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Title
Luria’s three-step test: what is it and what does it tell us?
Presenter: Pongsatorn Paholpak M.D. Faculty of Medicine KhonKaen University, Thailand 2011
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Clinical Epidemiology Course: Critical Appraisal
Module: How to read the clinical journal
Objective: To be able to critically appraise the medical research articles.
Title: Luria’s three-step test: what is it and what does it tell us? Authors: Myron F. Weiner, Linda S. Hynan, Heidi Rossetti and Jed Falkowski1
Journal: International Psychogeriatrics. 2011 May 4:1-5.
Presenter: Pongsatorn Paholpak, MD.
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Content Page 1. Clinical scenario 2. Background and Rationale 3. Selection of the article 4. Summary of article 5. Materials and methods 6. Result 7. Discussion 8. Conclusion 9. Clinical appraisal
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Clinical Scenario 56 years old male, an early-retired teacher, visited our psychiatric outpatient department for cognitive follow after he was diagnosed with “senile forgetfulness” since 3 months ago. At this visit, even though he is able to perform other hand praxis tests, he cannot do Luria three steps test. Then he asks the question that “Is this from my normal aging process or any disorder?” Question: Can we use Luria three steps test to distinguish between demented patients and normal cognitive people?
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Back ground and rationale In the past decade, with rapid development of medical sciences and health care systems, our senile populations have increased significantly. Dementia is one among the most burdened and devastated neurodegenerative diseases which affect these old ages people primarily. Developing country in Asia may found 3 times rising of dementia prevalence1. Currently, Alzheimer’s disease leads all causes of dementia and is followed by mixed dementia, vascular dementia and frontotemporal lobe dementia respectively2. With deteriorative natural courses of dementia, these groups of patients will slowly suffer from mild cognitive impairment in the beginning. Then it will progress to significant daily activities disability after 3-10 years. Finally these demented patients will develop behavioral problems and they will be totally depended on caregivers. Making diagnosis of dementia and its spectrum is very challenging. Since the goal standard is only brain autopsy. Currently we use either DSM-IV-tr3 or NINCDS-ADRA4 criteria to establish diagnosis with good sensitivity and specificity. But these diagnosis criteria require us to evaluate patients extensively with full neuropsychological test which take a lot of time. Thus MMSE5, CDR6 and many others screening tools were developed for practical feasibility. Still, these tests require 15-45 minutes in clinical setting to be completed, that make these tests become not practical, especially, in crowded outpatient clinical setting. Luria three steps test7, imitating 3 hand sequencing gestures, is very easy to instruct and it require only 1-2 minutes. It was first introduced by Aleksandr Luria, a Russian Psychologist, in 1970. It was studied in traumatic brain injury patients extensively. Together with other motor task, LuriaNebraska neuropsychological test could distinguish between brain damaged patients and psychiatric patients. This motor sequencing test, technically, also elicit frontal lobe and parietal lobe functions which firstly be affected by frontotemporal dementia8. However, previous study found deficit in Luria test from Alzheimer’s dementia patient more frequent than frontotemporal dementia patients9. Thus, we need further studies which will bring us to truly understanding about its validity and application in neurocognitive sciences.
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References 1. Kukull WA. The growing global burden of dementia. Lancet neurology 2006;5:199-200. 2. Mathers C, Fat DM, Boerma JT, World Health O. The global burden of disease : 2004 update. Geneva, Switzerland: World Health Organization, 2008. 3. American Psychiatric A, American Psychiatric Association. Task Force on D-I. Diagnostic and statistical manual of mental disorders : DSM-IV-TR. Washington, DC: American Psychiatric Association, 2000. 4. Blacker D, Albert MS, Bassett SS, Go RC, Harrell LE, Folstein MF. Reliability and validity of NINCDSADRDA criteria for Alzheimer's disease. The National Institute of Mental Health Genetics Initiative. Archives of neurology 1994;51:1198-1204. 5. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. Journal of psychiatric research 1975;12:189-198. 6. Morris JC. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology 1993;43:2412-2414. 7. Luria AR. Higher cortical functions in man. New York: Basic Books : Consultants Bureau, 1980. 8. Dubois B, Slachevsky A, Litvan I, Pillon B. The FAB: a Frontal Assessment Battery at bedside. Neurology 2000;55:1621-1626. 9. Lipton AM, Ohman KA, Womack KB, Hynan LS, Ninman ET, Lacritz LH. Subscores of the FAB differentiate frontotemporal lobar degeneration from AD. Neurology 2005;65:726-731.
