Apraxia Screen of TULIA

Original Editor - Janine van Dyk Top Contributors - Janine van Dyk and Kim Jackson

Objective

The Apraxia Screen of TULIA (AST) was developed out of the comprehensive standardised test for upper limb Apraxia (TULIA) in 2011 by T VanBellingen et all. The purpose of AST is to assist bedside screening for patients presenting with Apraxia. The screening consists of 12 imitation tasks that need to be executed, after which a score is calculated to determine the severity of apraxia.

Intended Population

• Stroke

• Alzheimer disease

• Parkinsons

• Schizophrenia
• Multiple Sclerosis
  

Method of use

The patient is seated in front of the examiner. Both forearms are placed on the table. In patients with hemiplegia, the patient executes the gestures with their non-hemiplegia upper limb.

In non-hemiplegia patients, both upper limbs are tested. The test can be scored online or with a scoring sheet and calculated afterward.

Imitation:

• General instruction to the patient: Seven gestures are demonstrated in a mirror fashion, imitate them as precisely as possible:
• After number 2 the additional instructions is as follow:“For the next five gestures, imagine holding a tool or an object in hand, don’t use your fingers a tool". ( Number 3-7). For items number 8-12 the movement we want to elicit is called a Pantomine (the process of eliciting a meaningful, transitive movement )
• For instructions on number 8 and 9: “Now gestures are asked. Listen very carefully and perform them as precisely as possible”
• For the last 3 items on the list the instruction is as follow: “Again imagine holding a tool or an object in hand, don’t use the fingers”
  1. Bring- thumb extended on foreheads, other fingers point upwards

  2. Wipe dust from shoulder.
  3. Drink from a glass.
  4. Smoke a cigarette.
  5. Use a hammer.
  6. Use scissors.
  7. Use a stamp or postmark.
  8. “Show as if someone is crazy” *
  9. “Make a threatening sign”**
  10. "Brush your teeth"
  11. “Comb your hair”
  12. “Use a screwdriver”

Item 1= meaningless; Item 2,8,9= intransitive ( Communicative) Items 3-7 and 10-12 = transitive ( Tool related)

*Repetitive tapping of the index finger at the temple (Rotating movements of index fingers are also correct)

**Upraised clenched fist (Upraised index finger or open hand are also correct).

Scoring

Dichotomous scale:

0= fail 1= pass

• Maximum score =12 No apraxia present

• Total cut off score < 9* Mild apraxia

• Severe Apraxia < 5

*Alternative cut-off score < 5 for imitation part only, in case of severe language comprehension problem (can be presumed, if three or more amorphous movements occur for pantomime)

Score 0= Appearance of body part as object errors

• Considerable spatial errors, extra movements and omissions, false end positions, substitutions and preservation.

• Amorphous (unstructured) or seeking movements, not related to the desired gestures.

Score =1 Normal movements

• Slight slowdown or discrete spatial errors (e.g. diminished amplitude) are allowed.

• Discrete extra movements or omissions can occur.

• Also when brief substitutions or preservation occurs, which are correct the score is still given.

Evidence

With the cut of values from the the TULIA there was a high specificity of 93% and a high sensitivity of 88% was achieved.

Resources

Apraxia screening of TULIA