Limb Apraxia Research Articles

Abstract- Poster

INTRODUCTION.§ Frontotemporal dementia (FTD) refers to a group of dementias characterized by degeneration in the frontal and temporal lobes of the brain. Rates of early-onset FTD are high with 13% of individuals with FTD being under the age of 50.§ Younger cases of FTD tend to exhibit frequent abrupt mood changes, increased aggression, behavioral disinhibition, lack of empathy, and deficits in working memory.There are three clinical presentations of FTD: behavioral variant (bvFTD) and two forms of primary progressive aphasia.Here we report a a 37 yr Old married man was brought with complaints of a progressive history of changes in behaviour and personality.The patient was in good baseline health until age 35 years, when his family noticed an increase in change in behavior with history of cannabis smoking for 2 yrs, H/O multiple extra marital affairs for 2 yrs,with H/O restlessness,dull and withdrawn, sleep disturbance,poor self care, refusing to eat properly, slowly not speaking to anyone, poor work performance for the past 6 months. He was diagnosed as a case of substance induced psychosis with catatonic features and treated. Again after three months pt presented to psychiatric opd with complaints of restlessness, speech difficulty forgetting things, inappropriate laugh,disinterest in daily activities, walking in the house all the time, disinhibited behaviour,weight loss,excessive craving for tobacco,putting inedible things at mouth all these symptoms for one month.On Mse O/E he was alert,ambulant,kempt,yawning frequently during interview, not cooperative, sits in chair and gets up frequently, no Spontaneous speech. He did not attempt to initiate conversation, answering questions with short, terse responses. relevant replies. He often gazed with a prolonged, fixed stare and exhibited motor stereotypies such as clapping his thighs or tapping his feet vigorously.— There were no upper or lower motor neurone signs, frontal release signs positive, and no parkinsonism or limb apraxia. His gait was normal. He scored only 55 out of 100 on the Addenbrooke’s Cognitive Examination-III, with impairments across domains but with particularly poor executive function (naming only two words beginning with P in a minute, and only 10 animals over a minute, leading to a very low verbal fluency score of 4 out of 14). Attention (score 12 out of 18), language (19 out of 26), memory (9 out of 26) and visuospatial (11 out of 16) abilities were also affected.— Further neuropsychological testing identified a global reduction in general intellectual function, with severe executive function deficits as well as poor verbal working— Neurology opinion obtained as a case of young onset FTD— MRI scan of the brain showed substantial bilateral, symmetrical frontal atrophy, with no evidence of white matter changes that would be typical of a vascular, vasculitic or inflammatory cause (figure 1). In addition, autoimmune encephalitis was negative; and HIV and syphilis serology were all normal or negative. Cerebrospinal fluid (CSF) contained no white cells or abnormal cells and therefore no evidence of an active inflammatory, infective or malignant process; the CSF protein concentration was also normal. PET scan suggestive of FTDReference 1. Rascovsky K, Hodges JR, Knopman D, et al. Sensitivity of revised diagnostic criteria for the behavioural variant of frontotemporal dementia. Brain 2011;134:2456?77.2. Lebert F, Stekke W, Hasenbroekx C, et al. Frontotemporal dementia: a randomised, controlled trial with trazodone. Dement Geriatr Cogn Disord 2004;17:355?9.3. Warren JD, Rohrer JD, Rossor MN. Clinical review. Frontotemporal dementia. BMJ 2013;347:f4827.4. Neumann M, Mackenzie IRA. Review: Neuropathology of non-tau frontotemporal lobar degeneration. Neuropathol Appl Neurobiol 2019;45:19?40.5. Mann DMA, Snowden JS. Frontotemporal lobar degeneration: pathogenesis, pathology and pathways to phenotype. Brain Pathol 2017;27:723?36. Ct brain showed bilateral frontoparietotemporal Subdural HYGROMA.Neurologist opinion obtained. There was no focal neurological defecit and conservative management suggested. Patient was treated with tab risperidone 2mg 1-0-1 tab sodium valproate 200 mg 1-1-1, tab diazepam 5mg 0-0-1, her symptom improved with treatment (ymrs-12.)

