Apraxia

Evidence Reviewed as of before: 28-08-2020
Author(s): Annabel McDermott, OT; Annie Rochette, erg./OT (c) Ph.D.
Content consistency: Gabriel Plumier
Patient/Family Information Table of contents

Introduction

Apraxia is a neuropsychological deficit that interrupts an individual’s ability to perform purposeful movement, in the absence of basic sensorimotor difficulties such as lack of sensation or muscle weakness. Approximately 30% of individuals display apraxia or partial signs of apraxia (i.e. dyspraxia) following stroke, with a greater incidence among individuals with left hemisphere damage. Apraxia effects an individual’s autonomy for work and daily activities.

Patient/Family Information

What is apraxia?

Apraxia is a cognitive disorder that can occur after stroke. Apraxia is the inability to make purposeful movement, but is not due to sensory or motor disturbances (e.g. loss of sensation, muscle weakness). Apraxia effects the ability to perform movements and gestures.

Why do people get apraxia?

Approximately 30% of people who have had a stroke will display apraxia or partial signs of apraxia (i.e. dyspraxia). Apraxia is more common among people with damage to the left hemisphere of the brain. However, apraxia can also result from damage to other parts of the brain.

Are there different types of apraxia?

There are many different types of apraxia. The most common type of apraxia is buccofacial (or orofacial) apraxia:

  • Buccofacial apraxia: difficulty making movements of the mouth, eyes or face.

The most common forms of limb apraxia (i.e. affecting use of the arms/legs) are ideational apraxia and ideomotor apraxia:

  • Ideational apraxia: difficulty organizing actions to achieve a goal.
  • Ideomotor apraxia: difficulty selecting, sequencing and using objects.

Different forms of apraxia can also affect speech, touch, writing/drawing skills, eye movements, and body movements.

How can I recognize limb apraxia?

Limb apraxia affects a person’s ability to perform simple movements. This may be seen as difficulty imitating an action, performing an action in response to a spoken command, or understanding an action. Limb apraxia can affect the person’s arm movements for communication (e.g. using gestures) and daily activities (e.g. using familiar objects for everyday tasks).

Who diagnoses and treats apraxia?

Apraxia is difficult to diagnose because of the many different types of apraxia, the different definitions used to describe apraxia, and a lack of suitable assessments. Medical/health professionals can assess for apraxia in several different ways including using formal tests, and by observing the patient’s movements when imitating gestures, following spoken commands (e.g. “pretend to drink from a cup”), or using common objects.

Treatment will depend on the type of apraxia.

  • A Speech Language Pathologist can help the person who is experiencing difficulties with speech, language, communication/gestures, feeding, swallowing and mouth movements.
  • A Physiotherapist can help the person who is experiencing difficulties moving their body and limbs to make intended movements.
  • An Occupational Therapist can help the person who is having difficulty doing activities around the home and at work.

How does apraxia affect my recovery?

Apraxia impacts on a person’s ability to perform movements and gestures. Apraxia can impact on the person’s ability to do rehab activities (e.g. walking), communicate with others (e.g. using gestures) and complete common tasks (e.g. self-care tasks). This can affect their ability to relearn movements or learn new skills after stroke, which can impact on the person’s recovery, as well as their ability to perform daily activities and work tasks.

Will my apraxia get better?

Apraxia typically spontaneously recovers in the first few months post-stroke and is responsive to rehabilitation. The recovery process and rate of recovery will be different for each individual.

What can I expect from apraxia therapies?

Intervention can be customized to suit the person’s difficulties. Interventions for apraxia include:

  • Strategy training for daily activities (i.e. teaching specific strategies to overcome the difficulties to patient experiences)
  • Gesture training (i.e. relearning gestures)
  • Direct ADL training (i.e. relearning – or learning new ways to perform – daily tasks)
  • Using assistive technology to compensate for difficulties.

Will apraxia therapies work?

A small number of studies have investigated apraxia treatment. Results from these studies show benefits immediately after the treatment, but benefits may not last several months later. The lack of research regarding apraxia interventions impacts on the ability to draw strong conclusions regarding their effectiveness at this time.

