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The excessive pressor response triggered in patients by an alerting reaction to a doctor's presence has been termed the "white coat effect." A 68-year-old man with verbal apraxia after multiple lacunar infarctions was referred to the hospital for speech rehabilitation. He experienced difficulty in talking with the speech therapist during therapy sessions but not when talking with his friends or family. Because the therapist's presence was stressful to the patient, it was considered that his anxiety might produce an excessive increase in blood pressure. Blood pressure monitoring was performed during 2 separate days of speech therapies consisting of two sessions each. In one session, therapy was directed by the therapist; in the other, therapy was self-directed. The therapist-directed approach substantially increased both systolic and diastolic blood pressures, whereas the self-directed therapy slightly increased only systolic pressure. It was concluded that the excessive pressor response seen in this patient during therapist-directed speech therapy resulted from the white coat effect induced by the therapist's presence.

Objective: Evaluation of a therapy programme for stroke patients with apraxia. The programme is based on teaching patients strategies to compensate for the presence of apraxia. This programme was designed for assessment and treatment by occupational therapists., Design: The outcome was studied in a pre-post test design. Measurements were conducted at baseline and 12 weeks later., Subjects: Thirty-three stroke patients with apraxia were treated at occupational therapy departments n general hospitals, rehabilitation centres and nursing homes., Main Outcome Measures: The following measurements were conducted: an apraxia test, a motor functioning test, observation of activities of daily living (ADL), Barthel Index, and an ADL questionnaire for the therapist and the patient., Results: The patients showed large improvements in ADL functioning on all measures and small improvements on the apraxia test and the motor functioning test. The effect sizes for the disabilities, ranging from 0.92 to 1.06, were large compared to the effect sizes for apraxia (0.34) and motor functioning (0.19). The significant effect of treatment is also seen when individual improvement and subjective improvement are considered. Measured with the Barthel Index for instance, 71% of the patients improved., Conclusions: These results suggest that the programme seems to be successful in teaching patients compensatory strategies that enable them to function more independently, despite the lasting presence of apraxia.

Hypoxic brain injury can be a complication following several well known situations or disorders. The neurological and neuropsychological characteristics of patients who suffer hypoxic brain injury depend on the mechanism of injury and the structures of the brain that are particularly vulnerable to hypoxia. Injury to the hippocampus with resultant memory impairment is a well described clinical feature. Motor apraxia has not been described as a common feature following hypoxic injury. This paper describes an unusual case of hypoxic brain injury that resulted from an anaphylactic reaction to hymenoptera venom. The patient presented with severe ideomotor apraxia as he emerged from coma after cardiorespiratory arrest. Surprisingly, the patients memory was relatively preserved in relation to other cognitive impairments. A brief discussion of the pathophysiology of hypoxic brain injury and the patient's rehabilitation outcome is presented.

Excitability of functionally different alpha-motoneurons was studied in 62 patients with gunshot injuries of nervous trunks of lower extremities both before and during process of rehabilitation by means of physical factors. The correlation of reactions of spinal cord motoneurons and the degree of injuries of nervous trunks was observed. Neuroapraxia of nervous trunks was accompanied by multidirectional alterations in reflex activity of large and small alpha-motoneurons. It was depressed in axonothermesis and lost in simultaneous full anatomic interruption of ischiatic nerve and trunks of both fibular and tibial nerves. Under influence of physical factors the function of motoneurons was normalized in neuroapraxia and was improved in axonothermesis of nervous trunks.

Objectives: The purpose of this study was to determine whether persons with developmental dyspraxia and apraxia make similar errors during the performance of four types of tasks., Method: Three groups of subjects with dyspraxia or apraxia (i.e., children with learning disabilities and dyspraxia, young adults with learning disabilities and dyspraxia, older adults with left-hemisphere brain damage with apraxia) and three groups of age-matched control subjects (i.e., children, young adults, older adults) were observed performing transitive, intransitive, verbal command, and imitation tasks. Performance was scored on the basis of the types of errors made. Errors were classified as conceptual (nonrelated, unrecognizable, sequencing) or production (omission, perseveration, related, internal configuration, external configuration, incorrect movement, body part as object)., Results: No significant difference was found between conceptual and production error patterns for any group. In addition, there was no significant difference between the dyspraxia and apraxia groups or among the control groups on the specific types of production errors made. However, the dyspraxia and apraxia groups differed in the type of conceptual error made on the intransitive task. The body-part-as-object error was the most frequently made error on the transitive, verbal command, and imitation tasks, whereas the movement error was the most frequently made error on the intransitive task., Conclusion: Subjects with dyspraxia or apraxia make similar errors, suggesting that the praxis behaviors are similar.