Workshop Compiled

Progressive supranuclear palsy (PSP) is a type of neurodegenerative extrapyramidal syndrome. The prevalence of PSP in studies is found to be 5.8-6.5 per 100,000 individuals with a slightly male preponderence. Onset is usually between 55 and 70 years of age and median survival is around 6 years after the onset of symptomatology.It is characterized by motor symptoms, such as postural instability, rigidity, akinesia, supranuclear gaze palsy, pseudobulbar palsy; levodopa-unresponsive parkinsonism, and behavioral and cognitive symptoms. Early PSP is also difficult to differentiate from PD; as it shares many features like abnormalities in gait, speech, and eye movements. Neuropsychiatric symptoms commonly observed in patients with PSP are dementia, apathy, depression, anxiety, disorders of sleep and disinhibition.A 60 year old man presented with impaired memory, disturbed sleep and restless behaviour for 2months in geriatric mental health outpatient department. He had a history of tremors on both the hands and stiffness of body which was gradually progressive for last 4 years. They consulted a neurologist 1.5 years back as his symptoms were severe enough to hamper in day to day functioning. He was diagnosed as a case of idiopathic Parkinson’s Disease and was prescribed Tab Levodopa 100mg and Carbidopa 25mg combination preparation thrice daily. On medication within 2months, family members reported decrease in his symptoms. For last 6months new symptoms like frequent falls during walking without any precipitant developed. Falls usually occurred within a few steps of walking mostly towards the left side and following which he sustained an injury over his left eye leading to lower lid ectropion. The activity of the patient became restricted and he started to remain confined to his bed for the fear of falls since last 3months. They consulted a physician again and he was prescribed Tab Trihexyphenydyl 2mg three times a day and dose of Tab Levodopa 100mg and Carbidopa 25mg combination increased to four times a day and Tab Levodopa 100mg and Carbidopa 25mg combination contolled relase preparation was added at bedtime. After taking those medications the frequency of falls increased, forgetfulness appeared, sleep got disturbed, at night he becomes restless and some confusion in behavior like pointing things, picking bed linen were noticed during evening hours.On examination the patient had prominent vertical wrinkling of forehead, wide opened eyes with reduced blinking, ‘procerus sign’ was present. His speech revealed hypophonia and reduced fluency. On the first two days his orientation was fluctuating; from the third day no abnormality was noticed in his mental state. Neurological examination revealed wide based festinating gait, intention tremor in upper limb, lead pipe rigidity in all four limbs bilaterally(right>left), axial rigidity and impaired balance and coordination; and supranuclear gaze palsy.During the hospital stay the anticholinergic drug (trihexyphenydyl 2mg) and Tab Levodopa 100mg and Carbidopa 25mg combination contolled relase preparation was withheld; Tab Melatonin 5mg was added along with other drugs were continued. Within 2days of hospitalization, his sleep improved, restlessness and confusion in behavior decreased, also his cognition was improved.Workshop Description:Approach to Parkinson plus syndromes presenting in Geriatric Psychiatric population.Case scenarios from the literature.Discussion on diagnostic and management issues.Methods/Issues:Progressive supranuclear palsy (PSP) is often difficult to discriminate clinically from idiopathic Parkinson’s disease (PD). Diagnosis in early stage is important for maximal benefit from disease modifying treatment for PSP. Delirium is defined as an acute organic brain syndrome which presents with decreased level of consciousness, varied psychomotor activity, wake-sleep rhythm disorders, cognitive impairment and attention deficits. High dose of Levodopa in Parkinson’s disease is reported to cause confusion and psychosis.Moreover dopaminergic drug in Progressive Supranuclear Palsy has response in only 20-40% cases.Anticholinergic drugs in ageing brain with comorbidities are known to cause confusion and delirium.Learning Objectives:Parkinsonism plus syndrome as a heterogeneous degenerative neurological disorders that differs from the classical idiopathic Parkinson’s disease in certain associated clinical features, poor response to levodopa, distinctive pathological characteristics and poor prognosis. Associated clinical features include symmetrical onset, infrequent or atypical tremor, prominent rigidity in axial musculature, bradykinesia, early postural instability, supranuclear gaze palsy, early autonomic failure, pyramidal affection, cerebellar involvement, alien limb phenomenon, apraxia and significant early cognitive dysfunction in some cases. Progressive supranuclear palsy (PSP), multiple system atrophy (MSA) and dementia with Lewy body disease (DLB) are commoner disorders. Less frequent disorders are cortico-basal ganglionic degeneration (CBGD), frontotemporal dementia with chromosome 17 (FTDP-17), Pick’s disease, parkinsonian-dementia complex of Guam, Pallidonigral degeneration, Wilson’s disease and a rigid variant of Huntington’s disease.Conclusions/ Strategies:Patients with Parkinsonism-plus syndromes represent a relatively small portion of Parkinsonism patients.They have wide spectrum of disease phenotypes associated with these disorders and the often subtle clinical differences, establishing the correct diagnosis, especially at disease onset, can be difficult despite serial clinical observations and repeated neurological examination.

