Stroke continues to be one of the leading causes of long-term disability worldwide. Advances in acute management have helped to improve survival rates. However, many stroke survivors are left with significant impairments that impact their ability to perform the activities of daily living (ADLs) independently. One such common and debilitating consequence of stroke is apraxia of daily living (ADL). Apraxia of daily living refers to an acquired impairment in executing learned purposeful actions, frequently resulting from stroke-induced damage to specific areas of the brain responsible for coordinating and planning the movement sequences.
Unlike other motor or sensory deficits post-stroke, ADL manifests as difficulties completing familiar ADLs such as dressing, grooming, preparing food, etc., despite intact motor and sensory abilities. This perplexing phenomenon arises due to the disruptions in the intricate communication pathways between the frontal, parietal, and temporal lobes that enable storage and retrieval of the learned motor programs. The complexity and variability of the symptoms, along with the lack of awareness, make apraxia of daily living challenging to recognize and manage effectively in standard stroke rehabilitation programs. However, there is robust evidence indicating that ADL has many significant detrimental impacts on the regaining of independence in the activities of daily living and overall quality of life after a stroke. Hence, a deeper understanding of various aspects of this unique condition is imperative for improving rehabilitation efforts and outcomes in this population.
Prevalence and Clinical Manifestations
Apraxia of daily living has been estimated to affect almost 30% to 50% of stroke survivors; however, reported prevalence rates show wide variability in the literature secondary to the heterogeneity of study methodologies and populations. According to a comprehensive review by Pizzamiglio et al. (2019), apraxia prevalence estimates ranged widely from 15% in acute stroke settings to as high as 74% in chronic stroke cases. This could be attributed to the difficulties in diagnosing this condition early during the recovery phase when other basic motor and cognitive skills are also affected.
Manifestations of ADL encompass the impairments in adequately performing the commonplace multistep activities smoothly. Clinical presentations are often fluctuating and task-specific, reflecting the complex integrative planning mechanisms. For instance, a study noted that while 80% of stroke survivors could not accurately pantomime brushing their teeth, nearly 94% faced significant trouble lighting a candle (O’Malley et al., 2020). Activities demanding greater sequencing of steps, such as alternating buttoning and unbuttoning a shirt or assembling the parts of objects, pose greater handicaps. The heterogeneity of errors and inconsistency adds to the complications in prompt identification and interventions.
Neuroanatomical Correlates
Recent advances in structural and functional neuroimaging techniques have gained crucial insights into the neural substrates implicated in apraxia of daily living post-stroke. Lesions causing left hemisphere damage, notably involving the frontal-parietal and temporal lobes, are most frequently associated with ADL. Martin et al. (2019) utilized the voxel-based lesion-symptom mapping (VLSM) approach to demonstrate praxis deficits specifically arise due to left hemisphere lesions affecting the frontoparietal connections rather than damage to the exclusive discrete cortical areas.
Furthermore, diffusion tensor imaging (DTI) has revealed ADL symptoms demonstrate strong correlations with the disrupted white matter tracts linking left hemispheric motor, premotor, and supplementary motor regions to the parietal lobe (Waszczuk et al., 2022). The study also found greater declines in the fractional anisotropy values within these tracts, predicted worse error profiles and functionality. This expanding knowledge of the neural correlates underpinning the ADL lays the foundation for the development of imaging-based biomarkers for early detection and neural-targeted interventions.
Impact on the Functional Independence
Beyond motor dysfunction, ADL confers a significant burden on stroke survivors’ capacity to perform the activities pivotal for maintaining independence in daily life. Kongsawasdi et al. (2019) demonstrated that apraxic errors while executing daily tasks were a major determinant of requiring assistance for personal care, mobility, and community living post-hospital discharge. Furthermore, it imposed a substantial caregiver strain in providing supervision for safety concerns during ADL attempts.
