Rehabilitation Outcome Following Acute Stroke: Considering Ideomotor Apraxia

Abstract

Stroke is a leading cause of death and the leading cause of adult disability in the United States affecting approximately 795,000 people yearly. Stroke sequelae often span multiple domains, including motor, cognitive, and sensory subsystems. Impairments can contribute to difficulty participating in activities of daily living (ADLs) and translate into disability - a concern for patients and occupational therapists alike. The role of ideomotor apraxia (IMA) in stroke rehabilitation is unclear. Thus, the purpose of these two studies is to investigate stroke rehabilitation outcome while considering the presence of ideomotor apraxia. Stroke causes dysfunctional movement patterns arising from an array of potential etiologies. Agreement exists that understanding the patient's functioning serves as the basis for the rehabilitation process and it is insufficient for clinicians simply to determine functional movement problems without knowing how underlying impairments contribute. Stroke-induced paresis is a prevalent impairment and frequent target of traditional rehabilitation. Stroke rehabilitation often addresses paresis narrowly with little consideration for other stroke consequences. Ideomotor apraxia is one such disorder after stroke that could conceivably limit rehabilitation benefit of otherwise efficacious treatment interventions aimed at remediating paresis. This led us to an initial study of a subject who experienced a single left, ischemic stroke with paresis of his right upper extremity and comorbid ideomotor apraxia. The subject participated in combined physical and mental practice for six consecutive weeks to improve use of his right arm. After intervention, the subject demonstrated clinically significant improvements in functional performance of his more-affected right upper extremity and reported greater self-perception of performance. The subject continued to demonstrate improvements after four weeks with no intervention and despite persistent IMA. This single case report highlights the importance of recognizing that ideomotor apraxia does present after stroke, and traditional stroke rehabilitation efforts directed at paresis can be efficacious for subjects with IMA. Traditional beliefs suggested that ideomotor apraxia does not translate to disability in everyday life and that IMA resolves spontaneously. Despite accumulating evidence of the influence of IMA on functional ability, this topic remains relatively neglected. It is unclear how ideomotor apraxia affects the rehabilitation process. The second study reports rehabilitation outcomes of a group of subjects following acute stroke. The Florida Apraxia Battery gesture-to-verbal command test was used to detect IMA in subjects. Level of independence with a set of ADLs and motor impairment of the more-affected upper extremity was documented at admission and discharge. Study subjects participated in standard of care stroke rehabilitation in the inpatient rehabilitation units. A total of fifteen subjects who sustained a left hemisphere stroke participated in this study - ten with IMA and five without IMA. After rehabilitation, subjects with IMA improved ADL independence and displayed decreased motor impairment of their right upper extremity. Subjects with and without IMA exhibited comparable improvements in ADL independence, but subjects with IMA exhibited less ADL independence upon when compared to subjects without IMA. Additional findings suggested that subjects with IMA were not different with respect to motor impairments and length of stay; however, additional studies with larger sample sizes are needed. In summary, these two studies aid to elucidate the implications of ideomotor apraxia on traditional stroke rehabilitation efforts. Study subjects with ideomotor apraxia after acute stroke still derive benefit from traditional rehabilitation. Because traditional rehabilitation interventions narrowly target motor impairment, these findings support the need for considering IMA as a factor in developing interventions tailored to patients with IMA and possibly as a specific focus for interventions. A step toward addressing this need is to assess whether IMA is present after stroke on a regular basis. This work provides a framework for researchers and clinicians to investigate further how ideomotor apraxia translates into disability. These findings are important since consideration of ideomotor apraxia could influence selection and design of rehabilitation interventions to optimize patient daily functioning after stroke.