扭动运动评估在早产及足月高危儿神经发育结局预测中的比较北大核心CSCD

目的对比研究扭动运动评估对早产及足月脑损伤高危儿神经发育结局的预测价值。方法以2013年7月至2014年4月在天津市第五中心医院新生儿科接受全身运动（general movements,GMs）评估和定期随访至1岁以上的早产及足月脑损伤高危儿为研究对象。在扭动运动阶段和不安运动阶段至少各记录1次GMs,1岁时采用Peabody运动发育量表明确运动发育结局,计算并比较GMs在早产及足月高危儿运动发育结局的预测效度。结果早产儿组与足月儿组扭动运动异常的检出率差异无统计学意义（χ2＝1.592,P＝0.207）,不安运动异常的检出率差异亦无统计学意义（χ2＝1.605,P＝0.205）。扭动运动阶段对于运动发育异常结局的预测表现为对早产儿组的敏感性、特异性及阴性预测值均较高,分别为92.9%、90.0%和97.8%;而不安运动阶段对于运动发育异常结局的预测表现为对早产儿组的敏感性、特异性以及阴性预测值分别为85.7%、94.0%和95.9%。其敏感性较不安运动阶段明显增高;扭动运动评估与Peabody运动发育量表的一致性检验Kappa值＝0.703（P〈0.01）。扭动运动对于运动发育异常结局的预测表现为对足月儿组的特异性、阳性预测值均较低,分别为71.0%和55.6%;扭动运动评估与Peabody运动发育量表的一致性检验Kappa值＝0.555（P〈0.01）。扭动运动评估对于早产儿组脑性瘫痪（脑瘫）结局预测的敏感性、特异性较差,均为75.0%,与Peabody运动发育量表的一致性检验Kappa值＝0.311（P〈0.05）。扭动运动评估对足月儿脑瘫结局预测的特异性及阳性预测值均较低,分别为85.4%和22.2%,与Peabody运动发育量表的一致性检验Kappa值＝0.319（P〈0.05）。不安运动评估无论在早产儿组,还是足月儿组,其对脑瘫结局预测的敏感性和阴性预测值均为100.0%。结论扭动运动评估对早产儿运动发育结局的预测效度高于足月儿,更适合作为早产儿早期运动发育评估的工具。扭动运动评估对脑瘫结局的预测效度较差。不安运动评估对早产儿和足月儿脑瘫结局的预测敏感性均较高,不安运动可能有助于早期预测脑瘫。     

全身运动质量结合诱发电位在预测高危新生儿运动发育中的应用

目的探讨早期应用全身运动(GMs)质量评估技术结合诱发电位(EPs)对预测高危新生儿运动发育的临床价值。方法选择112例儿童神经康复科门诊随访的高危新生儿,分别在GMs扭动运动阶段和不安运动阶段进行GMs评估和EPs检测,连续随访并在纠正年龄12月龄时根据2006年脑瘫(CP)诊断标准及Peabody运动发育量表确定其运动发育结局,计算全身运动质量、诱发电位以及两者结合的预测效度。结果 112例研究对象运动发育结局,脑瘫26例(23.2%)、运动发育迟缓14例(12.5%)、正常72例(64.3%)。扭动运动阶段GMs及正中神经诱发电位(MNSEP)均异常对运动发育异常的预测灵敏度80.0%,特异度98.6%,阳性预测值97.0%,阴性预测值89.9%;不安运动阶段GMs异常对于脑瘫的预测灵敏度96.1%,特异度97.7%,阳性预测值92.6%,阴性预测值98.8%;GMs及MNSEP均异常预测效度无显著提高。两阶段中MNSEP均异常对运动发育异常的预测灵敏度82.5%,特异度91.7%,阳性预测值84.6%,阴性预测值90.4%。结论在扭动运动阶段联合GMs及MNSEP可提高对高危新生儿运动发育异常的预测效度。     

