Praxies and Apraxies: Understanding and Rehabilitating Voluntary Movements
Comprehensive guide on planning and executing complex movements disorders
Tying shoelaces, brushing teeth, using cutlery, drawing a star... These everyday gestures seem natural and automatic, yet they require a complex cognitive function called "praxis." When this function is impaired, it is referred to as apraxia, a neurological disorder that can significantly impact autonomy. Understanding praxies and their dysfunction is essential for effectively supporting affected individuals.
What is a praxis?
Praxis refers to the ability to plan, organize, and execute coordinated voluntary movements aimed at a specific goal. It is not about simple reflex movements like withdrawing a hand from a hot surface, but about intentional actions that require a planned and learned motor sequence.
When we perform a praxic gesture, our brain activates a "motor program" stored in memory that indicates the order in which to mobilize the muscles, with what force, amplitude, and spatial orientation. This motor programming primarily occurs in the left parietal cortex, closely linked to the frontal motor areas.
of left hemisphere strokes cause apraxia
of Alzheimer’s patients develop apraxia
of children suffer from developmental dyspraxia
The different types of praxies
Neuropsychologists distinguish several categories of praxies based on the nature and complexity of the performed gesture. Each involves specific brain networks.
👋 Ideomotor Praxies
Definition: Ability to perform conventional symbolic gestures on verbal command, without a real object.
Examples: Waving goodbye, performing a military salute, miming drinking from an invisible glass, making the sign of the cross.
In case of impairment: The person knows what is being asked but cannot produce the correct gesture. They may make an approximate gesture or a completely inappropriate one.
🔧 Ideatory Praxies
Definition: Ability to correctly use real objects in a sequence of organized actions to achieve a goal.
Examples: Preparing a cup of coffee (taking the cup, pouring water, adding coffee, stirring), brushing teeth, folding a letter and putting it in an envelope.
In case of impairment: The person misuses objects (brushes teeth with the handle of the brush), reverses the order of steps, or abandons the task midway without knowing why.
👗 Dressing Praxies
Definition: Ability to dress coherently while respecting the order and orientation of clothing.
Examples: Putting on a sweater, buttoning a shirt, putting shoes on the correct feet, zipping a zipper.
In case of impairment: The person puts on several layers on top of each other, wears pants inside out, or no longer knows the order to dress (underwear over pants).
🏗️ Constructive Praxies
Definition: Ability to assemble elements to create a two- or three-dimensional structure.
Examples: Building a tower of blocks, copying a complex geometric figure, assembling a puzzle, making origami.
In case of impairment: Drawings are simplified or deconstructed, angles are rounded, proportions incorrect, spatial organization chaotic.
🗣️ Buccofacial Praxies
Definition: Ability to perform voluntary movements with the muscles of the face, mouth, and tongue.
Examples: Sticking out the tongue, puffing cheeks, blowing a kiss, whistling, blowing out a candle.
In case of impairment: The person cannot reproduce these movements on request, even though they can do them spontaneously (for example, sticking out the tongue to lick their lips).
🧠 Neurological Basis of Praxies
Praxies depend on a complex brain network primarily involving the left parietal lobe (motor program storage area), the frontal premotor cortex (movement planning), and the basal ganglia (execution control). Close connections with visual and somatosensory areas allow gestures to be adjusted based on sensory feedback.
Apraxia: When Gestures Become Impossible
Apraxia is an acquired neurological disorder characterized by an inability to execute coordinated voluntary movements, while basic motor skills, muscle strength, and understanding of instructions are preserved. The patient knows what they need to do and wants to do it, but their gesture does not match their intention.
Causes of Apraxia
Apraxias occur following damage to brain areas involved in motor programming and control. The main causes are strokes (CVA) affecting the left hemisphere, severe head trauma, brain tumors, and neurodegenerative diseases (Alzheimer's disease, frontotemporal dementia, corticobasal degeneration).
