Manual and oral apraxia in acute stroke, frequency and influence on functional outcome: The Copenhagen Stroke Study

Adaptation in the spinal cord after stroke: Implications for restoring cortical control over the final common pathway

Control of voluntary movement is predicated on integration between circuits in the brain and spinal cord. Although damage is often restricted to supraspinal or spinal circuits in cases of neurological injury, both spinal motor neurons and axons linking these cells to the cortical origins of descending motor commands begin showing changes soon after the brain is injured by stroke. The concept of 'transneuronal degeneration' is not new and has been documented in histological, imaging and electrophysiological studies dating back over a century. Taken together, evidence from these studies agrees more with a system attempting to survive rather than one passively surrendering to degeneration. There tends to be at least some preservation of fibres at the brainstem origin and along the spinal course of the descending white matter tracts, even in severe cases. Myelin-associated proteins are observed in the spinal cord years after stroke onset. Spinal motor neurons remain morphometrically unaltered. Skeletal muscle fibres once innervated by neurons that lose their source of trophic input receive collaterals from adjacent neurons, causing spinal motor units to consolidate and increase in size. Although some level of excitability within the distributed brain network mediating voluntary movement is needed to facilitate recovery, minimal structural connectivity between cortical and spinal motor neurons can support meaningful distal limb function. Restoring access to the final common pathway via the descending input that remains in the spinal cord therefore represents a viable target for directed plasticity, particularly in light of recent advances in rehabilitation medicine.

Verbal and oral apraxia in patients with acute stroke: Frequency, relationship, and some risk factors

Verbal and oral apraxia are two possible consequences of stroke. It seems that there are not sufficient studies regarding the frequency of these disorders. This study aimed to evaluate the frequency of Verbal and oral apraxia. In addition, the relationship between apraxia and some variables such as age, gender, and education, as well as the relationship between types of apraxia with each other, and damaged areas of the brain in apraxia of the oral system in Persian-speaking patients with stroke were studied. In this descriptive-analytical study, 42 patients participated using the convenient sampling method. Verbal and oral apraxia were assessed using the oral and verbal apraxia tasks for adults test. Data were analyzed using independent t-test, Chi-square, and Fisher's exact test. The frequency of patients with oral apraxia was 35.7%, those with verbal apraxia was 2.3%, and the combination of both verbal and oral apraxia was 4.7%. People with apraxia were significantly older than those without apraxia. There was not any significant relationship between apraxia and gender, apraxia and education, and oral apraxia with verbal apraxia (p < 0.05). The present study's findings showed the high frequency of post-stroke apraxia and the high rate of its incidence with age.

Buccofacial apraxia in primary progressive aphasia

Buccofacial apraxia (BFA) is associated with nonfluent/agrammatic variant primary progressive aphasia (nfvPPA) as well as with the severity of apraxia of speech (AOS), a core symptom of nfvPPA. However, an association with agrammatism has not been established. The aim of this study was to examine the association between BFA and agrammatism in nfvPPA and to determine differences in atrophic regions in primary progressive aphasia (PPA) with and without BFA. Seventy-four patients with PPA were recruited, including 34, 15, 10, and 15 patients with nfvPPA, semantic variant PPA, logopenic variant PPA, and unclassified PPA, respectively. All patients underwent language examination and BFA evaluations. Voxel-based morphometry (VBM) was performed to determine whether atrophy of a specific lesion correlated with the presence of BFA. BFA was observed in 20 and 3 patients with nfvPPA and unclassified PPA, respectively. In a comparison of patients with nfvPPA with and without BFA, the BFA group showed significantly worse spontaneous speech and writing in the Western Aphasia Battery. The agrammatism ratio or the ratio of agrammatic errors to the total number of particles was higher in the BFA group; however, the severity of prosodic and phonetic components of AOS did not differ between the two groups. VBM showed that the severity of BFA correlated with atrophy of the opercular and triangular areas of the inferior frontal gyrus to a part of the left middle frontal gyrus. BFA has a different anatomical basis from AOS in patients with nfvPPA and that BFA is characterized by more anterior degeneration compared to that of AOS.

The Incidence of Aphasia, Cognitive Deficits, Apraxia, Dysarthria, and Dysphagia in Acute Post Stroke Persian Speaking Adults

Stroke is a major cause of serious disabilities in adults. While communication deficits post stroke are prevalent and disabling, early detection of them is important during acute phase. There is limited data published on the incidence of communication disorders in Persian speaking adults following post stroke to our knowledge. The present study aims to determine the incidence and associated factors of aphasia, cognitive deficits, motor speech disorders (apraxia and dysarthria) as well as dysphagia following acute post stroke in Persian speaking adults. 100 stroke patients were assessed using P-WAB, MMSE, Oral Apraxia test, Informal Dysarthria assessment, and MASA. The data was collected from 2 hospitals in Tehran using convenient sampling for the duration of 1 year. Based on our findings, the incidence of aphasia, cognitive deficits, oral apraxia, dysarthria, and dysphagia was in respectively 61.8%, 76%, 30%, 61%, and 39% of stroke patients during the acute phase. Patients with aphasia were significantly older (mean age, 59.29 vs. 64.95), and had fewer education years (9.21 vs. 5.45) compared to individuals without aphasia (p < .05). Co-occurrence of aphasia and dysarthria, dysphasia, cognitive deficits, and apraxia was in respectively 40%, 31%, 55%, and 25%. Due to the high incidence of neurogenic communication disorders and dysphagia during the acute post stroke, especially in the elderly and the less educated patients, prompt and rapid detection of these deficits and rehabilitation is essential to ameliorate patients' quality of life and social participation, and reduce the comorbidities risk.

