RehabVisual: Development of an Application to Stimulate

Visuomotor Skills

Raquel Machado

, Ana Ferreira

1,2,3

, Carla Quintão

1,4

and Cláudia Quaresma

1,4

Departamento de Física, Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa, Caparica, Portugal

Serviço Medicina Física e Reabilitação - Hospital de D. Estefânia, Centro Hospitalar de Lisboa Central, Lisboa, Portugal

Departamento de Saúde, Escola Superior de Saúde, Instituto Politécnico de Beja, Beja, Portugal

LIBPhys - UNL, Faculdade de Ciências e Tecnologia, Universidade Nova de Lisboa, Caparica, Portugal

Keywords: Rehabilitation, Visuomotor Skills, Pediatrics, Software.

Abstract: The stimulation of visuomotor skills has a relevant role in the rehabilitation of children with neurological

dysfunctions / pathologies. However, the methods of evaluation and intervention for children under the age

of 18 months are few systematic and not directed to the problem of each one. For this reason it was

important to develop a system that will fill this gap. Therefore, the main purpose of this paper is to present

the development process of a tool called RehabVisual - evaluation and stimulation of visuomotor

competences. RehabVisual has the objective to promote the evaluation and the stimulations of visuomotor

skills in children between the ages of 0 and 18 months. The platform has two sessions: database that records

all the clinical information of the child and protocol with stimuli according to the development of the child.

This plataform it was realized with physicians and occupations therapists from the Service of Physical

Medicine and Rehabilitation (PMR) of the Hospital D. Estefânica of the Hospital Center of Lisbon Central

and it was approved by the Portuguese Ethics Committees of this Hospital. The RehabVisual can be used by

physicians, occupational therapists, and caregivers and is characterized for being a tool user-friendly,

versatile and adaptable to the needs of each child.

1 INTRODUCTION

The Physical Medicine Rehabilitation is an area with

a growing development in the last years and

increasingly necessary, by all age groups, being an

area of interest for all aspects of medicine, namely

the pediatric.

Pediatric Rehabilitation is focused on the child

and his / her family cell, preventing, qualifying and

habilitating in the health, education and social

action, taking into account its development (Ortibus

et al., 2011). For this reason, it is necessary to

establish a intervention plan that contemplates the

different aspects of the overall development of the

child - motor, sensory, cognitive, socio - affective

and familiar (Ortibus et al., 2011).

The understanding oh how to characterize the

disorder to make best use of vision and effectively

teach children with cerebral visual impairment is in

its infancy (Lueck and Dutton, 2015)

The methods used to stimulate the visualmotor

skills are considered generic and very little directed

to the individual needs of each child, there is no

systematic treatment method (Best and Miller,

2010). In terms of (re) evaluation of children older

than 18 months, there are three scales that are used

and that allow a standardized evaluation

(Aarnoudse-Moeus et al., 2009). However, in

children below to 18 months of age, the lack of a

methodology to analyse the initial visual reaction

state of the child and / or effectiveness of the

implemented therapy was identified (Ortibus et al.,

2011; Aarnoudse-Moeus et al., 2009). This gap

makes the rehabilitation process difficult, especially

at two levels: understanding the needs of the child;

in monitoring the child's progress.

Thus, it is necessary to improve the methodology

of evaluation and intervention at the level of

visuomotor skills in children up to 18 months with

developmental disorders.

Please note that the children who are born with

the normal visual system do not need additional

visual stimulation (Catalano et al., 1986). In children

without associated pathology / dysfunction, the

Machado, R., Ferreira, A., Quintão, C. and Quaresma, C.

RehabVisual: Development of an Application to Stimulate Visuomotor Skills.

DOI: 10.5220/0006597001730178

In Proceedings of the 11th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2018) - Volume 1: BIODEVICES, pages 173-178

ISBN: 978-989-758-277-6

173

development of vision is performed spontaneously

and extra stimulation may be harmful to the child,

leading to an unnecessary effort that causes stress,

excitement and disorientation. The children with

visual dysfunctions, in the ocular apparatus or in the

optical pathways or were deprived of environmental

stimuli need adequate additional stimuli to develop

visual perception (Giovannett et al., 2013).

