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Dyspraxia post-stroke

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on 22 September 2013

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Transcript of Dyspraxia post-stroke


An evidence-based case study
Definition & Epidemiology
Praxsis - to perform voluntary, purposeful movement.

Apraxia can be defined as the lack of ability to understand an action or perform an action on command or imitation.

Dyspraxia is when only partial effects of apraxia are evident

(Koski, Iacobon, & Mazziott, 2002)
Apraxia is twice as likely to occur in the left hemisphere than the right.

Based on limited evidence, the incidence of ideational apraxia is ~40% of stroke patients. Ideomotor apraxia presents in 81% of stroke patients.

(Smania, Giradia, Domenicali, Lora, & Aglioti, 2000)
Dyspraxia is a disruption of the cortical pathways that are responsible for acquired, complex movement patterns - specifically, damage to the left inferior partietal lobe.
In some cases, the supplementary motor area or the premotor cortex can be damaged and elicit similar symptoms.
(Chawla, 2013)
Causes of dyspraxia:
Tumour or other mass lesions
CNS infection/inflammation
Multiple Sclerosis

(Chawla, 2013), (Koski, Iacobon, & Mazziott, 2002), (Tidy, 2012)
Sub-types of Apraxia
• Dressing apraxia
• Constructional apraxia
• Conceptual apraxia
• Gait apraxia
• Ideomotor apraxia
• Ideational apraxia
• Speech apraxia

(Chawla, 2013), (Koski, Iacobon, & Mazziott, 2002), (Tidy, 2012)
Assessment of Apraxia
A battery of motor performance tests can be used but no gold standard exists for the diagnosis of apraxia. It is difficult to differentiate between apraxia syndromes as presentation is similar and the essential components of movement and sequencing can be similar.
(Buxbaum, et al., 2008)
Sensory Integration and Praxis Test (SIPT)
Involves 17 tests such as tactile, visual, kinaesthetic and motor tasks. More for a paediatric population, no attainable evidence for use/appropriateness on adult populations.
(Buxbaum, et al., 2008)
De Renzi Apraxia Battery
Imitation tasks, can be performed bedside as no test material is required.
Hasn’t been verified on an appropriate population
(Dovern, Fink, & Weiss, 2012)
Test of Upper Limb Apraxia (TULIA)
Tests the structural and symbolic gestures and therefore neural pathways, includes transitive and intratransitive tasks (with and without objects); a verified tool for apraxia assessment (Dovern, Fink, & Weiss, 2012)
Evidence Based Practice
"Specific therapeutic intervention for motor apraxia following stroke cannot be supported or refuted by results from randomised controlled trial"
(West, Bowen, Hesketh, & Vail, 2009)
Generally there is very limited evidence for the efficacy of physiotherapy in the treatment of post-stroke motor apraxia. The National Stroke Guidelines state that apraxia treatment is best achieved with PT and OT intervention using gesture exercises and strategy training
(National Stroke Foundation, 2010), (West, Bowen, Hesketh, & Vail, 2009)
Gesture Production
pantomime, transitive imitation and association gestures
shown to improve measures of ideomotor and ideational limb apraxia and aphasia
(Smania, Giradia, Domenicali, Lora, & Aglioti, 2000)
Strategy Training
Compensating for deficits using aids or specific strategies after function plateaus.
Shown to be somewhat effective with ideomotor, ideational and gesture comprehension tasks.
(Smania, Giradia, Domenicali, Lora, & Aglioti, 2000)
EBP Summary
The most effective and retained gains in motor performance were in self-care and mobility; essentially tasks that patients are compentant in prior to their stroke
There is very limited evidence to show that apraxia rehabilitation transfers across to new tasks and environments
Based on the neuroplastic model of the brain, large volumes and high repetitions of training are recommended
Only gesture production and strategy training have been shown to be slightly more effective than other treatments
(Buxbaum, et al., 2008), (Chawla, 2013), (Dovern, Fink, & Weiss, 2012), (Koski, Iacobon, & Mazziott, 2002), (Smania, Giradia, Domenicali, Lora, & Aglioti, 2000), (West, Bowen, Hesketh, & Vail, 2009)
Case Study: Mr P
78 y.o. male BIBA to BTH on 13/8/13 with (R) sided weakness. CTB showed a (L) MCA territory infarct and a possible old (R) parietal infarct

Initial Ax:
Completely aphasic
Motor performance: jerky, decreased WB on (R) LL
Reflexes grossly intact
Clonus and 4/4 tone in (R) LL
Nil (R) UL movement

Previously independant with ADLs, assistance with medication and dependant on wife for domestics and community access

Physio Rx:
Part practise
Static balance

Upon D/C:
Bed mobility - 1 x S/B A
STS - 1 x S/B-min A
T/F - 2 x min A, nil aid
Mob - 2 x min A, nil aid // Decreased (R) knee and hip flexion, decreased pelvic rotation, scissor gait
Admitted to MDH on 5/9/13

Physio Rx:
Berg Balance Ax on 11/9/13, score =27/64
LL strengthening; esp (R) hip flexors
Mobilising - litegait
Static balance
Prescription of W/S
Dynamic balance
Berg Balance ReAx on 20/9/13, score 37/64
Current Mobility:
Bed mobility: 1 x S/B A
STS: 1 x S/B A
T/F: 1 x S/B A + W/S
Mob: 1 x S/B-min A + W/S

Buxbaum, L. J., Haaland, K. Y., Wheaton, L., Heilman, K. M., Rodriguez, A., & Gonzalez-Rothi, L. J. (2008, May).
Treatmentof limb apraxia: moving forward to improved action. American Journal of Physical Medicine and Rehabilitation, 87(5), 424-439.
Chawla, J. (23013, May 9). Apraxia and Related Syndromes. Retrieved from Medscape: http:/
Dovern, A., Fink, G. R., & Weiss, P. H. (2012, July). Diagnosis and treatment of upper limb apraxia. Journal of
Neurology, 259(7), 1269-1283.
Koski, L., Iacobon, M., & Mazziott, J. C. (2002). Deconstructing apraxia: understanding disorders of intentional
movement after stroke. Current Opinion in Neurology, 71-77.
National Stroke Foundation. (2010). Australian Government National Health and Medical Research Centre.
Retrieved from Clinical Guidelines for Stroke Management: http://www.nhmrc.gov.au/guidelines/publications/cp126
Mutha, P. K., Sainburgb, R. L., & Haalanda, K. Y. (2010, November). Coordination deficits in ideomotor apraxia during
visually targeted reaching reflect impaired visuomotor transformations. Neuropyschologica, 48(13), 855–3867.
Smania, N., Giradia, F., Domenicali, C., Lora, E., & Aglioti, S. (2000, April). The Rehabilitation of Limb Apraxia: A Study
in Left--Brain-Damaged Patients. Physical Medicine and Rehabilitation, 81, 379-388.
Teasell, R. W., Foley, N. C., Bhogal, S. K., & Speechley, M. R. (2003). An Evidence-Based Review of Stroke
Rehabilitation. Top Stroke Rehabilitation, 10(1), 29-58.
Tidy, Colin. (2012, June 16). Dyspraxia and Apraxia. Retrieved from Patient: http://www.patient.co.uk/doctor
West, C., Bowen, A., Hesketh, A., & Vail, A. (2009). Interventions for motor apraxia following stroke (review). The
Cochrane Collaboration , 1-16.
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