Effectiveness of a Functional Rehabilitation Program for Upper Limb Apraxia in Poststroke Patients: A Randomized Controlled Trial

OBJECTIVE

To analyze the effectiveness of a home-based restorative and compensatory upper limb apraxia (ULA) rehabilitation program.

DESIGN

Randomized controlled trial.

SETTING

Neurology Unit of San Cecilio Hospital and 2 private and specialized health care centers.

PARTICIPANTS

Community dwelling participants (N=38) between the ages of 25 and 95 years old (sex ratio, 1:1) with unilateral mild-to-moderate poststroke lesions (time of evolution since stroke, 12.03±8.98mo) and secondary ULA.

INTERVENTIONS

Participants were randomly assigned to an 8-week combined ULA functional rehabilitation group (n=19) 3 days per week for 30 minutes or to a traditional health care education protocol group (n=19) once a month for 8 weeks. Both interventions were conducted at home.

MAIN OUTCOME MEASURES

Sociodemographic and clinical data, Barthel Index (primary outcome), Lawton and Brody Scale, observation and scoring activities of daily living, the De Renzi tests for ideational and ideomotor apraxia and imitating gestures test, recognition of gestures, test for upper limb apraxia , and stroke-specific quality of life scale were assessed at 3 time points: baseline, posttreatment (8wk), and follow-up (8wk).

RESULTS

There were statistically significant differences among the groups regarding ideomotor apraxia, imitating gestures, global recognition of gestures, intransitive gestures, and comprehension of gesture production (P<.05) in favor of the experimental group. However, no statistically significant differences were found between the groups regarding functionality or quality of life (P>.05). Regarding the within-group effect, statistically significant differences were found in all neuropsychological outcomes at posttreatment and follow-up (P<.05).

CONCLUSION

A functional rehabilitation program was found to be superior to a traditional health care education program and resulted in improvements in neuropsychological functioning in ULA poststroke. Conventional education showed an insufficient effect on apraxia recovery. Further studies with larger sample sizes are needed to determine the effect of rehabilitation strategies on functionality and quality of life of poststroke ULA patients.

The course of apraxia and ADL functioning in left hemisphere stroke patients treated in rehabilitation centres and nursing homes

Objective: To study the course of apraxia and daily life functioning (ADL) in left hemisphere stroke patients with apraxia.

Design: Prospective cohort study.

Setting: Rehabilitation centres and nursing homes.

Subjects: One hundred and eight left hemisphere stroke patients with apraxia, hospitalized in rehabilitation centres and nursing homes.

Measures: ADL-observations, Barthel ADL Index, Apraxia Test, Motricity Index.

Results: During the study period of 20 weeks, patients showed small improvements in apraxia (standardized mean differences of 0.19 and 0.33) and medium-sized improvements in ADL functioning (standardized mean differences from 0.37 to 0.61). About 88% of the patients were still apraxic at week 20. Less improvement in apraxia was observed in initially less severe apraxic patients. Less improvement in ADL functioning was found to be associated with more severe apraxia, a more independent initial ADL score, higher age, impaired motor functioning and longer time between stroke and first assessment.

Conclusions: Apraxia in stroke patients is a persistent disorder, which has an adverse influence on ADL recovery.

Functional rehabilitation of upper limb apraxia in poststroke patients: study protocol for a randomized controlled trial

Background

Upper limb apraxia is a common disorder associated with stroke that can reduce patients’ independence levels in activities of daily living and increase levels of disability. Traditional rehabilitation programs designed to promote the recovery of upper limb function have mainly focused on restorative or compensatory approaches. However, no previous studies have been completed that evaluate a combined intervention method approach, where patients concurrently receive cognitive training and learn compensatory strategies for enhancing daily living activities.

Methods/Design

This study will use a two-arm, assessor-blinded, parallel, randomized controlled trial design, involving 40 patients who present a left- or right-sided unilateral vascular lesion poststroke and a clinical diagnosis of upper limb apraxia. Participants will be randomized to either a combined functional rehabilitation or a traditional health education group. The experimental group will receive an 8-week combined functional program at home, including physical and occupational therapy focused on restorative and compensatory techniques for upper limb apraxia, 3 days per week in 30-min intervention periods. The control group will receive a conventional health education program once a month over 8 weeks, based on improving awareness of physical and functional limitations and facilitating the adaptation of patients to the home. Study outcomes will be assessed immediately postintervention and at the 2-month follow-up. The primary outcome measure will be basic activities of daily living skills as assessed with the Barthel Index. Secondary outcome measures will include the following: 1) the Lawton and Brody Instrumental Activities of Daily Living Scale, 2) the Observation and Scoring of ADL-Activities, 3) the De Renzi Test for Ideational Apraxia, 4) the De Renzi Test for Ideomotor Apraxia, 5) Recognition of Gestures, 6) the Test of Upper Limb Apraxia (TULIA), and 7) the Quality of Life Scale For Stroke (ECVI-38).

