Limb apraxia in individuals with multiple sclerosis: Is there a role of semi-immersive virtual reality in treating the Cinderella of neuropsychology?

BACKGROUND: Limb apraxia is an acquired cognitive-motor disorder characterized by spatial and temporal disorganization of limb movements, negatively affecting the quality of life of patients, including those with multiple sclerosis (MS). Although recent studies have shown the potential role of VR in increasing cognitive and motor functions, only a few studies have been carried out on the rehabilitation of upper limb apraxia. Hence, our study aims to evaluate the potential efficacy of VR training to improve upper limb ideomotor apraxia in patients with MS. METHODS: One hundred and six patients, affected by secondary progressive MS, who attended our Robotic and Behavioral Neurorehabilitation Service from March 2019 to February 2020, were enrolled in this study and randomly divided into two groups: the control group (CG: 53 patients) performed traditional therapy whereas the experimental group (EG:53 patients) received training using semi-immersive VR. All patients underwent the same amount of cognitive training, 3 times a week for 8 weeks. They were submitted to a specific neuropsychological assessment before (T0) and after the rehabilitation treatment (T1). RESULTS: The VR training led to a significant improvement in global cognitive functions, with regard to constructive and ideomotor apraxia. On the contrary, the CG achieved significant improvements only in ideomotor apraxia. Moreover, only in the EG, we observed an improvement in the mood at the end of training. CONCLUSION: The present study demonstrates that VR rehabilitation can be an effective tool for the treatment of apraxia, which is a neuropsychological problem often underestimated in MS patients. Further studies with long-term follow-up periods are needed to confirm the effect of this promising approach.

Efficacy of virtual reality therapy in ideomotor apraxia rehabilitation: A case report.

RATIONALE: We report the possible therapeutic efficacy of immersive virtual reality (VR) rehabilitation for the treatment of ideomotor apraxia in a patient with stroke. PATIENT CONCERNS: A 56-year-old man with sudden weakness of his left side caused by right frontal, parietal, and corpus callosal infarction was transferred to rehabilitation medicine center for intensive rehabilitation. Although his left-sided weakness had almost subsided 10 days after the onset of symptoms, he presented difficulty using his left hand and required assistance in most activities of daily living. DIAGNOSES: Ideomotor apraxia in a patient with right hemispheric infarction. INTERVENTIONS: VR content was displayed to the study participants using a head-mounted display that involved catching of moving fish in the sea by grasping. Before and after of rehabilitative intervention including VR, functional measurements incorporating the Test of Upper Limb Apraxia (TULIA) were conducted. To directly compare therapeutic potencies under different conditions, success rates of consecutive grasping gesture performance were observed in VR, conventional occupational therapy setting, and augmented reality intervention. OUTCOMES: The patient demonstrated remarkable amelioration of apraxic symptoms while performing the task in the VR environment. At 1 and 3 months after the training, he showed significant improvement in most functions, and the TULIA score increased to 176 from 121 at the initiation of therapy. The number of successful grasps during 30 trials of each grasp trial was 28 in VR, 8 in the occupational therapy setting, and 20 in augmented reality. LESSONS: This case report suggests the possible therapeutic efficacy of immersive VR training as a rehabilitative measure for ideomotor apraxia.

Motor recovery of hemiparetic leg by improvement of limb-kinetic apraxia in a chronic patient with traumatic brain injury: A case report.

