Skip to main content
SpringerLink
Log in

Limb Apraxia: a Disorder of Learned Skilled Movement

  • Behavior (H. Kirshner, Section Editor)
  • Published:
Current Neurology and Neuroscience Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This chapter focuses on limb apraxia, a cognitive-motor disorder of learned skilled movement, and the nature of the spatiotemporal errors that disrupt movement sequences.

Recent Findings

A cognitive model that attempts to reconcile conceptual and preparatory aspects of the motor program with perceptual and kinematic features will be discussed. An update on the localization of the praxis network will be provided. In addition, a long-held view that limb apraxia does not have ecological relevance will be disputed in the context of studies that have shown that limb apraxia (i) is one of the most important predictors of increased caregiver burden and (ii) is associated with impaired activities of daily living in post-stroke patients. This review summarizes current screening tools and the few randomized clinical controlled treatment studies to date.

Summary

Limb apraxia is underdiagnosed and very few therapeutic options are available. Cognitive process models should be used to inform future controlled multi-modal treatment strategies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Agostoni E, Coletti A, Orlando G, Tredici G. Apraxia in deep cerebral lesions. J Neurol Neurosurg Psychiatry. 1983;46:804–8.

    CAS  PubMed Central  PubMed  Google Scholar 

  2. Alexander MP, Baker E, Naeser MA, Kaplan E, Palumbo C. Neuropsychological and neuroanatomical dimensions of ideomotor apraxia. Brain. 1992;115:87–107.

    PubMed  Google Scholar 

  3. Ashendorf L, Swenson R, Libon DJ, The Boston process approach to neuropsychological assessment: a practitioner’s guide: Oxford University Press; 2013.

  4. Barrett AM, Dore LS, Hansell KA, Heilman KM. Speaking while gesturing: the relationship between speech and limb praxis. Neurology. 2002;58:499–500.

    PubMed  Google Scholar 

  5. Barrett AM, Foundas AL Apraxia. In: Rizzo M, P. Eslinger P, editors. Principles and Practice of Behavioral Neurology and Neuropsychology. W.B. Saunders Company, 2004.

  6. Basso A, Luzzatti C, Spinnler H. Is ideomotor apraxia the outcome of damage to well-defined regions of the left hemisphere? Neuropsychological study of CAT correlation. J Neurol Neurosurg Psychiatry. 1980;43:118–26.

    CAS  PubMed Central  PubMed  Google Scholar 

  7. Beauchamp MS, Martin A. Grounding object concepts in perception and action: evidence from fMRI studies of tools. Cortex. 2007;43:461–8.

    PubMed  Google Scholar 

  8. • Bianchi M, Cosseddu M, Cotelli M, Manenti R, Brambilla M, Rizzetti MC, et al. Left parietal cortex transcranial direct current stimulation enhances gesture processing in corticobasal syndrome. Eur J Neurol. 2015;22:1317–22 Corticobasal syndrome (CBS) is a neurodegenerative disorder with asymmetric onset of levodopa-resistant parkinsonism, dystonia, myoclonus, and limb apraxia. Transcranial direct current stimulation (tDCS), a non-invasive cortical stimulation procedure, was used to determine whether anodal tDCS over the parietal cortex (PARC) would improve ideomotor upper limb apraxia in CBS patients. Patients with a diagnosis of CBS and upper limb apraxia were studied (N = 14). Each study participant had two sessions of anodal tDCS (left and right PARC) and one session of placebo tDCS. Apraxia was assessed using the De Renzi ideomotor imitation apraxia test. Results showed a significant improvement in the apraxia test scores (post-stimulation versus pre-stimulation) after active anodal stimulation over the left PARC (χ(2) = 17.6, P = 0.0005). No significant effect was found following active anodal stimulation over the right PARC (χ(2) = 7.2, P = 0.07). Post hoc analysis showed selective improvement in the apraxia score of both right (P = 0.03) and left upper limbs (P = 0.01) after active anodal stimulation over the left PARC compared with placebo stimulation. These results suggest that tDCS to the PARC may represent a promising treatment tool to improve functional outcomes in people with a diagnosis of CBS.

    CAS  PubMed  Google Scholar 

  9. • Bolognini N, Convento S, Banco E, Mattioli F, Tesio L, Vallar G, et al. Improving ideomotor limb apraxia by electrical stimulation of the left posterior parietal cortex. Brain. 2015;138:428–39 The authors hypothesized that electrical stimulation of the left posterior parietal cortex would improve limb apraxia. Anodal transcranial direct current stimulation (tDCS) was delivered to the left posterior parietal cortex (PPC), the right motor cortex (M1), and in a sham stimulation condition in a group of left-hemispheric stroke patients (n = 6) compared to healthy controls (n = 6). Subjects were instructed to imitate hand gestures and to perform skilled hand movements with the left hand. Results showed that tDCS to the left PPC reduced the time required to perform skilled movements, and planning, but not execution, times in imitating gestures, in both patients and controls. In patients, the planning time decrease by left PPC tDCS was influenced by lesion size, with a larger parietal lesion associated with a smaller improvement. Left PPC stimulation also ameliorated accuracy in imitating hand gestures in the patient group. In contrast, tDCS to the right M1 diminished execution, but not planning, times in both groups. These results suggest that tDCS may temporarily improve limb apraxia in the left hand of left-brain-damaged patients. Future studies to examine the use of tDCS in the rehabilitation of limb apraxia are warranted.

