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The Perfetti method, a novel Virtual Fine Motor Rehabilitation system for
Chronic Acquired Brain Injury

Conference Paper · May 2014

DOI: 10.4108/icst.pervasivehealth.2014.255251

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 The Perfetti method, a novel Virtual Fine Motor
Rehabilitation system for Chronic Acquired Brain Injury
Sergio Albiol-Pérez, Nancy Guerrón-Paredes José-Antonio Gil-Gómez, Pilar Manzano
Guillermo Palacios- Universidad de las Fuerzas José-Antonio Lozano Quilis, Hospital S. José
Navarro Armadas ESPE, Hermenegildo Gil-Gómez Av. Zaragoza 16,
Universidad de Zaragoza Av. General Rumiñahui s/n, Universitat Politècnica de València, 44001-Teruel,
Ciudad Escolar s/n Sangolquí, ECUADOR SPAIN
C. Vera S/N, 46022, Valencia,
44003 – Teruel, SPAIN +593 (03) 2810-206 ext. 131 SPAIN +34 978 60 53 68
+34 978 61 81 02
[email protected] +34 96 387 70 00 pilarmanzanoh@
{salbiol|g.palacios} {jgil | jlozano | hgil }@upv.es hotmail.com
@unizar.es
ABSTRACT U.S. is around 795,000 every year (with an 87% ischemic, a 10%
Acquired Brain Injury (ABI) is a disability with a high worldwide intracranial, and a 3% subarachnoid hemorrhage). In 2008,
incidence that requires the assistance of a multidisciplinary team approximately one out of 18 deaths was due to stroke [1]. The
of clinic specialists. Motor disorders in patients of this type incidence of Traumatic Brain Injury (TBI) in the U.S. is
include dysfunctions in upper limbs, arm-hand impairments, approximately 1.74 million per year, with long-term disability
spasticity, and functionalities that patients need to recover in order from 3.32 million to 5.3 million, with mild severity of 80% [2].
to perform the basic and instrumented activities of daily living. Stroke is defined as a neurological disorder due to an acute injury
Traditional rehabilitation techniques in upper-limb rehabilitation of the central nervous system [3] that is produced by changes in
for improving motor recovery are focused on repetitive and high- the supply of blood to the brain [4]. These types of disorders are
intensity task-specific training. Promising new systems based on due to ischemic diseases (impairment or occlusion of an artery in
Virtual Fine Motor Rehabilitation (VFMR) are a novel approach the brain), intracerebral hemorrhage (ICH), and subarachnoid
in the rehabilitation process. In this paper, we describe a VFMR hemorrhage (SAH) [5].
system (VPREHAB) for Chronic ABI patients to improve the
effectiveness of upper-limb rehabilitation. For this purpose, we Disability in TBI patients can be classified as primary or
are testing the usefulness of the Perfetti method, a cognitive secondary. Primary damage is produced through external forces
sensory motor therapy. on the injured brain as a result of hits or penetration of objects
caused by a blast [6]. Events of this type, which are influenced by
the nature of the matter, intensity, direction, and length of external
Categories and Subject Descriptors forces, determine the severity of the damage. Secondary damage is
H5.1. [Multimedia Information Systems]: Artificial, augmented, produced by bimolecular and physiological changes after the
and virtual realities; H.5.2 [Information Interfaces and primary damage. This produces edemas, disturbances in brain
Presentation]: User Interfaces – Graphical user interfaces (GUI), functionality, increases in brain pressure, and reduction in blood
Interaction styles, Screen design, User-centered design. J.3 flow [6]. Other types of secondary injuries are: 1) intracranial
[Computer Applications]: Life and medical Sciences – Health, hematomas; 2) ischemia; 3) infection; 4) epilepsy; and 5)
Medical information systems. endocrine disturbances [7].
General Terms Clinical disturbances in ABI patients are related to loss of
Design, Experimentation, Performance. functionality in upper limbs, arm impairments, and spasticity [8],
leading to dependence in their basic activities of daily living
(ADL) and instrumented activities of daily living (iADL) [9].
