Makindo Medical Notes

📖 About

• 🧠 Apraxia is a disorder of learned, voluntary actions resulting from neurological impairment — often overlooked after stroke unless specifically assessed.
• 📊 Seen in ~1/3 of those in rehabilitation centres and nursing homes following left hemisphere stroke.

📝 Introduction

• 👩‍⚕️ Motor apraxia after left hemispheric (dominant) stroke → difficulty with daily activities (e.g. making a hot drink).
• 🥄 Patients may misuse objects (e.g. spoon, toothbrush, razor) or fail to select the correct one at the right time.
• 📉 Evidence for specific therapies is limited, but recognising apraxia is crucial for supporting recovery, independence, and function.

📌 Definitions

• ❌ Apraxia = inability to correctly carry out purposeful, skilled actions, not explained by weakness, sensory loss, involuntary movements, or cognitive decline.
• 🧩 It reflects impaired storage/translation of motor representations in the brain → difficulty linking higher-level action concepts to lower-level muscle activation.
• 📚 Liepmann’s model: left parietal lobe stores a “space-time form picture” of movement → relayed to frontal engrams → motor cortex → corticospinal tracts. - For right limb: remains in left hemisphere. - For left limb: info must cross via corpus callosum to right motor areas.

🧭 Anatomical Basis

• 🧠 Localised to dominant (left) hemisphere.
• 🏷️ Key region: supramarginal gyrus & deep white matter of left parietal lobe.
• 💬 May co-exist with Wernicke’s aphasia, but also occurs independently.

🔎 Types

• 💡 Ideational apraxia: loss of the “idea” of movement; impaired conceptual organisation of actions (e.g. cannot pantomime tool use).
• ⚙️ Ideomotor apraxia: idea intact, but poor translation into motor execution → errors in timing, sequencing, force. Classic error = “body-part-as-object” (e.g. using finger as toothbrush).

🗂️ Subtypes of Apraxia

🧪 Clinical: Screening Tasks

• 🎭 Pantomime: “Show me how you brush your teeth / hammer a nail / use scissors.”
• ✋ Gestures: Salute, wave goodbye, hitch a lift.
• 👄 Buccofacial: Lick lips, blow out a match, drink through a straw.
• 🧩 Functional: Make a cold drink, put paper in an envelope, file punched sheets.

⚙️ Ideomotor Apraxia Errors

• 📍 Spatial orientation errors
• ⏱️ Timing/temporal errors
• 💪 Force errors
• ✋ Poor distal differentiation
• 🤲 “Body-part-as-object” substitutions

💡 Ideational Apraxia Errors

• 🔀 Wrong object chosen
• 📉 Sequencing errors (omissions, blends)
• ⏱️ Action overshoots or remains incomplete
• 🔁 Perseveration

🩺 Management

• 👩‍⚕️ Therapy-led assessment → targeted strategies for initiation, execution & control.
• 🎯 Use of instructions, cues, errorless learning, and task-based practice.
• 🤝 Multidisciplinary input essential for optimising independence.

📚 References

• Cassidy A. Clinical assessment of apraxia. Practical Neurology 2016
• Apraxia: A review. Progress in Brain Research
• Apraxia following stroke – Jackson (Stroke Association)
• Cochrane: Interventions for motor apraxia after stroke