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MANAGEMENT OF APPAXIA IN

STROKE
CONTENTS
1. INTRODUCTION
2. ANATOMY
3. AETIOLOGY
4. PATHO PHYSIOLOGY
5. PATHOLOGHY
6. CLINICAL MANIFESTATION
7. DIAGNOSTIC PROCEDURES
8. MEDICAL MANAGEMENT
9. ASSESMENT
10. TYPE OF APROXIA
11. PHYSIO THERAPY MANAGEMENT
i. THERETICAL FRAME WORK
ii. TREATMENT

12. HOME CARE

13. COMPLICATIONS
14. CASE STUDIES

15. CONCLUSTION

16. BIBLIOGRAPHY
INTRODUCTION
INTRODUCTION
 Stroke is a neurological deficit of cerebrovascular cause that persists beyond 24hrs or
is interrupted by death within 24hrs

 Stroke is the third leading cause of the death and the most common cause of disability
among adults 30 to 40% of the survivors after stroke are estimated to have significant
disability.

 Degree of disability that fallows a stroke depends upon which area of the brain is
damaged.

 They include motor disability or paralysis, sensory disturbances including pain,


problem using or understanding language. [Problem with orientation, memory &
emotional disturbances. ]Cognitive & perceptual dysfunctions.

 With the resent medical and surgical advances the death rate of primary stroke is
reducing drastically and with advances in physiotherapy they are able to overcome the
motor disability.

 In sub acute stage of stroke, where the recovery is quite rapid and maximum by
functional re organization of the CNS (functional induced plasticity) occurs. The
stimulation from active rehabilitation and an enriched environment plays an important
part in brain repair and recovery. Thus apraxia management at this stage plays a
major role in rehabilitation.

 But, the main them of rehabilitation is making the person independent, this primary
goal is not being attained in the person in whom MIDDLE CEREBRAL ARTERY is
involved.

 Lesions of the right parietal lobe of the non dominant hemisphere (usually the right
hemisphere) typically produce PERCEPTUAL DISSORDERS [Unilateral neglect,
agnosica apraxia and disorganization]
 Among the perceptual disorders “APRAXIA” causes disability of “VOLUNTARY
LEARNED MOVEMENTS” mainly affecting the UPPER LIMBS as they perform
wide range of skilled movements and more complex movements. So, if not treated
and neglected person cannot overcome his disability and causes obstacle to fulfill the
goal of rehabilitation
 Praxis is a Greek word which is used to describe the learned ability to plan and to
carry out sequences of coordinated movements in order to achieve an objective.

 Praxis means “action based on will” and comes from Greek words for “doing,
acting, deed, practice.” (Safire 1989.)

 Praxis pertains primarily to the planning of a motor act. It is a process that requires
knowledge of actions and of objects, motivation and intention on the part of the
person.

 It is that ability by which we figure out how much to use our hands in simple task’s
[to play with toys, use a pencil, or fork, build a tower, tidy up a room] or up to
engage in many “human” occupations.

Practice ability includes three components (Ayres V) 79, 1989)

1. Ideation – forming the idea and knowing what to do

2. 2. Motor Planning: organizing the sequence of movement involved in a task.

3. Execution: carrying out the planned movements, smooth sequence.

 Apraxia: a psycho motor defect characterized by the inability to make proper use of
a known object.

 Apraxia is a neurological disorder characterized by loss of the ability to execute or


carry out learned purposeful movements, despite having the desire and the physical
ability to perform the movements.

 Researcher’s interest in praxis arose from investigations with adults who had
sustained traumatic brain injury, primarily to the left frontal or parietal lobe
resulting in the inability to perform voluntary or goal directed actions (Frederick’s
and Saladin 1996)
The Aim of the Project
The present project is a descriptive study on apraxia in hemiplegics [lesion of the
right parietal lobe of non dominant hemisphere.] and is intended to present the
identification assessment and its management, which is otherwise causing
hindrance to the neurological rehabilitation.

ANATOMY
CIRCULUS ARTERIOSUS OR CIRCLE OF WILLIS
 IT IS AN ARERIAL CIRCLE SITUATED IN THE
INTERPEDUNCULAR CISTERN at the base of the brain.
 It is formed anteriorly by the anterior communicating artery
 Anterolaterally by the anterior cerebral arteries,
 Laterally by the posterior communication
The middle cerebral artery (MCA)
 The middle cerebral artery (MCA) is one of the three major paired arteries
that supplies blood to the cerebrum. The MCA arises from the internal
carotid and continues into the lateral sulcus where it then branches and
projects to many parts of the lateral cerebral cortex. It also supplies blood
to the anteriortemporal lobes and the insular cortices.
 The left and right MCAs rise from trifurcations of the internal carotid
arteries and thus are connected to the anterior cerebral arteries and
the posterior communicating arteries, which connect to the posterior
cerebral arteries.
 The MCAs are not considered a part of the Circle of Willis
BRANCHES:
The middle cerebral artery can be classified into 4 parts
 M1: The sphenoidals egment, so named due to its origin and loose lateral
tracking of the sphenoid bone. Although known also as
the horizontalsegment, this may be misleading since the segment may
descend, remain flat, or extend posteriorly the anterior (dorsad) in different
individuals. The M1 segment perforates the brain with
numerous anterolateral central (lateral lenticulostriate) arteries, which
irrigate the basal ganglia.
 M2: Extending anteriorly on the insual, this segment in known as
theinsular segment. It is also known as the Sylvian segment when the
opercular segments are included. The MCA branches may bifurcate or
sometimes trifurcate into trunks in this segment which then extend into
branches that terminate towards the cortex.
 M3: The opercular segments and extends laterally exteriorly from the insula
towards the cortex. This segment is sometimes grouped as part of M2.
 M4: These finer terminal or cortical segments irrigate the cortex. They
begin at the external of the Sylvian fissure and extend distally away on the
cortex of the brain.
Outer surface of cerebral hemisphere, showing areas supplied by
cerebral arteries. ( Pink is region supplied by middle cerebral artery. )

