Preface

Chapter 8 **Plasma Growth Factors in Cerebral Palsy 123**

Chapter 9 **Hip Surgery in Cerebral Palsy 131** João Lameiras-Campagnolo

**VI** Contents

Jesús Alcaraz Rubio and Juana María Sánchez López

Cerebral palsy (CP) is a common pediatric problem and is the leading cause of childhood disability. It occurs at a rate of 3.6 cases per 1000 children. Spastic CP is the most common form accounting for about 77%. It represents a major social and psychological impact on both family and society, and is a group of disorders with movement difficulties being com‐ mon for all affected patients. Its severity and extent are variable from one patient to another. Additionally, the impacts of CP on daily activities, communications, and requirements are also variable. So, probably each patient is unique in his or her presentation and require‐ ments. Wide-spectrum problems in CP are furthermore compromised by many associated medical problems, including epilepsy (40%), visual impairment (15%), hearing impairment (7%), and communication difficulties (25%). Recent advances in clinical research increase our knowledge and understanding of causal pathways, possible preventive measures, spe‐ cific intervention strategies, and the value of new treatment modalities such as botulinum toxin and intrathecal baclofen in the management of cerebral palsy. Therefore, I am extreme‐ ly honored to present this book with its four sections and 10 very interesting chapters, which cover various fields in CP.

The first chapter by assistant professor Ali A. AL-Mayahi discusses the early markers for anticipating CP. Since cerebral palsy is a permanent disorder in the development of move‐ ment and posture in the developing fetal or infant brain, which usually manifest before 18 months of age, the most challenging tasks for medical practitioners is to identify specific risk factors in early infancy and predict severe impairment that manifests later in development. So, early detection of signs of motor impairment is crucial to assist physicians to give close follow-up of those infants and to reassure parents whose children are normal. It has been shown that intervention may be most efficient when the plasticity of the brain is high, and an early detection of brain impairment is therefore crucial. An earlier follow-up and training program can have a positive effect on the motor development of a child with CP, in particu‐ lar through prevention of limb contractions, and might make a difference in the child's abili‐ ty to handle everyday challenges. In addition, an early detection of CP gives the parents more time for adjustment and preparation. Since clinical manifestations of CP do not emerge before a child is at least six months, the general movement is considered the most reliable early marker for monitoring fetal and infant movement. Abnormal general move‐ ment carries a high risk of developing CP. In addition, the absence of so-called fidgety movements at 3–5 months post-term age. Besides high sensitivity (>91%) and specificity (>81%), the assessment of general movement is quick, non-intrusive, and easy to acquire.

In the second chapter, Dr. Ogoke Christian gives a review of the clinical classification of CP. Classification of CP remains a debatable issue. In this chapter, the author discusses the vari‐ ous classifications of CP, highlights the clinical features used in the various classifications,

outlines the recent functional classifications of CP such as the Gross Motor Function Classifi‐ cation System, Manual Ability Classification System, Communication Function Classifica‐ tion System, and Eating and Drinking Ability Classification System and finely highlights how these recent classifications guide the current management of CP. Each classification used alone is incomplete. Therefore, multiaxial classification gives a more comprehensive description of a child with CP. The recent WHO International Classification of Functioning, Disability, and Health emphasized the importance of focusing on the functional consequen‐ ces of various states of health and has stimulated the development of newer functional scales in CP. Currently, there are functional scales for some of the functions impaired in CP. It is widely accepted that functional classification is the best classification for the patient be‐ cause it guides management.