Discussion

This trial is expected to clarify the effectiveness of a combined functional rehabilitation approach compared to a conservative intervention for improving upper limb movement and function in poststroke patients.

Trial registration

Clinical Trial Gov number NCT02199093. The protocol registration was received 23 July 2014. Participant enrollment began on 1 May 2014. The trial is expected to be completed in March 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-1034-1) contains supplementary material, which is available to authorized users.

Diagnosis and treatment of upper limb apraxia

Upper limb apraxia, a disorder of higher motor cognition, is a common consequence of left-hemispheric stroke. Contrary to common assumption, apraxic deficits not only manifest themselves during clinical testing but also have delirious effects on the patients' everyday life and rehabilitation. Thus, a reliable diagnosis and efficient treatment of upper limb apraxia is important to improve the patients' prognosis after stroke. Nevertheless, to date, upper limb apraxia is still an underdiagnosed and ill-treated entity. Based on a systematic literature search, this review summarizes the current tools of diagnosis and treatment strategies for upper limb apraxia. It furthermore provides clinicians with graded recommendations. In particular, a short screening test for apraxia, and a more comprehensive diagnostic apraxia test for clinical use are recommended. Although currently only a few randomized controlled studies investigate the efficacy of different apraxia treatments, the gesture training suggested by Smania and colleagues can be recommended for the therapy of apraxia, the effects of which were shown to extend to activities of daily living and to persist for at least 2 months after completion of the training. This review aims at directing the reader's attention to the ecological relevance of apraxia. Moreover, it provides clinicians with appropriate tools for the reliable diagnosis and effective treatment of apraxia. Nevertheless, this review also highlights the need for further research into how to improve diagnosis of apraxia based on neuropsychological models and to develop new therapeutic strategies.

Transfer effects of a cognitive strategy training for stroke patients with apraxia

The objective of this study was to evaluate transfer effects of cognitive strategy training for stroke patients with apraxia. During 8 weeks, 29 apraxic patients received cognitive strategy training to teach them how to perform activities of daily living (ADL) as independently as possible. ADL functioning was assessed at the rehabilitation centre at baseline and after 8 weeks of training. In addition, assessment took place at the patients' own homes after 8 weeks of training and 5 months after the start of the training. The performance of both trained and nontrained tasks was observed. Patients performed trained tasks and nontrained tasks at the same level of independency at the rehabilitation centre as well as at home, indicating transfer of training effects. These effects turned out to be stable over time.

Transfer of training effects in stroke patients with apraxia: an exploratory study

The goal of the present study was to examine the transfer of the effects of cognitive strategy training for stroke patients with apraxia from trained to non-trained tasks. In strategy training, the occurrence of transfer is expected as the training programme is aimed, not at relearning specific tasks, but at teaching patients new ways to handle the problems resulting from the impairment. Exploratory analyses were conducted on data previously collected in a randomised controlled trial on the efficacy of the strategy training. A total of 113 left hemisphere stroke patients were randomly assigned to a strategy training group and a group receiving occupational therapy as usual. Assessment of apraxia, motor functioning and activities of daily living (ADL) took place at baseline, after an eight-week treatment period, and five months after baseline. The primary outcome measure consisted of standardised ADL observations of trained and non-trained tasks. The analyses showed that in both treatment groups, the scores on the ADL observations for non-trained tasks improved significantly after eight weeks of training as compared with the baseline score. Change scores of non-trained activities were larger in the strategy training group as compared with the usual treatment group. By using previously collected data we are able to illustrate the potential transfer of treatment effects in a large sample of stroke patients. We found indications for the occurrence of transfer, although the study was not originally designed for the purpose of evaluating transfer. Therefore these results are worth exploring more profoundly. We will further investigate our preliminary conclusions in a new prospective study which is specifically designed to examine the transfer of training effects.