Longitudinal data from follow-up studies have revealed that chronic ADL has a detrimental influence on stroke survivors’ functional status, adaptive capacities, and social participation over the period (Norvang et al., 2022). Researchers found that sustained ADL, even one 1-year post-stroke, was predictive of 3-fold higher odds of requiring institutional care compared to those without ADL. This cumulative evidence highlights the need to recognize apraxia early to enable multidisciplinary actions to counter its threats to stroke patients’ functional independence and well-being.
Rehabilitation Strategies and Directions
Despite the high prevalence and significance, management guidelines dedicated specifically to rehabilitating apraxia in daily living remain sparse. Conventional neurorehabilitation programs targeting general motor and cognitive deficits have failed to address the unique mechanisms underlying ADL. In recent years, the the development of tailored interventions utilizing task-specific training, external cues, home-based modules, and virtual reality tools has been very promising (Sun et al., 2023). For instance, a trial using patient-tailored everyday activity training with strategy learning demonstrated persistent improvement in task performance accuracy.
Additionally, using wearable sensors and home-based robotics to provide customized real-time feedback during ADL practice to encourage self-correction of errors has gained much attention (Manjunatha et al., 2021). Progress in elucidating the neural correlates of ADL also promotes possibilities to enhance praxis through non-invasive brain stimulation or virtual reality action observation protocols. Nevertheless, the availability of robust guidelines integrating screening tools, tailored programs, and technologies is imperative to enhance the rehabilitation potential and also reduce the long-term burden among stroke survivors with apraxia.
Caregiver Education and Psychosocial Support
Apraxia of daily living after the stroke places a substantial demand on the caregivers, who must provide supervision and assistance during the daily activities. A study by Gaur et al. (2023) found that caregivers of stroke survivors with apraxia reported significantly greater strain and also distress compared to caregivers of patients without apraxia. They emphasized the vital need to provide proper education and training to caregivers on the techniques to support their loved ones’ engagement in daily tasks. Additionally, Ghezelbash et al. (2021) highlighted that addressing caregiver stress and enhancing their coping skills through formal psychosocial interventions also facilitates better management of the patients’ apraxia symptoms. They advocated for improved integration of caregiver well-being components and patient-focused rehabilitation efforts targeting the apraxia of daily living post-stroke.
A key priority in managing apraxia should be providing comprehensive training to caregivers on the techniques to assist with daily tasks while promoting the patients’ active participation. Structured modules covering strategies like verbal cueing, gestures, physical guidance, and checklists can empower caregivers to play an enabling role in rehabilitation. Pilot trials delivering such standardized caregiver training programs through in-person workshops and tele-rehab modalities have yielded many promising improvements in caregiver preparedness, competence, and reduced burden levels Gaur et al. (2023). Furthermore, continual progress monitoring through questionnaires and interviews is vital to ensure the training adequately addresses their evolving needs and challenges over the patient’s recovery trajectory.
Besides competency-based education models, embedding formal psychosocial interventions within the apraxia rehabilitation processes is imperative to promote caregiver adjustment and coping. Example initiatives may include individual or group counseling focused on stress management, peer support meetings, mindfulness, and relaxation techniques. A clinical trial by Ghezelbash et al. (2021) incorporated such a multi-component psychosocial caregiving program added to the usual occupational therapy for apraxia, which led to significant positive effects on lowering anxiety, depression, and also improving the caregiving self-efficacy at 3-month follow-up. Hence, an integrated biopsychosocial framework prioritizing the holistic needs of both stroke survivors with apraxia and their caregivers is the key to enabling optimal rehabilitation progress and community reintegration.
Conclusion
In essence, apraxia of daily living is increasingly recognized as a distinct phenomenon that adds unique challenges for a significant proportion of stroke survivors in regaining the independence lost due to the disrupted ability to perform everyday tasks competently. Advances made towards decoding its clinical manifestations, neural mechanisms, and long-term impact have forged many paths for specialized diagnostic and therapeutic approaches. Nevertheless, the availability of screening tools and standardized interventions remains inadequate relative to the scale of issues imposed by the ADL. Further research addressing these gaps, coupled with increased awareness among clinicians, holds great promise to improve stroke rehabilitation efforts targeting this complex yet common condition.
References
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