Dr. Adel A. Kareem in the sixth chapter reviews his experience in using botulinum toxin in children with CP. In the last 25 years, botulinum toxin type A (BTX-A) has been proved as an effective medicine strategy to decrease hypertonia in children with CP. Nowadays, BTX-A has a major role in the multidisciplinary treatment of spastic CP, in addition to physio‐ therapy, occupational therapy, speech therapy, casting, ankle-foot orthoses and knee-anklefoot orthoses, surgical application of intrathecal baclofen, selective dorsal rhizotomy, and different other orthopedic interventions. Its use after the age of two years has been adopted by most experts all over the world. Botulinum toxin use in the management of CP is recom‐ mended to improve function and to support motor development. Furthermore, botulinum toxin injection has an additional role in the decrease of pain associated with focal spasticity. The seventh chapter by Dr. Moneer Faraj discusses relatively new treatment modalities for CP, namely intrathecal baclofen. He discusses the rationale for the use of this mode of treat‐ ment in spasticity. Different treatment options are used to reduce spasticity and increase the range of motion in CP, including non-pharmacological methods (splints or braces, electrical or vibratory stimulation, physical and occupational therapy, massage, heat or ice, and serial or inhibitory casting), pharmacological methods by different medications (nerve block, anes‐ thetics injection, alcohol or phenol, neurotoxins, and oral medications such as oral baclofen and anticonvulsant), surgical methods such as dorsal entry zone rhizotomy, and augmented therapy such as baclofen pump implantation (a surgical procedure performed to permanent‐ ly implant a pump that delivers baclofen to the spinal fluid to treat severe to moderately severe spasticity that is refractory to oral medications). As compared to oral medications, the direct infusion of baclofen into the intrathecal space minimizes the amount of drug needed to be effective and it will limit or eliminate the common undesirable side effects associated with taking oral medications for spasticity. The pumps can deliver a precise and consistent drug dose throughout the day, so avoiding the peaks and valleys of taking oral medication. Dosing is very flexible and can be programmed as required, from the same dose adminis‐ tered on an hourly basis 24 hours a day to different doses at different times of the day or

Preface IX

The eighth chapter by Dr. Alcaraz Jesús discusses the use of plasma growth factors in CP. Nowadays, platelet-rich plasma is a common medical technique within so-called regenera‐ tive medicine. Its use in various fields of medicine, especially traumatology, dentistry, and general surgery, has undergone an extraordinary development given the enormous capacity for regeneration, differentiation, and chemotaxis that produce the so-called growth factors, modulating angiogenesis and the cellular plasticity of injured tissues. Among them, the best known are the so-called insulin-like growth factor, transforming growth factor A or B, vas‐ cular endothelium-derived growth factor, and platelet-derived growth factor. Neuroendoc‐ rinology and neurorehabilitation are the new branches of medicine where plasma growth factor application opens up new expectations. These factors infuse locally or systemically by the intravenous route, and have the capacity for immunomodulation and chemotaxis on neural cells. Furthermore, it has been demonstrated that in patients with neurological de‐ generative diseases (e.g. Alzheimer's disease, vascular encephalopathy, multiple sclerosis, amyotrophic lateral sclerosis, and hypoxic–anoxic encephalopathy), the plasmatic levels of certain growth factors were below the baseline, so it was hardened that could interfere in the mechanism of cellular hypoxia, producing both a neuroprotection function and regeneration

days of the week.

and differentiation of neuronal tissue.

Dr. Day Steven et al. in the third chapter discuss the survival, mortality, and life expectancy of patients with CP. The level of disability in CP ranges from immaterial to profound. In concert with the continuum of level of severity of disability/independent functioning, healthcare needs, therapies, medications, surgical interventions, costs of care, daily demands on parents and other family members, and expectations for the future in terms of education, employment, and other milestones of life all vary widely. Similarly, life expectancy in CP follows a continuum, from far lower than to potentially as high as the general population life expectancy, and parallels the continuum of levels of disability. The authors review the literature documenting this and examine the specific factors that are known to be strongly associated with mortality and longevity in CP. They also examine the evidence regarding the causes of death in CP, and present some new findings related to this. They finely outline important methodological considerations for future research in this area.

