The different types of limb apraxia errors made by patients with left vs. right hemisphere damage

Localizing apraxia in corticobasal syndrome: a morphometric MRI study

Apraxia localization has relied on voxel-based, lesion-symptom mapping studies in left hemisphere stroke patients. Studies on the neural substrates of different manifestations of apraxia in neurodegenerative disorders are scarce. The primary aim of this study was to look into the neural substrates of different manifestations of apraxia in a cohort of corticobasal syndrome patients (CBS) by use of cortical thickness. Twenty-six CBS patients were included in this cross-sectional study. The Goldenberg apraxia test (GAT) was applied. 3D-T1-weighted images were analyzed via the automated recon-all Freesurfer version 6.0 pipeline. Vertex-based multivariate General Linear Model analysis was applied to correlate GAT scores with cortical thickness. Deficits in imitation of meaningless gestures correlated with bilateral superior parietal atrophy, extending to the angular and supramarginal gyri, particularly on the left. Finger imitation relied predominantly on superior parietal lobes, whereas the left angular and supramarginal gyri, in addition to superior parietal lobes, were critical for hand imitation. The widespread bilateral clusters of atrophy in CBS related to apraxia indicate different pathophysiological mechanisms mediating praxis in neurodegenerative disorders compared to vascular lesions, with implications both for our understanding of praxis and for the rehabilitation approaches of patients with apraxia.

Production of co-speech gestures in the right hemisphere: Evidence from individuals with complete or anterior callosotomy

INTRODUCTION

A right-hand preference for co-speech gestures in right-handed neurotypical individuals as well as the co-occurrence of speech and gesture has induced neuropsychological research to primarily target the left hemisphere when investigating co-speech gesture production. However, the substantial number of spontaneous left-hand gestures in right-handed individuals has, thus far, been unexplained. Recent studies in individuals with complete callosotomy and exclusive left hemisphere speech production show a reliable left-hand preference for co-speech gestures, indicating a right hemispheric generation. However, the findings raise the issue if the separate right hemisphere is able to also generate representational gestures. The present study challenges the proposition of a specific right hemispheric contribution to gesture production by differentiating gesture types including representational ones in individuals with complete callosotomy and by including individuals with anterior callosotomy in whom neural reorganization is less extensive.

METHODS

Three right-handed individuals with complete commissurotomy (A.A., N.G., G.C.) and three right-handed individuals with anterior callosotomy (C.E., S.R., L. D), all with left hemisphere language dominance, and a matched right-handed neurotypical control group (n = 10) were examined in an experimental setting, including re-narration of a nonverbal animated cartoon and responding to intelligence questions. The participants' video-taped hand movement behavior was analyzed by two independent certified raters with the NEUROGES-ELAN system for nonverbal behavior and gesture. Unimanual right-hand and left-hand gestures were classified into eight gesture types.

RESULTS

The individuals with complete and anterior callosotomy performed unimanual co-speech gestures with the left as well as the right hand, with no significant preference of one hand for gestures overall. Concerning the specific gesture types, the group with complete callosotomy showed a significant right-hand preference for pantomime gestures, which also applied to the callosotomy total group. The group with anterior callosotomy displayed a significant left-hand preference for form presentation gestures. As a trend, the callosotomy total group differed from the neurotypical group as they performed more left-hand egocentric deictic and left-hand form presentation gestures.

DISCUSSION

The present study replicates the finding of a substantial left-hand use for unimanual co-speech gestures in individuals with complete callosotomy. The proposition of a right hemispheric contribution to gesture production independent from left hemispheric language production is corroborated by the finding that individuals with anterior callosotomy show a similar pattern of hand use for gestures. Representational gestures were displayed with either hand, suggesting that in particular right hemispheric spatial cognition can be directly expressed in gesture. The significant right-hand preference for pantomime gesture was outstanding and compatible with the established left hemispheric specialization for tool use praxis. The findings shed a new light on the left-hand gestures in neurotypical individuals, suggesting that these can be generated in the right hemisphere.

Ipsilesional arm training in severe stroke to improve functional independence (IPSI): phase II protocol

BACKGROUND

We previously characterized hemisphere-specific motor control deficits in the ipsilesional, less-impaired arm of unilaterally lesioned stroke survivors. Our preliminary data indicate these deficits are substantial and functionally limiting in patients with severe paresis.

METHODS

We have designed an intervention ("IPSI") to remediate the hemisphere-specific deficits in the ipsilesional arm, using a virtual-reality platform, followed by manipulation training with a variety of real objects, designed to facilitate generalization and transfer to functional behaviors encountered in the natural environment. This is a 2-site (primary site - Penn State College of Medicine, secondary site - University of Southern California), two-group randomized intervention with an experimental group, which receives unilateral training of the ipsilesional arm throughout 3 one-hour sessions per week for 5 weeks, through our Virtual Reality and Manipulation Training (VRMT) protocol. Our control group receives a conventional intervention on the contralesional arm, 3 one-hour sessions per week for 5 weeks, guided by recently released practice guidelines for upper limb rehabilitation in adult stroke. The study aims to include a total of 120 stroke survivors (60 per group) whose stroke was in the territory of the middle cerebral artery (MCA) resulting in severe upper-extremity motor impairments. Outcome measures (Primary: Jebsen-Taylor Hand Function Test, Fugl-Meyer Assessment, Abilhand, Barthel Index) are assessed at five evaluation points: Baseline 1, Baseline 2, immediate post-intervention (primary endpoint), and 3-weeks (short-term retention) and 6-months post-intervention (long-term retention). We hypothesize that both groups will improve performance of the targeted arm, but that the ipsilesional arm remediation group will show greater improvements in functional independence.

DISCUSSION

The results of this study are expected to inform upper limb evaluation and treatment to consider ipsilesional arm function, as part of a comprehensive physical rehabilitation strategy that includes evaluation and remediation of both arms.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov (Registration ID: NCT03634397 ; date of registration: 08/16/2018).

