Sensory Integration Deficits in Neurodegenerative Diseases: Implications for Apraxia

OBJECTIVE

Apraxia is the inability to perform voluntary, skilled movements following brain lesions, in the absence of sensory integration deficits. Yet, patients with neurodegenerative diseases (ND) may have sensory integration deficits, so we tested the associations and dissociations between apraxia and sensory integration.

METHODS

A total of 44 patients with ND and 20 healthy controls underwent extensive testing of sensory integration (i.e., localization of tactile, visual, and proprioceptive stimuli; agraphesthesia; astereognosis) and apraxia (i.e., finger dexterity, imitation, tool use).

RESULTS

The results showed (i) that patients with Alzheimer's disease, corticobasal syndrome, or posterior cortical atrophy were impaired on both dimensions; (ii) An association between both dimensions; (iii) that when sensory integration was controlled for, the frequency of apraxia decreased dramatically in some clinical subgroups.

CONCLUSION

In a non-negligible portion of patients, the hypothesis of a disruption of sensory integration can be more parsimonious than the hypothesis of apraxia in case of impaired skilled gestures. Clinicians and researchers are advised to integrate sensory integration measures along with their evaluation of apraxia.

Meaningless imitation in neurodegenerative diseases: Effects of body part, bimanual imitation, asymmetry, and body midline crossing

Visuo-imitative apraxia has been consistently reported in patients with dementia, yet there have been substantial methodological differences between studies, while multiple, sometimes competing hypotheses have been put forward to explain this syndrome. Our goals were to study specific imitation deficits in groups of patients who have been selected and assigned to a group solely based on clinical criteria. We tested the effects of body part, bimanual imitation, asymmetry of the model, and body midline crossing, in patients with cortical atrophy of the temporal lobes (semantic dementia, SD), frontal-parietal networks (FPN, i.e., posterior cortical atrophy and corticobasal syndrome) or both (Alzheimer's disease, AD). Sixty-three patients and 32 healthy controls were asked to imitate 45 meaningless finger/hand, uni-/bimanual, asymmetrical/symmetrical, and crossed/uncrossed postures. SD patients had subnormal imitation scores. FPN patients showed frequent and marked deficits in most conditions, better performance with hand than finger postures (probably because of visuo-constructive deficits), and better performance with uncrossed than crossed configurations (probably because of body schema disorganization). Bimanual configurations were difficult for AD patients, not because of bimanual activity in itself, but rather because of the complexity of the model. The finding of dissociations in 34/63 cases (54%) suggests that some patients, even within the same clinical category, can have variable performance in imitation tests as a function of the abovementioned factors. Clinicians are advised to use tests with a large array of items to properly capture patients' imitation skills. This provides a new basis for future research to unpack which neurocognitive mechanisms are disrupted to cause specific patterns of impaired imitation.

Imitation of meaningless gestures in normal aging

While imitation of meaningless gestures is a gold standard in the assessment of apraxia in patients with either stroke or neurodegenerative diseases, little is known about potential age-related effects on this measure. A significant body of literature has indicated that different mechanisms (i.e., executive functioning, visuospatial skills, sensory integration, body knowledge, categorical apprehension) may underlie the performance depending on imitation conditions (i.e., finger/hand, uni-/bimanual, symmetric/asymmetric, crossed/uncrossed configurations). However, neither the effects of these conditions on performance, nor the contribution of the abovementioned mechanisms to imitation have been explored in normal aging. The aim of the present study was to fill this gap. To do so, healthy adults (n = 103) aged 50 to 89 were asked to imitate 45 meaningless gestures. The authors controlled for general cognitive function, motor function, visual-spatial skills, executive function, sensory integration, body knowledge, and mechanical problem-solving skills. The results showed that asymmetry, body-midline crossing and, to a lesser extent, bimanual activity added an additional layer of difficulty to imitation tasks. After controlling for motor speed and cognitive function, age had an effect on imitation skills after 70 years old. This may reflect a decline in body knowledge, sensory integration, and executive functions. In contrast, the visuospatial and mechanical problem-solving hypotheses were ruled out. An additional motor simulation hypothesis is proposed. These findings may prove useful for clinicians working in memory clinics by providing insights on how to interpret imitation deficits. Lower performance after 70 years old should not be considered abnormal in a systematic manner.

Effect of object substitution, spontaneous compensation and repetitive training on reaching movements in a patient with optic ataxia

We report the case of M.B. who demonstrated severe optic ataxia with the right hand following stroke in the left hemisphere. The clinical picture may shed light on both the pathological characteristics of reaching and grasping actions, and potential rehabilitation strategies for optic ataxia. First, M.B. demonstrated a dissociation between severely impaired reaching and relatively spared grasping and tool use skills and knowledge, which confirms that grasping may be more intermingled with non-motoric cognitive mechanisms than reaching. Besides, M.B.'s reaching performance was sensitive to movement repetition. We observed a substitution effect: Reaching time decreased if M.B. repeatedly reached toward the same object but increased when object identity changed. This may imply that not only object localization but also object identity, is integrated into movement programming in reach-to-grasp tasks. Second, studying M.B.'s spontaneous compensation strategies ascertained that the mere repetition of reaching movements had a positive effect, to the point M.B. almost recovered to normal level after an intensive one-day repetitive training session. This case study seems to provide one of the first examples of optic ataxia rehabilitation. Reaching skills can be trained by repetitive training even two years post-stroke and despite the presence of visuo-imitative apraxia.