Dr. Kholin Alexey in the fourth chapter discusses the problem of epilepsy in children with CP. Different types of epilepsy occur in about 40% of children with CP. It will aggravate the clinical course of CP, complicate rehabilitation, affect prognosis of the motor and intellectual functions, and could be life threatening. The spectrum of epilepsies in CP is wide ranging from favorable combinations with benign idiopathic forms to extremely severe epileptic en‐ cephalopathies. Frequent combinations of epileptic and non-epileptic paroxysms cause diffi‐ culty in their interpretation and differential diagnosis. Video-EEG monitoring is a "golden standard" for differential diagnosis of epileptic and non-epileptic events and is very useful for investigation of patients with CP. Treatment of epilepsy in combination with CP strictly requires an individual approach due to the form of epilepsy, seizure types, the age of the patient, comorbidity, and the somatic and mental condition of the patient.

In the fifth chapter, Dr. Akhter Rahena et al. give a description of the oral health status and factors affecting dental caries in children with CP. Oral health can be significantly affected in children with CP. Many factors operate, including changes in the structure of the orofacial region, feeding problems, and difficulties with maintaining oral hygiene. Difficulties and barriers in accessing oral health care are additional factors. Caries rates in CP have been ex‐ amined by several studies but to date no population-based studies have been published de‐ fining the risk factors for dental caries among children with CP. There is a high prevalence of orofacial motor dysfunction among people with CP, which can hinder oral hygiene and hence increase dental biofilm formation and retention. Factors such as food consistency, snacking between meals, and associated oromotor dysfunction have also been reported to contribute to the high incidence of caries found in those with CP. The chapter also provides preventive and restorative recommendations to combat the prevalence of this problem.

Dr. Adel A. Kareem in the sixth chapter reviews his experience in using botulinum toxin in children with CP. In the last 25 years, botulinum toxin type A (BTX-A) has been proved as an effective medicine strategy to decrease hypertonia in children with CP. Nowadays, BTX-A has a major role in the multidisciplinary treatment of spastic CP, in addition to physio‐ therapy, occupational therapy, speech therapy, casting, ankle-foot orthoses and knee-anklefoot orthoses, surgical application of intrathecal baclofen, selective dorsal rhizotomy, and different other orthopedic interventions. Its use after the age of two years has been adopted by most experts all over the world. Botulinum toxin use in the management of CP is recom‐ mended to improve function and to support motor development. Furthermore, botulinum toxin injection has an additional role in the decrease of pain associated with focal spasticity.

outlines the recent functional classifications of CP such as the Gross Motor Function Classifi‐ cation System, Manual Ability Classification System, Communication Function Classifica‐ tion System, and Eating and Drinking Ability Classification System and finely highlights how these recent classifications guide the current management of CP. Each classification used alone is incomplete. Therefore, multiaxial classification gives a more comprehensive description of a child with CP. The recent WHO International Classification of Functioning, Disability, and Health emphasized the importance of focusing on the functional consequen‐ ces of various states of health and has stimulated the development of newer functional scales in CP. Currently, there are functional scales for some of the functions impaired in CP. It is widely accepted that functional classification is the best classification for the patient be‐

Dr. Day Steven et al. in the third chapter discuss the survival, mortality, and life expectancy of patients with CP. The level of disability in CP ranges from immaterial to profound. In concert with the continuum of level of severity of disability/independent functioning, healthcare needs, therapies, medications, surgical interventions, costs of care, daily demands on parents and other family members, and expectations for the future in terms of education, employment, and other milestones of life all vary widely. Similarly, life expectancy in CP follows a continuum, from far lower than to potentially as high as the general population life expectancy, and parallels the continuum of levels of disability. The authors review the literature documenting this and examine the specific factors that are known to be strongly associated with mortality and longevity in CP. They also examine the evidence regarding the causes of death in CP, and present some new findings related to this. They finely outline

Dr. Kholin Alexey in the fourth chapter discusses the problem of epilepsy in children with CP. Different types of epilepsy occur in about 40% of children with CP. It will aggravate the clinical course of CP, complicate rehabilitation, affect prognosis of the motor and intellectual functions, and could be life threatening. The spectrum of epilepsies in CP is wide ranging from favorable combinations with benign idiopathic forms to extremely severe epileptic en‐ cephalopathies. Frequent combinations of epileptic and non-epileptic paroxysms cause diffi‐ culty in their interpretation and differential diagnosis. Video-EEG monitoring is a "golden standard" for differential diagnosis of epileptic and non-epileptic events and is very useful for investigation of patients with CP. Treatment of epilepsy in combination with CP strictly requires an individual approach due to the form of epilepsy, seizure types, the age of the

