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Rehabilitation and management of apraxia after stroke
Caroline M van Heugten
Reviews in Clinical Gerontology / Volume 11 / Issue 02 / May 2001, pp 177 - 184
DOI: 10.1017/S0959259801011285, Published online: 22 October 2001
Link to this article: http://journals.cambridge.org/abstract_S0959259801011285
How to cite this article:
Caroline M van Heugten (2001). Rehabilitation and management of apraxia after stroke. Reviews in
Clinical Gerontology, 11, pp 177-184 doi:10.1017/S0959259801011285
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Reviews in Clinical Gerontology 2001 11; 177–184
Rehabilitation and management of apraxia after
stroke
Caroline M van Heugten
Institute for Rehabilitation Research and Rehabilitation Centre, Hoensbroek, The Netherlands
Introduction
A stroke patient puts on his shoes and then tries
to put on his socks over his shoes. Entering the
kitchen, this patient puts milk in the teapot, places
the sugar bowl in the oven, and tries to drink from
the milk jug. This patient is most probably
apractic. Apraxia is one of the four classical neuropsychological deficits – such as agnosia, amnesia
and aphasia – causing restrictions in the ability to
carry out purposeful and learned activities. One of
the first definitions of apraxia was given by
Geschwind1: ‘Disorders of the execution of
learned movements which cannot be accounted
for by either weakness, inco-ordination, or
sensory loss, nor by incomprehension of, or inattention to commands.’
Although much has been written since
Steinthal2 first used the term apraxia, it remains a
difficult concept for both clinicians and
researchers. Tate and McDonald3 refer to apraxia
as ‘the clinician’s dilemma’ and, for assessment of
apraxia, this is still true to a large extent, since
clinical batteries need improvement and reliable
diagnostic criteria are needed. Recent intervention
studies have shed some light on the issue of management and treatment of apraxia: positive
treatment effects have been found reducing the
disrupting influence of apraxia on everyday
life.4,5,6 The latest attempts of intervention were
directed to functional and pragmatic treatment
approaches in natural environments, which was
already suggested by Maher and Ochipa.7 Unfortunately, there are still researchers and clinicians
neglecting apraxia and the need to treat these
patients seriously. In a recent systematic review on
evidence-based cognitive rehabilitation leading to
recommendations for clinical practice,8 apraxia
was not even entered into the search as a key
Address for correspondence: CM van Heugten, Institute
for Rehabilitation Research, P.O. Box 192, 6430 AD
Hoensbroek, The Netherlands.
word. The practical significance and ecological
impact of apraxia should however convince the
clinician to incorporate the treatment of apraxia
into the overall rehabilitation programme.
In this paper, the rehabilitation and management of apraxia after stroke is discussed on the
basis of a review of studies on the treatment and
effectiveness of treatment of apraxia. By means of
introduction, some issues concerning apraxia in
general and assessment of apraxia in particular are
presented.
Apraxia: the clinical picture
Apraxia is usually found in stroke patients with a
left-hemispheric lesion. The exact prevalence of
apraxia is not known, but different studies
conclude that approximately one-third of the leftbrain damaged patients are found to be
apractic.9,10 Apraxia and aphasia frequently
coexist and the association between the two
deficits is likely due to the involvement of contiguous structures.3,9 Many different forms and
classifications of apraxia are described in the literature, but there is not one accepted taxonomy.
Ideational and ideomotor apraxia have been the
object of most studies in recent years and are
sometimes labelled as the two classic forms of
apraxia.3 A patient with ideational apraxia does
not know what to do because the idea or concept
of the motor act is lacking, while a patient with
ideomotor apraxia does know what to do, but not
how to do it.9 The types of error one can observe
in ideational apraxia are omissions, mislocation or
misuse of objects and sequence errors.11 The most
frequent errors in ideomotor apraxia are the use
of body-parts as objects, spatial orientation
problems, inappropriate hand postures, perseverations and content errors.12-14 Patients with
ideomotor apraxia may not be able to perform on
command, while exactly the same activity may be
executed perfectly in a natural setting.15
178
CM van Heugten
Assessment
Tate and McDonald reviewed the literature on
apraxia from three perspectives: definitions, taxonomies and examination procedures.3 On the
basis of their review, the authors refer to apraxia
as ‘the clinician’s dilemma’: clinicians are faced
with inconsistencies and contradictions in terminology, poorly defined concepts, and the lack of
integration between empirical results and clinical
practice. They present an overview of testing procedures using many different task demands and
quantitative and qualitative scoring methods.
