Wednesday, June 29, 2016

Fidgety movements during the fidgety movement period

Sæther R, Støen R, Vik T, Fjørtoft T, Vågen RT, Silberg IE, Loennecken M, Møinichen UI, Lydersen S, Adde L. A change in temporal organization of fidgety movements during the fidgety movement period is common among high risk infants. Eur J Paediatr Neurol. 2016 Jul;20(4):512-7.

General movement assessment (GMA) at 9-20 weeks post-term, can effectively predict cerebral palsy. Our aim was to evaluate intra-individual variability of the temporal organization of fidgety movements (FMs) in high risk infants.
104 High risk infants (66 males) with at least two video recordings from the FMs period participated. 45 of the infants had GA <28 weeks and/or BW ≤800 g. Mean post-term age at first and second assessments was 11.0 (8-16) and 14.0 (11-17) weeks, respectively, and median time-difference between the assessments was 2.0 (range: three days to six weeks) weeks. Video recordings were analyzed according to Prechtl's GMA.
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.
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.

From the article

The assessment of general movements (GMs) is a non-invasive, reliable and valid method to predict severe neurological impairments.  In particular the absence or sporadic occurrence of fidgety movements (FMs), during the fidgety movement's period (9–20 weeks post term age), is highly predictive of cerebral palsy (CP).  Knowledge of the intra-individual variability of FMs in high risk infants during this period is sparse.  However, such knowledge is essential for appropriate prediction of neurological outcome…

Fidgety movements can be classified as either normal or abnormal. Normal FMs are present either intermittently (F+) or in a continual pattern (F++), whereas abnormal FMs are present sporadically (interspersed with long pauses, F+/−), exaggerated with respect to speed and amplitude (Fa), or as absent (F−).  As absent or only sporadically present FMs are found to be a good predictor of neurological impairment,  and accurate classification of the temporal organization of FMs is essential.

The reliability of GM assessment is found to be very good  however, variability of infants temporal organization of FMs during the time period when normal FMs are considered essential for a normal neurodevelopment, have not been well described in large groups of high risk infants.  

The aim of our study was to evaluate intra-individual variability of the temporal organization of FMs in infants with high risk for neurodevelopmental sequelae…

General movement assessment (GMA) is a non-invasive method that estimates the integrity of the infant nervous system by observing the quality of spontaneous movement patterns involving the limbs, neck, and trunk, which emerge over the first few months of life.  There is good evidence that lack of normal FMs, normally present at 9–20 weeks post-term,  5  can accurately predict the development of CP in high risk populations. 

GMA were performed 9–20 weeks post term age, during the fidgety movement's period. The infant's GMs were video recorded using a standardized video set-up consisting of a mattress and a stationary digital video camera (Sanyo VPC HD-200)…

The FMs were classified as normal if they were continual (F++) or intermittent (F+) and abnormal if absent (F−), sporadic (F+/−), or exaggerated with respect to speed and amplitude (Fa). The temporal organization of FMs was classified according to the duration of their interspersed pauses. Continual FMs are interspersed with short pauses, the intermittent FMs have prolonged pauses (giving the impression that FMs are present for only half the observation time), and the sporadic FMs are interspersed with even longer pauses...

Among infants who changed from abnormal to normal FMs there was a predominance of extremely preterm infants. Extremely preterm infants are delayed in motor development, and little is known about the neural mechanisms underlying GM changes. However, it has been suggested that brain maturational processes like intra- and supraspinal reorganization may be possible neural mechanism underlying GM changes during the fidgety movement's period.  Hence, it could be speculated that the instability of the temporal organization of FMs in extremely preterm infants found in our study may be related to such delayed brain maturational processes. This underscores the importance of assessing GMs along a developmental trajectory also within the mid-fidgety movement's period (10–15 weeks post term age).  Moreover, the classification of extremely preterm infants may be challenging, as these infants have shorter periods in an optimal behavioral state (active wakefulness).  It may also be challenging to classify the sporadic FMs correctly, particular from the absent ones, as they occur in periods lasting less than 3 s. 

The clinical implications of our study are in line with previous research: “ …a single assessment is not enough ”, and it emphasizes that this is of particular importance for extremely preterm infants, and infants classified with sporadic FMs. However, future research is needed to explore these findings further and to reveal if sporadic FMs at one assessment are of any clinical relevance in infants who are later identified with normal FMs. The natural course of temporal organization of FMs should be further explored in future studies. Our findings indicate that this is especially important in extreme preterm infants.

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