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inability to make purposeful movements

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2013/12/15 21:44:29」(JST)

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Apraxia (from Greek praxis, an act, work, or deed^[1]) is the inability to execute learned purposeful movements,^[2] despite having the desire and the physical capacity to perform the movements. Apraxia is an acquired disorder of motor planning, but is not caused by incoordination, sensory loss, or failure to comprehend simple commands (which can be tested by asking the person to recognize the correct movement from a series). It is caused by damage to specific areas of the cerebrum. Apraxia should not be confused with ataxia, a lack of coordination of movements; aphasia, an inability to produce and/or comprehend language; abulia, the lack of desire to carry out an action; or allochiria, in which patients perceive stimuli to one side of the body as occurring on the other. Developmental coordination disorder (DCD) is the developmental disorder of motor planning.

Types[edit]

There are several types of apraxia including:

Ideomotor apraxia: These patients have deficits in their ability to plan or complete motor actions that rely on semantic memory. They are able to explain how to perform an action, but unable to "imagine" or act out a movement such as "pretend to brush your teeth" or "pucker as though you bit into a sour lemon." The ability to perform an action automatically when cued, however, remains intact. This is known as automatic-voluntary dissociation. For example they may not be able to pick up a phone when asked to do so, but can perform the action without thinking when the phone rings.^[3]^[4]

Ideational/conceptual apraxia: Patients have an inability to conceptualize a task and impaired ability to complete multistep actions. Consists of an inability to select and carry out an appropriate motor program. For example, the patient may complete actions in incorrect orders, such as buttering bread before putting it in the toaster, or putting on shoes before putting on socks. There is also a loss of ability to voluntarily perform a learned task when given the necessary objects or tools. For instance, if given a screwdriver, the patient may try to write with it as if it were a pen, or try to comb one's hair with a toothbrush.^[3]^[4]

Buccofacial or orofacial apraxia: Non-verbal oral or buccofacial ideomotor apraxia resulting in difficulty carrying out movements of the face on demand. For example, an inability to lick one's lips or whistle.

Constructional apraxia: The inability to draw or construct simple configurations, such as intersecting pentagons.

Gait apraxia: The loss of ability to have normal function of the lower limbs such as walking. This is not due to loss of motor or sensory functions.^[5]

Limb-kinetic apraxia: Difficulty making precise movements with an arm or leg.

Oculomotor apraxia: Difficulty moving the eye, especially with saccade movements that direct the gaze to targets. This is one of the 3 major components of Balint's syndrome.

Apraxia of speech: Difficulty planning and coordinating the movements necessary for speech.^[1]

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 toothbrush) and ask them to use it.

Apraxia of speech[edit]

Main article: Apraxia of speech

Apraxia of speech (AOS) involves the loss of previously acquired speech levels. It occurs in both children and adults who have (prior to the onset of apraxia) acquired some level of speaking ability. AOS is typically the result of a stroke, tumor, or other known neurological illness or injury. Apraxia may be accompanied by a language disorder called aphasia.

Symptoms of AOS 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.

Developmental verbal dyspraxia 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.

Causes[edit]

Apraxia is most often due to a lesion located in the left hemisphere of the brain, typically in the frontal and parietal lobes. Lesions may be due to stroke, acquired brain injuries, or neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, and dementia. It is also possible for apraxia to be caused by lesions in other areas of the brain including the right hemisphere. ^[4]

Ideomotor apraxia is typically due to a decrease in blood flow to the left hemisphere of the brain and particularly the parietal and premotor areas. It is frequently seen in patients with corticobasal degeneration. ^[4]

Ideational apraxia often results in functional impairments in activities of daily living (ADLs) similar to those seen with late stage dementia. More recently, it has been observed in patients with lesions in the left hemisphere near areas associated with aphasia, however more research is needed on ideational apraxia due to brain lesions. The localization of lesions in areas of the frontal and temporal lobes would provide explanation for the difficulty in motor planning seen in ideational apraxia as well as its difficulty to distinguish it from certain aphasias.^[6]

Constructional apraxia is often caused by lesions of the inferior right parietal lobe, and can be caused by brain injury, illness, tumor or other condition that can result in a brain lesion. ^[6]

