Praxies and apraxies: practical rehabilitation exercises
of left hemisphere strokes cause apraxia
of Alzheimer's patients develop apraxia
of children suffer from developmental dyspraxia
of improvement possible with early rehabilitation
1. What is a praxis?
Praxis refers to the ability to plan, organize, and execute coordinated voluntary gestures with a specific goal in mind. It is not about simple reflex movements like withdrawing your hand from a hot surface, but rather 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 tells it in what order 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.
The complexity of praxies lies in their multimodal nature: they integrate visual information (recognition of objects and space), somatosensory (tactile and proprioceptive feedback), mnemonic (recall of learned motor sequences), and executive (planning and control of action) information. This sophisticated orchestration explains why praxic disorders can be so disabling in daily life.
💡 Did you know?
Praxies develop throughout childhood and continue to refine in adulthood. A virtuoso pianist or a surgeon has developed praxies of exceptional precision through thousands of hours of training that have created ultra-specialized neural circuits.
🔑 Key points about praxies
- Praxies require the integrity of several connected brain regions
- They become automated with repetition but remain under conscious control
- Each praxic gesture follows a specific "motor program" stored in memory
- Praxies can be relearned even after a brain injury
- They vary according to cultures and individual learning
To keep your praxies in shape, regularly vary your manual activities: DIY, cooking, gardening, drawing, music... This diversity stimulates different neural circuits and maintains brain plasticity. Cognitive stimulation applications like COCO THINKS and COCO MOVES offer fun exercises to work on hand-eye coordination and motor planning.
2. The different types of praxies
Neuropsychologists distinguish several categories of praxies according to the nature and complexity of the gesture performed. Each involves specific brain networks and can be independently impaired during a brain injury.
👋 Ideomotor praxies
Definition: Ability to perform conventional symbolic gestures on verbal command, without a real object present.
Concrete examples: Waving goodbye, performing a military salute, miming the gesture of drinking from an invisible glass, making the sign of the cross, showing a raised fist as a sign of victory, making the "shh" gesture with the index finger on the lips.
These gestures have strong cultural and social significance. They are acquired through imitation and social repetition. In the case of a disorder (ideomotor apraxia), the person knows perfectly well what is being asked of them and understands the instruction, but cannot produce the correct gesture. They may make an approximate gesture, use an inappropriate part of the body, or produce a completely unsuitable gesture.
🔧 Ideatory praxies
Definition: Ability to correctly use real objects in a sequence of organized actions to achieve a functional goal.
Concrete examples: Preparing a cup of coffee (taking the cup, pouring hot water, adding coffee, stirring with a spoon), brushing teeth (taking the toothbrush, opening the toothpaste, putting some on the brush, brushing), folding a letter and putting it in an envelope, lighting a candle with matches.
Ideatory apraxia is manifested by inappropriate use of objects: the person may brush their teeth with the handle of the brush, drink from the toothpaste, or completely reverse the order of steps. They may also abandon the task midway without understanding why they can no longer do it.
Ideatory apraxia in Alzheimer's disease
"In my practice, I often observe that ideational apraxia is one of the first signs of loss of autonomy in Alzheimer's patients. They retain their physical strength and recognize objects, but can no longer use them coherently. This is very destabilizing for families who do not understand why their loved one 'is doing it on purpose' wrong. The neurological explanation helps a lot to demystify and adapt the support."
👗 Dressing Praxies
Definition: Ability to dress coherently while respecting the logical order and spatial orientation of clothing.
Concrete examples: Putting on a sweater the right way, buttoning a shirt from bottom to top, putting shoes on the right feet, zipping up a zipper, tying a tie, fastening a bra.
Dressing apraxia creates situations that are sometimes comical but very disabling: the person puts on several layers of clothing on top of each other, wears their pants inside out, no longer knows the order to dress (for example, putting underwear over pants), or gets stuck with a garment half on.
🏗️ Constructive Praxies
Definition: Ability to assemble elements to create an organized structure in two or three dimensions, respecting spatial relationships.
Concrete examples: Building a tower of blocks while maintaining balance, copying a complex geometric figure (cube in perspective, house with details), assembling a puzzle, making origami, building a Lego model according to a plan, drawing an apartment layout.
Constructive apraxia is reflected in simplified and deconstructed drawings: angles become rounded, proportions are incorrect, spatial organization is chaotic. The person may omit important details or conversely persist on one element to the detriment of the whole.
