number of participants was 118. None of the final eligible studies included late-preterm neonates. All three studies reported on sensitivity, specificity, and positive predictive and negative predictive values. An abnormal General Movement Assessment at 3-5 months has a high specificity (84.6-98%) for cerebral palsy with a similarly high negative predictive value (84.6-98%) when it was normal. Absent fidgety movements, in particular, are highly specific (96%) for moderate to severe cerebral palsy and carry a high negative predictive value (98%) when normal. In the time period between term and 4-5 months post-term, any cramped synchronized movements had results of 100% sensitivity and variable results for specificity, positive predictive value, and negative predictive value.

CONCLUSIONS

A normal General Movements Assessment at 3 months in a term high-risk infant is likely associated with a low risk for moderate/severe cerebral palsy. The finding of cramped synchronized General Movements is a strong predictor for the diagnosis of cerebral palsy by 2 years of age in the term population with neonatal encephalopathy. The deficit of high-quality research limits the applicability, and so the General Movements Assessment should not be used in isolation when assessing this population.

SYSTEMATIC REVIEW REGISTRATION

Title registration with Joanna Briggs Institute. URL: http://joannabriggswebdev.org/research/registered_titles.aspx .

Usability and inter-rater reliability of the NeuroMotion app: A tool in General Movements Assessments

BACKGROUND

Early intervention after perinatal brain insults requires early detection of infants with cerebral palsy (CP). General Movements Assessments (GMA) in the fidgety movement period has a high predictive value for CP.

AIM

To investigate the NeuroMotion™ app's usability regarding film quality and user experience and to assess the inter-rater reliability of GMA in a neonatal risk group.

METHODS

GMA, inter-rater reliability and film quality was assessed in a cohort consisting of 37 infants enrolled in a multicentre study of GMA as part of the Swedish neonatal follow-up program for high-risk infants. Some of these infants were filmed twice. For evaluation of user experience 95 parents of 52 infants were addressed with a web-based questionnaire. A GMA expert assessed film quality and performed GMA and three on-site assessors, individually performed GMA. Inter-rater reliability was computed using Krippendorff's alpha (k-alpha).

RESULTS

In all, 45 films showed good or excellent quality. The response rate of the questionnaire survey was 40% and revealed predominantly positive perceptions of the NeuroMotion™ app. GMA in 36 infants resulted in substantial agreement (k-alpha = 0.72, 95%CI = 0.3-1.0) between the three on-site assessors' consensus and the GMA expert. Inter-rater reliability for GMA between the on-site assessors was moderate (k-alpha = 0.48, 0.18-0.74).

CONCLUSION

The NeuroMotion™ app produces good technical quality films and the app user experience was overall positive. High agreement was observed between the on-site assessors and the GMA expert. The study design is feasible for more extensive GMA studies in cohorts of infants at risk of CP.

Die Bedeutung fötaler und neonataler Motorik für die kindliche Entwicklung und die Früherkennung von Entwicklungsstörungen

Zusammenfassung. Theoretischer Hintergrund: Die von Central Pattern Generators (CPGs) generierten Bewegungen des Neugeborenen und jungen Säuglings haben eine lange pränatale Vorgeschichte. Fragestellung: Welche Bedeutung hat die Analyse der CPG-Aktivität, besonders der General Movements (GMs) in der entwicklungsneurologischen Diagnostik? Methode: Unsere Übersichtsarbeit bezieht sich auf Prechtl’s General Movement Assessment (GMA), das ab dem Frühgeborenenalter bis zum Ende des 5. Monats nach einer Termingeburt anwendbar ist. Ergebnisse: Das GMA ermöglicht die Vorhersage einer Zerebralparese mit einer Sensitivität von 98 % und einer Spezifität von 91 %. Abnormale cramped-synchronized GMs sind ein früher Marker für spastische Zerebralparesen. Das Fehlen von Fidgety Movements (im 3.–5. Monat) weist auf alle Formen der Zerebralparese hin und kann auch bei bestimmten genetischen Erkrankungen auftreten. Zwei von drei Säuglingen mit einer späteren Diagnose Autismus haben atypische GMs und fallen vor allem durch ihre Monotonie in den Bewegungen auf. Diskussion und Schlussfolgerung: Mittels GMA lassen sich mit großer Treffsicherheit typische Entwicklungsverläufe vorhersagen oder aber ein Risiko für einen atypischen Verlauf erkennen und somit frühzeitige Interventionen einleiten.