    PubMed  Google Scholar 

  10. Borghi AM. Action language comprehension, affordances and goals. In: Coello Y, Bartolo A, editors. Language and Action in Cognitive Neuroscience. Contemporary Topics in Cognitive Neuroscience Series. London; New York, NY: Psychology Press; 2012. p. 125–44.

    Google Scholar 

  11. Borod JC, Fitzpatrick PM, Helm-Estabrooks N, Goodglass H. The relationship between limb apraxia and the spontaneous use of communicative gesture in aphasia. Brain Cogn. 1989;10:121–31.

    CAS  PubMed  Google Scholar 

  12. Buxbaum LJ, Haaland KY, Hallett M, Wheaton L, Heilman KM, Rodriguez A, et al. Treatment of limb apraxia: moving forward to improved action. Am J Phys Med Rehabil. 2008;87:149–61.

    PubMed  Google Scholar 

  13. •• Buxbaum LJ, Randerath J. Limb apraxia and the left parietal lobe. Handb Clin Neurol. 2018;151:349–63 The authors provide a comprehensive review of the nature of limb apraxia and discuss the network of regions in the left temporal, parietal, and frontal lobes most commonly implicated in stroke patients with this syndrome. In the past few years, there have been advances in understanding the functional neuroanatomy and connectivity of the left-hemisphere “tool use network,” and the patterns of performance that emerge from different lesion locations. This chapter focuses on the left inferior parietal lobe, and its role in tool and body representation, action prediction, and action selection. The authors discuss how these functions relate to the deficits seen in patients with limb apraxia following left parietal stroke. The chapter also provides suggestions for future research directions to facilitate rehabilitation protocols to treat this debilitating disorder.

    PubMed  PubMed Central  Google Scholar 

  14. •• Buxbaum LJ, Shapiro AD, Coslett HB. Critical brain regions for tool related and imitative actions: a componential analysis. Brain. 2014;137:1971–85 Functional neuroimaging studies have shown that bilateral parietal, temporal, and frontal regions are involved in tool-related and pantomimed gesture performance. The potential role of these regions in specific aspects of gestural tasks remains unclear. This study was designed as a prospective study of limb apraxia-related lesions to assess the critical neural substrates of gestures produced in response to viewed tools, imitation of tool-specific gestures demonstrated by the examiner, and imitation of meaningless gestures. To achieve this goal, voxel-based lesion-symptom mapping on data from 71 left hemisphere stroke patients was examined in the context of these two tool-related tasks, and two imitation tasks, enabling pairwise comparisons to highlight commonalities and differences. Lesioned voxels in the left posterior temporal gyrus were significantly associated with lower scores on the posture component for both tool-related gesture tasks. Degraded performance on the kinematic component of all three-gesture tasks was significantly associated with left inferior parietal and frontal lesions. Based on these data, the authors propose a componential neuroanatomical model of action that delineates specific components required for different gestural action tasks. These distinctions advance traditional accounts of apraxia.

    PubMed Central  PubMed  Google Scholar 

  15. • Cimino-Knight AM, Gonzalez Rothi LJ, He Y, Heilman KM. Callosal ideomotor apraxia in Alzheimer’s disease. J Clin Exp Neuropsychol. 2017;39:1–8 Patients with corpus callosum injury have difficulty performing skilled movements with the left upper limb. This is called callosal apraxia and can be demonstrated by spatial-temporal errors primarily in response to verbal commands (verbal callosal disconnection apraxia), with imitation, and when using actual tools (callosal ideomotor apraxia). Some patients with callosal injury may make content errors when selecting and using the incorrect tool with their left upper limb. This type of deficit has been called callosal conceptual apraxia. Patients with Alzheimer’s disease (AD) have anatomic evidence of callosal degeneration, but callosal apraxia in AD has not been previously described. This study was designed to learn whether patients with AD display different forms of callosal apraxia. Study participants included right-handed patients with AD (n = 22) and matched controls (n = 24). Both upper limbs were tested by examining transitive limb movements to command and to imitation. Participants also viewed pictures of an incomplete task and were instructed to pantomime the action needed to complete the task. The AD group had performance deficits consistent with ideomotor and conceptual apraxia of both upper limbs compared to controls. Errors were more pronounced in ideomotor apraxia of the left compared to the right hand, suggesting a hemispheric disconnection.