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Selection of the article Searching - PICO model: P = Participant: Normal cognitive and Dementia patients I = Intervention: Hand Luria test C = Comparison: O = Outcome: Diagnosis of dementia and normal cognitive - Searching strategies: 1. First approach in Pubmed
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("Luria three step" OR "Ideomotor apraxia" OR "Hand Luria") AND ("Dementia" OR "Mild Cognitive inpairment" OR "Normal Cognitive") 2. Second approach in Scopus
("Luria three step" OR "Ideomotor apraxia" OR "Hand Luria") AND ("Dementia" OR "Mild Cognitive inpairment" OR "Normal Cognitive") With 45 search results from Pubmed and another 45 from Scopus, I have read through their titles and abstracts. I found that there was only one article that correlated with my question. The title of this article is “Luria’s three step test : what is it and what does it tell us?”
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Summary of the article Title : “Luria’s three step test : what is it and what does it tell us? Authors : Myron F. Weiner, Linda S. Hyan, Heidi Rosetti, and Jed Falkowki Source: International Psychogeriatrics. 2011 May 4:1-5. Objective of study : To determine if the Luria three-step test is useful for differentiating between cognitive disorders. Study design : Retrospective case control study Study setting : UT South western Alzheimer’sdisease research center Population : 383 records at Alzheimer’s disease research center Inclusion criteria : 1) Alzheimer’s Dementia, Frontotemporal Dementia , Mild cognitive Impairments, Normal Cognitive patients 2) Paients has been tested with Luria, CDR, MMSE at least 1 time
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Materials and methods : Procedure: 1. Patient data collection - Located records of MCI, FTD, AD from patients at Alzheimer’s center FTD diagnosed by Neary et al criteria (1998) AD diagnosed by probable AD criteria of NINCDS ADRDA (McKhann 1984) MCI required cognitive task > 1 SD below normative population - Located record of NC from healthy elderly control in longitudinal cohort - Subjects had been asked for age and educational years - Subjects had been tested with Luria three steps test at least once - Subjects had been tested with CDR , MMSE to level functional impairment - Of the 581 persons seen from 2002 to 2010, 383 were included in this analysis. The ratio of total persons seen to total persons studied in each diagnostic group was 131/143 NC, 56/64 MCI, 43/64 FTD, and 153/183 AD subjects.
2. Testing patients with Luria three steps - Patients imitate three hand motions performed by the examiner with fingers fully extended and the patient following, the examiner places his right hand with a cutting motion on his right knee or on a table, then in a fist with the knuckles down, and then palm down with fingers extended. - Examiner and patient then repeat this three more times. - The hand motions could be reinforced by counting from 1 to 3 along with each segment, or by saying “cut, fist, and slap.” - Patients are then asked to repeat the movements unguided by the examiner. - A score of 0 is recorded if the patient is unable to mimic the movement or complete three independent cycles, considering as abnormal. - The test was judged to be abnormal if the hand motions differed in type or sequence from that of the examiner.
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3. Statistical analysis - Used SPSS version 18 - Two-way analysis of variance (ANOVA) compared diagnostic groups (NC, MCI, FTD and AD) and Luria test (abnormal versus normal) on the measures of education and age - Bonferroni post hoc pairwise comparisons were performed if the ANOVA was found to be significant. - χ2 was used to compare groups when the data were dichotomous - If χ2 was found to be significant, a Tukeytype multiple comparison test among proportions was performed - Assumptions for all statistical tests were checked for violations. - Significance level for all analyses was p