Objectives: The purpose of this study was to examine the performance of persons with right cerebrovascular accident (RCVA) and persons with left cerebrovascular accident (LCVA) on a variety of measures of praxis and visual perception in order to examine the relative contributions of the left and right cerebral hemispheres to praxis and perception., Methods: Forty-five subjects, 15 with RCVA, 15 with LCVA, and 15 without CVA (control subjects), were tested on three tests of praxis-praxic production, gesture comprehension, and gesture discrimination-and selected tests of visual perception, including the Judgement of Line Orientation Test, the Motor Free Visual Perception Test, the Hooper Visual Organization Test, and the Line Bisection Test., Results: Subjects in both groups with CVA performed more poorly on all of the tests than did control subjects. The group with LCVA performed most poorly on tests of gesture comprehension and praxis production, whereas the group with RCVA performed most poorly on tests of gesture discrimination and visual perception., Conclusion: These findings suggest that both the right and left cerebral hemispheres contribute to different aspects of praxis. Elements of visual perception may be related to gesture comprehension, gesture discrimination, and praxis production in adults who have had stroke. These findings have clinical implications regarding instructional style and perceptual and praxic training.

Previous comparisons of constructional apraxia after right and left hemisphere damage have not investigated the influence of time since onset. This paper reports some preliminary findings from stroke patients in a physical rehabilitation trial. Fifty-five patients with right hemisphere damage and 65 with left hemisphere damage were assessed on the WAIS-R Block Design test at 1 month and 6 months post stroke. The groups were similar at 1 month but the left hemisphere group showed better average recovery by 6 months. There was great variability in amount of recovery within the left hemisphere group, suggesting individual differences in initial reasons for failing Block Design, and corresponding differences in the recovery process. Compensation by the right hemisphere is discussed as one possible process. Future detailed longitudinal studies may be useful in contrasting the cognitive deficits which underlie constructional apraxia after right-sided and left-sided lesions, and would provide evidence on mechanisms of recovery and adaptation.

The indications for a specific rehabilitation training programme for elderly stroke patients are discussed. Special symptomatology, such as hemi-anesthesia as a result of a damaged perceptual process, apraxia including apraxia of dressing, communication disorders and affective disorders are presented. The measures to be taken for effective rehabilitation in hospital, in an institution for the elderly or in the home care situation are indicated. In addition, the physician has to have marked ability for empathic comportment.

A speech-language pathologist describes how she uses oral myofunctional therapy techniques in the treatment of speech articulation disorders, voice disorders, stuttering and apraxia of speech. Specific exercises are detailed.

Objectives: Treatment protocols derived from research literature can help therapists provide more rigorous treatment and more systematic assessment of client progress., Method: This study applied research findings about the influence of task, subject, and feedback parameters on adult performance with block designs to an occupational therapy treatment protocol for parquetry block assembly--an activity occupational therapists use to remediate constructional deficits. Task parameter research suggests that parquetry tasks can be graded according to the features of the design cards, with cards having all block boundaries drawn in being easier than those with some block boundaries omitted., Results: Subject parameter findings suggest that clients' lesions and initial constructional competence can influence their approaches to parquetry tasks., Conclusion: Feedback parameter research suggests that a combination of perceptual and planning cues is most effective for parquetry tasks. Methods to help clients transfer constructional skills from parquetry to functional tasks are also discussed.

Object manipulation skills are a vital area for client assessment in occupational therapy, but in-hand manipulation skills are not specifically included in any standardized tests of hand function for children. The In-Hand Manipulation Test (IMT) was developed for use by occupational therapists with preschool and young school-age children. Assessment of the IMT's content validity was an important precursor to further development of the test. Twenty-four certified occupational therapists rated young children's performance during administration of the IMT before completing a content validity survey about the test. Overall, the IMT's content validity was supported by the feedback from the raters. A final test length of 50 items with two trials per item was considered acceptable, provided that the test takes no longer than 20 to 30 min to administer. The therapists were positive about the content and structure of the rating scale and the approach used in presenting activities to the children. Some issues related to functional validity of some skills or the proportions of in-hand manipulation skills were raised. Further development of the IMT for clinical and research use seems warranted. Revisions to the test will be made, and another pilot study will be conducted before normative data collection. Training for administering and scoring the test will incorporate the recommendations on the basis of this study's results.