In Alzheimer's disease, apraxia typically appears in the moderate stage of the illness and progressively worsens. It significantly contributes to the loss of autonomy: the patient no longer knows how to use cutlery, wash, dress, and becomes dependent for daily activities.
How to Recognize Apraxia?
⚠️ Signs Suggestive of Apraxia
- Difficulty reproducing symbolic gestures on command (military salute, sign of the cross)
- Inadequate use of common objects (toothbrush used as a comb)
- Clumsy, imprecise gestures, with hesitations or multiple corrections
- Reversals in the order of motor sequences (lighting a cigarette before taking it out of the pack)
- Difficulty dressing despite the absence of motor or visual deficits
- Inability to draw or copy simple geometric figures
- Difficulties in buccofacial gestures (sticking out the tongue, puffing cheeks) despite fluent speech
- Preservation of automatic gestures (the person can spontaneously greet someone but cannot imitate the gesture)
🩺 Diagnosis of Apraxia
The diagnosis of apraxia is made by a neurologist or neuropsychologist using standardized tests. The patient is asked to imitate gestures, mime the use of objects, manipulate real objects, draw, and copy figures. The evaluation helps determine the type of apraxia and its severity, essential information for guiding rehabilitation.
Developmental Dyspraxia in Children
Distinct from acquired apraxia, developmental dyspraxia (or Coordination Acquisition Disorder according to the DSM-5) is a neurodevelopmental disorder that affects the planning and automation of gestures. The dyspraxic child has always had motor difficulties, unlike the apraxic patient who loses a function they previously mastered.
Dyspraxic children are often labeled as "clumsy": they spill their drink, struggle to ride a bike, tie their shoes, or cut with scissors. At school, writing is laborious, slow, and illegible, which hinders learning despite normal or even superior intelligence.
"My son Léo, 9 years old, is dyspraxic. For a long time, we thought he wasn't making an effort. In reality, every gesture requires intense concentration: tying his shoelaces, cutting his meat, writing neatly. Since the diagnosis, he has benefited from accommodations (computer in class, no dual task listening/writing, extra time for assessments) and occupational therapy support. He finally has confidence in himself."
Visuospatial Dyspraxia
Difficulty organizing vision and gestures in space: problems in geometry, puzzles, writing
Buccofacial Dyspraxia
Articulation disorders, difficult chewing, frequent drooling, swallowing difficulties
Dressing Dyspraxia
Difficulty dressing alone, buttoning, tying, distinguishing the right side from the wrong side of clothing
Gestural Dyspraxia
Clumsiness in everyday gestures: using cutlery, grooming, riding a bike, catching a ball
Rehabilitation and Compensatory Strategies
The rehabilitation of praxic disorders primarily involves occupational therapists and psychomotor therapists. The approach combines intensive repetition of specific gestures, development of compensatory strategies, and environmental adaptations.
General Principles of Rehabilitation
🎯 Decomposition of the Gesture
Principle: Break down a complex gesture into simple steps and practice them one by one before chaining them together.
Example: To brush teeth: 1) Take the toothbrush, 2) Open the toothpaste, 3) Put toothpaste on the brush, 4) Bring the brush to the mouth, 5) Brush in circular motions.
🔄 Repetition and Automation
Principle: Intensive and repeated practice allows for the creation of new neural circuits and gradual automation of the gesture.
Example: Practicing daily to tie shoelaces, first slowly verbalizing each step, then increasingly quickly until automation.
👁️ Use of Visual Cues
Principle: Visual cues (colors, arrows, pictograms) guide the execution of the gesture.
Example: Stick colored stickers on clothing to indicate right/wrong side, use a red dot on the left shoe and a blue one on the right.
🗣️ Verbalization of Steps
Principle: Saying aloud what you are doing helps better plan and control the gesture.
Example: "I take the knife in my right hand, the fork in my left, I poke the meat with the fork, I cut with the knife..."