    PubMed  Google Scholar 

  16. Clark MA, Merians AS, Kothari A, Poizner H, Macauley B, Rothi LJ, et al. Spatial planning deficits in limb apraxia. Brain. 1994;117:1093–106.

    PubMed  Google Scholar 

  17. Cubelli R, Marchetti C, Boscolo G, Della Sala S. Cognition in action: testing a model of limb apraxia. Brain Cogn. 2000;44:144–65.

    CAS  PubMed  Google Scholar 

  18. De Renzi E. Apraxia. In: Boller F, Grafman J, editors. Handbook of clinical neurology. Amsterdam: Elsevier; 1990.

    Google Scholar 

  19. De Renzi E, Faglioni P, Lodesani M, Vecchi A. Performance of left brain-damaged patients on imitation of single movements and motor sequences. Frontal and parietal-injured patients compared. Cortex. 1983;19:333–43.

    PubMed  Google Scholar 

  20. De Renzi E. Methods of limb apraxia examination and their bearing on the interpretation of the disorder. In: Roy EA, editor. Neuropsychological studies of apraxia and related disorders. Amsterdam: North Holland; 1985. p. 45–64.

    Google Scholar 

  21. De Renzi E, Lucchelli F. Ideational apraxia. Brain. 1988;111:1173–85.

    PubMed  Google Scholar 

  22. Dee HL, Benton AL, Van Allen MW. Apraxia in relation to hemispheric locus of lesion and aphasia. Trans Am Neurol Assoc. 1970;95:147–50.

    CAS  PubMed  Google Scholar 

  23. Donkervoort M, Dekker J, Stehmann-Saris JC, Deelman BG. Efficacy of strategy training in left hemisphere stroke patients with apraxia: a randomized clinical trial. Neuropsychol Rehabil. 2001;11:549–66.

    Google Scholar 

  24. •• Dovern A, Fink GR, Weiss PH. Diagnosis and treatment of upper limb apraxia. J Neurol. 2012;259:1269–83 There were two main goals of this review article. First, the authors provide the clinician with the tools needed to reliably diagnose limb apraxia. This goal was achieved by an analysis of all of the tests developed to diagnose upper limb apraxia in the past 20 years, followed by a systematic analysis of strengths and weaknesses of validated screening tests. The second goal was to review and discuss the few randomized controlled studies that have investigated the efficacy of different apraxia treatments. In addition, this review article provides a comprehensive update on issues related to the ecological or real-world implications of limb apraxia.

  25. •• Evans C, Edwards MG, Taylor LJ, Ietswaart M. Impaired communication between the dorsal and ventral stream: indications from apraxia. Front Hum Neurosci. 2016;1(10):8 This study examined grasping performance in 27 right-handers including left-hemispheric stroke patients with (n = 3) and without (n = 9) limb apraxia, and healthy controls (n = 14). The hypothesis was that disrupted communication between dorsal and ventral pathways leads to limb apraxia because of the patient’s difficulty with successfully utilizing these stored representations. The authors found that the patients with limb apraxia had more difficulty with utilizing memory-associated or visual-spatial cued information compared to the other groups. Individual differences were seen in the patients with limb apraxia; lesion location may explain some of these behavioral differences. These results suggest that disruption to the ventro-dorsal pathways impairs use of familiar objects (i.e., tools) and can lead to difficulty in manipulating new or novel objects.

    Google Scholar 

  26. • Evans C, Edwards MG, Taylor LJ, Ietswaart M. Perceptual decisions regarding object manipulation are selectively impaired in apraxia or when tDCS is applied over the left IPL. Neuropsychologia. 2016;86:153–66 This study evaluated whether apraxia can be understood as due to impaired motor representations or motor imagery necessary for appropriate object-use, imitation, and pantomime. The causal role of the left inferior parietal lobe (IPL) was evaluated by using transcranial direct current stimulation (tDCS). Using a task assessing object-use perception, unilateral stroke patients with apraxia had a selective deficit during perceptual decisions reliant on the integration of visible and known object properties to select the appropriate grasp for object use. Apraxia severity was related to the severity of this deficit. Converging evidence was found using a modified version of the same task that used tDCS to target the left IPL in healthy participants. Inhibitory stimulation over the left IPL reduced performance during perceptual decisions regarding object manipulation; performance was unaffected during functional semantic decisions. Excitatory stimulation of the left IPL did not affect performance in either task. These results suggest that the left inferior parietal lobe is critical for motor imagery, and apraxia may be due in part to the inability to use internal motor representations of object manipulation. The authors propose an additional ventro-dorsal sub-stream within the dorsal and ventral visual pathways model to explain these results.

