Apraxia differs in corticobasal degeneration and left-parietal stroke: A case study.

Corticobasal degeneration (CBD) is a progressive disorder characterized by both cortical and basal ganglia dysfunction such as asymmetrical apraxia, and akinetic rigidity, involuntary movements, and cortical sensory loss. Although apraxia is a key finding for the differential diagnosis of CBD, it has not been determined whether the features of apraxia seen in subjects with CBD are similar to those features exhibited by subjects with left-hemisphere damage from stroke. Therefore, for both clinical purposes and in order to better understand the brain mechanisms that lead to apraxia in CBD, we studied praxis in a patient with CBD and compared him to patients who are apraxic from left-parietal strokes. We used three-dimensional movement analyses to compare the features of apraxic movement. This subject with CBD was a dentist whose initial complaint had been that he "forgot" how to use his tools in the mouths of his patients. Analyses were performed on the trajectories made when using a knife to actually slice bread, and when repetitively gesturing slicing made to verbal command. Movements of the left hand, wrist, elbow, and shoulder were digitized in 3-D space. Although the CBD subject was clearly apraxic, the features of his apraxia differed markedly from those of the subjects with lesions in the left parietal lobe. For movements to command, the CBD subject showed joint coordination deficits, but his wrist trajectories were produced in the appropriate spatial plane, were correctly restricted to a single plane, and, like control subjects, were linear in path shape. However, when he was actually manipulating the tool and object, all of these aspects of his trajectories became impaired. In contrast, the deficits of the apraxic subjects with left-parietal damage were most pronounced to verbal command with their movements improving slightly although remaining impaired during actual tool and object manipulation. Unlike patients with parietal strokes, patients with CBD have degeneration in several systems and perhaps deficits in these other areas may account for the differences in praxic behavior.     

Gestural imitation and limb apraxia in corticobasal degeneration

Limb apraxia is a common symptom of corticobasal degeneration (CBD). While previous research has shown that individuals with CBD have difficulty imitating transitive (tool-use actions) and intransitive non-representational gestures (nonsense actions), intransitive representational gestures (actions without a tool) have not been examined. In the current study, eight individuals with CBD and eight age-matched healthy adults performed transitive, intransitive representational and intransitive non-representational gestures to imitation. The results indicated that compared to controls, individuals with CBD were significantly less accurate in the imitation of transitive and intransitive non-representational gestures but showed no deficits for the imitation of intransitive representational gestures. This advantage for intransitive representational gestures was thought to be due to fewer demands being placed on the analysis of visual-gestural information or the translation of this information into movement when imitating these gestures. These findings speak to the importance of context and the representation of gestures in memory in gesture performance.     

Apraxia in a patient with atypical cerebral dominance

Liepmann postulated that the left hemisphere of right-handed persons contains the "movement formulas" that control purposeful skilled movements of the limbs on both sides of the body. Accordingly, in right-handers apraxia should follow damage to the left hemisphere, whereas right hemisphere damage should not lead to apraxia. Although this is generally true, we recently examined a right-handed man who after a right hemispheric stroke became aphasic and apraxic with his nonparalyzed right hand. Our observations suggest that the right hemisphere of this right-handed man made a critical contribution to the planning and execution of skilled movements. This case provides evidence that right-handers should not be considered a homogeneous group in terms of cerebral motor dominance and that contrary to Liepmann's postulate, hemispheric dominance for the control of skilled movements does not entirely determine handedness.     

Pantomime, praxis, and aphasia.

The production and comprehension of pantomimed movements by asphasic subjects were studied with respect to their relationship to the aphasic deficit on one hand and apraxia on the other. At issue was whether impaired use of pantomime is a manifestation of reduced symbolic capacity or purely a manifestation of an apraxic impairment of purposeful movement or both. Tests of pantomime included a Pantomime Recognition Test, a nonverbal Transitive Pantomime Production Test, and an Intransitive Pantomime Production Test (to oral command). Imitation of Nonmeaningful Movements served as a measure of apraxia, uncontaminated by symbolic or linguistic factors. Imitation of Meaningful Movements taken from the pantomime tasks was also tested. Independent measures of auditory comprehension, picture naming, and reading comprehension were used as indices of language impairment. Intellectual function was measured by the Performance scale of the WAIS. Thirty aphasic subjects were examined. Twenty healthy age-matched normals served to establish scoring standards for the pantomime tests. Multiple regression analysis revealed significant, independent contributions from both auditory comprehension and imitation of Nonmeaningful Movements to all of the tests of pantomime production and pantomime recognition. All measures of pantomime production and pantomime recognition were strongly intercorrelated. While the three language measures were strongly correlated with each other, auditory comprehension was the only one of them that was significantly and consistently related to the pantomime tests. None was related to the imitation of nonmeaningful movement. The results are taken as indicating (1) that pantomime production and imitation share common factors with both praxis and auditory comprehension; (2) apraxia entails impairment of both production and interpretation of purposeful movements. Possible theoretical accounts for these results are offered.     