RATIONALE: Limb-kinetic apraxia (LKA), a kind of apraxia, means the inability to perform precise and voluntary movements of extremities resulting from injury of the premotor cortex (PMC) or the corticofugal tract (CFT) from the PMC. Diagnosis of LKA is made by observation of movements without specific assessment tools. PATIENT CONCERNS: A 44-year-old male underwent conservative management for traumatic intracerebral hemorrhage in the left basal ganglia and subarachnoid hemorrhage due to a pedestrian-car crash. When he was admitted to the rehabilitation department of a university hospital after 41 months after onset, he presented with right hemiparesis (Medical Research Council (MRC): shoulder abductor; 3, elbow flexor; 3, finger extensor; 0, hip flexor; 2- [range: 30°], knee extensor; 1 and ankle dorsiflexor; 3-). In addition, he exhibited slow, clumsy, and mutilated movements when performing movements of his right ankle. DIAGNOSES: The patient was diagnosed as traumatic brain injury (TBI). INTERVENTIONS: Clinical assessments and DTI were performed at 41 and 44 months after onset. During three months, rehabilitative therapy was performed including dopaminergic drugs (pramipexole 2.5 mg, ropinirole 2.5 mg, and amantadine 300 mg, and carbidopa/levodopa 75 mg/750 mg). OUTCOMES: The right leg weakness slowly recovered during 3 months, until 44 months after the initial injury (MRC: shoulder abductor, 3; elbow flexor, 3; finger extensor, 0; hip flexor, 3; knee extensor, 3; and ankle dorsiflexor, 3+). The fiber number of the right corticospinal tract (CST) was decreased on 44-month diffusion tensor tractography (DTT) (1319) compared with 41-month DTT (1470) and the left CST was not reconstructed on both DTTs. The fiber number of both CRTs were decreased on 44-month DTT (right: 1547, left: 698) than 41-month DTT (right: 3161, left: 1222). LESSONS: A chronic patient with TBI showed motor recovery of the hemiparetic leg by improvement of LKA after rehabilitation. This results have important implications for neurorehabilitation.

The Effectiveness of Action Observation Therapy Based on Mirror Neuron Theory in Chinese Patients with Apraxia of Speech after Stroke.

OBJECTIVE: The present study aimed to evaluate the efficacy of action observation therapy (AOT) on apraxia of speech (AOS) in patients after stroke. MATERIALS AND METHODS: Forty-two patients diagnosed with AOS after stroke were randomly divided into an experimental group (n = 21) and a control group (n = 21). Both groups received 30 min of conventional language therapy twice daily, 5 days a week for 4 weeks. The patients in the experimental group additionally received 20 min of AOT before 10 min language therapy each day. The speech function and aphasia severity of the 2 groups were assessed using the speech apraxia assessment method of the China Rehabilitation Research Center, Western Aphasia Battery (WAB), and the Boston Diagnostic Aphasia Examination before and after treatment. RESULTS: AOS and WAB scores increased significantly after treatment in both groups (p < 0.05). AOS and WAB scores exhibited significant differences between the experimental group and the control group after training (p < 0.05). The response rate in the experimental group was significantly higher than that in the control group (p < 0.05). CONCLUSION: AOT based on mirror neuron theory may improve language function in patients with AOS after stroke.

Crossover learning of gestures in two ideomotor apraxia patients: A single case experimental design study.

Crossover learning may aid rehabilitation in patients with neurological disorders. Ideomotor apraxia (IMA) is a common sequela of left-brain damage that comprises a deficit in the ability to perform gestures to verbal commands or by imitation. This study elucidated whether crossover learning occurred in two post-stroke IMA patients without motor paralysis after gesture training approximately 2 months after stroke onset. We quantitatively analysed the therapeutic intervention history and investigated whether revised action occurred during gesture production. Treatment intervention was to examine how to influence improvement and generalisation of the ability to produce the gesture. This study used an alternating treatments single-subject design, and the intervention method was errorless learning. Results indicated crossover learning in both patients. Qualitative analysis indicated that revised action occurred during the gesture-production process in one patient and that there were two types of post-revised action gestures: correct and incorrect gestures. We also discovered that even when a comparably short time had elapsed since stroke onset, generalisation was difficult. Information transfer between the left and right hemispheres of the brain via commissural fibres is important in crossover learning. In conclusion, improvements in gesture-production skill should be made with reference to the left cerebral hemisphere disconnection hypothesis.