    PubMed  Google Scholar 

  27. •• Foundas AL. Apraxia: neural mechanisms and functional recovery. Handb Clin Neurol. 2013;110:335–45 This chapter provides an update on limb apraxia with reference to the two praxis systems including a production system (action plan and production) and a conceptual system (action knowledge). Dysfunction of the former produces ideomotor apraxia (e.g., difficulty using a scissors), and dysfunction of the latter induces ideational apraxia (e.g., difficulty making a cup of coffee). Neural mechanisms, including how to evaluate apraxia, are presented in the context of these two praxis systems. Information about these praxis systems, including the nature of the disordered limb movement, was reviewed in the context of improving diagnosis and treatment of this debilitating cognitive-motor disorder. Unfortunately, very few treatments have been systematically studied in large numbers of patients with limb apraxia. These treatment studies are reviewed in order to help rehabilitation clinicians educate patients and caregivers about this debilitating problem, and to facilitate the development of better treatments that could benefit many people in the future.

    PubMed  Google Scholar 

  28. •• Foundas AL. Limb Apraxia: A disorder of goal directed actions. In: Chatterjee A, Coslett HB, editors. The Roots of Cognitive Neuroscience: Behavioral Neurology and Neuropsychology. Oxford University Press, 2014 Apraxia is a disturbance in goal-directed behavior defined as a cognitive-motor disorder specific to learned skilled movements (e.g., tool use). The disordered movement can manifest as the imprecise orientation (spatial disturbance) of the object (e.g., toothbrush not oriented correctly to the teeth) or as the incorrect sequencing (temporal disturbance) of an action at a proximal rather than a distal limb joint (e.g., rotating at the shoulder rather than moving at the wrist to brush your teeth). This chapter reviewed several cognitive-process models of limb apraxia including Liepmann’s early model, Geschwind’s disconnection model, De Renzi’s multi-modal model, and the Heilman-Rothi dual-component model of limb apraxia. Lesion localization studies and converging evidence from functional imaging studies are reviewed in order to present an updated anatomical model of limb praxis with an emphasis on the praxis production system.

  29. Foundas AL, Daniels SK, Maher LM, Raymer A, Rothi LJG, Heilman KM. Lesion localization in ideomotor limb apraxia: a relationship to praxis. Neurology. 2002 58:499–500

  30. Foundas AL, Henchey R, Gilmore RL, Fennell EB, Heilman KM. Apraxia during Wada testing. Neurology. 1995a;45:1379–83.

    CAS  PubMed  Google Scholar 

  31. Foundas AL, Macauley BL, Raymer MA, Maher LM, Heilman KM, Gonzalez Rothi LJ. Ecological implications of limb apraxia: evidence from mealtime behavior. J Int Neuropsychol Soc. 1995b;1:62–6.

    CAS  PubMed  Google Scholar 

  32. Foundas AL, Macauley BL, Raymer AM, Maher LM, Heilman KM, Rothi LJ. Gesture laterality in aphasic and apraxic stroke patients. Brain Cogn. 1995c;29:204–13.

    CAS  PubMed  Google Scholar 

  33. Freund HJ. The parietal lobe as a sensorimotor interface: a perspective from clinical and neuroimaging data. Neuroimage. 2001;14:S142–6.

    CAS  PubMed  Google Scholar 

  34. Freund HJ, Hummelsheim H. Lesions of premotor cortex in man. Brain. 1985;108:697–733.

    PubMed  Google Scholar 

  35. Frey SH. What puts the how in where? Tool use and the divided visual streams hypothesis. Cortex. 2007 Apr;43(3):368–75.

    PubMed  Google Scholar 

  36. Geschwind N. Disconnexion syndromes in animals and man. Brain. 1965;88:237–94.

    CAS  PubMed  Google Scholar 

  37. Geschwind N, Kaplan E. A human cerebral deconnection syndrome. A preliminary report. Neurology. 1962;12:675–85.

    CAS  PubMed  Google Scholar 

  38. Goldenberg G. Defective imitation of gestures in patients with damage in the left or right hemispheres. J Neurol Neurosurg Psychiatry. 1996;61:176–80.

    CAS  PubMed Central  PubMed  Google Scholar 

  39. Goldenberg G, Daumuller M, Hagmann S. Assessment and therapy of complex activities of daily living in apraxia. Neuropsychol Rehabil. 2001;11:147–69.

    Google Scholar 

  40. Goldenberg G, Hagmann S. Therapy of activities of daily living in patients with apraxia. Neuropsychol Rehabil. 1998;8:123–41.

