Rehabilitation of graphomotor disturbances by means of the spatio temporal Terzi’s Method

Perrone, I.¹, Accardo, A.², Antoniazzi, A.¹, Mina A .¹, Moro, S.¹¹ Dept. of Development Age, ULSS 7, Pieve di Soligo (TV) Italy

²DEEI, University of Trieste, Trieste, ItalyContact: iolanda.perrone@ulss7.it

This work presents the results pertinent to the evaluation of a new rehabilitation treatment, the Terzi Method, utilized to recover grapho motor problems and dysgraphia of 14 non-proficienthandwriters italian children (www.ulss7.it),

Many different treatment approaches, mainly based on perceptual-motor, visual-motor, motor control, individualized interventions /exercises, and supplementary handwriting instruction, have been applied for poor handwriting remediation in school-aged children [4]. In this paper a new treatment protocol (Spatio-temporal Terzi’sMethod www.metodoterzi.it) is proposed; it is based on a motor-cognitive approach [1] aimed to correctly process and integrate spatio-temporal information coming from different sensorial inputs (kinesthetic, vestibular, proprioceptive, tactile, visual) [5]. Its effectiveness are evaluated on the graphomotor problem and/or dysgraphia and the other correlated cognitive and motor functions.

Sample group14 children (2 girls, 12 boys, average age 9.7 years)Main diagnosis and comorbidity with graphomotor problem and/or dysgraphia.I.Q. includedbetween the average standard and the border level (WISC-R); no neurological damage.

M A IN D IA GN OSI ( I.C .D . 10)

Asse I I- F8 2

S pe c if i c

ev o lu t iv e

de se ase o f

mot o r a bi l i t y ;

n ° 4

Asse I - F 90 - 9 8;

F3 9 ; F41

B eha vi ou r

dese a se

( anx ie t y ,

mood ) ; n ° 3

A sse I I - F8 1

S pe c if i c

e v ol u t iv e

de sea se of

sc ho l ast i c

educa t i ona l

ab i l i t ie s; n° 7

Prevalence in Italy (3-4% of the studentsfrom 8 to 13 years old)

Standard test protocolsBefore and after rehabilitation process: investigat ed areas

• Neurological : neurological examination• Cognitive/motivational : Wisc-R, WPPSI; Evaluation of the Leiter-R marker• Visual-spatial and Spatio-temporal organization : V.M.I.; REY complex Figure Test; Apraxia constructive graphic performance ; Terzi Method evaluation Protocol• Motor/praxic : Movement ABC; Bimanual praxia evaluation scale; Posture and grasping observation scheme• Handwriting : Letter’s check-list.; analyses of the writingquality (sequence of ‘lelele’ and sentence to be transcribed in italic as better and as faster as possible) acquired by a digitizing tablet (Intuos3®, Watcom); static and kinematic parameters linked to pressure, trajectory and velocity features of each identified stroke [2].

Rehabilitation projectTreatment: Terzi Method for about 15 sessions of 45 min. each (individual or in couple), carried on by speech therapist and development age neuro psicomotion therapist.Involvement: the "contract", the "evaluation", 10 minutes daily exercises (child); sharing the aims, strategies and enhancement of the child effort (family and teachers).

Scientific basis• Cognitive neuropsychology; Neuroscience and mental imaging • Internal representation of the personal space can be modified through experience• Space is a transverse sensory function

METRIC SPACE / GRAPHIC SPACE ØO- Qualitative and quantitative distinctionsand modal integration: translation, rotation, circle - Maintenance of stable metric parameters

PERIPERSONAL SPACESpace close to the body that

can be explored with our hands.

From EXTRAPERSONAL to

PERIPERSONALSPACERelationship between

subject and space,geometrically defined

PEN GRASPING

� Awareness of a correct posture during handwriting � Modulation and differentiation in the complementary roles of the upper limbs

POSTURE HANDWRITING

� Organization in thehandwriting space � Correct letters grapho-motor scheme and metric relations between letters

� Isolated and coordinated movements of the fingers � Angle of the wrist and finger posture relationship� Pressure, modulation and speed

SYNCHRONIZED RHYTHM Ø- Body axis perception, - Bilateral integration - Wrist and limbs relaxation - Complex motor schemesynchronized with vocal computation

“ATTITUDE” and “TOUCHES” Ø O- Correct metric and angular relationsamong the positions of body parts

- Overcoming the midline body axis

MODELING WITH PLASTICINE Ø- Tactile and proprioceptive sensitivity- In-hand manipulation

GAME OF “THE PAINTER” Ø- Pronosupination palm/hand-back - Movements of shoulder progression

PERSONAL and PERIPERSONAL SPACEBody scheme organization

(static and dynamic)

Ø closed eyesO open eyes

CONSTRUCTION OF LETTERS Ø O

-Spatio-temporal geometric analysis

of each alphabetic symbol

- Ambulatory construction of the

letter in italic, blindfolded

(on verbal or motor task)Motor and grafic rapresentation

TERZI METHOD AND DYSGRAPHIAIntegration between motor mental imaging

(in self perspective and external perspective) and visual-spatial image

R.G. 8,9 years old

M. D. 9,9 years old

The effectiveness of the Terzi’s rehabilitation program is proved by statistically relevant improvements in the following areas:

Fig. 5

Check-list Letters - Sentence copied in italics - M ore accurate mode

0

5

10

15

20

25

30

n. o

f err

ors

Pre 16,09 8,83 5,03 4,63 8,80 10,80 14,42 9,62 25,53 24,67

Post 4,02 3,02 0,99 1,23 2,38 5,84 3,17 2,97 6,88 3,44

Incorrect Links Mean

(p<0,0001)

Incorrect Links SD

Self-corrections Mean (p<0,009)

Self-corrections SD

Direction Orientation

Mean (p<0,042)

Direction Orientation SD

Grapho-motorial Scheme Mean

(p<0,0001)

Grapho-motorial Scheme SD

Dimensional proportions

Mean (p< 0,017)

Dimensional proportions SD

Example of writing test (‘lelele’) in a child befor e (left) and after (right) the rehabilitation program. In both cases the subject w rote for one minute. It is evident that after the treatment the total number o f written letters is more than doubled as well as the corresponding curviline ar velocity.