The impact of apraxia and neglect on early rehabilitation outcome after stroke

Background

This study aims to characterize the impact of apraxia and visuospatial neglect on stroke patients’ cognitive and functional outcomes during early rehabilitation. Prior work implies an unfavorable effect of visuospatial neglect on rehabilitation; however, previous findings remain ambiguous and primarily considered long-term effects. Even less is known about the impact of apraxia on rehabilitation outcomes. Although clinicians agree on the significance of the first few weeks after stroke for the course of rehabilitation, studies exploring the impact of neglect and apraxia in this early rehabilitation period remain scarce.

Methods

Based on a screening of 515 hospitalized stroke patients from an early rehabilitation ward, 150 stroke patients (75 left-hemispheric strokes, 75 right hemispheric strokes) fulfilled the inclusion criteria and were enrolled in this observational, longitudinal study. The patients’ cognitive and functional statuses were documented at admission to the early rehabilitation ward and discharge. Also, detailed apraxia and neglect assessments were performed at midterm. The predictive values of age and apraxia and neglect severity (as reflected in two components from a principal component analysis of the neglect and apraxia assessments) for cognitive and functional outcomes at discharge were evaluated by multiple regression analyses.

Results

Besides the expected influence of the respective variables at admission, we observed a significant effect of apraxia severity on the cognitive outcome at discharge. Moreover, neglect severity predicted the Early Rehabilitation Barthel Index (Frühreha-Barthel-Index) at discharge. Supplementary moderator analysis revealed a differential effect of neglect severity on the cognitive outcome depending on the affected hemisphere.

Conclusion

Data indicate a strong association between apraxia and visuospatial neglect and early rehabilitation outcomes after stroke.

Speech apraxia and oral apraxia: association or dissociation? A multivariate lesion-symptom mapping study in acute stroke patients

The anatomical relationship between speech apraxia (SA) and oral apraxia (OA) is still unclear. To shed light on this matter we studied 137 patients with acute ischaemic left-hemisphere stroke and performed support vector regression-based, multivariate lesion–symptom mapping. Thirty-three patients presented with either SA or OA. These two symptoms mostly co-occurred (n = 28), except for few patients with isolated SA (n = 2) or OA (n = 3). All patient with either SA or OA presented with aphasia (p < 0.001) and these symptoms were highly associated with apraxia (p < 0.001). Co-occurring SA and OA were predominantly associated with insular lesions, while the insula was completely spared in the five patients with isolated SA or OA. Isolated SA occurred in case of frontal lesions (prefrontal gyrus and superior longitudinal fasciculus), while isolated OA occurred in case of either temporoparietal or striatocapsular lesions. Our study supports the notion of a predominant, but not exclusive, role of the insula in verbal and non-verbal oral praxis, and indicates that frontal regions may contribute exclusively to verbal oral praxis, while temporoparietal and striatocapsular regions contribute to non-verbal oral praxis. However, since tests for SA and OA so far intrinsically also investigate aphasia and apraxia, refined tests are warranted.

Body representation in people with apraxia post Stroke- an observational study

Objective: To investigate how two types of body representation (body schema and body image) were affected in people with and without apraxia following a supratentorial stroke.Design: Observational cross-sectional studySetting: Level 1 Specialist Neurological Rehabilitation UnitParticipants: 30 participants post-stroke diagnosed with (n = 10) and without apraxia (n = 20) according to a modified version of the short Ideomotor Apraxia Test.Interventions: Not applicableMain Outcome Measures: Body schema assessed using the hand laterality recognition test and body part knowledge test; Implicit body image assessed using the sidedness test.Results: Left-sided lesions were more common in the apraxic group. Compared to people without apraxia post-stroke, those with apraxia showed significantly reduced accuracy and longer reaction times on the hand laterality test and fewer correct responses on the body part knowledge test. There was no between-groups difference in the sidedness test.Conclusions: People with apraxia showed deficits in online body representations (body schema) that are used to plan and execute actions. Future research studies could target body schema deficits as an adjunct in the rehabilitation of apraxia.

Technology for maintaining oral care after stroke: considerations for patient-centered practice

PURPOSE

Activities of daily living including oral care may be challenging after stroke. Some stroke survivors are not able to complete oral care independently and need assistance from healthcare professionals and care partners. Poor oral hygiene may impact stroke recovery and rehabilitation possibly incurring issues such as aspiration pneumonia, malnutrition, and social isolation. The objective of this paper is to outline practical ways to apply oral care technology in daily use for stroke survivors.