CEREBRUM:
 Functional divisions
1. Archi cortex
2. Paleo cortex
3. Neo cortex

 Archi cortex:
• It is the core of the brain.
• It is comprised of the hippocamPai formation, which is involved
in learning and memory.
• The archi cortex is believed to be phylogenitically ancient.

 paleo cortex:
• It is the outer layer that sits over the core.
• It includes the para hippocampai. gyrus. it relays information
between the hippocarnpus and other brain regions.

 Neo cortex:
• It is the newest part of the brain phylogenitically.
• It includes primary motor, sensory and association cortices.

ROLE OF CEREBRUM IN MOTOR CONTROL:


 PRIMARY MOTOR AREA:
• It is the pre central gyrus where voluntary / conscious movement is
initiated.
• Cortico spinal tracts originate here.
 LESION:
• Causes loss of voluntary movement to the contralateral body part.
• It may also result in a loss of the ability to implement a specific motor
plan.

 PRE MOTOR AREA:


• Located just anterior to the Primary motor area.
• It has a role in motor Planning or praxis
LESION:
• Causes apraxia or motor Planning difficulties, either the inability to understand
the demands of the task or the inability to access the appropriate motor plan.

 MOTOR ASSOCIATION AREA:


• Also called prefrontal area, located in the anterior frontal lobe.
• It has a role in cognitive planning of movement.

LESION:
• Causes loss of Storage of motor plans.
• Inability to think cognitively about how to carry out a motor task,
which was once known before injury or disease.

CORPUS CALLOSUM:
• It is the largest commeasure in the brain.
• It allows the right and left cerebral hemispheres to communicate with
each other.
• The corpus callosum arches around the anterior horn of the lateral
ventricles.

FUNCTIONS OF CORPUS CALLOSUM


• Fibers in the corpus callosum provide abundant
bi directional neural Connections between most of
the respective Cortical areas of the two hemispheres
except for the anterior portions of the temporal lobes.
• One of the functions of corpus callosum and the anterior commeasure is to
make information stored in the cortex of one hemisphere available to
corresponding cortical areas of the opposite hemisphere.

Etiology
 Stroke is a rapid loss in brain function due to an alteration in blood
supply.
 Atherosclerosis:-is a major contributory factor in cerebrovascular
disease it is characterized by plaque formation with an accumulation of
lipids, fibrin, complex carbohydrates and calcium deposits on arterial
walls that leads to progressive narrowing of blood vessels.
 The most common sites for lesions to occur are at the origin of the
common carotid artery or at its transition into the middle cerebral
artery at the main bifurcation of the middle cerebral artery.

 Cerebral Thrombosis:-Refers to the formation or


development of a blood clot or thrombus within
the cerebral arteries or their branches thrombi lead
to ischemia or occlusion of an artery with resulting
infraction or fissure death

 Cerebral embolus (CE):-are travelling bits of matter


formal elsewhere that are released into the blood
stream and travel to the cerebral arteries where
they lodge in a vessel, Producing occlusion and
infarction.

 Strokes can also be hemorrhagic with abnormal bleeding into extra


vascular areas of the brain secondary to aneurysm or trauma
 Hemorrhage results in increased intracranial pressure with injury to
brain tissues and restriction of distal blood flow.
 Intra cerebral hemorrhage (IH):is caused by rupture of a cerebral
vessel with subsequent bleeding into the brain
 Primary cerebral hemorrhage typically occurs in small blood vessels
weakened by atherosclerosis producing an aneurysm
Subarachnoid hemorrhage (SH):- Occurs from bleeding into the subarachnoid
space typically from a sacular or berry aneurysm affecting primarily large
blood vessels.

Arteriovenous malformation (AVM) is another congenital defect that can


result in stroke.
Arteriovenous malformation (AVM)

Risk Factors
Modifiable:-

 Hypertension
 Type II Diabetes
 Obesity
 Sedentary life style
 Oral contraceptive use
 Smoking – Heavy alcohol use

Non – Modifiable:-

 Hyper Cholesterolemia
 MI
 Age
 Gender – Males are more affected
 Race
PATHO PHYSIOLOGY
PATHO PHYSIOLOGY
THE FIRST HORIZONTAL SCHEMA OF LIEPMANN (1900)

A lesion in the left « sensomotorium » (1) gives rise to a left hemiplegia and
aphasia and to a motor apraxia of the left hand, due to the absence of information
linking the left and right « sensomotorium » via callosal connections

(B). A lesion disconnecting the cortical areas

(C), kinæsthetic images are engrammed, and the left sensomotorium leads to an
ideomotor apraxia of the right hand.
SECOND HORIZONTAL SCHEMA OF LIEPMANN (1920),

Lesions resulting in a dyspraxia of the left hand may be localized in the cortical
motor representation

(1) (1)in the left hemisphere (L.H.), by interruption of callosal


connections

(2, 3) with the right hemisphere (R.H.), or by interrupting


connections

(4) Between occipital (C.o.), parietal (C.p.), temporal (C.t.)


association cortex and the motor cortex of the left hemisphere.