Error analyses are in general less reliable than
quantitative methods, but these methods have
provided some insight into praxis performance.
The reader interested in this description should
consult their paper, as well as some other
reviews.3,16,17 In short, all authors conclude that no
standardized methods of praxis assessment seem
to be available.
Methods which are used in empirical studies are
not easily applied in clinical practice and many
clinicians rely on clinical reasoning and personal
experience.18 The clinician can, however, be
supported by the notions of two recent studies on
the assessment and treatment of apraxia4,5 in
which the researchers used a diagnostic procedure
consisting of two complementary levels. First, a
clinical assessment of apraxia was used, based on
a neuropsychological test in a standardized
context, including imitation of gestures,
pantomime and the use of objects. This part can
be used to differentiate between patients with and
without apraxia. Second, standardized activities of
daily living (ADL) tests are needed in order to
examine to what degree the impairments in praxis
function lead to problems in everyday functioning.
Several standardized observational methods can be
applied to assess the problems in performance and
derive plans for treatment.19–22 This interplay of
standardized tests and observation techniques is
important in clinical practice. The underlying
deficits can be made explicit to a certain degree,
but the subjective elements in behaviour are also
taken into account. In performing daily activities,
it is important to consider the subject’s background and family and cultural influences. In
certain religious cultures, for instance, the use of
a kitchen knife is restricted to the adult men in the
family. A woman handling a kitchen knife in a
strange way is therefore not necessarily a case of
apractic behaviour. Performance is not by definition inadequate if it is not within the range of possibilities of the clinician. Landry and Spaulding23
also recommend observation of the client
engaged in his or her occupation. Structured
testing in isolation may not correlate strongly with
occupational performance, while analyses of performance errors, in addition to formal test results,
will provide the therapist with meaningful
information to plan interventions. Self-report
devices and interviews with patients and their
families should be equally appreciated in
diagnostic settings. Combining the diagnostic
findings of the psychologist with those of the occupational, speech and physical therapists, nurses
and social workers, is advisable in the light of
these issues.
Recovery of apraxia
The natural recovery course of apraxia has not
been the focus of many studies. Basso and colleagues24 conducted one of the few studies on the
recovery from ideomotor apraxia in acute stroke
patients. They investigated variables which could
predict the evolution of this form of apraxia.
Improvement was found to take a long time and
was only related to the site of the lesion: anterior
lesions have a better chance of recovery than
posterior lesions. Age, gender, type of aphasia,
level of education, initial severity of apraxia, the
presence of a second lesion in the right hemisphere
and the size of the lesion had no influence. It
appeared that five months after the first examination, 13 of the initial 26 patients still showed
apraxia. In another study,25 the pattern of recovery
of limb apraxia was investigated over a period of
six months. The patterns of recovery appeared to
differ between gestures. The natural course of
apraxia seemed to be related to gestures which
were meaningful and recognizable. A final study
reported findings on the recovery of constructional
apraxia five months poststroke.26 The group of
left-hemispheric patients showed more improvement than the right-hemispheric group.
Despite the lack of sufficient empirical evidence,
many clinicians tend to think that in most
patients, apraxia recovers spontaneously within
the first few weeks after the lesion.7 If, however,
the apraxia is still apparent after a period of spontaneous recovery, this is most probably a lasting
and irreversible deficit for which rehabilitation
Rehabilitation and management of apraxia after stroke
should be considered. Persistent apraxia can result
in considerable handicap.
Influence of apraxia on daily life
For a long time researchers believed that apraxia
only occurred when performance was requested in
testing conditions, and that patients would act
correctly when performing spontaneously in a
natural context.18,27,28 This would suggest that
there is no negative influence on daily life and that
therapy for apraxia is not necessary. In recent
years, this claim has been challenged by many
studies. Bjorneby and Reinvang29 found that
apraxia variables were significant predictors of
subsequent dependency. Sundet and colleagues30
reported similar results: apraxia variables at the
start of the rehabilitation correlated significantly
with the level of dependency after discharge.