In the fifth chapter, Dr. Akhter Rahena et al. give a description of the oral health status and factors affecting dental caries in children with CP. Oral health can be significantly affected in children with CP. Many factors operate, including changes in the structure of the orofacial region, feeding problems, and difficulties with maintaining oral hygiene. Difficulties and barriers in accessing oral health care are additional factors. Caries rates in CP have been ex‐ amined by several studies but to date no population-based studies have been published de‐ fining the risk factors for dental caries among children with CP. There is a high prevalence of orofacial motor dysfunction among people with CP, which can hinder oral hygiene and hence increase dental biofilm formation and retention. Factors such as food consistency, snacking between meals, and associated oromotor dysfunction have also been reported to contribute to the high incidence of caries found in those with CP. The chapter also provides preventive and restorative recommendations to combat the prevalence of this problem.

important methodological considerations for future research in this area.

patient, comorbidity, and the somatic and mental condition of the patient.

cause it guides management.

VIII Preface

The seventh chapter by Dr. Moneer Faraj discusses relatively new treatment modalities for CP, namely intrathecal baclofen. He discusses the rationale for the use of this mode of treat‐ ment in spasticity. Different treatment options are used to reduce spasticity and increase the range of motion in CP, including non-pharmacological methods (splints or braces, electrical or vibratory stimulation, physical and occupational therapy, massage, heat or ice, and serial or inhibitory casting), pharmacological methods by different medications (nerve block, anes‐ thetics injection, alcohol or phenol, neurotoxins, and oral medications such as oral baclofen and anticonvulsant), surgical methods such as dorsal entry zone rhizotomy, and augmented therapy such as baclofen pump implantation (a surgical procedure performed to permanent‐ ly implant a pump that delivers baclofen to the spinal fluid to treat severe to moderately severe spasticity that is refractory to oral medications). As compared to oral medications, the direct infusion of baclofen into the intrathecal space minimizes the amount of drug needed to be effective and it will limit or eliminate the common undesirable side effects associated with taking oral medications for spasticity. The pumps can deliver a precise and consistent drug dose throughout the day, so avoiding the peaks and valleys of taking oral medication. Dosing is very flexible and can be programmed as required, from the same dose adminis‐ tered on an hourly basis 24 hours a day to different doses at different times of the day or days of the week.

The eighth chapter by Dr. Alcaraz Jesús discusses the use of plasma growth factors in CP. Nowadays, platelet-rich plasma is a common medical technique within so-called regenera‐ tive medicine. Its use in various fields of medicine, especially traumatology, dentistry, and general surgery, has undergone an extraordinary development given the enormous capacity for regeneration, differentiation, and chemotaxis that produce the so-called growth factors, modulating angiogenesis and the cellular plasticity of injured tissues. Among them, the best known are the so-called insulin-like growth factor, transforming growth factor A or B, vas‐ cular endothelium-derived growth factor, and platelet-derived growth factor. Neuroendoc‐ rinology and neurorehabilitation are the new branches of medicine where plasma growth factor application opens up new expectations. These factors infuse locally or systemically by the intravenous route, and have the capacity for immunomodulation and chemotaxis on neural cells. Furthermore, it has been demonstrated that in patients with neurological de‐ generative diseases (e.g. Alzheimer's disease, vascular encephalopathy, multiple sclerosis, amyotrophic lateral sclerosis, and hypoxic–anoxic encephalopathy), the plasmatic levels of certain growth factors were below the baseline, so it was hardened that could interfere in the mechanism of cellular hypoxia, producing both a neuroprotection function and regeneration and differentiation of neuronal tissue.