Pantomime of tool use: looking beyond apraxia

Pantomime has a long tradition in clinical neuropsychology of apraxia. It has been much more used by researchers and clinicians to assess tool-use disorders than real tool use. Nevertheless, it remains incompletely understood and has given rise to controversies, such as the involvement of the left inferior parietal lobe or the nature of the underlying cognitive processes. The present article offers a comprehensive framework, with the aim of specifying the neural and cognitive bases of pantomime. To do so, we conducted a series of meta-analyses of brain-lesion, neuroimaging and behavioural studies about pantomime and other related tasks (i.e. real tool use, imitation of meaningless postures and semantic knowledge). The first key finding is that the area PF (Area PF complex) within the left inferior parietal lobe is crucially involved in both pantomime and real tool use as well as in the kinematics component of pantomime. The second key finding is the absence of a well-defined neural substrate for the posture component of pantomime (both grip errors and body-part-as-tool responses). The third key finding is the role played by the intraparietal sulcus in both pantomime and imitation of meaningless postures. The fourth key finding is that the left angular gyrus seems to be critical in the production of motor actions directed towards the body. The fifth key finding is that performance on pantomime is strongly correlated with the severity of semantic deficits. Taken together, these findings invite us to offer a neurocognitive model of pantomime, which provides an integrated alternative to the two hypotheses that dominate the field: The gesture-engram hypothesis and the communicative hypothesis. More specifically, this model assumes that technical reasoning (notably the left area PF), the motor-control system (notably the intraparietal sulcus), body structural description (notably the left angular gyrus), semantic knowledge (notably the polar temporal lobes) and potentially theory of mind (notably the middle prefrontal cortex) work in concert to produce pantomime. The original features of this model open new avenues for understanding the neurocognitive bases of pantomime, emphasizing that pantomime is a communicative task that nevertheless originates in specific tool-use (not motor-related) cognitive processes.

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Mapping the human praxis network: an investigation of white matter disconnection in limb apraxia of gesture production

Left hemispheric cerebral stroke can cause apraxia, a motor-cognitive disorder characterised by deficits of higher-order motor skills such as the failure to accurately produce meaningful gestures. This disorder provides unique insights into the anatomical and cognitive architecture of the human praxis system. The present study aimed to map the structural brain network that is damaged in apraxia. We assessed the ability to perform meaningful gestures with the hand in 101 patients with chronic left hemisphere stroke. Structural white matter fibre damage was directly assessed by diffusion tensor imaging and fractional anisotropy mapping. We used multivariate topographical inference on tract-based fractional anisotropy topographies to identify white matter disconnection associated with apraxia. We found relevant pathological white matter alterations in a densely connected fronto-temporo-parietal network of short and long association fibres. Hence, the findings suggest that heterogeneous topographical results in previous lesion mapping studies might not only result from differences in study design, but also from the general methodological limitations of univariate topographical mapping in uncovering the structural praxis network. A striking role of middle and superior temporal lobe disconnection, including temporo-temporal short association fibres, was found, suggesting strong involvement of the temporal lobe in the praxis network. Further, the results stressed the importance of subcortical disconnections for the emergence of apractic symptoms. Our study provides a fine-grain view into the structural connectivity of the human praxis network and suggests a potential value of disconnection measures in the clinical prediction of behavioural post-stroke outcome.

Gesture errors in left and right hemisphere damaged patients: A behavioural and anatomical study

OBJECTIVE

Erroneous gesture execution is at the core of motor cognition difficulties in apraxia. While a taxonomy of errors may provide important information about the nature of the disorder, classifications are currently often inconsistent. This study aims to identify the error categories which distinguish apraxic from non-apraxic patients.

METHOD

Two groups of mixed (bucco-facial and limb) and bucco-facial apraxic patients suffering from stroke were compared to non-apraxic, left and right hemisphere damaged patients in tasks tapping the ability to perform limb and bucco-facial actions. The errors were analysed and classified into 6 categories relating to content, configuration or movement, spatial or temporal parameters and unrecognisable actions. Furthermore, an anatomical investigation (VLMS) was conducted in the whole group of left hemisphere damaged patients to investigate potential correlates of the various error categories.

RESULTS

Although all the above error typologies may be observed, the most indicative of mixed apraxia is the content-related one in all the typologies of actions (transitive and intransitive), and configuration errors in transitive ones. Configuration and content errors in mouth actions seem to be typical of bucco-facial apraxia. Spatial errors are similar in both apraxic and right brain damaged, non-apraxic patients. A lesion mapping analysis of left-brain damaged patients demonstrates that all but the spatial error category are associated with the fronto-parietal network. Moreover, content errors are also associated with fronto-insular lesions and movement errors with damage to the paracentral territory (precentral and postcentral gyri). Spatial errors are often associated to ventral frontal lesions.

CONCLUSIONS

Bucco-facial and mixed apraxic patients make different types of errors in different types of actions. Not all errors are equally indicative of apraxia. In addition, the various error categories are associated with at least partially different neural correlates.

Motor Deficits in the Ipsilesional Arm of Severely Paretic Stroke Survivors Correlate With Functional Independence in Left, but Not Right Hemisphere Damage

Chronic stroke survivors with severe contralesional arm paresis face numerous challenges to performing activities of daily living, which largely rely on the use of the less-affected ipsilesional arm. While use of the ipsilesional arm is often encouraged as a compensatory strategy in rehabilitation, substantial evidence indicates that motor control deficits in this arm can be functionally limiting, suggesting a role for remediation of this arm. Previous research has indicated that the nature of ipsilesional motor control deficits vary with hemisphere of damage and with the severity of contralesional paresis. Thus, in order to design rehabilitation that accounts for these deficits in promoting function, it is critical to understand the relative contributions of both ipsilesional and contralesional arm motor deficits to functional independence in stroke survivors with severe contralesional paresis. We now examine motor deficits in each arm of severely paretic chronic stroke survivors with unilateral damage (10 left-, 10 right-hemisphere damaged individuals) to determine whether hemisphere-dependent deficits are correlated with functional independence. Clinical evaluation of contralesional, paretic arm impairment was conducted with the upper extremity portion of the Fugl-Meyer assessment (UEFM). Ipsilesional arm motor performance was evaluated using the Jebsen-Taylor Hand Function Test (JTHFT), grip strength, and ipsilesional high-resolution kinematic analysis during a visually targeted reaching task. Functional independence was measured with the Barthel Index. Functional independence was better correlated with ipsilesional than contralesional arm motor performance in the left hemisphere damage group [JTHFT: [r ₍₁₀₎ = -0.73, p = 0.017]; grip strength: [r ₍₁₀₎ = 0.64, p = 0.047]], and by contralesional arm impairment in the right hemisphere damage group [UEFM: [r ₍₁₀₎ = 0.66, p = 0.040]]. Ipsilesional arm kinematics were correlated with functional independence in the left hemisphere damage group only. Examination of hemisphere-dependent motor correlates of functional independence showed that ipsilesional arm deficits were important in determining functional outcomes in individuals with left hemisphere damage only, suggesting that functional independence in right hemisphere damaged participants was affected by other factors.