🗣️ Buccofacial Praxies
Definition: Ability to perform voluntary and coordinated movements with the muscles of the face, mouth, and tongue.
Concrete examples: Sticking out the tongue voluntarily, puffing out the cheeks, blowing a kiss, whistling, blowing out a candle, making expressive faces, licking lips, clicking the tongue.
Paradoxically, in the case of buccofacial apraxia, the person cannot reproduce these movements on request even though they can do them spontaneously in a natural context (for example, sticking out the tongue to lick dry lips). This automatic-voluntary dissociation is characteristic of praxic disorders.
To assess your own praxies or those of a loved one, try these simple tests: miming the action of combing without a comb, drawing a 3D house, performing a military salute, dressing with your eyes closed. Any unusual difficulty warrants a specialized consultation. The application COCO THINKS and COCO MOVES offers evaluation and training exercises for all these functions.
3. Neurological basis of praxies
Praxies depend on a complex and interconnected brain network. Unlike reflex movements that primarily involve the spinal cord and brainstem, praxic gestures require the coordination of multiple cortical and subcortical areas.
The left parietal cortex plays the central role of "motor program library." This region stores the abstract representations of learned gestures and activates them during action planning. Left parietal lesions are the most common cause of apraxia, explaining why strokes in the left hemisphere are so often accompanied by praxic disorders.
The frontal premotor cortex translates these abstract programs into concrete motor sequences, defining the temporal order of muscle contractions. It also ensures the adaptation of the gesture to the context (force, speed, amplitude according to the situation).
The basal ganglia control the fluidity and automation of movements. Their dysfunction in Parkinson's disease explains the praxic disorders observed in these patients (micrographia, difficulties with complex gestures).
🧠 Neuroplasticity and recovery
Brain plasticity allows for partial recovery even after significant injury. The right hemisphere can partially compensate for the praxic functions of the left hemisphere, and new circuits can be created with intensive training. This is why early rehabilitation is crucial to optimize functional recovery.
Close connections with the occipital visual areas allow for object recognition and adaptation of movement to their physical properties. The parietal somatosensory areas integrate the tactile and proprioceptive feedback necessary for real-time adjustment of movement.
This complex neural architecture explains why praxic disorders can take very diverse forms depending on the precise location of the lesion. A pure parietal lesion will result in ideomotor apraxia, while a fronto-parietal lesion will associate praxic disorders with executive planning difficulties.
4. Apraxia: when gestures become impossible
Apraxia is an acquired neurological disorder characterized by an inability to perform coordinated voluntary movements, while basic motor skills (muscle strength, elementary coordination), sensory functions, and understanding of instructions are preserved. It is this dissociation that makes apraxia so confusing for patients and their surroundings.
The apraxic patient knows perfectly well what they need to do and wants to do it, but their gesture does not correspond to their intention. This mismatch between intention and execution creates intense frustration and a feeling of incompetence that can lead to avoidance of activities and social isolation.
Apraxia is not limited to a simple motor problem: it reveals a profound disruption of the mental representation of action. Patients may lose access to the "procedural knowledge" that normally allows us to act automatically and effectively in our environment.
🔍 Characteristics of apraxia
- Inconsistency between intention and gestural execution
- Preservation of automatic movements and reflexes
- Variability of performance depending on the context
- Possible improvement with visual or verbal cues
- Major impact on autonomy and self-esteem
- Often unknown and underdiagnosed
5. Causes of apraxia
Apraxias occur following damage to the brain areas involved in motor programming and control. Understanding these causes is essential for adapting care and prognosis.
🩸 Cerebrovascular accidents (Stroke)
Strokes represent the most frequent cause of acquired apraxia. Accidents affecting the left hemisphere, particularly in the territory of the middle cerebral artery, cause apraxia in 60 to 80% of cases. Post-stroke apraxia can be transient (a few weeks) or permanent depending on the extent and location of the lesion.
Hemorrhagic strokes tend to result in more severe apraxias than ischemic strokes, as the hematoma compresses and destroys brain tissue more extensively. However, the prognosis for recovery may be better as there is no persistent vascular obstruction.
🤕 Traumatic brain injuries
Severe traumatic brain injuries can cause apraxias through several mechanisms: direct contusion of praxic areas, diffuse axonal injuries disrupting inter-hemispheric connections, or compressive hematomas. Post-traumatic apraxia is often associated with other cognitive disorders (attention, memory, executive functions).
