Assessment and management of apraxic agraphia: applying principles from the management of apraxia of speech and the principles of motor learning

Abstract

Background: Apraxic agraphia is a writing disorder that is characterised by poor letter formation that cannot be attributed to impaired letter shape knowledge or to sensorimotor, extrapyramidal, or cerebellar dysfunction. Like apraxia of speech (AOS) and speech production, apraxic agraphia reflects a difficulty in programming the skilled movements for writing production. There is currently limited research into its assessment and management. Many of the current treatment approaches used in the management of AOS are consistent with the principles of motor learning. Given the observable comparisons between AOS and apraxic agraphia, it is reasonable to consider application of the treatment principles for AOS in the treatment of apraxic agraphia.Aims: The aims of the present study are (1) to demonstrate the diagnosis of apraxic agraphia and draw comparisons between the characteristics of apraxic agraphia and AOS; and (2) to investigate the effectiveness of a treatment plan for apraxic agraphia based on the treatment principles in the management of AOS and the principles of motor learning.Methods & Procedures: The current paper utilises a case study design to address the above aims, using a single participant, Mrs. M. Assessment and diagnosis of apraxic agraphia is outlined. Treatment comprised of a novel treatment hierarchy incorporating the treatment principles for AOS and the principles of motor learning. Writing legibility before and after treatment was used as the primary outcome measure, and was calculated as an average percentage score based on assessment of writing samples of five independent non-clinicians.Outcomes & Results: Assessment indicated that Mrs. M presented with apraxic agraphia. Following treatment based on the principles of motor learning, legibility at word level improved from 12% to 100% and in connected writing from 22% to 100%.Conclusions: Results support the hypothesis that apraxic agraphia is comparable to AOS and results from impairment in graphemic-motor programming for writing. Following engagement in a proposed treatment hierarchy based on the treatment of motor learning, Mrs. M demonstrated a clinically significant improvement in her writing legibility. The results of this case provide a primary indication that the principles of motor learning as applied in AOS management are also relevant and appropriate in the management of apraxic agraphia. Limitations and future directions are discussed.