Assessment[edit]

Although qualitative and quantitative studies exist, there is little consensus on the proper method to assess for apraxia. The criticisms of past methods include failure to meet standard psychometric properties as well as research-specific designs that translate poorly to non-research use.^[7]

The Test to Measure Upper Limb Apraxia (TULIA) is one method of determining upper limb apraxia through the qualitative and quantitative assessment of gesture production. In contrast to previous publications on apraxic assessment, the reliability and validity of TULIA was thoroughly investigated.^[8] The TULIA consists of subtests for the imitation and pantomime of non-symbolic (“put your index finger on top of your nose”), intransitive (“wave goodbye”) and transitive (“show me how to use a hammer”) gestures.^[7] Discrimination (differentiating between well- and poorly-performed tasks) and recognition (indicating which object corresponds to a pantomimed gesture) tasks are also often tested for a full apraxia evaluation.

However, there may not be a strong correlation between formal test results and actual performance in everyday functioning or activities of daily living (ADLs). A comprehensive assessment of apraxia should include formal testing, standardized measurements of ADLs, observation of daily routines, self-report questionnaires and targeted interviews with the patients and their relatives.^[7]

Treatment[edit]

Treatment for individuals with apraxia includes speech therapy, occupational therapy, and physical therapy.^[9] Yet, treatments for apraxia have received little attention for several reasons, including the tendency for the condition to resolve spontaneously in acute cases. Additionally, the very nature of the automatic-voluntary dissociation of motor abilities that defines apraxia means that patients may still be able to automatically perform activities if cued to do so in daily life. Nevertheless, research shows that patients experiencing apraxia have less functional independence in their daily lives,^[10] and that evidence for the treatment of apraxia is scarce.^[11] However, a literature review of apraxia treatment to date reveals that although the field is in its early stages of treatment design, certain aspects can be included to treat apraxia.^[12] One method is through rehabilitative treatment, which has been found to positively impact apraxia, as well as activities of daily living.^[12] In this review, rehabilitative treatment consisted of 12 different contextual cues, which were used in order to teach patients how to produce the same gesture under different contextual situations.^[12] Additional studies have also recommended varying forms of gesture therapy, whereby the patient is instructed to make gestures (either using objects or symbolically meaningful and non-meaningful gestures) with progressively less cuing from the therapist.^[13] No single type of therapy or approach has been proven as the best way to treat a patient with apraxia, since each patient's case varies. However, one-on-one sessions usually work the best, with the support of family members and friends. Since everyone responds to therapy differently, some patients will make significant improvements, while others will make less progress.^[14]

Prognosis[edit]

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. However, many people with apraxia are no longer able to be independent. They should avoid activities in which they might injure themselves or others.

Occupational therapy and counseling and play therapy may help both patients and their caregivers learn ways to deal with the apraxia. However, because people with limb apraxia may have trouble directing their motor movements, occupational therapy for stroke or other brain injury can be difficult.

No drug has been shown useful for treating apraxia.

References[edit]