The role of the dynamic body schema in praxis: evidence from primary progressive apraxia

On an influential model of limb praxis, ideomotor apraxia results from damage to stored gesture representations or disconnection of representations from sensory input or motor output (Heilman & Gonzalez Rothi, 1993; Gonzalez Rothi et al., 1991). We report data from a patient with progressive ideomotor limb apraxia which cannot be readily accommodated by this model. The patient, BG, is profoundly impaired in gesturing to command, to sight of object, and to imitation, but gestures nearly normally with tool in hand and recognizes gestures relatively well. In addition, performance is profoundly impaired on imitation of meaningless gestures and on tasks requiring spatiomotor transformations of body-position information. We provide evidence that BG's apraxia is largely attributable to impairments external to the stored gesture system in procedures coding the dynamic positions of the body parts of self and others; that is, the body schema. We propose a model of a dynamic, interactive praxis system subserved by posterior parietal cortex in which stored representational elements, when present, provide "top-down" support to spatiomotor procedures computed on-line. In addition to accounting for BG's performance, this model accommodates a common pattern of ideomotor apraxia more readily than competing accounts.     

Task demands and limb apraxia in stroke

The present study was designed to examine the frequency and severity of apraxia in patients with left- or right-hemisphere stroke in both pantomime and imitation conditions and to compare the frequency of apraxia in each stroke group across the three patterns of apraxia described in Roy's model (Roy, 1996). Ninety-nine stroke patients and 15 age-matched healthy adults performed eight transitive gestures to pantomime and to imitation. Gestural performance was quantified as accuracy on five performance dimensions; a composite score, an arithmetic combination of the five performance dimensions, was used as an index of the overall accuracy. Analyses revealed a comparable proportion of patients in each stroke group were classified as apraxic in the imitation condition, but a higher proportion of left stroke patients were apraxic in the pantomime condition. The severity of apraxia in each stroke group and the performance dimensions affected were, however, comparable. Analyses of the patterns of apraxia (pantomime alone, imitation alone or apraxia in both conditions) revealed a higher frequency of apraxia in both stroke groups for the pattern reflecting apraxia in both conditions, indicating that a disruption at the movement execution stage of gesture performance was most common.     

Posture recognition in Alzheimer's disease

BACKGROUND: Apraxia is neurologically induced deficit in the ability perform purposeful skilled movements. One of the most common forms is ideomotor apraxia (IMA) where spatial and temporal production errors are most prevalent. IMA can be associated Alzheimer's disease (AD), even early in its course, but is often not identified possibly because the evaluation of IMA by inexperienced judges using performance tests is unreliable. The purpose of this study, therefore, is to learn if the Postural Knowledge Test (PKT), a praxis discrimination test that assesses knowledge of transitive (PKT-T subtest) and intransitive (PKT-I subtest) postures and does not require extensive training, is as sensitive and specific as the praxis performance tests. METHODS: We studied 15 subjects with probable AD as well as 18 age-matched controls by having them perform transitive and intransitive gestures to command and imitation, as well as having them discriminate between correct and incorrect transitive and intransitive postures. RESULTS: Overall on all tests, the control subjects performed better than those with AD. In addition all subjects had more trouble with transitive than intransitive gestures. Using a stepwise discriminative analysis, 81.8% of the subjects could be classified according to Group (94.4% of Controls, 66.7% of AD subjects). In this analysis, the PKT-T (transitive posture subtest) was the only measure that contributed to the discrimination of subjects. CONCLUSION: We found that having subjects select the correct transitive hand postures in this "booklet test" was more sensitive than grading their praxis performances even when using judges with extensive training. This suggests that this discrimination test might be an excellent means for diagnosing and screening patients for AD. The reason why recognition of transitive postures is relatively more difficult for our AD subjects is not known. Two possibilities are that the representations for intransitive movements are stronger than those for transitive movements, and hence, more resistant to degradation, or that intransitive acts are stored in parts of the brain not affected by AD.     

