ORIGINAL ARTICLE

Effects of Perfetti's Method on Cognition, Dexterity and Sensory Motor

Function of the Upper Extremity in Stroke Patients: A Randomized
Controlled Trial
Syed Muhammad Mateen1, Ayesha Jamil2, Umair Ahmad3
1 Lecturer, AKFA College of Physiotherapy, Dera Ghazi Khan, Pakistan
2 Assistant Professor University of Lahore, Lahore, Pakistan
3 Associate Professor University of Lahore, Lahore, Pakistan

Author`s Contribution
2Conception and design, 3Collection A B S T R A C T
and assembly of data, 1,2,,3Analysis and Background: A stroke is the sudden loss of neural function caused by an interruption of
interpretation of the data, Statistical blood flow to the brain. It causes symptoms such as paresis, hypoesthesia, cognitive
expertise, drafting of article, 4Critical
revision of the article for important
impairment, and spasticity.
intellectual content, Final approval and
2 Objective(s): To compare the effects of Perfetti's Method versus routine physical therapy
guarantor of the article. on the upper extremities' cognition, dexterity, and sensorimotor function in stroke patients.
Article Info. Methodology: In this study, 74 stroke participants were enrolled and randomized into two
Received: June 9, 2023 groups by the Goldfish Bowl Procedure, with 37 patients in each group. Group A was
Acceptance: November 30, 2023 treated with routine physical therapy, and Group B was treated with Perfetti's Method and
Conflict of Interest: None routine physical therapy. The measurements of both groups were recorded at the
Funding Sources: None beginning of the study and after the 12th post-treatment week. Sensorimotor function was
Address of Correspondence measured with the Fugal-Meyer Assessment Upper Extremity (FMA-UE), dexterity was
Syed Muhammad Mateen measured with the Box and Block Test (BBT), and level of cognition was measured with
Email Id: mateenrizvi707@gmail.com the Mini-Mental State Exam (MMSE) in both groups at the beginning of the study and after
ORCID: 0009-0007-2821-5037 the end of training (12th post-treatment weak).
Cite this article as. Mateen SM, Jamil Results: According to this study, 74 participants had a mean age of 53.21±12.02; males
A, Ahmad U. Effects of Perfetti's were 45(60.8%), and females were 29(40.2%). The mean Body Mass Index was
Method on Cognition, Dexterity and 23.23±3.47. The right side was affected by 32(43.2%), and Left Side was affected by
Sensory Motor Function of the Upper 42(56.8%). Sensorimotor Function mean was Pre-treatment 66.70±26.88 and post-
Extremity in Stroke Patients: A treatment 110.09±11.91. The level of cognition mean was pre-treatment 22.62±3.30 and
Randomized Controlled Trial. JRCRS. post-treatment 29.31±1.47. Dexterity means Pre-treatment was 8.18±11.64 and post-
2024; 12(1):28-32.
treatment was 84.48±15.03. P-Value was 0.00, which was <0.005, which means that there
DOI:
was a significant difference between the mean value of pre-treatment and post-treatment
https://dx.doi.org/10.53389/JRCRS.20
24120106 Sensorimotor function, Level of Cognition, and Dexterity. There was a significant difference
between the mean values of Groups A and B in sensorimotor function, level of cognition,
and dexterity, as the P-values were 0.027, 0.04, and 0.02, respectively.
Conclusion: Perfetti's Method, combined with routine physical therapy, resulted in
significantly improved cognition levels, dexterity and sensory motor function in the upper
extremity of stroke patients compared to those receiving only routine physical therapy.
Keywords: Cognition, Dexterity, Perfetti's, Stroke, Sensorimotor.
It causes muscle weakness, decreased sensory function,
Introduction cognitive impairment, spasticity, excessive reflexes, apraxia,
Stroke is the abrupt loss of neurological function and agnosia.4 Upper limb hemiparesis after stroke is a common
caused by a disruption of the blood flow to the brain.1 It can be debilitating and persistent problem. Motor impairments and
divided into two main categories: ischemic and hemorrhagic.2, 3 limitations in the use of the upper limbs have been identified as

