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Rehab Measures: Apraxia Screen of Tulia

Link to instrument

Apraxia Screen of Tulia PDF 

Title of Assessment

Apraxia Screen of Tulia 

Acronym

AST

Instrument Reviewer(s)

Initially reviewed by Lauren Wiseman MS, OTRL on 9/29/14

Summary Date

5/17/2015 

Purpose

A 12 item bedside screen to assess the presence and severity of apraxia. The screen is extracted from the comprehensive test of upper limb apraxia (TULIA).

Description

12 total gestures, including 1 meaningless imitation, 3 intra-transitive (communicative), and 8 transitive (tool-related).

Minimum score= 0 Maximum score= 12; Maximum score indicates no apraxia

For each item, the participants receives a score of 1 (=pass) or 0 (=fail). Cut-off scores of 9 and 5 estimate abnormal/mild and severe apraxia, respectively.

The participant is seated in front of the examiner with both forearms placed on a table. Patients with hemiparesis execute gestures with their non-affected limb. Otherwise both upper limbs are tested.

Area of Assessment

 

Body Part

 

ICF Domain

Activity 

Domain

 

Assessment Type

 

Length of Test

 

Time to Administer

Approximately 3 minutes

Number of Items

12 items (gestures) 

Equipment Required

Seat surface (for participant) , table-top surface

Training Required

No training required

Type of training required

no training 

Cost

Free 

Actual Cost

Free

Age Range

 

Administration Mode

 

Diagnosis

 

Populations Tested

  • Stroke
  • Multiple Sclerosis
  • Parkinson’s Disease

Standard Error of Measurement (SEM)

Stroke: (Vanbellingen et al, 2011; n = 31; mean age = 63.4 (13.7); mean time post-acute CVA = 19.0 (5.3); mean time post chronic stroke = 57.3 (25.5)) (calculated from statistics in Vanbellingen et al, 2011)

  • SEM for AST apraxic = .648 *points (0-12 point scale)
  • SEM for AST non-apraxic = .22 * points (0-12 point scale)
    * compared to same 12 items in original full-version of TULIA

Minimal Detectable Change (MDC)

Stroke: (calculated from statistics in Vanbellingen et al, 2011)

  • MDC for AST = 1.79 points (0-12 point scale)

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Stroke: (Vanbellingen et al, 2011)

  • Score of 10-12 indicates no praxis errors
  • Score of 6-9 indicates abnormal praxis or mild apraxia
  • Score of 5 or less indicates severe apraxia
  • Alternative cut-off score <5 for imitation part only, in case of severe language comprehension problems (can be presumed, if three or more amorphous movements occur for pantomime)
Multiple Sclerosis: (Kamm et al, 2012; n = 76; mean age 44.8 (12.5); disease duration = 11.2 (9.6) years; average clinically isolated syndrome = 2 (2.6); average relapsing remitting type = 45 (59.2); average secondary progressive type = 23 (30.2); average primary progressive type = 6 (7.8); average Expanded Disability Status Scale = 3.4 (1.8)

  • Score of 10-12 indicates no praxis errors
  • Score of 6-9 indicates abnormal praxis or mild apraxia
  • Score of 5 or less indicates severe apraxia
  • Alternative cut-off score <5 for imitation part only, in case of severe language comprehension problems (can be presumed, if three or more amorphous movements occur for pantomime)
Parkinson's Disease:(Vanbellingen et al, 2011; n = 75; mean age 63.4 (10.72); disease duration = 9.41 (5.79) years; mean Levadopa equivalent 806.87 (314.12) mg/day; Hoehn & Yahr stage 1 = 11, stage 2 = 31, stage 3 = 25, stage 4 = 8)

  • Score of 10-12 indicates no praxis errors
  • Score of 6-9 indicates abnormal praxis or mild apraxia
  • Score of 5 or less indicates severe apraxia
  • Alternative cut-off score <5 for imitation part only, in case of severe language comprehension problems (can be presumed, if three or more amorphous movements occur for pantomime)

Normative Data

Not Established

Test-retest Reliability

Not Established

Interrater/Intrarater Reliability

Not Established

Internal Consistency

Stroke: (Vanbellingen et al, 2011)

  • Excellent internal consistency (Cronbach alpha =0.92)

Criterion Validity (Predictive/Concurrent)

Not Established

Construct Validity (Convergent/Discriminant)

Multiple Sclerosis

  • Excellent construct validity for correlation with Expanded Disability Status Scale (EDSS) scores (r = -.63) and Scale for the Assessment and Rating of Ataxia scores (r = -.60) (Kamm et al, 2012)

