Apraxia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Parul Pahal, M.B.B.S[2]

Synonyms and keywords: Dyspraxia

Overview

'Praxis', a Greek work, is the ability to perform the learned movements. It usually comprises of three components, namely, ideation, motor planning, and execution that results in purposeful movements. Apraxia, however, is the inability to perform these skilled and learned movements when there is a breakdown in any component of praxis. This disorder makes it difficult to perform daily tasks and negatively impact the quality of life. Apraxia is a complex neurological disease with cognitive-motor dysfunction. It can occur as a result of brain trauma/disease, and higher motor functional neuronal pathways damage in the setting of preserved comprehension, coordination, sensory and motor systems. The most common types of apraxia are Ideational and Ideomotor.

Historical Perspective

• Steinthal introduced the term 'apraxia' in 1971. However, a German physician, Hugo Lipmann first established the conceptual knowledge and published complete description of apraxia after studying the gestures in a 48-year old stroke patient who had a left hemispheric stroke.
• Lipmann noticed that, despite of resolution of the paresis, the patient was unable to perform tasks such as buttoning the shirt, with no affect on spontaneous movements, and doing simple tasks on command.
• He observed this phenomenon specifically in patients with left hemispheric lesions. He also concluded that the planning of the motor movements occurs in the motor area of the left side of the brain.
• Lipmann further proposed that the 'praxis' information flows from the posterior brain areas (parietal and occipital lobes) to the anterior (motor cortex).

Classification

• Apraxia, Buccofacial
• Apraxia, Classic
• Apraxia, Constructional
• Apraxia, Ideational
• Apraxia, Ideokinetic
• Apraxia, Ideomotor
• Apraxia, Motor
• Apraxia, Oculomotor

https://rarediseases.org/rare-diseases/apraxia/

Patients with a neurological disorder that affect the learned moivement neural pathways lead to 'apraxia'. Patients suffering from apraxia are unable to execute familiar or learned movements on command despite of understanding the command and willingness to perform that action. It becomes difficult to perform daily activities and are invariably affected if there is significant apraxia.

Apraxia comes in several different forms:

Limb-kinetic apraxia is the inability to make precise or exact movements with a finger, an arm or a leg. An example is the inability to use a screwdriver notwithstanding that the person affected understands what is to be done and has done it in the past.

Ideomotor apraxia is the inability to carry out a command from the brain to mimic limb or head movements performed or suggested by others.

Conceptual apraxia is much like ideomotor ataxia but infers a more profound malfunctioning in which the function of tools is no longer understood.

Ideational apraxia is the inability to create a plan for a specific movement.

Constructional apraxia affects the person's ability to draw or copy simple diagrams or to construct simple figures.

Oculomotor apraxia is a condition in which patients find it difficult to move their eyes.

Apraxia is believed to be caused by a lesion in the neural pathways of the brain that contain the learned patterns of movement. It is often a symptom of neurological, metabolic, or other disorders that can involve the brain.

• Buccofacial apraxia- is the most common form of apraxia. In this, there is loss of ability to coordinate lip and facial movement on command. The movements which are affected in this type include coughing, whistling, etc.
• Apraxia, Classic
• Apraxia, Constructional
• Apraxia, Ideational
• Apraxia, Ideokinetic
• Apraxia, Ideomotor
• Apraxia, Motor
• Occulomotor Apraxia

https://rarediseases.org/rare-diseases/apraxia/

Pathophysiology

'Praxis' comprises three components, which include ideation, motor planning, and execution to carry out the purposeful movement. There are particular regions of the brain that represent specific component functions, and these regions together work as a ‘praxis system’ to process and execute a purposeful movement. Dysfunction in any of these regions, namely, frontal and parietal cortex, basal ganglia, and the white matter which connects theses areas, leads to apraxia.

Apraxia is a frequent manifestation of cortical dysfunction and is defined as difficulty performing learned and purposeful skilled movements despite having the desire to do so; it is not explained by deficits in comprehension or elemental motor or sensory function [50].

Various types of apraxia are observed in CBD, including ideomotor apraxia (inability to perform goal-directed movements) and ideational apraxia (inability to coordinate activities that require multiple sequential movements). With ideomotor apraxia, the most frequent type in CBD, unilateral damage to the dominant hemisphere and supplemental motor area can produce bilateral symptoms [32,51]. Ideational apraxias tend to occur in more advanced stages of CBD and in AD [32].

Apraxia may occur any time in the course of illness, including before the emergence of dystonia and myoclonus. In such cases, the apraxia alone may render the hand useless. Apraxia may also present after the onset of other motor symptoms and may then be difficult to detect because rigidity, dystonia, and myoclonus can themselves prevent the proper performance of skilled movements. The usual complaint of the patient is that the limb will not do what they want it to do. Apraxia is usually associated with cortical sensory loss such as agraphesthesia and astereognosis. Patients may complain of numbness and tingling, and examination may also demonstrate impaired two-point discrimination

https://www.uptodate.com/contents/corticobasal-degeneration?search=apraxia&source=search_result&selectedTitle=2~61&usage_type=default&display_rank=2#H20808476

Overview

Apraxia is a neurological disorder characterized by loss of the ability to execute or carry out learned purposeful movements, 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 may not be caused by incoordination, sensory loss, or failure to comprehend simple commands (which can be tested by asking the person tested to recognize the correct movement from a series). The root word of Apraxia is praxis, Greek for an act, work, or deed. It is preceded by a privative a, meaning 'without'.

Types

There are several types of apraxia including:

• ideomotor (inability to carry out a motor command, for example, "act as if you are brushing your teeth" or "salute") - the form most frequently encountered by physicians,
  • limb apraxia when movements of the arms and legs are involved,
  • nonverbal-oral or buccofacial (inability to carry out facial movements on command, e.g., lick lips, whistle, cough, or wink),
• ideational (inability to create a plan for or idea of a specific movement, for example, "pick up this pen and write down your name"),
• limb-kinetic (inability to make fine, precise movements with a limb),
• verbal (difficulty planning the movements necessary for speech), also known as Apraxia of Speech (see below)
• constructional (inability to draw or construct simple configurations),
• oculomotor (difficulty moving the eye)

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 tooth brush) and ask them to use it.

Apraxia may be accompanied by a language disorder called aphasia.

Apraxia of speech

Developmental Apraxia of Speech (DAS) 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.

Symptoms of Acquired Apraxia of Speech (AOS) and Developmental Apraxia of Speech (DAS) 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.

Causes

Ideomotor apraxia is almost always caused by lesions in the language-dominant (usually left) hemisphere of the brain, and as such these patients often have concomitant aphasia, especially of the Broca or conduction type. Left-side ideomotor apraxia may be caused by a lesion of the anterior corpus callosum.

Ideational apraxia is commonly associated with confusion states and dementia.

Treatment

Generally, treatment for individuals with apraxia includes physical therapy, occupational therapy or speech therapy, or Oral Motor Therapy and IVIG. If apraxia is a symptom of another disorder (usually a neurologic disorder), the underlying disorder should be treated.

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.

Related Chapters

• Dyspraxia

References

• Epstein, O. (2003). Clinical Examination. London: Mosby. p. 294. ISBN 0-7234-3229-5.
• Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. Harrison's Principles of Internal Medicine. New York: McGraw-Hill, 2005. ISBN 0-07-139140-1.