(2) The right hand is paralyzed after lesions at 1 and 2, whereas a


melokinetic apraxia is produced by a less severe lesion at 1a.

(3) A lesion at 4 causes an ideomotor apraxia and more diffuse,


posterior lesions produce ideatory disorders. A lesion of the internal
capsule

(4) Leads to paralysis of the right hand without dyspraxia of the left
hand.
PATHOLOGY
PATHOLOGY
MIDDLE CEREBRAL ARTERY SYNDROME:-

The middle cerebral artery (MCA) is the second of the two main branches of
the internal carotid artery and supplies the entire lateral aspect of the
cerebral hemisphere (frontal, temporal and parietal lobes) and sub cortical
structures, including the internal capsule (Posterior portion) corona radiate,
globuspallidus (Otter part) most of the caudate nucleus and the putamen.

Occlusion of the proximal MCA produces extensive neurological damage with


significant cerebral edema. Increased intracranial pressures typically lead to
loss of consciousness brain herniation and possibly death.

 The most common characteristics of MCA syndrome are contralateral


apastic hemi paresis and sensory loss of the face upper extremity (UE)
and lower extremity (CE) with the face and upper extremity more
involved than the lower extremity.
 Lesions of the parieto – occipital cortex of the dominant hemisphere
(usually left hemisphere) typically produce aphasia.
 Lesions of the right, parietal lobe of the non dominant hemisphere
(usually the right, hemisphere) typically produce perceptual deficits
(unilateral neglect, anosognosia, apraxia and spatial disorganization)
 Homonymous hemianopia (a visual field defect,) is also a common
finding the MCA is the most common site of occlusion in stroke.
Apraxia has a neurological cause that localizes fairly within the parietal lobe,
frontal lobes (especially the pre motor cortex, supplementary motor area,
corpus callosum. )
• In planning movements, previously learned, stored complex representative
movements are used. These three dimenSi0flal, supram0 codes are stored in the
inferior parietal lobule of the left hemisphere.

• It can also occur with lesions in other locations as well. Information


contained in praxis representation is transcoded into innervatory
patterns by the pre motor cortices, including the supplementary motor
area, possibly the convexity of the pre motor cortex.The information is
then tranSffl1tt to the prima motor area after which the movement is
performed.
• Lesions of sensory motor area or other pre motor Cortices also can cause apraxia,
where the knowledge about movement is still present but the ability to perform
movement is absent.
• The corpus callosum is not known to be involved directly in the performance of
skilled movements, significant where the crossing fibres from the right hemisphere to
pre motor cortex.
• The left hemisphere appears to be superior to right in the control of certain types of
complex, sequenced motor acts, if damage is sustained to the left hemisphere, the
patient’s ability to acquire and perform tasks involving skilled movements may be
impaired. Lesions in the left parietal lobe (normally the dominant one) are likely to
produce bilateral apraxia.
• Lesions between this region and the left pre central gyres may lead to apraxia of the
limbs on the right side, and lesions involving the anterior part of corpus callosum or of
the sub cortical white matter on the right side, may cause left sided apraxia. The ability
to isolate joint movement or muscle contraction contributes to the stereo typical
dominant active motor synergies. This loss of fractionation illustrates that the accurate
seletion or sequencing of muscle activation or in activation necessary to perform a task
is impaired.In stroke the part of the brain that contains information for previously
learned skilled motor activities, has been either lost (or) cannot be acessed. The
condition is usually due to an insult to the dominant hemisphere of brain.
Clinical manifestations
Signs:
 Sudeen weakness, numbness or paralysis of the face, arm or legs on one or
both sides of the body.

 Sudden blurred vision or blindness in one or boath eyse.

 Sudden difficulty in speaking, slurring of sppech or difficulty understanding.

 Sudden severe headache with sudden onset that occurs with out apparent
reasons.

 Sudden loss of balance, dizziness or falling with out any apparent reason.

Symptoms:
 Pares is of contra lateral face, arm, and leg (leg is least affected)
Sensory impairment over the contra lateral face, arm, and leg (pain,
temperature, touch, vibration, position, two-point discrimination,
stereo gnosis)

 Motor speech disorder (expressive-aphasia


telegraphic halting speech) Wernicke’s or receptive aphasia
(fluent but often jargon speech, poor comprehension)

 Perceptual problems such as unilateral neglect, apraxia, depth


perception problems, spatial relation difficulties

 Homonymous hemianopia

 Loss of conjugate gaze to the opposite side


 Ataxia of contra lateral limb(s) (sensory ataxia)

 Perceptual problems such as unilateral neglect, apraxias, depth


perception problems, spatial relation difficulties.
DIAGNOSIS

Diagnostic Procedures

Blood Tests
Includes:
complete blood count
blood sugar
cholesterol
fat levels
clotting levels
and a check of other elements in the blood : for analysing the leval of risk.