Are there any side effects?

There are no significant side-effects from apraxia treatments.

My family member has apraxia. How can I help?

Stroke recovery requires patience and persistence from the person who had a stroke and their family/caregivers. If you or your loved one is experiencing apraxia after a stroke, the recovery process might be frustrating and stressful. It is important to continue with therapies, even if apraxia makes it challenging.

Follow this link to the Stroke Association (https://www.stroke.org.uk) for useful tips for communicating with a person who has had a stroke.

Where can I find more information about apraxia?

  • American Stroke Association (https://www.stroke.org)

Clinician Information

When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Apraxia is a neuropsychological deficit that disrupts an individual’s ability to perform purposeful movement, in the absence of basic sensorimotor difficulties such as lack of sensation or muscle weakness (Koski, Iacoboni & Mazziotta, 2002; Landry & Spaulding, 1999; West et al., 2008). Approximately 30% of individuals display apraxia or dyspraxia (i.e. partial signs of apraxia) following stroke, with a greater incidence among individuals with left hemisphere damage (Koski, Iacoboni & Mazziotta, 2002; Pazzaglia & Galli, 2019). Apraxia effects an individual’s independence for work and daily activities (Cantagallo, Maini & Rumiati, 2012; Dovern, Fink & Weiss, 2012; Koski, Iacoboni & Mazziotta, 2002; van Heugten, 2001).

Apraxia is most common among individuals with damage to the left parietal lobe, however can also result from damage to the right parietal lobe, temporal lobe, frontal lobe or subcortical regions (Koski, Iacoboni & Mazziotta, 2002). Apraxia impacts on an individual’s mental representation of an action, which in turn affects his/her ability to organize and imitate actions to achieve a goal (Bowen et al., 2009). Accordingly, apraxia limits an individual’s participation in rehabilitation, use of gestures for non-verbal communication, and performance of daily activities (Koski, Iacoboni & Mazziotta, 2002).

Numerous forms of apraxia have been defined (Koski, Iacoboni & Mazziotta, 2002). Ideational apraxia and ideomotor apraxia are the most common forms of the disorder, and are defined as follows:

Ideational apraxia: Difficulty in the ability to organize actions required to achieve a goal.

Ideomotor apraxia: Difficulty in the ability to select, sequence and use objects (West et al., 2008).

The heterogeneity of apraxia, as well as inconsistent definitions and the absence of a gold standard for assessment contribute to difficulty diagnosing the disorder (Dovern, Fink & Weiss, 2012; Lindsten-McQueen et al., 2014; West et al., 2008). For research purposes diagnosis is based on (i) neuropsychological testing to determine the presence/absence of apraxia; and (ii) standardized assessment of activities of daily living (ADLs) to determine the degree of impairment (van Heugten, 2001).

Apraxia typically spontaneously recovers in the first few months post-stroke (Cantagallo, Maini & Rumiati, 2012) and is responsive to rehabilitation (Buxbaum et al., 2008). Intervention can be customized to the presenting difficulties (Landry & Spaulding, 1999). Accordingly, interventions used in the treatment of apraxia include strategy training for ADLs using internal/external compensatory strategies; sensory stimulation using proprioceptive/deep pressure and sharp/soft touch; cueing using verbal or physical prompts; error reduction through chaining (forward/backward strategies); gesture training; conductive education; and normal movement approaches (Buxbaum et al., 2008; West et al., 2008).

A number of systematic reviews of interventions for apraxia have been conducted (Bowen et al., 2009; Lindsten-McQueen et al., 2014; Pazzaglia & Galli, 2019; Saikaley et al., n.d.; Worthington, 2016; van Heugten, 2001). A Cochrane Review of apraxia interventions following stroke by West et al. (2008) included three randomized controlled trials (two of which were considered suitable for inclusion in this review) that used strategy training, gesture training and transfer of training. The review showed a significant treatment effect immediately following apraxia intervention, but results were not sustained at 6 months post-stroke. Conclusive evidence of the benefit of apraxia therapies was not attained.