The reliability and validity of the Turkish version of the apraxia screen of TULIA in multiple sclerosis patients

Purpose The study was aimed to analyze the psychometric properties of the Turkish version of the Apraxia Screen of TULIA (T-AST). Methods A total of 112 patients with multiple sclerosis (MS) were included in the study. T-AST tasks were performed once while recording with a video camera. Two physiotherapists scored T-AST, independently. Rater(1) performed a second assessment of apraxia with AST one week later. The disability was evaluated by Expanded Disability Status Scale (EDSS). Cognitive assessment was carried out with Mini-Mental State Examination (MMSE). Depression was evaluated with Hamilton Depression Rating Scale (HAM-D). Multiple Sclerosis International Quality of Life (MusiQoL) was used to assess the quality of life. In addition, fatigue was evaluated with Fatigue Severity Scale (FSS). Results The mean age of the patients was 42.3 ± 11.0 years. The Cronbach's alpha coefficient of the rater(1)’s and rater(2)’s evaluation was 0.820 and 0.800, respectively. ICC score of the intra-rater reliability was 0.960. ICC score of the inter-rater reliability was 0.971. The Spearman correlation coefficients between T-AST and MMSE, EDSS, MusiQoL, HAM-D, FSS were low to excellent, respectively (r = 0.863; p < 0.001, r = −0.768; p < 0.001, r = −0.560; p < 0.001, r = −0.393, p < 0.001, r = −0.324, p < 0.001). Conclusion The Turkish version of the AST is a reliable and valid tool for assessing upper limb apraxia in patients with MS. Implications for Rehabilitation The Turkish version of the Apraxia Screen of TULIA (T-AST) is a reliable and valid test for assessing apraxia in patients with multiple sclerosis. Considering the short structure, high reliability, and validity, T-AST could be used in clinical practice and clinical trials.

Upper Limb Apraxia.

Limb apraxia is one of the most common and most disabling disorders caused by brain damage. However, apraxia is one of the least recognized disorders associated with cerebral disease. This article discusses the signs and symptoms of, means of testing for, the pathophysiology of, and possible management of upper limb apraxia. Upper limb apraxia has four major forms: ideomotor, limb-kinetic, conceptual, and ideational. Although recent findings are included in this article, a full understanding of these disorders, including the means of testing, their possible pathophysiology, and the diseases that may cause these disorders, requires that some older literature is also discussed. This article guides clinicians in testing for and diagnosing the different forms of upper limb apraxia, identifying the underlying diseases that may cause apraxia, managing the different forms of the disorder, and possible forms of rehabilitation.

Corticobasal syndrome associated with a novel Lys694del variant of the TBK1 gene.

Variants of the TANK-Binding Kinase 1 (TBK1) gene have been associated with frontotemporal dementia - amyotrophic lateral sclerosis (FTD-ALS) spectrum diseases. Corticobasal syndrome (CBS), characterized by asymmetric limb rigidity, dystonia or myoclonus, in association with speech or limb apraxia, cortical sensory deficit, and/or alien limb can result from a variety of underlying pathologies. It is most commonly sporadic, although it has been rarely described in association with genetic defects, especially MAPT and GRN genes. Case study. We describe the proband of a family with multiple occurrences of FTD-ALS spectrum disease who presented with a primary asymmetric akinetic-rigid syndrome with later speech involvement and cognitive dysfunction, contralateral anterior temporal lobe atrophy on MRI and corresponding hypometabolism by FDG-PET, who carried a novel Lys694del variant of the TBK1 gene and predominant Type A TDP-43 pathology in a frontotemporal distribution that was contralateral to the affected side. Although CBS has been described as a late feature of agrammatic primary progressive aphasia (PPA) in a patient carrying a different variant TBK1, to our knowledge our case is the first report of a patient presenting with asymmetric akinetic rigidity as the initial expression of a TBK1 variant. This case provides further support to consider TBK1 genetic screening in patients with CBS and a family history suggestive of FTD-ALS spectrum diseases, as this may be an underrepresented population on the spectrum of genetic FTD-ALS.

