therese jackson

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APRAXIA

WORKSHOP

10TH Sept 2010

College of Occupational Therapists

Specialist Section in Neurology

Thérèse Jackson

Consultant Occupational Therapist in Stroke

NHS Grampian

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APRAXIA

`A cognitive motor planning disorder leading to an inability to perform actions in the absence of weakness or sensory loss`

Prevalence – 1/3 of those in rehabilitation centres and nursing homes

Donkervoort 2000

Apraxia can have a negative impact on the performance of activities of daily living (ADL), and that therefore the treatment of apraxia should be incorporated into the rehabilitation programme

Donkervoort, Dekker,Stehmann-Saris, & Deelman, 2001; Foundas et al., 1995; Goldenberg & Hagmann, 1998; Poizner et al., 1997; Saeki et al., 1995; van Heugten, 2001; van Heugten et al., 1998

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Intervention

The core expertise of the occupational

therapist is in the complex interaction

between the person, the environment and

the activity they engage in. (occupational

engagement).

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The Cochrane Collaboration®

A systematic review of the evidence for `Interventions for motor apraxia following stroke (review) 2008, Issue 1

Objective of review – to determine which interventions targeted at motor apraxia reduce disability

Included RCTs of therapeutic Intervention for motor apraxia in stroke – 3 trials, 132 patients

Results – evidence of a small but short lived therapeutic effect in the two studies that reported change in ADLs –effect did not persist in the longer term

Conclusion – insufficient evidence to support or refute the effectiveness of specific therapeutic interventions for motor apraxia after stroke.

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Treatment

van Heugten CM, Dekker J, Deelman BG, van Dijk AJ, Stehmann Saris JC and Kinebanian A (1998) Outcome of strategy training in stroke patients with apraxia, a phase II study : Clinical Rehabilitation: 12 :216 – 225.

Donkervoort M, Dekker J, Stehmann-Saris J, Deelman BG. (2001) Efficacy of strategy training in left hemisphere stroke patients with apraxia; a randomised clinical trial. Neuropsychological Rehabilitation 11(5); 549-566

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Intervention

Performance breakdown

– initiation, execution and control

– Interventions in a hierarchical order -

instruction, assistance, feedback.van Heugten et al (1999)

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Transfer effects

Geusgens C, Van Heugten C, Cooijmans J, Jolles J, and Van den Heuvel W. Transfer effects of a cognitive strategy training for stroke patients with apraxia: An exploratory study Neuropsychological Rehabilitation. 2006, 16(2), 213-229

Geusgens C, Van Heugten C, Donkervoort M, Van den Ende E, Jolles J, and Van den Heuvel W. Transfer of training effects in stroke patients with apraxia. Journal of Clinical and Experimental neuropsychology 2007, 29 (8), 831-841

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Treatment

Using activities in contextClark et al 1994; Ma H et al 1999

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Task specific training (non -generalisation of skills)

Goldenberg & Hagmaan 1998; Wilson 1998

Errorless learning Goldenberg and Hagman 1998

Practice and repetition Goldenberg & Hagmaan 1998; Wilson 1998

Goal directed activity Goldenberg & Hagmaan 1998

Structured tasks Wilson 1998

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Treatment tips

Sensory Stimulation protocol (Butler 2000)

Minimise distractions and verbal

commands

Hand over hand guidance

Educate family and carers

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Tempest S, & Roden P. Exploring evidence based practice by Occupational Therapists when working with people with apraxia. British Journal of Occupational Therapy, 71(1), 33-37

– Most commonly used interventions (over 75%) were :-Activities in context, familiar environment, appropriate time of day for given activity

– Moderate use (45% - 65%) of Physical facilitation, errorless learning, chaining and copying

gestures

– Less than 30%visual imagery, and practice and repetition.

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Landry J, Spaulding S. Assessment and

Intervention with clients with apraxia:

Contributions from the literature. Canadian

Journal of Occupational Therapy 1999 Vol 66 (1)

– Interventions – appropriate methods of instruction

(clear & concise); providing opportunities for

repetition; varying practice demands and conditions;

multi sensory cueing; therapeutic guiding and

modelling; visualisation; teaching compensatory

strategies such as goal orientated verbal strategies;

perform activities in context; cueing; don’t expect

generalisation.

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Treatment tips - MDT

Work as a team

Assess other motor, sensory, cognitive

deficits in detail

Minimise distractions initially

Support and reassurance

Use principles for intervention throughout

interventions as a team