MANAGEMENT OF APPAXIA IN STROKE

CONTENTS

1. INTRODUCTION2. ANATOMY3. AETIOLOGY4. PATHO PHYSIOLOGY5. PATHOLOGHY6. CLINICAL MANIFESTATION7. DIAGNOSTIC PROCEDURES8. MEDICAL MANAGEMENT9. ASSESMENT10. TYPE OF APROXIA11. PHYSIO THERAPY MANAGEMENT

i. THERETICAL FRAME WORKii. TREATMENT

12. HOME CARE

13. COMPLICATIONS

14. CASE STUDIES

15. CONCLUSTION

16. BIBLIOGRAPHY

INTRODUCTION

INTRODUCTION

Stroke is a neurological deficit of cerebrovascular cause that persists beyond 24hrs or is interrupted by death within 24hrs

Stroke is the third leading cause of the death and the most common cause of disability among adults 30 to 40% of the survivors after stroke are estimated to have significant disability.

Degree of disability that fallows a stroke depends upon which area of the brain is damaged.

They include motor disability or paralysis, sensory disturbances including pain, problem using or understanding language. [Problem with orientation, memory & emotional disturbances. ]Cognitive & perceptual dysfunctions.

With the resent medical and surgical advances the death rate of primary stroke is reducing drastically and with advances in physiotherapy they are able to overcome the motor disability.

In sub acute stage of stroke, where the recovery is quite rapid and maximum by functional re organization of the CNS (functional induced plasticity) occurs. The stimulation from active rehabilitation and an enriched environment plays an important part in brain repair and recovery. Thus apraxia management at this stage plays a major role in rehabilitation.

But, the main them of rehabilitation is making the person independent, this primary goal is not being attained in the person in whom MIDDLE CEREBRAL ARTERY is involved.

Lesions of the right parietal lobe of the non dominant hemisphere (usually the right hemisphere) typically produce PERCEPTUAL DISSORDERS [Unilateral neglect,

agnosica apraxia and disorganization]

Among the perceptual disorders “APRAXIA” causes disability of “VOLUNTARY LEARNED MOVEMENTS” mainly affecting the UPPER LIMBS as they perform wide range of skilled movements and more complex movements. So, if not treated and neglected person cannot overcome his disability and causes obstacle to fulfill the goal of rehabilitation

Praxis is a Greek word which is used to describe the learned ability to plan and to carry out sequences of coordinated movements in order to achieve an objective.

Praxis means “action based on will” and comes from Greek words for “doing, acting, deed, practice.” (Safire 1989.)

Praxis pertains primarily to the planning of a motor act. It is a process that requires knowledge of actions and of objects, motivation and intention on the part of the person.

It is that ability by which we figure out how much to use our hands in simple task’s [to play with toys, use a pencil, or fork, build a tower, tidy up a room] or up to engage in many “human” occupations.

Practice ability includes three components (Ayres V) 79, 1989)

1. Ideation – forming the idea and knowing what to do

2. 2. Motor Planning: organizing the sequence of movement involved in a task.

3. Execution: carrying out the planned movements, smooth sequence.

Apraxia: a psycho motor defect characterized by the inability to make proper use of a known object.

Apraxia is a neurological disorder characterized by loss of the ability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform the movements.

Researcher’s interest in praxis arose from investigations with adults who had sustained traumatic brain injury, primarily to the left frontal or parietal lobe resulting in the inability to perform voluntary or goal directed actions (Frederick’s and Saladin 1996)

The Aim of the Project The present project is a descriptive study on apraxia in hemiplegics [lesion of the right parietal lobe of non dominant hemisphere.] and is intended to present the identification assessment and its management, which is otherwise causing hindrance to the neurological rehabilitation.

ANATOMY

CIRCULUS ARTERIOSUS OR CIRCLE OF WILLIS

IT IS AN ARERIAL CIRCLE SITUATED IN THE INTERPEDUNCULAR CISTERN at the base of the brain.

It is formed anteriorly by the anterior communicating artery

Anterolaterally by the anterior cerebral arteries,

Laterally by the posterior communication

The middle cerebral artery (MCA) The middle cerebral artery (MCA) is one of the three major paired arteries

that supplies blood to the cerebrum. The MCA arises from the internal carotid and continues into the lateral sulcus where it then branches and projects to many parts of the lateral cerebral cortex. It also supplies blood to the anteriortemporal lobes and the insular cortices.

The left and right MCAs rise from trifurcations of the internal carotid arteries and thus are connected to the anterior cerebral arteries and the posterior communicating arteries, which connect to the posterior cerebral arteries.

The MCAs are not considered a part of the Circle of Willis

BRANCHES:The middle cerebral artery can be classified into 4 parts

M1: The sphenoidals egment, so named due to its origin and loose lateral tracking of the sphenoid bone. Although known also as the horizontalsegment, this may be misleading since the segment may descend, remain flat, or extend posteriorly the anterior (dorsad) in different individuals. The M1 segment perforates the brain with numerous anterolateral central (lateral lenticulostriate) arteries, which irrigate the basal ganglia.