MATERIALS AND METHODS

We reviewed the literature on i) stroke-related impairments impacting oral care, ii) oral hygiene dental devices, and iii) technology for oral care education.

RESULTS

Oral care activities involve integrated skills in the areas of motivation, energy, planning, body movement and sensation, and mental acuity and health. Post-stroke impairments such as fatigue, hemiparesis, and mental impairments may impact oral care activities. Technology may help survivors and caregivers overcome some barriers. Three types of technologies are available for facilitating post-stroke oral care: i) non-powered tools and adaptations; ii) powered oral care tools, and; iii) electronic aids to guide oral care activities. Particular choices should maximise patient safety and autonomy while ensuring accessibility and comfort during oral care tasks.

CONCLUSION

The available device and technologies may help substantially with the accommodations needed for post-stroke oral care, improving the oral health of stroke survivors. Good oral health confers benefit to overall health and well-being and could enhance recovery and rehabilitation outcomes. Nonetheless, more research is necessary to demonstrate the feasibility and effectiveness of technology in stroke contexts.IMPLICATIONS FOR REHABILITATIONOral care may be challenging after stroke due to patient fatigue, hemiparesis, cognitive impairments, and other impaired body functions.Poor oral hygiene may impact stroke recovery and rehabilitation due to risk of aspiration pneumonia, malnutrition, and social isolation.Powered oral care tools, non-powered tools, and adaptations to non-powered tools are some of the technology available to help overcome post-stroke barriers for oral care.Computer programs and online resources for education and guidance for oral care activities may help improve recommendation uptake and compliance.

Reviewing the limb apraxia concept: From definition to cognitive neuropsychological models

Apraxia is a disorder of learned skilled movements, in the absence of elementary motor or sensory deficits and general cognitive impairment such as inattention to commands, object-recognition deficits or poor oral comprehension. The first studies on apraxia were performed between the late 19th and early 20th centuries, however controversy remains in praxis literature concerning apraxia types, neuroanatomical and functional correlates, as well as assessment and treatment of apraxia. Thus, a critical review of the literature was conducted searching the literature for evidence contributing to a more detailed description of apraxia and its clinical patterns, physiopathology and clinico-anatomical correlations, as well as apraxia assessment.

EVALUATION OF IDEOMOTOR APRAXIA IN PATIENTS WITH STROKE: A STUDY OF RELIABILITY AND VALIDITY

OBJECTIVE

This aim of this study was to determine the reliability and validity of an established ideomotor apraxia test when applied to a Turkish stroke patient population and to healthy controls.

SUBJECTS

The study group comprised 50 patients with right hemiplegia and 36 with left hemiplegia, who had developed the condition as a result of a cerebrovascular accident, and 33 age-matched healthy subjects.

METHODS

The subjects were evaluated for apraxia using an established ideomotor apraxia test. The cut-off value of the test and the reliability coefficient between observers were determined.

RESULTS

Apraxia was found in 54% patients with right hemiplegia (most being severe) and in 25% of left hemiplegic patients (most being mild). The apraxia scores for patients with right hemiplegia were found to be significantly lower than for those with left hemiplegia and for healthy subjects. There was no statistically significant difference between patients with left hemiplegia and healthy subjects.

CONCLUSION

It was shown that the ideomotor apraxia test could distinguish apraxic from non-apraxic subjects. The reliability coefficient among observers in the study was high and a reliability study of the ideomotor apraxia test was therefore performed.

A new account of face apraxia based on a longitudinal study

The aim of this paper is to provide an interpretation of face apraxia which accounts also for the role of right hemisphere lesions. Thirty-one patients with left hemisphere (L/pts) and 31 patients with right hemisphere (R/pts) lesions entered a cross-sectional study to identify those presenting with either lower or upper face apraxia. The 16L/pts and 8R/pts who presented with face apraxia in the acute stage and could be retested 4 months later, were followed up longitudinally. The degree of recovery did not differ between the two groups of patients. The traditional hypothesis of face apraxia based on the presence of a left-sided praxis centre could not account for these findings. A new trade-off model of face praxis resources distributed across the two hemispheres is presented. This model, based on individual differences in the healthy brain, accounts for the presence and persistence of face apraxia in a proportion of R/pts.

[Apraxia--neuroscience and clinical aspects. A literature synthesis]

Apraxic phenomena occur in various neurological conditions. Selective motion control is viewed as the basic capacity to make fine and precise, isolated or independent face or limb movements. Its deficit can indicate limb-kinetic apraxia if it is not explained by paresis, somatosensory deafferentation, or ataxia. The core deficit in ideomotor apraxia could be deficient movement representations, i.e. the combination of invariant features of intrinsic and extrinsic coding for a given movement, which are most important when movements have to be performed outside their typical context. Ideational apraxia would be defined by a semantic deficit related to action. Frontal apraxia is characterised by an action-sequencing deficit. A detailed model is proposed regarding processes relevant to praxis.