Speed of finger tapping as a predictor of functional outcome after unilateral stroke

OBJECTIVES

To determine (1) if the speed of finger tapping of the hand ipsilateral to the lesion (ie, unaffected hand) remains stable during the first 6 months after stroke and (2) if the speed of finger tapping of the unaffected hand is related to functional outcome after neurorehabilitation, which is of relevance to clinical practice.

DESIGN

Prospective cohort study with measurements at admission to inpatient rehabilitation (t0), 4 weeks after admission (t1), at discharge (t2), and 3 months after discharge (t3).

SETTING

Neurorehabilitation unit of a Dutch rehabilitation center.

PARTICIPANTS

Fifty-seven patients with a unilateral first-ever stroke and 42 spouses (controls) of stroke patients without history of neurologic disorders were administered the finger-tapping test to generate normative scores.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Finger-tapping speed of the ipsilateral hand from the Amsterdam Neuropsychological Test battery. The Barthel Index, Frenchay Activities Index (FAI), and Sickness Impact Profile-68 (SIP-68) were also used as outcome measures.

RESULTS

The speed of finger tapping of the ipsilateral hand improved significantly from t0 (mean, 44.13) to t1 (mean, 47.30, P=.02) but consecutively remained stable until 3 months after discharge. Four weeks after admission, the speed of finger tapping was comparable to the scores of the controls. The speed of finger tapping at admission was significantly correlated with the Barthel Index score at discharge (r=.39) and the FAI score at discharge (r=.32) and follow-up (r=.37) but not with the SIP-68 score (r=.28). Regression analyses showed that the Barthel Index score at discharge could be predicted by the initial Barthel Index score and finger tapping at admission (R(2)=.49); the variance of FAI score at discharge and follow-up was largely explained by the initial Barthel Index score.

CONCLUSIONS

The speed of finger tapping improved over the first 4 weeks postadmission until normative speeds were reached and remained stable during the next 4 months. The speed of finger tapping correlated with functional outcome but not with quality of life; it was a predictor of activity of daily living functioning, although not a strong one. These findings suggest that the speed of finger tapping of the ipsilateral hand is a useful measure of recovery, although other variables such as the initial level of independent functioning are of more importance.

How comparable are tests of apraxia?

OBJECTIVE

To compare commonly used tests for the diagnosis of apraxia.

MEASURES

People with unilateral left hemisphere lesions, diagnosed with apraxia, were compared in their scoring on commonly used tests for apraxia (n = 17).

SETTING

Rivermead Rehabilitation Centre, Oxford, England, a specialist inpatient neurological unit.

RESULTS

Production moment correlations were low, or did not reach significance level between three tests for ideomotor apraxia (r = 0.46 p < 0.05 one-tailed test, r = 0.005 NS, r = -0.23 NS, df = 15). Six of the seventeen apraxic patients scored above cut-off point on one test, but below cut-off point on others, indicating that commonly used tests for apraxia may not be reliable for diagnosis if used singly. Internal consistency within tests was also variable (Cronbach's alpha 0.72, 0.85, 0.85).

CONCLUSION

The commonly used tests for apraxia may identify different people as 'apraxic', possibly by eliciting different aspects of apraxia and identifying potential subtypes of the condition. The use of multiple tests is, therefore, recommended in order to identify people with apraxia. The need for repeat reliability studies for apraxia assessments, together with a search for a 'gold standard' test is apparent.

Sensitivity of different ADL measures to apraxia and motor impairments

OBJECTIVE

To determine whether specifically designed activities of daily living (ADL) observations can measure disability due to apraxia with more sensitivity than the Barthel ADL Index, a conventional functional scale.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation centres and nursing homes.

SUBJECTS

One hundred and six left hemisphere stroke patients with apraxia, hospitalized in rehabilitation centres and nursing homes.

MEASURES

ADL observations, Barthel ADL Index, an apraxia test, Motricity Index, Functional Motor Test.

RESULTS

Multivariate analyses showed that the specific ADL observations were associated with severity of apraxia (and not with motor impairments). The Barthel ADL Index was associated with motor impairments (and not with severity of apraxia).

CONCLUSION

The assessment of disability in stroke patients with apraxia cannot rely only on the Barthel ADL Index. In addition, the specific ADL observation procedure is needed to measure disability due to apraxia.