Motor recovery by improvement of limb-kinetic apraxia in a chronic stroke patient.

OBJECTIVES: We report on a chronic stroke patient who showed motor recovery by improvement of limb-kinetic apraxia (LKA) after undergoing intensive rehabilitation for a period of one month, which was demonstrated by diffusion tensor tractography (DTT) and transcranial magnetic stimulation (TMS). METHODS: A 50-year-old male patient presented with severe paralysis of the left extremities at the onset of thalamic hemorrhage. At thirty months after onset, the patient exhibited moderate weakness of his left upper and lower extremities. In addition, he exhibited a slow, clumsy, and mutilated movement pattern during grasp-release movements of his left hand. During a one-month period of intensive rehabilitation, which was started at thrity months after onset, the patient showed 22% motor recovery of the left extremities. The slow, clumsy, and mutilated movement pattern of the left hand almost disappeared. RESULTS: DTTs of the corticospinal tract (CST) in both hemispheres originated from the cerebral cortex, including the primary motor cortex, and passed along the known CST pathway. The DTT of the right CST was located anterior to the old hemorrhagic lesion. TMS study performed at thirty and thirty-one months after onset showed normal and similar findings for motor evoked potential in terms of latency and amplitude of the left hand muscle. CONCLUSIONS: We think that the motor weakness of the left extremities in this patient was mainly ascribed to LKA and that most of the motor recovery during a one-month period of rehabilitation was attributed to improvement of LKA.

Assessing limb apraxia in traumatic brain injury and spinal cord injury.

People with traumatic brain injury (TBI) may demonstrate action planning disorders and limb apraxia. Many patients, who sustain a spinal cord injury (SCI), sustain a co-occurring TBI (11-29 percent of people with SCI) and therefore are at risk for limb apraxia. People with SCI and TBI (SCI/TBI) rely on powered assistive devices which amplify movement. Their ability to learn complex motor compensatory strategies, that is, limb praxis, is critical to function. We wished to identify methods of screening for apraxia in patients with SCI/TBI. We reviewed instruments available for limb praxis assessment, presenting information on psychometric development, patient groups tested, commercial/clinical availability, and appropriateness for administration to people with motor weakness. Our review revealed that insufficient normative information exists for apraxia assessment in populations comparable to SCI/TBI patients who are typically young adults at the time of injury. There are few apraxia assessment instruments which do not require a motor response. Non-motoric apraxia assessments would be optimal for patients with an underlying motor weakness.

Dyspraxia series: part one. At sixes and sevens.

Developmental Co-ordination Disorder (DCD), also known as Dyspraxia in the UK, is a common disorder affecting motor co-ordination in children and for many continues into adulthood. This condition is formally recognised by international organisations including the World Health Organisation. DCD is distinct from other motor disorders such as cerebral palsy and stroke. The range of intellectual ability is in line with the general population. Individuals may vary in how their difficulties present. The co-ordination difficulties may affect participation and functioning of everyday life skills in education, work and employment. Children may present with difficulties in writing, typing, riding a bike, self care tasks, and recreational activities. In adulthood many of these difficulties will continue, as well as learning new skills at home and work such as planning, organisation, driving a car and DIY.

Improved function after combined physical and mental practice after stroke: a case of hemiparesis and apraxia.

This study describes change in functional performance and self-perception after participation in combined training with physical practice followed by mental practice. The patient was a 44-yr-old white man who experienced a single left ischemic stroke 7 mo before enrollment in the study. He engaged in physical and mental practice of two functional tasks: (1) reaching for and grasping a cup and (2) turning pages in a book with the more-affected arm. Practice took place 3 times per week during 60-min sessions for 6 consecutive wk. Primary outcome measures were the Arm Motor Ability Test (AMAT) and the Canadian Occupational Performance Measure (COPM). An abbreviated version of the Florida Apraxia Battery gesture-to-verbal command test approximated severity of ideomotor apraxia. After intervention, the patient demonstrated increased functional performance (AMAT) and self-perception of performance (COPM) despite persistent ideomotor apraxia. The results of this single-case report indicate functional benefit from traditional rehabilitation techniques despite comorbid, persisting ideomotor apraxia.