Blood glucose: a raise in blood glucose after a troke increases infarct size and adversely
affects functional outcome. This is probably because hyperglycemia exacerbates the anaerobic
production of lactic acid in the ischaemic penembra.
Electrocardiogram (EKG) – to measure heart rhythm and check for an irregular
heart beat
Ultrasound– a test that uses sound waves to help determine if there are blockages
in the arteries supplying the brain. And systemic problems.
MRI Scan – a test that uses magnetic waves to make pictures of structures inside
the head
CT Scan – a type of x-ray that uses a computer to make pictures of structures
inside the head
Magnetic Resonance Angiography – performed prior to carotid artery surgery to
determine how much the artery has narrowed. Gadolinium, a type of dye, may beinjected into
your vein for this test
Arteriogram - during a conventional arteriogram, a contrast dye is injected and
x-ray images are produced to precisely locate the blockage and to determine how
much of the artery is blocked. This test is usually only done to confirm the need
for surgery.
Echocardiogram - an ultrasound test that looks for blood clots and valve
abnormalities within the heart.
Electroencephalogram (EEG) - a test that can detect seizures by measuring
brain waves (used only if a seizure is suspected)
MANAGEMENT

Medical Management
a. Steroids/corticosteroids given in full stomach with antacid or H2
receptorAntagonists.
b. Vitamin B complex – promote restitution of function of neurons which have

reversible damage.

c. Cerebral activator/stimulants – stimulate CNS function.

nootrophil- PIRACETAM

encephabol- PYRITINOL HCl

hydergine- CODERGOCRIN

d. Drugs if it is due to thrombus, give ANTI-COAGULANT

heparin- HEPARIN SODIUM

coamadin- WARFARIN SODIUM

e. anti convulsants in case of seizures.

Insuline in case of hyperglycemia.

Aspirin (300mg daily): immediately after an ischaemic stroke and carries a far lower risk
of haemorrhagic complications.

Surgical Management
Endarterectomy – purpose is to remove the atherosclerotic plaque from the inner

lining of the carotid artery.

Extracranial-Incracranial Bypass – bypasses the blocked artery by making a

graft or a bypass from the first artery to the second artery.

Management Of Anteriovenous Malformation - is an interventional therapy to

occlude abnormal arteries or veins and prevent bleeding from the vascular lesions.

Whenever possible the affected vessels are totally removed. The surgeon ligates

the vessels and removes the defect.

Management of Cerebral Aneurism – Aneurysm may be repaired via

craniotomy. Less invasive procedure is interventional Radiology

Management of Intracranial Bleeding – Blood clots are removed via

craniotomy.

NURSING MANAGEMENT

A. Initial nursing objective is to support life and prevent complications.


B. Maintain patient airway and ventilation: elevate head of bed 20 degrees unless

shock is present.

B. Monitor clinical status to prevent complications.

1. Neurological

a. Include assessment of recurrent CVA, increased intracranial

Pressure, hyperthermia.

b. Continued coma: negative prognostic’ sign

2. Cardiovascular: shock and arrhythmias, hypertension.

3. Lungs: Pulmonary emboli.

D. Maintain optimal positioning.

1. During acute stages, quiet environment and minimal handling to prevent

further bleeding.

2. Upper motor lesion--- spastic paralysis, flexion deformities, external rotation

of hip.

3. Position schedule--- 2hours on unaffected side, 20minutes on affected side.

4. Complications common with hemiplegic, frozen shoulder, foot drop.

E. Maintain skin integrity: turn and provide skin care.

F. Maintain personal hygiene: encourage self-help.


G. Promote adequate nutrition, fluid, and electrolyte balance.

1. Encourage self-feeding.

2. Food should be placed in unparalyzed side of mouth.

3. Tube feedings or gastrostomy feeding may be necessary.

H. Administer tube feedings.

I. Promote elimination.

1. Bladder control may be regained within three to five days.

2. Retention catheter may not be part of treatment regimen.

3. Offer urinal or bedpan every two hours day and night.

J. Provide emotional support.

1. Behavior changes as consciousness is regained--- loss of memory, emotional

liability, confusion, language disorders.

3. Reorient, reassure, and establish means of communication.


K. Promote rehabilitation to maximal functioning.

1. Comprehensive program: begins during acute phase and follows through

convalescence.

2. Guidelines to assist client with lesion left hemisphere.

a) Do not underestimate ability to learn.


b) Assess ability to understand speech.
c) Act out, pantomime communication; use client’s term to
communicate; speak in normal tone of voice.
d) Divide tasks into simple terms; give frequent feedback.

4. Guidelines to assist client with lesion right hemisphere.

a. Do not overestimate abilities.

b. Use verbal cues as demonstrations; pantomimes may confuse.

c. Use slow, minimal movements and avoid clutter around client.

d. Divide tasks into simple steps; elicit return demonstration of skills.

e. Promote awareness of body and environment on affected side.