In the ninth chapter, Dr. João Lameiras Campagnolo discusses various aspects of hip sur‐ gery in children with CP. He discusses in particular theoretical and practical strategies used to treat specific CP hip dislocation. Hip pathology is one of the main orthopedic problems in children with CP. In several countries, hip dislocation is significantly prevalent and is still a major concern in these patients. Depending on the age, the disability grade, the rehabilita‐ tion support, and the surgical strategies, results of hip treatment are variable. The ideal out‐ come of a stable, reduced, and long-lasting pain-free hip is not always achieved.

Finally, I hope this book with its interesting chapters will shed light on some of the stimulat‐ ing aspects of this important disease. I would like to thank all authors who contributed with their chapters and for their patience and cooperation throughout the processing of the book. Also, I would like to thank the IntechOpen personnel, especially Ms. Dolores Kuzelj, who helped me through the publishing process of this book.

#### **Prof. Isam Jaber AL-Zwaini, PhD**

Department of Pediatrics AL-Kindy Medical College University of Baghdad Baghdad, Iraq **Section 1**

**Predictors of Cerebral Palsy**

**Predictors of Cerebral Palsy**

In the ninth chapter, Dr. João Lameiras Campagnolo discusses various aspects of hip sur‐ gery in children with CP. He discusses in particular theoretical and practical strategies used to treat specific CP hip dislocation. Hip pathology is one of the main orthopedic problems in children with CP. In several countries, hip dislocation is significantly prevalent and is still a major concern in these patients. Depending on the age, the disability grade, the rehabilita‐ tion support, and the surgical strategies, results of hip treatment are variable. The ideal out‐

Finally, I hope this book with its interesting chapters will shed light on some of the stimulat‐ ing aspects of this important disease. I would like to thank all authors who contributed with their chapters and for their patience and cooperation throughout the processing of the book. Also, I would like to thank the IntechOpen personnel, especially Ms. Dolores Kuzelj, who

**Prof. Isam Jaber AL-Zwaini, PhD**

Department of Pediatrics AL-Kindy Medical College University of Baghdad

Baghdad, Iraq

come of a stable, reduced, and long-lasting pain-free hip is not always achieved.

helped me through the publishing process of this book.

X Preface

**Chapter 1**

**Provisional chapter**

**Early Markers for Cerebral Palsy**

**Early Markers for Cerebral Palsy**

DOI: 10.5772/intechopen.79466

Cerebral palsy (CP) is a term referring to a nonprogressive disease of the brain originating during the antenatal, neonatal, or early postnatal period when brain neuronal connections are still evolving. Secondary effects of spasticity on growth may, however, be progressive. There may be additional disturbances of sensation, perception, cognition, communication, and behavior. Babies who are neurologically abnormal as newborns are at increased risk of neurologic abnormality in later months and years. Being born preterm (born <37 weeks of gestation) or with a very low birth weight (weighing <1500 g/<32 weeks of gestation) or extreme low birth weight (<1000 g/<28 weeks of gestation) is associated with significant motor impairment. Which specific signs in the neonate are of greatest predictive power, what long-term disability these signs predict, and how well they predict it remain unclear? Physician's major concern is to identify specific risk factors for severe impairment in early infancy so as to predict the developmental outcome of those children that may manifest later on with neurological deficit especially if they have perinatal insult. Parents on the other hand are also concerned about their growing infants, their development, and neurological outcome. Since cerebral palsy is a permanent disorder, early detection of signs of motor impairment is crucial to assist physicians to give close follow-up of those infants and to reassure parents whose children are normal. It has been shown that intervention may be most efficient when the plasticity of the brain is high, and an early detection of brain impairment is therefore crucial. An earlier follow-up and training program can have a positive effect of the motor development of the child with CP, in particular through prevention of limb contractions, and might make a difference in the child's ability to handle everyday challenges. In addition, an early detection of CP gives the parents more time for adjustment and preparation. Since clinical manifestations of cerebral palsy do not emerge before a child is at least 6 months, the general movement (GM) is considered the most reliable early markers for monitoring of fetal and infant movement. Abnormal General movements and absence of the so-called fidgety movements at 3-5 months post-term carries a high risk of developing cerebral palsy. Beside a high specificity (82–99%) and sensitivity (95–100%), the assessment

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

of the general movements (GMs) is quick, nonintrusive, and easy to acquire.