M2: Extending anteriorly on the insual, this segment in known as theinsular segment. It is also known as the Sylvian segment when the opercular segments are included. The MCA branches may bifurcate or sometimes trifurcate into trunks in this segment which then extend into branches that terminate towards the cortex.

M3: The opercular segments and extends laterally exteriorly from the insula towards the cortex. This segment is sometimes grouped as part of M2.

M4: These finer terminal or cortical segments irrigate the cortex. They begin at the external of the Sylvian fissure and extend distally away on the cortex of the brain.

CEREBRUM:

Functional divisions 1. Archi cortex 2. Paleo cortex 3. Neo cortex

Archi cortex: • It is the core of the brain. • It is comprised of the hippocamPai formation, which is involved in learning and memory.• The archi cortex is believed to be phylogenitically ancient.

paleo cortex: • It is the outer layer that sits over the core. • It includes the para hippocampai. gyrus. it relays information between the hippocarnpus and other brain regions.

Neo cortex: • It is the newest part of the brain phylogenitically. • It includes primary motor, sensory and association cortices.

ROLE OF CEREBRUM IN MOTOR CONTROL:

PRIMARY MOTOR AREA: • It is the pre central gyrus where voluntary / conscious movement is initiated. • Cortico spinal tracts originate here.

LESION: • Causes loss of voluntary movement to the contralateral body part. • It may also result in a loss of the ability to implement a specific motor plan.

PRE MOTOR AREA: • Located just anterior to the Primary motor area. • It has a role in motor Planning or praxis LESION: • Causes apraxia or motor Planning difficulties, either the inability to understand the demands of the task or the inability to access the appropriate motor plan.

MOTOR ASSOCIATION AREA: • Also called prefrontal area, located in the anterior frontal lobe. • It has a role in cognitive planning of movement.

LESION: • Causes loss of Storage of motor plans. • Inability to think cognitively about how to carry out a motor task, which was once known before injury or disease.

CORPUS CALLOSUM: • It is the largest commeasure in the brain. • It allows the right and left cerebral hemispheres to communicate with each other. • The corpus callosum arches around the anterior horn of the lateral ventricles.

FUNCTIONS OF CORPUS CALLOSUM

• Fibers in the corpus callosum provide abundant bi directional neural Connections between most of the respective Cortical areas of the two hemispheres except for the anterior portions of the temporal lobes.• One of the functions of corpus callosum and the anterior commeasure is to make information stored in the cortex of one hemisphere available to corresponding cortical areas of the opposite hemisphere.

Etiology Stroke is a rapid loss in brain function due to an alteration in blood supply. Atherosclerosis:-is a major contributory factor in cerebrovascular disease it is

characterized by plaque formation with an accumulation of lipids, fibrin, complex carbohydrates and calcium deposits on arterial walls that leads to progressive narrowing of blood vessels.

The most common sites for lesions to occur are at the origin of the common carotid artery or at its transition into the middle cerebral artery at the main bifurcation of the middle cerebral artery.

Cerebral Thrombosis:-Refers to the formation or development of a blood clot or thrombus within the cerebral arteries or their branches thrombi lead to ischemia or occlusion of an artery with resulting infraction or fissure death

Cerebral embolus (CE):-are travelling bits of matter formal elsewhere that are released into the blood stream and travel to the cerebral arteries where they lodge in a vessel, Producing occlusion and infarction.

Strokes can also be hemorrhagic with abnormal bleeding into extra vascular areas of the brain secondary to aneurysm or trauma

Hemorrhage results in increased intracranial pressure with injury to brain tissues and restriction of distal blood flow.

Intra cerebral hemorrhage (IH):is caused by rupture of a cerebral vessel with subsequent bleeding into the brain

Primary cerebral hemorrhage typically occurs in small blood vessels weakened by atherosclerosis producing an aneurysm

Subarachnoid hemorrhage (SH):- Occurs from bleeding into the subarachnoid space typically from a sacular or berry aneurysm affecting primarily large blood vessels.

Arteriovenous malformation (AVM) is another congenital defect that can result in stroke.

Arteriovenous malformation (AVM)

Risk FactorsModifiable:-

Hypertension Type II Diabetes Obesity Sedentary life style Oral contraceptive use Smoking – Heavy alcohol use

Non – Modifiable:-

Hyper Cholesterolemia MI Age Gender – Males are more affected Race

PATHO PHYSIOLOGY

PATHO PHYSIOLOGY

THE FIRST HORIZONTAL SCHEMA OF LIEPMANN (1900)

A lesion in the left « sensomotorium » (1) gives rise to a left hemiplegia and aphasia and to a motor apraxia of the left hand, due to the absence of information linking the left and right « sensomotorium » via callosal connections

(B). A lesion disconnecting the cortical areas

(C), kinæsthetic images are engrammed, and the left sensomotorium leads to an ideomotor apraxia of the right hand.

