Apraxia and dyspraxia

 

Brain injury may make it difficult for people to perform everyday tasks purposefully, even though she or he still is able to understand instructions.
Dyspraxia from birth is a motor developmental disorder. This is called Developmental Coordination Disorder (DCD). Information about this can be found here.

 

 

This disorder concerns intentional motor behavior.

It concerns actions that could be performed in a normal way before the brain injury.

The disorder does not stem from paralysis or poor coordination. It is also not caused by neglect, facial loss, and certainly not by unwillingness.

It is possible that one day something works better than another. The functioning of someone with a brain injury can fluctuate due to various factors.

 

This inability is called apraxia. It can make it impossible to perform all sorts of common, everyday activities, such as self-care.

 

Roughly speaking: not knowing how or not knowing what

There may be a disorder in planning and sequencing (ideatory apraxia), but there may also be a disorder in handling objects (ideomotor apraxia).

The person either doesn't know what to do because she or he lacks an idea or action plan, or she or he knows what to do, but does not know how to do it because the application of the correct motor program is disrupted.

 

Difficulty imitating movements

In some cases a person can imitate a complex action immediately after seeing it, but is unable to perform it later. Imitation may therefore be intact while commands or spontaneous actions cannot be carried out.

 

Different forms of apraxia

There are two main types of apraxia:

  • Ideational apraxia
  • Ideomotor apraxia

 

Learn more about different types of apraxia in the drop-down menus below.

 

Ideational apraxia

The person no longer knows the correct SEQUENCE of actions.

The person can still perform the action itself, for example, writing a letter or making coffee.

 

We have learned a specific sequence for washing and dressing from a young age. In people with ideational apraxia (the disturbed use of sequence), you see someone forgetting to put water in the coffee maker, putting a shirt on over a dress, or putting two pairs of pants on top of each other.

 

Clothes on a chair cause confusion because the person doesn't know how or where to begin. One way to deal with this is to always lay out the clothes in a fixed order. If you then point out which side to start on, it often works. The ability to plan the sequence of movements is lost.

 

Many people have invisible ideational apraxia.

This is particularly true for sequence planning, learning new (or already familiar) tasks, where fatigue and distraction (internal and external) are significant negative factors.

The lesion is usually in the parietal lobe.

Ideomotor apraxia

With ideomotor apraxia, the person knows what the object is used for, but cannot think of the movements required to do so. "Motor" refers to making movements. The person can no longer perform the action, for example, combing hair or brushing teeth.

This makes the person appear very clumsy. For example, when cutting a sandwich, the knife is held with the cutting edge facing up, or instead of spreading a sandwich, the person mashes.

 

Buttoning a shirt can be difficult because the person doesn't know how to use their fingers to get the button through the buttonhole. When tying shoelaces, the person doesn't know how to use their fingers to secure the loop.

 

The damage is usually in the left hemisphere (both anterior: frontal lesions and posterior: posterior parietal lesions).

It may also affect the corpus callosum or the right premotor area.

Speech apraxia / Verbal apraxia

We dedicated a page to this form of apraxia, in which the muscles of the mouth, lips, and tongue are not properly controlled to pronounce letters and sounds correctly, or to whistle, protrude the tongue, whisper, reverse letters, etc.

The word comes out differently than intended.

 

If the person is also unable to control facial muscles properly, such as blinking, this is classified as buccofacial/orofacial apraxia.

 

Find more infromation about speech apraxia under this link.

Constructional apraxia

In this form of apraxia, the spatial aspect of an action is disrupted, making it difficult for someone to draw (or copy) properly, construct simple figures, or assemble something.
See also the page on visual construction problems.

Buccofacial or orofacial apraxia

With this form of apraxia, the person cannot properly perform facial movement, lips, tongue, and eyes, when instructed. Examples include whistling, protruding the tongue, whispering, and blinking.
It is considered a subtype of ideomotor apraxia. See the description in that paragraph.
Lesions can occur in the frontal and central opercula, the anterior insula, and a small area of ​​the first temporal gyrus (adjacent to the frontal and central opercula).
In orafacial apraxia, lesions may occur in the inferior frontal, deep frontal white matter, insula, and basal ganglia.

Oculomotor apraxia

Persons with oculomotor apraxia have difficulty directing his or her eyes. When asked to look at a specific finger or object, she or he is unable to do so.

These persons struggle significantly with saccadic movements that direct their gaze to targets.


Motor refers to motor skills. In this case, the control of the eye muscles ('oculo' means 'eye').

Limb kinetic apraxia

This apraxia involves the inability to make precise or accurate movements with a finger, arm, or leg.
An example is the inability to use a screwdriver, even though the person understands what needs to be done and has worked with screwdrivers in the past.

Gait apraxia / Walking apraxia

Gait apraxia is a gait disorder in which movement planning is impaired. Severe gait apraxia may result in the inability to stand and walk. Normal leg movements are only possible when lying down or sitting. There are no muscle problems, paralysis, or psychiatric disorders.

It is characterized by difficulty initiating walking and difficulty entering a turn while walking.


It is often accompanied by a tendency to freeze. This is a sudden blocking of the legs, giving the person a feeling as if the feet are glued to the floor.

Dyspraxia

A milder form of apraxia is called dyspraxia. It is derived from the words dys and praxis.
Praxis refers to the conscious control over the various muscle signals (motor programs) required to perform complex learned actions. Dys means limited.


Dyspraxia from birth is a motor developmental disorder. In this case, it is called Developmental Coordination Disorder (DCD). See this website. 

Where is the injury located?

Apraxia is a motor disorder caused by damage to the brain, the posterior parietal cortex, or the corpus callosum.


