Apraxia
Specialty	Psychomotor education, occupational therapy

Apraxia (from the Greek root word praxis, for an act, work, or deed, preceded by an privative a, meaning without^[1]) is characterized by loss of the ability to execute or carry out learned purposeful movements,^[2] despite having the desire and the physical ability to perform the movements. It is a disorder of motor planning, which may be acquired or developmental, but is not caused by incoordination, sensory loss, or failure to comprehend simple commands (which can be tested by asking the person to recognize the correct movement from a series). It is caused by damage to specific areas of the cerebrum. Apraxia should not be confused with ataxia, a lack of coordination of movements; aphasia, an inability to produce and/or comprehend language; abulia, the lack of desire to carry out an action; or allochiria, in which patients perceive stimuli to one side of the body as occurring on the other.

Types

There are several types of apraxia including:

• Ideomotor apraxia: These patients have deficits in their ability to plan or complete motor actions that rely on semantic memory. They are able to explain how to perform an action, but unable to "imagine" or act out a movement such as "pretend to brush your teeth" or "pucker as though you bit into a sour lemon." The ability to perform an action automatically when cued, however, remains intact. This is known as automatic-voluntary dissociation. For example they may not be able to pick up a phone when asked to do so, but can perform the action without thinking when the phone rings.^[3][4]

• Ideational/conceptual apraxia: Patients have an inability to conceptualize a task and impaired ability to complete multistep actions. Consists of an inability to select and carry out an appropriate motor program. For example, the patient may complete actions in incorrect orders, such as buttering bread before putting it in the toaster, or putting on shoes before putting on socks. There is also a loss of ability to voluntarily perform a learned task when given the necessary objects or tools. For instance, if given a screwdriver, the patient may try to write with it as if it were a pen, or try to comb one's hair with a toothbrush.^[3][4]

• Buccofacial or orofacial apraxia: Non-verbal oral or buccofacial ideomotor apraxia resulting in difficulty carrying out movements of the face on demand. For example, an inability to lick one's lips or whistle.

• Constructional apraxia: The inability to draw or construct simple configurations, such as intersecting pentagons.

• Gait apraxia

• Limb-kinetic apraxia: Difficulty making precise movements with an arm or leg.

• Oculomotor apraxia: Difficulty moving the eye, especially with saccade movements that direct the gaze to targets. This is one of the 3 major components of Balint's syndrome.

• Apraxia of speech: Difficulty planning and coordinating the movements necessary for speech.^[1]

Each type may be tested at decreasing levels of complexity; if the person tested fails to execute the commands, you can make the movement yourself and ask that the person mimic it, or you can even give them a real object (like a toothbrush) and ask them to use it.

Verbal apraxia of speech

Apraxia may be accompanied by a language disorder called aphasia. Because this is such a frequently encountered type of apraxia, an entire section is devoted to it:

Symptoms of Acquired Apraxia of speech (AOS) and Childhood Apraxia of Speech (CAS) include inconsistent articulatory errors, groping oral movements to locate the correct articulatory position, and increasing errors with increasing word and phrase length. AOS often co-occurs with Oral Apraxia (during both speech and non-speech movements) and Limb Apraxia.

Childhood Apraxia of Speech (CAS) presents in children who have no evidence of difficulty with strength or range of motion of the articulators, but are unable to execute speech movements because of motor planning and coordination problems. This is not to be confused with phonological impairments in children with normal coordination of the articulators during speech.

Acquired apraxia of speech involves the loss of previously acquired speech levels. It occurs in both children and adults who have (prior to the onset of apraxia) acquired some level of speaking ability. Unlike Childhood Apraxia of Speech, AOS is typically the result of a stroke, tumor, or other known neurological illness or injury.

Causes

Apraxia is most often due to a lesion in the left hemisphere, and is typically in the parietal lobe and frontal lobe; however lesions in other brain areas, including the right hemisphere, due to stroke, ABI, or neurodegenerative diseases can result in apraxia.^[4]

Due to the common left parietal and frontal lobe locations, apraxia is often accompanied by aphasia which can make diagnosis challenging as it is difficult to tell if the patient's motor impairments are due to apraxia or from the decreased language comprehension associated with aphasia.^[5]

Ideational apraxia is commonly associated with confusion states and dementia.