    Google Scholar 

  41. Goodglass H, Kaplan E. Disturbance of gesture and pantomime in aphasia. Brain. 1963;86:703–20.

    CAS  PubMed  Google Scholar 

  42. Haaland KY. Left hemisphere dominance for movement. Clin Neuropsychol. 2006;20:609–22.

    PubMed  Google Scholar 

  43. Haaland KY, Flaherty D. The different types of limb apraxia errors made by patients with left vs. right hemisphere damage. Brain Cogn. 1984;3:370–84.

    CAS  PubMed  Google Scholar 

  44. Haaland KY, Harrington DL. Hemispheric asymmetry of movement. Curr Opin Neurobiol. 1996;6:796–800.

    CAS  PubMed  Google Scholar 

  45. Haaland KY, Harrington DL, Knight RT. Neural representations of skilled movement. Brain. 2000;123:2306–13.

    PubMed  Google Scholar 

  46. Hamilton AF, Grafton ST. Repetition suppression for performed hand gestures revealed by fMRI. Hum Brain Mapp. 2009;30:2898–906.

    PubMed  Google Scholar 

  47. Hanna-Pladdy B, Daniels SK, Fieselman MA, Thompson K, Vasterling JJ, Heilman KM, et al. Praxis lateralization: errors in right and left hemisphere stroke. Cortex. 2001;37:219–30.

    CAS  PubMed  Google Scholar 

  48. Hanna-Pladdy B, Heilman KM, Foundas AL. Cortical and subcortical contributions to ideomotor apraxia: analysis of task demands and error types. Brain. 2001;124:2513–27.

    CAS  PubMed  Google Scholar 

  49. Hanna-Pladdy B, Heilman KM, Foundas AL. Ecological implications of ideomotor apraxia: evidence from physical activities of daily living. Neurology. 2003;60:487–90.

    CAS  PubMed  Google Scholar 

  50. Harrington DL, Haaland KY. Representations of actions in ideomotor limb apraxia: clues from motor programming and control. In: Rothi LJ, Heilman KM, editors. Apraxia: The Neuropsychology of Action. East Sussex: Psychology Press; 1997. p. 111–47.

    Google Scholar 

  51. Heilman KM, Gonzalez Rothi LJ. Apraxia. In: Heilman KM, Valenstein E, editors. Clinical neuropsychology. 4th ed. Oxford: Oxford University Press; 2003. p. 215–35.

    Google Scholar 

  52. Heilman KM, Maher LM, Greenwald ML, Rothi LJ. Conceptual apraxia from lateralized lesions. Neurology. 1997;49:457–64.

    CAS  PubMed  Google Scholar 

  53. Heilman KM, Rothi LJ, Valenstein E. Two forms of ideomotor apraxia. Neurology. 1982;32:342–6.

    CAS  PubMed  Google Scholar 

  54. Helm-Estabrooks N. Test of oral and limb apraxia (TOLA). Austin: PRO-ED; 1998.

    Google Scholar 

  55. Kable JW, Chatterjee A. Specificity of action representations in the lateral occipitotemporal cortex. J Cogn Neurosci. 2006;18:1498–517.

    PubMed  Google Scholar 

  56. Kawahira K, Noma T, Iiyama J, Etoh S, Ogata A, Shimodozono M. Improvements in limb kinetic apraxia by repetition of a newly designed facilitation exercise in a patient with corticobasal degeneration. Int J Rehabil Res. 2009;32:178–83.

    PubMed  Google Scholar 

  57. Kertesz A. The aphasia quotient: the taxonomic approach to measurement of aphasic disability. Can J Neurol Sci. 2004 31:175–84.

    Google Scholar 

  58. Kertesz A, Ferro JM. Lesion size and location in ideomotor apraxia. Brain. 1984;107:921–33.

    PubMed  Google Scholar 

  59. Kertesz A, Hooper P. Praxis and language: the extent and variety of apraxia in aphasia. Neuropsychologia. 1982;20:275–86.

    CAS  PubMed  Google Scholar 

  60. Kroliczak G, Frey SH. A common network in the left cerebral hemisphere represents planning of tool use pantomimes and familiar intransitive gestures at the hand-independent level. Cereb Cortex. 2009;19:2396–410.

    PubMed Central  PubMed  Google Scholar 

  61. • Króliczak G, Piper BJ, Frey SH. Specialization of the left supramarginal gyrus for hand-independent praxis representation is not related to hand dominance. Neuropsychologia. 2016;93:501–12 There is considerable evidence that the left hemisphere has a dominant role for language and manual gestures, although the pattern of laterality may be more variable in left-handers compared to right-handers. That is, more left than right-handers have atypical right-hemispheric dominance for language. The authors postulated that if this dependence is linked to a common cerebral organization, then left-handers with atypical language organization would show a similar pattern of organization for manual gestures. To test this hypothesis, the authors used a functional MRI paradigm to evaluate laterality. Consistent with the a priori hypothesis, fMRI data showed that left-handers (5/15) with bilateral, or right-lateralized, language representations in the inferior frontal cortex exhibited a similar atypical pattern in the representations of familiar gestures in the inferior parietal cortex.