A new approach to rhythm cueing of cognitive functions: the case of ideomotor apraxia.

Although positive effects of rhythm cueing on motor control in neurologic disorders are known, no studies have yet focused on patients suffering from impaired programming of complex actions. One patient suffering from ideomotor apraxia (a potentially ideal experimental paradigm to test the effect of rhythm on high-level motor control) underwent two rehabilitation training sets differing only for the presence or absence of rhythm cueing. Both sets of training increased the patient's proficiency, but rhythm cueing was significantly more effective, during the training as well as during the post-training uncued test. Ideomotor apraxia represents an effective model to test the effects of rhythm on high-level motor control.

Improvements in limb kinetic apraxia by repetition of a newly designed facilitation exercise in a patient with corticobasal degeneration.

Corticobasal degeneration is a progressive neurological disorder characterized by a combination of parkinsonism and cortical dysfunction such as limb kinetic apraxia, alien limb phenomenon, and dementia. To study the effect of repetitive facilitation exercise (RFE) in a patient with corticobasal degeneration, we used a newly designed facilitation exercise designed to elicit movements isolated from the synergy in hemiplegia. This exercise included movements of each isolated finger using stretch reflex and skin-muscle reflex and repetitive movements demanded in activities of daily living (ADL) and manipulating objects. To evaluate improvements in hand functions by RFE, 1-week RFE sessions for the hand were administered alternatively to the left or right hand. The number of finger taps by the hand increased during each 1-week RFE session for the hand, but did not increase during 1-week sessions without RFE. After 1 month of treatment, the patient's difficulties in ADL, including wearing clothes, manipulating objects and cooking, decreased. Our results suggest the importance of the repetition of facilitation exercises and movements in ADL for recovery in patients with degenerative neurogenic diseases.

Treatment of limb apraxia: moving forward to improved action.

Limb apraxia is a common disorder of skilled, purposive movement that is frequently associated with stroke and degenerative diseases such as Alzheimer disease. Despite evidence that several types of limb apraxia significantly impact functional abilities, surprisingly few studies have focused on development of treatment paradigms. Additionally, although the most disabling types of apraxia reflect damage to gesture and/or object memory systems, existing treatments have not fully taken advantage of principles of experience known to affect learning and neural plasticity. We review the current state of the art in the rehabilitation of limb apraxia, indicate possible points of contact with the learning literature, and generate suggestions for how translational principles might be applied to the development of future research on treatment of this disabling disorder.

Ideomotor apraxia: a review.

Ideomotor apraxia (IMA) is a disorder traditionally characterized by deficits in properly performing tool-use pantomimes (e.g., pretending to use a hammer) and communicative gestures (e.g., waving goodbye). These deficits are typically identified with movements made to verbal command or imitation. Questions about this disorder relate to its diagnosis, anatomical correlates, physiological mechanisms involved, and the patients in whom IMA is best characterized. In this review, utilizing information presented at an international workshop, we summarize the present state of knowledge about IMA. We include insights on how to distinguish IMA from the other motor apraxias and confounding disorders. We discuss testing for IMA and the need for more rigorous tests that examine more elements, such as imitation, actual use, task selection, and recognizing proper use. From neurophysiological insights, we propose hypotheses of the necessity of networks in praxis performance. We also point out that more neurophysiological knowledge in humans might lead to a better understanding of how different brain structures may aid in the rehabilitation of praxis. While little is known about exactly how rehabilitation may be pursued, biological evidence warrants the further exploration of this issue.

Evaluation of ideomotor apraxia in patients with stroke: a study of reliability and validity.

