Rehabilitation of limb apraxia in patients following stroke: A systematic review.

Apraxia is widely used to describe one of the more disabling deficits following left strokes. The role of rehabilitation in treating apraxic stroke patients remains unclear. This systematic review was conducted to study the impacts of various rehabilitation interventions on the limb apraxia post-stroke. PubMed, SCOPUS, PEDro, CINAHL, MEDLINE, REHABDATA, and Web of Science were searched for the experimental studies that investigated the effects of the rehabilitation interventions on apraxia in patients with stroke. The methodological quality was rated using the Physiotherapy Evidence Database scale (PEDro). Six studies met our inclusion criteria in this systematic review. Four were randomized controlled trials, pilot (n = 1), and case study (n = 1). The scores on the PEDro scale ranged from two to eight, with a median of seven. The results showed some evidence for the effects of strategy training and gesture training interventions on the cognitive functions, motor activities, and activities of daily livings outcomes poststroke. The preliminary findings showed that the effects of the strategy training and the gesture training on apraxia in patients with stroke are promising. Further randomized controlled trials with long-term follow-ups are strongly needed.

Effectiveness of a Functional Rehabilitation Program for Upper Limb Apraxia in Poststroke Patients: A Randomized Controlled Trial.

OBJECTIVE: To analyze the effectiveness of a home-based restorative and compensatory upper limb apraxia (ULA) rehabilitation program. DESIGN: Randomized controlled trial. SETTING: Neurology Unit of San Cecilio Hospital and 2 private and specialized health care centers. PARTICIPANTS: Community dwelling participants (N=38) between the ages of 25 and 95 years old (sex ratio, 1:1) with unilateral mild-to-moderate poststroke lesions (time of evolution since stroke, 12.03±8.98mo) and secondary ULA. INTERVENTIONS: Participants were randomly assigned to an 8-week combined ULA functional rehabilitation group (n=19) 3 days per week for 30 minutes or to a traditional health care education protocol group (n=19) once a month for 8 weeks. Both interventions were conducted at home. MAIN OUTCOME MEASURES: Sociodemographic and clinical data, Barthel Index (primary outcome), Lawton and Brody Scale, observation and scoring activities of daily living, the De Renzi tests for ideational and ideomotor apraxia and imitating gestures test, recognition of gestures, test for upper limb apraxia , and stroke-specific quality of life scale were assessed at 3 time points: baseline, posttreatment (8wk), and follow-up (8wk). RESULTS: There were statistically significant differences among the groups regarding ideomotor apraxia, imitating gestures, global recognition of gestures, intransitive gestures, and comprehension of gesture production (P<.05) in favor of the experimental group. However, no statistically significant differences were found between the groups regarding functionality or quality of life (P>.05). Regarding the within-group effect, statistically significant differences were found in all neuropsychological outcomes at posttreatment and follow-up (P<.05). CONCLUSION: A functional rehabilitation program was found to be superior to a traditional health care education program and resulted in improvements in neuropsychological functioning in ULA poststroke. Conventional education showed an insufficient effect on apraxia recovery. Further studies with larger sample sizes are needed to determine the effect of rehabilitation strategies on functionality and quality of life of poststroke ULA patients.

Rehabilitation of Alien Hand Syndrome Complicated by Contralateral Limb Apraxia.

A previously independent 66-yr-old right-handed man presented with right-sided weakness, preferring the lower limbs with additional impaired gait and dysarthria for 1-day duration. Imaging found a large left hemispheric anterior cerebral artery ischemic infarction with multiple lacunar infarcts. He exhibited frontal, callosal, and posterior variants of alien hand syndrome, which impeded activities of daily living. Though limited in evidence, a trial of clonazepam was initiated based on previous case reports describing suspected efficacy. Botulinum toxin A was not used given the patient's immediate need and limited hospital length of stay. Right upper limb constricting therapies improved intermanual conflict and spontaneous grasping and levitation (arm elevation in retroflexion) activity; however, concomitant left upper limb motor apraxia complicated task-oriented activities. The combination of pharmaceutical and therapeutic interventions improved the patient's quality of life as assessed by clinical observation, functional independence measures from 41 to 57, and patient reporting. This case report aims to increase awareness of a potential barrier to rehabilitation of a debilitating and rare condition and to discuss current assessment tools and treatment options supported by available evidence.

