INTRODUCTION

 

Apraxia is a disorder affecting the purposeful execution of learned and meaningful skills. Along with aphasia, agnosia and amnesia, they represent the neuropsychological syndromes in stroke patients¹. A patient with apraxia has difficulty with, or is not able to perform learned and purposeful activities. These disturbances in the organization of voluntary actions are not due to primary motor or sensory impairments. Neither are these difficulties the result of lack of motivation, attention, memory or comprehension².

Patients with ideomotor apraxia (IMA) have inability to correctly perform gesture, pantomimes and imitations, whereas actual use of tools is less affected. Patients with IMA do know what to do, but don’t know how³. The idea or plan of the action is not impaired, but the implementation of the movement plan into proper action execution is disrupted⁴.

Ideomotor apraxia is caused by the disturbance of the relationship between the sites storing images for movements and the sites executing them. Lesion of supramarginal gyrus in the dominant parietal lobe, supplementary motor areas or corpus callosum, results in apraxia^5,6.

Spatial performance in patients with right hemispheric lesions is adversely affected by lesions occurring anywhere in a relatively wide area while patients with left hemisphere damage, with relatively severe damage to a well defined area, show impaired performance on spatial tasks. Thus patients with dominant hemisphere infarction appear to make a quick recovery from hemiparesis, but fail to regain a normal pattern of walking and postural control⁷.

The aim of this study is to examine the presence of ideomotor apraxia in stroke patients and to investigate its impact on functional abilities of such patients.

 

PATIENTS AND METHODS

 

Subjects

Sixty right handed Egyptian stroke patients and fifteen normal healthy subjects participated in this study. Patients had hemiparesis due to ischemic cerebrovascular accident (CVA) in the domain of the carotid system, diagnosed clinically and by computed tomography (CT) or magnetic resonance imaging (MRI) of the brain. They were recruited from the outpatient clinics of the Faculty of Physical Therapy, Cairo University, and Madinet Nasr hospital for Health Insurance in the period from June 2011 to May 2012.

Patients were assigned into two groups:

§   Group A: included 30 patients with right hemiparesis. (16 males and 14 females) with mean of age (51.26±3.67 years), evaluated at three months (A1a) and re-evaluated at 12 months (A1b) of onset of stroke.

§   Group B: included 30 patients with left hemiparesis. (16 males and 14 females) with mean age of (54.06±3.67 years), evaluated at three months (B1a) and re-evaluated at 12 months (B1b) of onset of stroke.

 

Fifteen normal healthy subjects matched in age and sex, were also included as a control group.

Inclusion criteria were: age below 60 years, MMSE > 25, mild degree of spasticity (grade 1 and grade 1 + according to modified Ashwarth scale). The grade of motor power of the hemiparetic limb > grade 3.

Exclusion criteria were hemiparesis due to  causes other than vascular insult age above 60 years, MMSE scores 26, moderate or severe grade of spasticity, grade of motor power < 3, history of previous or recurrent strokes, cognitive problems, medically or psychologically unstable patients.

 

Patients were submitted to:

Thorough clinical assessment including complete medical and neurological examination.

a.        Mini Mental State Examination (MMSE): Only patients with scores more than 25 are included⁸.

b.        Ideomotor apraxia test: This test was used to detect ideomotor apraxia in our stoke patients. The IAT comprises 20 items, divided into 4 categories (facial, upper extremity, instrumental and complex) each containing 5 items. A correct performance was awarded 3 points, insufficient but recognizable performance 2 points, and partially recognizable movements 1 point. When the subject was able to perform correctly only when given an object, 1 point was awarded. Zero points were given when an unrecognizable, irrelevant or no response was obtained, or when a mistake was made in using any object. The maximum score for the test is 60. A score from 57-60 is considered normal, a score from 51-56 is considered boarder line apraxia, and a score below 51 is considered apraxia⁹.

c.        Barthel Index: Barthel Index (BI) consists of 10 items that measure a person’s daily function specifically the activities of daily living and mobility. The assessment was used to determine a baseline level of functioning. The person receives a score based on whether he or she has received help while doing the task. The scores for each of the items are summed to create a total sore. The higher the score, the more independent the person is¹⁰.