Early intervention and its short-term effect on the temporal organization of fidgety movements

BACKGROUND

The Prechtl General Movement Assessment (GMA) predicts various neurological and developmental disorders while also documenting therapeutic effects.

AIMS

To describe the temporal organization of fidgety general movements in infants with mild to moderate postural asymmetries and/or tonus regulation problems, and to analyze to what extent the temporal organization of fidgety movements will change after physiotherapy.

STUDY DESIGN

Repeated measure design.

PARTICIPANTS

Twelve infants (five females) with mild to moderate postural asymmetries and/or tonus regulation problems were admitted for an early intervention program. The gestational age ranged from 27 to 40 weeks (Median, 36 weeks; nine infants born preterm) with birth weights ranging from 740 g to 3500 g (Median, 2590 g).

MEASURES

Fidgety movements and their temporal organization were measured using the Prechtl GMA at 9 to 19 weeks post term age (Median, 14 weeks) before and after an early motor training procedure. The movements of one of the infants were analysed using a computer-based approach, measuring the mean and standard deviation of quantity of motion, height of motion and width of motion.

RESULTS

Seven infants had sporadic fidgety movements, and five had intermittent fidgety movements. None had continual fidgety movements before the intervention was initiated. After intervention, the temporal organization of fidgety movements increased in all infants. The observations of these movements were supported by computer-based analysis.

CONCLUSION

The study indicates that early intervention increases the temporal organization of fidgety movements in infants with postural asymmetries and/or tonus regulation problems. The clinical significance of this finding needs to be further evaluated.

Avaliação dos Movimentos Gerais de Prechtl (GMA) na detecção precoce de risco ao desenvolvimento

RESUMO Verificar a relação entre a avaliação dos movimentos gerais (General Movements Assessment - GMA) com as variáveis obstétricas (aleitamento materno, intercorrência na gestação, medicação na gestação, álcool na gestação, fumo na gestação, intercorrência ao nascer, necessidade de internação em UTI neonatal e necessidade de ventilação mecânica), a presença de risco psíquico e o desfecho no desenvolvimento da linguagem, cognitivo e motor aos 18 e 24 meses. A amostra foi composta por 42 bebês, que foram filmados até a faixa etária de quatro meses, em movimentação espontânea por 15 minutos. Os movimentos gerais foram avaliados por vídeos usando a avaliação qualitativa de Prechtl e classificados como normais ou anormais dependendo da presença de fluência, complexidade e variabilidade. Os dados foram analisados estatisticamente em sua relação com variáveis obstétricas e com a presença de risco psíquico, avaliada por meio dos Sinais PREAUT, dos indicadores clínicos de risco ao desenvolvimento e do M-CHAT. Verificou-se que não houve associação entre o método GMA e as variáveis analisadas. Acredita-se que, pelo fato de a amostra ter sido composta, em sua maioria, por bebês nascidos a termo ou prematuros tardios sem intercorrências e de a avaliação ter sido de forma transversal, em um único momento, não foi possível analisar se os movimentos avaliados como anormais foram ou não transitórios. A alteração dos movimentos por meio do método Prechtl não apresentou associação com as variáveis analisadas na amostra de bebês prematuros tardios e nascidos a termo.