However, other studies4,31 have showed that
apraxia has an adverse impact on ADL and the
ability to return to work.32 All of these studies
suggest that the treatment of apraxia should be
part of a rehabilitation plan. The fact that most
apractic patients seem to perform better when old
routines and habits can be reinforced suggests that
rehabilitation in the patient’s own environment
may be the most effective treatment model.
Treatment models
In the area of cognitive rehabilitation, psychologists and therapists can apply many different
approaches in order to promote the recovery of
cognitive functions and reduce cognitive disabilities. Cognitive retraining, for instance, is aimed at
recovery of the distorted function by repeated
practice (‘mental body building’).33 Methods of
activation and stimulation are based on the
concept of plasticity within the neural substrate.
However, sufficient plasticity to restore higher
cognitive functions completely may not always
exist.34,35 Improving cognitive functions may also
be limited by a lack of generalization to everyday
situations. Recovery from apraxia is not a realistic
goal for therapy. Instead, the aim of rehabilitation
should be to help the patient develop new patterns
of cognitive activity through internal or external
compensatory mechanisms, or through adaptation
of the tasks or environment. The research on the
rehabilitation of apraxia is sparse, but the intervention studies that have been conducted suggest
179
that compensatory strategies may be the most
effective method. The recommendations from a
recent review are that cognitive rehabilitation
should always be directed toward improving
everyday functioning by applying compensatory
strategies to functional contexts.8
Occupational therapy guidelines for intervention
In occupational therapy journals it is not
uncommon to formulate practical guidelines based
on literature reviews in combination with clinical
experience. Two recent papers have addressed
current occupational therapy treatments for
apraxia or dyspraxia.23,36 Both papers suggest that
interventions should focus on teaching new strategies. Some practical guidelines are offered as well.
Instructions should be clear and concise and
include feedback; physical guidance, visualization,
modelling, and step-by-step verbal instructions are
also found to be successful; during therapy, the
training of functional activities is preferred within
the usual context of the patient; and combining
different modalities can assist performance in
apractic patients.23 Jackson36 applies some general
treatment principles to the rehabilitation of
apraxia: treatment should be functional, goaloriented, structured and involve errorless learning
and compensatory techniques. These guidelines
are useful in clinical practice, but are not all
evidence-based.
Intervention studies
In order to establish evidence-based recommendations on the rehabilitation of apraxia, it is essential
to review the scientific literature on the effectiveness of apraxia treatment. Intervention studies on
apraxia can be divided into three categories which
are reviewed below.
Single case studies
A few single case studies on the rehabilitation of
a patient with apraxia are reported. Wilson37
described a case of remediation of apraxia
following an anaesthetic accident. In the treatment
programme, the activities were broken down into
small steps which were practised a few times
together with the patient, supported by the overt
verbalization of an occupational therapist. Selfhelp skills improved as a result of this approach.
180
CM van Heugten
Maher and colleagues38 studied the effects of
treatment on a 55-year-old man with ideomotor
apraxia and preserved gesture recognition. Daily
one-hour therapy sessions were given during a
two-week period. During therapy sessions, many
cues were offered which were withdrawn systematically while feedback and correction of errors
were given as well. The production of gestures
improved qualitatively. Ochipa and colleagues39
subsequently developed a treatment programme
aimed at specific error types. Praxis performance
was studied in two stroke patients. It appeared
that both patients achieved considerable improvements in performance, but the observed effects
were treatment-specific: treatment of a specific
error type did not improve across untreated
gestures. Jantra and colleagues40 studied a 61year-old man with a right-sided stroke followed
by apractic gait. After three weeks of gait training
supplemented with visual cues, the patient became
independent with safe ambulation. Pilgrim and
Humphreys41 described the use of an educational
approach for the rehabilitation of brain-damaged
children and adults, aimed at functional motor
goals42 in a left-handed head-injured patient with
ideomotor apraxia of the left upper limb. The
principle of this treatment was to restore performance through a restructuring of the functional
system by involving the role of speech in motor
actions. The use of objects improved, but only for
those objects that were trained. Bergego and
others43 report the successful use of re-education
treatment of the use of objects in an apractic
patient. Butler44 conducted a case-study exploring
the effectiveness of tactile and kinesthetic stimulation as an intervention strategy, in addition to
verbal and visual mediation input, in the rehabilitation of a man with ideomotor and ideational
apraxia following a head injury. In this training,
the patient is cued to look at what he is doing and
where he is going, and demonstrating activities
and movements, thereby giving a visual model. In
addition, the patient is encouraged to verbalize
performance and its results. Evaluation of the
motor performance in an ABA design showed
mixed results related to an intervention effect. The
hypothesis that additional sensory stimulation
could increase motor performance was supported
partially. The study however had some limitations
because the results could in part be explained by
motor recovery and some ceiling effects were
present.
