Associations and dissociations of transitive and intransitive gestures in left and right hemisphere stroke patients

The study investigated performance on pantomime and imitation of transitive and intransitive gestures in 80 stroke patients, 42 with left (LHD) and 38 with right (RHD) hemisphere damage. Patients were also categorized in two groups based on the time that has elapsed between their stroke and the apraxia assessment: acute–subacute (n = 42) and chronic (n = 38). In addition, patterns of performance in apraxia were examined. We expected that acute–subacute patients would be more impaired than chronic patients and that LHD patients would be more impaired than RHD patients, relative to controls. The hemisphere prediction was confirmed, replicating previous findings. The frequency of apraxia was also higher in all LHD time post-stroke groups. The most common impairment after LHD was impairment in both pantomime and imitation in both transitive and intransitive gestures. Selective deficits in imitation were more frequent after RHD for transitive gestures but for intransitive gestures they were more frequent after LHD. Patients were more impaired on imitation than pantomime, relative to controls. In addition, after looking at both gesture types concurrently, we have described cases of patients who suffered deficits in pantomime of intransitive gestures with preserved performance on transitive gestures. Such cases show that the right hemisphere may be in some cases critical for the successful pantomime of intransitive gestures and the neural networks subserving them may be distinct. Chronic patients were also less impaired than acute–subacute patients, even though the difference did not reach significance. A longitudinal study is needed to examine the recovery patterns in both LHD and RHD patients.     

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.     

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.     

Transitive gesture production in apraxia: visual and nonvisual sensory contributions

The production of transitive limb gestures is optimized when the appropriate tool can be physically manipulated. Little research has addressed the independent contributions of visual and nonvisual sources of sensory information to this phenomenon. In this study, 12 control, 37 LHD, and 50 RHD stroke patients performed transitive limb gestures to pantomime (to verbal command with the object visible) and object manipulation. Performance was more accurate in the object manipulation condition, suggesting that haptic and kinesthetic cues are important for transitive gesture production. Various patterns of performance were observed in the stroke groups, indicating that selective damage to the haptic/kinesthetic processing system is possible and common following unilateral stroke.     

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.     

Neuropragmatics: Extralinguistic pragmatic ability is better preserved in left-hemisphere-damaged patients than in right-hemisphere-damaged patients

The aim of the present study is to compare the pragmatic ability of right- and left-hemisphere-damaged patients excluding the possible interference of linguistic deficits. To this aim, we study extralinguistic communication, that is communication performed only through gestures. The Cognitive Pragmatics Theory provides the theoretical framework: it predicts a gradient of difficulty in the comprehension of different pragmatic phenomena, that should be valid independently of the use of language or gestures as communicative means. An experiment involving 10 healthy individuals, 10 right- and 9 left-hemisphere-damaged patients, shows that pragmatic performance is better preserved in left-hemisphere-damaged (LHD) patients than in right-hemisphere-damaged (RHD) patients.     

Comprehension of humorous and nonhumorous materials by left and right brain-damaged patients

Right hemisphere-damaged (RHD) and left hemisphere-damaged (LHD) aphasic patients were tested on a nonverbal cartoon completion task that included a humorous (Joke) and a nonhumorous (Story) condition. In both conditions, RHD patients performed worse than LHD patients. More importantly, the qualitative difference between the errors produced by the two groups suggests that right and left hemisphere brain damage impairs different components of narrative ability. RHD patients showed a preserved sensitivity to the surprise element of humor, and a diminished ability to establish coherence. Conversely, LHD patients, when they erred, showed an impaired sensitivity to the surprise element of humor, and a preserved ability to establish coherence by integrating content across parts of a narrative. These results suggest that the observed humor comprehension deficits of RHD patients result specifically from right hemisphere disease and not from brain damage irrespective of locus. The performances of the RHD and LHD patients groups together support a separation of narrative ability from the traditional aspects of language ability typically disrupted in aphasia.     