Anosognosia for limb and bucco-facial apraxia as inferred from the recognition of gestural errors

Anosognosia is a multifaceted syndrome characterized by a lack of awareness of motor, cognitive, or emotional deficits. While most studies have focused on basic motor disorders such as hemiplegia, only recently, the issue of whether anosognosia also concerns higher-order motor disorders like apraxia has been addressed. Here, we explore the existence of a specific form of anosognosia for apraxia in forty patients with uni-hemispheric vascular lesions. The patients were requested to imitate actions involving upper limb or bucco-facial body parts and then judge their performance. Successively, they were also asked to observe video recordings of the same actions performed by themselves or by other patients and judge the accuracy of the displayed actions. The comparison of participants versus examiner judgement and between error recognition of others' versus self's actions was considered as an index of awareness deficit for the online and offline conditions, respectively. Evidence was found that awareness deficits occurred both immediately after action execution (online anosognosia) and in the video recording task (offline anosognosia). Moreover, bucco-facial and limb apraxic patients were specifically unaware of their errors in bucco-facial and limb actions, respectively, indicating for the first time a topographical organization of the syndrome. Our approach allowed us to distinguish awareness deficits from more general disorders in error recognition; indeed, anosognosic patients were able to identify errors when the same action was executed by another patient but not when the video showed their own actions. Finally, we provide evidence that anosognosia for apraxia might be associated with frontal cortical and subcortical networks.

Functional Deficits in the Less-Impaired Arm of Stroke Survivors Depend on Hemisphere of Damage and Extent of Paretic Arm Impairment

Background. Previous research has detailed the hemisphere dependence and specific kinematic deficits observed for the less-affected arm of patients with unilateral stroke. Objective. We now examine whether functional motor deficits in the less-affected arm, measured by standardized clinical measures of motor function, also depend on the hemisphere that was damaged and on the severity of contralesional impairment. Methods. We recruited 48 left-hemisphere-damaged (LHD) participants, 62 right-hemisphere-damaged participants, and 54 age-matched control participants. Measures of motor function included the following: (1) Jebsen-Taylor Hand Function Test (JHFT), (2) Grooved Pegboard Test (GPT), and (3) grip strength. We measured the extent of contralesional arm impairment with the upper-extremity component of the Fugl-Meyer (UEFM) assessment of motor impairment. Results. Ipsilesional limb functional performance deficits (JHFT) varied with both the damaged hemisphere and severity of contralesional arm impairment, with the most severe deficits expressed in LHD participants with severe contralesional impairment (UEFM). GPT and grip strength varied with severity of contralesional impairment but not with hemisphere. Conclusions. Stroke survivors with the most severe paretic arm impairment, who must rely on their ipsilesional arm for performing daily activities, have the greatest motor deficit in the less-affected arm. We recommend remediation of this arm to improve functional independence in this group of stroke patients.

Differences between the Influence of Observing One's Own Movements and Those of Others in Patients with Stroke

We aimed to investigate differences between the influence of observing one's own actions and those of others in patients with stroke with hemiplegia. Thirty-four patients with stroke who had experienced a right or left hemispheric lesion (RHL: n = 17; LHL: n = 17) participated in this study. Participants viewed video clips (0.5× speed) of their own stepping movements (SO) as well as those of others (OO). After viewing the video clips, participants were asked to evaluate the vividness of the mental image of the observed stepping movement using a five-point scale, in accordance with that utilized in the Kinesthetic and Visual Imagery Questionnaire (KVIQ). We also examined changes in imagery and execution times following action observation. When all patients were considered, there were no significant differences between SO and OO conditions. However, in the RHL subgroup, KVIQ kinesthetic subscore and changes in imagery and execution times were greater in the OO condition than in the SO condition. In the LHL subgroup, changes in imagery times were greater in the SO condition than in the OO condition. These findings indicated that viewing the movements of others led to more vivid imagery and alteration in performance in patients with right-sided stroke, when compared to viewing one's own movements. Therefore, the present study suggests that clinicians should consider the side of the damaged hemisphere when implementing action observation therapy for patients with stroke.

Bilateral functional connectivity at rest predicts apraxic symptoms after left hemisphere stroke

Increasing evidence indicates that focal lesions following stroke cause alterations in connectivity among functional brain networks. Functional connectivity between hemispheres has been shown to be particularly critical for predicting stroke-related behavioral deficits and recovery of motor function and attention. Much less is known, however, about the relevance of interhemispheric functional connectivity for cognitive abilities like praxis that rely on strongly lateralized brain networks. In the current study, we examine correlations between symptoms of apraxia-a disorder of skilled action that cannot be attributed to lower-level sensory or motor impairments-and spontaneous, resting brain activity in functional MRI in chronic left hemisphere stroke patients and neurologically-intact control participants. Using a data-driven approach, we identified 32 regions-of-interest in which pairwise functional connectivity correlated with two distinct measures of apraxia, even when controlling for age, head motion, lesion volume, and other artifacts: overall ability to pantomime the typical use of a tool, and disproportionate difficulty pantomiming the use of tools associated with different, competing use and grasp-to-move actions (e.g., setting a kitchen timer versus picking it up). Better performance on both measures correlated with stronger interhemispheric functional connectivity. Relevant regions in the right hemisphere were often homologous to left hemisphere areas associated with tool use and action. Additionally, relative to overall pantomime accuracy, disproportionate difficulty pantomiming the use of tools associated with competing use and grasp actions was associated with weakened functional connectivity among a more strongly left-lateralized and peri-Sylvian set of brain regions. Finally, patient performance on both measures of apraxia was best predicted by a model that incorporated information about lesion location and functional connectivity, and functional connectivity continued to explain unique variance in behavior even after accounting for lesion loci. These results indicate that interhemispheric functional connectivity is relevant even for a strongly lateralized cognitive ability like praxis and emphasize the importance of the right hemisphere in skilled action.

Motor Adaptation Deficits in Ideomotor Apraxia

OBJECTIVES

The cardinal motor deficits seen in ideomotor limb apraxia are thought to arise from damage to internal representations for actions developed through learning and experience. However, whether apraxic patients learn to develop new representations with training is not well understood. We studied the capacity of apraxic patients for motor adaptation, a process associated with the development of a new internal representation of the relationship between movements and their sensory effects.