This review of interventions for apraxia following stroke includes 1 high quality RCT, 3 fair quality RCTs and 6 non-randomized studies. The majority of studies were conducted with individuals in the subacute phase of stroke recovery. Interventions include gesture training (3 studies), strategy training (5 studies) and direct training of ADLs (2 studies). While strategy training and gesture training were both shown to benefit some outcomes, the lack of research regarding apraxia interventions impacts on the ability to draw strong conclusions regarding their effectiveness at this time.

Results Table

View results table

Outcomes

Acute phase

No studies have been conducted in the acute phase of stroke recovery.

Subacute phase: Direct training of Activities of Daily Living for apraxia

Activities of Daily Living (ADLs)
Effective
2b

One non-randomised study (Goldenberg & Hagmann, 1998) investigated the use of direct training for apraxia on activities of daily living (ADLs) in the subacute phase of stroke recovery. This study assigned patients with left hemisphere stroke and apraxia to receive direct training and explorative training of daily tasks. Performance of ADLs was measured according to the number of fatal and reparable errors made during three trained/untrained tasks, assessed weekly over the intervention period (2-5 weeks) and at follow-up (6-30 months). At end of treatment 10 participants were able to complete all three ADL tasks without fatal errors; the remaining 5 participants made one fatal error. There was no generalisation of training effects from trained to untrained tasks. Participants who continued to practice activities at home showed fewer fatal errors at follow-up.

Conclusion: There is limited evidence (level 2b) from one non-randomised study that direct training of activities of daily living is effective in improving performance of trained activities of daily living among individuals with apraxia in the subacute phase of stroke recovery.
Note: Between-group comparisons were not made.

Subacute phase: Gesture training for apraxia

Gestural expression
Effective
2b

One non-randomised study (Daumuller & Goldenberg, 2010) investigated the effect of gesture training on gestural expression among individuals with apraxia in the subacute phase of stroke recovery. The non-randomised study assigned patients with left hemisphere stroke and severe aphasia (number of patients with apraxia not specified) to receive gestural therapy for 3 weeks or no gestural therapy. Gestural expression of participants who received gesture training was measured at week 1, week 2 and week 3 (practised gestures, unpractised gestures). A significant improvement in practised gestures was found at all timepoints, and a significant improvement in unpractised gestures was found at week 1 and week 2. A significant between-group difference in expression of unpractised gestures was found at week 2, in favour of gestural therapy vs. no therapy.

Conclusion: There is limited evidence (level 2b) from one non-randomised study that gesture training is more effective than no training for improving gestural expression in the subacute phase of stroke recovery. The study also reported a significant improvement in gestural expression following gesture training.

Chronic phase: Direct training of Activities of Daily Living for apraxia

Activities of Daily Living (ADLs)
Effective
2b

One non-randomised study (Goldenberg, Daumuller & Hagmann, 2001) investigated the use of direct training for apraxia on activities of daily living (ADLs) in the chronic phase of stroke recovery. This non-randomized crossover trial assigned patients with left hemisphere stroke and severe apraxia to receive direct training or explorative training of four activities. ADLs were measured according to number of errors and assistance provided during performance of trained and untrained tasks at 2-weekly intervals. A significant reduction in errors and assistance for ADL tasks was found at post-treatment (4 weeks) following direct training only. Results remained significant for assistance (but not errors) at follow-up (3 months).

Conclusion: There is limited evidence (level 2b) from one non-randomised study that direct training of activities of daily living is effective in improving performance of trained activities of daily living among patients with apraxia in the chronic phase of stroke recovery.
Note: Between-group comparisons were not made.

Phase not specific to one period: Gesture training for apraxia

Activities of Daily Living (ADLs) – carers’ perception
Effective
2a

One fair quality RCT (Smania et al., 2006) investigated the effect of gesture training for apraxia on carers’ self-perception of the patient’s ability to perform activities of daily living (ADLs) following stroke. The fair quality RCT randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. ADLs were measured by caregiver questionnaire at post-treatment (30 sessions) and follow-up (2 months post-treatment). A significant between-group difference was found at post-treatment, in favour of gesture training vs. aphasia rehabilitation. Results did not remain significant at follow-up.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is more effective than a comparison intervention (aphasia rehabilitation) for improving carers’ perception of the patient’s ability to perform activities of daily living immediately following treatment.