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the main factors contributing to reduced health and quality of female, Diagnosed with all types of Stroke patients with an
life post-stroke.5Stroke affects around 15 million individuals onset of not more than 3 months, and Fugal-Meyer Assessment
annually globally.6 Approximately 6 million people die, while 5 Upper Extremity (FMA-UE) score was higher than 60.10.
million become permanently disabled.7 In the acute stage Participants excluded were those with Other neurological
following a stroke, around 70–80% of stroke patients disorders, Orthopedic disease impairing arm function, Fracture
experience motor and somatosensory deficits of the upper limb, of the Arm, Frozen shoulder, No previous history of Stroke and
which continues in 55-75% of these individuals for six months Re stroke during the study.10 Equipment used in this study was
after the stroke.8 The most significant risk factors that can cause Chair, Blindfold, Stick, Cube, Tennis ball and Pen. In the study,
stroke are hypercholesterolemia, dysrhythmia, hypertension, Patients were divided randomly into two groups.
atrial fibrillation, and smoking. However, some other risk factors
Group A was the Control Group, and Group B was
include migraines, and oral contraceptive pill intake are other
the Experimental Group using the Goldfish Bowl Procedure. All
risk factors for stroke that are usually observed in females.9
assessment tests were performed before and after the 12th
A distinctive, comprehensive rehabilitation program, week of treatment. The sensorimotor function was Assessed
cognitive sensorimotor therapy, involves systematic training and with Fugal-Meyer Assessment Upper Extremity (FMA-UE)1, 14
retraining of guided sensorimotor control. It is referred to as Dexterity was assessed with box and block test, and cognition
Perfetti's Method since Professor Carlo Perfetti proposed it. It is was assessed with Mini-Mental State Exam(MMSE)
frequently used in several European nations today, such as
Group A: Participants were treated with routine
Austria, Germany, and Italy.10
physical therapy for 20 minutes five days a week for the 12th
Perfetti's Cognitive Sensory Motor Training Therapy is week. Activities included routine Physical therapy such as
distinguished by its focus on sensory retraining, especially the Bimanual placing cone, Graded pinch exercise, Arm bicycling,
perception of joint position. For example, Patients who cannot Double-curved arch, shoulder curved arch, Block-stacking,
accurately describe the joint's location are asked to feel and Skateboard-supported arm sliding exercises on a tabletop,
predict where the limb has moved while wearing blindfolds. The Putty kneading, Pegboard exercise, Picking up a ball and
therapist then passively moves the affected limb. One joint is putting it into a basket, Plastic cone stacking. Depending on the
initially only moved at a time. Then, by the patients best patient's ability, therapists may offer active assistance, active
perception, various joints are manipulated concurrently to training, or passive.10
increase complexity and difficulty. Only patients who could
Group B: In this group, Perfetti's Method and routine
accurately assess the location of the limbs were allowed to
physical therapy treatment were given for 35 minutes five times
move on to the following training phase. They are instructed to
a week for 12 weeks. A therapist treated only one patient. At
use effort to actively move the trained limb over a stationary
the time of treatment, the patient was first blindfolded and then
item during this stage of exploratory movement in order to
asked to feel the movements of the limb. The therapist
sense the object's length, height, hardness, or shape. 10 The
passively moved the shoulder, elbow, wrist, or finger in different
purpose of Perfetti’s Method is to improve upper extremity
directions. After completing the movement, the patient was
motor impairment or disability.11, 12, 13
asked about it. Initially, only two movements were asked. If a
patient answered correctly, he would be asked about three,
Methodology
four, or five more sides.
A randomized controlled trial was conducted. Data
During the treatment, the patient was not allowed to
was collected from DHQ Teaching Hospital Dera Gazi Khan
do any other movement except rest and feel the movements.
and Central Park Teaching Hospital Lahore. The study was
The joint can move in all directions, but in training, it was moved
completed within nine months after the approval taken from
in two directions. For example, shoulder flexion/extension,
university of Lahore ethical committee (ref no: IRB-UOL-
abduction/adduction, internal rotation/external rotation. If the
FAHS/1005/2021). The calculated sample size is 37 in each
patient had correctly indicated the position of the different joints,
group. I.e., n =74 (37 in each group). By adding a 20% dropout
he would have been given a more difficult perceptive task. For
rate, the final sample size was 88 (44 in each group. 10 Non-
example, when the patient felt the movement of both shoulders
probability purposive sampling technique was used for data
and arms during the task, he was asked what position the arm
collection. Patients fulfilling the inclusion criteria were divided
was on the table in front of him/her.
randomly into groups (Group A/Control Group and Group B /
Experimental Group) using the Goldfish Bowl Procedure. In stage one, the therapist would move the patient's
Participants included those aged 18-79 years, Both male and arm up and down or at another angle, and the arm would be