METHODS

Thirteen healthy adults and 23 patients with left hemisphere stroke (12 apraxic, 11 nonapraxic) adapted to a 30-degree visuomotor rotation.

RESULTS

While healthy and nonapraxic participants successfully adapted, apraxics did not. Rather, they showed a rapid decrease in error early but no further improvement thereafter, suggesting a deficit in the slow, but not the fast component of a dual-process model of adaptation. The magnitude of this late learning deficit was predicted by the degree of apraxia, and was correlated with the volume of damage in parietal cortex. Apraxics also demonstrated an initial after-effect similar to the other groups likely reflecting the early learning, but this after-effect was not sustained and performance returned to baseline levels more rapidly, consistent with a disrupted slow learning process.

CONCLUSIONS

These findings suggest that the early phase of learning may be intact in apraxia, but this leads to the development of a fragile representation that is rapidly forgotten. The association between this deficit and left parietal damage points to a key role for this region in learning to form stable internal representations. (JINS, 2017, 23, 139-149).

Rehabilitation in Severe Ideomotor Apraxia Using Sensory Stimulation Strategies: A Single-Case Experimental Design Study

This study was designed to evaluate the treatment of a young head-injured woman with ideomotor apraxia. An ABA (baseline, intervention, baseline) single-case experimental design was employed to evaluate the impact of sensory stimulation on motor performance, using a range of measures including a simple timed task and active finger and hand movements measured by goniometry.

A key finding was the extent of variance in performance day by day in both the baseline and intervention phases, although a reduction in that variability was achieved in the intervention phase of the study. Improvements were noted in motor performance across all the measures in the intervention phase of the study, although such improvements could not be attributed to sensory stimulation procedures alone. Improvements in motor performance were found immediately following sensory stimulation procedures, but no carryover was noted from one day to the next. This study suggests that practice in motor performance could enhance specific actions in people with ideomotor apraxia.

Intervention Effectiveness: Evidence from a Case Study of Ideomotor and Ideational Apraxia

This paper considers the characteristics of apraxia and presents a case study which explores the effectiveness of tactile and kinaesthetic stimulation as an intervention strategy, in addition to visual and verbal mediation input, in the rehabilitation of a man with ideomotor and ideational apraxia following a head injury. Using an ABA design, quantitative measures were used to monitor change in motor performance. The results indicated some significant differences in measured performances between baseline and intervention phases and provided limited evidence of the effectiveness of additional sensory input. The implications for occupational therapy are discussed as are the limitations of the study.

Dyspraxia: Guidelines for Intervention

‘Clinicians wishing to base their assessment on sound, empirically and theoretically based principles are soon daunted by the diverse, poorly integrated and sometimes contradictory nature of apraxia research’ (Tate and McDonald 1995). This paper attempts to identify some of the common ground in research and, by using this along with clinical experience, identifies guidelines for occupational therapists working with adults who have acquired dyspraxia.

Much of the neuropsychological literature refers to the term ‘apraxia’; however, many occupational therapists use the term ‘dyspraxia’ and it is therefore the term of choice in this paper. Literature searches should make use of both terms.

Dysfunction of the Human Mirror Neuron System in Ideomotor Apraxia: Evidence from Mu Suppression

Stroke patients with ideomotor apraxia (IMA) have difficulties controlling voluntary motor actions, as clearly seen when asked to imitate simple gestures performed by the examiner. Despite extensive research, the neurophysiological mechanisms underlying failure to imitate gestures in IMA remain controversial. The aim of the current study was to explore the relationship between imitation failure in IMA and mirror neuron system (MNS) functioning. Mirror neurons were found to play a crucial role in movement imitation and in imitation-based motor learning. Their recruitment during movement observation and execution is signaled in EEG recordings by suppression of the lower (8-10 Hz) mu range. We examined the modulation of EEG in this range in stroke patients with left (n = 21) and right (n = 15) hemisphere damage during observation of video clips showing different manual movements. IMA severity was assessed by the DeRenzi standardized diagnostic test. Results showed that failure to imitate observed manual movements correlated with diminished mu suppression in patients with damage to the right inferior parietal lobule and in patients with damage to the right inferior frontal gyrus pars opercularis-areas where major components of the human MNS are assumed to reside. Voxel-based lesion symptom mapping revealed a significant impact on imitation capacity for the left inferior and superior parietal lobules and the left post central gyrus. Both left and right hemisphere damages were associated with imitation failure typical of IMA, yet a clear demonstration of relationship to the MNS was obtained only in the right hemisphere damage group. Suppression of the 8-10 Hz range was stronger in central compared with occipital sites, pointing to a dominant implication of mu rather than alpha rhythms. However, the suppression correlated with De Renzi's apraxia test scores not only in central but also in occipital sites, suggesting a multifactorial mechanism for IMA, with a possible impact for deranged visual attention (alpha suppression) beyond the effect of MNS damage (mu suppression).

The Representation of Objects in Apraxia: From Action Execution to Error Awareness

Apraxia is a well-known syndrome characterized by the sufferer's inability to perform routine gestures. In an attempt to understand the syndrome better, various different theories have been developed and a number of classifications of different subtypes have been proposed. In this article review, we will address these theories with a specific focus on how the use of objects helps us to better understand upper limb apraxia. With this aim, we will consider transitive vs. intransitive action dissociation as well as less frequent types of apraxia involving objects, i.e., constructive apraxia and magnetic apraxia. Pantomime and the imitation of objects in use are also considered with a view to dissociating the various different components involved in upper limb apraxia. Finally, we discuss the evidence relating to action recognition and awareness of errors in the execution of actions. Various different components concerning the use of objects emerge from our analysis and the results show that knowledge of an object and sensory-motor representations are supported by other functions such as spatial and body representations, executive functions and monitoring systems.