Statistical Methods

Data were collected and statistically analyzed using descriptive statistical analysis. The mean value as an average describing the central tendency of the observations, the standard deviation (SD) as a measure of the dispersion of the result around the mean, independent T-test was used to compare the measurement outcome between two groups, one way analysis of variance (ANOVA) to compare the measurement outcome between more than two groups and post hoc to compare each subgroups with each other and with normal controls.

Pearson correlation (r) to study correlation between the IAT scores and BI scores, and correlation of there scores with age and sex of patients.

The difference between parameters was considered statistically significant if the probability (p) value is <0.05, highly significant when (p) value is <0.001 and non significant when (P) value is >0.05¹¹.

 

RESULTS

 

Statistical significant lower mean score of IAT and BI between groups (A1a, A1b) and controls (Table 2).

 

Post-hoc Test revealed

A statistically significant difference was detected between groups A1a, A1b and control group (group C) as regards mean scores of IAT and BI. After posthoc: Significant lower mean score of IAT and BI was found in group A1a compared to groups A1b and controls (p=0.004, 0.0001, 0.0001 respectively).

A significantly lower mean score of IAT and BI was detected in group A1b compared to group C (p=0.002, 0.0001 respectively) (Tables 2 and 3).

Statistical significant lower mean scores between groups B1a, B1b and controls

 

Post-hoc test revealed

A statically significant difference was detected between groups B1a, B1b and control group (group c) as regards mean scores of IAT and BI. After post –hoc: significantly lower mean scores of IAT and BI in group B1a compared to groups B1b and group C (p=0.01, 0.03, 0.001 respectively).

No significant difference between mean scores of IAT in group B1b compared to group C (p=0.74, 0.38 respectively). While statistically significant difference between their mean scores of BI with lower mean in B1b.

 

Comparison between groups (A1a) and (B1a):

               A statistically highly significant difference was detected between groups (A1a) and (B1a) as regards the mean scores of IMAT and B1 being significantly lower in group (A1a) compared to (B1a) (p=0.0001).

Comparison between groups (A1b) and group (B1b):

               A statistically highly significant difference was detected between groups (A1b) and (B1b) as regards the mean scores of IAT and B1 significantly lower in group (A1b) (p=0.0001).

 

Correlations:

No significant correlation was found between age of right or left hemiparetic patients with the scores of IAT, (P = 0.51 and 0.64 respectively) (Figure 2).

 

 

No significant correlation was found between age of right or left hemiparetic patients and scores of BI test (P= 0.68, 0.78 respectively) (Figure 3).

               No significant correlation was detected between sex and IAT scores in the patients groups A and B (P = 0.27 and 0.22 respectively).  (Fig. 4). Moreover, no significant correlation was detected between sex and BI scores in groups A and B (p=0.07, 0.14 respectively).

No significant correlation was found between sex and BI scores in the patients groups (A and B) (P = 0.07 and 0.22 respectively) (Table 6 and Figure 5).

Table 1. Age and sex distribution among the study groups.

 

Groups	Age		P-value	Sex
	Mean	SD		Male	Female
Group (A)	51.26	4.96	0.42	8	7
Group (B)	54.06	3.67		9	6
Group (C)	53.2	4.94		6	9

 

Table 2. Comparison of IAT and BI scores between groups (A1a, A1b) and control group.

 

Groups	IAT		P-value	BI		P-value
	Mean	SD		Mean	SD
Group A1a	21.26	11.06	0.0001*	47.8	11.35	0.0001*
Group A1b	30.73	9.45		76.13	9.16
Group C	59.66	0.48		100.0	0.0

* Significant at P<0.01

 

Table 3. Posthoc test for comparison of IAT and BI Scores between group A & C.

 

Groups	IAT		BI
	Mean	P-value	Mean	P-value
A1a Vs A1b	9.46	0.004*	28.33	0.004*
A1a Vs C	38.4	.0001*	52.2	.0001*
A1b Vs C	28.93	.0001*	23.86	.0001*

* Significant at P<0.01

 

Table 4. Comparison of IAT and BI scores between groups (B1a, B1b, B2 and C).