Enhancing early detection of neurological and developmental disorders and provision of intervention in low-resource settings in Uttar Pradesh, India: study protocol of the G.A.N.E.S.H. programme

INTRODUCTION

Around 9% of India's children under six are diagnosed with neurodevelopmental disorders. Low-resource, rural communities often lack programmes for early identification and intervention. The Prechtl General Movement Assessment (GMA) is regarded as the best clinical tool to predict cerebral palsy in infants <5 months. In addition, children with developmental delay, intellectual disabilities, late detected genetic disorders or autism spectrum disorder show abnormal general movements (GMs) during infancy. General Movement Assessment in Neonates for Early Identification and Intervention, Social Support and Health Awareness (G.A.N.E.S.H.) aims to (1) provide evidence as to whether community health workers can support the identification of infants at high-risk for neurological and developmental disorders and disabilities, (2) monitor further development in those infants and (3) initiate early and targeted intervention procedures.

METHODS

This 3-year observational cohort study will comprise at least 2000 infants born across four districts of Uttar Pradesh, India. Community health workers, certified for GMA, video record and assess the infants' GMs twice, that is, within 2 months after birth and at 3-5 months. In case of abnormal GMs and/or reduced MOSs, infants are further examined by a paediatrician and a neurologist. If necessary, early intervention strategies (treatment as usual) are introduced. After paediatric and neurodevelopmental assessments at 12-24 months, outcomes are categorised as normal or neurological/developmental disorders. Research objective (1): to relate the GMA to the outcome at 12-24 months. Research objective (2): to investigate the impact of predefined exposures. Research objective (3): to evaluate the interscorer agreement of GMA.

ETHICS AND DISSEMINATION

G.A.N.E.S.H. received ethics approval from the Indian Government Chief Medical Officers of Varanasi and Mirzapur and from the Ramakrishna Mission Home of Service in Varanasi. GMA is a worldwide used diagnostic tool, approved by the Ethics Committee of the Medical University of Graz, Austria (27-388 ex 14/15). Apart from peer-reviewed publications, we are planning to deploy G.A.N.E.S.H. in other vulnerable settings.

Motor outcome after perinatal stroke and early prediction of unilateral spastic cerebral palsy

BACKGROUND

Unilateral spastic cerebral palsy (USCP) occurs in 30%-68% of infants with perinatal stroke. Early detection of USCP is essential for referring infants to early intervention. The aims of this study were to report motor outcomes after perinatal stroke, and to determine the predictive value of the General Movements Assessment (GMA) and Hand Assessment for Infants (HAI) for detection of USCP.

MATERIALS AND METHODS

This was a prospective observational study involving infants with perinatal stroke. GMA was conducted between 10 and 15 weeks post term-age (PTA). The HAI was performed between 3 and 5 months PTA. Motor outcome was collected between 12 and 36 months PTA.

RESULTS

The sample consisted of 46 infants. Fifteen children (32.6%) were diagnosed with CP, two children with bilateral CP and 13 with USCP. Abnormal GMA had a sensitivity of 85% (95% confidence interval [CI] 55-98%) and a specificity of 52% (95% CI 33-71%) to predict USCP. When asymmetrically presented FMs were also considered as abnormal, sensitivity increased to 100%, hence the specificity declined to 43%. A HAI asymmetry index cut-off of 23, had both a sensitivity and a specificity of 100% to detect USCP.

CONCLUSION

Using GMA and HAI can enable prediction of USCP before the age of 5 months in infants with perinatal stroke. Nevertheless, GMA must be interpreted with caution in this particular population. The HAI was found to be a very accurate screening tool for early detection of asymmetry and prediction of USCP.

AI Approaches Towards Prechtl's Assessment of General Movements: A Systematic Literature Review

General movements (GMs) are spontaneous movements of infants up to five months post-term involving the whole body varying in sequence, speed, and amplitude. The assessment of GMs has shown its importance for identifying infants at risk for neuromotor deficits, especially for the detection of cerebral palsy. As the assessment is based on videos of the infant that are rated by trained professionals, the method is time-consuming and expensive. Therefore, approaches based on Artificial Intelligence have gained significantly increased attention in the last years. In this article, we systematically analyze and discuss the main design features of all existing technological approaches seeking to transfer the Prechtl's assessment of general movements from an individual visual perception to computer-based analysis. After identifying their shared shortcomings, we explain the methodological reasons for their limited practical performance and classification rates. As a conclusion of our literature study, we conceptually propose a methodological solution to the defined problem based on the groundbreaking innovation in the area of Deep Learning.