**Keywords:** infant, cerebral palsy, early markers, general movement, neuroimaging

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79466

Ali A. Al-Mayahi

Ali A. Al-Mayahi

**Abstract**

#### **Chapter 1 Provisional chapter**

#### **Early Markers for Cerebral Palsy Early Markers for Cerebral Palsy**

#### Ali A. Al-Mayahi Ali A. Al-Mayahi

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79466

#### **Abstract**

Cerebral palsy (CP) is a term referring to a nonprogressive disease of the brain originating during the antenatal, neonatal, or early postnatal period when brain neuronal connections are still evolving. Secondary effects of spasticity on growth may, however, be progressive. There may be additional disturbances of sensation, perception, cognition, communication, and behavior. Babies who are neurologically abnormal as newborns are at increased risk of neurologic abnormality in later months and years. Being born preterm (born <37 weeks of gestation) or with a very low birth weight (weighing <1500 g/<32 weeks of gestation) or extreme low birth weight (<1000 g/<28 weeks of gestation) is associated with significant motor impairment. Which specific signs in the neonate are of greatest predictive power, what long-term disability these signs predict, and how well they predict it remain unclear? Physician's major concern is to identify specific risk factors for severe impairment in early infancy so as to predict the developmental outcome of those children that may manifest later on with neurological deficit especially if they have perinatal insult. Parents on the other hand are also concerned about their growing infants, their development, and neurological outcome. Since cerebral palsy is a permanent disorder, early detection of signs of motor impairment is crucial to assist physicians to give close follow-up of those infants and to reassure parents whose children are normal. It has been shown that intervention may be most efficient when the plasticity of the brain is high, and an early detection of brain impairment is therefore crucial. An earlier follow-up and training program can have a positive effect of the motor development of the child with CP, in particular through prevention of limb contractions, and might make a difference in the child's ability to handle everyday challenges. In addition, an early detection of CP gives the parents more time for adjustment and preparation. Since clinical manifestations of cerebral palsy do not emerge before a child is at least 6 months, the general movement (GM) is considered the most reliable early markers for monitoring of fetal and infant movement. Abnormal General movements and absence of the so-called fidgety movements at 3-5 months post-term carries a high risk of developing cerebral palsy. Beside a high specificity (82–99%) and sensitivity (95–100%), the assessment of the general movements (GMs) is quick, nonintrusive, and easy to acquire.

DOI: 10.5772/intechopen.79466

**Keywords:** infant, cerebral palsy, early markers, general movement, neuroimaging

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **1. Introduction**

Cerebral palsy (CP) is a permanent disorder in the development of movement and posture in the developing fetal or infant brain which usually manifests before 18 months of age [1]. Prematurity is a major risk factor for later motor impairment, and the prevalence of CP increases from 0.1% in term babies to 14.6% in those born preterm [2, 3].

**3. General movements**

cord [25].

the arms and legs.

may indicate fetal or neonatal motor compromise [25].

**3.1. Fetal and preterm general movements**

movements are smaller than previously [29].

ing, and stretching movements [12].

**3.2. Writhing movements**

General movement is a part of spontaneous movement activity that is generated by the developing nervous system; it appears from the 7th week postmenstrual until 3–5 months post-term. The beginning of early fetal movement at the 7th week is correlated with the development of synapsis in the spinal cord, the emergence of neuromuscular contacts, and before the development of spinal reflex pathway at 10–11 weeks postmenstrual [22–24]. It is characterized by a movement that involves the whole body in a variable sequence involving the arm, leg, neck, and trunk. They are complex in nature that wax and wane vary in intensity, speed, and range of motion and have a gradual onset and end. It has been proposed that GMs consist of rhythmic bursts of action potentials [16]. GMs are generated from a large neuronal generator network that extends from the brain stem to the spinal