Early intervention is very important in children

with visual impairment para estimular o processo de

mielinização. It can have a preventive character,

reducing the appearance of secondary dysfunctions

and / or taking an active action in the residual visual

stimulation in the child (Heyl and Hintermair, 2015;

Sonksen, 1983; Hyva

rinen, 2012).

Early visual intervention addresses the following

objectives (Cicerone et al., 2010):

• Stimulate visual efficiency;

• Encourage the functional use of vision in all

everyday situations, no matter how small the

residual view of the subject;

• Encourage the establishment of the mother-child

relationship;

• Provide functional activities that integrate

sensations captured by the sense organs with the

psychomotor functions.

The present paper has as main objective to present

development process of a plataform - RehabVisual -

evaluation and stimulation of visuomotor

competences.

2 THE REAHAB VISUAL

PLATAFORM

RehabVisual was developed with physicians and

occupational therapists from the Service of Physical

Medicine and Rehabilitation (PMR) of the Hospital

D. Estefânia of the Hospital Center of Lisbon

Central. This study was approved by the Portuguese

Ethics Committees of this Hospital

RehabVisual has the objective to promote the

stimulation of visiomotor skills in children up to 18

months old and provide the systematic report.

The RehabVisual platform has two sessions:

database that records all the clinical information of

the child and protocol with stimuli according to the

development of the child.

The platform allows access to three types of

users: physician, occupational therapist and

caregivers.

The caregiver only has access to some stimuli

selected by the therapists, not having access to any

information that is in the domains of other users.

The physician can record all clinical information

such as age, diagnosis, evaluation of ophthalmic

parameters performed at children. The occupational

therapists can consult this information.

The occupational therapist can record all the

information concerning the behavioural assessment,

the functional evaluation and can choose the

stimulus protocol during the procedure. The

physician can consult this information.

RehabVisual was created using several

programming languages such as JS, PHP, HTML

and CSS. This diversity of languages, namely

HTML and CSS, gives the site a more appealing and

professional template. PHP makes possible the

communication and JS makes the site more dynamic

and with more intuitive functionalities, can be can

seen from the query figure1. To create the database,

the language chosen in SQL was chosen.

2.1 Development of the Database

The requirements defined for the database were:

• be user-friendly

• be versatile registration;

• be in digital format;

• allow the recording of personal information,

therapy session details, performance assessment

and other relevant clinical information;

• facilitate the analysis of the child's clinical

evolution;

• provide a change to the method implemented;

• provide reports, such as a systematic evaluation,

for delivery to caregivers or even to file service

or the hospital itself.

The database allows the recording of patient data

and clinical assessment. Thus, it is divided into:

patient chart; assessment of ophthalmological

parameters; behavioural evaluation; functional

evaluation of the vision; monitoring of intervention

sessions.

The patient's record contains socio-demographic

data about the patient and caregivers, family

composition and diagnosis. These are data

considered relevant to identify the social

environment that around the child and define the

intervention in a personalized way (Hyva

rinen,

2012).

In the ophthalmologic evaluation session is

carried out the analysis of the evolutionary

development of the following parameters: setting

and search for objects, reflecting direct fotomotor,

visual acuity and stereopsis.

The behavioural assessment session consists of

observing how the child reacts to the stimuli

BIODEVICES 2018 - 11th International Conference on Biomedical Electronics and Devices

174

presented (fixation, follow, try touch or not). They

are considered activities that help in the perception

of the visual functioning of the child, such as the

activities of daily living. The behavioural traits

observed during the performance of activities are

relevant information for a better understanding of

visual characteristics. In this evaluation process, the

presence of a family member of the child involved is

advisable to provide all the details considered

important (Ortibus et al., 2011; Aarnoudse-Moeus et

al., 2009; Fox and McDaniel, 1982).

To optimize the time of evaluation and

behavioural analysis, it was adopted the scale

implemented in the visual evaluation (Gordon and

Martin, 2010). The scale consists of the following

parameters:

1. Never - (0%)

2. Rarely - (25%)

3. Occasionally - (50%)

4. Often - (75%)

5. Always - (100%)

If the child's collaboration is successful, the

occupational therapist applies a functional

assessment program for vision / motor skills. In this

context, the therapist makes an evaluation based on a

systematized protocol, elaborated for that purpose

based on standardized criteria.

