Discovery of Apraxia (Historical Note) / Descoberta da apraxia (Nota Histórica)

Skilled movements certainly exist since the dawn of the humans, embedded in the actions of daily living, and also represented by tools and weapons making and use, as well as by artistic activities as drawing and engraving. A very long period of time elapsed until such actions were recognized as special, and the designation 'praxis' was attributed to such ability of produce refined movements. Another long time passed, and only recently disturbances of such actions caused by brain lesions were identified, leading to the concept of 'apraxia'. Studies on this subject progressed quickly, and in a few decades reached the state resembling to what is seen nowadays.

Movimentos hábeis certamente existem desde a aurora dos humanos, incluídos nas ações da vida diária e também representados na feitura e uso de ferramentas e de armas, assim como por atividades artísticas como desenhar e gravar. Decorreu um longo período de tempo até que tais ações fossem reconhecidas como especiais e a designação de 'praxia' foi atribuída para tais habilidades para produzir movimentos refinados. Outro tempo prolongado passou, e apenas recentemente desordens de tais ações causadas por lesões cerebrais fossem identificadas, levando ao conceito de 'apraxia'. Estudos sobre esse assunto progrediram rapidamente e em poucas décadas alcançaram o estado que se assemelha ao que é visto atualmente.

Parietal Involvement in Constructional Apraxia as Measured Using the Pentagon Copying Task.

Deficits in copying ("constructional apraxia") is generally defined as a multifaceted deficit. The exact neural correlates of the different types of copying errors are unknown. To assess whether the different categories of errors on the pentagon drawing relate to different neural correlates, we examined the pentagon drawings of the MMSE in persons with subjective cognitive complaints, mild cognitive impairment, or early dementia due to Alzheimer's disease. We adopted a qualitative scoring method for the pentagon copy test (QSPT) which categorizes different possible errors in copying rather than the dichotomous categories "correct" or "incorrect." We correlated (regional) gray matter volumes with performance on the different categories of the QSPT. Results showed that the total score of the QSPT was specifically associated with parietal gray matter volume and not with frontal, temporal, and occipital gray matter volume. A more fine-grained analysis of the errors reveals that the intersection score and the number of angles share their underlying neural correlates and are associated with specific subregions of the parietal cortex. These results are in line with the idea that constructional apraxia can be attributed to the failure to integrate visual information correctly from one fixation to the next, a process called spatial remapping.

A critical review of closing-in.

When performing complex actions, like graphic copying or imitation of gestures, some patients may perform these actions very close to, or directly on the top of the model. This peculiar behavior, known as closing-in, is the focus of the present literature review, which will provide a critical picture of the research in this field, highlighting the difficulties in defining and assessing closing-in and the contrasting results about the nature and the characteristics of this phenomenon. Most importantly, we will discuss the 2 hypotheses proposed to explain closing-in, namely the compensation and the attraction account, in light of the most recent work. This critical review will provide substantial evidence that closing-in represent a primitive default tendency in which movements are attracted toward the focus of attention. On the other hand, the possibility that this interpretation might not be fully exhaustive and that different components of closing-in might exist will also be discussed. (PsycINFO Database Record

STIMA: a short screening test for ideo-motor apraxia, selective for action meaning and bodily district.

We propose STIMA, a short test for ideo-motor apraxia, allowing us to quantify the apraxic deficit according to action meaning and affected body segment. STIMA is based on a neurocognitive model holding that there are two processes involved in action imitation (i.e., a semantic route for recognizing and imitating known gestures, and a direct route for reproducing new gestures). The test allows to identify which imitative process has been selectively impaired by brain damage (direct vs. semantic route) and possible deficits depending on the body segment involved (hand/limb vs. hand/fingers). N = 111 healthy participants were administered with an imitation task in two separated blocks of known and new gestures. In each block, half of the gestures were performed mainly with the proximal part of the upper limb and the remaining half with the distal one. It resulted in 18 known gestures (nine proximal and nine distal) and 18 new gestures (nine proximal and nine distal) for a total of 36. Each gesture was presented up to a maximum of two times. Detailed criteria are used to assign the final imitation score. Cut offs, equivalent scores and main percentile scores were computed for each subscale. Participants imitated better known than new gestures, and proximal better than distal gestures. Age influenced performance on all subscales, while education only affected one subscale. STIMA is easy and quick to administer, and compared to previous tests, it offers important information for planning adequate rehabilitation programs based on the functional locus of the deficit.