The frontal lobes are important for voluntary movement, expressive language, and managing higher-level executive functions.

 

Lesions to the premotor frontal cortex of both hemispheres, the left (lower and posterior) inferior parietal lobe, and the brainbar (corpus callosum) may cause apraxia. Apraxia is more common with damage to the left hemisphere than to the right hemisphere and often coexists with aphasia.

 

  • Ideomotor apraxia usually results from lesions in the left hemisphere, both frontal lesions (in the forehead) and posterior parietal lesions (in the posterior parietal lobe).

 

  • Bilateral lesions in the left hemisphere may also result in ideomotor apraxia.

 

  • Unilateral ideomotor apraxia on the left may result from lesions in the corpus callosum or the right premotor area.

 

  • Lesions in the prefrontal and premotor cortex and the left inferior parietal lobe may result in ideational apraxia.

 

 

 

Apraxia after brain injury and forms of dementia

Apraxia may occur due to brain damage caused by acquired brain injury or various forms of dementia. A common apraxia in people with dementia is ideational and ideomotor apraxia.

 

In Alzheimer's disease, different forms of apraxia may occur at all stages of the disease: ideational, ideomotor, constructional apraxia (in an early stage) and buccofacial gait apraxia (in a late stage).

 

Frontotemporal dementia exhibited buccofacial and gait apraxia late in the disease.
Cortical-basal degeneration exhibited limb kinetic apraxia.
Lewy body dementia exhibited more agnosia and less apraxia. Agnosia is the inability to recognize things (images, sounds, smells) perceived through the senses (eyes, ears, nose, mouth, touch).

 

Apraxia with aphasia

Apraxia often co-occurs with aphasia. Those who only have aphasia are able to lead a relatively normal life, but in case significant apraxia is also present, the person is almost always dependent.

 

Tips when a loved one has difficulty performing a task

  • It may help the person with apraxia to break down the task into smaller steps or to simplify the tasks.

     

  • It may be helpful to provide concrete instructions while performing a task. A person may benefit from having everything prepared in the correct order or using pictograms as a step-by-step plan. A clear structure for (difficult) tasks is important. For example, by thinking about them in advance and dividing the task into steps.

     

  • It is important to be patient and understanding and to give the person time. It is also important to connect with the established (life) habits of the person with apraxia.

     

  • Establish a fixed pattern or rhythm when organizing the day and week. A daily activity schedule can help structure the day. This also reduces the number of choices to make.

     

  • Assign the person to tasks he or she can still perform.

 

Support methods and examples


Asking to perform an activity:
When your partner/loved one is sitting at the sink to wash, ask if they would like to wash their upper body. This helps them get started.


Asking questions about the activity:
If your partner/loved one doesn't show any signs of wanting to begin, ask: "What do you need?"


Clarifying the question through gestures:
Making a washing motion.


Starting the activity together:
Turn on the faucet together by taking your partner/loved one's hand and guiding it to the faucet.


Showing pictures of the activity:
If you are making coffee together, first look at the pictures of making coffee.


Preparing the necessary items, if necessary in the correct order:
Prepare the coffee, the filter, or coffee cups from specific coffee makers.


Pointing out the items:
When dressing, you can point out the items of clothing.

 

State what needs to be done next:

When putting on a blouse, say: take the blouse, unbutton the buttons, put your arm in the sleeve, etc.

 

Let each other know how the activity went:

Discuss both the steps that went well and those that caused problems.

 

More information

Information on apraxia can be found on the following websites:

https://medlineplus.gov/ency/article/007472.htm

https://www.ncbi.nlm.nih.gov/books/NBK585110/

https://www.mayoclinic.org/diseases-conditions/childhood-apraxia-of-speech/symptoms-causes/syc-20352045

https://www.asha.org/public/speech/disorders/apraxia-of-speech-in-adults

https://www.otdude.com/students/apraxia-made-easy-ideational-ideomotor-dressing-constructional-more-occupational-therapy/

 

Resources

Hugo Liepman Heilman en Rothi, model van apraxie, ergotherapie richtlijn voor diagnostiek en behandeling van apraxie bij CVA-clienten,neuropsychologische behandeling.nl, hersenstichting nederland, slotervaartziekenhuis behandeling na een beroerte, btsg bibliotheek innovatie inouderenzorg, St Lievensziekenhuis neurologie, Zorgtraject OVL, Logopedie.nl, Apraxie.org, Slingeland ziekenhuis ergotherape, M.T. Banich (2004).Cognitive Neuroscience and Neuropsychology. 2e editie. Houghton Mifflin Cie en J.B.M. Kuks, J.W. Snoek, H.J.G.H. Oosterhuis. Klinische Neurologie15e druk, Bohn Stafleu Van Loghum, Houten, 2003, ISBN 90-313-4028-6 National Aphasia Association, NIH/National Institute of NeurologicalDisorders and Stroke, Adams, Principles of neurology Nadeau, Stephen E. (2007).

Gait Apraxia: Further Clues to Localization.https://doi.org/10.1159/000104714

https://www.ntvg.nl/artikelen/loopstoornissen-door-neurologische-aandoeningen

Chandra, S. R., Issac, T. G., Abbas, M.M. (2015). Apraxias in Neurodegenerative Dementias. Indian Journal of Psychological Medicine, Jan.-March,37(1): 42-47.

Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4341309/.

Accessed on August 22, 2016 https://medlineplus.gov/ency/article/007472.htm

Hersenletsel-uitleg.nl https://www.hersenletsel-uitleg.nl/gevolgen/lichamelijke-gevolgen/apraxie-1