Clinical History

While some patients complain of a loss of ability to perform skilled movements, most do not recognize their disability or complain about it. The activities to be inquired about include the use of common bathroom tools such as toothbrushes, razors, combs, and brushes. Furthermore, the clinician should ask whether the patient can prepare his or her own meals and use typical kitchen utensils including forks, knives, spoons, and other ancillary household equipment. Because the apraxia associated with hemispheric injury such as strokes and trauma is often associated with a hemiparesis, patients with these disorders who attempt to perform skilled acts with the nonpreferred arm during daily activities state that they are impaired. Although patients may attribute the difficulty to a premorbid clumsiness of the nonpreferred arm, this potential error in interpretation of the clinical history should not be committed by the physician.

Patients with hemispheric strokes may be anosognosic for the apraxia and state that they are able to use their nonpreferred hand correctly although they are clearly apraxic.[1i Additionally, many caretakers of chronically impaired individuals may find it easier to anticipate the patient's needs and perform mechanical tasks for them rather than await failures. It is, therefore, important to ask the caregiver about the presence of any impaired skills in the patient's activities of daily living. Since apraxia is most commonly seen in patients with strokes or Alzheimer's disease, special attention should be paid to obtaining the important elements of a history of praxis when the patient interview suggests these neurological disorders. Apraxia may, however, be seen in patients with many other diseases of the central nervous system including trauma and can be the presenting sign in those with corticobasal ganglionic degeneration.

TABLE 4-1 -- APRAXIAS AND THE TYPES OF ERRORS COMM

Errors to Command

Apraxia Type

Postural

Orientation

Discrimination: Movement

Comprehension

Imitation

Series

Mechanical Knowledge

Ideomotor

Anterior

+ + +

+ + +

O

O

+ +

O

O

Posterior

++ +

+ + +

+ + +

+ + +

+ +

O

O

Conduction

O

O

O

O

+ + +

O

O

Disassociation

+ + +

+ + +

O

O

O

O

O

Ideational

O

O

O

O

O

+ + +

O

Conceptual

O

O

O

O

O

O

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