Post Stroke Apraxia
Cheryl Edwards
Highly Specialist Occupational Therapist
St. George‟s Hospital
October 2010
Contents
• What is praxis?
• What is Apraxia?
• The Praxis Network
• Types of Apraxia
• Assessment
• Treatment
• Summary & Questions
What is Praxis?
What is praxis?
• From Greek for „doing‟…..
• Doing of volitional, goal directed movements
• Praxis is a complex interplay between motor/ sensory/
perceptual & cognitive processes
• A performance skill
• Forms the foundation for development of performance
patterns and occupation
The Cognitive Hierarchy
Executive
Functions
Praxis
Memory
Object Recognition
Visual and Spatial Perception
Attention
Sensory Registration
Programmes for action
• Motor programme: a stored action memory for a
particular movement
• Not only which muscles to use to activate but the
force, direction and timing of the movement
• Open loop versus closed loop movement
• Can involve the use of multiple objects
• Motor schema-actions are combined in a certain order
to achieve goal
• Correct sequence is essential to success
• Errors are possible usually at transition points
What is Apraxia?
Apraxia and Dyspraxia –
Is there a difference?
Dyspraxia
Impairment in new learning of
motor patterns and sequences
i.e. developmental / related to
paediatrics (Cermak,1985)
•
•
•
Sensory /perceptual disorder
Paediatrics
Sensory Integration Treatment
Apraxia
A disorder of learned movement
i.e. previously able and now this
ability is absent / related to
acquired brain injury
(Grieve and Gnanasekaran,2008)
•
•
•
Cognitive/Motor disorder
Adults
Restoring existing motor
pathways (repetition, mental
imagery treatments)
Apraxia
• A complex higher order cognitive-motor deficit
(Leiguarda & Marsden, 2000; McClain & Foundas, 2004)
• An “inability to perform skilled sequential purposeful
movement” (Banich, 2004: 178)
• “A cognitive motor disorder that involves the loss or
impaired ability to programme motor systems to
perform purposeful, skilled movements” (Zoltan,
2007:109)
Apraxia: Error Types in Function
•
•
•
•
•
•
•
•
•
Omissions
Difficulty terminating movements
Repetitions
Disturbances to order of movements in sequence
Difficulties co-ordinating limbs in time and space
Perseveration
Performance in wrong plane
Using body part as object
Verbalise performance without completing
(Grieve and Gnanasekaran, 2008)
The Praxis Network
The Praxis Network
Neuroanatomy
Praxis Processes
• Seeking to locate the
parts of the brain
responsible for praxis
• Historically thought to be
the left hemisphere and
the left parietal lobe due
to impact of language
• Seeking to identify the
levels of processing
involved in creating
skilled movements.
(Liepmann, 1908;
Geschwind, 1975;
Heilman,1979)
(Roy and Square, 1994;
Rothi & Heilman, 1997)
Neuroanatomy: Not just the Left Parietal Lobe
Bilateral distribution
Hanna-Pladdy et al 2001
Occipital and temporal lobe
Makuuchi et al 2005
Left frontal lobe
Haaland et al 2000
Basal Ganglia
Pramstaller et al 1996
Apraxia: Not just the Left Parietal Lobe
Frontal lobe:
Pre-motor cortex
Frontal lobe:
Primary motor area for
execution of movement
Right and left parietal
lobe:
perceptual analysis
Left occipital parietal
lobe:
Action memory store
Dominant occipital lobe:
visual information
Apraxia and Aphasia
• 80% of patients with apraxia are also aphasic
• Close relationship between apraxia and
aphasia well researched
• Exact impact of each on other remains poorly
understood
• Clear evidence one can exist without the
other.
(Alexander, 1992; Papagno et al, 1993)
Praxis Processes
Based on three level system:
• Sensory/ Perceptual Level
• Conceptual Level
• Production Level
Disruption at Conceptual or Production level would
result in Apraxia
Sensory /
Perceptual
system
Visual / Gestural
Information
Auditory / Verbal
Information
Visual Tool / Object
Information
…..P Route
.…..P Route…..
Conceptual
System
Knowledge of Action
Knowledge of Tool /
Object Function
Response selection
Image generation
Production
System
Working memory
Response
organisation /
control
DI route
CI route
Key Process Concepts
Movement is processed in similar way to language
Meaning associated with gesture that is important
Meaning of gesture determines route:
• One route for processing meaningful gestures
(transitive & intransitive)
• One route for processing meaningless gestures
Types of Apraxia
Apraxia: Are there different types?
Apraxia: Are there different types?
Ideomotor
Dressing
Ideational
Apraxia
BuccoFacial
Limb/
Manual
Constructional
Speech
Apraxia: Are there different types?