Influence of infections on the quality of general movements in premature infants

INTRODUCTION

The task of contemporary neonatology is not only to save the lives of children born prematurely, but also to provide them with the highest possible quality of life. The Prechtl method, one of several methods of assessing the quality of general movement patterns, enables early identification of immaturity or damage to the central nervous system.

AIM

Dynamic assessment of the type and quality of general movement (GMs) in preterm infants to determine indications for early neurodevelopmental support and to identify the relationship between the occurrence of maternal and neonatal perinatal risk factors and the type and quality of general movements.

MATERIAL AND METHOD

90 infants were assessed between 28 0/7 and 36 6/7 weeks gestational age. Dominant cases (57 cases) were infants born between 32 and 36 weeks GE. Most cases (48) received low Apgar score at 1 min (≤7), including two born in very severe condition. Neonatal infections were diagnosed in 26 infants. The study included three GM assessments: I - up to 14th day post-partum, II at term and III between 12 and 15 weeks corrected age. The analysis included gestational age, general condition of the newborn as per Apgar score as well as early and late infections.

RESULTS

Neonatal infections were found to show a close correlation with the occurrence of abnormal general movements. It was confirmed that gestational age and congenital infections are important variables affecting the occurrence of abnormal general movements.

The Predictive Accuracy of the General Movement Assessment for Cerebral Palsy: A Prospective, Observational Study of High-Risk Infants in a Clinical Follow-Up Setting

BACKGROUND

Early prediction of cerebral palsy (CP) using the General Movement Assessment (GMA) during the fidgety movements (FM) period has been recommended as standard of care in high-risk infants. The aim of this study was to determine the accuracy of GMA, alone or in combination with neonatal imaging, in predicting cerebral palsy (CP).

METHODS

Infants with increased risk of perinatal brain injury were prospectively enrolled from 2009-2014 in this multi-center, observational study. FM were classified by two certified GMA observers blinded to the clinical history. Abnormal GMA was defined as absent or sporadic FM. CP-status was determined by clinicians unaware of GMA results.

RESULTS

Of 450 infants enrolled, 405 had scorable video and follow-up data until at least 18-24 months. CP was confirmed in 42 (10.4%) children at mean age 3 years 1 month. Sensitivity, specificity, positive and negative predictive values, and accuracy of absent/sporadic FM for CP were 76.2, 82.4, 33.3, 96.8, and 81.7%, respectively. Only three (8.1%) of 37 infants with sporadic FM developed CP. The highest accuracy (95.3%) was achieved by a combination of absent FM and abnormal neonatal imaging.

CONCLUSION

In infants with a broad range of neonatal risk factors, accuracy of early CP prediction was lower for GMA than previously reported but increased when combined with neonatal imaging. Sporadic FM did not predict CP in this study.

Cerebral Palsy: Early Markers of Clinical Phenotype and Functional Outcome

The Prechtl General Movement Assessment (GMA) has become a cornerstone assessment in early identification of cerebral palsy (CP), particularly during the fidgety movement period at 3-5 months of age. Additionally, assessment of motor repertoire, such as antigravity movements and postural patterns, which form the Motor Optimality Score (MOS), may provide insight into an infant's later motor function. This study aimed to identify early specific markers for ambulation, gross motor function (using the Gross Motor Function Classification System, GMFCS), topography (unilateral, bilateral), and type (spastic, dyskinetic, ataxic, and hypotonic) of CP in a large worldwide cohort of 468 infants. We found that 95% of children with CP did not have fidgety movements, with 100% having non-optimal MOS. GMFCS level was strongly correlated to MOS. An MOS > 14 was most likely associated with GMFCS outcomes I or II, whereas GMFCS outcomes IV or V were hardly ever associated with an MOS > 8. A number of different movement patterns were associated with more severe functional impairment (GMFCS III-V), including atypical arching and persistent cramped-synchronized movements. Asymmetrical segmental movements were strongly associated with unilateral CP. Circular arm movements were associated with dyskinetic CP. This study demonstrated that use of the MOS contributes to understanding later CP prognosis, including early markers for type and severity.