OBJECTIVE: This aim of this study was to determine the reliability and validity of an established ideomotor apraxia test when applied to a Turkish stroke patient population and to healthy controls. SUBJECTS: The study group comprised 50 patients with right hemiplegia and 36 with left hemiplegia, who had developed the condition as a result of a cerebrovascular accident, and 33 age-matched healthy subjects. METHODS: The subjects were evaluated for apraxia using an established ideomotor apraxia test. The cut-off value of the test and the reliability coefficient between observers were determined. RESULTS: Apraxia was found in 54% patients with right hemiplegia (most being severe) and in 25% of left hemiplegic patients (most being mild). The apraxia scores for patients with right hemiplegia were found to be significantly lower than for those with left hemiplegia and for healthy subjects. There was no statistically significant difference between patients with left hemiplegia and healthy subjects. CONCLUSION: It was shown that the ideomotor apraxia test could distinguish apraxic from non-apraxic subjects. The reliability coefficient among observers in the study was high and a reliability study of the ideomotor apraxia test was therefore performed.

Sensitivity of different ADL measures to apraxia and motor impairments.

OBJECTIVE: To determine whether specifically designed activities of daily living (ADL) observations can measure disability due to apraxia with more sensitivity than the Barthel ADL Index, a conventional functional scale. DESIGN: Cross-sectional study. SETTING: Rehabilitation centres and nursing homes. SUBJECTS: One hundred and six left hemisphere stroke patients with apraxia, hospitalized in rehabilitation centres and nursing homes. MEASURES: ADL observations, Barthel ADL Index, an apraxia test, Motricity Index, Functional Motor Test. RESULTS: Multivariate analyses showed that the specific ADL observations were associated with severity of apraxia (and not with motor impairments). The Barthel ADL Index was associated with motor impairments (and not with severity of apraxia). CONCLUSION: The assessment of disability in stroke patients with apraxia cannot rely only on the Barthel ADL Index. In addition, the specific ADL observation procedure is needed to measure disability due to apraxia.

The rehabilitation of limb apraxia: a study in left-brain-damaged patients.

OBJECTIVE: To assess the effectiveness of a rehabilitative training program for patients with limb apraxia. DESIGN: Randomized, controlled trial. SETTING: Neurologic rehabilitation unit of a university hospital. PATIENTS: Thirteen patients with acquired brain injury and limb apraxia (lasting more than 2 months) as a result of lesions involving the left cerebral hemisphere. Patients were assigned to a study group or to a control group following a randomization scheme. The study group underwent an experimental training for limb apraxia. The control group received conventional treatment for aphasia. INTERVENTION: A behavioral training program consisting of gesture-production exercises. The rehabilitative program was made up of 3 sections dedicated to the treatment of gestures with or without symbolic value and related or nonrelated to the use of objects. Thirty-five experimental sessions, each lasting 50 minutes, were given. MAIN OUTCOME MEASURES: Neuropsychologic tests for assessment of aphasia, verbal comprehension, "general intelligence," oral apraxia, constructional apraxia, and 3 tests concerning limb praxic function (ideational apraxia, ideomotor apraxia, gesture recognition). Scores related to each test were used to measure the outcome. Video recordings of ideational and ideomotor apraxia tests allowed us to register type and number of praxic errors. All outcome measures, except the aphasia test, were recorded before and after the experimental (or control) treatment time interval. RESULTS: The patients in the study group achieved a significant improvement of performance in both ideational (p = .039) and ideomotor (p = .043) apraxia tests. They also showed a significant reduction of errors in ideational (p = .001) and ideomotor (p < .001) apraxia tests. A trend toward improvement was found in the gesture comprehension test (p = .058), while other outcome measures did not show any significant amelioration. Control patients did not show any significant change in performance. CONCLUSIONS: The results show the possible effectiveness of a specific training program for the treatment of limb apraxia.