^ ^a ^b Heilman KM, Watson RT, Gonzalez-Rothi LJ. Praxis. In: Goetz CG. Goetz: Textbook of Clinical Neurology. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2007:chap 4.
^ "apraxia" at Dorland's Medical Dictionary
^ ^a ^b Sathian, K; et al. (Jun 2011). "Neurological and rehabilitation of action disorders: common clinical deficits". Neurorehabilitation and Neural Repair 25 (5): 21S–32S. doi:10.1177/1545968311410941. PMID 21613535. Cite uses deprecated parameters (help)
^ ^a ^b ^c ^d Gross, RG; Grossman, M. (Nov 2008). "Update on apraxia". Current Neurology and Neuroscience Reports 8 (6): 490–496. PMC 2696397. PMID 18957186. Cite uses deprecated parameters (help)
^ Nadeau SE (2007). "Gait apraxia: further clues to localization". Eur. Neurol. 58 (3): 142–5. doi:10.1159/000104714. PMID 17622719.
^ ^a ^b Tonkonogy, Joseph & Puente, Antonio (2009). Localization of clinical syndromes in neuropsychology and neuroscience. Springer Publishing Company. pp. 291–323. ISBN 0826119670.
^ ^a ^b ^c Vanbellingen, T.; Bohlhalter, S. (2011). "Apraxia in neurorehabilitation: Classification, assessment and treatment". NeuroRehabilitation 28 (2): 91–98. doi:10.3233/NRE-2011-0637. PMID 21447909. Cite uses deprecated parameters (help)
^ Vanbellingen, T.; Kersten, B., Van Hemelrijk, B., Van de Winckel, A.L.J., Bertschi, M., Muri, R., De Weerdt, W., & Bohlhalter, S. (2010). "Comprehensive assessment of gesture production: a new test to measure upper limb apraxia". European Journal of Neurology 17 (1): 59–66. doi:10.1111/j.1468-1331.2009.02741.x. PMID 19614961. Cite uses deprecated parameters (help)
^ "NINDS Apraxia Information Page". Retrieved 8 March 2012.
^ Hanna-Pladdy, B; Heilman, K.M., and Foundas, A.L. (Feb 2003). "Ecological implications of ideomotor apraxia: evidence from physical activities of daily living". Neurology 60 (3): 487–490. PMID 12578932. Cite uses deprecated parameters (help)
^ West, C; Bowen, A., Hesketh, A., and Vail, A. (Jan 2008). "Interventions for motor apraxia following stroke". Cochrane Database of Systematic Reviews 23 (1): CD004132. doi:10.1002/14651858.CD004132.pub2. PMID 18254038. Cite uses deprecated parameters (help)
^ ^a ^b ^c Buxbaum LJ, Haaland KY, Hallett M, et al. (February 2008). "Treatment of limb apraxia: moving forward to improved action". Am J Phys Med Rehabil 87 (2): 149–61. doi:10.1097/PHM.0b013e31815e6727. PMID 18209511. Cite uses deprecated parameters (help)
^ Smania, N; et al. (Dec 2006). "Rehabilitation of limb apraxia improves daily life activities in patients with stroke.". Neurology 67 (11): 2050–2052. doi:10.1212/01.wnl.0000247279.63483.1f. PMID 17159119. Cite uses deprecated parameters (help)
^ Dovern, A.; Fink, GR.; Weiss, PH. (Jul 2012). "Diagnosis and treatment of upper limb apraxia.". J Neurol 259 (7): 1269–83. doi:10.1007/s00415-011-6336-y. PMC 3390701. PMID 22215235. Cite uses deprecated parameters (help)

External links[edit]

Acquired Apraxia of Speech: A Treatment Overview
Apraxia: Symptoms, Causes, Tests, Treatments

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. 小児における発話および言語障害の病因 etiology of speech and language disorders in children
2. 大脳皮質基底核変性症 corticobasal degeneration
3. 成人における精神状態検査 the mental status examination in adults
4. 舞踏病の概要 overview of chorea
5. 成人における小脳性運動失調の概要 overview of cerebellar ataxia in adults

English Journal

Frontal-executive constructional apraxia: When delayed recall is better than copying.

Roth HL, Bauer RM, Crucian GP, Heilman KM.Author information a Department of Neurology , University of North Carolina , Chapel Hill , NC , USA.AbstractIn assessments of visuospatial function and memory, patients are often required to copy a figure and later to reproduce that figure from memory. Whereas most people perform better on a copying task than when drawing from memory, in this study we describe an unusual pattern of performance in which patients are better at drawing from memory than copying. Consecutive patients in a neurocognitive disorders clinic were given a battery of clinical cognitive tests that included copying a figure of intersecting pentagons and then drawing the figure from memory. Patterns of drawing performance at the two time points were compared to the profile of other cognitive deficits. Results: A subgroup of four patients with frontal dysfunction showed marked improvement in drawings at a delay compared to copying. Prior studies have indicated that most patients have declines in drawing performance at a delay. The unusual pattern of better performance at a delay compared to an initial copy occurred in patients with frontal dysfunction. These patients' visuoconstructive deficit and subsequent improvement could be related to either a failure to disengage when a model is present, to memory consolidation with increased reliance on top-down processing in the delay condition, or to relative preservation of global versus local aspects of a stimulus in memory. The addition of a task to assess drawing after a delay to a standard clinical screening battery such as the Mini-Mental Status Examination (MMSE) provides the opportunity to evaluate this phenomenon that may be indicative of frontal-executive dysfunction.
Neurocase.Neurocase.2014 Jun;20(3):283-95. doi: 10.1080/13554794.2013.770879. Epub 2013 Apr 15.
In assessments of visuospatial function and memory, patients are often required to copy a figure and later to reproduce that figure from memory. Whereas most people perform better on a copying task than when drawing from memory, in this study we describe an unusual pattern of performance in which pa
PMID 23581561