 

Groups	IAT		P-value	BI		P-value
	Mean	SD		Mean	SD
B1a	52.06	9.9	0.009**	64.66	11.2	0.0001*
B1b	57.73	3.32		92.4	6.7
C	59.66	0.48		100.0	0.0

* Significant at P<0.01

 

Table 3. Posthoc test for comparison of IAT and BI Scores between group B & C.

 

Groups	IAT		BI
	Mean	P-value	Mean	P-value
B1a Vs B1b	5.66	0.01*	27.3	0.0001*
B1a Vs C	7.6	.0001*	35.33	0.0001*
B1b Vs C	1.93	0.38	7.6	0.0002*

* Significant at P<0.01

 

 

Figure 1. Comparison of IAT MEAN SCORES BEYWEEN GROUPS (A1a) and (B1b).

 

 

Table 4. Comparison of mean scores of IAT between groups (A1b) and (B1b).

 

IAT	Group (A1b)	Group (B1b)
Mean	30.73	57.73
±S.D	9.45	3.32
Mean difference	27.0
t-value	10.43
p-value	0.0001*

SD standard deviation,  

* Significant at P<0.01

 

 

 

Figure 2. Correlation between age and IAT scores in group A

 

 

 

Figure 3. Correlation between age and BI scores in group B

 

 

 

 

Figure 4. Correlation between sex and IAT scores in group A

 

 

Table 5. Correlation between sex and IAT scores in group A.

 

	Correlation coefficient
R-value	-0.33
P-value	0.22
S	NS

* R-value: correlation coefficient, P-value: probability, S: significance, NS: no significant

Table 6. Correlation between sex and IAT scores in group B

 

	Correlation coefficient
R-value	+0.46
P-value	0.07
S	NS

*R-value: correlation coefficient, P-value: probability, S: significance, NS: no significant

 

 

 

 

Figure 5. Correlation between sex and BI scores in group B.

 

 

DISCUSSION

 

It has been shown that specific areas of neuropsychological impairment are predictive of functioning and independence at discharge from acute stroke rehabilitation ⁽¹²⁾. Apraxia and pathological emotional reactions were found to be the most important predictors of dependency in left-hemisphere and right hemisphere stroke patients respectively¹³.

In present study, ideomotor apraxia was found in 14 patients (93.3%) with left hemispheric stroke evaluated at 3 and 12 months of stoke onset. On the other hand in right hemispheric stroke patients ideomotor apraxia was detected in: 4 patients (26.6%) evaluated at 3 months of stoke onset and one patient (6.7%) evaluated at 12 months of stroke onset. Moreover, in right hemispheric stroke patients, border line apraxia was found in 3 patients (20%) evaluated at 3 and 12 months of stroke onset. These results agreed with De Rienzi (1989); Donkervoot et al. (2000), who found that ideomotor apraxia is a common consequence of left hemisphere damage

Owing to the dominance of the left hemisphere on motor control planning.

In the present study, the mean IMA scores were significantly lower in left hemispheric stroke patients compared to right hemispheric stroke patients and control subjects, however the mean IAT scores of right hemispheric stroke patients were significantly lower compared to control only for those assessed at 3 months of stroke onset. These finding showed that ideomotor apraxia disorder is persistent and enduring in left hemispheric stroke patients even after 12 month of stroke onset, while improvement and even recovery can occur after 12 months for right hemispheric stroke patients. Our results supported the findings of Donkervoort et al.¹⁴, who reported that about 88% of left hemispheric stroke the patients were still apractic after 20 weeks which negatively influenced ADL functioning. Moreover, Donkervoort et al.¹⁵, concluded that apraxia is a persistent disorder and may not recover spontaneously especially in left hemispheric stroke patients.

Abnormality in imitation of gestures was detected in 20% of right hemispheric stroke patients and 50% of left hemispheric patients. These findings agreed with Sunderland et al.¹⁶, who found impaired gesture imitation in 66% of left hemispheric stroke cases while a marginal impairment was seen in 13% of right hemispheric stroke. This solid evidence of a high incidence of IMA after left hemisphere damage gives impetus to theoretical and clinical researchers that we are not dealing with some rare or non-specific disorder but a common selective deficit whose nature and clinical implications need to be fully understood.