🧠 Brain tumors
Tumors in the left hemisphere, particularly parietal gliomas, may present with progressive apraxia. Unlike strokes, the onset is insidious, sometimes allowing for partial compensation by healthy brain areas. Tumor surgery may temporarily worsen apraxia before improvement.
🧓 Neurodegenerative diseases
In Alzheimer's disease, apraxia generally appears at the moderate stage and progressively worsens. It first affects complex praxies (dressing, cooking) before extending to simple gestures. Apraxia significantly contributes to loss of autonomy and institutional placement.
Frontotemporal dementia can lead to early apraxia, associated with behavioral disorders. Corticobasal degeneration is characterized by severe asymmetrical apraxia, often associated with rigidity and myoclonus.
Prevalence of apraxia according to pathologies
Left hemisphere Stroke: 60-80% develop apraxia
Moderate Alzheimer's disease: 30-50%
Severe traumatic brain injury: 20-35%
Corticobasal degeneration: 90-100%
General population > 65 years: 2-5%
6. How to recognize apraxia?
The early diagnosis of apraxia is crucial for implementing effective rehabilitation and adapting the patient's environment. Unfortunately, this disorder often remains unknown, with gestural difficulties wrongly attributed to a lack of motivation or a depressive state.
⚠️ Signs of apraxia to recognize
🚨 Alarm signals in daily life
- Impossible symbolic gestures: Can no longer wave goodbye, salute, or make the sign of the cross on command
- Aberrant use of objects: Toothbrush used as a comb, knife for eating soup, phone held upside down
- Clumsy and disorganized gestures: Imprecise movements with hesitations, multiple corrections, incomplete gestures
- Disrupted sequences: Puts on socks after shoes, lights a cigarette before taking it out of the pack
- Unexplained blockages: Stops in the middle of a familiar action without knowing why
Dressing apraxia is manifested by characteristic situations: the patient puts on several sweaters one over the other, wears their pants inside out, does not know which piece of clothing to start with, gets stuck with a sleeve or a pant leg. These difficulties contrast with the preservation of strength and mobility.
In the case of constructive apraxia, drawings become simplified and destructured. A house becomes a square topped with a triangle, without details or perspective. The angles are rounded, proportions incorrect, spatial organization chaotic. Copying geometric figures (cube, star) becomes impossible.
Bucco-facial apraxia creates a striking paradox: the patient can no longer stick out their tongue, puff their cheeks, or blow a kiss on command, while they perform these same movements spontaneously (licking their lips, blowing on hot food). This automatic-voluntary dissociation is pathognomonic.
🩺 Clinical diagnosis of apraxia
The diagnosis of apraxia is made by a neurologist or neuropsychologist using standardized test batteries. The examination includes several specific tests that evaluate each type of praxia.
Evaluation of ideomotor praxias: The patient is asked to imitate symbolic gestures (military salute, "OK" sign, cross), to mime the use of absent objects (hammer, scissors, toothbrush), to produce gestures on verbal command.
Evaluation of ideational praxias: Tests with real objects (lighting a candle with matches, preparing a cup of tea, folding a letter into an envelope), multi-step sequences, use of complex tools.
Constructive evaluation: Copying geometric figures, spontaneous drawings (clock, house, character), 3D constructions with cubes, assembling puzzles.
Here is a simple test you can perform: ask the person to mime the action of brushing their teeth (without a toothbrush), then to draw a house with details, and finally to show how to say goodbye. If these three tasks present unusual difficulties, a specialized consultation is necessary. Feel free to discreetly film to show the doctor.
7. Developmental dyspraxia in children
To be absolutely distinguished 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 movements from childhood. The dyspraxic child has always had motor difficulties, unlike the apraxic patient who loses a function they previously mastered.
Dyspraxia affects about 5 to 6% of children, with a male predominance (3 boys for 1 girl). It results from immaturity or dysfunction of the brain areas involved in motor planning, without visible lesions on standard brain imaging.
These children are often labeled as "clumsy," "slow," "disorganized" by those around them who do not understand their difficulties. They frequently spill their drink, struggle to ride a bike, tie their shoes, cut with scissors, and manipulate buttons and zippers.
🏫 School impact of dyspraxia
At school, writing is the main challenge for the dyspraxic child. It is laborious, slow, illegible, and tiring. The child must concentrate intensely on forming letters, which prevents them from focusing on the content of what they write. This dual task (graphism + thinking) is exhausting and penalizes all learning.