Constructional apraxia is associated with hepatic encephalopathy due to cerebral edema.

Assessment

Although qualitative and quantitative studies exist, there is little consensus on the proper method to assess for apraxia. The criticisms of past methods include failure to meet standard psychometric properties as well as research-specific designs that translate poorly to non-research use.^[6]

The Test to Measure Upper Limb Apraxia (TULIA) is one method of determining upper limb apraxia through the qualitative and quantitative assessment of gesture production. In contrast to previous publications on apraxic assessment, the reliability and validity of TULIA was thoroughly investigated.^[7] The TULIA consists of subtests for the imitation and pantomime of non-symbolic (“put your index finger on top of your nose”), intransitive (“wave goodbye”) and transitive (“show me how to use a hammer”) gestures.^[6] Discrimination (differentiating between well- and poorly-performed tasks) and recognition (indicating which object corresponds to a pantomimed gesture) tasks are also often tested for a full apraxia evaluation.

However, there may not be a strong correlation between formal test results and actual performance in everyday functioning or activities of daily living (ADL). A comprehensive assessment of apraxia should include formal testing, standardized measurements of ADLs, observation of daily routines, self-report questionnaires and targeted interviews with the patients and their relatives.^[6]

Treatment

Recommended treatment for individuals with apraxia includes physical therapy, occupational therapy, play therapy, music therapy, and/or speech therapy.^[8] Yet, treatments for apraxia have received little attention for several reasons, including the tendency for the condition to resolve spontaneously in acute cases. Additionally, the very nature of the automatic-voluntary dissociation of motor abilities that defines apraxia means that patients may still be able to automatically perform activities if cued to do so in daily life. Nevertheless, research shows that patients experiencing apraxia have less functional independence in their daily lives,^[9] and that evidence for the treatment of apraxia is scarce.^[10] However, a literature review of apraxia treatment to date reveals that although the field is in its early stages of treatment design, certain aspects can be included to treat apraxia.^[11] One method is through rehabilitative treatment, which has been found to positively impact apraxia, as well as activities of daily living.^[11] In this review, rehabilitative treatment consisted of 12 different contextual cues, which were used in order to teach patients how to produce the same gesture under different contextual situations.^[11] Additional studies have also recommended varying forms of gesture therapy, whereby the patient is instructed to make gestures (either using objects or symbolically meaningful and non-meaningful gestures) with progressively less cuing from the therapist.^[12] Thus, gesture therapy has been found to be the most effective treatment for apraxia at the current time. While other modes of therapy, including direct, exploratory, and strategy training hold promise, there is insufficient evidence of their efficacy.^[5]

Prognosis

The prognosis for individuals with apraxia varies. With therapy, some patients improve significantly, while others may show very little improvement. Some individuals with apraxia may benefit from the use of a communication aid. However, many people with apraxia are no longer able to be independent. They should avoid activities in which they might injure themselves or others.

Occupational therapy and counseling and play therapy may help both patients and their caregivers learn ways to deal with the apraxia. However, because people with limb apraxia may have trouble directing their motor movements, occupational therapy for stroke or other brain injury can be difficult.

No drug has been shown useful for treating apraxia.

References

Further reading

• Steinman KJ, Mostofsky SH, Denckla MB (2010). "Toward a narrower, more pragmatic view of developmental dyspraxia". J. Child Neurol. 25 (1): 71–81. doi:10.1177/0883073809342591. PMC 2892896. PMID 20032517. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
• Kasper, D.L.; Braunwald, E.; Fauci, A.S.; Hauser, S.L.; Longo, D.L.; Jameson, J.L.. Harrison's Principles of Internal Medicine. New York: McGraw-Hill, 2005. ISBN 0-07-139140-1.

External links

• Ontario Association for Families of Children with Communication Disorders
• Apraxia-Kids
• Apraxia Research
• What is Childhood Apraxia of Speech?
• Motor development

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