Keywords Positive symptomatology of spasticity is composed of permanent
Virtual Fine Motor Rehabilitation; Perfetti method; Acquired
contraction of the muscles, hypertonia (muscle tension with
Brain Injury; Physical Therapy; Hand Rehabilitation; Arm
passive resistance of stress), stiffness, and contractions between
Rehabilitation.
agonist and antagonist muscles. Negative symptomatology is
based on loss of skills and dexterity [10].
1. INTRODUCTION
Acquired brain injury (ABI) is one of the leading causes of 2. RELATED WORK
disability and death worldwide. The incidence of stroke in the
Due to these disturbances, traditional rehabilitation in upper limbs
requires different assessments of specific repetitive tasks, specific
Permission to make digital or hard copies of all or part of this work for movements, and position routine.
personal or classroom use is granted without fee provided that copies are
A Systematic Review was published in 2004 [11]. This review
not made or distributed for profit or commercial advantage and that
copies bear this notice and the full citation on the first page. To copy
found that treatments of this type are carried out by occupational
otherwise, or republish, to post on servers or to redistribute to lists, therapists and specialists in brain injury. The techniques used are
requires prior specific permission and/or a fee. the following: 1) constraint-induced movement therapy (CIMT)
PervasiveHealth 2014, REHAB workshop, May 20–23, 2014, [12], which is a method that trains the affected upper limb by
Oldenburg, Germany.
Copyright 2014.
constraining the non-affected limb. However, this technique has
the drawback that not all ABI patients can perform it due to the
high severity of restriction in upper-limb movement; 2) repetitive
and intensive upper-limb tasks, with significant improvement in
neuromuscular, ADL, and functional outcomes [13]; 3) bilateral
arm-training and dexterity of the paretic arm, with isometric and
isotonic exercises in the affected arm (grip strength, isometric and
isotonic hand extension etc.)[14]; 4) mirror therapy, moving the
non-paretic arm while the ABI patient looks at a mirror and thinks
that he/she is moving the paretic arm [15]. This type of therapy Figure 1. Subject using VPREHAB.
provides visual-feedback.
Few studies have validated the efficacy of Cognitive Sensory
Motor Training Therapy (the Perfetti method) in the motor The sample consists of 20 chronic ABI patients (stroke and TBI
recovery of upper-limb ABI patients [16], but the outcomes are patients), with residual paresis or plegia in upper limb.
promising and encouraging.
In accordance with these clinical requirements, the designed
However, these techniques do not maintain the interest of the system is composed of three main stages: selection of
patient who loses motivation. This leads to a decrease in the patient/games, game play, and results.
stimulation of working alliance and a reduction in the functional
outcomes.
3.2 VPREHAB System
Currently, Virtual Motor Rehabilitation (VMR) that is carried out
VPREHAB is composed of different Virtual Environments (VE)
in the rehabilitation process of ABI patients is a promising
that have been designed and developed by a multidisciplinary
approach. Different studies have tested and validated with
team that is composed of therapists and clinical specialists in
effectiveness of VMR in balance, postural control, lowers limb,
rehabilitation.
and uppers limb [17],[18],[19]. The use of customizable Virtual
Environments (VE) with visual and auditory feedback produces In our opinion, the goals that we want to achieve are: 1) an
comfortable training sessions, thereby improving the final results increase in the recovery of upper limbs for different pathologies in
and outperforming traditional rehabilitation. chronic ABI patients such as stroke, TBI, and others; 2) the use of
a system that motivates chronic ABI patients; 3) the use of
New systems using personal tablets or low-cost optical tracking
visual/auditory feedback that shows the results achieved in the
devices (Ms. Kinect) are a novel discipline in the rehabilitation of
therapeutic sessions; 4) improvements in upper limbs and muscle
ABI patients that provides sensory feedback to the brain
tone in chronic ABI patients; 5) the creation of a novel system to
[20],[21]. The drawback of these systems is the use of commercial
perform the virtual Perfetti method at home; 6) the customization
games that are not suitable for virtual rehabilitation therapies, due
of virtual sessions for each patient in this study.