SECOND HORIZONTAL SCHEMA OF LIEPMANN (1920),

Lesions resulting in a dyspraxia of the left hand may be localized in the cortical motor representation

(1) (1)in the left hemisphere (L.H.), by interruption of callosal connections

(2, 3) with the right hemisphere (R.H.), or by interrupting connections

(4) Between occipital (C.o.), parietal (C.p.), temporal (C.t.) association cortex and the motor cortex of the left hemisphere.

(2) The right hand is paralyzed after lesions at 1 and 2, whereas a melokinetic apraxia is produced by a less severe lesion at 1a.

(3) A lesion at 4 causes an ideomotor apraxia and more diffuse, posterior lesions produce ideatory disorders. A lesion of the internal capsule

(4) Leads to paralysis of the right hand without dyspraxia of the left hand.

PATHOLOGY

PATHOLOGY

MIDDLE CEREBRAL ARTERY SYNDROME:-

The middle cerebral artery (MCA) is the second of the two main branches of the internal carotid artery and supplies the entire lateral aspect of the cerebral hemisphere (frontal, temporal and parietal lobes) and sub cortical structures, including the internal capsule (Posterior portion) corona radiate, globuspallidus (Otter part) most of the caudate nucleus and the putamen.

Occlusion of the proximal MCA produces extensive neurological damage with significant cerebral edema. Increased intracranial pressures typically lead to loss of consciousness brain herniation and possibly death.

The most common characteristics of MCA syndrome are contralateral apastic hemi paresis and sensory loss of the face upper extremity (UE) and lower extremity (CE) with the face and upper extremity more involved than the lower extremity.

Lesions of the parieto – occipital cortex of the dominant hemisphere (usually left hemisphere) typically produce aphasia.

Lesions of the right, parietal lobe of the non dominant hemisphere (usually the right, hemisphere) typically produce perceptual deficits (unilateral neglect, anosognosia, apraxia and spatial disorganization)

Homonymous hemianopia (a visual field defect,) is also a common finding the MCA is the most common site of occlusion in stroke.

Apraxia has a neurological cause that localizes fairly within the parietal lobe, frontal lobes (especially the pre motor cortex, supplementary motor area, corpus callosum. )

• In planning movements, previously learned, stored complex representative movements are used. These three dimenSi0flal, supram0 codes are stored in the inferior parietal lobule of the left hemisphere.

• It can also occur with lesions in other locations as well. Information contained in praxis representation is transcoded into innervatory patterns by the pre motor cortices, including the supplementary motor area, possibly the convexity of the pre motor cortex.The information is then tranSffl1tt to the prima motor area after which the movement is performed.

• Lesions of sensory motor area or other pre motor Cortices also can cause apraxia, where the knowledge about movement is still present but the ability to perform movement is absent.• The corpus callosum is not known to be involved directly in the performance of skilled movements, significant where the crossing fibres from the right hemisphere to pre motor cortex. • The left hemisphere appears to be superior to right in the control of certain types of complex, sequenced motor acts, if damage is sustained to the left hemisphere, the patient’s ability to acquire and perform tasks involving skilled movements may be impaired. Lesions in the left parietal lobe (normally the dominant one) are likely to produce bilateral apraxia. • Lesions between this region and the left pre central gyres may lead to apraxia of the limbs on the right side, and lesions involving the anterior part of corpus callosum or of the sub cortical white matter on the right side, may cause left sided apraxia. The ability to isolate joint movement or muscle contraction contributes to the stereo typical dominant active motor synergies. This loss of fractionation illustrates that the accurate seletion or sequencing of muscle activation or in activation necessary to perform a task is impaired.In stroke the part of the brain that contains information for previously learned skilled motor activities, has been either lost (or) cannot be acessed. The condition is usually due to an insult to the dominant hemisphere of brain.

Clinical manifestations Signs:

Sudeen weakness, numbness or paralysis of the face, arm or legs on one or both sides of the body.

Sudden blurred vision or blindness in one or boath eyse.

Sudden difficulty in speaking, slurring of sppech or difficulty understanding.

Sudden severe headache with sudden onset that occurs with out apparent reasons.

Sudden loss of balance, dizziness or falling with out any apparent reason.

Symptoms: Pares is of contra lateral face, arm, and leg (leg is least affected)

Sensory impairment over the contra lateral face, arm, and leg (pain, temperature, touch, vibration, position, two-point discrimination, stereo gnosis)

Motor speech disorder (expressive-aphasia telegraphic halting speech) Wernicke’s or receptive aphasia (fluent but often jargon speech, poor comprehension)

Perceptual problems such as unilateral neglect, apraxia, depth perception problems, spatial relation difficulties

Homonymous hemianopia

Loss of conjugate gaze to the opposite side

Ataxia of contra lateral limb(s) (sensory ataxia)

Perceptual problems such as unilateral neglect, apraxias, depth perception problems, spatial relation difficulties.

