The Apraxia Is defined as the inability to perform voluntary movements in the absence of paralysis or other motor or sensory disorders (Kolb & Whishaw, 2006).
Dr. Liepman, who discovered this disorder, described it as the"inability to carry out intentional movements, even though mobility is preserved"(Mohr, Lazar, Marshall, & Hier, 2004).
That is, people suffering from this type of disorder can not perform the movements required to perform an action, such as buttoning, but they can move normally if the movements are spontaneous.
Apraxia should not be confused with dyspraxia or with ataxia , As these disorders involve a lack of general motor coordination in a way that affect all kinds of movements.
Types of apraxia
Apraxia is classified according to the type of specific motor action that is affected or the area of the brain that is injured. The most common apraxia will be described: Apraxia ideomotor, constructive, ideational and the Apraxia of speech . The less frequent ones will be included in the aparatado"other apraxias".
Apopodia ideomotor
This type of apraxia is the most common, although it is considered a rare disease already, and is characterized because patients who suffer from it can not copy movements or make everyday gestures such as nodding or waving.
These patients can describe what steps need to be taken to perform the action, but are unable to imagine performing the action or performing it themselves.
In the following video you can see an example of a person with ideomotor apraxia:
There are several levels of ideomotor apraxia according to their severity, in mild cases the patients perform the actions without precision and with awkwardness while in the most serious cases the actions are vague becoming unrecognizable.
At all levels of severity, the most affected type of actions are those that must be performed when given verbal instructions, so this is a type of test widely used to check if the person suffers ideomotor apraxia.
Another type of test widely used in the diagnosis of this disorder is the copy of serial movements, elaborated by Kimura who showed that the deficits in these patients can be quantified if they were instructed to copy a series of movements made with an area Specific body.
According to Heilman The parietal lobe Would cause ideomotor apraxia because that is the place where humans would keep the"motor programs"to perform daily actions.
In order to carry out the actions these programs should be transmitted to the primary motor area (in the Frontal lobe ), Which would be in charge of sending the order to perform the action to the muscles.
According to Heilman's theory, there would be two types of lesions that could cause ideomotor apraxia: (1) direct lesions in the areas containing"motor programs"and (2) injury of fibers connecting"motor programs"with Primary motor area.
Cases with symptoms similar to those of ideomotor apraxias have also been observed after an injury in the hard body , Which connects both hemispheres, but it is necessary to study these cases more thoroughly to know if we are really facing an ideomotor apraxia and what is its cause.
There is no specific method for treating apraxia since its symptoms are not reversible, but occupational therapy can help improve the patient's quality of life.
This type of therapy consists of dividing by components the daily actions such as brushing teeth and teaching components separately, with great perseverance the patient can get back to performing the actions, albeit a bit awkward.
Construction apraxia
Construction apraxia is the second most common. Patients suffering from this type of apraxia are unable to perform motor actions that require spatial organization, such as drawing, making figures with blocks or mimicking a specific facial movement.
This type of apraxia can develop after an injury to the posterior part of the parietal lobe of any of the hemispheres, although it is not clear whether the symptoms differ depending on the hemisphere where they occur.
Mountcastle proposes that lesions in the parietal lobe cause apraxia because this zone receives information about the position and movement of our own body, so if it is injured it would cause a dysfunction in controlling the movement of our limbs.
Construction apraxia usually occurs due to cerebral infarctions or as a cause of the development of Alzheimer's disease.
One of the tests most used to diagnose this type of apraxia is to ask the patient to copy a drawing. This test can be differentiated even if apraxia is caused by lesions in the left parietal lobe, right or Alzheimer disease , Since the type of damage causes the patients to copy the drawings with certain characteristics.
The most used therapy in cases of apraxia of construction is the mental simulation of motor acts, as its own name indicates this therapy consists of having the patient imagine himself performing the motor actions step by step.
Apraxia ideatoria
Patients with Apraxia ideatory Are characterized by the deficit in the accomplishment of complex actions that require a planning like sending an e-mail or prepare the food. Some researchers say that it is simply a more serious level of ideomotor apraxia, but there are others who argue that it is another type of apraxia.
Like ideomotor apraxia, it occurs due to lesions in the parietal lobe of the dominant hemisphere, but the exact area where this lesion occurs is unknown.
This type of apraxia is difficult to diagnose since it usually presents with other disorders such as agnosia or aphasia. One of the tests most used to diagnose it is to present the patient with a series of objects, he must simulate that he is using each one three times using different steps for each simulation. De Renzi and Luchelli will elaborate a scale to check the level of deterioration of the patient according to the errors made.
The treatment for this type of apraxia is complicated because it is usually irreversible but the occupational therapy can help, doing the same type of exercises as in the treatment of the ideomotor apraxia. The prognosis is better if the patient is young and the injury has been caused by a cerebral infarct because, thanks to the cerebral plasticity, other brain regions can supply part of the function of the injured region.