A novel technique for the quantitative assessment of apraxic deficits: Application to individuals with mild cognitive impairment

The purpose of this study was to apply two novel quantitative assessments of apraxia to issues surrounding the cognitive profile of individuals with mild cognitive impairment (MCI) who are at increased risk of Alzheimer's disease (AD). In particular, it was wished to determine whether such quantitative assessment techniques can detect minor degrees of impairment at a stage in the putative disease process before apraxia has become clinically obvious. A total of 23 individuals with MCI and 75 healthy controls were assessed on two 3‐item sequential movement tasks involving either meaningful or meaningless actions. A traditional rating scale assessment of gesture‐to‐command was also administered. MCI patients took significantly longer than control subjects to complete the sequential movement tasks despite unimpaired performance on the traditional gesture production tasks. Furthermore, retrospective analyses revealed that, at the group level, only MCI patients who subsequently proceeded to a clinical diagnosis of AD were significantly slower than controls at the initial assessment. These findings provide the first evidence that the neuropsychological deficits associated with MCI may extend to the domain of praxic functions. Consequently, this work contributes to the growing literature questioning the clinical usefulness of the concept of MCI and the appropriateness of current diagnostic criteria for distinguishing this condition from mild AD.     

Patterns of limb apraxia in primary progressive aphasia

Primary progressive aphasia (PPA) is a syndrome characterized by a progressive language deficit without other dementia features for at least two years (). Other deficits that are likely to co-exist with aphasia, such as apraxia, have only been investigated in a few case studies and only at a rudimentary level for the most part. In this study we investigate the frequency and severity of apraxic deficits in PPA patients. Ten PPA patients and twelve aged-matched healthy adults performed eight transitive gestures to pantomime and to imitation. Gesture performance was measured along five movement dimensions and a composite score based on the arithmetic mean of the five dimensions was calculated. Overall, PPA patients performed worse than controls with both pantomime and imitation. Furthermore, individual comparisons revealed that out of the three apraxia patterns described by (pantomime alone, imitation alone, or apraxia in both conditions), the most frequent pattern in PPA patients was apraxia in both conditions. This result corresponds with previous findings in populations of stroke and Alzheimer's patients. Considering the occurrence of apraxia in this population, this study supports the idea that a comprehensive apraxia assessment should be administered in cases of PPA.     

Dissociations of writing and praxis: Two cases in point

For normal writing it is essential that both motoric and linguistic competence be present; disruption of one or the other of these faculties may result in qualitatively different types of agraphia. Two right-handed patients became agraphic after left hemisphere lesions; pure apraxic agraphia in the absence of limb apraxia developed in one patient and pure linguistic agraphia in association with severe ideomotor limb apraxia in the other. The performance of these patients not only serves to illustrate the dissociation between the motoric and linguistic faculties that underlie writing but also confirms that ideomotor limb apraxia and apraxic agraphia are distinct and dissociable entities.     

Screening for apraxia: a short assessment for stroke patients

Apraxia is a disorder that involves impaired ability to execute previously learned movements that cannot be attributed to basic sensory or motor disturbances. A thorough assessment of apraxia typically entails both pantomiming and imitation of transitive (tool-related), intransitive (communication-related), and meaningless gestures, presented in an array of different, process-dependent sensory conditions. Precise and detailed assessment tools are often time-consuming and a shorter screening tool may be desirable for efficient surveillance of this disorder in stroke patients. In the present study, stroke patients (N = 37) were compared to healthy controls (N = 30) in their production of commonly used transitive and intransitive gestures. Five gestures (knife, flipper, tweezers, okay sign, cab hailing) were consistently performed with poorer accuracy in stroke patients when compared to healthy controls. The combination of gestures that best captured apraxic performance was statistically determined based on Z-score data. Results provide a shortened and sensitive method of detecting apraxia in stroke patients.     

Visual perception of writing and pointing movements

Studies of movement production have shown that the relationship between the amplitude of a movement and its duration varies according to the type of gesture. In the case of pointing movements the duration increases as a function of distance and width of the target (Fitts' law), whereas for writing movements the duration tends to remain constant across changes in trajectory length (isochrony principle). We compared the visual perception of these two categories of movement. The participants judged the speed of a light spot that portrayed the motion of the end-point of a hand-held pen (pointing or writing). For the two types of gesture we used 8 stimulus sizes (from 2.5 cm to 20 cm) and 32 durations (from 0.2 s to 1.75 s). Viewing each combination of size and duration, participants had to indicate whether the movement speed seemed "fast", "slow", or "correct". Results showed that the participants' perceptual preferences were in agreement with the rules of movement production. The stimulus size was more influential in the pointing condition than in the writing condition. We consider that this finding reflects the influence of common representational resources for perceptual judgment and movement production.     