Praxis deficits in patients with Parkinson’s disease

AbstractBackgroundLimb apraxia has been described in several neurological disorders including Parkinson’s disease (Leiguarda and Marsden, 2000) and may predict progression to Alzheimer’s dementia in patients with mild cognitive impairment. Our aim was to study presence of apraxia and subtypes of deficits in patients with idiopathic Parkinson’s Disease.Method20 patients with idiopathic Parkinson’s disease, recruited from the Oxford Parkinson’s Disease Centre, were tested for presence of limb apraxia, measured on a battery of tasks, comparing their performance to deficits measured using the UPDRS, and independent measures of cognition (MOCA), and dexterity. Results were analysed using Pearson’s correlations, with correction for multiple comparisonsResultDetailed neuropsychological testing revealed significant deficits in praxis with 9 out of 20 patients displaying significant ideomotor deficits on finger and hand imitation, 2 patients showing ideational deficits on pantomime of tool use. Most patients made errors in the praxis tasks even though they did not qualify as apraxic per se, with only one patient performing faultlessly at all the screening tasks.Both ideational and ideomotor deficits correlated with Part 3 of the UPDRS score. Similarly, Part 3 of the UPDRS correlated with cognitive performance on the MOCA. Ideomotor deficits also correlated with deficits in dexterity and response inhibition. Whereas deficits in dexterity correlated with PD severity; praxis and cognitive deficits did not.ConclusionThe study shows different deficits in limb praxis assessed using batteries of tasks in patients with Parkinson’s disease. We identified relationships between praxis deficits and cognitive as well as motor performance in PD patients. Testing for apraxia in PD patients might provide a useful way for stratifying patients’ impairments, progression to PD dementia and response to treatment.

Proprioception-based movement goals support imitation and are disrupted in apraxia

The ability to imitate observed actions serves as an efficient method for learning novel movements and is specifically impaired (without concomitant gross motor impairments) in the neurological disorder of limb apraxia, a disorder common after left hemisphere stroke. Research with apraxic patients has advanced our understanding of how people imitate. However, the role of proprioception in imitation has been rarely assessed directly. Prior work has proposed that proprioceptively sensed body position is transformed into a visual format, supporting the attainment of a desired imitation goal represented visually (i.e., how the movement should look when performed). In contrast, we hypothesized a more direct role for proprioception: we suggest that movement goals are also represented proprioceptively (i.e., how a desired movement should feel when performed), and the ability to represent or access such proprioceptive goals is deficient in apraxia. Using a novel imitation task in which a robot cued meaningless trajectories proprioceptively or visually, we probed the role of each sensory modality. We found that patients with left hemisphere stroke were disproportionately worse than controls at imitating when cued proprioceptively versus visually. This proprioceptive versus visual disparity was associated with apraxia severity as assessed by a traditional imitation task, but could not be explained by general proprioceptive impairment or speed-accuracy trade-offs. These data suggest that successful imitation depends in part on the ability to represent movement goals in terms of how those movements should feel, and that deficits in this ability contribute to imitation impairments in patients with apraxia.

100 years after Liepmann–Lesion correlates of diminished selection and application of familiar versus novel tools

100 years ago, Liepmann highlighted the role of left ventro-dorsal lesions for impairments in conceptual (rather ventral) and motor (more dorsal) related aspects of apraxia. Many studies thereafter attributed to an extended left fronto-temporo-parietal network. Yet, to date there are only few studies that looked at apraxic performance in the selection and application of familiar versus novel tools.In the current study we applied modern voxel-based lesion-symptom mapping (VLSM) to analyze neural correlates of impaired selection and application of familiar versus novel tools. 58 left (LBD) and 51 right brain damaged (RBD) stroke patients participated in the Novel Tools Test (NTT) and the Familiar Tools Test (FTT) of the Diagnostic Instrument for Limb Apraxia (DILA-S). We further assessed performance in control tasks, namely semantic knowledge (BOSU), visuo-spatial working memory (Corsi Block Tapping) and meaningless imitation of gestures (IML).Impaired tool use was most pronounced after LBD. Our VLSM results in the LBD group suggested that selection- versus application-related aspects of praxis and semantics of familiar versus novel tool use can be behaviorally and neuro-anatomically differentiated. For impairments in familiar tool tasks, the major focus of lesion maps was rather ventral while deficiencies in novel tool tasks went along with rather dorsal lesions. Affected selection processes were linked to rather anterior lesions, while impacted application processes went along with rather posterior lesion maps. In our study, particular tool selection processes were rather specific for familiar versus novel tools. Foci for lesion overlaps of experimental and control tasks were noticed ventrally for semantic knowledge and FTT, in fronto-parietal regions for working memory and NTT, and ventro-dorsally for imitation of meaningless gestures and the application of NTT and FTT.We visualized our current interpretation within a neuroanatomical model for apraxia of tool use.