Manual/Limb Apraxia
Ideational Apraxia
Ideomotor Apraxia
Ideational Apraxia
•
•
•
•
•
•
•
Network
Disturbance in the conceptual
system
Agnosia of object utilisation
Able to recognize objects, but
unable to explain use
Most evident in complex tasks
when using multiple objects
Least evident in routine/simple
tasks
Disturbance of serial ordering of
actions
Often accompanied by
language problems
•
•
•
•
•
•
•
•
Signs
Inappropriate object use
Incorrect order of elements of
activity
Sections of the sequence
omitted
Two or more elements blended
Overshooting of action
Action remains incomplete
After interruption unable to
continue
Perseveration
Ideomotor Apraxia
•
•
•
•
•
•
Network
Disturbance in the production
system
Intact conceptual system
Ability to verbalize task
Automatic vs. non-natural
context
Actions to command/imitating
actions
Timing, direction and force of
movements
•
•
•
•
•
•
•
•
Signs
Spatial orientation errors
Initiation and timing
Poor distal differentiation
Body part as object
Verbalisation
Gestural enhancement
Perseveration
Fragmentary responses
Sensory /
Perceptual
system
Visual / Gestural
Information
Auditory / Verbal
Information
Visual Tool / Object
Information
…..P Route
.…..P Route…..
Conceptual
System
Knowledge of Action
Knowledge of Tool /
Object Function
Response selection
Image generation
Production
System
Working memory
Response
organisation /
control
DI route
CI route
Assessment
Diagnosis: Apraxia
Based on a differential diagnosis of what it is not:
•
Comprehension deficit
•
Muscle weakness
•
Sensory Impairment
•
Tone abnormality
•
Other movement disorder
(Butler, 2002)
Apraxia-How should we assess?
Assessment should include:
1.
2.
3.
4.
5.
Pantomime (transitive & intransitive)
Delayed Imitation (transitive & intransitive)
Concurrent Imitation (transitive & intransitive)
Assessment with the object
Functional Assessment (familiar sequential task, different tasks &
environments)
(Jackson, 1999; Butler, 2002; Zwinkels et al, 2004; Bartolo et al,
2008)
Apraxia-How should we assess?
 How the instruction is given is important
(Bartolo et al, 2003)
 Presentation of blocked meaningful actions then blocked meaningless
actions
(Tessari et al, 2007; Press & Hayes, 2008;
Murray, 2009; Carmo & Rumiati, 2009)
Treatment
A Cure for Apraxia?
•
Recovery of apraxia should not be goal for rehabilitation
•
Treatment involves teaching compensatory techniques for impairments
but does not cure apraxia
•
Will not improve underlying impairments
•
Aims to enable more independent function despite presence of apraxia
•
Minimise extent to which impairment influences performance of daily
life
Buxbaum et al, 2008
Apraxia InterventionEvidence Base
Cochrane Review (Level 1 Evidence)
•
•
•
•
•
•
Strategy training
Sensory stimulation
Proprioceptive stimulation
Cueing, verbal or physical prompts
Chaining (forward or backward)
Normal movement approaches
West et al, 2008
Evidence Base
Evidence Based Review of Stroke Rehab (EBRSR)
“There is strong (level 1) evidence that strategy training is
effective in the treatment of apraxias post stroke. Training
effects may include improvement in performance of ADL‟s that
appear to be sustained over time”
“There is strong (level 1) evidence that gesture training is
associated with improvement in ideomotor apraxia.
Improvements may extend to ADL‟s and these effects may be
sustained for at least 2 months following the end of treatment”
Cicerone et al, 2005;
Salter et al, 2008
What is Strategy Training?
•
•
•
•
•
Focus on teaching ways to compensate for impairment
Compensation can be internal or external
Incorporates errorless learning through practice & repetition
The individual is guided through the tasks but is not allowed to make
errors.
When repeating and practising the task only the „correct‟ sequence of
actions will be learnt to successfully completed the task.
van Heugten et al, 1998
Buxbaum et al, 2008
Evidence for Strategy Training
•
Significant improvement in ADL function through successful teaching of
compensatory strategies (van Heugten et al, 1998)
•
Strategy training used in conjunction with usual OT intervention is more
effective than usual OT alone (Donkervoort et al, 2001)
•
Strategy training of specific activities reduces errors and need for
assistance (Goldenberg et al, 2001)
•
Errors in learning compensatory strategies are disruptive- errorless
learning beneficial (Buxbaum et al, 2008)
Important Considerations
•
•
•
•
•
Therapeutic results are restricted to the trained activity does not
generalise to non-trained tasks
Training needs to be task specific
Tasks must be meaningful to patient and part of daily routine
Environment for training is very important
Limited evidence on transfer of skill/ environment
Goldenberg et al, 1998
Geusgens et al, 2007
What is GestureTraining?