DIAGNOSIS

Diagnostic Procedures

Blood Tests Includes:complete blood countblood sugar cholesterol fat levelsclotting levels and a check of other elements in the blood : for analysing the leval of risk.

Blood glucose: a raise in blood glucose after a troke increases infarct size and adversely affects functional outcome. This is probably because hyperglycemia exacerbates the anaerobic production of lactic acid in the ischaemic penembra.Electrocardiogram (EKG) – to measure heart rhythm and check for an irregularheart beatUltrasound– a test that uses sound waves to help determine if there are blockagesin the arteries supplying the brain. And systemic problems.MRI Scan – a test that uses magnetic waves to make pictures of structures insidethe headCT Scan – a type of x-ray that uses a computer to make pictures of structuresinside the headMagnetic Resonance Angiography – performed prior to carotid artery surgery todetermine how much the artery has narrowed. Gadolinium, a type of dye, may beinjected into your vein for this testArteriogram - during a conventional arteriogram, a contrast dye is injected andx-ray images are produced to precisely locate the blockage and to determine howmuch of the artery is blocked. This test is usually only done to confirm the needfor surgery.Echocardiogram - an ultrasound test that looks for blood clots and valve abnormalities within the heart.Electroencephalogram (EEG) - a test that can detect seizures by measuring brain waves (used only if a seizure is suspected)

MANAGEMENT

Medical Management

a. Steroids/corticosteroids given in full stomach with antacid or H2 receptorAntagonists.

b. Vitamin B complex – promote restitution of function of neurons which have

reversible damage.

c. Cerebral activator/stimulants – stimulate CNS function.

nootrophil- PIRACETAM

encephabol- PYRITINOL HCl

hydergine- CODERGOCRIN

d. Drugs if it is due to thrombus, give ANTI-COAGULANT

heparin- HEPARIN SODIUM

coamadin- WARFARIN SODIUM

e. anti convulsants in case of seizures.

Insuline in case of hyperglycemia.

Aspirin (300mg daily): immediately after an ischaemic stroke and carries a far lower risk of haemorrhagic complications.

Surgical Management

Endarterectomy – purpose is to remove the atherosclerotic plaque from the inner

lining of the carotid artery.

Extracranial-Incracranial Bypass – bypasses the blocked artery by making a

graft or a bypass from the first artery to the second artery.

Management Of Anteriovenous Malformation - is an interventional therapy to

occlude abnormal arteries or veins and prevent bleeding from the vascular lesions.

Whenever possible the affected vessels are totally removed. The surgeon ligates

the vessels and removes the defect.

Management of Cerebral Aneurism – Aneurysm may be repaired via

craniotomy. Less invasive procedure is interventional Radiology

Management of Intracranial Bleeding – Blood clots are removed via

craniotomy.

NURSING MANAGEMENT

A. Initial nursing objective is to support life and prevent complications.

B. Maintain patient airway and ventilation: elevate head of bed 20 degrees unless

shock is present.

B. Monitor clinical status to prevent complications.

1. Neurological

a. Include assessment of recurrent CVA, increased intracranial

Pressure, hyperthermia.

b. Continued coma: negative prognostic’ sign

2. Cardiovascular: shock and arrhythmias, hypertension.

3. Lungs: Pulmonary emboli.

D. Maintain optimal positioning.

1. During acute stages, quiet environment and minimal handling to prevent

further bleeding.

2. Upper motor lesion--- spastic paralysis, flexion deformities, external rotation

of hip.

3. Position schedule--- 2hours on unaffected side, 20minutes on affected side.

4. Complications common with hemiplegic, frozen shoulder, foot drop.

E. Maintain skin integrity: turn and provide skin care.

F. Maintain personal hygiene: encourage self-help.

G. Promote adequate nutrition, fluid, and electrolyte balance.

1. Encourage self-feeding.

2. Food should be placed in unparalyzed side of mouth.

3. Tube feedings or gastrostomy feeding may be necessary.

H. Administer tube feedings.

I. Promote elimination.

1. Bladder control may be regained within three to five days.

2. Retention catheter may not be part of treatment regimen.

3. Offer urinal or bedpan every two hours day and night.

J. Provide emotional support.

1. Behavior changes as consciousness is regained--- loss of memory, emotional

liability, confusion, language disorders.

1. Reorient, reassure, and establish means of communication.

K. Promote rehabilitation to maximal functioning.

1. Comprehensive program: begins during acute phase and follows through

convalescence.

2. Guidelines to assist client with lesion left hemisphere.

a) Do not underestimate ability to learn.b) Assess ability to understand speech.c) Act out, pantomime communication; use client’s term to communicate; speak in normal tone of voice.d) Divide tasks into simple terms; give frequent feedback.

2. Guidelines to assist client with lesion right hemisphere.

a. Do not overestimate abilities.

b. Use verbal cues as demonstrations; pantomimes may confuse.

c. Use slow, minimal movements and avoid clutter around client.

d. Divide tasks into simple steps; elicit return demonstration of skills.

e. Promote awareness of body and environment on affected side.