Use of the General Movements Assessment for the Early Detection of Cerebral Palsy in Infants with Congenital Anomalies Requiring Surgery

The general movements (GMs) assessment is recognised as one of the most important tools in the early detection of cerebral palsy (CP). However, there remains a paucity of data on its application to infants with congenital anomalies requiring surgery. This was a prospective study of 202 infants (mean gestation 38 weeks, SD 2.2) who had undergone major surgery for congenital anomalies in the neonatal period. Infants were assessed at three months of age (mean 12 weeks, SD 1.6) and GMs videos were independently rated by three clinicians, two blinded to clinical details. Developmental follow-up was at three years of age. Of the twenty-five infants (9%) rated as having an absence of fidgety movements, 22 were seen at 3 years, and 17 had an abnormal outcome: 11 with CP, and 6 with a developmental disability. Infants with absent fidgety movements were 21.5 (95% CI 7.3-63.8) times more likely to have an abnormal outcome including CP. None of the infants with normal fidgety movements had a diagnosis of CP and 86% were assessed to be developing normally. The GMs assessment has predictive value for cerebral palsy and neurodevelopment for infants with congenital anomalies, and should be incorporated into routine follow-up to facilitate early referral.

Occurrence of and temporal trends in fidgety general movements in infants born extremely preterm/extremely low birthweight and term-born controls

BACKGROUND

Fidgety general movements have high predictive validity for later cerebral palsy (CP) but their temporal organisation requires further understanding for assessment accuracy.

AIMS

To describe the occurrence of and temporal trends in fidgety movements, and whether they differ between infants born preterm and at term.

STUDY DESIGN

Cohort study.

SUBJECTS

We assessed 155 EP/ELBW infants and 185 term-born infants born extremely preterm (EP; <28 weeks' gestation) and/or extremely low birthweight (ELBW; <1000 g birthweight) or at term (37-42 weeks' gestation) in the state of Victoria, Australia.

OUTCOME MEASURES

Parents of infants submitted up to two videos at 12-13⁺⁶ and/or 14-16⁺⁶ weeks' corrected age of infants' general movements. Videos were scored using the Prechtl General Movements Assessment (GMA) (fidgety) and classified as normal or absent/abnormal. Infants with at least one normal GMA were classified as normal. Individual GMA trajectories were analysed over time using logistic regression.

RESULTS

Overall, infants born EP/ELBW were more likely to have absent/abnormal fidgety movements than term-born infants (23% versus 3%, odds ratio [OR] 8.50 (95% confidence interval (CI) 3.48-20.8, p < 0.001). Fewer EP/ELBW and term-born infants showed absent/abnormal fidgety movements with each week of increasing age (EP/ELBW OR 0.46, 95% CI 0.25-0.84, p = 0.01; term-born OR 0.35, 95% CI 0.16-0.8, p = 0.01; interaction, p = 0.53).

CONCLUSIONS

Absent/abnormal fidgety movements are more prevalent in infants born EP/ELBW than at term. Fidgety movements normalise with older age in both infants born EP/ELBW and at term between 12 and 16⁺⁶ weeks' corrected age.

Evaluation of Fidgety Movements of Infants Based on Gestalt Perception Reflects Differences in Limb Movement Trajectory Curvature

BACKGROUND

Infants aged 2 to 5 months show spontaneous general movements (GMs) of the whole body, which are referred to as fidgety movements (FMs). Although previous studies have shown that evaluation of GMs by the General Movement Assessment (GMA) has predictive value about later neurological impairments, it remains unknown whether raters consistently perceive and rate such complex kinematic information.