Limb apraxia in multiple sclerosis.

BACKGROUND/AIM: There are almost no studies on apraxia in people with multiple sclerosis. Although the white matter is damaged in MS, it is not the only location in which the pathological changes are present. Demyelinated lesions in the cortex have recently been recognized as important components of multiple sclerosis pathology. The aim of this study was to determine whether apraxia is present among people with MS, and the importance of demographic characteristics and impairment of functional systems at conceptualization and execution of movements. METHODS: The experimental group consisted of 30 patients, mean age 51.34 +/- 7.70 years. The patients in the experimental group were diagnosed with MS according to the McDonald criteria. The control group consisted of 30 healthy subjects, mean age 50.30 +/- 10.47 years. For research purposes, we used the following instruments: Questionnaire for Collecting Demographic Data, Kurtzke Functional Systems Scores, Waterloo-Sunnybrook Apraxia Battery (WatAB). Execution of motion tasks that are a part of the WatAB were incorporated in the System for the Observation and Analysis of Motor Behavior. RESULTS: Our study showed that limb apraxia was common in people with MS. Apraxia was present during pantomime in 26.70% of the patients, and during the imitation of movements in 44.80% of the patients. Gender, age, education level, duration of disease and a form of MS did not determine the quality of conceptualization and execution of movements. The time elapsed from the last exacerbation was a determinant of quality of executed movements. Impairments of functional systems predicted impairments of movement execution. The expanded disability scale score correlated with the severity of apraxia. CONCLUSION: Our study confirm the presence of apraxia in MS. It is necessary to carry out further studies using functional magnetic resonance imaging, as well as the conduct longitudinal studies to determine the precise structure of motor behavior in people with MS.

Motor recovery by improvement of limb-kinetic apraxia in a chronic stroke patient.

OBJECTIVES: We report on a chronic stroke patient who showed motor recovery by improvement of limb-kinetic apraxia (LKA) after undergoing intensive rehabilitation for a period of one month, which was demonstrated by diffusion tensor tractography (DTT) and transcranial magnetic stimulation (TMS). METHODS: A 50-year-old male patient presented with severe paralysis of the left extremities at the onset of thalamic hemorrhage. At thirty months after onset, the patient exhibited moderate weakness of his left upper and lower extremities. In addition, he exhibited a slow, clumsy, and mutilated movement pattern during grasp-release movements of his left hand. During a one-month period of intensive rehabilitation, which was started at thrity months after onset, the patient showed 22% motor recovery of the left extremities. The slow, clumsy, and mutilated movement pattern of the left hand almost disappeared. RESULTS: DTTs of the corticospinal tract (CST) in both hemispheres originated from the cerebral cortex, including the primary motor cortex, and passed along the known CST pathway. The DTT of the right CST was located anterior to the old hemorrhagic lesion. TMS study performed at thirty and thirty-one months after onset showed normal and similar findings for motor evoked potential in terms of latency and amplitude of the left hand muscle. CONCLUSIONS: We think that the motor weakness of the left extremities in this patient was mainly ascribed to LKA and that most of the motor recovery during a one-month period of rehabilitation was attributed to improvement of LKA.

Teaching video neuroimages: callosal apraxia: a straightforward model of ideomotor apraxia.

A 57-year-old right-handed man complained of difficulty using his hands post-coronary artery bypass graft (figure). Neurologic examination revealed signs of callosal disconnection without hemiparesis. When asked to perform limb gestures like "brush your teeth" or "wave goodbye," the right hand performed flawlessly whereas the left hand was severely apraxic (video on the Neurology Web site at www.neurology.org).

Assessing limb apraxia in traumatic brain injury and spinal cord injury.