•
•
•
Focuses on training both transitive and intransitive gestures
Transitive training consists of 3 phases:
- shown use of tool
- shown static picture of a portion of action using tool- produce
pantomime
- shown picture of tool – produce associated gesture
Intransitive training:
- shown a picture of context and one of related gesture
- shown context picture – asked to produce gesture
- shown picture of different but related cotextual situation & asked to
reproduce gesture
Buxbaum et al, 2008
Evidence for Gesture Training
•
Significant improvement on measures of ideational and ideomotor
apraxia (Smania et al, 2000)
•
Significant reduction in praxis errors (Smania et al, 2000)
•
Significant increase in gesture comprehension (Smania et al, 2000)
•
Patients and carers reported more independence in ADL‟s after
treatment (Smania et al, 2006)
•
Maintenance of gains shown at 2 months after treatment (Smania et al,
2006)
Clinical Guidelines
•
•
•
•
•
•
•
•
Grade A evidence for effectiveness compensatory strategies
Treatment should focus on functional activities
Activities should be structured
Activities should be practised using errorless learning approaches
Transfer of training is difficult to achieve
Training should focus on specific activities in a specific context, close to
normal routines of patient
Recovery of apraxia should not be goal for rehabilitation
Repetition & practice most utilised approach
European Federation of Neurological Societies: Task Force for Cognitive Rehabilitation
(Cappa et al, 2005)
(Tempest & Roden, 2008)
Summary
• Apraxia & dyspraxia are different-utilisation of correct terminology
• The underlying knowledge and framework of the praxis system remains
poorly understood
• Assess all other modalities first (motor/ sensory/ communication &
baseline cognition)
• Assessment should include pantomime, imitation of transitive/
intransitive gesture presented in blocks of meaningful & meaningless
gesture
• Functional assessment & activity analysis is key
• Utilise model to determine ideational / ideomotor
• Limited transferability of current evidence into pratice
• Utilisation of strategy training & gesture training
• More research is needed into effective treatment for apraxia
Thank You for Listening
Any Questions?
Special thanks to Andrea Ralpothy and Karynka Wulf for the use of a few
slides!
References
•
•
•
•
•
•
•
•
•
Almeida Q, Black S, Roy E. (2002) Screening for apraxia: a short assessment for stroke patients. Brain
Cognition 48(2-3):253-8.
Bartolo A, Cubelli R, Della Sala, Drei S. (2003) Pantomimes are special gestures which rely on working
memory. Brain and Cognition 53:483-494
Bartolo A, Cubelli R, Della Salla S. (2008) Cognitive Approach to the assessment of limb apraxia. The
Clinical Neuropsychologist 22: 27-45
Butler J (1997) Intervention Effectiveness: Evidence from a case study of ideomotor and ideational apraxia.
British Journal of Occupational Therapy 60 (11)
Butler J. (2002) How comparable are tests of apraxia? Clinical Rehabilitation 16: 389-398
Buxbaum L, Haaland K, Hallett M, Wheaton L, Heilman K, Rodriguez A, Gonzalez-Rothi L. (2008)
Treatment of limb apraxia: moving forward to improved action. American Journal of Physical Medicine and
Rehabilitation. 87: 149-161
Carmo J, Rumaiati R. (2009) Imitation of transitive and intransitive actions in healthy individuals. Brain and
Cognition 69: 460-464.
Cappa SF, Benke T, Clarke S, Rossi B, Stemmer B, van Heugten CM. (2005) EFNS Guidelines on
cognitive rehabilitation: a report of an EFNS task force. European Journal of Neurology. 12: 665 -680
Cermak S (1985) Developmental Dyspraxia pp 225-243 In: Advances in Psychology 23:
Neuropsychological studies of apraxia and related disorders Ed EA Roy Elseiver Science Publishers,
Amsterdam
References
•
•
•
•
•
•
•
•
•
•
•
•
Cicerone K, Dahlberg C, Malec J, Langenbahn D, Felicetti T, Kneipp S, Ellmo W, Kalmar K, Giacino J, Harley J,
Laatsch L, Morse P, Catanese J. (2005) Evidence Based Cognitive Rehabilitation: Updated review of the literature
from 1998 through 2002. Archives of Physical Medicine. 86: 1681- 1692
Donkervoort M, Dekker J, Stehmann-Saris FC, Deelman BG. (2001) Efficacy of strategy training in left hemisphere
stroke patients with apraxia: A randomised controlled trial. (2001) Neuropsychological Rehabilitation 11 (5): 549-566
Geschwind N (1975) The Apraxias: Neural Mechanisms of disorders of learned movement. American Scientist 63
188
Geusgens C, van Heugten C, Donkervoort M, van den Ende E, Jolles J, van den HW. (2006) Transfer of training
effects in stroke patients with apraxia: an exploratory study. Neuropsychological Rehabilitation 16: 213-229
Geusgens C, van Heugten, Cooijmans J, Jolles J, van den Heuvel (2007) Transfer effects of a cognitive strategy
training for stroke patients with apraxia
Goldenberg G, Hagmann S (1998). Therapy of Activities of Daily Living in
Patients with Apraxia. Neuropsychological Rehabilitation 8 (2) pp 123-141
Goldenberg G, Daumuller M, Hagmann S. (2001) Assessment and therapy of complex activities of daily living in
apraxia. Neuropsychological Rehabilitation 11 (2) 147-169
Grieve J, Gnanasekaran (2008) Neuropsychology for Occupational Therapists Cognition in Occupational
Performance 3rd edition Blackwell Publishing
Haaland K, Harrington D, Knight R (2000) Neural representations of skilled movement Brain 123 (11) pp 2306-2313
Hanna-Pladdy B, Heilman KM, Foundas AL (2001a) Praxis lateralisation:
errors in right and left hemisphere strokeCortex 37 (4) pp 219-230
Hanna-Pladdy B, Heilman KM, Foundas AL (2001b) Cortical and Subcortical contributions to ideamotor apraxia –
analysis of task demands and error typesBrain 124 (12) pp 2513-2527
Intercollegiate Stroke Working Party (2008) National Clinical Guidelines for Stroke 3rd edition. Royal College of
Physicians.
