Discovery of Apraxia (Historical Note) / Descoberta da apraxia (Nota Histórica)

Skilled movements certainly exist since the dawn of the humans, embedded in the actions of daily living, and also represented by tools and weapons making and use, as well as by artistic activities as drawing and engraving. A very long period of time elapsed until such actions were recognized as special, and the designation 'praxis' was attributed to such ability of produce refined movements. Another long time passed, and only recently disturbances of such actions caused by brain lesions were identified, leading to the concept of 'apraxia'. Studies on this subject progressed quickly, and in a few decades reached the state resembling to what is seen nowadays.

Movimentos hábeis certamente existem desde a aurora dos humanos, incluídos nas ações da vida diária e também representados na feitura e uso de ferramentas e de armas, assim como por atividades artísticas como desenhar e gravar. Decorreu um longo período de tempo até que tais ações fossem reconhecidas como especiais e a designação de 'praxia' foi atribuída para tais habilidades para produzir movimentos refinados. Outro tempo prolongado passou, e apenas recentemente desordens de tais ações causadas por lesões cerebrais fossem identificadas, levando ao conceito de 'apraxia'. Estudos sobre esse assunto progrediram rapidamente e em poucas décadas alcançaram o estado que se assemelha ao que é visto atualmente.

The influence of education on performance of adults on the Clock Drawing Test / A influência da escolaridade no desempenho de adultos no teste do desenho do relógio

ABSTRACT. The Clock Drawing Test (CDT) is an important instrument for screening individuals suspected of having cognitive impairment. Objective: To determine the influence of education on the performance of healthy adults on the CDT. Methods: A total of 121 drawings by healthy adults without neurological complaints or impairments were analysed. Participants were stratified by educational level into 4 subgroups: 27 illiterate adults, 34 individuals with 1-4 years of formal education, 30 with 5-11 years, and 30 adults with >11 years' formal education. Scores on the CDT were analyzed based on a scale of 1-10 points according to the criteria of Sunderland et al. (1989).¹ The Kruskal-Wallis test was applied to compare the different education groups. Tukey's multiple comparisons test was used when a significant factor was found. Results: Although scores were higher with greater education, statistically significant differences on the CDT were found only between the illiterate and other educated groups. Conclusion: The CDT proved especially difficult for illiterate individuals, who had lower scores. These results suggest that this screening test is suitable for assessing mainly visuoconstructional praxis and providing an overall impression of cognitive function among individuals, independently of years of education.

RESUMO. O Teste do Desenho do Relógio (TDR) é um instrumento importante para rastrear indivíduos com suspeita de alterações cognitivas. Objetivo: Verificar a influência da variável sociodemográfica escolaridade no desempenho de adultos saudáveis no TDR. Métodos: Foram analisados os desenhos de 121 adultos saudáveis sem queixas e/ou alterações neurológicas, distribuídos em 4 subgrupos, a partir de quatro níveis de escolaridade: 27 adultos analfabetos, 34 adultos com 1-4 anos de estudo formal, 30 adultos com 5-11 anos de estudo formal, 30 adultos com >11 anos de estudo formal. Os desenhos obtidos foram analisados segundo os critérios propostos por Sunderland et all (1989),¹ com uma escala que variou de 1 a 10 pontos. A comparação dos grupos segundo a escolaridade foi feita utilizando-se o teste de Kruskal-Wallis seguido do teste de comparações múltiplas de Tukey para verificar onde as diferenças se deram. Resultados: Apesar dos escores terem aumentado conforme a escolaridade, foram observadas diferenças estatisticamente significantes apenas entre analfabetos e os demais grupos no TDR. Conclusão: O desempenho dos indivíduos melhorou de acordo com a escolaridade, porém o TDR não sofreu forte influência da escolaridade em sua aplicação, exceto para indivíduos analfabetos, que apresentaram escores diminuídos. Deste modo, acredita-se que o teste pode ser utilizado na avaliação da praxia visuo-construtiva em indivíduos independentemente dos anos de escolarização.