People with traumatic brain injury (TBI) may demonstrate action planning disorders and limb apraxia. Many patients, who sustain a spinal cord injury (SCI), sustain a co-occurring TBI (11-29 percent of people with SCI) and therefore are at risk for limb apraxia. People with SCI and TBI (SCI/TBI) rely on powered assistive devices which amplify movement. Their ability to learn complex motor compensatory strategies, that is, limb praxis, is critical to function. We wished to identify methods of screening for apraxia in patients with SCI/TBI. We reviewed instruments available for limb praxis assessment, presenting information on psychometric development, patient groups tested, commercial/clinical availability, and appropriateness for administration to people with motor weakness. Our review revealed that insufficient normative information exists for apraxia assessment in populations comparable to SCI/TBI patients who are typically young adults at the time of injury. There are few apraxia assessment instruments which do not require a motor response. Non-motoric apraxia assessments would be optimal for patients with an underlying motor weakness.

[A 68 year-old man presenting ideomotor apraxia and incomplete Gerstmann syndrome with multiple cystic lesions in the left hemisphere].

A 68-year-old man was referred to our hospital with tension-type headaches and a 1-year history of dementia. On neurologic examination, he had ideomotor apraxia and incomplete Gerstmann syndrome that was characterized by acalculia, agraphia, and finger agnosia. On imaging, multiple cystic lesions reported as "unusually dilated perivascular spaces" were observed along the medullary arteries in the left hemisphere; some of them had adjacent hyperintense areas in fluid attenuated inversion recovery images. We assumed that the multiple cystic lesions caused his higher cerebral dysfunction, because ideomotor apraxia and Gerstmann syndrome are usually indicative of a left parietal lobe lesion. MR spectroscopy in the lesion site revealed increased lactate. On MR angiography, the left middle cerebral artery and the left posterior cerebral artery were poorly visualized without localized stenosis. Technetium-99 bicisate single-photon emission computed tomography showed severely decreased cerebral blood flow in the left hemisphere. Electroencephalography showed slow waves in the left hemisphere.

Dyspraxia series: Part Two. One step forward.

Dyspraxia is an often under-diagnosed problem that describes a difficulty in managing certain motor tasks. It's an impairment of the organisation of movement and also an immaturity in the way the brain processes information. This immaturity results in messages not being properly or fully transmitted. In brief, dyspraxia affects the planning of what to do and how to do it and is associated with problems of perception, language and thought. There are a variety of causes and therapy based on the knowledge of these allow affected individuals to reach their full developmental potential.

Dyspraxia series: part one. At sixes and sevens.

Developmental Co-ordination Disorder (DCD), also known as Dyspraxia in the UK, is a common disorder affecting motor co-ordination in children and for many continues into adulthood. This condition is formally recognised by international organisations including the World Health Organisation. DCD is distinct from other motor disorders such as cerebral palsy and stroke. The range of intellectual ability is in line with the general population. Individuals may vary in how their difficulties present. The co-ordination difficulties may affect participation and functioning of everyday life skills in education, work and employment. Children may present with difficulties in writing, typing, riding a bike, self care tasks, and recreational activities. In adulthood many of these difficulties will continue, as well as learning new skills at home and work such as planning, organisation, driving a car and DIY.

Impaired finger dexterity in Parkinson's disease is associated with praxis function.

A controversial concept suggests that impaired finger dexterity in Parkinson's disease may be related to limb kinetic apraxia that is not explained by elemental motor deficits such as bradykinesia. To explore the nature of dexterous difficulties, the aim of the present study was to assess the relationship of finger dexterity with ideomotor praxis function and parkinsonian symptoms. Twenty-five patients with Parkinson's disease participated in the study. Their left and right arms were tested independently. Testing was done in an OFF and ON state as defined by a modified version of the Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS). Finger dexterity was assessed by a coin rotation (CR) task and ideomotor praxis using a novel test of upper limb apraxia (TULIA), in which the patients were requested to imitate and pantomime 48 meaningless, as well as communicative and tool-related gestures. Coin rotation significantly correlated with TULIA irrespective of the motor state and arm involved, but not with the MDS-UPDRS. This association was significantly influenced by Hoehn and Yahr stage. The strong association of finger dexterity with praxis function but not the parkinsonian symptoms indicates that impaired finger dexterity in Parkinson's disease may be indeed apraxic in nature, yet, predominantly in advanced stages of the disease when cortical pathology is expected to develop. The findings are discussed within a cognitive-motor model of praxis function.