In all of these single-case studies, some form of
strategy-training was applied, in which the
impaired function was compensated for by cueing
and feedback techniques addressing additional
systems, such as speech, vision, and touch.
Quasi- and pre-experimental effect studies
In 1998, Goldenberg and Hagman published a
study in which a therapy of activities of daily
living was evaluated in fifteen apractic patients
who made errors in performance.4 The researchers
distinguish fatal errors, which prevented successful completion of the activity, and reparable
errors. It appeared that the number of errors correlated with clinical measures of apraxia (such as
imitation, pantomime and object use). The aim of
therapy was restoration of independence in ADL
through ADL training by an occupational
therapist occurring five times a week. Patients who
made fatal errors in at least two out of three activities were admitted to the therapy study. Each
week one of the three activities was trained, while
the other two activities were given maximum
support during daily routines. Every week another
activity was trained, and each week ADL tests
were administered. After therapy, which had a
mean duration of about four weeks, 10 patients
could perform all three activities without fatal
errors, and three patients made only one fatal
error. Elimination of fatal errors was restricted to
the week the activity was trained; in other words,
no generalization of training effects from trained
to non-trained activities was shown. It appeared
that there was no spontaneous recovery of ADL
capacities, but specific training could restore ADL
independence for trained activities. The training
effect was preserved after six months only in those
patients who kept practising in their home
situation.
Van Heugten and colleagues5 conducted a noncontrolled intervention study to evaluate a therapy
programme for stroke patients based on teaching
patients strategies to compensate for the presence
of apraxia. Changes were expected in ADL performance after treatment. More specifically,
improvements in ADL were expected, though little
change was predicted in the severity of apraxia.
Thirty-three stroke patients were treated at occupational therapy departments for a period of 12
weeks. The number of treatments per week was
determined by the therapist. During the treatment
Rehabilitation and management of apraxia after stroke
period, activities were trained that were relevant
for the patients to learn. The focus of the
programme was on disabilities resulting from
apraxia that impaired ADL. Every two weeks an
activity was chosen. The specific interventions
administered during treatment corresponded with
the specific problems that were assessed during
standardized ADL observations. ADL were conceptualized as being composed of three successive
events: the proper plan of action as well as the
correct objects have to be selected (initiation),
followed by adequate performance of the plan
(execution), which has to be evaluated in terms of
the result (controlling and if necessary correcting
the activity). The specific interventions in the form
of instructions, assistance and feedback were
presented to the OTs in a protocol. The following
measurements were conducted: an apraxia test, a
test of motor functioning, standardized observation of four activities of daily living, the Barthel
index and an ADL questionnaire for the patients
and the therapists. The neuropsychological
apraxia test consisted of two subsets: demonstrating the use of objects and imitating gestures. The
standardized ADL observations consisted of four
activities being scored on four aspects: independence, initiation, execution and control. Subsequently, the four measures were added to arrive at
a total ADL score. The results showed large
improvements in ADL functioning on all measures
and small improvements on the apraxia test and
motor functioning test. The effect sizes for the disabilities, ranging from 0.92 to 1.06, were large,
compared to the effect sizes for the apraxia test
(0.34) and motor functioning (0.19). The significant effect of treatment was also seen when individual improvement and subjective improvement
was considered. These results suggest that the
therapy programme seems to be successful in
teaching patients compensatory strategies that
enable them to function more independently,
despite the lasting presence of apraxia.
Experimental effect studies
Poole45 published a study in which the ability of
participants with left-hemisphere stroke to learn
one-handed shoe-tying was examined. Participants were five stroke patients with, and five
without apraxia, and five control patients.
Retention was assessed after a five-minute interval
during which participants performed other tasks.
181
All groups differed significantly with regard to the
number of trials needed to learn the task of
shoe-tying with one hand. However, on the
retention task, the stroke patients with apraxia
required significantly more trials than the other
two groups. All groups required fewer tasks on the
retention tasks than the learning task. Poole
concluded that stroke patients with apraxia have
difficulty learning and retaining a functional
sequencing task. These findings confirm clinical
observations showing that apractic patients have
difficulties learning new ADL techniques.