ASSESSMENT

NEUROLOGICAL ASSESSEMENT

A. Demo Graphic Data

Name

Age

Gender

Occupation

Address

B.Chief Complaints

The Patient Should Give His Complains In His Simple Words as Completely As Possible

Vital Signs:

Pulse rate:

Blood preasure:

Temperature:

Respiratory Rate:

C.History

a. Present History:-

This Should Consist Information about the Type of Onset, Whether Acute, Sub acute or chronic.

Duration Of The Illness Progression Of The Disorder,Stable,Condition Improving Or Deteriorating Pain Aggravating Factors And Ceasing Factors Any Speech Abnormalities, Any Visual Disturbance Bladder And Bowel Problems Day To Day Function, Home Situation, Mobility, And Self Care.

b. Past History:-

Past History Could Be Includes Patient Has Gone For Any Surgeries, Any Medications For Others Conditions And Whether He Has Any Diseases That Has No Related To Present Condition(I.E.,Diabetes,Hypertension,Allergies Etc.,)And Taking Any Medications For Those Conditions.

D. Pain History:-

Onset

Mode

Type

Side

Site

Durations

Pain Aggravating Factors

Pain Relieving Factors

E. On Observation:-

a. Posture And Attitude Of The Body Partsb. Atrophy Of Musclec. Tropic Changesd. Involuntary Movementse. Swellingf. Certain Abnormal Psychological Features like Depression. Over Excitabilities, Emotional

Liabilities.g. Contractures and Deformities.

F. On Palpation

a. Tendernessb. Warmthc. Crepitusd. Muscle Spasme. Scar: Mobile/Adheref. Edema

G. On Examination

A. Higher Function Testing

Consciousness Memory Intelligence Behavior Orientation To Time, Place Etc.,

B. Cranial Nerve Testing

Cranial Nerve Testing Includes Assessing The

Olfactory Optic Oculomotor Tracheas Trigeminal

Abducence Facial Vestibule Cochlear Glaso Pharyngeal Vagus Accessory Hypoglossal

These Nerves Are Assessed For Their Involvement As Their Affection May Interfere In The Rehabilitation Process.

A) Sensory Examination:- Evaluation Of Sensory Involvement Gives An Indication About The Severity Of The Primary Lesion And Also Determine The Extent Of Improvement In These Patients.

The Following Sensory Involvement Should Be Carried Out:

Superficial: Crude Touch, Fine Touch. Deep: Pressure, Proprioception, Kinesthetic and Vibration Sensation. Cortical Sensation: Tactilelocalization, Localization, Discrimination, Stereognosis.

B) Motor Examination:-

Tone Ram MMT Contractures And Deformities Muscle Girth, Limb Length

H. Reflexes

The Common Deep Reflexes:

Biceps Triceps Ancones Knee Ankle

Superficial Reflexes:

Corneal Reflex Cremastic Reflex Are Tested

I. Balance and Cardinal Assessment

Various Equilibrium And Non Equilibrium Test Should Be Done For Coordination And Romberg Test Should Be Done For Balance Assessment.

J. Posture:

The Posture of the Neurological Disabled Person Should Be Assessed

K. Functional Assessment:

The Activities Of Daily Living Needs To Assess By Barthel Index.

L. Investigations:

M. Diagnosis:

N. List of Problems:

O. Physiotherapy Treatment in Aims, Means

Scale of Assessmen t

Tone Grading:-

O – No Response 1+ - Decreased Response 2+ - Normal Response 3+ - Exaggerate Response 4+ - Sustained Response.

Modified Athwart Scale for Spasticity Grading:-

O – No Increase In Muscle Tone 1 – Slight Increase In Muscle Tone 1+ - Slight Increase In Muscle Tone(Less Than Half Of Rom) 2 – More Marked Increase In Muscle Tone Through Most Of The Rom 3 – Considerer able Increase in Muscle Tone, Passive Movement Difficult. 4 – Affected Parts Rigid In Flexion Or Extension.

Reflex Grading:-

O+ - Absent 1+ - Tone Charge, Slight, Transient with No Movement of Extremities. 2+ - Visible Movement of Extremities. 3+ - Exaggerated, Full Movement Of Extremities 4+ - Obligatory And Sustained Movement, Lasting For More Than 30 Sec.,

Voluntary Control Testing:-

Grade O – No Contraction or Flicker or Initiation.

Grade I – Flickes of Contraction Present or Imitation of Movement.

Grade II – Half Range of Motion in Synergy or Abnormal Pattern.

Grade III – Full Range of Motion in Synergy or Abnormal Pattern.

Grade IV – Initial Half Range Is Performed In Isolation and the Latter Half in Pattern

Grade V – Full Range Of Motion In Isolation But Goes Into Pattern When Resistance Is Offered.

Grade VI – Full Range of Motion in Isolation against Resistance.