Teaching Undergraduate Clinicians Empirically Supported Practices for Preschool Vocabulary Instruction.

Purpose To incorporate evidence-based practice into clinical settings, there is a need for efficient, effective ways to share information from research to speech-language pathologists (SLPs) and to students preparing to become SLPs. The purpose of this study was to implement and evaluate a method for teaching undergraduate student clinicians to use empirically supported practices in vocabulary instruction during shared storybook reading with preschoolers. Method Undergraduate students enrolled in a semester-long preschool practicum participated in the study. In Study 1, 11 students participated in a multiple-baseline, single-case design. In Study 2, an additional 10 students were included in a quasi-experimental group design. All students completed prerecorded, online teaching modules that taught empirically supported practices for teaching vocabulary during shared storybook reading. Half of the students received weekly e-mails with performance feedback. Targeted practices included selection of appropriate vocabulary targets, explicit teaching, and use of interactive teaching strategies. Results In Study 1, treatment effects were observed for targeted practices for many of the student clinicians. In Study 2, group comparisons indicated an effect of e-mail performance feedback for 1 of 3 outcomes with a large effect size. Conclusion Prerecorded teaching modules may be an efficient, effective way to teach specific empirically supported practices to undergraduate student clinicians. E-mail feedback might improve use of taught practices for some students or for some practices. Future studies can examine the potential of these types of teaching modules for other outcomes or with groups of practicing SLPs.

Single Session Transcranial Magnetic Stimulation Ameliorates Hand Gesture Deficits in Schizophrenia.

Social interaction is impaired in schizophrenia, including the use of hand gestures, which is linked to poor social perception and outcome. Brain imaging suggests reduced neural activity in a left-lateralized frontoparietal network during gesture preparation; therefore, gesturing might be improved through facilitation of left hemispheric brain areas or via disruption of interhemispheric inhibition from the right homolog. This study tested whether repetitive transcranial magnetic stimulation (rTMS) protocols would improve gesture performance in schizophrenia. This randomized, placebo-controlled, double-blind, crossover trial applied 3 different protocols of rTMS separated by 48 h. Twenty right-handed schizophrenia patients and 20 matched healthy controls received facilitatory intermittent theta burst stimulation (iTBS) over the left inferior frontal gyrus (IFG), inhibitory continuous theta burst stimulation (cTBS) over right inferior parietal lobe (IPL), and placebo over left IPL in randomized order. Primary outcome was change in the test of upper limb apraxia (TULIA), rated from video recordings of hand gesture performance. Secondary outcome was change in manual dexterity using the coin rotation task. Participants improved on both tasks following rTMS compared with baseline. Only patients improved gesture performance following right IPL cTBS compared with placebo (P = .013). The results of the coin rotation parallel those of the TULIA, with improvements following right IPL cTBS in patients (P = .001). Single sessions of cTBS on the right IPL substantially improved both gesture performance accuracy and manual dexterity. The findings point toward an inhibition of interhemispheric rivalry as a potential mechanism of action.

Effect of object substitution, spontaneous compensation and repetitive training on reaching movements in a patient with optic ataxia.

We report the case of M.B. who demonstrated severe optic ataxia with the right hand following stroke in the left hemisphere. The clinical picture may shed light on both the pathological characteristics of reaching and grasping actions, and potential rehabilitation strategies for optic ataxia. First, M.B. demonstrated a dissociation between severely impaired reaching and relatively spared grasping and tool use skills and knowledge, which confirms that grasping may be more intermingled with non-motoric cognitive mechanisms than reaching. Besides, M.B.'s reaching performance was sensitive to movement repetition. We observed a substitution effect: Reaching time decreased if M.B. repeatedly reached toward the same object but increased when object identity changed. This may imply that not only object localization but also object identity, is integrated into movement programming in reach-to-grasp tasks. Second, studying M.B.'s spontaneous compensation strategies ascertained that the mere repetition of reaching movements had a positive effect, to the point M.B. almost recovered to normal level after an intensive one-day repetitive training session. This case study seems to provide one of the first examples of optic ataxia rehabilitation. Reaching skills can be trained by repetitive training even two years post-stroke and despite the presence of visuo-imitative apraxia.

Recast type, repair, and acquisition in AAC mediated interaction.

