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

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


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

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


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

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


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

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


70. Romeo DM, Guzzetta A, Scoto M, Cioni M, Patusi P, Mazzone D, Romeo GM.
Early neurologic assessment in preterm-infants: Integration of traditional neurologic examination and observation of general movements.
Eur J Pediatr Neurol 2007; 17: in press.

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


69. Snider LM, Majnemer A, Mazer B, Campbell S, Bos AF.
A comparison of the general movements assessment with traditional approaches to newborn and infant assessment: Concurrent validity.
Early Hum Dev 2007; 31: in press.

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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


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


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

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


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

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


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

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


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

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


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

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


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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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

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


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


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

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


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

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


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

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


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

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


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

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


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

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


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


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

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


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

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


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

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


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

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


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

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


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


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

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


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

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


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

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


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


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