Apraxia- Motor Apraxia Overview

Jen Thompson, MS, OTR/L

Terminology:

• Apraxia: inability to implement purposeful movement, that cannot be explained by deficits in sensation, movement, or coordination (Gazzaniga, Ivey, & Mangun, 2009).
• Pantomime: the act of showing or explaining something through the movement of the body and face, instead of speaking.
• Intratransitive Gestures: movements expressing an idea not associated with a particular object (ex: waving hello or goodbye). (Enticott et al., 2010)
• Transitive gestures: goal directed movements that express an idea entailing object use (ex: grasping a cup).  (Enticott et al., 2010)

Type of Limb Apraxia	Error Type	How Elicited	Functional Example
Ideomotor	Production Errors	Most errors are made on pantomiming transitive tasks, improves with imitation and usually does best with the actual object	Movements will be awkward but bear a resemblance to the intended movement. Able to use tools to complete tasks, but may appear clumsy or awkward.
Conceptual	Content errors:Tool action knowledgeTool-association knowledgeMechanical knowledgeTool fabrication	Use of tools; actions associated with specific tools, association between tool and object	Patient has obvious difficulty with tool use: may use tube of toothpaste to brush teeth, comb hair with fork, etc.
Disassociation	Thought to be a disconnection between hemispheres; therefore, there is no recognizable movement on command	Pantomime (gesture) to command is impaired; imitation and use of object will be much better	Unable to pantomime movements, but since able to imitate and use tools, minimal effect on functional activities.
Conduction	Difficulty decoding and understanding gestures	Impaired imitation of gestures; does better when asked to pantomime	A client with aphasia may have difficulty understanding and using gestures
Ideational	Difficulty with a series of task	Tasks requiring a series of activities (ex: clean pipe, put in tobacco, and light pipe)	Task may be completed more skillfully than with ideomotor apraxia, but client will have difficulty sequencing steps in the correct order (ex: client may try to light empty pipe, then put the tobacco in, and then clean it).

Adapted from Heilman, Watson, & Rothi (2003). Disorders of skilled movement: Limb apraxia. In T. E. Fineberg & M. J. Farah (Eds), Behavioral neurology and neuropsychology (2nd ed.). New York: McGraw-Hill.

Apraxia- Additional Types

Constructional Apraxia: specific deficit in spatial-organizational performance (Chaikin, 2007). 

• Difficulty with copying, drawing and constructing designs in two and three dimensions.
• Related to ADL/IADL performance including light meal preparation (making a sandwich), setting a table, sewing and other mechanical activity where parts are combined into a whole.
• Two types:

1. Graphic tasks: copying drawings to commands, starting with simple geometric shapes to those that are more complex without a model. More complicated drawings require more skill in interpretation.

• Ex: draw the face of a clock showing numbers and the two hands; draw a daisy; draw an elephant; draw a cube shaped block in perspective, as it would look if you could see the top and two sides.

2. Assembly tasks: patient has to assemble items. Errors include incorrect length, failing to reproduce part of the object, etc. 

• Ex: block and stick designs, pegboard designs
• Not standardized
• Make note of the patient’s ways of performing tasks: errors made, the patient’s clients, any emotional display, etc. 

Dressing Apraxia: inability to dress oneself.

• Typically due to right-hemisphere damage and secondary visuospatial disorganization.
• Underlying deficits must be determined- visual deficits, unilateral neglect, apraxia, or constructional apraxia.

Apraxia Error Types

Error Type	Description
Content Errors
Perseveration	Patient’s responses include all, or part, of a previously produced pantomime
Related	Pantomime is correctly produced but is only related to that requested (ex: playing the trombone instead of playing a flute as requested).
Nonrelated	Pantomime is accurately produced but unrelated to request (ex: playing the trombone instead of shaving)
Hand	Performs the action without use of a real or imagined tool (ex: turning a screw with the fingers rather than with an imaginary screwdriver).
Temporal Errors
Sequencing	Addition, deletion, or transposition of the movement elements in a sequence
Timing	Any alteration in the timing or speed of a pantomime: abnormally increased, decreased, or irregular rate of production (ex: brushing teeth very, very slowly)
Occurrence	Any multiplication of a characteristically single cycle movement (ex: unlocking a door), or reduction of a characteristically repetitive cycle to a single event (screwing in a screw).
Spatial Errors
Amplitude	Any increase, decrease, or irregularity of the characteristic movement
Internal configuration	Any abnormality of the required finger/hand posture and it’s relationship to the target tool (ex: when pretending to brush teeth, the hand may be closed in a tight fist without leaving space for imaginary toothbrush)
Body part as tool	Patient using finger, hand or arm as imaginary tool rather than imaginary tool (ex: using finger to brush teeth)
External configuration	Difficulties orienting fingers/hand/arm to object or placing object in space (ex: brushing teeth with hand so close to mouth that there is no room for imaginary toothbrush)
Movement	Any disturbance of characteristic movement used when acting on the object (ex: activates movement of incorrect joint- when pantomiming use of screwdriver, rotation occurs at shoulder weather than forearm).
Other
Concretization	Patient performs pantomomine no on imagined object but on real object not typically used to perform task (instead of pretending to saw wood, patient pantomimes sawing on their leg)
No Response
Unrecognizable	Response shares no temporal or spatial features of the target; it is unrecognizable.