Barthel Index

Activity

Feeding:-

O=Unable

5=Needs Help Cutting, Spreding Butter Etc.,

or Required Modified Diet

10=Normal or Independent

Bathing:-

O=Dependent

5=Independent or In Shower

Grooming:-

O=Needs To Help With Personal Care

5=Independent (Face/Hair/Teeth/Shaving)

Dressing:-

O=Dependent

5=Needs Help But Can Do About Half Unaided

10=Independent (Including Buttons, Zips, Laces)

Bowels:-

O=Incontinent (Or Needs To Be Given Enemas)

5=Occasional Accident

10=Continent

Bladder:-

O=In Continent or Cachet Erized and Unable To Mange Alone

5=Occasional Accident

10=Continent

Toilet Use:-

O=Dependent

5=Needs Some Help, But Can Do Something Alone

10=Independent (On and Off, Dressing, Wiping)

Transfers: - (Bed To Chair and Back)

O=Unable, No Sitting Balance

5=Major Help (One or Two People, Physical) Can Sit

10=Minor Help (Verbal or Physical)

15=Independent

Mobility: - (On Level Surface)

O=Immobile or < 50 Years

5=Wheel Chair Independent, Including Corners>50 Years

10=Walks With Help of One Person (Verbal or Physical)>50 Years

Stairs:-

O=Unable

5=Needs Help

10=Independent

TYPES OF APRAXIA

TYPES OF APRAXIA

There are five of apraxia:

1. verbal apraxia 2. buccofacial or oro facial apraxia 3. Limb apraxia, 4. Constructional Apraxia,5. Dressing apraxia.

1. VERBAL APRAXIA: The patient will have trouble in coordinating mouth movements and speech.

2. BUCCO FACIAL OR ORO FACIAL APRAXIA: Difficulty in carrying out movements on the face o demand. For Ex: The patient may not be able to whistle or lick wh his lips.

3. LIMB APRAXIA It is characterized by loss of abilitY to make finely graded precise finger of limb movements. There are six types apraxia: a. Limb kinetic b. IdeomotOr c. Ideational d. Dissociation e. Conduction and f. Conceptual Limb apraxia is usually associated with left brain damage in right handed patients and right brain damage in left handed patients. 4. CONSTRUCTIONAL APRAXIA:

It has to do with the translation of an object from one spatial dimension to another. The defect appears to be in poor conceptualization of the spatial requirements of

certain activities. The person in copying simple pictures or diagrams. When attempting to write there may be crowding and obliquity of the words.

Difficulty with arithmetic may be evident, or telling the time, sewing or constructing a model when copying a figure, one half may be left out.

i The person may be unable to interet maps or find their way about { topographagnosia) There are two types of constructional activities used in assessment Graphic: e. g copying line drawings and drawing to commands.

Assembly tasks: e. g Block and stick designs.

5. DRESSING APRAXIA: it refers to inability to dress one self. It is evaluated functionally by watching patients dress themselves. The dressing problem includes the tasks of dressing the upper part of the body, including Putting on items such as under wear, t-shirts, pullovers, sweaters, shirts, bra’s, cardigans, or dresses, putting on pants, socks, panty, hose, shoes and manipulating fasteners, such as Zippers, buckles, laces, arm into the sleeve Until the end of the sleeve is up to the elbow or Shoulder.

An individual may Place both legs in the se leg hole or may not perceive that one of the leg holes is turned inside out.

An individual may put the right shoe the left foot.

The individual may be unable to tie shoe laces because of difficulty in handling the spatial relations aspects of manipulating shoe strings.

KINETIC OR MOTOR OR INNERVATORY APRAXIA: In this type the patient will be unable to carry out purposeful deliberate acts, usually restricted to one extremity without any motor weakness.

Arnadottir has described movements in patients with motor apraxia as clumsy and inflexible.

Someone with motor apraxia has difficulty in imitating a motor command, sequencing and orienting elements of a task together.

It may be helpful for the therapist to give only general information about the activity goal and leave out the specific instructions.

IDEOKINETIC OR IDEOMOTOR OR CLASSIC APRAXIA: In this type the idea is correctly formulated but plan fails to reach motor expression. It is characterized by diskinesia in which movements in response to commands are awkward and clumsy, and there is an inability to use sensory feed back to correct movement errors.

Simple component movements can be carried out, but not the complex movements requiring a sequence of muscular activities.

Often bilateral and symmetrical.

The patient performs automatic acts normally, such as blowing his nose, shaking hands, pushing back hair etc,and is able to formulate the idea of an act and to describe how it Should be done, but when it comes to carlying out the movement on command, he is unable to do it correctly. There is a common tendency to substitute a body part for the object, for ex: using the index finger as a tooth brush rather than pretending to hold one.

IDEATIONAL OR SENSORY APRAXIA: It involves a disruption in the concept formation of action planning. • The ability to select and organize movements to execute an action is impaired. • The patient with ideational apraxia seems confused, stubborn or unco-operative. • The most striking characteristic of this form of apraxia is the inability to recognize objects and their uses.

SOME OF APRAXIA LIKE SYNDROMES

SOME OF APRAXIA LIKE

SYNDROMES: LID OPENING TYPE OF APRAXIA: Difficulty in opening the eye lids.