This paper introduces a practice model based on the occupational adaptation frame of reference (Schkade & Schultz, 1992). The occupational adaptation practice model emphasizes the creation of a therapeutic climate, the use of occupational activity, and the importance of relative mastery. Practice based on occupational adaptation differs from treatment that focuses on acquisition of functional skills because the practice model directs occupational therapy interventions toward the patient's internal processes and how such processes are facilitated to improve occupational functioning. The occupational adaptation practice model is holistic. The patient's occupational environments (as influenced by physical, social, and cultural properties) are as important as the patient's sensorimotor, cognitive, and psychosocial functioning and the patient's experience of personal limitations and potential is validated. The integration of these concepts drives the treatment process. Through a description of treatment with a variety of patients, this paper presents the model's diversity and illustrates the relationship between the concepts. The occupational adaptation practice model reflects the uniqueness of occupational therapy and integrates the profession's historical practice with contemporary interventions and methods.

This study was designed to obtain a detailed picture of the fine motor requirements in regular elementary school classrooms. This knowledge is critical for occupational therapists in working with children with fine motor and handwriting problems who are main-streamed into regular classes. The allocation of time to fine motor activities and the types of fine motor tasks children are expected to perform in elementary school were investigated through the observation of six elementary school classrooms. A written minute-by-minute record of one whole day's activities in each classroom showed that 30% to 60% of the day was allocated to fine motor activities, with writing tasks predominating over other manipulative tasks. Implications for children with fine motor difficulties include the need for modifications to volume of work, types of tasks, and materials.

This paper describes the organisation and procedures of the Communication Aids Centre for children at the Wolfson Centre, London, including a model for assessment and recommendation of appropriate aids, such as symbol charts, switches and speech synthesisers. Of the children seen over an 18-month period, most had cerebral palsy and two-thirds were wheelchair-dependent. Almost half were assessed before the age of five years. A detailed follow-up of nine children is presented which reveals how long children may have to wait for the provision of an aid in the UK. Possible problems in establishing use of an aid are discussed; these include inadequate training of children and their communication partners. Suggestions for future improvements of communication-aids services are explored.

The main objective of the present study was to assess the efficiency of the melodic intonation therapy (MIT) in the rehabilitation of Romanian aphasics. Eighty predominantly Broca aphasics used the melodic intonation therapy when no other therapy methods were very efficient. The speech therapist intonated the respective word, then together with the patient and finally let him continue alone. The control group counted 80 aphasics and it applied other therapy methods. Each patient, regardless of the group, was tested twice, before and after therapy. Since most of the patients displayed severe language disorders, and other therapy methods failed in rehabilitating them, MIT was considered an efficient method in the early stages of Broca aphasia with bucco-lingual apraxia.

This study investigated patterns of neurodevelopmental dysfunction in children with writing disorders (WD). Records of children, ages 9 to 15 years, referred to a school problems clinic were examined. Using teacher questionnaire information, including ratings of writing legibility, mechanics, rate, linguistic sophistication, and spelling, 99 cases of WD were found. Sixty-three children without WD served as clinic controls. A cluster analysis revealed four discrete subtypes of WD and two non-WD control clusters. The four WD clusters were found to have different patterns of writing and reading characteristics. Neurodevelopmental tests discriminated among the clusters (F = 2.8, p less than .0001), and an examination of neurodevelopmental performance characteristics among the clusters showed different patterns of strengths and weaknesses. An empirically derived subtyping of WD is proposed: WD with fine motor and linguistic deficits, WD with visual-spatial deficits, WD with attention and memory deficits, and WD with sequencing deficits. This subtyping, if confirmed in a population study, may have important diagnostic and therapeutic implications.

There is little information available regarding management of apraxic gait. We present a 61-year-old man with a five-year history of right-sided cerebrovascular accident, apraxic gait, difficulty in walking, and frequent falls. A CT head scan revealed moderate cerebral atrophy, a small lacunar infarction. The patient was unable to initiate walking, was bed ridden and housebound. Traditional gait training and balance exercises failed to improve his gait. Two straight canes were modified by fixing florescent horizontal projections approximately two inches up from the tip of the cane. The patient was instructed to step over the horizontal projected portion, making use of visual cues from the florescent painted projections. The patient became independent with safe ambulation after practicing for approximately three weeks and was discharged home.