The influence of age, gender and education on the performance of healthy individuals on a battery for assessing limb apraxia / A influência da idade, do sexo e da escolaridade no desempenho de indivíduos normais em uma bateria para avaliação de praxia de membros

ABSTRACT Introduction: Apraxia is defined as a disorder of learned skilled movements, in the absence of elementary motor or sensory deficits and general cognitive impairment, such as inattention to commands, object-recognition deficits or poor oral comprehension. Limb apraxia has long been a challenge for clinical assessment and understanding and covers a wide spectrum of disorders, all involving motor cognition and the inability to perform previously learned actions. Demographic variables such as gender, age, and education can influence the performance of individuals on different neuropsychological tests. Objective: The present study aimed to evaluate the performance of healthy subjects on a limb apraxia battery and to determine the influence of gender, age, and education on the praxis skills assessed. Methods: Forty-four subjects underwent a limb apraxia battery, which was composed of numerous subtests for assessing both the semantic aspects of gestural production as well as motor performance itself. The tasks encompassed lexical-semantic aspects related to gestural production and motor activity in response to verbal commands and imitation. Results: We observed no gender effects on any of the subtests. Only the subtest involving visual recognition of transitive gestures showed a correlation between performance and age. However, we observed that education level influenced subject performance for all sub tests involving motor actions, and for most of these, moderate correlations were observed between education level and performance of the praxis tasks. Conclusion: We conclude that the education level of participants can have an important influence on the outcome of limb apraxia tests.

RESUMO Introdução: A apraxia é definida como sendo um distúrbio na realização de gestos ou atos motores aprendidos. Há poucos estudos sobre a avaliação da praxia de membros incluindo o controle de variáveis sócio-demográficas. Objetivo: O presente estudo teve por objetivo avaliar o desempenho de indivíduos saudáveis em uma bateria de praxia de membros, analisando-se a influência das variáveis sexo, idade e escolaridade nas habilidades práxicas avaliadas. Métodos: Quarenta e quatro indivíduos foram submetidos à aplicação de uma bateria de praxia de membros, composta de subtestes que avaliaram tanto aspectos semânticos relacionados à produção gestual, quanto a produção motora propriamente dita. Resultados: Não houve influência do sexo em nenhum dos subtestes. Apenas o subteste que envolvia o reconhecimento visual da correta realização de gestos transitivos, mostrou-se sensível à variação da idade. Já a escolaridade influenciou o desempenho dos participantes em todos os testes que envolviam a realização de atos motores, sendo que para a maior parte deles foram encontradas correlações moderadas entre a escolaridade e o desempenho nas tarefas práxicas. Conclusão: Variáveis sócio demográficas, principalmente a escolaridade, podem interferir no desempenho de indivíduos em testes que avaliam a praxia de membros e devem ser consideradas na avaliação clínica.

Tratamiento de la disgrafia fonológica cinestésica en un paciente con apraxia oral post accidente cerebro vascular / Treatment of kinesthetic phonological disgraphia in patients with oral apraxia sequelar a stroke

Introducción: los problemas en la ejecución de la escritura dificultan las actividades de la vida diaria. El conocimiento de las características de esta habilidad, en personas que han padecido de una lesión del sistema nervioso, es imprescindible para la estruturación de un abordage terapéutico con vista a un mejor desempeño en su medio social. Objetivo: describir las características de la escritura de un paciente con apraxia oral y comprobar la influencia de un sistema de actividades para compensar la disgrafia fonológica cinestésica. Metodología: se presentó un paciente (FBZ) que presentava apraxia oral y disgrafia fonológica. Durante dos meses recibió por parte de los especialistas un sistema de actividades que tenía como objetivo mejorar la percepción y diferenciación de los sonidos del habla por su posición articulatoria con vista a compensar el transtorno que presentava en la escritura. Como protocolo de evaluación se le aplicó al inicio y final del tratamiento el capítulo V referente al diagnóstico de la escritura del test Boston. Resultados: mejoró la composición y orden de los grafemas dentro de la palabra y su inteligibilidad en el plano oral. Conclusiones: el sistema de actividades aplicado influyó positivamente en la corrección de la disgrafia fonológica.

Introduction: problems in the execution of the deed hinder activities of daily life. Knowledge of the characteristics of this ability, in people who have suffered injury to the nervous system, it is essencial to structure a therapeutic approach with a view to improved performance in their social environment. Objective: to discribe the characteristics of the writing of a patient with oral apraxia and check the influence of a system to compensate knesthetic activities phonological dysgraphia. Methodology: A patient (FBZ) presenting oral apraxia and phonological dysgraphia presented. For two months he received from specialists a system of activities aimed to improve the reception and differentiation of speech sounds by the articulatory position overlooking compensate disorder presenting in writing. As evaluation protocol was applied at the beginning and end of treatment Chapter V concerning the diagnostic test script Boston. Results: Improved composition and order of graphemes within the word and inteligibility planus. Conclusions: The applied system positively influenced the activities in the correction of phonoaudiological dysgraphia.