A new bedside test of gestures in stroke: the apraxia screen of TULIA (AST).

BACKGROUND: Apraxia in patients with stroke may be overlooked, as clumsiness and deficient gestural communication are often attributed to frequently coexisting sensorimotor deficits and aphasia. Early and reliable detection of apraxia by a bedside test is relevant for functional outcome in patients with stroke. The present study was aimed at constructing a new bedside screening test for apraxia, called the Apraxia Screen of TULIA (AST), based on the comprehensive standardised Test for Upper-Limb Apraxia (TULIA). METHODS: First, an item-reduction analysis of the TULIA (48 gestures) was performed, based on the methods of classical test theory and on a larger sample of patients with stroke (n=133) and matched healthy controls (n=50). Stepwise elimination of items resulted in a set of 12 items, demonstrating high internal consistency (Cronbach alpha=0.92). The six-point scoring method of the TULIA was dichotomised to the score levels pass and fail. In the second part of this study the validity of the AST was assessed prospectively in a new cohort of patients with stroke (n=31) by using the Pearson correlation analysis and binary classification display with the TULIA. RESULTS AND DISCUSSION: Validation of the 12-item AST with the TULIA showed a remarkable diagnostic reliability with high specificity, sensitivity and positive predictive value, for the presence and severity of apraxia. The AST is shown to be a reliable and valid bedside test in patients with stroke, allowing a straightforward assessment of apraxia within a few minutes.

Apraxia related with subcortical lesions due to cerebrovascular disease.

OBJECTIVES: To examine whether ideomotor apraxia exists in patients with subcortical ischemic lesions. PATIENTS AND METHODS: A matched-control, prospective and multi-centered research design was used. Ideomotor apraxia, anxiety and depression were assessed by the Movement Imitation Test and the Hamilton scales, respectively. RESULTS: Forty two consecutive patients with subcortical ischemic stroke and an equal number of healthy participants, matched in age and sex were included. Paired-sample t-tests showed that patients had significantly more apractic elements in their movements (t = 5.03, P < 0.01), higher anxiety (t = -2.55, P = 0.0014) and depression levels (t = -2.61, P = 0.012) than their healthy matched participants. Participants with higher anxiety and depression scores performed worse on the Movement Imitation Test. CONCLUSIONS: Ischemic damage of subcortical modular systems may affect praxis.

Association of ideomotor apraxia with frontal gray matter volume loss in corticobasal syndrome.

OBJECTIVE: To determine the brain areas associated with specific components of ideomotor apraxia (IMA) in corticobasal syndrome (CBS). DESIGN: Case-control and cross-sectional study. PARTICIPANTS: Forty-eight patients with CBS and 14 control subjects. Intervention Administration of the Test of Oral and Limb Apraxia. MAIN OUTCOME MEASURES: Differences between patients with CBS and healthy controls and associations between areas of gray matter volume and IMA determined by voxel-based morphometry in patients with CBS. RESULTS: Overall, IMA was associated with decreased gray matter volume in the left supplemental motor area, premotor cortex, and caudate nucleus of patients with CBS. The overall degree of apraxia was independent of the side of motor impairment. Praxis to imitation (vs command) was particularly impaired in the patients with CBS. Patients demonstrated equal impairment in transitive and intransitive praxis. CONCLUSIONS: In patients with CBS, IMA is associated with left posterior frontal cortical and subcortical volume loss. Despite showing left frontal volume loss associated with IMA, patients with CBS have particularly impaired imitation of gestures. These findings suggest either that the IMA of CBS affects a route of praxis that bypasses motor engrams or that motor engrams are affected but that they exist in areas other than the inferior parietal cortex.