全身运动质量评估对窒息新生儿24月龄时不良结局的预测价值

目的探讨全身运动(GMs)质量评估预测足月窒息新生儿24月龄时不良结局的价值。方法 2009~2012年入住NICU、且出院后获得随访的114例足月窒息患儿为研究对象。生后3个月内进行GMs质量评估。出院后随访至24月龄时采用贝利婴幼儿发展量表(BSID)测试发育商。结果 GMs评估结果:扭动运动阶段为单调性全身运动的有20例(17.5%),为痉挛性同步运动的有7例(6.1%);不安运动阶段评估为不安运动缺乏的有8例(7.0%)。24月龄时发育商评估结果:有不良发育学结局共7例(6.1%),其中脑瘫伴智力发育迟滞6例,智力发育迟滞1例。GMs评估示扭动运动阶段单调性全身运动与24月龄时患儿发育结局的一致性差(Kappa=-0.019,P0.05)。痉挛性同步运动与24月龄时患儿发育结局的一致性较高(Kappa=0.848,P0.05),其对24月龄发育结局的预测效度为98.2%,敏感度为85.7%,特异度为99.1%,阳性预测值为85.7%,阴性预测值为99.1%。不安运动阶段不安运动缺乏与24月龄时患儿发育结局的一致性较高(Kappa=0.786,P0.05),其对24月龄发育结局的预测效度为97.4%,敏感度为85.7%,特异度为98.1%,阳性预测值为75.0%,阴性预测值为99.1%。结论 GMs评估示痉挛性同步运动和不安运动缺乏对窒息新生儿24月龄时的不良发育结局有较好的预测价值。     

不安运动的评估对高危新生儿运动发育的预测价值

目的评估高危新生儿不安运动（FMs）对运动发育结局的早期预测价值。方法随访高危新生儿39例，矫正日龄6～20周记录FMs，10～18月进行Gesell发育量表或丹佛发育筛查量表评估，结合婴儿神经系统检查确定发育结局。结果FMs正常的33例中随访诊断运动发育迟缓1例；未出现FMs的6例中，随访诊断脑性瘫痪4例，全面发育迟缓2例。FMS评估预测脑性瘫痪敏感度为100％，特异度为94％，阳性预测值为67％，阴性预测值为100％。预测运动发育迟缓的敏感度为86％，特异度为100％，阳性预测值为100％，阴性预测值为97％。结论FMs缺乏是早期预测脑性瘫痪良好而可靠的指标。矫正年龄10～14周单次FMs评估对运动发育也具有良好的预测价值，但对脑性瘫痪的阳性预测值较低。     

不安运动的评估对高危新生儿运动发育的预测价值

目的 评估高危新生儿不安运动(FMs)对运动发育结局的早期预测价值.方法 随访高危新生儿39例,矫正日龄6～20周记录FMs,10～18月进行Gesell发育量表或丹佛发育筛查量表评估,结合婴儿神经系统检查确定发育结局.结果 FMs正常的33例中随访诊断运动发育迟缓1例;未出现FMs的6例中,随访诊断脑性瘫痪4例,全面发育迟缓2例.FMs评估预测脑性瘫痪敏感度为100%,特异度为94%,阳性预测值为67%,阴性预测值为100%.预测运动发育迟缓的敏感度为86%,特异度为100%,阳性预测值为100%,阴性预测值为97%.结论 FMs缺乏是早期预测脑性瘫痪良好而可靠的指标.矫正年龄10～14周单次FMs评估对运动发育也具有良好的预测价值,但对脑性瘫痪的阳性预测值较低.     

