Surely if we were to ask what the Cognitive Therapeutic Exercise (ETC) or better known as the Perfetti Method is for, those who have heard of it would answer that it is aimed at the recovery of patients with neurological disorders and, specifically, those with hemiplegia.

The idea is not false, but it is incomplete. Beyond being able to address other and varied pathologies and neurological alterations, the ETC can be very suitable for traumatological affects. ETC in trauma? Yes.

Going step by step, ETC is based on Neurocognitive theory. What does Neurocognitive theory tell us? It proposes, as a working hypothesis, the fact that the quality of recovery depends on the types of cognitive processes (attention, memory, language, image…) that are activated and, in addition, on the modality of their activation.

Patient with closed eyes and directing attention to tactile information, to be able to recognize the texture of the different surfaces that the physiotherapist presents to him

In other words, at the same time as working with ETC, the patient, during the exercise, has his eyes closed and is made to pay attention to what he feels and perceives in his body, he is asked about how the patient lives the his injury, he is asked about the sensations he notices in the area, it is assessed and focused on how the patient talks about that part of the body… The mind-body union is fundamental in the therapeutic relationship.

You may think and ask yourself “but what does the patient’s memory have to do with a fractured wrist while we are treating him? Or the intention and motivation he has to make that gesture? And why should the direction of attention be important when it comes to gaining strength?”.

This relationship between cognition and recovery really exists and I will try to explain it to you.

But, to understand it, you need to keep in mind 3 fundamental points of the Neurocognitive theory: The first point is to interpret man from a systemic point of view. Referring to the movement of the human body, the systemic view means that to recover it, the physiotherapist cannot give importance to the muscle, the joint, the ligament alone but must analyze the existing relationship between these elements, within the action that the subject wants to develop. According to this view, would we consider strengthening only one muscle?

Secondly, the movement must lead the person to relate to their environment, to the objects that surround them… in the best possible way in order to collect information from them (e.g. feeling that the floor is irregular, that the bottle cap has roughness…) and this is possible through the fragmentation of our body. Fragmentation is understood as the ability to direct the different segments of the body in various directions through the joints.

For example, the hand is very fragmentable as it has many joints, which allows us to move our fingers independently of each other and in each finger in a very diverse way, to adapt to the shape of what we want to touch, caress or, just to point something out. The more fragmented the movement, the more information we can obtain from the environment. Therefore, the movement has a cognitive function, of knowledge, which will be interesting to take into account in the relationship with our patient since we have all experienced that when we have had pain, for example in the knee or in the neck, or if we have Sprained ankle… what we do is the opposite of fragmenting, since we have to move in a block.

The properties of the injured tissues represents the third point. What happens, for example, when a patient comes to us with anterior cruciate ligament (ACL) surgery? Beyond its mechanical and sustaining function, there will be an alteration of the cognitive function, of transmitting information, which depends on the integrity and proper functioning of the tissues (ligaments, tendons, muscles…).

Are we sure that all of us, in our actions, take into account this cognitive function? In the ETC exercises, the physical aspects are considered from the first phases of intervention (mobilization of the patient’s body is carried out; active muscular participation is requested, if necessary, etc.) but at the same time great importance is given to the informative aspects, since the body is seen as a receiving surface of information capable of being fragmented.

Already since the 80s, with neuroscience studies such as those of Merzenich and Kaas, among others, it has been stated that when there is a decrease or loss of the information source (as would be the case of the ACL), at brain level changes occur: the space previously allocated by information from the knee will be occupied, over time, by new information from other parts of the body. And what does it depend on? From the experiences one has, and hence the importance of our role at the same time as intervening, with the exercises. Do we provide the most necessary information that is more functional for our patient?

In short, the ETC never loses sight of the fact that the peripheral tissues affected in the event of a traumatic injury are highly rich in nerve endings, which send information to the brain and that this information serves to reorganize the movement, always taking care of the relationship between the parts of the body and what the patient feels and thinks (cognitive processes), thus being a therapeutic approach indicated for the observation, evaluation and treatment of these pathologies.

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