Constructional apraxia
Not effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on constructional apraxia following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Constructional apraxia was measured at post-treatment (35 sessions). No significant improvement was found.
Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Constructional apraxia was measured at post-treatment (30 sessions). No significant between-group difference was found.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is not more effective than a comparison intervention (aphasia rehabilitation) for improving constructional apraxia following stroke. A second fair quality RCT found no significant improvement in constructional apraxia following gesture-production training.

Gesture comprehension
Effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on gesture comprehension following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Gesture comprehension was measured by the gesture comprehension test at post-treatment (35 sessions). No significant improvement was found.

Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Gesture comprehension was measured at post-treatment (30 sessions) and follow-up (2 months post-treatment). A significant between-group difference was found at post-treatment, in favour of gesture training therapy vs. aphasia rehabilitation. Results did not remain significant at follow-up.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is more effective than a comparison intervention (aphasia rehabilitation) for improving gesture comprehension among patients with apraxia following stroke.
Note: However, a second fair quality RCT found no significant improvement in gesture comprehension following gesture production training.

Ideational apraxia
Not effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on ideational apraxia following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Ideational apraxia was measured at post-treatment (35 sessions) according to the use of real objects and errors made (inadequate utilisation, sequence error, substitution, perplexity, localisation error, awkwardness, omission, total errors). A significant improvement in ideational apraxia was found following gesture-production training, but not conventional aphasia rehabilitation. Significant reduction in some errors (awkwardness, omissions, total errors) was also seen following gesture-production training.
Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Ideational apraxia was measured at post-treatment (30 sessions) and follow-up (2 months post-treatment). No significant between-group difference was found at either timepoint.
Note: There was a significant improvement in ideational apraxia at post-treatment, within the gesture training group only.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is not more effective than a comparison intervention (aphasia rehabilitation) for improving ideational apraxia following stroke.
Note:
However, both fair quality RCTs reported a significant improvement in ideational apraxia among participants who received gesture training.

Ideomotor apraxia
Effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on ideomotor apraxia following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Ideomotor apraxia was measured at post-treatment (35 sessions) using De Renzi’s test of ideomotor apraxia and errors made (unrecognisable, intrusion, position, perseveration, omission, inappropriate sequence, conduit d’approche, substitution, total errors). A significant improvement was found following gesture-production training, but not conventional aphasia rehabilitation. Significant reduction in some errors (unrecognisable, intrusion, position, total errors) was also seen following gesture-production training.
Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Ideomotor apraxia was measured at post-treatment (30 sessions) and follow-up (2 months post-treatment). A significant between-group difference was found at post-treatment, in favour of gesture training therapy vs. aphasia rehabilitation. Results did not remain significant at follow-up.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is more effective than a comparison intervention (aphasia rehabilitation) for improving ideomotor apraxia following stroke.
Note: The other fair quality RCT also reported a significant improvement in ideomotor apraxia following gesture training but not aphasia rehabilitation.

Intelligence
Not effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on intelligence following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Intelligence was measured using Raven’s Progressive Matrices at post-treatment (35 sessions). No significant improvement was found.
Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Intelligence was measured using Raven’s Progressive Matrices at post-treatment (30 sessions). No significant between-group difference was found.
Note: There was a significant improvement in intelligence within the aphasia rehabilitation group only.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is not more effective than a comparison intervention (aphasia rehabilitation) for improving performance on a test of intelligence following stroke.

Verbal comprehension
Not effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on verbal comprehension following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Verbal comprehension was measured using the Token Test at post-treatment (35 sessions). No significant improvement was found.
Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Verbal comprehension was measured by the Token Test at post-treatment (30 sessions). No significant between-group difference was found.
Note: There was a significant improvement in verbal comprehension within the aphasia rehabilitation group only.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training for apraxia is not more effective than a comparison intervention (aphasia training) for improving verbal comprehension following stroke.