The alien hand sign was first described by Brion and Jedynak as a "feeling of estrangement between the patient and one of his hands." The affected hand frequently shows a grasp reflex and an instinctive grasp reaction as well as elements of what Denny-Brown referred to as a "magnetic apraxia" associated with frontal lobe damage. Most notably, however, the affected hand is observed to perform apparently purposive behaviors that are perceived as being outside the volitional control of the patient. The patients interpret the behavior of their own affected limb as being controlled by an external agent. They do not feel that they are initiating or controlling the behavior of the hand and often express dismay at the hand's "extravolitional" activity. The patients attempt to control behavior of the alien hand with the unimpaired hand by forcibly restraining the affected limb, an act that may be termed "self-restriction." In this paper, we report an additional four cases of alien hand sign in right-handed subjects: two involving the right hand and two involving the left hand. In each case, the clinical findings were associated with extensive unilateral damage of the medial frontal cortex of the hemisphere contralateral to the affected hand. Furthermore, the alien movement gradually disappears over the course of 6-12 months after the stroke. These clinical case studies are presented and discussed in the context of the "dual premotoer systems hypothesis," an anatomicophysiological model that proposes that action is organized by two separate but interactive premotor brain systems corresponding to evolutionarily defined medial and lateral cortical moieties. It is hypothesized that the alien mode behavior results from unconstrained activity of the lateral premotor system in the damaged hemisphere. The residual volitional control in the limb occurs through the activity of the intact medial premotor system of the ipsilateral hemisphere. Recovery may occur through extension of these ipsilateral control mechanisms by compensatory changes in subcortical systems controlling hemispheric activation associated with adaptive behavior. This observation may be important in understanding mechanisms involved in motor recovery after stroke.

The present retrospective analysis reports two studies. In Study 1, clinical aspects of aphasia are compared in right-handed (RH) and non-right-handed (NRH) patients; in Study 2, recovery from aphasia is compared in RH and NRH aphasic patients with a minimum of 5 months of daily language rehabilitation. From a continuous series of 1200 brain-damaged subjects, 24 NRH patients with a vascular lesion documented by computerized tomography were selected. In 19 cases the lesion was in the left hemisphere and in 5 cases in the right hemisphere. For 14 NRH patients, a RH subject with similar lesion, matched for age, education, length of illness, etiology (ischemic vs. hemorrhagic), and, when possible, sex was found. Presence and type of aphasia were compared in the two patients of the same pair and were found similar except for Pair 14; the RH subject had global aphasia and the NRH had conduction-like aphasia. Fifteen NRH patients were rehabilitated and reexamined at least 5 months after the first examination. Recovery of the 12 patients with a left-hemisphere lesion was compared with recovery of a group of RH subjects and no significant differences were found. Recovery of the three patients with right-hemisphere lesions is described. It is concluded that differences in type of aphasia and recovery between RHs and NRHs have been overemphasized in the past and must be reconsidered.

This investigation was designed to determine if delayed auditory feedback (DAF) might have a facilitating effect on dyspraxic speech. Five subjects with dyspraxia of speech and minimal aphasic involvement were used. Two reading tasks were administered under conditions of DAF and no DAF. Reading tasks were constructed of 24 monosyllabic words with initial consonant clusters and 10 polysyllabic words. Three experienced judges scored word production, consonant cluster production, and 12 types of production errors. Temporal duration of word productions was measured in both conditions. No significant differences between the conditions were found in any of the measured parameters. There was no demonstrable improvement of dyspraxia of speech errors under DAF. Contrary to earlier research, distortions rather than phonemic substitutions were found to be the most frequently occurring articulatory errors.

A previously reported treatment program for patients with severe apraxia of speech suggested that (1) some communicative ability could be restored, (2) it might be feasible to develop home programs from the original program, (3) the complete eight-step continuum may not be necessary, and (4) some patients had difficulty at step 4 in the program. Protocols from four severely apractic patients supported the contention that some communicative ability could be restored using this program. Effective home programs, based on the original program, were successfully developed. The complete program was not needed for two of the four patients. Finally, a methodology for reducing the difficulty at step 4 in the program was discussed.