Praxis and writing in a right-hander with crossed aphasia.

Falchook AD, Burtis DB, Acosta LM, Salazar L, Shushrutha Hedna V, Khanna AY, Heilman KM.Author information a Department of Neurology , University of Florida , Gainesville , FL , USA.AbstractStudies of patients with brain lesions have demonstrated that language and praxis are mediated by dissociable networks. However, language has the capacity to influence the selection of purposeful actions. The abilities to use language and to program purposeful movements are often mediated by networks that have anatomic proximity. With hemispheric injury, the diagnosis of apraxia is often confounded by the specific influence of language impairments on the ability to select and produce transitive gestures. We report a patient who illustrates this confound. This patient is a right-handed man who developed global aphasia and neglect after a right hemispheric stroke. His right hand remained deft, and when asked to produce specific transitive gestures (pantomimes), he often performed normally but did make some body part as object and perseverative errors. However, he did not demonstrate the temporal or spatial errors typical of ideomotor apraxia. He also had a perseverative agraphia. Our patient's left hemisphere praxis system appeared to be intact, and the error types demonstrated during production of transitive gestures cannot be attributed to a degradation of postural and movement (praxis) programs mediated by his left hemisphere. The praxis errors types are most consistent with a deficit in the ability to select the necessary praxis programs. Thus, our patient appeared to have dissociation between language and praxis programs that resulted in body part as object and perseverative errors.
Neurocase.Neurocase.2014 Jun;20(3):317-27. doi: 10.1080/13554794.2013.770883. Epub 2013 Apr 5.
Studies of patients with brain lesions have demonstrated that language and praxis are mediated by dissociable networks. However, language has the capacity to influence the selection of purposeful actions. The abilities to use language and to program purposeful movements are often mediated by network
PMID 23557340

Limb apraxia in acute ischemic stroke: a neglected clinical challenge?

Schell C, Suchan J, Himmelbach M, Haarmeier T, Borchers S.Author information a Department of Neurology and Epileptology , Hertie-Institute for Clinical Brain Research, Eberhard Karls University , Tübingen , Germany.AbstractSymptoms of limb apraxia and executive dysfunctions are currently not explicitly considered by the National Institutes of Health Stroke Scale and, thus, not routinely tested by clinicians in the acute care of patients with suspected stroke. Neuropsychological testing, clinical examination, MRI, and functional magnetic resonance imaging (fMRI) were performed in a right-handed patient with acute onset of left-sided sensorimotor hemiparesis due to a right hemisphere ischemic stroke. Deficits in the execution of meaningless and meaningful gestures were not detected properly on initial clinical examination but were revealed later on through neuropsychological testing. Instead, the patient's inability to respond to specific instructions in the acute care setting was mistaken to reflect severe deficits in auditory comprehension. fMRI revealed right-hemispheric localization of language in the right-handed patient. We suggest including a bedside test for limb apraxia symptoms in acute clinical care of stroke patients. The distinction between deficits in limb praxis and impairments of language can be complicated owing to the common hemispheric co-localization of the two functions.
Neurocase.Neurocase.2014 Apr;20(2):158-62. doi: 10.1080/13554794.2012.741253. Epub 2013 Jan 4.
Symptoms of limb apraxia and executive dysfunctions are currently not explicitly considered by the National Institutes of Health Stroke Scale and, thus, not routinely tested by clinicians in the acute care of patients with suspected stroke. Neuropsychological testing, clinical examination, MRI, and
PMID 23286466