Practical Rehabilitation Exercises
💪 Exercises for Ideomotor Praxies
- Imitate gestures in front of a mirror (military salute, goodbye gesture, thumbs up)
- Mime actions without objects (pretend to drink, pretend to phone, pretend to comb hair)
- Reproduce gesture sequences (clap hands twice then snap fingers)
- Play Simon Says by varying symbolic gestures
🍴 Exercises for Ideatory Praxies
- Practice using everyday objects (knife, fork, toothbrush, comb)
- Perform simple sequential tasks: prepare a sandwich, fold laundry, set the table
- Follow illustrated step-by-step cooking recipes
- Participate in adapted household chores: drying dishes, watering plants
🎨 Exercises for Constructive Praxies
- Assemble puzzles of increasing complexity
- Reproduce constructions with Lego or blocks according to a model
- Copy geometric figures (square, triangle, house, 3D cube)
- Draw by following numbered points (connect the dots)
- Make simple origami with visual instructions
- Play with Kapla, construction games
👄 Exercises for Buccofacial Praxies
- Stick out the tongue up, down, left, right
- Puff cheeks then deflate them
- Blow bubbles with a closed mouth
- Blow out a candle (at varying distances)
- Make faces in front of a mirror (exaggerated smile, pout, wide eyes)
- Chew foods of different textures (soft, crunchy, hard)
EDITH: Cognitive and Praxic Rehabilitation
The EDITH program from DYNSEO offers cognitive games that stimulate motor planning and constructive praxies. Puzzle activities, image reconstruction, logical sequences, and spatial orientation engage praxic abilities in a playful and gradual manner. Ideal for patients in rehabilitation after a stroke or those with Alzheimer's disease, EDITH automatically adapts to the individual's level.
Discover EDITHAdaptations to Facilitate Autonomy
In addition to rehabilitation, practical adaptations can help circumvent praxic difficulties and preserve autonomy for as long as possible.
🏠 Home and Equipment Adaptations
- Adaptive Clothing: Prefer Velcro or elastic clothing instead of buttons, shoes with Velcro instead of laces
- Ergonomic Cutlery: Thickened non-slip handles, plates with edges, glasses with nasal cutouts
- Visual Sequencers: Display illustrated steps for routines (washing, dressing, preparing a meal)
- Spatial Organization: Always store objects in the same place, label drawers and cupboards
- Simplification of Tasks: Prepare clothing in the order they need to be put on, reduce the number of steps
Apraxia and Daily Life
Living with apraxia presents a daily challenge that requires patience, adaptation, and support from those around. Caregivers play a crucial role in encouraging the person to maintain their autonomy while providing targeted assistance when necessary.
"Apraxia is an invisible disability. From the outside, the patient seems physically capable, making their difficulties hard to understand for those around them. It is essential to explain that it is neither a lack of will nor laziness, but a real neurological disorder that requires time and repetition."
Advice for Caregivers
💙 How to Help Without Doing It for Them
- Allow the necessary time: do not finish the gesture for the person out of impatience
- Verbally decompose: "First you take the brush, then you put on the toothpaste..."
- Show rather than explain: demonstrate the gesture slowly so it can be imitated
- Value successes: encourage every small progress to maintain motivation
- Adapt expectations: accept that the gesture may be less precise but sufficiently functional
- Maintain activities: continue to offer enjoyable manual activities (gardening, simple cooking, adapted DIY)
Living with Praxic Disorders
Praxic disorders, whether acquired apraxia or developmental dyspraxia, profoundly impact autonomy and self-esteem. These difficulties are all the more frustrating as they concern seemingly simple gestures that everyone naturally masters.
However, with intensive rehabilitation, appropriate compensatory strategies, and a supportive environment, individuals with praxic disorders can regain a satisfactory quality of life. Brain plasticity allows the brain to create new neural pathways to bypass damaged areas, provided these learnings are stimulated regularly and targeted.
For dyspraxic children, early diagnosis and appropriate school accommodations enable them to succeed in their education despite their motor difficulties. They often develop remarkable strengths in other areas (language, memory, reasoning) that should be valued.