References
•
•
•
•
•
•
•
•
•
•
•
•
•
Jackson T (1999) Dyspraxia: Guidelines for intervention. British Journal of Occupational Therapy. 62 (7) 321- 326
Makuuchi M, Kaminaga T, Sugishita M (2005) Brain activation during ideomotor praxis: imitation and movements
executed by verbal command. Journal Neurology, Neurosurgery and Psychiatry 76: 25-33
Murray M, De Santis L, Thut G, Wylie G. (2009) The costs of crossing paths and switching tasks between audition
and vision. Brain and Cognition 69: 47-55
Pramstaller P, Mardsen CD (1996)The Basal Ganglia and Apraxia. Brain 119 pp 319-340
Press C, Heyes C. (2008) Stimulus-driven selection routes in imitation. Expert Brain Research 188: 147-152
Rothi LJG, Heilman K, Ochipa C. (1997) A Cognitive Neuropsychological Model of Apraxia in Apraxia: The
Neuropsychology of Action. Psychology Press, USA
Roy EA and Square P (1994) Ch 11: Hand preference, manual asymmetries and limb apraxia. Manual asymmetries
in motor control Eds D Elliott and EA Roy (1996) CRC Press Boca Raton
Smania N, Giraldi F, Domencialli C, Lora E, Aglioti S. (2000) The rehabilitation of limb apraxia: a study in left brain
damaged patients. Archives of Physical Medicine. 81: 379-388
Smania N, Aglioti S, Girardi F, Tinazzi M, Fiaschi A, Cosentino A, Corato E. (2006) Rehabilitation of limb apraxia
improves daily activities on patients with stroke. Neurology. 67: 2050-2052.
Salter K, Teasell R, Bitensky J, Foley N, Bhogal S. (2009) Chapter 12: Cognitive Disorders and Apraxia. The
Evidence Based Review of Stroke Rehabilitation. www.ebrsr.com
Sutherland A, Shinner C (2007) Ideomotor apraxia and functional ability. Cortex. 43, 359-367
Tempest S, Roden P. (2008) Exploring evidence based practice by Occupational Therapists when working with
people with apraxia. British Journal of Occupational Therapy: 71(1) 33-37.
Tessari A, Canessa N, Ukmar M, Rumiati R. (2007) Neuropsychological evidence for a strategic control of multiple
routes of imitation. Brain 130: 111-1126
References
•
•
•
•
•
Van Heugten CM, Dekker J, Deelman BG, van Dijk AJ, Stehmann-Saris JC, Kinebanian A. (1998) Outcome of
strategy training in stroke patients with apraxia: a phase II study. Clinical Rehabilitation 12: 294-303
Van Heugten C, Dekker J, Deelman B, Stehmann-Saris F, Kinebanian A. (1999) A Diagnostic Test for apraxia in
stroke patients : Internal consistency and diagnostic value. The Clinical Neuropsychologist 13 (2) 182-192
West C, Bowen A, Hesketh A, Vail A. (2008) Interventions for motor apraxia following stroke. Cochrane Database of
Systematic Reviews. Issue 1 Art No: CD004132.
Zoltan B (2007) Apraxia (pp109-132) in Vision, Perception & Cognition 4 th Edition. SLACK Incorporated, USA.
Zwinkels A, Geusgens C, van de Sande P, van Heugten C. (2004) Assessment of apraxia :inter-rater reliability of a
new apraxia test, association between apraxia and other cognitive deficits and prevalence of apraxia in a
rehabilitation setting. Clinical Rehabilitation 18: 819-827