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.

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.

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.

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.

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.

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 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.

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.

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.

The rehabilitative effects on written language of a combined language and parietal dual-tDCS treatment in a stroke case.

In this paper we report the effect of a combined transcranial direct current stimulation (tDCS) and speech language therapy on linguistic deficits following left brain damage in a stroke case. We show that simultaneous electrical excitatory stimulation to the left and inhibitory stimulation to the right parietal regions (dual-tDCS) affected writing and reading rehabilitation, enhancing speech therapy outcomes. The results of a comparison with healthy controls showed that application of dual-tDCS could improve, in particular, sub-lexical transcoding and, specifically, the reading of non-words with increasing length and complexity. Positive repercussions on patient's quality of functional communication were also ascertained. Significant changes were also found in other language and cognitive tasks not directly treated (comprehension and constructive apraxia).

The effectiveness of aided augmented input techniques for persons with developmental disabilities: a systematic review.

When working with individuals with little or no functional speech, clinicians often recommend that communication partners use the client's augmentative and alternative communication (AAC) device when speaking to the client. This is broadly known as "augmented input" and is thought to enhance the client's learning of language form and content. The purpose of this systematic review was to determine the effects of augmented input on communication outcomes in persons with developmental disabilities and persons with childhood apraxia of speech who use aided AAC. Nineteen studies met the inclusion criteria. Each included study was reviewed in terms of participant characteristics, terminology used, symbol format, augmented input characteristics, outcomes measured, effectiveness, and study quality. Results indicate that augmented input can improve single-word vocabulary skills and expression of multi-symbol utterances; however, comprehension beyond the single word level has not been explored. Additionally, it is difficult to form conclusions about the effect of augmented input on specific diagnostic populations. Directions for future research are posited.

Post-stroke pure apraxia of speech - A rare experience.

Apraxia of speech (AOS) is a motor speech disorder, most typically caused by stroke, which in its "pure" form (without other speech-language deficits) is very rare in clinical practice. Because some observable characteristics of AOS overlap with more common verbal communication neurologic syndromes (i.e. aphasia, dysarthria) distinguishing them may be difficult. The present study describes AOS in a 49-year-old right-handed male after left-hemispheric stroke. Analysis of his articulatory and prosodic abnormalities in the context of intact communicative abilities as well as description of symptoms dynamics over time provides valuable information for clinical diagnosis of this specific disorder and prognosis for its recovery. This in turn is the basis for the selection of appropriate rehabilitative interventions.

Simultaneous natural speech and AAC interventions for children with childhood apraxia of speech: lessons from a speech-language pathologist focus group.

In childhood apraxia of speech (CAS), children exhibit varying levels of speech intelligibility depending on the nature of errors in articulation and prosody. Augmentative and alternative communication (AAC) strategies are beneficial, and commonly adopted with children with CAS. This study focused on the decision-making process and strategies adopted by speech-language pathologists (SLPs) when simultaneously implementing interventions that focused on natural speech and AAC. Eight SLPs, with significant clinical experience in CAS and AAC interventions, participated in an online focus group. Thematic analysis revealed eight themes: key decision-making factors; treatment history and rationale; benefits; challenges; therapy strategies and activities; collaboration with team members; recommendations; and other comments. Results are discussed along with clinical implications and directions for future research.

Inpatient rehabilitation outcomes of patients with apraxia after stroke.

BACKGROUND: Stroke-induced paresis commands much attention during rehabilitation; other stroke-related consequences receive less consideration. Apraxia is a stroke disorder that may have important implications for rehabilitation and recovery. OBJECTIVE: To investigate association of apraxia with stroke rehabilitation outcomes during inpatient rehabilitation. METHODS: This cohort study compared patients with and without apraxia after a first left hemispheric stroke. All study patients received standard of care. Clinical measures were the Functional Independence Measure (FIM) and the upper extremity section of the Fugl-Meyer Assessment (FMA) administered upon admission and at discharge. Length of stay was also documented. Florida Apraxia Battery subtests were used to classify patients with apraxia. RESULTS: Fifteen patients were included in this study, 10 of whom had apraxia. Data analysis revealed that patients with apraxia exhibited improvement from admission to discharge in clinical measures; however, admission FIM score was significantly lower compared to patients without apraxia. There was no statistically significant difference between groups on FMA score, length of stay, or amount of change on clinical measures. CONCLUSIONS: This study of acute patients found those with apraxia to be significantly less independent upon admission to inpatient rehabilitation compared to patients without apraxia. Although both groups improved a similar amount during rehabilitation, patients with apraxia discharged at a level of independence comparable to patients without apraxia upon admission. Such disparity in independence is of concern, and apraxia as a factor in stroke rehabilitation and recovery deserves further attention.