Nature and Specificity of Gestural Disorder in Children with Developmental Coordination Disorder: A Multiple Case Study

Aim: Praxis assessment in children with developmental coordination disorder (DCD) is usually based on tests of adult apraxia, by comparing across types of gestures and input modalities. However, the cognitive models of adult praxis processing are rarely used in a comprehensive and critical interpretation. These models generally involve two systems: a conceptual system and a production system. Heterogeneity of deficits is consistently reported in DCD, involving other cognitive skills such as executive or visual-perceptual and visuospatial functions. Surprisingly, few researches examined the impact of these functions in gestural production. Our study aimed at discussing the nature and specificity of the gestural deficit in DCD using a multiple case study approach. Method: Tasks were selected and adapted from protocols proposed in adult apraxia, in order to enable a comprehensive assessment of gestures. This included conceptual tasks (knowledge about tool functions and actions; recognition of gestures), representational (transitive, intransitive), and non-representational gestures (imitation of meaningless postures). We realized an additional assessment of constructional abilities and other cognitive domains (executive functions, visual-perceptual and visuospatial functions). Data from 27 patients diagnosed with DCD were collected. Neuropsychological profiles were classified using an inferential clinical analysis based on the modified t-test, by comparison with 100 typically developing children divided into five age groups (from 7 to 13 years old). Results: Among the 27 DCD patients, we first classified profiles that are characterized by impairment in tasks assessing perceptual visual or visuospatial skills (n = 8). Patients with a weakness in executive functions (n = 6) were then identified, followed by those with an impaired performance in conceptual knowledge tasks (n = 4). Among the nine remaining patients, six could be classified as having a visual spatial/visual constructional dyspraxia. Gestural production deficits were variable between and within profiles. Discussion: This study confirmed the heterogeneity of gestural production deficit among children with a diagnosis of DCD, at both intra- and inter-individual levels. The contribution of other cognitive deficits in most of the profiles allows discussing the specificity of gestural difficulties. This argues in favor of the necessity to distinguish gestural problems with other deficits made apparent through gesture.

Tool use in neurodegenerative diseases: Planning or technical reasoning?

Recent works showed that tool use can be impaired in stroke patients because of either planning or technical reasoning deficits, but these two hypotheses have not yet been compared in the field of neurodegenerative diseases. The aim of this study was to address the relationships between real tool use, mechanical problem-solving, and planning skills in patients with Alzheimer's disease (AD, n = 32), semantic dementia (SD, n = 16), and corticobasal syndrome (CBS, n = 9). Patients were asked to select and use ten common tools, to solve three mechanical problems, and to complete the Tower of London test. Motor function and episodic memory were controlled using the Purdue Pegboard Test and the BEC96 questionnaire, respectively. A data-transformation method was applied to avoid ceiling effects, and single-case analysis was performed based on raw scores and completion time. All groups demonstrated either impaired or slowed tool use. Planning deficits were found only in the AD group. Mechanical problem-solving deficits were observed only in the AD and CBS groups. Performance in the Tower of London test was the best predictor of tool use skills in the AD group, suggesting these patients had general rather than mechanical problem-solving deficits. Episodic memory seemed to play little role in performance. Motor dysfunction tended to be associated with tool use skills in CBS patients, while tool use disorders are interpreted as a consequence of the semantic loss in SD in line with previous works. These findings may encourage caregivers to set up disease-centred interventions.

Involvement of Technical Reasoning More Than Functional Knowledge in Development of Tool Use in Childhood

It is well-known that even toddlers are able to manipulate tools in an appropriate manner according to their physical properties. The ability of children to make novel tools in order to solve problems is, however, surprisingly limited. In adults, mechanical problem solving (MPS) has been proposed to be supported by "technical reasoning skills," which are thought to be involved in every situation requiring the use of a tool (whether conventional or unusual). The aim of this study was to investigate the typical development of real tool use (RTU) skills and its link with technical reasoning abilities in healthy children. Three experimental tasks were adapted from those used with adults: MPS (three different apparatus), RTU (10 familiar tool-object pairs), and functional knowledge (FK; 10 functional picture matching with familiar tools previously used). The tasks were administered to 85 healthy children divided into six age groups (from 6 to 14 years of age). The results revealed that RTU (p = 0.01) and MPS skills improve with age, even if this improvement differs according to the apparatus for the latter (p < 0.01 for the Hook task and p < 0.05 for the Sloping task). Results also showed that MPS is a better predictor of RTU than FK, with a significant and greater weight (importance weight: 0.65; Estimate ± Standard Error: 0.27 ± 0.08). Ours findings suggest that RTU and technical reasoning develop jointly in children, independently from development of FK. In addition, technical reasoning appears partially operative from the age of six onward, even though the outcome of these skills depends of the context in which they are applied (i.e., the type of apparatus).