to the complexity of the games. To obtain adequate motor
recovery, it is necessary to develop specific and customizable The therapeutic exercises that patients carry out are based on
systems that are focused on the rehabilitation of the upper limbs in abnormal reactions to stretching. These types of movements are
chronic ABI patients. included in the first level of the Perfetti method, where the
perceptive hypothesis is the recognition of figures or letters of the
The purpose of this study is to test gross/fine motor rehabilitation
alphabet (Figure 1).
in chronic ABI patients using Perfetti method. To do this, we have
designed a specific system, Virtual Perfetti Rehabilitation The cognitive tasks that chronic ABI patients perform are
(VPREHAB), which is focused on hand movements training composed of two phases: 1) the sensorimotor exploration phase,
(hand opening/closing and flexion/extensions) and forearm in which patients are sitting in front of a wood board (in the
rotation (pronation/supination and adduction/abduction of the traditional Perfetti method session)/ or in from of a personal tablet
wrist). By using VPREHAB, the therapeutic process will increase (in the VPREHAB session). At this point, the patients are shown
the recovery of the hand and arm in chronic ABI patients through different figures or letters, with special attention to the outline of
highs levels of satisfaction and enjoyable rehabilitation sessions. the shape of the objects; 2) the sensorimotor identification phase,
in which patients close their eyes and the therapist places a part of
3. METHODS the patient’s hand guiding his/her fingertip with precise and
uniform movements along the outline of the shape selected. In this
3.1 Participants phase, VPREHAB plays sound cues to reinforce the precise and
The study is being conducted with chronic ABI patients. The controlled fingertip movements.
inclusion criteria are: 1) age≥18 years and ≤70 years; 2) The exercises of this study are related to the repetition of
chronicity≥24 months; 3) comprehension of VPREHAB flexion/extension movements with the collaboration of the
instructions (the Mississippi Aphasia Screening Test (MAST) ≥45 therapist and the chronic ABI patients and to the perceptive task
[22]); 4) baseline outcomes of the modified Ashworth Spasticity of the recognition of the angle that the fingers acquire. The
Scale (ASS) ˂2 and close to zero; 5) patients without cognitive different levels of difficulty are based on parameters such as an
impairment (MEC-Lobo [27]) > 23. The exclusion criteria are: 1) increase in the number of figures, the use of a greater number of
chronic ABI patients with visual/auditory injuries; 2) patients with fingers, and an increase in average speed.
hemispatial neglect; 3) traumatological injury that is not properly For medium-level exercises, the assumed hypothesis for the first
solved; 5) refusal of the chronic ABI patient. module is based on the recognition of the length of the different
targets. In the sensorimotor identification phase, the patient closes
 performs the task correctly); 3) “Completion time” (the total time
VPREHAB MENU that the chronic ABI patients need to perform the task using
Trainning Difficulty Level Screenshot VPREHAB).
Finally, the system stores all the information related to the chronic
ABI patients in every session in the cloud. This information
allows the clinical specialists to obtain good feedback from the
The clinical specialist selects the level virtual rehabilitation process using VPREHAB, showing the
of difficulty of the active session.
improvements made by chronic ABI patients.
The originality of this contribution is based on: 1) the patient-
VPREHAB interaction, where the patient has to simulate
FINE MOTOR MOVEMENTS gross/fine upper-limb movements; and 2) the visual/auditory
Medium Level Screenshot
feedback added by VPREHAB, which increases the adherence to
the treatment and the motivation thanks to the playful component
of our system. This aspect is barely treated in traditional
rehabilitation.