Recognition and discrimination of emotional faces and pictures

In order to learn whether patients with right-hemisphere disease (RHD) had a deficit in their ability to discriminate and comprehend emotional faces and pictures, we studied nine patients with RHD, nine patients with left-hemisphere disease (LHD), and nine controls. The subjects were presented with six picture tests that comprised either emotional faces or emotional scenes. Their task was either to denote (name or choose) an emotion or to discriminate (same, different) between two faces or emotions. Patients with RHD performed significantly worse than subjects with LHD when asked to discriminate between faces, to discriminate between emotional faces, and to name emotional scenes. There was also a trend for the RHD group to be more impaired than the LHD group when asked to name the emotional face or choose the emotional face. Except for the facial and emotional discrimination tests, the LHD patients also performed worse than controls.     

Sources of performance on theory of mind tasks in right hemisphere-damaged patients

Patients with right hemisphere (RHD) or left hemisphere brain damage (LHD) were tested on Theory of Mind (ToM) tasks presented with visual aids that illustrated the relevant premises. As a measure of pragmatic ability, patients were also asked to judge replies in conversation that violated Gricean maxims. Both RHD and LHD patients performed well on the ToM tasks presented with visual aids, but RHD patients displayed difficulty when the same tasks were presented only verbally. In addition, RHD patients showed reduced sensitivity to pragmatic violations. These findings point to the role of right hemisphere structures in processing information relevant to conversations. They indicate that a crucial source of RHD patients' errors in ToM tasks may involve difficulties in utterance interpretation owing to impairments of visuospatial processing required for the representation of textual information.     

To drive or not to drive: Neuropsychological assessment for driver's license among stroke patients

Seventy-two stroke patients, 43 with right hemisphere (RHD) and 29 with left hemisphere damage (LHD), and 7 coronary infarct controls with no evidence of cerebral damage, were neuropsychologically tested as part of an assessment program for driver's license. Mean age in the group was 53 years. Stroke patients were tested on average 4 months post injury. The groups did not differ on major demographic variables except that RHD patients were more often hemiplegic than LHD patients. The test battery was factor analyzed into 4 valid principal components: (I) visual perception , (II) spatial attention , (III) visuospatial processing , and (IV) language/praxis. The presence of hemianopia (factor I) excludes driving. In addition, measures of neglect and reduced speed of mental processing from factor II, III and IV, were found to be the most discriminating variables when classifying patients for driving. Even though neglect was more frequently observed among RHD than LHD patients, the two hemisphere groups did not differ significantly in number of patients denied driving, 58% RHD compared to 41% LHD patients. The need for comprehensive neuropsychological assessment is underlined.     

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.     

The Assessment of Limb Apraxia: An Investigation of Task Effects and Their Cause

To test the effects of variations in the structure of tasks used to assess limb apraxia, eight tasks—differing in their modes of elicitation (tactile, verbal, visual, imitation) and/or types of movement elicited (transitive, intransitive, meaningless)—were administered to 25 carefully selected subjects with idiomotor limb apraxia. When standardized scores (based on the performance of 10 nonneurologically impaired control subjects) were used to measure the differences between tasks, no clinically significant task effects were found. Additional investigation was made of two causal hypotheses regarding the processes underlying limb apractic performance. The results of factor analyses and a search for double dissociations among individual subjects were consistent with the (severity) hypothesis that differences in task performances (raw scores) reflect degrees of task difficulty; and they failed to support the (disconnection) hypothesis that posits separate and independent neural/mental processes underlying task performances.     

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.     

Sensitivity to prosodic structure in left- and right-hemisphere-damaged individuals

An experiment was conducted in order to determine whether left- (LHD) and right-hemisphere-damaged (RHD) patients exhibit sensitivity to prosodic information that is used in syntactic disambiguation. Following the work of, a cross-modal lexical decision task was performed by LHD and RHD subjects, as well as by adults without brain pathology (NC). Subjects listened to sentences with attachment ambiguities with either congruent or incongruent prosody, while performing a visual lexical decision task. Results showed that each of the unilaterally damaged populations differed from each other, as well as from the NCs in terms of sensitivity regarding prosodic cues. Specifically, the RHD group was insensitive to sentence prosody as a whole. This was in contrast to the LHD patients, who responded to the prosodic manipulation, but in the unexpected direction. Results are discussed in terms of current hypotheses regarding the hemispheric lateralization of prosodic cues.     