Systematic review of apraxia treatments to improve occupational performance outcomes.

The objective was to assess effectiveness of apraxia treatments using a systematic review. In contrast to previous reviews, each study was rated as to its applicability to occupational therapy practice and its focus on occupational performance using the FAME rating system (defined by four categories: Feasibility, Appropriateness, Meaningfulness, Effectiveness). This systematic review included eight studies: four randomized controlled trials (level 1 evidence) and four pre-post designs (level 3 evidence). Three treatment approaches were reported: errorless learning with training of details; gesture training; and strategy training. FAME scores ranged from A to C. All studies reported significant treatment effects, but only one demonstrated an impact on observed occupational performance that transferred from clinic to home.

Effects of video modelling on emerging speech in an adult with traumatic brain injury: preliminary findings.

PRIMARY OBJECTIVE: Research has shown that traumatic brain injury (TBI) can affect a person's ability to perform previously learned skills. Dysexecutive syndrome and inattention, for example, alongside a number of other cognitive and behavioural impairments such as memory loss and lack of motivation, significantly affect day-to-day functioning following TBI. This study examined the efficacy of video modelling in emerging speech in an adult male with TBI caused by an assault. RESEARCH DESIGN: In an effort to identify functional relations between this novice intervention and the target behaviour, experimental control was achieved by using within-system research methodology, overcoming difficulties of forming groups for such an highly non-homogeneous population. METHODS AND PROCEDURES: Across a number of conditions, the participant watched a videotape in which another adult modelled a selection of 19 spoken words. When this modelled behaviour was performed in vivo, then generalization across 76 other words in the absence of a videotape took place. MAIN OUTCOMES AND RESULTS: It was revealed that video modelling can promote the performance of previously learned behaviours related to speech, but more significantly it can facilitate the generalization of this verbal behaviour across untrained words. CONCLUSIONS: Video modelling could well be added within the rehabilitation programmes for this population.

Environmental accommodations for a child with traumatic brain injury.

PRIMARY OBJECTIVE: Children with severe TBI frequently demonstrate language and cognition challenges and require accommodations to succeed academically. However, minimal research exists about accommodation efficacy for this population. This study examined the effect of environmental accommodations (reduced visual and auditory distractions) on the redirections, task variability and accuracy of a child with severe TBI when performing cognitive-linguistic activities. HYPOTHESIS: The researchers hypothesized no differences in variability between accommodation conditions; poorest task performance and most frequent task redirections given no environmental accommodations; comparable task performance and redirections with visual accommodation and auditory accommodation; and highest task performance and fewest redirections with combined visual and auditory accommodations. RESEARCH DESIGN: The researchers used an alternating treatment, single case design to compare task performance, variability and redirection averages across conditions. They used visual inspection, linear growth curve analyses and repeated measure analyses for data interpretation. METHODS AND PROCEDURES: Data collection occurred during label-object association, oral directions and divided attention tasks over 22 sessions varying in accommodation provision. MAIN OUTCOMES AND RESULTS: Findings showed visual plus auditory accommodations resulted in fewer redirections and superior average performance on all tasks although substantial variability persisted. Significant differences emerged across conditions only for the oral directions task.

People post-stroke perceive movement fluency in virtual reality.

We investigated the visual perception of biological movement by people post-stroke, using minimal kinematic displays. A group of twenty patients and a group of twelve age-matched healthy controls were asked to judge movement fluency. The movements to judge were either displayed as an end-point dot or as a stick-figure of the arm and trunk. It was found that the perception of movement fluency was preserved post-stroke, however, with an increase in the variability of judgment. Moreover, the end-point dot representation ameliorated what was perceived and judged, presumably by directing attention to the important kinematic cues: smoothness and directness of the trajectory. We conclude that, despite perception of actions is influenced by the ability of the observer to execute the observed movement, hemiparesis has a mild effect on the perception of biological movement. Yet, a valuable virtual learning environment for upper-limb rehabilitation should be implemented to provide the observer with neither too much, nor too little information to maximize learning.