Cognitive Multisensory Rehabilitation

Basic Course (6-Day Course)

Clinicians often experience good success at addressing motor deficits in adults with neurological disorders. However, clinicians often report difficulties with progressing patients with sensory deficits such as impaired awareness of where their body is in space or understanding how individual body parts relate to each other. Current treatment methods often do not address these issues. Further improvement in function may be hindered by the miscommunication between the feedback and feedforward loops in the sensorimotor circle in the brain.

Cognitive Multisensory Rehabilitation (CMR), developed by Professor Perfetti in Italy, is an evidence-based treatment approach to restore body awareness and awareness of the body in space in order to reduce (neuropathic or other) pain and improve sensorimotor function in adults with neurological disorders or chronic pain.

Several clinical trials have identified brain function changes as well as sustained (1-year) improvements in sensorimotor function and pain reduction in adults with stroke and spinal cord injury (SCI) with and without neuropathic pain (Van de Winckel et al, 2020, 2023). Explanations of the mechanism of CMR are given in the publications of Dr. Van de Winckel et al. (see publication list below).

The CMR approach is also useful to reduce pain in adults with shoulder impingement, phantom limb pain after amputation, cortical blindness, Parkinson’s Disease, Multiple Sclerosis, and other diagnoses. A reference list of published studies is provided at the end of this document. CMR is taught as a 3-year specialization course to licensed physical and occupational therapists in Italy (in Italian). Dr. Van de Winckel is bringing this curriculum in English to the United States in modules. Currently, we are offering a 6-day basic CMR course in the United States. The goal is to bring the whole curriculum so that therapists in the United States can also become certified over time.

The 6-day BASIC course is designed for PTs, OTs, MDs, DOs, DCs who want to learn in-depth basics of CMR and to learn the CMR reasoning approach for implementation in the clinic.

Course Objectives:
1. Define basic principles and origins of CMR based therapy.
2. Evaluate a patient’s behavior/ body awareness according to CMR principles (i.e., identify possible deficits in relation to body awareness and awareness of the body in space).
3. Create a patient-specific Profile based on results of initial CMR evaluation and hypothesis (i.e., impairment in proprioception, tactile discrimination, size of the affected body part, etc.).
4. Identify and apply CMR-based exercises, clinic tools, and strategies for the upper limb, lower limb, trunk, etc.
5. Apply CMR principles to a patient with neuropathic pain and/or other pain-based diagnoses.

Integrating the course content into practice will be facilitated through lectures, videos, live
demonstrations (peers and/or patients), and small group lab practice.

Main Topics related to classes focused on CMR for adults with stroke and SCI:
- Background: Main concepts and Research about CMR
- In-depth evidence-based information and results on the clinical application of CMR:

Stroke and SCI
- Upper Limb rehabilitation from CMR point of view
- Lower Limb rehabilitation from CMR point of view
- Trunk/ Base of Support rehabilitation from CMR point of view
- Neuropathic pain from CMR point of view
- CMR Reasoning on various clinical cases

New classes are organized as soon as 20 participants are interested. They can be organized throughout the United States.

Important information:

CMR is also translated in other publications as cognitive therapeutic exercises, Cognitive Sensory Motor Training, neurocognitive therapeutic exercise, cognitive exercise therapy, Perfetti method, or (neuro)cognitive approach.

The original Italian term is “Riabilitazione Neurocognitiva”. The center in Italy is: https://riabilitazioneneurocognitiva.it/

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List of publications of Cognitive Multisensory Rehabilitation (CMR) research

1. Cavallaro F, Portaro S, Pintaudi T, Ceccio M, Alito A. Remote Cognitive Therapeutic Exercise in Facial Nerve Palsy Rehabilitation: Pandemic Tips and Tricks. Innov Clin Neurosci. 2023 Jan-Mar;20(1-3):10-12. PMID: 37122569; PMCID: PMC10132273.

2. Celletti C, Paolucci T, Maggi L, Volpi G, Billi M, Mollica R, Camerota F. Pain Management through Neurocognitive Therapeutic Exercises in Hypermobile Ehlers-Danlos Syndrome Patients with Chronic Low Back Pain. Biomed Res Int. 2021 Jun 1;2021:6664864. doi: 10.1155/2021/6664864. PMID: 34124258; PMCID: PMC8189767.

3. Chanubol R, et al. A randomized controlled trial of cognitive sensory motor training therapy on the recovery of arm function in acute stroke patients. Clin.
Rehabil. 2012;26:1096–1104. [PubMed] [Google Scholar]

4. De Patre D, et al. Visual and motor recovery after ‘cognitive therapeutic exercises’ in cortical blindness: a case study. J. Neurol. Phys. Ther. 2017;41:164–172. [PubMed] [Google Scholar]

5. Lee S, Bae S, Jeon D, Kim KY. The effects of cognitive exercise therapy on chronic stroke patients’ upper limb functions, activities of daily living and quality of life. J. Phys. Therapy Sci. 2015;27:2787–2791. [PMC free article] [PubMed] [Google Scholar]

6. Marzetti E, et al. Neurocognitive therapeutic exercise improves pain and function in patients with shoulder impingement syndrome: a single-blind randomized controlled clinical trial. Eur. J. Phys. Rehabil. Med. 2014;50:255–264. [PubMed] [Google Scholar]