GAIT APRAXIA: Difficult in starting to walk.

AMNESTIC APRAXIA: Loss of ability to carry out a movement on command due to in ability to remember the command.

BRUN’S APRAXIA OF GAIT {OR} COGANS OCCULOMOTOR APRAXIA {OR} CONGENITAL OCCULOMOTOR APRAXIA: An absence or defect of horizontal eye movements so that the head must turn and the eyes exhibit nystagmuS in attempts to see an object off to one side.

CALLOSAL APRAXIA: Left hand inability upon verbal command.

APRAXIA ASSESSMENT

A. IDEOMOTOR APRAXIA:-

The good glass and Kaplan test for apraxia is composed of universally known movements, such as blowing, brushing teeth, hammering, shaving and so forth.

It is based on what the authors consider a hierarchy of difficulty for patients with apraxia.

First the patient is told “show me how you would bang a nail with a hammer” if the patient fails to do this or uses his or her first as if it were a hammer. The patient is asked, “pretend to hold the hammer” if the patient fails following this instruction. The therapist demonstrates the act and asks the patient to imitate it.

The patient with apraxia typically will not improve after demonstration but will improve with use of the actual implements.

Ability to correct oneself on following verbal suggestions is considered not indicative of apraxia.

B. The therapist sits opposite the patient the patient is asked to imitate different postures or limb movements

The patient with apraxia is unable to imitate postures

IDEATIONAL APRAXIA:-

The tests for ideational apraxia are essentially the same for ideational apraxias are essentially the same as those for ideomotor apraxia.

The major difference to be expected in response is that the patient with ideomotar apraxia can perform a motor act spontaneously and automatically at the appropriate time but the patient with ideational apraxia is unable to do so.

CONSTRUCTIONAL APRAXIA:-

The patient is asked to copy a drawing of a house, a flower or a clock face, figure depicts typical drawings of a house done by patients with left and right hemisphere lesions.

The patient is requested to copy geometric designs.(circle, Square, T shape)

The patient is instructed to copy block brings, match stick designs or pegboard configurations. Initially only three pieces are used and a progression is made to use more.

Visuoconstructive difficulties found with right and left sided lesions demonstrate qualitative differences in response to the assessment materials, patient with right sided damage tend to draw on the diagonal and neglect the left side of the page.

They draw pieces of the picture without any coherent relationship to each other. Thus their drawings tend to be complex, yet unrecognizable they have immense difficulty with coping or constructing anything in three dimensions, are not helped by the presence of a model or by landmarks in a picture and do not generally improve with practice.

The drawing of patients with left – hemisphere damage are usually more recognizable they are characterized by great simplicity.

Patients with left side lesions draw slowly and hesitatingly are often unable to draw angles and have general difficulty in execution in contrast to that of patients with right hemisphere stroke, their performance often improve with the aid of a model.

The use of landmarks in drawing and with repeated trials short-term visual memory impairment is thought to be associated with constructional apraxia in patients with right – sided lesions verbal and comprehension difficulties, poor manual dexterity and the presence of homonymous hemianopia must be ruled out during assessment for this disorder.

Factors influencing Assessment:-

1. Psychological and emotional status2. Poor judgments3. Anxiety4. Cultural bias5. Pre morbid intellectual ability6. Sensory Assessment

Physiotherapy Management

1. The transfer of training Approach:- The practices in one task with particular requirements will enhance performance on other tasks with similar perceptual demands.

2. Sensory Integrative Approach:-Is an effort to explain the relationship between neural functioning and the behavior of children with sensory motor or learning problem can be defined as the organization of sensation for use.

3. Neuro developmental Approach: - Perception is facilitated during normal infant neuro motor development by the kinesthetic, proprioceptive tactile and vestibular feedback received through normal movement experience.

4. Functional Approach:-Most widely used in treating perceptual dysfunction adults with brain trauma will have difficulty in generalizing and learning from dissimilar tasks.

a. Direct repetitive practice of specific functional skills that are impaired is an efficient means of enhancing the patient’s independence in those specific tasks.

b. Compensation:-Refers to changes that need to be made in the patients approach to tasks.

c. Adaptation:-Refers to alteration that needs to be made in the human and physical environment in order to facilitate relearning of skills.

5. Cognitive Rehabilitation:- focuses on training individuals with brain injury to structure and organized information.

-The functional approach is described as adoptative or compensatory. Key points in this approaches:-

a. Remedial Approach:-Focus on patient’s deficits and attempt to improve functional ability by retraining specific perceptual components of behavior.

b. Facilitation of or training in, underlying skills will enhance the recovery or reorganization of deficient CNS functioning.

Bottom up approaches

6. Adaptive/Compensatory Approach:-

a. Direct training in the functional skills that are deficient.b. Top down approach.