ASSESSMENT

NEUROLOGICAL ASSESSEMENT
A. Demo Graphic Data
Name
Age
Gender
Occupation
Address

B.Chief Complaints

The Patient Should Give His Complains In His Simple Words as Completely As Possible

Vital Signs:

Pulse rate:

Blood preasure:

Temperature:

Respiratory Rate:

C.History

a. Present History:-

This Should Consist Information about the Type of Onset, Whether Acute, Sub acute or
chronic.

 Duration Of The Illness


 Progression Of The Disorder,Stable,Condition Improving Or Deteriorating
 Pain Aggravating Factors And Ceasing Factors
 Any Speech Abnormalities, Any Visual Disturbance
 Bladder And Bowel Problems
 Day To Day Function, Home Situation, Mobility, And Self Care.
b. Past History:-
Past History Could Be Includes Patient Has Gone For Any Surgeries, Any Medications For Others
Conditions And Whether He Has Any Diseases That Has No Related To Present
Condition(I.E.,Diabetes,Hypertension,Allergies Etc.,)And Taking Any Medications For Those Conditions.

D. Pain History:-

Onset

Mode

Type

Side

Site

Durations

Pain Aggravating Factors

Pain Relieving Factors

E. On Observation:-

a. Posture And Attitude Of The Body Parts


b. Atrophy Of Muscle
c. Tropic Changes
d. Involuntary Movements
e. Swelling
f. Certain Abnormal Psychological Features like Depression. Over Excitabilities, Emotional
Liabilities.
g. Contractures and Deformities.

F. On Palpation

a. Tenderness
b. Warmth
c. Crepitus
d. Muscle Spasm
e. Scar: Mobile/Adhere
f. Edema

G. On Examination
A. Higher Function Testing

 Consciousness
 Memory
 Intelligence
 Behavior
 Orientation To Time, Place Etc.,

B. Cranial Nerve Testing

Cranial Nerve Testing Includes Assessing The

 Olfactory
 Optic
 Oculomotor
 Tracheas
 Trigeminal
 Abducence
 Facial
 Vestibule Cochlear
 Glaso Pharyngeal
 Vagus
 Accessory
 Hypoglossal

These Nerves Are Assessed For Their Involvement As Their Affection May Interfere In The
Rehabilitation Process.

A) Sensory Examination:- Evaluation Of Sensory Involvement Gives An Indication About The Severity Of
The Primary Lesion And Also Determine The Extent Of Improvement In These Patients.

The Following Sensory Involvement Should Be Carried Out:

 Superficial: Crude Touch, Fine Touch.


 Deep: Pressure, Proprioception, Kinesthetic and Vibration Sensation.
 Cortical Sensation: Tactilelocalization, Localization, Discrimination, Stereognosis.

B) Motor Examination:-

 Tone
 Ram
 MMT
 Contractures And Deformities
 Muscle Girth, Limb Length
H. Reflexes

The Common Deep Reflexes:

 Biceps
 Triceps
 Ancones
 Knee
 Ankle

Superficial Reflexes:

 Corneal Reflex
 Cremastic Reflex Are Tested
I. Balance and Cardinal Assessment

Various Equilibrium And Non Equilibrium Test Should Be Done For Coordination And Romberg Test
Should Be Done For Balance Assessment.

J. Posture:

The Posture of the Neurological Disabled Person Should Be Assessed

K. Functional Assessment:

The Activities Of Daily Living Needs To Assess By Barthel Index.

L. Investigations:

M. Diagnosis:

N. List of Problems:

O. Physiotherapy Treatment in Aims, Means


Scale of Assessment

Tone Grading:-

 O – No Response
 1+ - Decreased Response
 2+ - Normal Response
 3+ - Exaggerate Response
 4+ - Sustained Response.

Modified Athwart Scale for Spasticity Grading:-

 O – No Increase In Muscle Tone


 1 – Slight Increase In Muscle Tone
 1+ - Slight Increase In Muscle Tone(Less Than Half Of Rom)
 2 – More Marked Increase In Muscle Tone Through Most Of The Rom
 3 – Considerer able Increase in Muscle Tone, Passive Movement Difficult.
 4 – Affected Parts Rigid In Flexion Or Extension.

Reflex Grading:-
 O+ - Absent
 1+ - Tone Charge, Slight, Transient with No Movement of Extremities.
 2+ - Visible Movement of Extremities.
 3+ - Exaggerated, Full Movement Of Extremities
 4+ - Obligatory And Sustained Movement, Lasting For More Than 30 Sec.,

Voluntary Control Testing:-

Grade O – No Contraction or Flicker or Initiation.

Grade I – Flickes of Contraction Present or Imitation of Movement.

Grade II – Half Range of Motion in Synergy or Abnormal Pattern.

Grade III – Full Range of Motion in Synergy or Abnormal Pattern.

Grade IV – Initial Half Range Is Performed In Isolation and the Latter Half in Pattern

Grade V – Full Range Of Motion In Isolation But Goes Into Pattern When Resistance Is Offered.

Grade VI – Full Range of Motion in Isolation against Resistance.