The present study investigated the effects of different types of recasts and prompts on the rate of repair and spontaneous use of novel vocabulary by eight children with severe motor speech disabilities who used speech-generating technologies to communicate. Data came from 60 transcripts of clinical sessions that were part of a conversation-based intervention designed to teach them pronouns, verbs, and verb inflections. The results showed that, when presented alone, interrogative choice and declarative recasts led to the highest rates of child repair. The results also showed that when children were presented with recasts and prompts to repair, the rate of repair increased. Spontaneous use of linguistic targets was significantly and positively related to conversational sequences where the adult recast was followed by child repair. These findings suggest that using different recast types and prompts to repair may be beneficial for spontaneous use of linguistic targets in this population.

A combined therapy for limb apraxia and related anosognosia.

Left hemisphere stroke frequently leads to limb apraxia, a disorder that has been reported to impact independence in daily life and rehabilitation success. Nonetheless, there is a shortcoming in research and availability of applicable trainings. Further, to date, anosognosia for limb apraxia has largely been neglected. Therefore, we developed a Naturalistic Action Therapy that trains object selection and application with an errorless learning approach and which includes supported self-evaluation. The current study presents the results of two stroke patients participating in the training. The procedure entailed two baseline and one post-training sessions including standardized limb apraxia and anosognosia assessments as well as 18 naturalistic action tasks. The training consisted of 15 sessions during which 4-6 of the 18 naturalistic action tasks (e.g., pour water into a glass, make a phone call) were trained. Both patients showed improvement in trained and untrained tasks as well as in standardized apraxia and anosognosia assessments. Training effects appeared strongest for the trained items. The procedure is documented in detail and easy to administer and thus may have the potential to be applied by relatives. The results of this pilot-study are promising and suggest that the approach is suitable for further evaluation.

Automated Speech Recognition in Adult Stroke Survivors: Comparing Human and Computer Transcriptions.

OBJECTIVE: Speech sound errors are common in people with a variety of communication disorders and can result in impaired message transmission to listeners. Valid and reliable metrics exist to quantify this problem, but they are rarely used in clinical settings due to the time-intensive nature of speech transcription by humans. Automated speech recognition (ASR) technologies have advanced substantially in recent years, enabling them to serve as realistic proxies for human listeners. This study aimed to determine how closely transcription scores from human listeners correspond to scores from an ASR system. PATIENTS AND METHODS: Sentence recordings from 10 stroke survivors with aphasia and apraxia of speech were transcribed orthographically by 3 listeners and a web-based ASR service. Adjusted transcription scores were calculated for all samples based on accuracy of transcribed content words. RESULTS: As expected, transcription scores were significantly higher for the humans than for ASR. However, intraclass correlations revealed excellent agreement among the humans and ASR systems, and the systematically lower scores for computer speech recognition were effectively equalized simply by adding the regression intercept. CONCLUSIONS: The results suggest the clinical feasibility of supplementing or substituting human transcriptions with computer-generated scores, though extension to other speech disorders requires further research.

The emergence of clause construction in children who use speech generating devices.

This study aimed to detect patterns in clause construction structural changes produced by four participants aged 9;5-13;7 (years;months) with motor speech disorders who used speech-generating devices. Sequences of adult-child interactions, drawn from the data of a larger study focused on enhancing vocabulary and grammar skills, were examined. This current study comprises a secondary analysis of a corpus of 29 conversations totalling 808.36 min, analysing clause structures by type, linguistic complexity, and intensity of adult prompts (number of turns). Results show that, over time, the participants' clause structure complexity increased through addition of phrase-internal elements such as inflections, articles, and prepositions. Use of specific grammatical elements followed the developmental stages observed in children with typical development. For all participants, the personal pronoun I (first-person singular) emerged before she, he (third-person singular), and we or they (plural). Participants with the highest number of adult-child co-constructed clauses also had the highest number of well-formed clauses. The intensity of adult prompts increased as clause structures became more complex and as participants needed more support. Implications for practice and theory are discussed.

Error patterns and revisions in the graphic symbol utterances of 3- and 4-year-old children who need augmentative and alternative communication.