Phase not specific to one period: Strategy training for apraxia

Activities of Daily Living (ADLs)
Effective
1b

One high quality RCT (Donkervoort et al., 2001), one fair quality RCT (Geusgens et al., 2006), and two non-randomised studies (van Heugten et al., 1998; Geusgens et al., 2007) have investigated the effect of strategy training for apraxia on activities of daily living (ADLs) following stroke.

The high quality RCT (Donkervoort et al., 2001) randomised patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training integrated with occupational therapy or occupational therapy alone. ADLs were measured using (i) the Barthel Index, (ii) standardised ADL observations for apraxia, and (iii) an ADL judgement list scored by the occupational therapist at post-treatment (8 weeks) and follow-up (3 months post-treatment). Significant between-group differences were found on two measures (Barthel Index, standardised ADL observations) at post-treatment, in favour of strategy training vs. occupational therapy alone; results did not remain significant at follow-up.

Further to the study by Donkervoort et al. (2001), a fair quality study (Geusgens et al., 2006) measured transfer of skills during trained and untrained ADLs on standardised observation of 4 tasks (washing face and upper body, putting on a shirt/blouse, preparing and eating a sandwich, preparing a cup of hot chocolate) at post-treatment (8 weeks) and follow-up (3 months). A significant between-group difference in non-trained ADLs was seen at post-treatment*, in favour of strategy training vs. occupational therapy alone; results did not remain significant at follow-up.
* Note: Results reflect change scores from baseline to post-treatment.

The first non-randomised study (van Heugten et al., 1998) assigned patients with acute/subacute left hemisphere stroke and apraxia to receive strategy training. ADLs were measured using (i) the Barthel Index, (ii) standardized observations of ADL performance (independence, initiation, execution and control) when completing 4 tasks (washing face and upper body, putting on a shirt, preparing and eating a sandwich, preparing coffee or tea), and (iii) a 16-item ADL questionnaire derived from the Rivermead ADL index, completed by the OT at post-treatment (12 weeks). Significant improvements were found on all measures at post-treatment.
Note: Further, van Heugten et al. (2000) noted a ceiling effect on ADL observations, whereby patients who were competent with ADLs prior to intervention demonstrated minimal improvement over time.

The second non-randomised study (Geusgens et al., 2007) assigned patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training of ADLs. ADLs were measured by (i) the Barthel Index at post-treatment (8 weeks), and (ii) standardised ADL observations (trained tasks, untrained tasks, total) at post-treatment and follow-up (20 weeks). A significant improvement in all measures of ADLs was found at post-treatment; results did not remain significant at follow-up.
Note: Lasting transfer effects from trained to non-trained tasks was seen at follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that strategy training for apraxia is more effective, in the short term, than a comparison intervention (occupational therapy alone) for improving performance of activities of daily living following stroke. Further, two non-randomised studies reported significant improvements in activities of daily living following strategy training (significant improvements were not maintained at follow-up in one of these non-randomised studies).

Activities of Daily Living (ADLs) – patient perception
Not effective
1b

One high quality RCT (Donkervoort et al., 2001) investigated the effect of strategy training for apraxia on self-perception of activities of daily living (ADLs) following stroke. The high quality RCT randomised patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training integrated with occupational therapy or occupational therapy alone. Self-perception of ADLs was measured using an ADL judgement list scored by the patient at post-treatment (8 weeks) and follow-up (3 months post-treatment). No significant between-group difference was found at either timepoint.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that strategy training for apraxia is not more effective than a comparison intervention (occupational therapy alone) for improving individuals’ perception of their ability to perform activities of daily living following stroke.

Apraxia
Not effective
1b

One high quality RCT (Donkervoort et al., 2001) and two non-randomised studies (van Heugten et al., 1998; Geusgens et al., 2007) investigated the effect of strategy training for apraxia on apraxia following stroke.