Early Markers for Cerebral Palsy

5

http://dx.doi.org/10.5772/intechopen.79466

The variable nature of GM is explained by the presence of supraspinal projections that activate, inhibit, and modulate the central generator network [26]. Fetal and neonatal nervous system generates not only a variety of motor patterns such as simple startles or twitches but also more complex patterns such as stretching, yawning, or GM [12, 26]. General movements are movements which involve the entire body, rotations around the limb axes, and slight changes in the direction of movement that gives the GM its fluency and elegancy [10, 27]. The first-stage fetal movement that starts at the 7th week postmenstrual appears as movements that are restricted to the head and trunk, and then the second stage begins with the movement of all parts of the body as slow and simple movement of

More complex and variable GMs emerge at week 9–10 of postmenstrual age (PMA), where each phase has its own characteristics [28]. Complexity and variation of movements are brought about by the independent exploration of degrees of freedom in all body joints. The variable combinations of movement like flexion-extension, abduction-adduction, and endorotation-exorotation generate a series of changes in movement direction of the involved body parts. GMs are considered as the major tool of assessing fetal and infant brain integrity in which reduced modulation of the central neuronal generators results in less variable GM and

From week 9 up to term age, the GMs are referred to as fetal and preterm general movements. These movements have large amplitudes and fast speed in which the fetus develops the entire neonatal movement, which also includes arm and leg movements, startles, sucking, breath-

From term age onward till the second month post-term, the GM is called "writhing movement" which is characterized by small-to-moderate amplitude and speed. In addition, trunk

The physical impairment is often accompanied by disturbances in cognition and perception [4]. Preterm birth, perinatal asphyxia and neonatal encephalopathy, genetic predisposition, white matter disease, deep gray matter lesion, cerebral infarction, and intraventricular hemorrhage are associated with increased risk of CP [5–7].

The ability to predict CP earlier than 2 years of age would have many advantages. Earlier recognition of infants at high risk for neurodevelopmental delay would also benefit families through individualized case management and interventions and may also lead to more focused follow-up and reassure the parents of those children who are unlikely to develop CP. One of the most challenging tasks for medical practitioners is to identify specific risk factors in early infancy and predict severe impairment that manifest later in development. Parents on the other hand still concerned about the developmental perspectives of their infant, especially if he has a perinatal insult. One should consider that overt clinical symptoms of CP usually do not manifest before the child is at least half year old [4]. In addition to that, identification of language and cognitive function delay requires long time follow-up for accurate detection [8]. Early recognition of neurodevelopmental delay needs a good tool for early diagnosis to predict the outcome and to enable early intervention as soon as possible. The plasticity of the brain is at its highest during the first 2 years and decreases gradually thereafter [9]. It has been shown that spontaneous motility is an excellent marker for neural dysfunction caused by brain impairment, which normally would not become evident and clinically manifested for years [10, 11]. The general movement assessment (GMA) developed by Prechtl is a known diagnostic tool for the functional assessment of the young nervous system and has shown good results in predicting CP at an early stage [12–15]. GMA is noninvasive, even nonintrusive, cost-efficient, and easy to learn [12]. During the last 15 years, considerable research has been devoted to GMs, whose quality has proven to be most indicative of functional integrity of the young nervous system, with specificity of 82–99% and a sensitivity of 95–100% [10, 16–17]. GMA conducted at 3 months of corrected age is useful in a clinical setting for predicting CP at 2 years of corrected age for children born <32 weeks of gestation [18]. In its predictive power, the GM assessment is superior to cranial ultrasound (US) or neurological examination and equivalent to MRI (white matter assessment) [19–21].

#### **2. The aim of this chapter**

The aim of this chapter is to discuss the early markers of cerebral palsy from the general movement assessment to the neurological examination and then neuroimgaing studies when indicated in assessing high-risk infants to provide opportunity for early detection of any poor motor performance and for early possible intervention.