The right hemisphere syndrome is considered an area bordering on neurology, psychology, and psychiatry, a field today referred to as "neuropsychology". This syndrome as a rule is secondary to a right-hemisphere stroke, and in particular involves spatial disorders and constructional apraxia. Among the spatial disorders, the so-called neglect syndrome can be distinguished, i.e. unilateral spatial disorders pertinent to the left side. The right hemisphere syndrome constitutes an impairment of identification, of synthesizing perceptions that the sense organs, notably the eyes, deliver to the brain. It therefore is not a disturbance of perception, but of the processing of sensory information. The sense organs usually are intact, and there is no dementia. The so-called right hemisphere syndrome is not of scientific interest alone. Rather, in view of appropriate patient management and of not mistaking patients for demented or uncooperative, this syndrome must be diagnosed and treated in an early enough stage. Given correct diagnosis and treatment, the prognostic outlook is better in this syndrome than in the purely motor conditions.

It is becoming accepted that single-case studies can offer important contributions to theoretical aspects of neuropsychology. Such recognition has not been so forthcoming in the field of rehabilitation, where single-case studies can be employed to evaluate neuropsychological treatments. This paper describes behavioural approaches to treatment of the neurologically impaired which include single-case experimental designs that have originated in the field of behavioural psychology. Examples of behaviour programmes for the treatment of apraxia and alexia are provided together with examples of single-case experimental designs used to evaluate memory therapy. The paper concludes with a brief discussion of the role of statistics in single-case studies.

The performance of five aphasics with agraphia and right hemiplegia showing side differences in writing to dictation is reported on. It was found that writing with the paralyzed arm, supported by a writing aid, was better than writing with the left hand. In a control group of aphasics with agraphia, but without hemiplegia, such side differences were not found. The conclusion is drawn that in aphasia with hemiplegia the lesions intersect the path between the graphic region of the dominant hemisphere and the corpus callosum. Therefore the observed syndrome is termed "Graphic Disconnection Syndrome."

The purpose of this study was to gain further insight into the normal development of praxis in children and to identify some of the learning strategies used by children during a motor-sequencing task. I analyzed the errors made by kindergarten and third-grade children during a motor-sequencing task and their reported memory strategies. I studied the following three groups of children: kindergarteners who could not learn the motor-sequencing task, kindergarteners who did learn the task, and third graders. The groups were significantly different with respect to age, their ability to perform a cognitive sequencing task, the number of perseverations made during the motor task, and the time required to perform a correctly recalled motor sequence. The kindergarteners tended to use kinesthetic coding for recall, and third graders more often used verbal rehearsal. The notion that motor sequencing develops along an orderly continuum with increasing age was supported. The results suggest that when teaching children motor-sequencing tasks, learning is enhanced by using verbal rehearsal of relevant movement labels.

American Indian sign, used as a gestural communication system for the speechless, served the daily life needs of patients with a variety of deficits, many with unfavorable prognosis for oral speech rehabilitation. The project included total glassectomees, laryngectomees, dysphonics, dysarthrics and apraxics. Many of the last named were hemiplegics. The sign was effectively interpreted by hospital personnel, patients and visitors, none of whom had received any instruction in interpreting the sign. This system may be a desirable new tool from an old culture for the professional repertoire of the speech clinician. An illustrated manual and instructional videotapes are in preparation.

Although identifying descriptions of apraxia are numerous in recent literature, few articles present guidelines for apraxia therapy. In this paper, several therapeutic techniques for apraxia are introduced and discussed. Sequencing of speech sounds is recognized as the apraxic patient's most characteristic problem. Rapid repetition of consonant plus /a/, build-up of speech sounds into syllables, and word attack by phone and syllable are all recommended for the purpose of improving sequencing. Facilitation techniques are discussed for the acquisition of articulatory postures. Case histories are presented to illustrate the therapy approach.

The degree of self-care in 120 patients who had suffered unilateral cerebrovascular accident (CVA) was assessed at different stages of recovery. The level of ADL (activities of daily living) function was determined on admission and discharge. Patients with right-sided hemiplegia (r. hem.) were given a set of apraxia tests on admission to the hospital. The results of ADL evaluation showed improved ADL function between admission and discharge, but a worsening after returning home. There were some significant relationships between ADL function in hospital and apraxia. All the apraxia variables are significant as predictors of subsequent dependency. The results show the seriousness of problems related to apraxia in rehabilitation of stroke patients with a lesion in the left hemisphere. One conclusion is that the treatment procedure ought to be directed to the various symptoms of apraxia. The effect of apraxia on ADL in the domestic situation has to be given more attention. More treatment should be given in the home, as patients seem to have difficulty in transferring the skills learned in hospital to the home situation and in maintaining them.