Fig. 1

A.B. 9,4 years old

M. D. 10,2 years old

A.B. 9,7 years old

R.G. 9,4 years old

Terzi Method - Metric euclidean space

0,00

0,20

0,40

0,60

0,80

1,00

corr

ect a

nsw

er

Pre 0,55 0,16 0,50 0,31 0,51 0,18 0,37 0,27 0,33 0,34

Post 0,66 0,10 0,81 0,30 0,74 0,18 0,83 0,26 0,92 0,17

Qualitative Mean

Qualitative SD

Quantitative Mean

Quantitative SD

Synoptic Table

Synoptic Table SD

Extrapers. space

Extrapers. space SD

Peripersonal space

Peripersonal space

The authors wish to thank L. Antoniazzi, M. P. Palestini and the working group of the Department of Development Age of the ULSS 7- Pieve di Soligo(TV), Italy, for their operative contribute to the realization of this research.

Characteristics• Improves the construction of correct kinestetic-mot or, proprioceptive and visual-spatial mental imagesthrough the body "lived experience" phase and “external representation”• Use diversified tasks (motor, visual, imitative, verbal) that fit to the age and the cognitive level of the subject • Ecologic and metacognitive approach to the task: it does not directly intervene in a sectoral way on the "error-symptoms", but it analyses the outcomes and it investigates the mental processes that could have determined such a result..

DCD VIII Developmental Coordination Disorder Internati onal Conference June 23-26, Baltimore, MD, U.S.A.

Personal, peripersonal and extrapersonal space Improves in the topological accuracy and temporal sequence, syncrony and timing of movements; in the mentalrapresentation of space, both in the "lived experience" and in the “graphic rapresentation” (p< 0,0001); in the projects of motor planning (Terzi Method - Metric space Fig. 5 ). It is possible that comparable coupling between eye and body movements exists for locomotion. [ 5]

HandwritingLetter’s Check-list parameters (Fig. 1): decrement of the

number of errors sign of an increased mental representation of the correct grapho-motor schemeStatic and kinematic parameters : "lelele" test : mean curvilinear velocity increment (Fig. 2) during single stroke (p< 0,02), index of the old motor program substitution with with another more automated, ables to produce a more fluent tract.The interaction between perceptive and motor aspects (for the hand) and locomotive aspects (for the walking) is confirmed in the planning strategy.[4]

Visual-spatial and motor/praxisorganization• Visual-motor integration (V.M.I. Fig. 3) and coordination, on the graphic reproduction of geometric shapes of increasing difficulty. • (Movement ABC Fig. 4) in the ability with the ball and in static and dinamic equilibrium.

Movement ABC

0

10

20

30

40

50

60

Per

cent

ile

Pre 23,57 28,29

Post 55,43 37,55

M. ABC Mean (p<0,004) M. ABC SD

Test of Visual Motor Integration V.M.I.

0

10

20

30

40

50

60

70

Per

cent

ile

Pre 23,21 18,41 41,00 32,77 28,35 17,73

Post 46,07 17,29 63,36 22,50 51,5 27,35

V.M.I. Mean (p< 0,002)

V.M.I. SDVisual Test

Mean (p< 0,021)

Visual Test SD

Motor Coord. Test Mean (p< 0,024)

Motor Coord. Test SD

Fig. 3 Fig. 4

The application of the Terzi’s rehabilitation method improves both the accuracy and speed parameters of:• posture and pen grasping,• graphomotor patterns• handwriting quality.The digitizing tablets allowed objective quantitative kinematicanalyses of the writing quality. It measures the treatment efficacy and evaluates what parameters are more sensitive to the recovery processin non-proficient hand writers children.The Terzi Method approach improves the mental and visual-spatialimaging through the conscious use of body movements.Since space is a transverse sensory function, this approach improvesnot only the handwriting, but also the cognitive processes that utilizethe mental images representation.

1. Terzi I. (1995) Il Metodo Spazio-Temporale. Ed. Ghedini, Milano, Italy 2. Accardo A., Perrone I. (2008) Automatic quantification of handwriting characteristics before and after rehabilitation. 14th Nordic-Baltic Conference on Biomedical Engineering and Medical Physics –NBC 2008 - Riga, Latvia ,June 16-20,3. Berthoz A (1997) S. Le sens du mouvement Editions Odile Jacob, 4. Katya P. Feder et al. (2007) Handwriting development, competency, and intervention. Developmental Medicine & Child Neurology, 49: 312-317 5. Hicheur H., Vielledent S., Richardson M.J.E., Flash T, Berthoz A. (2005) Velocity and curvature in human locomotion along complex curved paths: a comparison with hand movements.Exp Brain Res 162: 145-154