OBJECTIVE

The purpose of this study was to construct a method to reveal which movement features are associated with each rater's evaluation of FMs based on the GMA.

DESIGN

GMA scores of 163 healthy infants aged 11 to 16 weeks postterm were matched with data obtained from a 3-dimensional motion analysis system.

METHODS

Three physical therapists performed the GMA and classified GMs into 9 types, from which we focused on 3 subtypes differing in the temporal organization of FMs (continual, intermittent, and sporadic FMs). We also calculated 6 movement indices (average velocity of limb movements, number of movement units, kurtosis of acceleration, jerk index, average curvature, and correlation between limb velocities) for arms and legs for each infant and analyzed which movement indices were associated with the ratings of the 3 FM subtypes by each rater.

RESULTS

Only the average curvature differed significantly among the ratings of the 3 FM subtypes for all 3 raters. Each rater showed significant differences in the average curvature in either arms or legs.

LIMITATIONS

It is difficult to generalize the present results to raters with various levels of expertise and experience in using the GMA. This issue calls for further research.

CONCLUSIONS

The method used revealed commonality and individuality about the perceived movement features that can be associated with the rating of FMs.

The Baby Moves smartphone app for General Movements Assessment: Engagement amongst extremely preterm and term-born infants in a state-wide geographical study

AIM

The Baby Moves smartphone application is designed for parents to video their infants' spontaneous movement for remote General Movements Assessment (GMA). We aimed to assess the engagement with Baby Moves amongst high- and low-risk infants' families and the socio-demographic variables related to engagement.

METHODS

Families of extremely preterm (EP; <28 weeks' gestational age) or extremely low-birthweight (ELBW; <1000 g) infants and term-born controls from a state-wide geographical cohort study were asked to download Baby Moves. Baby Moves provided reminders and instructions to capture videos of their infants' general movements. Parents were surveyed about Baby Moves' usability.

RESULTS

The parents of 451 infants (226 EP/ELBW; 225 control) were recruited; 416 (204 EP/ELBW; 212 control) downloaded Baby Moves, and 346 (158 EP/ELBW; 188 control) returned at least one scorable video for remote GMA. Fewer EP/ELBW families submitted a scorable video than controls (70 vs. 83%, respectively; odds ratio (OR) 0.48, 95% confidence interval (CI) 0.3-0.79, P = 0.003), but the difference diminished when adjusted for socio-demographic variables (OR 1.09, 95% CI 0.59-2.0, P = 0.79). Families who received government financial support (OR 0.28, 95% CI 0.1-0.78, P = 0.015), who spoke limited English at home (OR 0.39, 95% CI 0.22-0.69, P = 0.001) or with lower maternal education (OR 0.38, 95% CI 0.21-0.68, P = 0.001) were less likely to return a scorable video. Surveyed parents responded mostly positively to Baby Moves' usability.

CONCLUSIONS

Most parents in this study successfully used Baby Moves to capture infant movements for remote GMA. Families of lower socio-demographic status used Baby Moves less.

Computer-based video analysis identifies infants with absence of fidgety movements

BackgroundAbsence of fidgety movements (FMs) at 3 months' corrected age is a strong predictor of cerebral palsy (CP) in high-risk infants. This study evaluates the association between computer-based video analysis and the temporal organization of FMs assessed with the General Movement Assessment (GMA).MethodsInfants were eligible for this prospective cohort study if referred to a high-risk follow-up program in a participating hospital. Video recordings taken at 10-15 weeks post term age were used for GMA and computer-based analysis. The variation of the spatial center of motion, derived from differences between subsequent video frames, was used for quantitative analysis.ResultsOf 241 recordings from 150 infants, 48 (24.1%) were classified with absence of FMs or sporadic FMs using the GMA. The variation of the spatial center of motion (C_SD) during a recording was significantly lower in infants with normal (0.320; 95% confidence interval (CI) 0.309, 0.330) vs. absence of or sporadic (0.380; 95% CI 0.361, 0.398) FMs (P<0.001). A triage model with C_SD thresholds chosen for sensitivity of 90% and specificity of 80% gave a 40% referral rate for GMA.ConclusionQuantitative video analysis during the FMs' period can be used to triage infants at high risk of CP to early intervention or observational GMA.

