Implementation Fidelity of a Smartphone Application for Population-Based General Movement Assessment: The Early Moves Study.

Clinical measures after birth and studies such as electroencephalogram (EEG) and brain imaging do not fully predict neurodevelopmental outcomes of infants with hypoxic-ischemic encephalopathy. Early detection of adverse neurologic outcomes, and cerebral palsy in particular, in high-risk infants is essential for ensuring timely management. The General Movements Assessment is a tool that can be used in the early detection of cerebral palsy in infants with brain injury. The majority of studies on the General Movements Assessment in the late preterm and term population were performed prior to the introduction of therapeutic hypothermia. To apply the General Movements Assessment in late preterm and term infants with hypoxic-ischemic encephalopathy (including those who received therapeutic hypothermia), to determine if clinical markers of hypoxic-ischemic encephalopathy predict abnormal General Movements Assessment findings, and to evaluate interrater reliability of the General Movements Assessment in this population. Study design: Pilot prospective cohort study Subjects: We assessed 29 late preterm and full-term infants with mild, moderate, and severe hypoxic-ischemic encephalopathy in Philadelphia, PA. Most infants' general movements normalized by the fidgety age. Only infants with moderate or severe hypoxic-ischemic encephalopathy had abnormal general movements in both the writhing and the fidgety ages (n = 6). Seizure at any point during the initial hospitalization was the clinical sign most predictive of abnormal general movements in the fidgety age (sensitivity 100%, specificity 55%, positive predictive value 40%, negative predictive value 100%). Interrater reliability was greatest during the fidgety age (κ = 0.67). Seizures were the clinical predictor most closely associated with abnormal findings on the General Movements Assessment. However, clinical markers of hypoxic-ischemic encephalopathy are not fully predictive of abnormal General Movements Assessment findings. Larger future studies are needed to evaluate the associations between the General Movements Assessment and childhood neurologic outcomes in patients with hypoxic-ischemic encephalopathy who received therapeutic hypothermia.

BackgroundPrechtl'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. MethodsA 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. ResultsThe 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. ConclusionGMA 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.

IntroductionThis study aimed to investigate the relationship between prenatal, perinatal, and postnatal risk factors for neurodevelopmental impairment (NDI) with the outcomes of General Movement (GM) Assessment (GMA) in pre-term infants at 3–5 months of age. We sought to identify the risk factors associated with the predictors of psychomotor development in pre-term newborns, such as normal fidgety movements (FMs), absent FMs, or abnormal FMs, assessed during the fidgety period of motor development.MethodsThe SYNAGIS program (prophylactic of Respiratory Syncytial Virus Infection) was used to identify risk factors for the development of neuromotor deficits in 164 pre-term infants who were at high risk of developing these deficits. Based on the GMA, all participants were divided into three groups of infants who presented: (1) normal FMs; (2) absent FMs; and (3) abnormal FMs.ResultsThe results of the current study suggest that abnormal GMs not only indicate commonly known factors like birth asphyxia (BA), respiratory distress syndrome (RDS), periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH) grades 3–4, but also predict the development of motor impairments. In the present study, several specific risk factors including bronchopulmonary dysplasia (BPD), infertility treatments, maternal acute viral/bacterial infections during pregnancy, and elevated bilirubin levels were identified as attributes of an atypical fidgety movement pattern.ConclusionsAdditional clinical data, such as risk factors for NDI associated with early predictors of psychomotor development in pre-term newborns, i.e., absent or abnormal FMs, may be helpful in predicting neurological outcomes in pre-term infants with developmental concerns in the 1st month of life.

Background and purpose: Prechtl's general movement assessment is a tool to identify infants at risk of abnormal neurodevelopmental outcomes especially cerebral palsy. There is a need for further studies to establish its effectiveness in clinical practice. The main objective of this study was to find the diagnostic accuracy of prechtl's general movement assessment to predict neuromotor outcomes of preterm babies at one year corrected age when done in a standard clinical practice setting. The secondary objective was to find the inter-rater reliability of general movement assessment between two raters in a clinical setting.Methods: 116 preterm infants (55 females and 61 males) born below gestational age 35 weeks participated in this study. Prechtl's general movement assessment was done at two points of time – once between 33 to 40 weeks post menstrual age and later between 3 to 4 months corrected age. Babies were reassessed at 12 months (±1week) corrected age using the Infant Neurological International Battery and Alberta Infant Motor Scale to identify neuromotor dysfunction. To find the inter-rater reliability, 75 video recordings at preterm/term age and 73 recordings at fidgety age were viewed and rated independently by two raters.Results: Statistical analysis using the Fishers' exact test and Pearson's chi-square test showed significant association (p<.001) between Prechtl's General movement assessment and neuromotor outcomes at one year corrected age. General movement assessment at preterm age and fidgety age showed sensitivity of 85% (each) , specificity of 85% & 99%, positive predictive value of 27% & 85 %, and negative predictive value of 98% & 99% respectively in predicting neuromotor outcomes. Substantial agreement was found between two trained raters. Kappa values were 0.78 and 0.72for assessments done at preterm/ term age and three months corrected age respectively.Conclusion: The results suggest that Prechtl's general movement assessment done in routine clinical settings can reliably predict neuromotor outcomes of premature babies at one year corrected age. Thus, it has practical applications to identify premature babies at high risk of abnormal neurodevelopment in infancy.