Production of Stress Retraction by Left- and Right-Hemisphere-Damaged Patients

An acoustic-perceptual investigation of a phonological phenomenon in which stress is retracted in double-stressed words (e.g., thirTEEN vs THIRteen MEN) was undertaken to identify the locus of functional impairments in speech prosody. Subjects included left-hemisphere-damaged (LHD) and right-hemisphere-damaged (RHD) patients and nonneurological controls. They were instructed to read sentences containing double-stressed target words in the presence of a clause boundary or its absence. Whereas all three groups of subjects were capable of manipulating the acoustic parameters that signal a shift in stress, there were some differences between the performance of the patient groups and that of the normal controls. Further, stress production deficits were more severe in LHD aphasic patients than in RHD patients. LHD speakers exhibited deficits in the control of both temporal and F0 cues. Their F0 disturbance appears to be secondary to a primary deficit in temporal control at the phase or sentence level, as an increased number of continuation rises found for the LHD patients seemed to arise from lengthy pauses within sentences. Findings are highlighted to address the nature of breakdown in speech prosody and the competing views of prosodic lateralization.     

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.     

Differential effects of unilateral lesions on language production in children and adults.

We present the first direct comparison of language production in brain-injured children and adults, using age-corrected z scores for multiple lexical and grammatical measures. Spontaneous speech samples were elicited in a structured biographical interview from 38 children (5-8 years of age), 24 with congenital left-hemisphere damage (LHD) and 14 with congenital right-hemisphere damage (RHD), compared with 38 age- and gender-matched controls, 21 adults with unilateral injuries (14 LHD and 7 RHD), and 12 adult controls. Adults with LHD showed severe and contrasting profiles of impairment across all measures (including classic differences between fluent and nonfluent aphasia). Adults with RHD (and three nonaphasic adults with LHD) showed fluent but disinhibited and sometimes empty speech. None of these qualitative or quantitative deviations were observed in children with unilateral brain injury, who were in the normal range for their age on all measures. There were no significant differences between children with LHD and RHD on any measure. When LHD children were compared directly with LHD adults using age-corrected z scores, the children scored far better than their adult counterparts on structural measures. These results provide the first systematic confirmation of differential free-speech outcomes in children and adults and offer strong evidence for neural and behavioral plasticity following early brain damage.     

An experimental investigation of the automatic/voluntary dissociation in limb apraxia

The ability of apraxic patients to perform gestures in everyday life is a controversial issue. In this paper, we aimed to evaluate the automatic/voluntary dissociation (AVD) in four patients affected by clinically relevant limb apraxia. For this purpose, we sampled different kinds of gestures belonging to patients' motor repertoire and then assessed their production in a testing session. Our experimental procedure consisted of two steps: in the first phase, we recorded gestures produced by patients in two natural conditions; in the second phase, we assessed production of correctly produced tool-actions, and of spontaneous non tool-actions and meaningless conversational (cohesive and beats) gestures under different modalities. AVD was observed for all types of gestures, albeit to different degree in single patients. The present findings demonstrate that the context provides strong bottom-up cues for the retrieval of motor patterns, while artificial testing conditions impose an additional cognitive load.     

Appreciation of indirect requests by left- and right-brain-damaged patients: the effects of verbal context and conventionality of wording

Unilaterally right (RHD)- and left (LHD)-hemisphere-damaged patients were tested on their ability to discern the correct, nonliteral interpretation of indirect requests (e.g., "Can you open the door?") embedded in short vignettes and presented without any pictorial support. Each stimulus vignette incorporated two verbal cues--context and conventionality of form--designed to influence interpretations of a critical utterance located at the end of each vignette. Contexts were biased to encourage either the direct, literal reading of critical utterances as a question, or the indirect meaning of the utterance as a request for action. The critical utterances themselves were either high in conventionality (e.g., "Can you ...?") which encouraged an indirect interpretation, or low in conventionality (e.g., "Is it possible for you to ...?") which encouraged a direct interpretation. Results indicated that RHD patients were significantly impaired, relative to controls, in their ability to make judgments based on contextual information. RHD patients performed comparably to the aphasic, LHD group in the use of both context and conventionality. These results replicate earlier findings of disrupted indirect request comprehension by RHD patients tested in pictorially supported paradigms.     

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.