Barthel Index
Activity

Feeding:-

O=Unable

5=Needs Help Cutting, Spreding Butter Etc.,

or Required Modified Diet


10=Normal or Independent

Bathing:-

O=Dependent

5=Independent or In Shower

Grooming:-

O=Needs To Help With Personal Care

5=Independent (Face/Hair/Teeth/Shaving)

Dressing:-

O=Dependent

5=Needs Help But Can Do About Half Unaided

10=Independent (Including Buttons, Zips, Laces)

Bowels:-

O=Incontinent (Or Needs To Be Given Enemas)

5=Occasional Accident
10=Continent

Bladder:-

O=In Continent or Cachet Erized and Unable To Mange Alone

5=Occasional Accident

10=Continent

Toilet Use:-

O=Dependent

5=Needs Some Help, But Can Do Something Alone

10=Independent (On and Off, Dressing, Wiping)

Transfers: - (Bed To Chair and Back)

O=Unable, No Sitting Balance

5=Major Help (One or Two People, Physical) Can Sit

10=Minor Help (Verbal or Physical)

15=Independent

Mobility: - (On Level Surface)

O=Immobile or < 50 Years

5=Wheel Chair Independent, Including Corners>50 Years

10=Walks With Help of One Person (Verbal or Physical)>50 Years

Stairs:-
O=Unable

5=Needs Help

10=Independent

TYPES OF APRAXIA
TYPES OF APRAXIA
There are five of apraxia:

1. verbal apraxia
2. buccofacial or oro facial apraxia
3. Limb apraxia,
4. Constructional Apraxia,
5. Dressing apraxia.

1. VERBAL APRAXIA: The patient will have trouble in coordinating mouth


movements and speech.

2. BUCCO FACIAL OR ORO FACIAL APRAXIA:


Difficulty in carrying out movements on the face o demand.
For Ex: The patient may not be able to whistle or lick wh his lips.

3. LIMB APRAXIA It is characterized by loss of abilitY to make finely graded


precise finger
of limb
movements. There are six types
apraxia:
a. Limb kinetic
b. IdeomotOr
c. Ideational
d. Dissociation
e. Conduction and
f. Conceptual
Limb apraxia is usually associated with left brain damage in right handed patients
and right brain damage in left handed patients.
4. CONSTRUCTIONAL APRAXIA:

It has to do with the translation of an object from one spatial dimension to another.
The defect appears to be in poor conceptualization of the spatial requirements of
certain activities.
The person in copying simple pictures or diagrams. When attempting to write there
may be crowding and obliquity of the words.

Difficulty with arithmetic may be evident, or telling the time, sewing or


constructing a model when copying a figure, one half may be left out.

i The person may be unable to interet maps or find their way about {
topographagnosia)
There are two types of constructional activities used in assessment
Graphic: e. g copying line drawings and drawing
to commands.

Assembly tasks: e. g Block and stick designs.

5. DRESSING APRAXIA: it refers to inability to dress one self.


It is evaluated functionally by watching patients dress themselves.
The dressing problem includes the tasks of dressing the upper part of the body,
including Putting on items such as under wear, t-shirts, pullovers, sweaters, shirts,
bra’s, cardigans, or dresses, putting on pants, socks, panty, hose, shoes and
manipulating fasteners, such as Zippers, buckles, laces, arm into the sleeve Until
the end of the sleeve is up to the elbow or Shoulder.

An individual may Place both legs in the se leg hole or may not perceive that one
of the leg holes is turned inside out.
An individual may put the right shoe the left foot.

The individual may be unable to tie shoe laces because of difficulty in handling the
spatial relations aspects of manipulating shoe strings.

KINETIC OR MOTOR OR INNERVATORY APRAXIA:


In this type the patient will be unable to carry out purposeful deliberate acts,
usually restricted to one extremity without any motor weakness.

Arnadottir has described movements in patients with motor apraxia as clumsy and
inflexible.

Someone with motor apraxia has difficulty in imitating a motor command,


sequencing and orienting elements of a task together.

It may be helpful for the therapist to give only general information about the
activity goal and leave out the specific instructions.

IDEOKINETIC OR IDEOMOTOR OR CLASSIC


APRAXIA:
In this type the idea is correctly formulated but plan fails to reach motor
expression.
It is characterized by diskinesia in which movements in response to commands are
awkward and clumsy, and there is an inability to use sensory feed back to correct
movement errors.

Simple component movements can be carried out, but not the complex movements
requiring a sequence of muscular activities.

Often bilateral and symmetrical.

The patient performs automatic acts normally, such as blowing his nose, shaking
hands, pushing back hair etc,and is able to formulate the idea of an act and to
describe how it Should be done, but when it comes to carlying out the movement
on command, he is unable to do it correctly.
There is a common tendency to substitute a body part for the object, for ex: using
the index finger as a tooth brush rather than pretending to hold one.
IDEATIONAL OR SENSORY APRAXIA:
It involves a disruption in the concept formation of action planning.
• The ability to select and organize movements to execute an action is impaired.
• The patient with ideational apraxia seems confused, stubborn or unco-operative.
• The most striking characteristic of this form of apraxia is the inability to
recognize objects and their uses.