The purpose of this study was to explore the errors and revisions (i.e., repairs) that 3- and 4-year-old children who require augmentative and alternative communication (AAC) make as they construct 2-3-word utterances using graphic symbols. The current study involves supplemental analyses from a previously published manuscript. Various types of errors and revisions for four different semantic-syntactic structures-agent-action-object, entity-attribute, entity-locative, and possessor-entity-were analysed to explore patterns and differences across utterance types. Results indicated that the majority of errors were made during the baseline phase, and that error types varied depending on the utterance type. For example, inversions were common for agent-action-object utterances, but omissions were common for entity-attribute utterances. When the participants revised their utterances, the resulting messages were more accurate the majority of the time, regardless of utterance type. Past research has highlighted frequent word order errors within graphic symbol messages, but the current results indicate that error types are dependent upon utterance type. A more refined approach, then, is required to better our understanding of how children approach the task of learning to produce graphic symbol utterances.

The effects of explicit instruction in academic vocabulary during shared book reading on the receptive vocabulary of children with complex communication needs.

The purpose of this study was to evaluate the effect of explicit vocabulary instruction during shared reading experiences on the acquisition of receptive academic vocabulary for children with complex communication needs. A single-subject, multiple-probe design was used. Three preschool-aged children (i.e., one with autism spectrum disorder, one with developmental delay, and one with a rare genetic disorder) were each taught two sets of vocabulary words. Intervention consisted of explicit vocabulary instruction associated with shared reading of academic texts. All three children acquired 10 targeted academic vocabulary items receptively and maintained vocabulary knowledge for at least 4 weeks. Data also suggest probable generalization to new representations. Additionally, participants became more adept at learning via this method, acquiring the second vocabulary set in significantly less time. Results indicate that explicit vocabulary instruction during shared reading experiences can be effective for teaching receptive vocabulary to children with complex communication needs.

Early verbal categories and inflections in children who use speech-generating devices.

The use of early verbal categories, their event types, and the emergence of verbal inflections (-ing, -s, and -ed) were analyzed in data from four participants with motor speech disorders aged 9;5-13;9 (years;months) who used speech-generating devices to converse with a familiar adult. The study was conducted through a secondary analysis of a corpus of data collected as part of another study. It documents the production of verbs and the emergence of verb inflections in natural conversations between each of the participants and a member of their educational team over a period of up to 10 months. All participants used both action and state verbs, although action verbs were dominant. The emergence of the inflections -ing, -s, and -ed varied and were distributed selectively with different verb categories and event types. The results are discussed in terms of language development and are considered in terms of the findings from research with children without disabilities, which suggest that action verbs precede state verbs, and inflections are primarily acquired based on their correspondence to the verbal category (action-state). Implications for theory, practice, and further research are discussed.

Wearable Haptics and Immersive Virtual Reality Rehabilitation Training in Children With Neuromotor Impairments.

The past decade has seen the emergence of rehabilitation treatments using virtual reality (VR) environments although translation into clinical practice has been limited so far. In this paper, an immersive VR rehabilitation training system endowed with wearable haptics is proposed for children with neuromotor impairments: it aims to enhance involvement and engagement of patients, to provide congruent multi-sensory afferent feedback during motor exercises and to benefit from the flexibility of VR in adapting exercises to the patient's need. An experimental rehabilitation session conducted with children with cerebral palsy (CP) and developmental dyspraxia (DD) has been performed to evaluate the usability of the system and proof of concept trial of the proposed approach. We compared CP/DD performance with both typically developing children and adult control group. Results show the system was compliant with different levels of motor skills and allowed patients to complete the experimental rehabilitation session, with performance varying according to the expected motor abilities of different groups. Moreover, a kinematic assessmentbased on the presented system has been designed. Obtained results reflected different motor abilities of patients and participants, suggesting suitability of the proposed kinematic assessment as a motor function outcome.

Bilateral upper limb rehabilitation with videogame-based feedback in corticobasal degeneration: a case reports study.

Corticobasal degeneration (CBD) is a neurodegenerative disorder characterized by a combination of cortical and basal ganglia signs. We reported two cases treated with a bilateral upper limb rehabilitation tool with videogame based feedback for 3 time per week for 8 weeks. Both patients showed an improvement of pinch and grasp forces and motor function. However, both of them reported an increased upper limb pain. Bilateral upper limb mechanical device with exergame feedback was effective also in the two patients suffering of CBD for limiting the effects of apraxia by performing intensive purposeful task training.

Social Robotics in Therapy of Apraxia of Speech.