Predictive value of General Movements Assessment for developmental delay at 18 months in children with complex congenital heart disease

IntroductionAccurate prediction of long-term neurodevelopmental outcome is currently not possible for extremely preterm (EP) and/or extremely low birth weight (ELBW) infants before their discharge home from the hospital. While most EP and/or ELBW infants have normal outcomes, some will develop a significant neurodevelopmental disability and/or delay (NDD), including cerebral palsy (CP) and/or functional impairment (FI). These outcomes may not become apparent for months or even years after discharge. Significant time and resources are spent on surveillance of EP and/or ELBW infants assessing for possible complications of their preterm birth, which is a substantial burden for the child, family, and health system.Outcome prediction before hospital discharge relies upon a combination of birth history, neonatal complications, results of neuroimaging (cranial ultrasound [CUS], and magnetic resonance imaging [MRI]), and more recently, the general movements (GMs) assessment. Neuroimaging and GMs are qualitative assessments requiring specialist training and are subject to potential bias.The addition of quantifiable measures of the quality of movement before discharge from the hospital of an EP or ELBW infant may increase the sensitivity and specificity of the prediction of long-term neurodevelopmental outcomes. Accelerometers provide a low-cost method of quantifying movement and are easily applied without moving the baby. AimsThe aims of this thesis were to;· Review the literature surrounding outcome prediction for EP and/or ELBW infants focusing on investigations and assessments suitable for use before hospital discharge.· Undertake a prospective observational study to determine in EP and/or ELBW infants if;Routine inpatient CUS performed on EP and/or ELBW infants at approximately day five of life, day 28 of life, and 36-weeks post menstrual age (PMA), predicts NDD (i.e., CP or FI).General movements (GMs) assessment in EP and/or ELBW infants at 28-, 32-, or 36- weeks PMA predicts NDD.Developmental trajectories (calculated from two or more GMs assessments before hospital discharge) in EP and/or ELBW infants predicts NDD.Quantitative measures of motor activity at 28-, 32-, or 36-weeks PMA, obtained from a movement detection system (MDS) (comprising of four wireless tri-axial accelerometers), correlate with the GMs assessments undertaken before hospital discharge.Quantitative measures of motor activity in EP and/or ELBW infants at 28-, 32-, or 36-weeks PMA, obtained from the MDS, predicts NDD.Quantitative measures of motor activity in EP and/or ELBW infants obtained from the MDS change according to PMA at the time of assessment (28-, 32-, and 36-weeks).The PMA at which quantitative measures of motor activity obtained from the MDS in EP and/or ELBW infants first correlate with GMs assessment and predicts NDD. Research design and methodologyA prospective observational cohort was used to determine the predictive value of movement parameters obtained from an MDS consisting of four wearable sensors (tri-axial accelerometers). Participants were EP and/or ELBW infants admitted to the Mater Mothers’ Hospital (MMH), Brisbane. Movement detection system and video recordings for the GMs assessments were undertaken on infants at 28-, 32-, and 36-weeks PMA depending on their initial age at enrolment, clinical condition, and age at discharge. Results of routine CUS and long-term neurodevelopmental follow-up at one and/or two-years CA were recorded.ResultsThe CUS had an overall sensitivity of 50% and a specificity of 98% in predicting CP. The GMs assessment at 36-weeks PMA had an overall sensitivity of 20% and specificity of 100% for predicting CP and a sensitivity of 14% and specificity of 100% for predicting FI. Assessing the developmental trajectory on GMs did not improve the prediction of CP or FI. The intra- and inter- scorer reliability of the GMs assessments was poor. The MDS parameters did not differ significantly when comparing measures between; infants with and without cramped synchronised (CS) movements, infants with and without a diagnosis of CP, and infants with and without a diagnosis of FI. Many MDS parameters decreased in value with increasing PMA demonstrating a significant maturation effect. ConclusionCranial ultrasound findings continue to provide clinically useful information for long-term neurodevelopmental outcome prediction. General movements assessments performed before hospital discharge had poor sensitivity for predicting CP and FI. Isolated use of quantitative measures of movement, obtained from four tri-axial accelerometers before hospital discharge, did not appear to assist with outcome prediction for EP and/or ELBW infants. The study was limited by the large number of parameters used for comparison. Future research should use adequately powered studies and investigate the use of pattern recognition and artificial intelligence in movement analysis as well as the combination of new neuroimaging techniques and other biomarkers. Surveillance and assessments post-hospital discharge remain essential for the detection of neurodevelopmental problems in infants born EP and/or ELBW.