Abordagens fisioterapêuticas aplicadas à redução da apraxia motora e ao estímulo do uso das mãos em meninas com síndrome de Rett / Physical therapy approaches applicable to the reduction of the motor apraxia and to stimulating of the use of hands in girls with Rett syndrome

A Síndrome de Rett é caracterizada como uma desordem cerebral precoce que cursa com déficits em diversas áreas. Dentre essas alterações, a perda progressiva da função da mão (apraxia) e os movimentos estereotipados interferem na execução das atividades de vida diária. Nesse contexto, a fisioterapia pode atuar na prevenção da piora do quadro. O objetivo deste estudo foi descrever, segundo relatos de fisioterapeutas, as abordagens fisioterapêuticas utilizadas no tratamento da apraxia motora em meninas com a Síndrome de Rett. A pesquisa consistiu no envio de um questionário para 11 fisioterapeutas, de várias localidades do Brasil, que atendiam pelo menos uma menina com a síndrome. Observou-se que, dentre as abordagens que constavam no questionário, as mais utilizadas foram o Conceito Neuroevolutivo Bobath, a Integração Sensorial e a Facilitação Neuromuscular Proprioceptiva. As regressões que essas meninas apresentavam após um período de tratamento não correspondiam às técnicas utilizadas, mas sim a fatores relacionados ao seu estado de saúde ou à falta de assiduidade às terapias. Concluiu-se que, embora não tenha sido encontrada nenhuma abordagem específica para o tratamento da apraxia na síndrome de Rett, o trabalho realizado na habilitação e/ou reabilitação dessas crianças resulta em evolução de vários aspectos dessa condição.

Rett Syndrome is characterized as a brain disorder associated with early deficits in several areas. Among these disorders, progressive loss of hand function (apraxia) and stereotyped behavior interfere with the execution of daily activities. In this context, physical therapy can help preventing the worsening of the condition and stimulating some residual function. Physical therapy approaches used in the treatment of motor apraxia in girls with Rett syndrome are here described, according to physical therapists` reports. The survey consisted of a questionnaire that was sent to eleven physical therapists in different locations in Brazil who attended at least one girl with the syndrome. It was observed that the most used approaches were the Bobath Neuroevolutive Concept, Sensory Integration and Neuromuscular Proprioceptive Facilitation. Regressions presented by these girls did not match to the used techniques, but rather to factors related to health status or lack of attendance in therapy. It was concluded that, although it was not found any specific approach to apraxia in Rett syndrome, the work for habilitation / rehabilitation of these children result in improvements in several aspects of this condition.

Reviewing the limb apraxia concept - from definition to cognitive neuropsychological models / Revisando o conceito da apraxia de membros - da definição aos modelos da neuropsicologia cognitiva

Apraxia is a disorder of learned skilled movements, in the absence of elementary motor or sensory deficits and general cognitive impairment such as inattention to commands, object-recognition deficits or poor oral comprehension. The first studies on apraxia were performed between the late 19th and early 20th centuries, however controversy remains in praxis literature concerning apraxia types, neuroanatomical and functional correlates, as well as assessment and treatment of apraxia. Thus, a critical review of the literature was conducted searching the literature for evidence contributing to a more detailed description of apraxia and its clinical patterns, physiopathology and clinico-anatomical correlations, as well as apraxia assessment.

A apraxia é um distúrbio da realização de gestos ou atos motores aprendidos sem que haja anormalidades em canais sensoriais aferentes ou motores eferentes, deterioração intelectual, nem alteração de atenção ou de compreensão dos comandos verbais. Os estudos sobre a apraxia iniciaram-se entre o fim do século XIX e início do século XX, no entanto, a literatura ainda apresenta controvérsias no que se refere à classificação desse quadro, seus substratos neuroanatômicos e funcionais, bem como suas formas de avaliação e tratamento. Assim, o presente estudo realizou uma revisão crítica da literatura visando buscar evidências científicas que contribuam para melhor delinear a apraxia e suas formas de manifestação clínica, sua fisiopatologia e as correlações anátomofisiológicas, bem como suas formas de avaliação.

Progressive Nonfluent Aphasia With Ideomotor Apraxia and Rigidity in the Right Upper Extremity

A woman developed a slowly progressive speech disturbance at age 51. Three years latter she showed difficulty in calculation, reading and writing. At age 57, she complained of right shoulder pain. At age 58, neurological examination revealed rigidity, bradykinesia and ideomotor apraxia in the right upper extremity. This case demonstrats a clinical overlap between progressive nonfluent aphasia and corticobasal degeneration.

The alien hand syndrome: report of a case and review of the literature.

The term "alien hand syndrome (AHS)" comprises many clinical signs of which the common features are the involuntary motor movement of the affected limb and the denial of limb ownership. It can result from several diseases involving corpus callosum or medial frontal cortex. Two major types of AHS were previously classified, callosal and frontal types. Moreover posterior subtype of which the lesions do not involve corpus callosum have been reported. In the present report, the authors describe a 57-year-old man with AHS, aggressive behavior and hemispatial neglect which are the rare manifestations of callosal damage. Neuroimaging demonstrated subacute infarction of entire corpus callosum from the rostrum to splenium. A review of the literature on these abnormalities is included in the present paper.