Apraxia of speech is a motor speech disorder in which messages from the brain to the mouth are disrupted, resulting in an inability for moving lips or tongue to the right place to pronounce sounds correctly. Current therapies for this condition involve a therapist that in one-on-one sessions conducts the exercises. Our aim is to work in the line of robotic therapies in which a robot is able to perform partially or autonomously a therapy session, endowing a social robot with the ability of assisting therapists in apraxia of speech rehabilitation exercises. Therefore, we integrate computer vision and machine learning techniques to detect the mouth pose of the user and, on top of that, our social robot performs autonomously the different steps of the therapy using multimodal interaction.

Treating Childhood Apraxia of Speech With the Kaufman Speech to Language Protocol: A Phase I Pilot Study.

Purpose: A Phase I pilot study was designed to collect preliminary evidence on the use of the Kaufman Speech to Language Protocol (K-SLP; Kaufman, 2014) to treat children with childhood apraxia of speech. We hypothesized that the K-SLP approach would result in more accurate speech production in targeted words, whereas untrained (control) words and speech sounds would remain unchanged. Method: A single-case multiple-baseline across behaviors experimental design was used to see if experimental feasibility could be demonstrated. Two children each received a total of 12 1-hr treatment sessions over 3 weeks. The children's response to treatment and experimental control was measured by administering baseline, treatment, and posttreatment probes. Results: Both children showed some response to treatment, as measured by percent phonemes correct; however, the response to treatment varied. In general, for the treated words that improved with therapy, accuracy was maintained above baseline level during the maintenance phase. Minimal generalization was observed for this study, with only 1 participant generalizing treatment gains to 2 sets of untrained (similar) words. Conclusion: This Phase I pilot study provides limited preliminary evidence for the effectiveness of the K-SLP approach in treating childhood apraxia of speech in some children under the conditions specified in this study. Replication of these results in well-controlled studies is needed before this structured and operationalized version of the K-SLP approach can be recommended for clinical use.

The Effect of Hand Gesture Cues Within the Treatment of /r/ for a College-Aged Adult With Persisting Childhood Apraxia of Speech.

PURPOSE: Despite the widespread use of hand movements as visual and kinesthetic cues to facilitate accurate speech produced by individuals with speech sound disorders (SSDs), no experimental investigation of gestural cues that mimic that spatiotemporal parameters of speech sounds (e.g., holding fingers and thumb together and "popping" them to cue /p/) currently exists. The purpose of this study was to examine the effectiveness of manual mimicry cues within a multisensory intervention of persisting childhood apraxia of speech (CAS). METHOD: A single-subject ABAB withdrawal design was implemented to assess the accuracy of vowel + /r/ combinations produced by a 21-year-old woman with persisting CAS. The effect of manual mimicry gestures paired with multisensory therapy consisting of verbal instructions and visual modeling was assessed via clinician and naïve listener ratings of target sound accuracy. RESULTS: According to the perceptual ratings of the treating clinician and 28 naïve listeners, the participant demonstrated improved speech sound accuracy as a function of the manual mimicry/multisensory therapy. CONCLUSIONS: These data offer preliminary support for the incorporation of gestural cues in therapy for CAS and other SSDs. The need for continued research on the interaction of speech and manual movements for individuals with SSDs is discussed.

Variable Practice to Enhance Speech Learning in Ultrasound Biofeedback Treatment for Childhood Apraxia of Speech: A Single Case Experimental Study.

PURPOSE: The purpose of this study was to evaluate the role of practice variability, through prosodic variation during speech sound training, in biofeedback treatment for children with childhood apraxia of speech. It was hypothesized that variable practice would facilitate speech sound learning. METHOD: Six children ages 8-16 years with persisting speech sound errors due to childhood apraxia of speech participated in a single-subject experimental design. For each participant, 2 speech sound targets were treated with ultrasound visual feedback training: one with prosodic variation (i.e., practicing sound targets in words and phrases spoken fast, slow, loud, as a question, command, and declarative), and one without prosodic variation. Each target was treated for half of the 1-hr session for 14 treatment sessions. RESULTS: As measured by standardized effect sizes, all participants showed greater change on generalization probes for sound targets treated under the prosodic variation condition with mean effect sizes (d2) of 14.5 for targets treated with prosodic variation and 8.3 for targets treated without prosodic variation. The average increase in generalization scores was 38% in the prosodic variation condition compared to 31% without. CONCLUSIONS: Ultrasound visual feedback may facilitate speech sound learning and learning may be enhanced by treating speech sounds with explicit prosodic variation. SUPPLEMENTAL MATERIALS: https://doi.org/10.23641/asha.5150119.