Does a parent-administrated early motor intervention influence general movements and movement character at 3months of age in infants born preterm?

BACKGROUND

Studies of preterm and term-born infants have shown absent fidgety movements and an abnormal movement character to be related to brain lesions and unfavourable neurological outcomes.

AIMS

The present study examines what effect a parent-administered early intervention program applied to preterm infants in a randomised control trial (RCT) between 34 and 36weeks gestational age has on their fidgety movements and overall movement character at three months of age.

STUDY DESIGN

The study was part of the RCT in an early intervention programme including preterm infants born between 2010 and 2014 at three Norwegian university hospitals.

SUBJECTS

130 preterm infants participated in the study, with 59 of them in the control group and 71 in the intervention group.

OUTCOME MEASURES

Fidgety movements and overall movement character at three months corrected age.

RESULTS

No difference was found between the intervention group and the control group in terms of fidgety movements or movement character. Approximately half of the infants in both groups showed an abnormal movement character.

CONCLUSION

No evidence was found in this RCT to suggest that an intervention at 34 to 37weeks gestational age has a significant effect on the fidgety movements or overall movement character of preterm infants. This is in line with the assumption that absent fidgety movements and an abnormal movement character are due to permanent brain injury and are therefore good predictors for later neurological impairments.

Inter-observer agreement of the General Movements Assessment with infants following surgery

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.

White Matter Injury and General Movements in High-Risk Preterm Infants

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.

The ontogeny of fidgety movements from 4 to 20weeks post-term age in healthy full-term infants

BACKGROUND

Fidgety movements (FMs) are an early accurate marker for normal development.

AIM

The study assessed the ontogeny of normal FMs from 4 to 20weeks post-term age (PTA).

STUDY DESIGN

Longitudinal prospective study of healthy full-term infants video recorded every second week from birth to 20weeks PTA.

SUBJECTS

21 full-term newborns were enrolled.

OUTCOME MEASURES

Temporal organization, amplitude, character, predominance in proximal and/or distal parts of the body and the presence of FMs in fingers and wrists were independently scored by three observers.

RESULTS

From 4 to 10weeks PTA, FMs were sporadic, becoming intermittent in 1-2weeks; they occurred in the proximal parts, with larger and jerkier movements in the following period. From 11 to 16weeks PTA FMs became smaller in amplitude and slower in speed, they were present in all body parts and were more continual than before. Rotational movements in wrists and ankles and finger movements with open hands appeared. From 17 to 20weeks PTA, FMs became more discontinuous and disappeared at 18-20weeks PTA.

CONCLUSIONS

Developmental course of FMs was seen between 4 and 20weeks PTA with changes in temporal organization, amplitude, speed and body parts involved. The best time for scoring FMs is between 12 and 16weeks PTA.

Early motor repertoire in very low birth weight infants in India is associated with motor development at one year

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 (C_SD) 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 C_SD 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.

Very low birth weight infants in China: the predictive value of the motor repertoire at 3 to 5months for the motor performance at 12months

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.

A change in temporal organization of fidgety movements during the fidgety movement period is common among high risk infants

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.

MATERIAL AND METHODS

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.

Fidgety movements - tiny in appearance, but huge in impact

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.

Relationship between white matter pathology and performance on the General Movement Assessment and the Test of Infant Motor Performance in very preterm infants

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 10-15 weeks 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 28 weeks (range: 23-30 weeks) and a median birth weight of 1000 g (range: 515-1465 g).

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 3 months post-term age in a cohort of preterm infants.

The General Movement Assessment Helps Us to Identify Preterm Infants at Risk for Cognitive Dysfunction

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.