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placed on the table. Then, the patient would be asked to show between the mean values of Post-Treatment Group A and B
one or two movements. If he performed two movements, then Cognition as P-Value was 0.04. There was no significant
five more movements were performed. In this way, this training difference between the mean values of Pre-Treatment Group A
was done on the forearm, wrist, and fingers. and B Dexterity as P-Value was 0.08, while there was a
significant difference between the mean values of Post-
In the next stage, the therapist would give an object
Treatment Group A and B Cognition as P-Value was 0.02.
in the patient's hand. For example, a stick, pen, water bottle,
cube, or tennis ball, and the patient is asked to touch the object Table I: Descriptive Statistics
and feel its shape, position, and size. This object was again Descriptive Statistics
placed in its place, and another object was given. It was also N Minimum Maximum Mean SD
felt in the same way, and the difference between the two and Age in Group A 37 40.00 73.00 56.21 12.92
the name of the object was asked. If the patient felt the Age in Group B 37 28.00 65.00 50.21 11.99
difference between two objects, he was given more than five Height (Inches) in 37 60.00 70.00 66.05 3.23
Group A
objects. In this way, routine physiotherapy treatment was also
Height (Inches) in 37 60.00 70.00 64.51 3.25
given to the patient along with Parfittie's Method.
Group B
Data was entered into Statistical Package for Social Weight (Kilogram) in 37 45.00 85.00 65.64 13.32
Science (SPSS version 25) for analysis. Quantitative variables Group A
were presented in terms of mean, standard deviation, and Weight (Kilogram) in 37 45.00 86.00 63.64 13.07
histograms, whereas qualitative variables were portrayed as Group B
Body Mass Index in 37 17.00 29.50 23.23 3.47
frequencies, percentages, and bar or pie charts. Normality
Group A
tests, i.e., Kolmogorov-Smirnov test, were performed for
Body Mass Index in 37 17.00 29.50 23.23 3.22
assessment of the distribution of data, and the significance level
Group B
for this was p= >0.05. If data was normally distributed, for Table II: Paired Sample Statistics.
within-group comparison, a Paired sample t-test and between- Mean SD P Value
group comparison, an Independent sample t-test was applied to Pair 1 Sensorimotor Function at 66.70 26.88 0.00
evaluate the difference between Perfetti's Method versus Baseline
routine physical therapy on cognition, dexterity, and Sensorimotor Function at 12th 110.09 11.91
Sensorimotor function of the upper extremity in stroke patients. Weak
Pair 2 Cognition at Baseline 22.62 3.30 0.00
Results Cognition at 12th Weak 29.31 1.47
Pair 3 Dexterity at Baseline 8.18 11.64 0.00
Among 74 participants in group A, 28(75.7%) were
Dexterity at 12th Weak 84.48 15.03
male and 9(24.3%) were female. In Group B, among 37
participants, there were 17 males (45.9%) and 20 females Table III: Group Statistics for Independent Sample T Test.
(54.1%). In Group A, among 37 participants, the Right Side was Group Statistics
affected by 19(51.4%), and the Left Side was affected by Grouping P
18(48.6%). In Group B, among 37 participants, Right Side was Variable Mean SD Value
affected by 13(35.1%) and Left Side was affected among Sensorimotor Function at Group A 71.72 22.77
24(64.9%) Baseline Group B 61.67 29.91 0.108
Sensorimotor Function at Group A 109.72 10.30
P Value was 0.00, which was <0.005, which means 12th Weak Group B 110.45 13.47 0.027
that there was a significant difference between the mean value Cognition at Baseline Group A 23.16 2.85
of pre-treatment and post-treatment dexterity. Group B 22.08 3.65 0.160
Cognition at 12th Weak Group A 29.00 1.73
There was no significant difference between the
Group B 29.62 1.11 0.04
mean values of Pre-Treatment Group A and B Sensorimotor
Dexterity at Baseline Group A 11.35 14.65
Function as the P-Value was 0.108, while there was a
Group B 5.02 6.30 0.08
significant difference between the mean values of Post- Dexterity at 12th Weak Group A 83.35 14.41
Treatment Group A and B Sensorimotor Function as the P- Group B 85.62 15.73 0.02
Value was 0.027. There was no significant difference between
the mean values of Pre-Treatment Group A and B Cognition as
P-Value was 1.08, while there was a significant difference

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 sensory motor function in the upper extremity of stroke patients
Discussion
compared to those receiving only routine physical therapy,
Stroke is the abrupt loss of neurological function indicating its potential for enhancing post-stroke recovery in
caused by a disruption of the blood flow to the brain.1 It can be these aspects.
divided into two main categories, namely ischemic stroke and
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