1. 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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2. 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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3. 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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4. 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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5. 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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6. Intervention
Performance breakdown
– initiation, execution and control
– Interventions in a hierarchical order -
instruction, assistance, feedback.
van Heugten et al (1999)
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7. 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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8. Treatment
Using activities in context
Clark et al 1994; Ma H et al 1999
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9. 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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10. Treatment tips
Sensory Stimulation protocol (Butler 2000)
Minimise distractions and verbal
commands
Hand over hand guidance
Educate family and carers
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11. 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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12. 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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13. 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
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