The high quality RCT (Donkervoort et al., 2001) randomised patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training integrated with occupational therapy or occupational therapy alone. Apraxia was measured using the Apraxia Test (object use, gesture imitation) at post-treatment (8 weeks) and follow-up (3 months post-treatment). No significant between-group difference was found at either time point.

The first non-randomised study (van Heugten et al., 1998) assigned patients with acute/subacute left hemisphere stroke and apraxia to receive strategy training. Apraxia was measured at post-treatment (12 weeks) using a 2-item assessment adapted from De Renzi evaluating use of objects and imitation of gestures. A significant improvement in was found.

The second non-randomised study (Geusgens et al., 2007) assigned patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training of activities of daily living. Apraxia was measured by the Apraxia Test at post-treatment (8 weeks). A significant improvement was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that strategy training for apraxia is not more effective than a comparison intervention (occupational therapy alone) for improving apraxia following stroke.
Note: However, two non-randomised studies found a significant improvement in apraxia following strategy training. Results suggest that strategy training is as effective as occupational therapy alone for improving apraxia following stroke.

Motor function
Not effective
1b

One high quality RCT (Donkervoort et al., 2001) and two non-randomised studies (van Heugten et al., 1998; Geusgens et al., 2007) investigated the effect of strategy training for apraxia on motor function following stroke.

The high quality RCT (Donkervoort et al., 2001) randomised patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training integrated with occupational therapy or occupational therapy alone. Motor function was measured using the Functional Motor Test at post-treatment (8 weeks) and follow-up (3 months post-treatment). No significant between-group difference was found at either time point.

The first non-randomised study (van Heugten et al., 1998) assigned patients with acute/subacute left hemisphere stroke and apraxia to receive strategy training. Motor functioning was measured at post-treatment (12 weeks) using an 8-item assessment of contralateral function (trunk balance, shoulder movement, arm movement, grasp and release of a cylinder, grasp and release a dice, tactile sensitivity). A significant improvement in motor functioning was found.

The second non-randomised study (Geusgens et al., 2007) assigned patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training of activities of daily living. Motor function was assessed by the Functional Motor Test at post-treatment (8 weeks). No significant improvement was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that strategy training for apraxia is not more effective than a comparison intervention (occupational therapy alone) for improving motor function following stroke.
Note: Further, a non-randomized study found no significant improvement in motor function following strategy training. However, another non-randomized study found a significant improvement in motor function following strategy training.

Motor impairment
Not effective
1b

One high quality RCT (Donkervoort et al., 2001) investigated the effect of strategy training for apraxia on motor impairment following stroke. The high quality RCT randomised patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training integrated with occupational therapy or occupational therapy alone. Voluntary movement of the affected limbs was measured using the Motricity Index at post-treatment (8 weeks) and follow-up (3 months post-treatment). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that strategy training for apraxia is not more effective than a comparison intervention (occupational therapy alone) for reducing motor impairment following stroke.

References

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Smania, N., Aglioti, S.M., Girardi, F., Tinazzi, M., Fiaschi, A., Cosentino, A., & Corato, E. (2006). Rehabilitation of limb apraxia improves daily life activities in patients with stroke. Neurology, 67, 2050-2. https://doi.org/10.1212/01.wnl.0000247279.63483.1f

van Heugten, C.M., Dekker, J., Deelman, B.G., van Dijk, A.J., Stehmann-Saris, J.C., & Kinebanian, A. (1998). Outcome of strategy training in stroke patients with apraxia: a phase II study. Clinical Rehabilitation, 12, 294-303. https://doi.org/10.1191/2F026921598674468328

Van Heugten, C.M., Dekker, J., Deelman, B.G., Stehmann-Saris, J.C., & Kinebanian, A. (2000). Rehabilitation of stroke patients with apraxia: the role of additional cognitive and motor impairments. Disability and Rehabilitation, 22(12), 547-54. https://doi.org/10.1080/096382800416797

Excluded studies:

Bolognini, N., Convento, S., Banco, E., Mattioli, F., Tesio, L., & Vallar, G. (2015). Improving ideomotor limb apraxia by electrical stimulation of the left posterior parietal cortex. Brain, 138, 428-39.
Reason for exclusion: study compared anodal transcranial direct current stimulation with sham stimulation.