An update on the Conceptual-Production Systems model of apraxia: evidence from stroke

Limb apraxia is a neurological disorder characterized by an inability to pantomime and/or imitate gestures. It is more commonly observed after left hemisphere damage (LHD), but has also been reported after right hemisphere damage (RHD). The Conceptual-Production Systems model (Roy, 1996) suggests that three systems are involved in the control of purposeful movements: the conceptual, the production and the sensory/perceptual system. Depending on which system is damaged different patterns of apraxia are expressed. To determine the apraxia pattern, pantomime, delayed, and concurrent imitation tasks need to be administered, as well as conceptual tasks assessing one's knowledge of actions. Based on the model, eight patterns of apraxia should emerge. The purpose of this study is to determine whether these patterns are in fact observed in stroke patients and examine their frequency. If the performance of most stroke patients falls into one of the patterns, then we would have strong support for the conceptual-production model. Stroke (34 LHD and 39 RHD) patients and 27 age- and education-matched healthy controls participated in the study. Participants were assessed in four task modalities: pantomime, delayed imitation, concurrent imitation and conceptual knowledge (two tasks were used: tool naming by action and action identification). Patients were categorized as impaired on a task if they scored 2 SD below the mean performance of the controls for gesture production tasks, or below a cut-off score on the conceptual tasks. They were then classified into patterns depending on their performance on the four task modalities. Most patients (86%) fell into one of seven patterns originally predicted from the Conceptual-Production Systems model. The two most common patterns were deficits in pantomime and imitation with preserved gesture recognition and conduction apraxia (selective deficit in imitation). Four new patterns emerged, but mostly single cases of these were found. Overall, the study provides strong support for the Conceptual-Production Systems model.     

Tool-use and the left hemisphere: What is lost in ideomotor apraxia?

Impaired tool related action in ideomotor apraxia is normally ascribed to loss of sensorimotor memories for habitual actions (engrams), but this account has not been tested against a hypothesis of a general deficit in representation of hand-object spatial relationships. Rapid reaching for familiar tools was compared with reaching for abstract objects in apraxic patients (N = 9) and in a control group with right hemisphere posterior stroke. The apraxic patients alone showed an impairment in rotating the wrist to correctly grasp an inverted tool but not when inverting the hand to avoid a barrier and grasp an abstract object, and the severity of the impairment in tool reaching correlated with pantomime of tool-use. A second experiment with two apraxic patients tested whether barrier avoidance was simply less spatially demanding than reaching for a tool. However, the patient with damage limited to the inferior parietal lobe still showed a selective problem for tools. These results demonstrate that some apraxic patients are selectively impaired in their interaction with familiar tools, and this cannot be explained by the demands of the task on postural or spatial representation. However, traditional engram theory cannot account for associated problems with imitation of novel actions nor the absence of any correlated deficit in recognition of the methods of grasp of common tools. A revised theory is presented which follows the dorsal and ventral streams model ( Milner & Goodale, 2008) and proposes preservation of motor control by the dorsal stream but impaired modulating input to it from the conceptual systems of the left temporal lobe.     

Limb apraxia and motor performance

This study was desinged to determine if motor deficits in limb apraxia are task specific. Non-brain-damaged patients and apraxic and nonapraxic patients with left hemisphere damage performed language and limb apraxia tests and six motor tasks with the left hand. Contrary to previous data, no significant group differences occurred on a finger tapping task. Although task complexity or sequencing requirements affected group differences, greatest apraxic impairment was noted on a task of precise steadiness, but only when its response inhibition requirements were increased. This pattern of deficits appears to be associated with greater involvement of the premotor area in the apraxic group.     

Pantomime and imitation of limb gestures in relation to the severity of Alzheimer's disease

The present study was designed to investigate the relationship between performance of limb gestures and the severity of Alzheimer's disease (A.D.). Apraxia tends to occur at later stages of A.D., and the severity of apraxia has been shown to vary with the severity of A.D. dementia. Participants were 19 mild (including 9 with no cognitive impairment and 10 with mild impairment) and 18 moderate A.D. patients as well as 25 controls and they were asked to pantomime (P) or imitate (both concurrent (CI) and delayed (DI)), eight transitive gestures to assess praxis performance. Results indicated that the moderate patients performed less accurately than mild and non-impaired patients, and that across all groups, the imitation conditions were performed less accurately than pantomime, relative to controls. Correlational analyses revealed that MMSE scores were correlated with all three performance conditions suggesting that impaired praxis performance may relate to more global impairment. Finally, a frequency analysis was conducted to examine whether A.D. patients showed patterns of apraxia as described in Roy's model (1996). Results indicated that A.D. patients showed greatest impairment on pattern 7 (deficits in P, DI, and CI), reflecting late-stage gesture production, with a greater frequency of moderate patients exhibiting each apraxic pattern.     