Expresión de la pantomima en pacientes afásicos / Pantomimic expression in aphasic patients

El paciente afásico comúnmente muestra alteraciones a nivel gestual, observándose diferencias entre afásicos fluentes y no fluentes. Sin embargo, no está claro si la naturaleza del déficit es simbólica o práxica. El presente estudio compara el rendimiento de la pantomima en pacientes afásicos (Broca y Wernicke) según: severidad de afasia, comprensión de la pantomima, apraxia ideomotora y déficit cognitivo. Además, compara el rendimiento entre pacientes y sujetos normales, realizándose un análisis cualitativo de los tipos de errores cometidos por los pacientes. Los resultados muestran que los pacientes afásicos rinden significativamente peor que los normales y que los afásicos de Broca rinden significativamente mejor que los afásicos de Wernicke. Por otra parte, la severidad de afasia correlaciona significativamente con el rendimiento de la pantomima en ambos. La comprensión de la pantomima y la apraxia ideomotora correlacionaron significativamente solo con los afásicos de Wernicke. La respuesta más común en los afásicos de Broca fue la de tipo incompleta y en los afásicos de Wernicke fue la de tipo relacionada.

A Case with Corticobasal Degeneration Showing Asymmetric Apraxia with Concordant Hypometabolism on FDG-PET

Corticobasal degeneration (CBD) is characterized by asymmetric clinical manifestations including asymmetrical apraxia, alien limb movement and Parkinsonian symptoms. Cognitive function is relatively normal in the early course of illness. We report a 59 years old right-handed male with CBD. He showed asymmetrical ideomotor apraxia, alien limb movement and extrapyramidal symptom, such as cogwheel rigidity and bradykinesia, that were more severe in the right hand. These symptoms have deteriorated progressively for 2 years, but the cognitive function was relatively pre-served. Brain MRI revealed atrophic changes in both parietal lobes. FDG-PET showed an asymmetrical hypometabo-lism in supplementary motor area, parietal lobe, thalamus and basal ganglia, which was more severe in the left than the right hemisphere.

Two Cases of Callosal Disconnection Syndrome: Impaired Body Cognition of Nondominant Limbs

Callosal disconnection results in the functional independence of each hemisphere and usually produces characteristic signs including alien hand, left-sided apraxia, left agraphia and left tactile anomia. Our two patients; a 75-year-old right-handed woman with hypertension and a 71-year-old right-handed woman with diabetes mellitus, showed impairments in the identification of body parts with their left hands in addition to characteristic symptoms such as left ideomotor apraxia, agraphia, tactile anomia, and right alien hand signs with groping and grasping. Brain MRIs of these patients upon admission demonstrated infarcts in the medial portion of the left frontal lobes and in the corpus callosum supplied by the left anterior cerebral artery. The impairment of body parts cognition in our patients can be attributed to the failure of the patient's left hand to communicate with the body schema stored in the left hemisphere.

Errors of ideomotor apraxia in Alzheimer's disease

BACKGROUND & PURPOSE: Ideomotor apraxia is a gestural deficit which is not due to primary sensory or motor deficit, poor auditory comprehension or incooperation. Previous studies on apraxia in AD patients include advanced AD patients who exhibited marked impairment in auditory comprehension, This might have confounded the results of the studies. The purpose of this study is to observe the frequencies and patterns of gestural errors in the early stage of AD. METHOD: Eighteen patients with AD (M : F = 4 : 14, age 62.6 + 7.2) and eighteen age- and sex- matched controls participated in this research. Patients who scored below 80 % of Western Aphasia Battery comprehension subtest and showed marked cognitive impairments were excluded (MMSE; 19.9 + 4.4, CDR 1.1+/- 0.5). Gestures. In response to commands were videotaped and analyzed by 2 neurologists and 1 speech-language pathologist. Test items included 3 types of movements ; 10 limb intrasitive, 15 transitive, and 10 buccofacial. RESULTS: Limb transitive movements were the most affected while buccofacial was the least. The error patterns most frequently observed were body-part-as-objects (BPO, 20%), external configuration orientation (ECO, 16%), and movement error(M, 9%). In comparision, BPO, ECO, M errors in normal control were 2%, 3%, and 4% respectively. In addition, apraxia item, which are to detecting AD were identified. CONCLUSION: It is suggested that the apraxia is commonly associated with AD even in the early stage of the disease and an accurate anaIysis of errors may contribute to establishing an early diagnosis of AD.