SOME OF APRAXIA LIKE SYNDROMES


SOME OF APRAXIA LIKE
SYNDROMES:
LID OPENING TYPE OF APRAXIA: Difficulty in opening the eye lids.

GAIT APRAXIA: Difficult in starting to walk.

AMNESTIC APRAXIA: Loss of ability to carry out a movement on command due


to in ability to remember the command.

BRUN’S APRAXIA OF GAIT {OR}


COGANS OCCULOMOTOR APRAXIA {OR}
CONGENITAL OCCULOMOTOR APRAXIA:
An absence or defect of horizontal eye movements so that the head must turn and
the eyes exhibit nystagmuS in attempts to see an object off to one side.

CALLOSAL APRAXIA: Left hand inability upon verbal command.


APRAXIA ASSESSMENT
A. IDEOMOTOR APRAXIA:-

The good glass and Kaplan test for apraxia is composed of universally
known movements, such as blowing, brushing teeth, hammering, shaving
and so forth.

 It is based on what the authors consider a hierarchy of difficulty for


patients with apraxia.
 First the patient is told “show me how you would bang a nail with a
hammer” if the patient fails to do this or uses his or her first as if it
were a hammer. The patient is asked, “pretend to hold the hammer”
if the patient fails following this instruction. The therapist
demonstrates the act and asks the patient to imitate it.
 The patient with apraxia typically will not improve after
demonstration but will improve with use of the actual implements.
 Ability to correct oneself on following verbal suggestions is
considered not indicative of apraxia.
B. The therapist sits opposite the patient the patient is asked to imitate
different postures or limb movements
 The patient with apraxia is unable to imitate postures

IDEATIONAL APRAXIA:-

The tests for ideational apraxia are essentially the same for
ideational apraxias are essentially the same as those for ideomotor
apraxia.

The major difference to be expected in response is that the patient with


ideomotar apraxia can perform a motor act spontaneously and
automatically at the appropriate time but the patient with ideational
apraxia is unable to do so.
CONSTRUCTIONAL APRAXIA:-

 The patient is asked to copy a drawing of a house, a flower or a clock


face, figure depicts typical drawings of a house done by patients with
left and right hemisphere lesions.
 The patient is requested to copy geometric designs.(circle, Square, T
shape)
 The patient is instructed to copy block brings, match stick designs or
pegboard configurations. Initially only three pieces are used and a
progression is made to use more.

Visuoconstructive difficulties found with right and left sided lesions


demonstrate qualitative differences in response to the assessment materials,
patient with right sided damage tend to draw on the diagonal and neglect the left
side of the page.

They draw pieces of the picture without any coherent relationship to each other.
Thus their drawings tend to be complex, yet unrecognizable they have immense
difficulty with coping or constructing anything in three dimensions, are not helped
by the presence of a model or by landmarks in a picture and do not generally
improve with practice.

 The drawing of patients with left – hemisphere damage are usually more
recognizable they are characterized by great simplicity.
Patients with left side lesions draw slowly and
hesitatingly are often unable to draw angles and have general difficulty in
execution in contrast to that of patients with right hemisphere stroke, their
performance often improve with the aid of a model.
 The use of landmarks in drawing and with repeated trials short-term visual
memory impairment is thought to be associated with constructional apraxia
in patients with right – sided lesions verbal and comprehension
difficulties, poor manual dexterity and the presence of homonymous
hemianopia must be ruled out during assessment for this disorder.

Factors influencing Assessment:-

1. Psychological and emotional status


2. Poor judgments
3. Anxiety
4. Cultural bias
5. Pre morbid intellectual ability
6. Sensory Assessment

Physiotherapy Management

1. The transfer of training Approach:- The practices in one task with


particular requirements will enhance performance on other tasks with
similar perceptual demands.

2. Sensory Integrative Approach:-Is an effort to explain the relationship


between neural functioning and the behavior of children with sensory
motor or learning problem can be defined as the organization of sensation
for use.

3. Neuro developmental Approach: - Perception is facilitated during normal


infant neuro motor development by the kinesthetic, proprioceptive tactile
and vestibular feedback received through normal movement experience.
4. Functional Approach:-Most widely used in treating perceptual dysfunction
adults with brain trauma will have difficulty in generalizing and learning
from dissimilar tasks.

a. Direct repetitive practice of specific functional skills that are impaired


is an efficient means of enhancing the patient’s independence in
those specific tasks.
b. Compensation:-Refers to changes that need to be made in the
patients approach to tasks.
c. Adaptation:-Refers to alteration that needs to be made in the
human and physical environment in order to facilitate relearning of
skills.