Improvement of Apraxia With Augmented Reality: Influencing Pantomime of Tool Use via Holographic Cues.

Background: Defective pantomime of tool use is a hall mark of limb apraxia. Contextual information has been demonstrated to improve tool use performance. Further, knowledge about the potential impact of technological aids such as augmented reality for patients with limb apraxia is still scarce.Objective: Since augmented reality offers a new way to provide contextual information, we applied it to pantomime of tool use. We hypothesize that the disturbed movement execution can be mitigated by holographic stimulation. If visual stimuli facilitate the access to the appropriate motor program in patients with apraxia, their performance should improve with increased saliency, i.e., should be better when supported by dynamic and holographic cues vs. static and screen-based cues.Methods: Twenty one stroke patients and 23 healthy control subjects were randomized to mime the use of five objects, presented in two Environments (Screen vs. Head Mounted Display, HMD) and two Modes (Static vs. Dynamic) resulting in four conditions (ScreenStat, ScreenDyn, HMDStat, HMDDyn), followed by a real tool demonstration. Pantomiming was analyzed by a scoring system using video recordings. Additionally, the sense of presence was assessed using a questionnaire.Results: Healthy control participants performed close to ceiling and significantly better than patients. Patients achieved significantly higher scores with holographic or dynamic cues. Remarkably, when their performance was supported by animated holographic cues (e.g., striking hammer), it did not differ significantly from real tool demonstration. As the sense of presence increases with animated holograms, so does the pantomiming.Conclusion: Patients' performance improved with visual stimuli of increasing saliency. Future assistive technology could be implemented upon this knowledge and thus, positively impact the rehabilitation process and a patient's autonomy.

Do gestures have a hand in verb retrieval? Investigation of iconic and non-iconic gestures in aphasia

ABSTRACT Background According to the lexical retrieval hypothesis (LRH), the primary function of gestures is to facilitate word retrieval. Thus, individuals with aphasia (IWA) might benefit from gestures in case of word retrieval impairments. However, the facilitative effect of gestures on word finding is still unclear since most facilitation/treatment studies combined gesture with linguistic cues. The LRH claims that the semantic content of a gesture is decisive for a facilitation effect on word retrieval. However, it remains unclear if and how IWA can perform adequate iconic gestures, especially in the presence of hemiparesis or limb apraxia. Thus, in the present study, we systematically studied the effect of iconic and non-iconic gesture production on oral verb naming in IWA and analysed the iconicity of gestures produced by IWA and healthy controls. Aims In the present study, we aimed (1) to investigate the potential facilitation effect of iconic and non-iconic gestures on verb retrieval in IWA and (2) to examine the IWA’s ability to produce adequate iconic gestures. Methods & Procedures Six IWA with impairments in naming verbs arising from a phonological, a lexical-semantic, or a combined deficit participated in a multiple single-case study targeting oral verb production. In the first experiment, IWA were asked to name pictures and to simultaneously perform either a relevant iconic gesture, a non-iconic gesture, or no gesture at all. In the second experiment, the video-recorded gestures produced during verb naming in the iconic gesture condition were rated for iconicity and compared to the iconicity of iconic gestures produced by 12 language-unimpaired controls. Results The accuracy in oral naming of verbs (Experiment 1) did not differ significantly between all conditions. Most IWA (n = 5) were able to produce iconic gestures, irrespective of hemiparesis or limb apraxia, since the iconicity ratings did not differ significantly from language-unimpaired controls (Experiment 2). Conclusions In contrast to the general assumption of the LRH, no gesture facilitation effect was observed in the verb naming performance of IWA. Moreover, the majority of the IWA could perform iconic gestures in a similar way as language-unimpaired participants despite the presence of a hemiparesis or limb apraxia. Hence, the absence of a facilitation effect in the iconic gesture condition seems not to originate from an inability to produce adequate iconic gestures. Further research with more IWA is required in order to replicate our results.