The quality of general movements in infants with complex congenital heart disease undergoing surgery in the neonatal period

To determine the relationship between early motor repertoire and 2-year neurodevelopment in infants born extremely preterm (<28 weeks' gestation) or extremely-low-birthweight (ELBW) (<1000g). This was a geographical prospective cohort of 139 infants born extremely preterm/ELBW (mean gestational age 26.7 weeks, standard deviation [SD] 2.0, 68/139 [49%] male), with parent-recorded videos suitable for scoring the General Movements Assessment (GMA). Motor repertoire was assessed using the Motor Optimality Score-Revised (MOS-R), with and without the fidgety movement subsection, and the GMA alone at 12 to 13+6 weeks corrected age and 14 to 15+6 weeks corrected age. At 2years corrected age, impaired development was defined as Bayley Scales of Infant and Toddler Development, Third Edition motor and cognitive development scores 1SD or less relative to controls born at term; paediatricians diagnosed cerebral palsy (CP). Greater MOS-R scores at 14 to 15+6 weeks corrected age were associated with lower odds of CP (odds ratio [OR] per 1-point increase=0.83, 95% confidence interval [CI]=0.71-0.99), and motor (OR=0.93, 95% CI=0.87-0.99), or cognitive impairment (OR=0.94, 95% CI=0.88-0.99). Absent/abnormal GMA at 14 to 15+6 weeks was associated with CP and motor delay. There was little evidence that MOS-R scores at 12 to 13+6 weeks were associated with neurodevelopmental outcomes at 2years. Poorer MOS-R scores and absent/abnormal GMA, scored from parent-recorded videos at 14 to 15+6 weeks gestational age, are associated with CP and developmental impairment in 2-year-old infants born extremely preterm/ELBW.

This systematic review evaluates the accuracy of clinical tools used at a corrected age of 6months or younger to predict motor and cognitive delay (not cerebral palsy) at 24months' corrected age, in infants born very preterm. Six databases were searched. Quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies tool. Predictive analysis included calculation of sensitivity and specificity, inspection of summary receiver operating characteristics curves, and bivariate meta-analysis. Six assessments were identified in 10 studies of 992 infants. Overall prevalence of motor delay was 13.8% and cognitive delay was 11.7%. Methodological quality was variable for patient selection, reference standard, flow, and timing. All studies had a low risk of bias for the index test. General Movement Assessment (GMA) predicted motor and cognitive outcomes with good accuracy for mild, moderate, and severe delays (fidgety age: pooled diagnostic odds ratio=12.3 [5.9-29.8]; hierarchical summary receiver operating characteristics curve=0.733). The Hammersmith Infant Neurological Examination (HINE) demonstrated excellent predictive accuracy for severe motor delay (3mo and 6mo; sensitivity 93% [68-100%], specificity 100% [96-100%]) but showed limited ability to predict milder delays. In the population of infants born very preterm, few assessment tools used at 6 months or younger corrected age have proven predictive accuracy for cognitive and motor delay at 24 months' corrected age. Only the GMA and HINE demonstrated useful predictive validity. General movements have predictive validity for both motor and cognitive dysfunction in infants born very preterm. The Hammersmith Infant Neurological Examination showed the highest predictive accuracy for severe motor delay. The General Movement Assessment was the best tool to predict mild-to-moderate motor and cognitive delays.

O.052 Soft tissue profile changes following mandibular advancement and setback 12 years post-operatively

IntroductionInfants born extremely preterm (EP; <28 weeks' gestation) and/or with extremely low birth weight (ELBW; <1000 g birth weight) are at increased risk for adverse neurodevelopmental outcomes. However, it is...

A smartphone application to measure neurodevelopmental outcomes among infants with retinopathy of prematurity

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

General movements and magnetic resonance imaging in the prediction of neuromotor outcome in children born extremely preterm

To determine reproducibility and diagnostic accuracy of screening tools for neuromotor concerns indicative of cerebral palsy (CP) at 18 months corrected age by using the General Movements Assessment (GMA) and/or Hammersmith Infant Neurological Examination (HINE) in West Bengal, India. This prospective substudy tested psychometrics of screening tools nested within an overarching randomized control trial. A total of 785 infants with birth/infant-detectable risk factors, aged 12 to 40 weeks corrected age (n = 422 male, mean corrected age 22.6 weeks, SD = 10.2), were recruited. Infants were screened for 'high-risk CP' using the GMA (absent/abnormal fidgety, 12-17 weeks corrected age) and/or HINE (3 months < 56, 6 months < 59, 9 months < 62, 18-40 weeks corrected age). 'Neuromotor concerns indicative of CP' were classified at 18 months corrected age by a physician from a videoed neurological examination and semi-structured movement protocol. We analysed the results (1) using Gwet's AC1 and (2) for sensitivity and specificity. Interrater reproducibility was strong (Gwet's AC1 = 0.89, p < 0.001). A total of 165 out of 749 assessments were screened as 'high-risk CP' (22.0%; 95% confidence interval 19.2-25.1). The screening programme (GMA/HINE) was 80.1% accurate (GMA [only] sensitivity = 87.8%, specificity = 44.4%; HINE [only] sensitivity = 94.0%, specificity = 60.0%). The GMA and/or HINE are reliable and accurate tools for screening high-risk populations in India, and may be useful in other low- and middle-income countries to identify infants with neuromotor concerns indicative of CP who could be triaged to early intervention.