影响婴儿全身运动质量的高危因素

目的 婴儿全身运动（GMs）质量评估技术是预测婴儿脑功能异常的有价值的工具,该研究旨在探讨影响婴儿 GMs 质量的高危因素。方法 分别选取 618 例扭动运动阶段和 539 例不安运动阶段婴儿进行 GMs 评估。 采用单因素方差分析、卡方检验及多因素 logistic 回归分析调查影响婴儿 GMs 质量的高危因素。结果 扭动运动阶段,多因素 logistic 回归分析显示有统计学意义的影响因素为出生胎龄（OR=0.762,POR=0.264,POR=2.445,P=0.012）、宫内窘迫（OR=4.865,POR=0.786,P=0.003）、出生体重（OR=0.217,POR=3.765,P=0.001）、高胆红素血症（OR=2.640,P=0.028）。结论 出生胎龄、出生体重、重度窒息、宫内窘迫、高胆红素血症是异常 GMs 的高危因素,应早期筛查、干预。     

Infanib对新生儿重症监护病房出院早产儿早期运动发育及预后评估

目的：探讨 Infant Neurological International Battery (Infanib)对新生儿重症监护病房出院的高危早产儿后期运动发育异常的预测效度。方法：纳入对象为 2008年6月至2010年3月入住新生儿重症监护病房治疗出院的早产儿,在纠正年龄3~4月、6~7月龄时采用 Infanib 进行运动发育评估;在纠正年龄12月龄或12月龄以上采用 Peabody 运动发育量表或临床神经学体检评估运动结局。通过计算 Infanib 对后期运动发育结局评估的敏感性、特异性、阳性预测值以及阴性预测值等进行预测效度评价。结果：共147例早产儿参与临床随访,在纠正年龄3~4月、6~7月龄时进行 Infanib 评估的患儿分别为147例、117例;纠正年龄12月龄或12月龄以上 129例。最终运动发育正常90例(69.8％),运动发育落后 28例(21.7％),脑瘫 11例(8.5％)。纠正年龄3~4月龄和6~7月龄 Infanib评估对运动发育异常的敏感性分别为84.6％、100％;特异性75.6％、91.7％;阳性预测值60.0％、82.5％;阴性预测值91.9%、100％。结论：Infanib 可以用于早产儿运动发育的早期评估,并具有较好的预测效度。     

运动识别技术在评估早产儿自发性全身运动中的应用

早产是导致高危儿神经发育障碍尤其是发展为脑性瘫痪的重要原因,早期识别可能存在的神经发育损伤对于早期干预、改善早产儿的神经发育结局尤为重要。全身运动(GMs)评估是目前临床用于高危儿神经发育结局尤其是运动发育结局预测的重要工具。运动识别技术运用计算机化的方法,能有效地对相关肢体运动进行持续追踪和客观定量评估;研究者正在广泛探索针对脑瘫高危儿自发性全身运动的不同记录和分析方法。该文对GMs评估方法进行总结,并对通过运动识别技术评估早产儿自发性全身运动的转化研究进行综述。     

全身运动质量评估：超早期预测早产儿神经发育结局的可靠工具

脑瘫可导致脑发育中的婴儿出现运动功能及姿势的显著异常,早产是造成脑瘫最常见的高危因素,早期识别可能存在的神经发育损伤,以便在严重伤残发生之前进行早期干预显得十分重要。全身运动质量评估在超早期可有效地预测婴儿严重的神经发育缺陷,该方法采用视觉Gestalt知觉对处于早产阶段、足月阶段以及足月后5个月内婴儿的全身运动质量进行评估,其中“不安运动”对神经发育结局尤为重要。     

Alberta婴儿运动量表对新生儿重症监护室高危儿出院后筛查运动发育落后的准确性研究

目的 分析Alberta婴儿运动量表（AIMS）在NICU高危儿随访中筛查运动发育落后的应用价值，为更好解释患儿病情和尽早合理干预提供依据。方法 纳入经NICU治疗后并于2013年11月至2015年1月在上海健高儿科门诊部随访的高危儿，行AIMS和Peabody运动发育量表-第2版（PDMS-2）评估。将患儿的AIMS总分与PDMS-2的粗大运动发育商（GMQ）进行百分位数换算，分析两者的相关性。以6月龄后GMQ≥90作为运动发育正常的参考标准，绘制AIMS百分位数的ROC曲线，计算约登指数和预测界值。进而根据所得界值分析AIMS预测运动发育落后的价值。结果 70例高危儿进入分析，产生170个AIMS数据和70个6月龄PDMS-2 GMQ数据。0~3月龄的AIMS百分位数与PDMS-2的GMQ百分位数相关系数（r）为0.09（P=0.69）；≥4月龄两者的r为0.73（P＜0.001）。与参考标准比较，形成AIMS百分位数的ROC曲线，曲线下面积为0.929（95%CI:0.876~0.982），预测界值为P17.5。以AIMS百分位数＜17.5预测运动发育落后的敏感度为87.6%（95% CI:68.4％~95.4％），特异度为88.1%（95%CI:80.6％~93.1%），阳性预测值为65.0%（95%CI:48.3％~78.9％），阴性预测值为96.3%（95%CI:90.2％~98.8％）。结论 ＞3月龄的高危儿行AMIS评估对识别运动发育正常有很高的预测价值，为避免对高危儿过度诊断和干预提供依据。     