    PubMed Central  PubMed  Google Scholar 

  62. Leiguarda R. Limb apraxia: cortical or subcortical. Neuroimage. 2001;14:S137–41.

    CAS  PubMed  Google Scholar 

  63. Liepmann H. Apraxie. Ergebn Ges Med 1920;1:516–43.

  64. Maher LM, Ochipa C. Management and treatment of limb apraxia. In: Rothi LJG, Heilman KM, editors. Apraxia: the neuropsychology of action. Hove, East Sussex: Psychology Press; 1997.

    Google Scholar 

  65. Meador KJ, Loring DW, Lee K, Hughes M, Lee G, Nichols M, et al. Cerebral lateralization: relationship of language and ideomotor praxis. Neurology. 1999;53:2028–31.

    CAS  PubMed  Google Scholar 

  66. • Mutha PK, Stapp LH, Sainburg RL, Haaland KY. Motor adaptation deficits in ideomotor apraxia. J Int Neuropsychol Soc. 2017;23:139–49 This study was designed to examine motor learning in limb apraxia. The hypothesis was that deficits in patients with limb apraxia might arise from degraded internal representations of action plans. This deficit would be associated with an impaired ability to develop new representations through motor learning. Three groups were studied including healthy controls (n = 13) and unilateral stroke patients with (n = 12) and without (n = 11) limb apraxia. The paradigm required subjects to adapt movements in response to changing targets (i.e., using a cursor to reach from a central start position to one of eight targets). Baseline performance was compared to an Adaptation block, followed by an after-effect block identical to baseline. Results showed that the apraxic patients did develop an after-effect similar to the other groups; however, this initial benefit was not retained suggesting a disrupted slow learning process.

    PubMed Central  PubMed  Google Scholar 

  67. • Nobusako S, Ishibashi R, Takamura Y, Oda E, Tanigashira Y, Kouno M, et al. Distortion of visuo-motor temporal integration in apraxia: evidence from delayed visual feedback detection tasks and voxel-based lesion-symptom mapping. Front Neurol. 2018;9:709 It is unclear whether there is a specific deficit in the temporal integration of visuo-motor compared to visuo-tactile and visuo-proprioceptive integration in left-hemispheric stroke patients with limb apraxia. A delayed visual feedback detection task with three different conditions (tactile, passive movement, and active movement) was used to examine these different functions. The behavioral studies showed that the delay detection threshold was extended, and the probability curve for delay detection was less steep in the apraxic patients compared to controls (pseudo-apraxic patients and unaffected patients), but only for the active movement condition. Apraxia severity was correlated with the delay detection threshold and the steepness of the probability curve in the active movement condition. These results showed that apraxic patients had difficulties with visuo-motor temporal integration. Lesion analyses revealed that both apraxia and the distortion of visuo-motor temporal integration were associated with lesions to the left inferior parietal and left inferior frontal regions. Based on these data, the authors proposed that damage to the left inferior fronto-parietal network causes deficits in motor prediction for visuo-motor temporal integration, but not for sensory-sensory (visuo-tactile and visuo-proprioception) temporal integration.

    PubMed Central  PubMed  Google Scholar 

  68. Ochipa C, Rapcsak SZ, Maher LM, Rothi LJ, Bowers D, Heilman KM. Selective deficit of praxis imagery in ideomotor apraxia. Neurology. 1997;49:474–80.

    CAS  PubMed  Google Scholar 

  69. Ochipa C, Rothi LJ, Heilman KM. Ideational apraxia: a deficit in tool selection and use. Ann Neurol. 1989;25:190–3.

    CAS  PubMed  Google Scholar 

  70. Ochipa C, Rothi LJ, Heilman KM. Conceptual apraxia in Alzheimer’s disease. Brain. 1992;115:1061–71.

    PubMed  Google Scholar 

  71. •• Ortiz KZ, Mantovani-Nagaoka J. Limb apraxia in aphasic patients. Arq Neuropsiquiatr. 2017;75:767–72 This study was designed to evaluate the occurrence of limb apraxia in aphasic left-hemispheric stroke patients and to analyze the nature of these deficits. Two groups were evaluated including: aphasic patients (n = 28) and a group of age and education matched controls (n = 44). Limb apraxia subtests included tasks that evaluated lexical-semantic aspects related to the comprehension/production of gestures and to motor movements. Results showed that the aphasic patients were most impaired on tasks related to the conceptual aspects of gestures. The difficulty with imitation of dynamic gestures suggested that these aphasic patients also had difficulty with gesture planning. These results reinforce the importance of conducting a comprehensive assessment of limb apraxia based on a cognitive process model. In addition, the results support the notion that difficulties with pantomiming gestures to command (content errors) may be a good predictor of disorders at the level of semantics.