Motor neuron disease beginning with frontotemporal dementia: clinical features and progression

Objective: To study disease characteristics, progression and outcome in a group of motor neuron disease (MND) patients beginning with frontotemporal dementia (FTD) by comparing them with patients with the typical motor-onset. Methods: 849 patients recruited from tertiary centers were studied according to FTD-onset and motor-onset. We studied clinical data, functional decline and survival. Results: Twenty six patients (3.1%) had FTD-onset of whom seven (26.9%) had coincident motor dysfunction. In those with isolated FTD-onset, motor symptoms developed after a median of 12 months (IQR: 4–18). FTD-onset patients were older at presentation; the bulbar-region was more frequently first affected than in the motor-onset group; there was a predominant upper motor neuron (UMN) phenotype; fasciculations were less common than in motor onset disease but facial and upper limb apraxia was more frequent; as well as ALS and FTD familial history. No differences were observed for gender, frequency of C9orf72 hexanucleotide repeat expansion, family history of Alzheimer’s and Parkinson’s diseases, median delay from motor symptoms to diagnosis, median ALSFRS-R rate of change, handedness, emotional lability, depression, weight loss, resting tremor, bradykinesia, sensory changes or neuropathy. Clinical and demographic features were similar between FTD-onset patients developing bulbar MND and bulbar-onset ALS patients. Once bulbar symptoms manifested functional progression and survival were similar to those of bulbar-onset ALS patients. Conclusions: MND patients with FTD-onset have a distinctive phenotype characterized by predominant UMN presentation and rapid progression to bulbar involvement. The main factor impacting functional decline and survival is the onset of bulbar dysfunction.

Motor sequence learning in patients with ideomotor apraxia: Effects of long-term training

Recent studies show that limb apraxia is a quite frequent, yet often underdiagnosed, higher motor impairment following stroke. Because it adversely affects every-day life and personal independence, successful rehabilitation of apraxia is essential for personal well-being. Nevertheless, evidence of long-term efficacy of training schemes and generalization to untrained actions is still scarce. One possible reason for the tendency of this neurological disorder to persist may be a deficit in planning, conceptualisation and storage of complex motor acts.This pilot study aims at investigating explicit motor learning in apractic stroke patients. In particular, we addressed the ability of apractic patients to learn and to retain new explicit sequential finger movements across 10 training sessions over a 3-week interval.Nine stroke patients with ideomotor apraxia in its chronic stage participated in a multi-session training regimen and were included in data analyses. Patients performed an explicit finger sequence learning task (MSLT – motor sequence learning task), which is a well-established paradigm to investigate motor learning and memory processes.Patients improved task performance in terms of speed and accuracy across sessions. Specifically, they showed a noticeable reduction in the mean time needed to perform a correct sequence and the number of erroneous sequences. We found also a trend for improved performance at the Goldenberg apraxia test protocol: “imitation of meaningless hand and finger gestures” relative to when assessed before the MSLT training.Patients with ideomotor apraxia demonstrated the ability to acquire and maintain a novel sequence of movements; and, this training was associated with hints towards improvement of apraxia symptoms.

Characterising factors underlying praxis deficits in chronic left hemisphere stroke patients

Limb apraxia, a disorder of skilled action not consequent on primary motor or sensory deficits, has traditionally been defined according to errors patients make on neuropsychological tasks. Previous models of the disorder have failed to provide a unified account of patients' deficits, due to heterogeneity in the patients and tasks used. In this study we hypothesised that we may be able to map apraxic deficits onto principal components, some of which may be specific, whilst others may align with other cognitive disorders. We implemented principal component analysis (PCA) to elucidate core factors of the disorder in a preliminary cohort of 41 unselected left hemisphere chronic stroke patients who were tested on a comprehensive and validated apraxia screen. Three principal components were identified: posture selection, semantic control and multi-demand sequencing. These were submitted to a lesion symptom mapping (VBCM) analysis in a subset of 24 patients, controlled for lesion volume, age and time post-stroke. The first component revealed no significant structural correlates. The second component was related to regions in inferior frontal gyrus, primary motor area, and adjacent parietal opercular (including inferior parietal and supramarginal gyrus) areas. The third component was associated with lesions within the white matter underlying the left sensorimotor cortex, likely involving the 2nd branch of the left superior longitudinal fasciculus as well as the posterior orbitofrontal cortex (pOFC). These results highlight a significant role of common cognitive functions in apraxia, which include action selection, and sequencing, whilst more specific deficits may relate to semantic control. Moreover, they suggest that previously described ‘ideomotor’ and ‘ideational’ deficits may have a common neural basis within semantic control. Further research using this technique would help elucidate the cognitive processes underlying limb apraxia, its neural correlates and their relationship with other cognitive disorders.

