Apraxia as a Clinical Marker for Stroke Rehabilitation Outcomes

 

'Assessments' and predictions don't get you recovered, only EXACT PROTOCOLS DO! SURVIVORS WANT RECOVERTY! GET THERE!

I'd fire everyone involved with this crapola! You're 'assessing' based on the failure of the status quo! Change the status quo, you blithering idiots!

Apraxia as a Clinical Marker for Stroke Rehabilitation Outcomes

• Karishma A. Popli, MD, MBE, @karishma_popli

Rounis E, Ramanan S, Bickerton WL, Demeyere N, Lambon Ralph MA. Apraxia as a Predictor of Poststroke Recovery: Insights From the Birmingham Cognitive Screening Program. Stroke. 2025;56:3522–3526.

Although stroke remains a leading global cause of long-term morbidity, the persistent disabilities faced by survivors are not fully captured by the functional recovery measures most frequently used in clinical practice. Cognitive impairments are becoming recognized as key determinants of functional recovery, but several domains remain underassessed despite evidence linking them to prolonged disability and dependence. Limb apraxia, a disorder of skilled and purposeful action not attributable to motor weakness or sensory loss, is one such domain that can affect patient autonomy and safety in routine daily tasks such as grooming, dressing, and tool use. However, comprehensive assessment is challenging due to the time-intensive nature of neuropsychological testing and the heterogeneity of apraxic presentations. As a result, many patients leave acute stroke units without adequate identification of their praxis deficits or corresponding management strategies. Additionally, few studies have deployed broad neuropsychological assessments capable of capturing the range of cognitive deficits, including praxis disturbances, that influence poststroke outcomes or assessed long-term recovery trajectories to help guide poststroke care.

To address these gaps, Rounis et al. analyzed data from the Birmingham Cognitive Screen (BCoS), a large, multicenter stroke cohort in the United Kingdom specifically designed to deliver a time-efficient yet wide-ranging cognitive assessment inclusive of patients with aphasia or spatial neglect,1 to assess the effect of early praxis scores on predicting long-term activities of daily living outcomes. The study included 256 participants from the original BCoS cohort who had a first CT-confirmed stroke, no prior neurologic or psychiatric conditions, and complete data at early subacute (<1 month) and chronic (>9 months) stages. Participants completed 34 neuropsychological tasks across domains of executive function, memory, language, calculation, visuospatial attention, tactile extinction, and orientation, as well as four praxis-related tasks: meaningless gesture imitation, gesture production, gesture recognition, and multistep object use. Functional independence was assessed using the 20-point Barthel Index for Activities of Daily Living (BI-ADL) at both time points.

Using a multivariate stepwise linear regression model, the authors examined whether early subacute cognitive and praxis performance predicted changes in BI-ADL scores at nine months. The model accounted for 60% of the variance in functional outcomes (adjusted R² = 0.59), with early BI scores emerging as the strongest predictor. Importantly, multiple limb praxis measures including gesture production, gesture recognition, and meaningless gesture imitation significantly predicted ADL recovery. Additional cognitive predictors of ADL recovery included orientation measures, specific language tasks (reading and sentence construction), and tactile extinction. Sensitivity analyses comparing models with and without limb praxis measures confirmed that praxis significantly enhanced predictive accuracy: removing praxis tasks reduced explained variance to 56%, with ANOVA revealing a significant decrement in model fit.

These findings extend prior work suggesting an association between apraxia and functional outcome by demonstrating that multiple, distinct praxis tasks collected in the early subacute period independently contribute to long-term ADL recovery. The longitudinal duration (>9 months) for follow-up analyzed in this study is a better predictor of poststroke outcomes as previous large cohorts assessing cognitive measures, such as the Oxford Cognitive Screen program, only follow patients for six months or only incorporate one praxis task, which potentially misses later stages of praxis recovery or does not fully assess their baseline deficits. The broad cognitive sampling and extended follow-up in the study by Rounis et al. provide a more accurate characterization of the relationship between praxis impairments and functional trajectories, especially as prior studies have shown apraxia recovery can take between two to eight months poststroke.2

Despite its contributions, the study acknowledges limitations, including uncertainty about the predictive thresholds of specific praxis tasks due to the relatively high baseline praxis scores. The two-time-point design precluded mixed-effects modeling, and external validation was not possible due to the absence of comparable data sets with similarly detailed praxis and cognitive measures. However, despite the limitations, the results still highlight a critical gap in clinical practice: Limb apraxia remains undertested in acute stroke care, often overshadowed by language and general motor assessments. Systematic praxis evaluation that is integrated alongside other cognitive domains could improve identification of patients at elevated risk for persistent ADL limitations and inform targeted rehabilitative strategies. Overall, this study highlights the importance of comprehensive cognitive screening, including detailed praxis assessment, in predicting long-term stroke recovery and guiding personalized poststroke care.

References:

1. Humphreys GW, Bickerton WL, Samson D, Riddoch MJ. Birmingham cognitive screen. Hove, UK: Psychology Press; 2012.
2. Stamenova V, Black SE, Roy EA. A model-based approach to long-term recovery of limb apraxia after stroke. J Clin Exp Neuropsychol. 2011;33:954–971.