Using a qualitative error system, we found that differential patterns of recovery for intransitive gestures (i.e. gestures not requiring a tool or object, such as "waving goodbye") and transitive gestures (i.e. gestures requiring tool use),as there is a decrease in the number of content errors for intransitive gestures, While spatial and temporal errors were persistent for transitive gestures. Our result agreed with Raymer et al.⁴, who found that for intransitive gestures there was a spontaneous decrease in the number of content errors, whereas for transitive gestures there was a spontaneous decrease in the number of unidentifiable production errors. But spatial and temporal errors were found to be persistent. They concluded that in the natural course of recovery from apraxia, if performance improves, it is in the areas of meaning and recognition of gestures.

The functional assessment of stroke patients is critical for treatment- rehabilitation and management planning. One of the major goals of treatment-rehabilitation is to allow patients to live independently. To be independent, persons must be able to care for themselves and perform ADL that require learned skilled motor interactions with the environment^17,18.

Apractic patients displayed significant dependency in bathing, toileting and grooming especially in left hemispheric stroke patients. However, this study failed to establish a relationship between apraxia and dependence in either ambulation or dressing which are two major rehabilitation targets for stroke patients. Our results were in agreement with Kimura¹⁹, who found that stroke patients with IMA were able to dress independently if they had sufficient power in their paretic limb. Baum and Hall²⁰, also suggested that inability to dress independently is related to perceptual deficits instead of deficits in skilled movements.

In the present study, dependency in feeding was not reported by caregivers of patients with IMA a finding which agreed with Foundas et al.²¹.

It is not clear if specific effects of IMA can be observed in the case of more complex naturalistic tasks. Goldenberg et al.²², studied V/ tasks such as changing the batteries in a tape recorder. They found that left hemi-paretic patients with IMA exhibited more difficulties in performing the task than patients without apraxia, who in turn were impaired compared to controls. They suggested that IMA may act as an additional factor, augmenting the difficulties caused by left hemisphere damage alone, but acknowledged the alternative possibility that the greater deficit in the apractic cases might reflect a non-specific depletion of cognition and concluded that such complex naturalistic tasks may display "cognitive opacity". In other words, the complexity of the interaction between actor and environment may be such that we are unable to detect the impact of specific neuropsychological deficits] A similar conclusion was reached by Stewart et al.¹¹, who studied tasks such as making a packed lunch and found a similar pattern of errors in normal controls and in those with right or left hemisphere brain damage.

On the contrary, Goldenberg and Hagmann²³, studied aphasic patients as they carried out 3 ADL tasks - buttering bread, donning and doffing a T-shirt, and cleaning teeth. Only 25% of the sample were able to complete the tasks without error, and 17% were unable to complete any task. The total frequency of errors (content and accuracy combined) correlated significantly with tests of imitation or pantomime but was only weakly related to severity of aphasia, suggesting a specific impact of IMA.

Walker et al.²⁴, came to similar conclusions regarding the impact of IMA on basic ADL tasks — when a motor task such as dressing can be completed using an over-learned strategy then the apractic patient may be successful, whereas if hemiparesis demands discovery of a new compensatory strategy then IMA will present a barrier. This interaction between hemiparesis and apraxia may explain why IMA has not emerged as a simple correlate of dressing ability in other studies^25,26.

For a long time, researchers believed that apraxia only occurred when performance was requested in testing conditions, and that patients would act correctly when performing spontaneously in a natural context ^{(27, 28)}. This would suggest that there is no negative influence of IMA on daily life activities. However, Sundet et al.⁽¹³⁾ found that apraxia variables were significant predictors of subsequent dependency.

The present work provides a preliminary evidence of the adverse effect of IMA on activities of daily living of stroke patients. The demonstration that IMA might be a major source of disability suggests that its rehabilitation might be an important part of post-stroke therapy. Consequently, management of IMA should be taking into consideration in post-stroke rehabilitation in order to improve the functional outcome of stroke patient

In conclusion ideomotor apraxia is a common consequence of ischemic CVS especially those affecting the left cerebral hemisphere. It might be a major cause of disability as it has adverse impact on activities of daily living of stroke patients. Consequently, IMA should be taken into consideration when planning rehabilitation program for stroke patient in order to improve their functional outcome.

 

[Disclosure: Authors report no conflict of interest]

 

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