Hand gesture performance is impaired in major depressive disorder: A matter of working memory performance?

ObjectiveIndividuals with depression exhibit numerous interpersonal deficits. As effective use of gestures is critical for social communication, it is possible that depressed individuals’ interpersonal deficits may be due to deficits in gesture performance. The present study thus compared gesture performance of depressed patients and controls and examined whether these deficits relate to cognitive and other domains of dysfunction. MethodsGesture performance was evaluated in 30 depressed patients and 30 controls using the Test of Upper Limb Apraxia (TULIA). Clinical rating scales were assessed to determine if gesture deficits were associated with motor, cognitive or functional outcomes. ResultsCompared to controls, depressed patients exhibited impaired gesture performance with 2/3 of the patients demonstrating gesture deficits. Within depressed patients, gesture performance was highly correlated with working memory abilities. In contrast, no association between gesture performance and gestural knowledge, psychomotor retardation, depression severity, or frontal dysfunction was observed in patients. LimitationsThis is a cross-sectional study and a larger size would have allowed for confident detection of more subtle, but potentially relevant effects. ConclusionGesture performance is impaired in depressed patients, and appears to be related to poor working memory abilities, suggesting a disruption in the retrieval of gestural cues indicative of a distinct clinical phenomenon that might be related to social functioning.

Many Faces of the Hidden Souls: Medical and Neurological Complications and Comorbidities in Disorders of Consciousness.

Early and goal-directed management of complications and comorbidities is imperative to facilitate neurorecovery and to optimize outcomes of disorders of consciousness (DoC). This is the first large retrospective cohort study on the primary medical and neurological complications and comorbidities in persons with DoC. A total of 146 patients admitted to a specialized inpatient DoC rehabilitation program from 1 January 2014 to 31 October 2018 were included. The incidences of those conditions since their initial brain injuries were reviewed per documentation. They were categorized into reversible causes of DoC, confounders and mimics, and other medical/neurological conditions. The common complications and comorbidities included pneumonia (73.3%), pain (75.3%), pressure ulcers (70.5%), oral and limb apraxia (67.1%), urinary tract infection (69.2%), and 4-limb spasticity (52.7%). Reversible causes of DoC occurred very commonly. Conditions that may confound the diagnosis of DoC occurred at surprisingly high rates. Conditions that may be a source of pain occurred not infrequently. Among those that may diminish or confound the level of consciousness, 4.8 ± 2.0 conditions were identified per patient. In conclusion, high rates of various complications and comorbidities occurred in persons with DoC. Correcting reversible causes, identifying confounders and mimics, and managing general consequences need to be seriously considered in clinical practice.

Proposing a new short screening test for upper limb apraxia

Background Apraxia has a major impact on activities of daily living in stroke patients. The proper assessment and treatment of apraxia is important for maintaining a good quality of life. We developed a short evaluation test for upper limb apraxia. Patients and Methods The present Screening Test of Gestures for Stroke consists of 10 items for each verbal instruction and imitation. Each item includes three meaningless gestures, three meaningful gestures and four pantomimes. The Screening Test of Gestures for Stroke is scored based on a 3-point system: 10, 5 or 0 (maximum score: 200). The test took approximately 2–5 min to complete. We recruited 65 patients admitted to our hospital with left hemisphere stroke and 50 healthy subjects. Results The reliability of the Screening Test of Gestures for Stroke was as follows: the intraclass correlation coefficient of intra-rater reliability was 0.93 for both verbal instructions and imitations, and the intraclass correlation coefficient total scores for inter-rater reliability for verbal instructions and for imitations were 0.97 and 0.95, respectively. The alpha coefficient was ≥0.80. Conclusions The Screening Test of Gestures for Stroke is a reliable and valid bedside test that has a short assessment time, does not require special equipment and can evaluate upper limb apraxia in stroke patients from the acute to the chronic phase.