Buchmann, I., Finkel, L., Dangel, M., Erz, D., Harscher, K.M., Kaupp-Merkle, M., Liepert, J., Rockstroh, B., & Randerath, J. (2019). A combined therapy for limb apraxia and related anosognosia. Neuropsychological Rehabilitation. https://doi.org/10.1080/09602011.2019.1628075
Reason for exclusion: case study (n=2)

Edmans, J.A., Webster, J., & Lincoln, N.B. (2000). A comparison of two approaches in the treatment of perceptual problems after stroke. Clinical Rehabilitation, 14, 230-243.
Reason for exclusion: the majority of participants did not present with limb dyspraxia.

Additional references:

Bowen, A., West, C., Hesketh, A., & Vail, A. (2009). Rehabilitation for apraxia: evidence for short-term improvements in activities of daily living. Stroke, 40:e396-e397. https://doi.org/10.1161/STROKEAHA.108.536946

Buxbaum, L.J., Haaland, K.Y., Hallett, M., Wheaton, L., Heilman, K.M., Rodriguez, A., & Gonzalez Rothi, L.J. (2008). Treatment of limb apraxia: moving forward to improved action. American Journal of Physical Medicine & Rehabilitation, 87(2), 149-61. https://europepmc.org/article/med/18209511

Cantagallo, A., Maini, M., & Rumiati, R.I. (2012). The cognitive rehabilitation of limb apraxia in patients with stroke. Neuropsychological Rehabilitation, 22(3), 473-88. http://dx.doi.org/10.1080/09602011.2012.658317

Dovern, A., Fink, G.R., & Weiss, P.H. (2012). Diagnosis and treatment of upper limb apraxia. Journal of Neurology, 259, 1269-83. https://link.springer.com/article/10.1007/s00415-011-6336-y

Koski, L., Iacoboni, M., & Mazziotta, J.C. (2002). Deconstructing apraxia: understanding disorders of intentional movement after stroke. Current Opinion in Neurology, 15, 71-7. https://europepmc.org/article/med/11796953

Landry, J. & Spalding, S. (1999). Assessment and intervention with clients with apraxia: contributions from the literature. Canadian Journal of Occupational Therapy, 66(1), 52-61. https://doi.org/10.1177%2F000841749906600106

Lindsten-McQueen, K., Williamson Weiner, N., Wang, H.-Y., Josman, N., & Tabor Connor, L. (2014). Systematic review of apraxia treatments to improve occupational performance outcomes. OTJR: Occupation, Participation and Health, 34(4), 183-92. https://doi.org/10.3928/2F15394492-20141006-02

Pazzaglia, M. & Galli, G. (2019). Action observation for neurorehabilitation in apraxia. Frontiers in Neurology, 10:309. https://doi.org/10.3389/fneur.2019.00309

Saikaley, M., Iruthayarajah, J., Orange, J., Welch-West, P., Salter, K., Macaluso, S., & Teasell, R. (n.d.) Chapter 14: Aphasia and apraxia rehabilitation (19th edition). Evidence-Based Review of Stroke Rehabilitation. Retrieved from http://www.ebrsr.com/sites/default/files/ch%2014_version19.pdf

van Heugten, C. (2001). Rehabilitation and management of apraxia after stroke. Reviews in Clinical Gerontology, 11, 177-84.

West, C., Bowen, A., Hesketh, A., & Vail, A. (2008). Interventions for motor apraxia following stroke. Cochrane Database of Systematic Reviews, 2008(1), 1-17. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004132.pub2/abstract

Worthington, A. (2016). Treatment and technologies in the rehabilitation of apraxia and action disorganization syndrome: a review. NeuroRehabilitation, 39, 163-74 https://pubmed.ncbi.nlm.nih.gov/27314872/

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