Adaptive Approach Remedial Approach

1. The adult brain has limited potential to 1.The adult brain can repair and Repair and reorganize itself after injury. Reorganize itself after injury

2. Intact behaviors can be used to 2.This repair and reorganization is compensating for ones that are impaired influenced by environmental stimuli.

3. Adaptive retraining can facilitate the 3.cognitive perceptual and sessorimotor substitution of intact behaviors for exercises can promote brain recovery impaired once. and reorganization

4. Adaptive ADLs provide training in 4.Cognitive,percepture and functional behaviors sensorimotor exercises provide

5. Training in specific, essential activities of training in the cognitive and daily living tasks is necessary because perceptual skills needed for those adults with brain injury have difficulty exercised. Seneralizing learning. 5.Remedial training in cognitive and

perceptual skills will be generalized

6. Functional activities require cognitive across all activities requiring those and perceptive skills skills

7. Adaptation and compensation will lead to 6.Functional activities require cognitive improved functional performance. And perceptual skills.

7. Cognitive and perceptual remediation will lead to improved functional performance.

C. Education:-For the patient, family and friends is essential for continuity of care. Feed back is essential in the patient own education should be provided in the form of knowledge of Performance (KP)

TREATMENT:-

IDEOMOTOR APRAXIA AND IDEATIONAL APRAXIA:-

Anderson and Choy suggest the modification of instructional sets as follows: speak slowly and use the shortest possible sentences.

One command should be given at a time and the second command should not be given until the frost task is completed.

When teaching a new task, it should be broken down into its component parts:

o One component is taught at a time, physically guiding the patient through the task if necessary.

o It should be completed in precisely the same manner each time.

o When all the individual units are mastered, an attempt to combine them should be made.

o A great deal of repetition may be necessary family members must be advised to use the exact approach found to be successful in the clinic. Performing activities in as normal an environment as possible is also helpful

Using the sensorimotor approach body parts to enhance the production of appropriate motor response.

Constructional Apraxia:-with the transfer of training approach, the patient is asked to practice coping geometric designs, both by drawing and by building. Initially, simple patterns are used, progressing to the more complex.

Patients with left – hemisphere lesions may benefit from the use of landmarks and then their gradual with drawl as skill improves.

The remedial approach has been criticized by nested for its use of pediatric materials an underlying assumption that the sequence of recovery from brain injury follows the sequence of

normal child development, and the use of treatment materials that closely resemble assessment tools.

HOME CARE HOME CARE Safety measures Should be taken to compensate for weakness, confus deficiencies, or seizures ion, sensonj that may accompany this problem. Participation in normal activities is encouraged. One should have extreme patience with people who have apraxia. Take time to demonstrate tasks and allow enough time for person to perform the task.

Avoid complex directions. Environmental factors at home should be appropriate. Colorful things should be placed, such as toys of multiple colors. Way of communication by the family and parents should be good.

Way of andliflg to patients provides sensory input.

COMPLICATIONS COMPLICATIONS Patients with acquired type of apraxia have to face complications during their training session and it may lead to a high risk of falling. In case of developmental apraxia, children will have problem in following the normal psychological motor and social developmental patterns and they will be always lacking behind when compared to their peer group, if the early treatment session has not been initiated as early as possible.

PROGNOSIS

PROGNOSIS The prognosis for individuals with apraxia varies and depends partly on

the underlying cause.

Some individuals improve significantly while others may show very

little improvement.

Recovery from ideomotor apraxia was better from anterior lesions.

Although less than a third of the patients were followed beyond one-

year, they found improvement occurred beyond six- months.

Age, sex, lesion she, and pe did not seem to be related significantlY to

outcome.

CONCLUSIONPatients who are treated for apraxia in sub acute stage of stroke with physiotherapy

had maximum recovery and more independent and those treated in late stages

developed many perceptual complications like hemineglect thus taking long time

for recovery or sometimes rehabilitation is not successful

Therefore physiotherapy for apraxia in sub acute

stage of stroke preserves manipulative functions of the hand and makes the patient

self dependent.

BIBILOGRAPHY

BIBILOGRAHY • Neuro Science or Rehabilitation Professional -sharonA. Gutmen. • Text book of medical PhysiologyGuyton and Hall. • Stroke rehabilitation -Glen Gillen, Ann Burkhardt • Sensory integration — Theory and practice (2nd edition)- Anita C Bundy, Shelly J. Lane, Elizabeth A. Murray. • occupational therapy for physical dysfunction (5th edition) -CatherineA trombly • Brain and Bannisters -Roger banniser

• physical rehabilitation(4th edition) -Susan B.O’ Sullivan, Thomas J. SchmitZ. • BickerstaffS neurological examination in clinical practice (6th edition) - John Spillane. • pathophySi010g.Y of motor systems Christopher M. Fredericks, Lisa K. Saladin. • NeurO10g-’ examiflatb01 made up easy (2nd GeriafltFthl edition) • eUrOl0g” rehabilitation - Janet Carr, Shephere(t

Web sites:

• WWW.emedicine.corn • vw.medlinePlus.com • www.google.com• www.Msnsearch.corn