5. Cognitive Rehabilitation:- focuses on training individuals with brain injury


to structure and organized information.
-The functional approach is described as
adoptative or compensatory. Key points in this
approaches:-

a. Remedial Approach:-Focus on patient’s deficits and attempt to


improve functional ability by retraining specific perceptual
components of behavior.
b. Facilitation of or training in, underlying skills will enhance the
recovery or reorganization of deficient CNS functioning.
Bottom up approaches

6. Adaptive/Compensatory Approach:-

a. Direct training in the functional skills that are deficient.


b. Top down approach.
Adaptive Approach Remedial Approach

1. The adult brain has limited potential to 1.The adult brain can repair and
Repair and reorganize itself after injury. Reorganize itself after injury

2. Intact behaviors can be used to 2.This repair and reorganization is


compensating for ones that are impaired influenced by environmental
stimuli.
3. Adaptive retraining can facilitate the 3.cognitive perceptual and sessorimotor
substitution of intact behaviors for exercises can promote brain recovery
impaired once. and reorganization

4. Adaptive ADLs provide training in 4.Cognitive,percepture and


functional behaviors sensorimotor exercises provide
5. Training in specific, essential activities of training in the cognitive and
daily living tasks is necessary because perceptual skills needed for those
adults with brain injury have difficulty exercised.
Seneralizing learning. 5.Remedial training in cognitive and
perceptual skills will be generalized
6. Functional activities require cognitive across all activities requiring those
and perceptive skills skills

7. Adaptation and compensation will lead to 6.Functional activities require cognitive


improved functional performance. And perceptual skills.

7. Cognitive and perceptual


remediation will lead to improved
functional performance.

C. Education:-For the patient, family and friends is essential for continuity of


care. Feed back is essential in the patient own education should be
provided in the form of knowledge of Performance (KP)
TREATMENT:-

IDEOMOTOR APRAXIA AND IDEATIONAL APRAXIA:-

Anderson and Choy suggest the modification of instructional sets as


follows: speak slowly and use the shortest possible sentences.

 One command should be given at a time and the second command


should not be given until the frost task is completed.
 When teaching a new task, it should be broken down into its
component parts:
o One component is taught at a time, physically guiding the
patient through the task if necessary.
o It should be completed in precisely the same manner each
time.
o When all the individual units are mastered, an attempt to
combine them should be made.
o A great deal of repetition may be necessary family members
must be advised to use the exact approach found to be
successful in the clinic. Performing activities in as normal an
environment as possible is also helpful
 Using the sensorimotor approach body parts to enhance the
production of appropriate motor response.

Constructional Apraxia:-with the transfer of training approach, the


patient is asked to practice coping geometric designs, both by
drawing and by building. Initially, simple patterns are used,
progressing to the more complex.
 Patients with left – hemisphere lesions may benefit from the
use of landmarks and then their gradual with drawl as skill
improves.
 The remedial approach has been criticized by nested for its use
of pediatric materials an underlying assumption that the
sequence of recovery from brain injury follows the sequence of
normal child development, and the use of treatment materials
that closely resemble assessment tools.

HOME CARE
HOME CARE
Safety measures Should be taken to
compensate for weakness, confus
deficiencies, or seizures ion, sensonj
that may accompany
this problem.
Participation in normal activities is encouraged.
One should have extreme patience with people who have apraxia.
Take time to demonstrate tasks and allow enough time for person to perform the
task.

Avoid complex directions.


Environmental factors at home should be appropriate.
Colorful things should be placed, such as toys of multiple colors.
Way of communication by the family and parents should be good.

Way of andliflg to patients provides sensory input.


COMPLICATIONS
COMPLICATIONS
Patients with acquired type of apraxia have to face complications during
their training session and it may lead to a high risk of falling.
In case of developmental apraxia, children will have problem in
following the normal psychological motor and social developmental
patterns and they will be always lacking behind when compared to their
peer group, if the early treatment session has not been initiated as early
as possible.

PROGNOSIS
PROGNOSIS
The prognosis for individuals with apraxia varies and depends partly on
the underlying cause.
Some individuals improve significantly while others may show very
little improvement.
Recovery from ideomotor apraxia was better from anterior lesions.
Although less than a third of the patients were followed beyond one-
year, they found improvement occurred beyond six- months.
Age, sex, lesion she, and pe did not seem to be related significantlY to
outcome.

CONCLUSION
Patients who are treated for apraxia in sub acute stage of stroke with physiotherapy
had maximum recovery and more independent and those treated in late stages
developed many perceptual complications like hemineglect thus taking long time
for recovery or sometimes rehabilitation is not successful

Therefore physiotherapy for apraxia in sub acute


stage of stroke preserves manipulative functions of the hand and makes the patient
self dependent.
BIBILOGRAPHY

BIBILOGRAHY
• Neuro Science or Rehabilitation Professional
-sharonA. Gutmen.
• Text book of medical PhysiologyGuyton and Hall.
• Stroke rehabilitation -Glen Gillen, Ann
Burkhardt
• Sensory integration —
Theory and practice (2nd edition)- Anita C Bundy,
Shelly J. Lane,
Elizabeth A. Murray.
• occupational therapy for physical dysfunction (5th
edition) -CatherineA trombly
• Brain and Bannisters -Roger banniser
• physical rehabilitation(4th edition)
-Susan B.O’ Sullivan, Thomas J. SchmitZ.
• BickerstaffS neurological examination in clinical practice (6th edition) - John
Spillane.
• pathophySi010g.Y of motor systems
Christopher M. Fredericks,
Lisa K. Saladin.
• NeurO10g-’ examiflatb01 made up easy (2nd GeriafltFthl
edition)
• eUrOl0g” rehabilitation - Janet Carr,
Shephere(t

Web sites:

• WWW.emedicine.corn
• vw.medlinePlus.com
• www.google.com
• www.Msnsearch.corn

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