The therapist helps the patient to move
their fingertips by placing them on the
screen on the different bars so that the 4. PROCEDURE
patient can identify each one of them. The chronic ABI patients will perform a total of 20 sessions using
VPREHAB of 3 to 5 sessions per week of approximately 30
minutes using VPREHAB and 30 minutes of traditional upper-
limb rehabilitation. At the present time, we are testing different
Medium Level Screenshot standardized measures for three periods of time (Initial, Final, and
Follow-up Evaluation).
The patient (with the assistance of the
At recruitment, the chronic ABI patients’ characteristics will be
therapist) moves four fingers (except
the thumb) with a uniform movement stored, and the therapist will perform different clinical tests that
that traces the selected trajectory. The are related to Cognitive Sensory Motor training such as: the
patient should identify every single Action Research Arm test (ARAT) [23]; the Wolf Motor Function
trajectory. test (WMFT) [24]; the modified Ashworth Spasticity Scale (ASS)
[25]; and the Box and block test (BBT)[26].
High Level Screenshot Another secondary clinical test that we will perform is an adapted
and validated version of the Mini-Mental state examination [27].

The patient carries out movements that

At the end of the first session, we will use the Suitability
are harder to perform by guiding Evaluation Questionnaire (SEQ) [28] to obtain a metric of
his/her fingers in a uniform way usability of our Virtual Rehabilitation experiment, in order to
following one of the predetermined determine whether the VPREHAB system complies with the
trajectories. standards of usability, acceptance, robustness, and validity.

5. RESULTS
At the present time, the study is a work in progress. The
Table 1. VPREHAB Virtual Environtments. participants are Chronic ABI patients with mild to moderate
spasticity, mild to moderate hypertonia, and that have sufficient
his/her eyes and the VPREHAB system successively displays muscle tone with, with minimal resistance in the range of
different bars (of different lengths and colors), and the patient has flexion/extension motion of the paretic upper limb, and mean
to identify each one of them. In this therapeutic exercise, the level values in the ASS ranging from 0 to 2, which is appropriate for
of difficulty deals with the simultaneous use of a higher number of the purposes of this study.
bars or a greater number of fingers. The hypothesis for the second
module is based on space recognition by performing The results that we are currently obtaining are based on the
flexion/extension movements and adduction/abduction wrist patients’ feedback and their high level of satisfaction. We
movements. consider that, in the near future, we will obtain promising results
at the assessment stage.
For high-level exercises, the hypothesis is based on the
optimization of trajectory drawing. The patients have to perform
simple straight trajectories without the assistance of the therapist. 6. DISCUSSION AND CONCLUSIONS
Currently, this study is showing promising and satisfactory
The different fine virtual motor movements based on cognitive benefits for ABI patients in the rehabilitation process. The goal of
tasks are shown in Table 1. this study is to improve Cognitive Sensory Motor Training
Other measures that we test are: 1) “Reaction time” (the time Therapy by means of the Perfetti method, using of a VFMR. To
elapsed from when VPREHAB shows the Virtual Environment date, the chronic ABI patients who are participating in this study
until the patient starts and touches the screen); 2) “Movement are showing great motivation during the training sessions. For this
precision” (the accuracy with which the chronic ABI patient reason, we are encouraged to continue the treatment and to obtain
 high levels of functionality related to muscle tone, [13] Kwakkel G., Wagenaar R.C., Koelman T.W., Lankhorst G.J.,
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ACKNOWLEDGEMENTS [15] Bhasin A., Padma Srivastava M.V., Kumaran S.S., Bhatia R.,
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stroke patients: a functional magnetic resonance imaging study.
specialist team in designing the Virtual Environments and Game Neurol India, 60, 570-6.
Engines, especially Mr. Alejandro del Rio and Ms. Minerva
[16] Chanubol R., Wongphaet P., Chavanich N., Werner C., Hesse S.,
Rodriguez. Bardeleben A., Merholz J. 2012. A randomized controlled trial of
This contribution was partially funded by the Gobierno de Cognitive Sensory Motor Training Therapy on the recovery of arm
function in acute stroke patients. Clin Rehabil, 26, 1096-104.
Aragón, Departamento de Industria e Innovación, y Fondo Social
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