Adapted from Rothi, Raymer, and Heilman (1997). Limb praxis assessment. In L.J. . Rothi & K.M. Heilman (Eds), Apraxia: The neuropsychology of action (pp. 61-73), East Sussex, UK: Psychology Press Publishers.

Standardized Assessments:

• Florida Apraxia Screening Test (Rothi, Raymer & Heilman, 1997): 30 items, gesture to verbal command. Normal cutoff score: 15/30 correct.
• Assessment of Apraxia (van Heugten et al., 1999)a: 2 subtests: demonstration of object use and imitation of gestures. Total score below 86 = identification of apraxia
• Assessment of Disabilities in Stroke Patients with Apraxia (van Heughten et al., 1999b): set of standard ADL observations for assessment of disabilities caused by apraxia: personal hygiene, dressing, preparing food, and another of therapist’s choice. 
• Fugl-Meyer Motor Assessment (Fugl-Meyer et al., 1975): test of motor and sensory impairment after stroke. The higher the score ( out of 66), the higher functioning the patient is on the affected side.
• Motor Assessment Scale (Carr et al., 1985): designed to assess the return of function following a stroke or other neurological impairment. The test looks at a patient’s ability to move with low tone or in a synergistic pattern and finally move actively out of that pattern into normal movement. The higher the score – the higher functioning the patient is on the affected side. 
• Wolf Motor Function Test (Wolf et al., 2001): 17 items. 6 timed UE movements, 9 timed functional movements. Yields 2 scores: speed of performance, quality of performance, and strength of grip.

***Utilize other assessments and/or questionnaires to identify what areas of ADL, IADL, and leisure tasks patient is motivated to return to. This will better help inform treatment sessions and progress the patient through therapy, as well as helping him/her become more invested in working with OT.

Treatment Approaches:

• Compensatory Task Training: GOLD STANDARD for patients with limb apraxia (Donkervoort et al., 2001; Geusgens et al., 2007, van Heughten et al., 1998).
  • Goal: improve functioning in spite of impairments in motor planning.
• Blocked practice- efficient ADL/ IADL performance! Achieving mastery one task at a time
• Errorless learning/ Task grading
• Gesture training- grade/ adapt activities depending on patient’s understanding
• Strategy training: compensation internally (self-verbalization) or externally (pictorial cues).
• Remove external distractors/ unnecessary environmental stimuli to reduce patient using necessary tools for ADL task

**It’s important to differentiate between apraxia and aphasia:

• Use regular commands “show me how you would ….”
• Questions that can be answered by yes/no responses
  • If patient can answer Y/N questions, he or she may be apraxic
• Ability of the patient to point to the correct answers — if the patient cannot answer Y/N questions, consider aphasia or other language deficits. Seek clarification from SLP for language impairments.

Other types of apraxia

• Buccofacial – SLP evaluates
• Oculomotor – DO (doctor of optometry) evaluates. DO to instruct OT on specialized vision protocols if applicable.

References:

Almhdawi, Mathiowetz, and Bass. Assessing Abilities and Capacities: Motor planning and performance pp.255-268. In Occupational Therapy for Physical Dysfunction, 7th edition, 2014. Radomsky & Trombly (Eds). Lippincott, Williams & Wilkins: Baltimore, MD

Arnadottir, G. Impact of Neurobehavioral Deficits on Activities of Daily Living, pp. 573-611. In Stroke Rehabilitation: A Functional Based Approach, 4th edition. Glen Gillen, Ed. US: Elsever, St. Louis, Missouri.

Hamby, J.R. Altered Mental Status, pp.595-596. In Occupational Therapy Acute Care. Helene Smith-Gabai (Eds). American Occupational Therapy Association Inc, US: Bethesda MD.

Sabari, J.B., Capasso, N., and Feld-Glazman, R. Optimizing Motor Planning and Performance in Clients with Neurological Disorders, pp.615-656. In Occupational Therapy for Physical Dysfunction, 7th edition, 2014. Radomsky & Trombly (Eds). US: Lippincott, Williams & Wilkins, Baltimore, MD