7. Morreale M, et al. Early versus delayed rehabilitation treatment in hemiplegic patients with ischemic stroke: proprioceptive or cognitive approach? Eur. J. Phys. Rehabil. Med. 2016;52:81–89. [PubMed] [Google Scholar]

8. Perfetti C, Wopfner-Oberleit SD. hemiplegische Patient: kognitiv therapeutische Übungen. Dayton: Pflaum; 1997. [Google Scholar]

9. Perfetti C. L’exercice thérapeutique cognitif pour la rééducation du patient hémiplégique, 12. Paris: Masson; 2001. [Google Scholar]

10. Perfetti C, et al. Il Dolore Come Problema Riabilitativo. Padova: Piccin; 2015. [Google Scholar]

11. Sallés L, et al. A neurocognitive approach for recovering upper extremity movement following subacute stroke: a randomized controlled pilot study. J. Phys. Therapy Sci. 2017;29:665–672. [PMC free article] [PubMed] [Google Scholar]

12. Van de Winckel A, et al. Can quality of movement be measured? Rasch analysis and inter- rater reliability of the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES). Clin Rehabil. 2006 Oct;20(10):871-84. doi: 10.1177/0269215506072181. PMID: 17008339. [PubMed] [Google Scholar]

13. Van de Winckel A, et al. Passive somatosensory discrimination tasks in healthy volunteers: differential networks involved in familiar versus unfamiliar shape and length discrimination. Neuroimage. 2005;26:441–453. [PubMed] [Google Scholar]

14. Van de Winckel A, et al. Frontoparietal involvement in passively guided shape and length discrimination: a comparison between subcortical stroke patients and healthy controls. Exp. Brain Res. 2012;220:179–189. [PubMed] [Google Scholar]

15. Van de Winckel A, et al. Does somatosensory discrimination activate different brain areas in children with unilateral cerebral palsy compared to typically developing children? An fMRI study. Res. Dev. Disabil. 2013;34:1710–1720. [PubMed] [Google Scholar]

16. Van de Winckel A, et al. How does brain activation differ in children with unilateral cerebral palsy compared to typically developing children, during active and passive movements, and tactile stimulation? An fMRI study. Res. Dev. Disabil. 2013;34:183–197. [PubMed] [Google
Scholar]

17. Van de Winckel A, et al. Identifying Body Awareness-Related Brain Network Changes After Cognitive Multisensory Rehabilitation for Neuropathic Pain Relief in Adults With Spinal Cord Injury: Protocol of a Phase I Randomized Controlled Trial. Top Spinal Cord Inj Rehabil. 2022;28(4):33-43. doi: 10.46292/sci22-00006. PMID: 36457363; PMCID: PMC9678218. [PubMed] [Google Scholar]

18. Van de Winckel A, et al. Identifying Body Awareness-Related Brain Network Changes after Cognitive Multisensory Rehabilitation for Neuropathic Pain Relief in Adults with Spinal Cord Injury: Delayed Treatment arm Phase I Randomized Controlled Trial. medRxiv [Preprint]. 2023;2023.02.09.23285713. doi: 10.1101/2023.02.09.23285713. PMID: 36798345; PMCID: PMC9934787. [PubMed] [ MedRxiv ]

19. Zangrando F, Paolucci T, Vulpiani MC, Lamaro M, Isidori R, Saraceni VM. Chronic pain and motor imagery: a rehabilitative experience in a case report. Eur J Phys Rehabil Med. 2014 Feb;50(1):67-72. PMID: 24622048.

20. Zernitz M, Rizzello C, Rigoni M, Van de Winckel A. Case Report: Phantom limb pain relief after cognitive multisensory rehabilitation. Front Pain Res (Lausanne). 2024, 5:1374141. doi: 10.3389/fpain.2024.1374141. PMID: 38726352; PMCID: PMC11079144.

CMR Class Rules

Appropriate use of CMR course material

This form clarifies the common rules of copyright related to lectures and class material.
Course material received as part of the CMR class is for personal use only.
Attendees are not allowed to distribute/sell/share via Internet or other means lecture notes or instructor-provided materials with others, except with those in the same class.
Attendees are allowed to take notes, but not verbatim records of a lecture, nor recording the lecture.
Notes may be shared with others in the same class but not sold or distributed widely.
Pictures can only be taken with permission from the instructor and are for personal use only, or to share with others in the same class.
When sharing your own experience of using CMR with your patients (therapy or exercises), then it is important to mention that you had a 6-day CMR class, that you are not CMR-certified, and not allowed to teach CMR. Also, mention that the exercises that you did with your patient are a reflection of your interpretation of what you learned in class. This is to avoid misunderstandings of CMR.
If others want to learn CMR, you can share the contact information of Dr. Ann Van de Winckel (avandewi@umn.edu) so that they can receive information about future CMR classes and attend a class if they choose to do so.

Testimonials

"I learned so much the weekend of my CMR training about how to improve my patients mind- body representation of the affected limb/ body part and decrease neuropathic pain. My patients have progressed sensorimotor skills with implementation of CMR exercises/strategies including relearning force of grasp and relationship of fingers and thumb in order to use chopsticks for self-feeding for the first-time post-stroke!"

Nora, OT

For More Information

Please contact Dr. Ann Van de Winckel (avandewi@umn.edu) to be put on the contact list and be informed of future class offerings.