Does a detailed assessment of poor repertoire general movements help to identify those infants who will develop normally?

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.     

Does the assessment of general movements without video observation reliably predict neurological outcome?

OBJECTIVE: To assess the clinical value of a modified version, not employing video recording, of Precthl'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.     

Assessment of general movements and 2.5 year developmental outcomes: Pilot results in a diverse preterm group

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

Prognostic value of the qualitative assessments of general movements in late-preterm infants

Background

The quality of general movements (GMs) and its predictive value have never been evaluated in late-preterm (LP) infants.

Aims

To determine the characteristics of GMs and their predictive value for neurodevelopmental outcome in a cohort of infants born between 34 and 36 weeks' gestation.

Study design and subjects

574 LP infants were examined using the standard methodological principles of Prechtl's method for assessing GMs both during writhing and fidgety periods.

Outcome measures

Infants were assessed at 2 years of age with neuromotor and developmental scales.

Results

A significant correlation was found between GMs and outcome both at writhing (rs 0.68; p < 0.001) and at fidgety age (rs 0.78; p < 0.001). The assessment at 1 month showed 100% sensitivity and 86% specificity of predicting the development of cerebral palsy (CP), that at 3 months was 100% sensitivity and 97% specificity.

Conclusions

During the fidgety age GMs predict CP with very high sensitivity and specificity. The qualitative assessment of GMs should be employed to help identify LP infants who require early intervention for neurological abnormalities.     

Cramped synchronized general movements in preterm infants as an early marker for cerebral palsy

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.     

General movements of preterm infants in relation to their motor competence between 5 and 6 years

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

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

Background

Extremely preterm (EPT) birth is a major risk factor for brain injury and neurodevelopmental impairment. Reliable tools for early prediction of outcome are warranted.

Aim

To investigate the predictive value of general movements (GMs) at “fidgety age” for neurological outcome at age 30 months in EPT infants, both in comparison and in combination with structural magnetic resonance imaging (MRI) at term equivalent age (TEA).

Study design

Fifty-three infants born < 27 weeks of gestation were included prospectively. MRI was performed at TEA and images were evaluated for white and grey matter abnormalities. GMs were assessed at age 3 months corrected (“fidgety age”).

Outcome measures

Neuromotor outcome was assessed at age 30 months corrected. Children were classified as having a normal neurological status, unspecific signs, or cerebral palsy (CP).

Results

Abnormal GMs were a common finding, seen in 32% (17/53) of infants. Of these, six infants (11%) had definitely abnormal GMs. Four infants (8%) had a diagnosis of CP at follow up. Definitely abnormal GMs were significantly associated to CP at 30 months (Fisher's Exact test p = 0.03, sensitivity 50%, specificity 92%). Moderate–severe white matter abnormalities on MRI were more strongly associated with CP (Fisher's Exact test p < 0.001, sensitivity 100%, specificity 98%) than GMs. Combining GMs with MRI-findings at TEA increased the predictive specificity to 100% (Fisher's Exact test, p = 0.005), whereas sensitivity remained unchanged.

Conclusions

The presence of definitely abnormal GMs was predictive of CP: prediction was significantly enhanced when the GMs assessment was combined with findings from MRI obtained at TEA.