A topographical organization for action representation in the human brain

How the human brain represents distinct motor features into a unique finalized action still remains undefined. Previous models proposed the distinct features of a motor act to be hierarchically organized in separated, but functionally interconnected, cortical areas. Here, we hypothesized that distinct patterns across a wide expanse of cortex may actually subserve a topographically organized coding of different categories of actions that represents, at a higher cognitive level and independently from the distinct motor features, the action and its final aim as a whole. Using functional magnetic resonance imaging and pattern classification approaches on the neural responses of 14 right‐handed individuals passively watching short movies of hand‐performed tool‐mediated, transitive, and meaningful intransitive actions, we were able to discriminate with a high accuracy and characterize the category‐specific response patterns. Actions are distinctively coded in distributed and overlapping neural responses within an action‐selective network, comprising frontal, parietal, lateral occipital and ventrotemporal regions. This functional organization, that we named action topography, subserves a higher‐level and more abstract representation of finalized actions and has the capacity to provide unique representations for multiple categories of actions. Hum Brain Mapp 36:3832–3844, 2015. © 2015 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc.

Differences in cortical activation between observing one's own gait and the gait of others: a functional near-infrared spectroscopy study

Using functional near-infrared spectroscopy, we investigated cortical activation while participants observed their own gait and the gait of others. Further, we compared the vividness of motor imagery induced by observing one's own and the gait of others. Participants were instructed to perform a gait observation task. The task had two conditions: observing video clips of one's own walking and observing video clips of other individuals walking. After observing the videos, the participants were asked to evaluate the vividness of the mental image of the observed gait on a visual analog scale. When observing one's own gait, the right dorsal premotor cortex and the superior parietal lobule were activated, whereas when observing the gait of others, the left inferior parietal lobule was activated. Observing one's own gait induced imagery that was significantly more vivid than that induced when viewing the gait of others. We suggest that observing one's own gait generates a representation of one's own body in the brain and induces more vivid gait imagery.

Abnormal dynamics of activation of object use information in apraxia: evidence from eyetracking

Action representations associated with object use may be incidentally activated during visual object processing, and the time course of such activations may be influenced by lexical-semantic context (e.g., Lee, Middleton, Mirman, Kalénine, & Buxbaum (2012). Journal of Experimental Psychology: Human Perception and Performance, 39(1), 257-270). In this study we used the "visual world" eye-tracking paradigm to examine whether a deficit in producing skilled object-use actions (apraxia) is associated with abnormalities in incidental activation of action information, and assessed the neuroanatomical substrates of any such deficits. Twenty left hemisphere stroke patients, ten of whom were apraxic, performed a task requiring identification of a named object in a visual display containing manipulation-related and unrelated distractor objects. Manipulation relationships among objects were not relevant to the identification task. Objects were cued with neutral ("S/he saw the…."), or action-relevant ("S/he used the….") sentences. Non-apraxic participants looked at use-related non-target objects significantly more than at unrelated non-target objects when cued both by neutral and action-relevant sentences, indicating that action information is incidentally activated. In contrast, apraxic participants showed delayed activation of manipulation-based action information during object identification when cued by neutral sentences. The magnitude of delayed activation in the neutral sentence condition was reliably predicted by lower scores on a test of gesture production to viewed objects, as well as by lesion loci in the inferior parietal and posterior temporal lobes. However, when cued by a sentence containing an action verb, apraxic participants showed fixation patterns that were statistically indistinguishable from non-apraxic controls. In support of grounded theories of cognition, these results suggest that apraxia and temporal-parietal lesions may be associated with abnormalities in incidental activation of action information from objects. Further, they suggest that the previously-observed facilitative role of action verbs in the retrieval of object-related action information extends to participants with apraxia.

Frontal and parietal cortex contributions to action modification

Successful achievement of task goals depends critically on the ability to adjust ongoing actions in response to environmental changes. The neural substrates underlying action modification have been a topic of great controversy: both, posterior parietal cortex and frontal regions, particularly prefrontal cortex have been previously identified as crucial in this regard, with most studies arguing in favor of one or the other. We aimed to address this controversy and understand whether frontal and parietal regions might play distinct roles during action modification. We tested ipsilesional arm performance of 27 stroke patients with focal lesions to frontal or parietal regions of the left or right cerebral hemisphere, and left or right arm performance of 18 healthy subjects on the classic double-step task in which a target is unpredictably displaced to a new location, requiring modification of the ongoing action. Only right hemisphere frontal lesions adversely impacted the timing of initiation of the modified response, while only left hemisphere parietal lesions impaired the accuracy of the modified action. Patients with right frontal lesions tended to complete the ongoing action to the initially displayed baseline target and initiated the new movement after a significant delay. In contrast, patients with left parietal damage did not accurately reach the new target location, but compared to the other groups, initiated the new action during an earlier phase of motion, before their baseline action was complete. Our findings thus suggest distinct, hemisphere specific contributions of frontal and parietal regions to action modification, and bring together, for the first time, disparate sets of prior findings about its underlying neural substrates.

Contralesional motor deficits after unilateral stroke reflect hemisphere-specific control mechanisms

We have proposed a model of motor lateralization, in which the left and right hemispheres are specialized for different aspects of motor control: the left hemisphere for predicting and accounting for limb dynamics and the right hemisphere for stabilizing limb position through impedance control mechanisms. Our previous studies, demonstrating different motor deficits in the ipsilesional arm of stroke patients with left or right hemisphere damage, provided a critical test of our model. However, motor deficits after stroke are most prominent on the contralesional side. Post-stroke rehabilitation has also, naturally, focused on improving contralesional arm impairment and function. Understanding whether contralesional motor deficits differ depending on the hemisphere of damage is, therefore, of vital importance for assessing the impact of brain damage on function and also for designing rehabilitation interventions specific to laterality of damage. We, therefore, asked whether motor deficits in the contralesional arm of unilateral stroke patients reflect hemisphere-dependent control mechanisms. Because our model of lateralization predicts that contralesional deficits will differ depending on the hemisphere of damage, this study also served as an essential assessment of our model. Stroke patients with mild to moderate hemiparesis in either the left or right arm because of contralateral stroke and healthy control subjects performed targeted multi-joint reaching movements in different directions. As predicted, our results indicated a double dissociation; although left hemisphere damage was associated with greater errors in trajectory curvature and movement direction, errors in movement extent were greatest after right hemisphere damage. Thus, our results provide the first demonstration of hemisphere specific motor control deficits in the contralesional arm of stroke patients. Our results also suggest that it is critical to consider the differential deficits induced by right or left hemisphere lesions to enhance post-stroke rehabilitation interventions.