Effectiveness of a Functional Rehabilitation Program for Upper Limb Apraxia in Poststroke Patients: A Randomized Controlled Trial

ObjectiveTo analyze the effectiveness of a home-based restorative and compensatory upper limb apraxia (ULA) rehabilitation program. DesignRandomized controlled trial. SettingNeurology Unit of San Cecilio Hospital and 2 private and specialized health care centers. ParticipantsCommunity dwelling participants (N=38) between the ages of 25 and 95 years old (sex ratio, 1:1) with unilateral mild-to-moderate poststroke lesions (time of evolution since stroke, 12.03±8.98mo) and secondary ULA. InterventionsParticipants were randomly assigned to an 8-week combined ULA functional rehabilitation group (n=19) 3 days per week for 30 minutes or to a traditional health care education protocol group (n=19) once a month for 8 weeks. Both interventions were conducted at home. Main Outcome MeasuresSociodemographic and clinical data, Barthel Index (primary outcome), Lawton and Brody Scale, observation and scoring activities of daily living, the De Renzi tests for ideational and ideomotor apraxia and imitating gestures test, recognition of gestures, test for upper limb apraxia , and stroke-specific quality of life scale were assessed at 3 time points: baseline, posttreatment (8wk), and follow-up (8wk). ResultsThere were statistically significant differences among the groups regarding ideomotor apraxia, imitating gestures, global recognition of gestures, intransitive gestures, and comprehension of gesture production (P<.05) in favor of the experimental group. However, no statistically significant differences were found between the groups regarding functionality or quality of life (P>.05). Regarding the within-group effect, statistically significant differences were found in all neuropsychological outcomes at posttreatment and follow-up (P<.05). ConclusionA functional rehabilitation program was found to be superior to a traditional health care education program and resulted in improvements in neuropsychological functioning in ULA poststroke. Conventional education showed an insufficient effect on apraxia recovery. Further studies with larger sample sizes are needed to determine the effect of rehabilitation strategies on functionality and quality of life of poststroke ULA patients.

Pure Agraphia Associated with a Frontal Meningioma on Left Superior Frontal Gyrus

<i>Background</i>: The existence of cerebral area specifically involved in coding for writing movements in the left middle frontal gyrus is a matter of debate. We present a rare case of pure agraphia associated with a left frontal meningioma. The location of the lesion associated with this disorder could help to feed this debate. <i>Method</i>: We report a case of pure agraphia in a 69-year-old man. The patient had a writing disorder evolving over several months with a dominant, left frontal lesion. On neuropsychological evaluation, the writing difficulties were present whatever the nature of the writing (spontaneous, dictation, coping). The writing disorder was isolated, with no features of aphasia, alexia or limb apraxia. Phonological and lexical processing was preserved. The imaging showed a probable frontal meningioma restricted to the foot of the first and second left frontal circumvolutions (MNI coordinates /barycenter of the lesion: x=-19.8, y=1.5, z=52.2). <i>Results</i>: The patient was operated and the whole lesion was removed. After surgical resection, the patient’s writing disorder improved. Other components of language assessed were the same as before the surgery and showed no disturbances. The pathological study concluded on an OMS grade II atypical meningioma. <i>Conclusion</i>: We think that the disorder presented by our patient was related to the disturbance of the frontal graphemic center located in the Exner area. Here, we describe and analyze his condition through a neuro-anatomical and a cognitive approach.

Response to "Limb apraxia in NCSE: Fact or fake?"

Response to "Limb apraxia in NCSE: Fact or fake?"

To lump or to split? Possible subtypes of apraxia of speech

ABSTRACT Background The speculation that apraxia of speech (AOS) is not a unitary diagnosis, but consists of different subtypes instead, has been around for decades. However, attempts to empirically substantiate such a notion remain few and far between. Aims The primary objective of this article is to consider the different bases for identifying subtypes of AOS, review existing evidence regarding subtypes under each classification basis, and provide discussion and implications for future research. Main Contribution AOS subtypes have been proposed on the basis of clinical symptomatology, theoretical constructs, and an analogy to limb apraxia. Different possible subtypes of AOS are reviewed, along with their empirical support and limitations. Empirical evidence, particularly in the context of a progressive disease, supports the idea that AOS diagnosis may capture different underlying impairments of speech motor planning. Future research to advance our understanding of AOS should carefully consider the basis for subtype classification, and include large sample sizes to differentiate individual variability from possible subtypes. Conclusions Several proposed AOS subtypes have found some support in the literature. Further research is needed to determine the validity, coherence and utility of possible AOS subtypes for theoretical and clinical purposes.