    PubMed  Google Scholar 

  72. Papagno C, Della Sala S, Basso A. Ideomotor apraxia without aphasia and aphasia without apraxia: the anatomical support for a double dissociation. J Neurol Neurosurg Psychiatry. 1993;56:286–9.

    CAS  PubMed Central  PubMed  Google Scholar 

  73. • Pellicano A, Borghi AM, Binkofski F. Editorial: bridging the theories of affordances and limb apraxia. Front Hum Neurosci. 2017;11:148. https://doi.org/10.3389/fnhum.2017.00148 This editorial discusses the potential use of theories of affordances to understand the mechanisms of limb apraxia. Affordances integrate perceptual and cognitive variables into the action plan. Limb apraxia is a disorder of learned skilled movements that can lead to disruption of tool gestures, imitation of tool use, and can disrupt the actual manipulation of tools. This article discusses how these issues relate to mechanisms underlying affordances and implications for limb apraxia.

    Article  PubMed Central  PubMed  Google Scholar 

  74. Petreska B, Adriani M, Blanke O, Billard AG. Apraxia: a review. Prog Brain Res. 2007;164:61–83.

    PubMed  Google Scholar 

  75. Pomeroy VM. Stroke rehabilitation. Disabil Rehabil. 2006;28(13–14):813–4.

    PubMed  Google Scholar 

  76. Power E, Code C, Croot K, Sheard C, & Gonzalez Rothi LJ. Florida Apraxia Battery-Extended and Revised Sydney (FABERS): Design, description, and a healthy control sample. J Clin Exp Neuropsychol 2009, 32:1–19.

  77. Pramstaller PP, Marsden CD. The basal ganglia and apraxia. Brain. 1996;119:319–40.

    PubMed  Google Scholar 

  78. Randerath J, Li Y, Goldenberg G, Hermsdorfer J. Grasping tools: effects of task and apraxia. Neuropsychologia. 2009;47:497–505.

    PubMed  Google Scholar 

  79. Rapcsak SZ, Ochipa C, Beeson PM, Rubens AB. Praxis and the right hemisphere. Brain Cogn. 1993;23:181–202.

    CAS  PubMed  Google Scholar 

  80. Raymer AM, Maher LM, Foundas AL, Heilman KM, Rothi LJ. The significance of body part as tool errors in limb apraxia. Brain Cogn. 1997;34:287–92.

    CAS  PubMed  Google Scholar 

  81. Rothi LJ, Heilman KM, Watson RT. Pantomime comprehension and ideomotor apraxia. J Neurol Neurosurg Psychiatry. 1985;48:207–10.

    CAS  PubMed Central  PubMed  Google Scholar 

  82. Rothi LJ, Mack L, Verfaellie M, Brown P, Heilman KM. Ideomotor apraxia: error pattern analysis. Aphasiology. 1988;2:381–8.

    Google Scholar 

  83. Rothi LJ, Ochipa C, Heilman KM. A cognitive neuropsychological model of limb praxis. Cogn Neuropsychol. 1991;8:443–58.

    Google Scholar 

  84. Rothi LJ, Raymer AM, Heilman KM. Limb praxis assessment. In: Rothi LJ, Heilman KM, editors. Apraxia: The Neuropsychology of Action. East Sussex: Psychology Press; 1997. p. 61–73.

    Google Scholar 

  85. Rothi LJ, Raymer AM, Ochipa C, Maher, LM, Greenwald ML, & Heilman KM Florida apraxia battery, experimental edition, 1992.

    Google Scholar 

  86. Roy EA. Neuropsychological studies of apraxia and related disorders. New York: Elsevier Science; 1985.

    Google Scholar 

  87. Rushworth MF, Nixon PD, Wade DT, Renowden S, Passingham RE. The left hemisphere and the selection of learned actions. Neuropsychologia. 1998;36:11–24.

    CAS  PubMed  Google Scholar 

  88. Saeki S, Ogata H, Okubo T, Takahashi K, Hoshuyama T. Return to work after stroke. Stroke. 1995;26:399–401.

    CAS  PubMed  Google Scholar 

  89. Schwartz MF, Buxbaum LJ. Naturalistic action. In: Rothi LJ, Heilman KM, editors. Apraxia: the neuropsychology of action. East Sussex: Psychology Press; 1997. p. 269–89.

    Google Scholar 

  90. Schwartz MF, Segal M, Veramonti T, Ferraro M, Buxbaum LJ. The naturalistic action test: a standardised assessment for everyday action impairment. Neuropsychol Rehabil. 2002;12:311–39.