Error Types in Ideomotor Apraxia: A Qualitative Analysis

Seventeen brain-damaged subjects with dominant hemisphere pathology and 24 matched control subjects were asked to perform simple familiar gestures under four conditions: (1) verbal command (pantomime), (2) imitation, (3) with the actual object, and (4) verbal command a second time. The subjects subsequently watched a video of an actor performing simple movements and decided whether or not these were performed accurately. The gestural production task was videoed and analyzed for error type. Error type remained consistent over the four task conditions, although subgroups of patients made different types of errors. One group of patients with Ideomotor Apraxia (IMA) made more errors but of the same type as the controls, i.e., movement-related errors and the use of "body part as object" (BPO). The second group made mainly substituted (i.e. unrelated) movements and perseverative errors. The second group of subjects was also poorer at discriminating incorrectly performed movements in the recognition task. BPO errors were commonly made by the control group and they were also chosen as correct in the recognition task. This indicated that use of BPO may reflect a convention in symbolising gestures rather than pathology. The performance of the IMA subjects was discussed in relation to current theories of the mechanisms underlying apraxia.     

The different types of limb apraxia errors made by patients with left vs. right hemisphere damage

Limb apraxia errors were compared among normal controls and right- or left-hemisphere-damaged patients as they imitated gestures with the ipsilateral hand. Both brain-damaged groups made similar errors on nonrepresentative and representative/intransitive movements. In contrast for pretended object use movements (transitive), the left-hemisphere-damaged group made more arm position and classical body-part-as-object errors while the right hemisphere group made as many partial errors and more less-primitive, body-part-as-object errors than the left-hemisphere-damaged group. These results help explain why a certain percentage of right-hemisphere-damaged patients are labeled apraxic, but also suggest that the left hemisphere is more important for integrating intrapersonal space and the “representation” of extrapersonal space.     

Self-recognition of highly skilled actions: A study of orchestral conductors

The influence of movement skill on action representations and identification of agency was investigated. Point-light displays were created of highly skilled gestures of thirteen orchestral conductors in visual, auditory, and audiovisual versions and compared to two control conditions (static images and gait cycles of the same participants). In subsequent experimental sessions, participants indicated whether displays presented them or other conductors, whether the soundtrack contained their or others' musical interpretations, and rated the quality and emotional content of the gestures. Self-recognition was more accurate in conditions presenting highly skilled conducting movements as compared to other displays. Participants judged the quality of their own movements to be better than those of others, independently of whether or not they recognized movement agency. Emotional content was perceived accurately across conditions both for own and others' actions. These results point to the influence of dynamical characteristics of motor skill, rather than merely type of movement or emotional content, on action representations and self-other identification.     

Cognitive mechanisms of visuomotor transformation in movement imitation: Examining predictions based on models of apraxia and motor control

When we observe a movement and then reproduce it, how is this visual input transformed into motor output? Studies on stroke patients with apraxia suggest that there may be two distinct routes used for gesture imitation; an indirect route that recruits stored movement memories (motor programs) and a direct route that bypasses them. The present study examined 30 healthy adults ages 18–80 (mean age = 44.0 years, SD = 19.5) to learn how motor programs are recruited or bypassed in movement imitation depending upon task conditions (whether familiar letters or novel shapes are imitated) and perceptual factors (whether shapes or letters are perceived). Subjects were asked to imitate the movements of a model who formed shapes and letters on a sheer mesh screen, and to report whether they perceived the task as a shape or a letter. Movements were recorded using a Vicon motion analysis system, and subsequently analyzed to determine the degree of difference between the demonstrated and produced movements. As predicted, letter perception on the letter tasks resulted in increased temporal error when the demonstrated stroke order conflicted with subjects’ habitual pattern of letter formation. No such interference effects were observed when the letter tasks were perceived as shapes. These findings are discussed in the context of current theories on imitation, and implications for rehabilitation and motor re-learning are presented.