Two randomized controlled trials on the rehabilitation of apraxia have been recently
reported.6,46 One study on limb apraxia46 was
conducted in thirteen patients with acquired brain
injury in the left hemisphere and limb apraxia
lasting more than two months. Patients were
randomly assigned to a study group receiving
experimental training for limb apraxia or a
control group receiving conventional treatment
for aphasia. The experimental training involved a
behavioural training with gesture-production
exercises. Thirty-five sessions of fifty minutes each
were given. The patients receiving the experimental training showed a significant improvement of
performance on ideational and ideomotor apraxia
tests. On both tests they also showed a reduction
of errors. Control patients did not show any
significant change in performance. The authors
conclude that their specific training program is
possibly effective for the treatment of limb
apraxia. In addition, the improvement was not
restricted to trained items, but extended to
gestures requested during assessment. This study,
however, also leaves at least one important
question to be answered: is this specific rehabilitation programme also useful in improving
gestural performance under daily-life conditions?
The goal of the study by Donkervoort and
others6 was to determine the efficacy of strategy
training in left-hemisphere stroke patients with
apraxia. The main expectations to be tested were:
(1) that strategy training incorporated into the
usual treatment by occupational therapists will
lead to more independence than the usual
treatment alone; (2) while there will be no differential effect with regard to the apractic impairment itself; and (3) it is expected than the usual
treatment by occupational therapists will lead to
more improvement in motor functioning as a
result of more time being available for training
182
CM van Heugten
motor functions. The group of patients receiving
strategy training were given the same training as
in the study by van Heugten et al.5 The main focus
of the therapy for the control group of patients
was on sensorimotor impairments and disabilities.
This treatment was mainly based on trial and
error and the experience of the therapist. Patients
were assessed at baseline, post-treatment (eight
weeks) and follow-up (20 weeks). During the
study, 315 patients with apraxia were referred for
OT treatment; 113 patients were eligible for the
study, of which 56 were allocated to strategytraining and 57 to the usual treatment. The
amount of therapy did not differ significantly
between the treatment groups; the content of
treatment, in terms of training for motor impairments, cognitive training, advice, splinting, aids
and housing adjustments, did not differ either. The
use of other therapies was equally divided
between both groups, but the strategy training
group received more ADL training, which was to
be expected. Patients in the strategy-training
group improved more on the primary outcome
measure (p=0.03). The matching effect size (0.37)
indicates that strategy training is associated with
a small to medium effect on ADL functioning. The
Barthel index showed a significant medium effect
(0.48) in favour of strategy-training. However, at
follow-up, no significant differences between the
two groups were found.
Indications for treatment
The identification of patients who will benefit
most from a specific treatment is important for
caregivers in order to set realistic treatment goals
and allocate health care services efficiently.
Perhaps even more importantly, the patient and
the family should be informed adequately about
the expected outcome. As noted earlier, a few
studies confirmed the negative impact of apraxia
on everyday functioning and the increased dependency seen in patients in whom apraxia was
present at the start of rehabilitation. The only
factor found to be related to recovery was the site
of the lesion, which cannot be influenced by
therapy. In the two studies on the efficacy of
strategy-training for patients with apraxia,5,6 correlational and subgroup analyses were conducted
with respect to the primary outcome measures to
determine specific treatment effects. The results of
both studies suggested that strategy-training was
more beneficial in patients with more severe forms
of apraxia. The expectation that most apractic
patients have additional other impairments was
confirmed, but these negative influences on daily
functioning did not disturb the outcome of
treatment. The study by van Heugten5 suggests
that neither the presence of additional cognitive or
motor problems nor age should be an indication
for refraining from treating apraxia.
Conclusions
In recent years, the management and treatment of
apraxia has received more research interest and
clinical attention. Several studies have demonstrated the negative impact apraxia can have on
everyday life, which should serve as a strong motivation for clinicians to address apraxia during
rehabilitation. Studies on the effectiveness of
apraxia treatment have shown that compensatory
strategies may be the most effective approach.
Treatment should focus on functional activities
which are structured and practised using errorless
learning approaches. Recovery from apraxia
should not be the goal of rehabilitation. Further
studies of treatment interventions are needed
which also address how generalizable treatment
effects are to non-trained activities and situations.
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