Functional assessment of vision is performed by

analyzing the patient's record at the time of

application of the stimulus protocol.

Throughout the sessions an evaluation is made to

analyze the evolution of the patient.

In all evaluations it is possible to record

observations

2.2 Development of the Protocol of

Stimuli

It was defined for the protocol of the stimuli should:

• allow the stimulation of visuomotor skills

• have adequate incentives for the needs of each

child between the ages of 0 and 18 months

• take into account child's cognitive development

• be of increasing complexity

• provide a change to the implemented method;

• provide reports, as a systematic evaluation, for

delivery to care providers or even to file the

service or the hospital itself.

• Provide orientated stimulus for caregivers to use

at home

This protocol was developed based on the

bibliography consulted, on the professional

experience and on the stimuli developed for the

intervention program (Telles et al., 1974; Atkinson,

2008; Lueck and Dutton, 2015). Two programs were

divided in colour and black and white. Both are

constituted by the same evaluative sequence, being

they differ only in the introduction of colour in the

geometric figures. According to the characteristics

evaluated in the intervention program, the functional

evaluation consists of simple figures, figures with a

medium complexity pattern and horizontal, vertical,

diagonal and circular movements at medium speed.

For the sake of uniformity of the evaluative scheme,

the scale adopted in the behavioural evaluation was

implemented.

The attributes of visual stimulation can be

adjusted during the instruction, depending on the

purpose. These attributes relate to the following

characteristics:

1. Dimension;

2. Contrast;

3. Complexity;

4. Lighting;

5. Duration;

All these attributes must be taken into account in

order to optimize the visual functions (Lueck, 2004);

(Catalano et al., 1986). Based on these

characteristics, an intervention program was

designed to support the sessions of stimulation of

visuomotor skills. This intervention program will be

applied during an occupational therapy session.

As support for the evaluative level and for the

choice and presentation of the stimuli, a specific

menu was elaborated for the situation.

2.3 Characteristics of Stimulus

Visual stimulation at these early ages is dependent

on the visual response to stimuli, such as lights,

contrasts, colours, glows, objects, and so on (Beery

and Beery, 2010; Atkinson, 2008). Thus, the

response is an indicator of ocular development and

visual learning as well as visual evolution. For

children within the age bracket considered in this

study, from 0 to 18 months, this response is

observed from indicator behaviours such as looking,

smiling or balancing and can help the professional to

adapt the intervention strategy to be used, such as de

fining amore distant distance (Ortibus et al., 2011;

(Ortibus et al., 2011; Aarnoudse-Moeus et al., 2009;

Catalano et al., 1986).

Considering the response to the functional

evaluation protocol of visuomotor skills, the child is

directed by the occupational therapist to an

RehabVisual: Development of an Application to Stimulate Visuomotor Skills

175

intervention program aimed at developmental needs.

The main objective of this program is to be able to

define as many variables as possible, making it more

complete and universal. This provides the user with

a greater number of choices, allowing a more

specific and individualized treatment.

Based on previous studies and the high

experience of professionals of the PMR service, a

differentiated program was developed with a

succession of stimuli consisting of the

aforementioned attributes of increasing complexity.

To do so, these attributes were analysed based on the

visual and cognitive development of children aged 0

to 18 months.

The intervention protocol was based on the

following parameters: figures; dimension; colour;

contrast; movement; presentation distance.

• Forms:

Considering the cognitive development of children

in this age group, quadrangular, triangular, circular

or with a succession of these three intercalated

geometries were chosen. In order to increase the

complexity, the protocol of stimuli has figures with

the following characteristics:

• Simple figures that present only an image

with the same shape (Figure 1);

• Patterned figures - several images are

displayed with the same shape or with

different shapes (Figure 2).

Figure 1: Figures inserted in the intervention program.

The patterns figures are the most used elements

in the area of stimulation of visuomotor skills. As

such, it was considered appropriate to create a

section for its evaluation.

Figure 2: Sequence of average complexity with 4 cm

figures in alternate backgrounds.