Apraxia of speech
The Apraxia of speech Are described as the inability to reproduce the necessary motor sequence with the mouth to be able to speak clearly and intelligibly. It can occur in both adults and children of learning-age, although in childhood patients it is often called verbal developmental dyspraxia.
This type of apraxia is caused by lesions in the regions in the motor areas that control the muscular movement of the mouth, although cases of patients with lesions in the insula and in the Broca area .
Although in English, in the following video you can see children with apraxia of speech from minute 1:55:
These lesions are usually caused by an infarct or a tumor, but they may also be a consequence of neuronal degeneration typical of neurodegenerative diseases such as Alzheimer's.
Speech apraxia is usually diagnosed by a speech specialist, who must perform a thorough examination of the patient's deficits, including tasks such as puckering, blowing, licking, tongue-lifting, eating, speaking... Perform a physical examination of the mouth to check that there are no muscle problems that prevent the patient from speaking correctly. The diagnosis is usually supported by magnetic resonance imaging in which the damaged regions can be observed.
Most speech apraxia caused by infarction usually recover spontaneously but those caused by neurodegenerative disorders often require the use of therapies. Of the therapies studied, those that have demonstrated a greater effectiveness are those that include exercises of production of sounds and repetitions of the speed and the rhythm.
These exercises are usually performed with the support of the professional in terms of muscle positioning and articulatory movement. These treatments usually get good results and are effective in the long term.
Other apraxias
Apraxia of gait
The Apraxia of gait Is defined as the inability to move the legs in order to walk naturally, without the patient having any paralysis or muscular problem.
This type of apraxia usually occurs in elderly people who have suffered an ischemia, in the MRI is usually observed a dilation of the ventricles, which are involved in the correct movement of the lower limbs.
In addition to gait problems, patients often present with other symptoms such as urinary incontinence, imbalance, and even cognitive deficits.
If untreated, patients with this disorder may end up suffering from total paralysis of their lower limbs and a severe cognitive deficit.
One type of therapy that is proving quite effective is magnetic stimulation, in a study by Devathasan and Dinesh (2007) it was shown that patients treated with magnetic stimulation in motor zones for a week markedly improved their walking.
Kinetic apraxia of extremities
The Kinetic apraxia of the extremities , As its name implies, implies a deficit in the fluid movement of both the upper and lower extremities, people who suffer from this disorder often have problems both in gross motor (move arms and legs) and in fine motor (move the Fingers, writing, catching things...).
This type of apraxia is usually due to the degeneration of Motor neurons , Located in the frontal lobe and the parietal lobe, as a consequence of a neurodegenerative disorder such as Parkinson wave Multiple sclerosis , Although it can also occur as a cause of cerebral infarction.
The treatment of kinetic apraxies usually focuses on training the patient in the use of everyday objects to improve their quality of life.
Orofacial or facial-oral apraxia
Patients who suffer Orofacial apraxia Are unable to properly control the muscles of the face, tongue and throat; therefore, they have problems chewing, swallowing, winking, tongue out, etc.
This incapacity occurs when the person intends to perform the movements on purpose and not when they are involuntary, that is, it only occurs when the person thinks the movements before performing them.
The oropharynx apraxia usually occurs along with the kinetic apraxia of the extremities, although it is not yet known what is the relationship between these two types of apraxia, since kinetic apraxia usually occurs after suffering frontal and parietal lobe lesions, while lesions Suffered by people suffering from bucco-facial apraxia have very different locations such as the prefrontal cortex, the insula or the basal ganglia.
It has been shown that treatment with Biofeedback Is effective in this type of apraxia, but it is not yet known if this treatment is effective in the long term. The treatment with biofeedback consists of the provision of sensors that detect the muscular activation of the face and mouth, in this way the professional can observe the muscles that the patient is trying to move and correct if necessary.
Oculomotor apraxia
The Oculomotor apraxia Involves the difficulty or inability to perform eye movements, especially Saccadic movements (Moving eyes to the sides) intended to direct the gaze to a visual stimulus.
This type of apraxia differs from the previous ones in that it can occur both of acquired form as congenital form, that is to say can be given from birth due to the inheritance of a gene. Congenital oculomotor apraxia may be of several types depending on the affected gene.
One of the most studied is oculomotor apraxia type 2, caused by a mutation in the SETX gene. This apraxia is a characteristic symptom of Gaucher's disease, a degenerative disease that unfortunately causes the early death of the children who suffer it, although fortunately, an enzymatic treatment is beginning to take place, replacing inactive enzymes with new enzymes . More severe cases often require a bone marrow transplant.
When apraxia is acquired it is usually due to lesions in the corpus callosum, The cerebellum And the fourth ventricle, normally caused by various cerebral infarctions.
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