Hemispheric differences in the control of limb dynamics: a link between arm performance asymmetries and arm selection patterns

Human handedness has been described and measured from two perspectives: handedness inventories rate hand preferences, whereas other tests examine motor performance asymmetries. These two measurement approaches reflect a major controversy in a literature that defines handedness as either a preference or an asymmetry in sensorimotor processing. Over the past decade, our laboratory has developed a model of handedness based on lateralization of neural processes. This model attributes distinct control processes to each hemisphere, which in turn lead to observable interlimb sensorimotor performance asymmetries. We now hypothesize that arm preference, or choice, may depend on the interaction between sensorimotor performance asymmetries and the given task. The purpose of this study is to examine whether arm selection is linked to interlimb performance asymmetries during reaching. Right-handed subjects made choice and nonchoice reaches to each of eight targets (d = 3.5 cm) arranged radially (r = 13 cm) around a midline starting position. We displaced each cursor (one associated with each hand) 30 cm to the midline start circle to ensure that there were no hemispace-related geometric, mechanical, or perceptual biases to use either arm for the two midline targets. The three targets on each side of the midline received mostly reaches from the ipsilateral arm, a tendency previously described as a "hemispace bias." However, the midline targets, which were equidistant from each hand, received more dominant arm reaches. Dominant arm hand paths to these targets were straighter and more accurately directed. Inverse dynamics analyses revealed a more proficient dominant arm strategy that exploited intersegmental dynamics to a greater extent than did the nondominant arm. These findings suggest that sensorimotor asymmetries in dynamic coordination might explain limb choices. We discuss the implications of these results for theories of action selection, models of handedness, and models of neural lateralization.

Left parietal regions are critical for adaptive visuomotor control

The question addressed in this study is whether parietal brain circuits involved in adaptation to novel visuomotor conditions are lateralized. This information is critical for characterizing the neural mechanisms mediating adaptive behavior in humans, as well as for assessing the effects of unilateral brain damage on function. Moreover, previous research has been controversial in this regard. We compared visuomotor adaptation in 10 patients with focal, unilateral, left or right parietal lesions and healthy control participants. All subjects reached to each of eight targets over three experimental sessions: a baseline session, where the visually displayed and actual hand motion were matched; an adaptation session, where the visual feedback deviated from the actual movement direction by 30°; and an after-effect session, where visual feedback was again matched to hand motion. Adaptation was primarily quantified as a change in initial movement direction throughout the adaptation session and the presence of after-effects when the rotation was removed. Patients with right parietal damage demonstrated normal adaptation and large after-effects, which was comparable to the performance of healthy controls. In contrast, patients with left parietal damage showed a clear deficit in adaptation and showed no after-effects. Thus, our results show that left but not right parietal regions are critical for visuomotor adaptation. These findings are discussed in the context that left parietal regions are critical for the modification of stored representations of the relationship between movement commands and limb and environmental state, as is thought to occur during visuomotor adaptation.

Meal preparation abilities after left or right hemisphere stroke

OBJECTIVE

To examine meal preparation ability after right or left hemisphere damage (RHD, LHD) caused by stroke and whether cognitive (spatial abilities, aphasia, limb apraxia) and motor deficits are differentially associated with meal preparation.

DESIGN

Observational cohort design.

SETTING

Primary care Veterans Affair Medical Center and private medical center.

PARTICIPANTS

Volunteer right-handed sample of adults with LHD (n=30) or RHD (n=16) caused by stroke and healthy demographically matched adults (n=63) (N=109).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Total completion time, number and type of errors, and level of independence for a meal preparation task consisting of making a hot beverage and toast, eating part of the meal, and clean-up.

RESULTS

Both stroke groups took significantly more time to complete the meal preparation task than the control group. Total errors and level of independence were worse in the group with LHD than other groups, but individual errors did not significantly differ between the 2 stroke groups. While correlations should be interpreted cautiously, especially in the relatively small RHD group, poorer ipsilesional motor performance was associated with longer completion time in the RHD group, and poorer contralesional motor performance and greater aphasia were associated with less independence in the LHD group.

CONCLUSIONS

These findings demonstrate impaired meal preparation after LHD or RHD but greater impairment after LHD. Poorer meal preparation is associated with different cognitive and motor deficits in the 2 stroke groups.

Left parietal regions are critical for adaptive visuomotor control

The question addressed in this study is whether parietal brain circuits involved in adaptation to novel visuomotor conditions are lateralized. This information is critical for characterizing the neural mechanisms mediating adaptive behavior in humans, as well as for assessing the effects of unilateral brain damage on function. Moreover, previous research has been controversial in this regard. We compared visuomotor adaptation in 10 patients with focal, unilateral, left or right parietal lesions and healthy control participants. All subjects reached to each of eight targets over three experimental sessions: a baseline session, where the visually displayed and actual hand motion were matched; an adaptation session, where the visual feedback deviated from the actual movement direction by 30°; and an after-effect session, where visual feedback was again matched to hand motion. Adaptation was primarily quantified as a change in initial movement direction throughout the adaptation session and the presence of after-effects when the rotation was removed. Patients with right parietal damage demonstrated normal adaptation and large after-effects, which was comparable to the performance of healthy controls. In contrast, patients with left parietal damage showed a clear deficit in adaptation and showed no after-effects. Thus, our results show that left but not right parietal regions are critical for visuomotor adaptation. These findings are discussed in the context that left parietal regions are critical for the modification of stored representations of the relationship between movement commands and limb and environmental state, as is thought to occur during visuomotor adaptation.

Coordination deficits in ideomotor apraxia during visually targeted reaching reflect impaired visuomotor transformations

Ideomotor limb apraxia, commonly defined as a disorder of skilled, purposeful movement, is characterized by spatiotemporal deficits during a variety of actions. These deficits have been attributed to damage to, or impaired retrieval of, stored representations of learned actions, especially object-related movements. However, such deficits might also arise from impaired visuomotor transformation mechanisms that operate in parallel to or downstream from mechanisms for storage of action representations. These transformation processes convert extrinsic visual information into intrinsic neural commands appropriate for the desired motion. These processes are a key part of the movement planning process and performance errors due to inadequate transformations have been shown to increase with the dynamic complexity of the movement. This hypothesis predicts that apraxic patients should show planning deficits when reaching to visual targets, especially when the coordination and/or dynamic requirements of the task increase. Three groups (18 healthy controls, 9 non-apraxic and 9 apraxic left hemisphere damaged patients) performed reaching movements to visual targets that varied in the degree of interjoint coordination required. Relative to the other two groups, apraxic patients made larger initial direction errors and showed higher variability during their movements, especially when reaching to the target with the highest intersegmental coordination requirement. These problems were associated with poor coordination of shoulder and elbow torques early in the movement, consistent with poor movement planning. These findings suggest that the requirement to transform extrinsic visual information into intrinsic motor commands impedes the ability to accurately plan a visually targeted movement in ideomotor limb apraxia.