Using circular, quadrangular and triangular

geometric figures it was possible to create patterns

with various levels of complexity characterized by

an increase in the number of figures presented and a

decrease in the space between them. In each degree

of complexity it is also possible to find, mixed

patterns consisting of a random variance of the three

geometric figures presented. These patterns also

show the alternation of white and black background

for each of the three sizes considered and the

animation to fade at the end of the presentation of

each figure. This diversity allows a more specific

and individualized service to the child's visual

development needs.

• Dimension:

Considering the reduced information in this context,

it was decided to consider the dimensions of Teller

cards (Teller et al., 1974). These cards are used for

assessing visual acuity in children and adults at

ophthalmology visits and are approximately one size

12 x 12 cm (Gordon and Martin, 2010). It was then

decided to consider an initial size of 12 cm in the

figures, and the following presentations increase

their degree of complexity by reducing the size of

the figure to 8 cm and then to 4 cm.

• Colour:

In this age group are considered colours such us red,

yellow, blue, green, black and white. According to

the child's development the stimuli are arranged in

two groups: black and white; colours.

• Black and White Stimulus:

This category has a succession of black and white

images in high contrast background, white and

black, respectively, as shown in Figure 3.

Figure 3: Example of a black and white sequence present

in the intervention protocol.

• Colour Stimulus:

Colour is an extremely important element in the area

of visual stimulation. In order to present a range of

colours appropriate to the development of children's

colour vision, the following colours were

considered: red (RGB: 196/0/0), yellow (RGB:

235/230/0), blue / 57/205) and green (RGB:

0/153/0), with their respective black and white

background contrasts (Figure 4).

BIODEVICES 2018 - 11th International Conference on Biomedical Electronics and Devices

176

These are the stimuli that may arouse greater

interest on the part of a child with cerebral visual

impairment, because they have colour and are more

appealing than black and white. Studies show a

preference of these children for colours such as blue,

green, yellow and red, since most of these anomalies

translate into a vision partly dominated by these

colours (Gordon and Martin, 2010; Mohn et al.

1988).

Figure 4: Colours considered for the intervention program.

• Contrast:

To obtain greater contrast in the figures, white and

black backgrounds were considered, interspersed

with the colour of the figure.

• Presentation Distance:

The distance from the presentation of the stimulus to

the child is approximately 20 cm (Teller et al.,

1974).

Based on these attributes, an intervention

program was devised, which allowed the

optimization of the visual stimulus, favouring a

familiarization with the use of simple geometric

figures, working on the recognition and

discrimination of the same. It was considered an

increase in the degree of complexity of the stimuli,

present by a decrease in size from 12 cm to 8 cm and

then to 4 cm, each presenting the respective white

and black background, two initial categories were

defined: black and white and colours.

• Movement

The ability to detect the direction of movement is

one of the most basic and important perceptual

capacities and strongly attracts child attention.

Although there are no routine tests to assess the

perception of movement in children, visual

difficulties are associated with a perception of

impaired movement. Usually children have an

aversion to rapid television movements or difficulty

seeing a moving car (Gordon and Martin, 2010;

Mohn et al., 1988).

From the age of eight months, the child needs to

gain experience in the horizontal, vertical, diagonal

and circular direction. The stimulation of these

parameters favours the perception of the relative

distance of the objects and their spatial disposition.

Progress has also been recorded in the analysis of

movement sensitivity, including directional

sensitivity, velocity sensitivity, movement

perception and stability (Figure 5).

Figure 5: Trajectory guidelines considered for the figures

with movement intervention program.

A movement scale categorized them as slow,

medium and fast. With this variety it is possible to

carry out a more specific intervention by exercising

different skills in the field of movement. In all

movement orientations, the figures have the same

range of trajectory.

3 CONCLUSIONS

RehabVisual platform aims to allow the stimulation

of motor skills in children between the ages of 0 and

18 months. It is a tool that revels to be user-friendly

and intuitive. It allows the systematic registration of

clinical information, assessment and monitoring of

the child's progress. It has also one stimulus protocol

that allows adapted to each child's needs. This

plataform allows a global and integrated evaluation

and intervention because it has two sessions:

database that records all the clinical information of

the patient and protocol with a range of stimuli

standardized. This stimuli it was organized

according to the development of the child and the

pathology / dysfunction of each one.