Parkinson’s disease

  • Adequate construct validity of the AST for correlation with Hoehn & Yahr stage (r = -0.32) (Vanbellingen et al, 2011)
  • Poor discriminant validity comparing the AST to the Movement Disorders Society-Unified Parkinson’s Disease Rating Scale (MDS-UPDRS part III (r= 0.17, p= 0.1) (Vanbellingen et al, 2011)
  • Poor convergent validity between the AST and MDS-UPDRS part II (r= -0.35, p= 0.004) and Hoehn and Yahr (r= -0.32, p= 0.006) (Vanbellingen et al, 2011)

Stroke (Vanbellingen et al, 2011)

  • Adequate construct validity for correlation with the screening version of the Token Test score (r = .81)
  • Poor construct validity for correlation with the Bell Test (p =>0.05)
  • Apraxia Screen of Tulia (AST) was constructed using the Test for Upper Limb Apraxia (TULIA)
  • Using item-reduction analysis based on classical test theory, two clinical experts reviewed 48 items from the TULIA to reduce the screen to 12 items (to make the AST). TULIA items with less inter-rater reliability, floor and ceiling effects, less internal consistency and lower content validity were excluded.
  • The six-point scoring system used in the TULIA was simplified to a dichotomous pass/fail scoring system.
  • Excellent test-retest reliability (ICC = .95)* results of the AST were compared to the TULIA to assess test-retest (Vanbellingen et al, 2011)

Content Validity

The Apraxia Screen of Tulia (AST) was created by reducing the Test for Upper Limb Apraxia (TULIA) down to 12 items by two clinical experts.

Face Validity

Not Established

Floor/Ceiling Effects

Not Established

Responsiveness

Not Established

Professional Association Recommendations

Considerations

Multiple Sclerosis:

  • Limb apraxia may be associated with higher Expanded Disability Scale Status scores.
  • A higher prevalence of limb apraxia may be present in those with primary progressive and secondary progressive multiple sclerosis as compared to relapsing remitting multiple sclerosis.
  • Ataxia was not associated with apraxia in the multiple sclerosis population study. (Kamm et al, 2012)

Parkinson’s disease:

  • The scoring method of the AST neglects minor apraxic temporal-spatial errors that could be confounded by PD motor symptoms.
  • Ideomotor apraxia delineates PD from subtypes of atypical parkinsonism (corticobasal syndrome).
  • During advanced stages of PD, other motor and cognitive deficits (tremor, dysexecutive function) may confound errors not explained by apraxia alone. (Vanbellingen et al, 2011)

Stroke:

  • The AST is a convenient bedside screen for assessing apraxia
  • In the stroke population, the AST provides a 100% positive predictive value
  • In the stroke population, the AST provides 92% negative predictive value which may miss mild forms of apraxia
  • Aphasia with severe comprehension impairments may fall below cut-off scores in the AST due to impaired auditory comprehension during the pantomime items. (Vanbellingen et al, 2011)

Bibliography

Kamm, C., Heldner, M., Vanbellingen, T., Mattle, H., Müri, R., & Bohlhalter, S. (2012). Limb apraxia in multiple sclerosis: prevalence and impact on manual dexterity and activities of daily living. Archives Of Physical Medicine And Rehabilitation, 93(6), 1081-1085. doi:10.1016/j.apmr.2012.01.008 Find it on Research Gate

Ozkan, S., Adapinar, D., Elmaci, N., & Arslantas, D. (2013). Apraxia for differentiating Alzheimer's disease from subcortical vascular dementia and mild cognitive impairment. Neuropsychiatric Disease And Treatment, 9947-951. doi:10.2147/NDT.S47879 Find it on PubMed

Vanbellingen, T., Kersten, B., Van de Winckel, A., Bellion, M., Baronti, F., Müri, R., & Bohlhalter, S. (2011). A new bedside test of gestures in stroke: the apraxia screen of TULIA (AST). Journal Of Neurology, Neurosurgery, And Psychiatry, 82(4), 389-392. doi:10.1136/jnnp.2010.213371 Find it on Research Gate

Vanbellingen, T., Lungu, C., Lopez, G., Baronti, F., Müri, R., Hallett, M., & Bohlhalter, S. (2012). Short and valid assessment of apraxia in Parkinson's disease.Parkinsonism & Related Disorders, 18 (4), 348-350. doi:10.1016/j.parkreldis.2011.11.023 Find it on Research Gate

Year published

 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 5/13/2015 3:30 PM  by Jason Raad 
Last modified at 11/14/2016 10:05 AM  by Jason Raad