    Google Scholar 

  91. Schwartz RL, Adair JC, Raymer AM, Williamson DJ, Crosson B, Rothi LJ, et al. Conceptual apraxia in probable Alzheimer’s disease as demonstrated by the Florida action recall test. J Int Neuropsychol Soc. 2000;6:265–70.

    CAS  PubMed  Google Scholar 

  92. Smania N, Aglioti SM, Girardi F, Tinazzi M, Fiaschi A, Cosentino A, et al. Rehabilitation of limb apraxia improves daily life activities in patients with stroke. Neurology. 2006;67:2050–2.

    CAS  PubMed  Google Scholar 

  93. Smania N, Girardi F, Domenicali C, Lora E, Aglioti S. The rehabilitation of limb apraxia: a study in left-brain-damaged patients. Arch Phys Med Rehabil. 2000;81:379–88.

    CAS  PubMed  Google Scholar 

  94. Sunderland A. Recovery of ipsilateral dexterity after stroke. Stroke. 2000;31:430–3.

    CAS  PubMed  Google Scholar 

  95. Soulsby WD, El-Ruwie N, Gatla S, Anderson Zimmer K, Najmi S, Chen A, et al. Ideomotor limb apraxia as a staging tool in individuals with Alzheimer’s disease (ILIAD). Ann Clin Psychiatry. 2016;28:255–62.

    PubMed  Google Scholar 

  96. Sundet K, Finset A, Reinvang I. Neuropsychological predictors in stroke rehabilitation. J Clin Exp Neuropsychol. 1988;10(4):363–79.

    CAS  PubMed  Google Scholar 

  97. Vanbellingen T, Kersten B, Van de Winckel A, Bellion M, Baronti F, Müri R, et al. A new bedside test of gestures in stroke: the apraxia screen of TULIA (AST). J Neurol Neurosurg Psychiatry. 2011;82:389–92.

    CAS  PubMed  Google Scholar 

  98. Vanbellingen T, Kersten B, Van Hemelrijk B, Van de Winckel A, Bertschi M, Muri R, et al. Comprehensive assessment of gesture production: a new test of upper limb apraxia (TULIA). Eur J Neurol. 2009;17:59–66.

    PubMed  Google Scholar 

  99. van Heugten CM. Apraxia. In: Eslinger PJ, editor. Neuropsychological interventions: clinical research and practice. New York: Guilford; 2002.

    Google Scholar 

  100. Watson RT, Fleet WS, Gonzalez-Rothi L, Heilman KM. Apraxia and the supplementary motor area. Arch Neurol. 1986;43(8):787–92.

    CAS  PubMed  Google Scholar 

  101. •• Wirth K, Held A, Kalbe E, Kessler J, Saliger J, Karbe H, et al. A new diagnostic tool for apraxia in patients with right-hemisphere stroke: the revised Cologne apraxia screening (KAS-R). Fortschr Neurol Psychiatr. 2016;84(10):633–9 Limb apraxia is more commonly seen in patients with left-hemispheric (LH) stroke (up to 63%) compared to patients with a right-hemispheric (RH) stroke (up to 53%). The Cologne apraxia screening (KAS) was developed to diagnose apraxia following LH stroke. The goal of the current study was to modify the KAS for use in patients with RH stroke (KAS-R). The study sample included: RH stroke patients (n = 100), and healthy, matched controls (n = 77). Psychometric analyses led to the exclusion of eight items from the KAS for a final KAS-R, consisting of 12 items. The KAS-R was found to have good internal consistency (α = 0.795), and high sensitivity (79.4%) and specificity (84.4%). Using a cut-off value of ≤  46 (out of 48) points, 39 of 100 RH stroke patients were diagnosed with limb apraxia. Significant correlations were found between the KAS-R, an imitation test, and expert ratings, indicating high construct validity. These results showed that the KAS-R is a reliable and valid brief diagnostic screening tool for apraxic deficits in both RH and LH stroke patients.

  102. Zwinkels A, Geusgens C, van de Sande P, van Heugten C. Assessment of apraxia: inter-rater reliability of a new apraxia test, association of apraxia and other cognitive deficits and prevalence of apraxia in a rehabilitation setting. Clin Rehabil. 2004;18:819–27.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Brain Institute of Louisiana, 4204 Teuton Street, Suite 250, Metairie, Louisiana, 70006, USA

    Anne L. Foundas & E. Susan Duncan

  2. Louisiana State University, Baton Rouge, Louisiana, USA

    Anne L. Foundas & E. Susan Duncan

Authors
  1. Anne L. Foundas
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E. Susan Duncan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anne L. Foundas.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Behavior

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Foundas, A.L., Duncan, E.S. Limb Apraxia: a Disorder of Learned Skilled Movement. Curr Neurol Neurosci Rep 19, 82 (2019). https://doi.org/10.1007/s11910-019-0989-9

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11910-019-0989-9

Keywords

Search

Navigation