Utility of the Neuropsychological Assessment Battery in detecting cognitive impairment after unilateral stroke

This study evaluated the clinical utility of the Neuropsychological Assessment Battery (NAB) in a stroke sample by examining the NAB's ability to differentiate a chronic stroke group with radiologically confirmed unilateral damage (n = 42) and a demographically matched healthy control (HC) group (n = 36). The stroke group performed more poorly than the control group across NAB Total score and all five Domain scores. Receiver operator curves (ROC) were derived and area under the curve (AUC) showed moderate diagnostic effectiveness (AUC .70 to .90) for NAB Total score, all five Domain scores, a motor composite, and a Global Deficit Score (GDS) that has been shown to closely approximate clinical ratings of neuropsychological impairment. The NAB Total, GDS, and motor composite had comparable clinical utility, whereas the Attention and Executive domain scores demonstrated better classification utility compared with the Memory domain. Because 90.5% of our stroke sample had middle cerebral artery territory strokes, the comparison of motor and cognitive classification utility may be biased. However, follow-up analyses showed that the NAB accounted for additional variance even when motor composite was included in the model. Sensitivity, specificity, and odds ratios at various clinical cutoffs are provided. These results suggest that the NAB is a useful clinical tool for detection of cognitive deficits in individuals with chronic unilateral stroke, although lenient clinical cutoffs appear warranted to maximize sensitivity.

Critical brain regions for action recognition: lesion symptom mapping in left hemisphere stroke

A number of conflicting claims have been advanced regarding the role of the left inferior frontal gyrus, inferior parietal lobe and posterior middle temporal gyrus in action recognition, driven in part by an ongoing debate about the capacities of putative mirror systems that match observed and planned actions. We report data from 43 left hemisphere stroke patients in two action recognition tasks in which they heard and saw an action word ('hammering') and selected from two videoclips the one corresponding to the word. In the spatial recognition task, foils contained errors of body posture or movement amplitude/timing. In the semantic recognition task, foils were semantically related (sawing). Participants also performed a comprehension control task requiring matching of the same verbs to objects (hammer). Using regression analyses controlling for both the comprehension control task and lesion volume, we demonstrated that performance in the semantic gesture recognition task was predicted by per cent damage to the posterior temporal lobe, whereas the spatial gesture recognition task was predicted by per cent damage to the inferior parietal lobule. A whole-brain voxel-based lesion symptom-mapping analysis suggested that the semantic and spatial gesture recognition tasks were associated with lesioned voxels in the posterior middle temporal gyrus and inferior parietal lobule, respectively. The posterior middle temporal gyrus appears to serve as a central node in the association of actions and meanings. The inferior parietal lobule, held to be a homologue of the monkey parietal mirror neuron system, is critical for encoding object-related postures and movements, a relatively circumscribed aspect of gesture recognition. The inferior frontal gyrus, on the other hand, was not predictive of performance in any task, suggesting that previous claims regarding its role in action recognition may require refinement.

Associations and dissociations of transitive and intransitive gestures in left and right hemisphere stroke patients

The study investigated performance on pantomime and imitation of transitive and intransitive gestures in 80 stroke patients, 42 with left (LHD) and 38 with right (RHD) hemisphere damage. Patients were also categorized in two groups based on the time that has elapsed between their stroke and the apraxia assessment: acute-subacute (n=42) and chronic (n=38). In addition, patterns of performance in apraxia were examined. We expected that acute-subacute patients would be more impaired than chronic patients and that LHD patients would be more impaired than RHD patients, relative to controls. The hemisphere prediction was confirmed, replicating previous findings. The frequency of apraxia was also higher in all LHD time post-stroke groups. The most common impairment after LHD was impairment in both pantomime and imitation in both transitive and intransitive gestures. Selective deficits in imitation were more frequent after RHD for transitive gestures but for intransitive gestures they were more frequent after LHD. Patients were more impaired on imitation than pantomime, relative to controls. In addition, after looking at both gesture types concurrently, we have described cases of patients who suffered deficits in pantomime of intransitive gestures with preserved performance on transitive gestures. Such cases show that the right hemisphere may be in some cases critical for the successful pantomime of intransitive gestures and the neural networks subserving them may be distinct. Chronic patients were also less impaired than acute-subacute patients, even though the difference did not reach significance. A longitudinal study is needed to examine the recovery patterns in both LHD and RHD patients.

Ipsilateral deficits in 1-handed shoe tying after left or right hemisphere stroke

Poole JL, Sadek J, Haaland KY. Ipsilateral deficits in 1-handed shoe tying after left or right hemisphere stroke.

OBJECTIVE

To examine 1-handed shoe tying performance and whether cognitive deficits more associated with left or right hemisphere damage differentially affect it after unilateral stroke.

DESIGN

Observational cohort comparing ipsilesional shoe tying, spatial and language skills, and limb praxis.

SETTING

Primary care Veterans Affairs and private medical center.

INTERVENTIONS

Not applicable.

PARTICIPANTS

Volunteer right-handed sample of adults with left or right hemisphere damage and healthy demographically matched adults.

MAIN OUTCOME MEASURE

The number of correct trials and the total time to complete 10 trials tying a shoe using the 1-handed method.

RESULTS

Both stroke groups had fewer correct trials and were significantly slower tying the shoe than the control group. Spatial skills predicted accuracy and speed after right hemisphere damage. After left hemisphere damage, accuracy was predicted by spatial skills and limb praxis, while speed was predicted by limb praxis only.

CONCLUSIONS

Ipsilesional shoe tying is similarly impaired after left or right hemisphere damage, but for different reasons. Spatial deficits had a greater influence after right hemisphere damage, and limb apraxia had a greater influence after left hemisphere damage. Language deficits did not affect performance, indicating that aphasia does not preclude using this therapy approach. These results suggest that rehabilitation professionals should consider assessment of limb apraxia and ipsilesional skill training in the performance of everyday tasks.