The validation process it will be the next step

and it will performed at the Service of Physical

Medicine and Rehabilitation (PMR) of the Hospital

D. Estefânia of the Hospital Center of Lisbon

Central.

The present work aims to contribute significantly

to the prevention and / or reduction of possible

consequences at the level of functional vision. For

this reason, versatile and diversified protocols have

been developed.

The RehabVisual can be used by physicians,

occupational therapists, and caregivers. Therefore, it

permits to continue the treatment of the clinical

environment to the home context and monitories the

child progress in real time.

RehabVisual: Development of an Application to Stimulate Visuomotor Skills

177

ACKNOWLEDGEMENTS

The authors would like to thank all the healthcare

professionals of the Physical Medicine and

Rehabilitation Service at D. Estefânia Hospital.

REFERENCES

Aarnoudse-Moeus, C., Smidts, D., Oosterlaan, J.

Duivenvoorden , H., e Weisglas – Kupenns N.

Executive Function in Very Preterm Children at Early

School Age.Journal Abnormal Child Psychology.

2009; 37:981–993

Atkinson, J. (2008). The developing visual brain. Oxford

psychology series. New York.

Best J., Miller, P. A developmental perspective on

executive function. Child development. 2010; 81(6):

1641-1660

Beery, K., & Beery, N. (2010). The Beery – Buktenica

developmental test of visual – motor integration (6

ed). Pearson. Texas

Catalano A. R., Simon W. J., Krohel B. G., Rosenberg N.

P. Functional Visual Loss in Children.

Ophthalmology, 1986; 93 (3): 385-390

Cicerone D. K., Dahlberg C, Kalmar K., Donna

Langenbahn M. D., Malec F. J., Bergquist F. T.,

Felicetti P. T., Giacino T. J., Harley J.P., Douglas E.

H., Herzog J., Kneipp S., Laatsch L., Morse A. P.

Evidence-based cognitive rehabilitation:

Recommendations for clinical practice. 2010;

81(12):1615

Fox R., McDaniel C. The perception of biological motion

by human infants. Science, 1982; 218: 486–487

Giovannett M. A., Ragg A., Leonardi M.,

Sonksen PM. Vision and early development. In: Wybar K,

Taylor D, editors. Paediatric Ophthalmology: Current

Aspects. New York: Marcel Dekker; 1983; 85-95.

Gordon N.D., Martin B., Clinics in Developmental

Medicene nº186:Visual impairment in children due to

damage to the brain, chap. 1, 4, 14, 15, 19, 2010

Heyl V., Hintermair M. Executive function and behavioral

problems in students with visual impairments at

mainstream and special schools. Journaal of visul

impairment & blindness, 2015

Hyva

rinen L. Assessment of vision for educa- tional

purposes and early intervention. Cited 11.2.2012

Available from http://www.lea-test. fi/index.html

Lueck, A. (2004). Functional vision: A Practitioner´s

Guide to evaluation and intervention. American

Foundation for blind, NY.

Lueck, A., Dutton, G. (2015). Vision and the brain –

understanding cerebral visual impairment in children.

AFB Presss: American Foundation for the blind.

Mohn G, van Hof-Van Duin J, Fetter WP, De Groot L,

Hage M. Acuity assessment in non- verbal infants and

children: Clinical experience with the acuity-card

procedure, Dev. Med. Child Neurol. 1988; 30: 232-44.

Mosca F., Gang S., Sabbadin S., Picciolini O. Usefulness

of ICF-CY to define functioning and disability in very

low birth weight children: A retrospective study. Early

Human Development. 2013; 89(10): 825-831

Ortibus L. E., Cock De P., Lagae G. L. Visual Perception

in Preterm Children: What Are We Currently

Measuring? Pediatric Neurology. 2011; 45(1): P1-10

Teller D.Y., Morse R., Borton R., Regal D., Visual acuity

for vertical and diagonal gratings in human infants

Vision Res.. 1974; 14: 1433.

BIODEVICES 2018 - 11th International Conference on Biomedical Electronics and Devices

178