Dissociation of initial trajectory and final position errors during visuomotor adaptation following unilateral stroke

Previous studies have demonstrated that following stroke, motor impairment can occur ipsilateral to the lesion. Such impairments have provided insight into the contributions of each hemisphere to movement control, showing that left and right hemisphere damage produce different effects on movement: Left hemisphere damage produces deficits in specifying features of movement trajectory, while right hemisphere damage produces deficits in achieving an accurate and stable final position. We now propose that left and right hemisphere damage should also produce different deficits in the adaptation of trajectory and position. To test this idea, we examined adaptation to visuomotor rotations in the ipsilesional arms of hemiparetic stroke patients with left (LHD) and right hemisphere damage (RHD). We found that LHD interfered with adaptation of initial direction, but not with the ability to adapt the final position of the limb. In contrast, RHD interfered with online corrections to the final position during the course of adaptation. These findings support our hypothesis that the control of trajectory and steady-state position may be lateralized to the left and right hemispheres, respectively.

Hemispheric specialization and functional impact of ipsilesional deficits in movement coordination and accuracy

Previous studies have demonstrated that following unilateral stroke, motor impairment occurs both contralateral, as well as ipsilateral, to the lesion. Although ipsilesional impairments can be functionally limiting, they can also provide important insight into the role of the ipsilateral hemisphere in controlling movement and the lateralization of specific motor control mechanisms, given that unilateral arm movements are thought to recruit processes in each hemisphere. The purpose of this study was to examine whether left and right hemisphere damage following stroke produces different ipsilesional deficits, and whether our dynamic dominance model of motor lateralization can predict such deficits. Specifically, the dynamic dominance model attributes control of multijoint dynamics to the left hemisphere, and control of steady-state position to the right hemisphere. Chronic stroke patients with either left or right hemisphere damage (LHD or RHD) used their ipsilesional arm, and the control subjects used either their left or right arm (LHC or RHC), to perform targeted reaching movements in different directions within the workspace ipsilateral to their reaching arm. We found that the LHD group showed deficits in controlling the arm's trajectory due to impaired multijoint coordination, but no deficits in achieving accurate final positions. In contrast, the RHD group showed deficits in final position accuracy but not in the ability to coordinate multiple joints during movement, thereby providing additional evidence for the hemisphere-specific nature of motor deficits. Furthermore, while both the LHD and RHD groups were functionally impaired to the same degree on the Jebsen Hand Function Test (JHFT), our results suggest that the underlying mechanisms for such impairment may be hemisphere-dependent.

Arm use after left or right hemiparesis is influenced by hand preference

BACKGROUND AND PURPOSE

Despite strong evidence for hand preference and its impact on motor performance, its influence on stroke rehabilitation has not been routinely considered. Previous research demonstrates that patients with hemiparetic stroke use their ipsilesional, nonparetic arm 5 to 6 times more frequently than their paretic arm, but it is unknown if such use varies with laterality of hemiparesis. The purpose of our study was to determine if the right arm is used more frequently in right-handed patients with stroke.

METHODS

We assessed relative use of the right, left, and both arms with wrist accelerometers on patients with unilateral, paretic stroke matched for degree of paresis (12 with right hemisphere damage, 17 with left hemisphere damage) and 25 neurologically intact control participants as they performed the Arm Motor Ability Test.

RESULTS

We showed: (1) ipsilesional arm use was greater after right hemisphere damage than left hemisphere damage; (2) the left hemisphere damage group used both arms together more often than the right hemisphere damage group but less often than the control group; and (3) both stroke groups used their contralesional, paretic arm to the same degree.

CONCLUSIONS

These findings emphasize the influence of hand preference on arm use after stroke for the ipsilesional but not the contralesional arm. Although both stroke groups used their ipsilesional more than their contralesional arm, the difference was greater for the right hemisphere damage group who used their ipsilesional arm 4 times more frequently than their contralesional arm, whereas the left hemisphere damage group used their ipsilesional arm 2 times more frequently than their contralesional arm.

Gesture subtype-dependent left lateralization of praxis planning: an event-related fMRI study

Ideomotor apraxia is a disorder mainly of praxis planning, and the deficit is typically more evident in pantomiming transitive (tool related) than intransitive (communicative) gestures. The goal of the present study was to assess differential hemispheric lateralization of praxis production using event-related functional magnetic resonance imaging. Voxel-based analysis demonstrated significant activations in posterior parietal cortex (PPC) and premotor cortex (PMC) association areas, which were predominantly left hemispheric, regardless of whether planning occurred for right or left hand transitive or intransitive pantomimes. Furthermore, region of interest-based calculation of mean laterality index (LI) revealed a significantly stronger left lateralization in PPC/PMC clusters for planning intransitive (LI = -0.49 + 0.10, mean + standard deviation [SD]) than transitive gestures (-0.37 + 0.08, P = 0.02, paired t-tests) irrespective of the hand involved. This differential left lateralization for planning remained significant in PMC (LI = -0.47 + 0.14 and -0.36 + 0.13, mean + SD, P = 0.04), but not in PPC (-0.56 + 0.11 and -0.45 + 0.12, P = 0.11), when both regions were analyzed separately. In conclusion, the findings point to a left-hemispheric specialization for praxis planning, being more pronounced for intransitive gestures in PMC, possibly due to their communicative nature.

Functional significance of ipsilesional motor deficits after unilateral stroke

OBJECTIVE

To determine whether ipsilesional motor skills, which have been related to independent functioning, are present chronically after unilateral stroke and are more common in people with apraxia than in those without apraxia.

DESIGN

Observational cohort comparing the performance of an able-bodied control group, stroke patients with left- or right-hemisphere damage matched for lesion volume, and left-hemisphere stroke patients with and without ideomotor limb apraxia.

SETTING

Primary care Veterans Affairs and private medical center.

PARTICIPANTS

Volunteer right-handed sample; stroke patients with left- or right-hemisphere damage about 4 years poststroke; a control group of demographically matched, able-bodied adults.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Total time to perform the (1) Williams doors test and the (2) timed manual performance test (TMPT), which includes parts of the Jebsen-Taylor Hand Function Test.

RESULTS

Ipsilesional motor deficits were present after left- or right-hemisphere stroke when using both measures, but deficits were consistently more common in patients with limb apraxia only for the TMPT.

CONCLUSIONS

These findings add to a growing literature that suggests that ipsilesional motor deficits may have a functional impact in unilateral stroke patients, especially in patients with ideomotor limb apraxia.