In mathematics, visuospatial difficulties complicate the alignment of numbers, geometry, and reading graphs. In physical education, the dyspraxic child often fails, which affects their self-esteem and social relationships.
Living with a dyspraxic child
"My son Léo has dyspraxia. For a long time, we thought he wasn't making an effort, that he was lazy or provocative. In reality, every action requires intense concentration for him: tying his shoelaces, cutting his meat, writing neatly. Since the diagnosis at age 7, he has benefited from school accommodations (laptop, no double task listening/writing, extra time for assessments) and occupational therapy. He finally has confidence in himself and his academic results are improving. The most important thing was to understand that his difficulties are real and involuntary."
Types of developmental dyspraxia
✍️ Visuospatial dyspraxia: The most common (60% of cases). The child has difficulty organizing their gaze and movements in space. Difficulties in geometry, puzzles, cursive writing, dressing. Drawings lack spatial organization.
👄 Orofacial dyspraxia: Articulation disorders making speech hard to understand, difficult chewing with frequent drooling, swallowing difficulties. The child eats slowly and messily.
👗 Dressing dyspraxia: Persistent difficulties dressing independently, buttoning, lacing, distinguishing the front and back of clothes, putting on socks. Autonomy is delayed.
✋ Gestural dyspraxia: Clumsiness in all daily gestures: using cutlery, styling hair, riding a bike, catching a ball, using scissors. Motor learning is very slow.
Children with dyspraxia greatly benefit from adapted digital tools. The application COCO THINKS and COCO MOVES offers exercises specifically designed to work on coordination, spatial organization, and motor planning in a playful and progressive manner. The alternation between screen and physical activities respects the child's needs.
8. General principles of rehabilitation
The rehabilitation of praxic disorders is a complex challenge that primarily involves the occupational therapist and the psychomotor therapist. The modern approach combines intensive repetition of specific gestures, the development of compensatory strategies, and environmental adaptations to optimize functional autonomy.
Contrary to popular belief, praxic recovery remains possible even months or years after the initial injury. Brain plasticity allows for the creation of new neural circuits to bypass damaged areas, provided that intensive and targeted training is offered.
🎯 Sequential decomposition of the gesture
Principle: Break down a complex gesture into simple steps and practice them one by one before chaining them together progressively.
Practical example: To relearn how to brush teeth:
1) Identify and take the toothbrush
2) Open the toothpaste tube
3) Place a small amount of toothpaste on the brush
4) Bring the brush to the mouth
5) Make methodical circular movements
6) Rinse the mouth and the brush
Each step is first practiced in isolation, then two steps are gradually chained together, then three, until the complete sequence is automated. This analytical approach helps to bypass difficulties in global planning.
🔄 Intensive repetition and automation
Principle: Massive and repeated practice allows for the creation of new neural circuits and the gradual automation of the disrupted gesture.
Neuroscience has shown that it takes about 300 to 500 correct repetitions to create a new motor memory trace. This repetition must be "intelligent": focused, corrected in real-time, with immediate feedback on execution quality.
Example: Practicing daily to tie shoelaces, first very slowly verbalizing each step, then progressively faster until a fluid automaticity is regained. Using training shoes with laces of different colors facilitates learning.
⏰ Optimal training schedule
Short and frequent sessions (15-20 minutes, 3-4 times a day) are more effective than a long weekly session. The brain consolidates motor learning better during sleep, hence the importance of spreading training throughout the week. Plan for regular breaks to avoid cognitive fatigue.
👁️ Use of visual cues
Principle: Visual cues (colors, arrows, pictograms, sequencers) guide the execution of the gesture and compensate for planning difficulties.
Concrete examples:
- Stick colored dots on clothing to indicate inside/outside
- Use a red dot on the left shoe and a blue one on the right
- Display sequential pictograms for routines (toileting, dressing, meals)
- Mark the direction of screwing/unscrewing with colored arrows
- Use placemats with drawn locations for cutlery
🗣️ Verbalization of steps
Principle: Saying out loud what you are doing helps better plan and control the gesture being executed.
Verbalization activates the language areas that support the deficient motor areas. This strategy is particularly effective in post-Stroke apraxias where the right hemisphere (often preserved) can partially compensate for the damaged left hemisphere.
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 pressing down..."
9. Practical rehabilitation exercises by type of apraxia
Apraxia rehabilitation requires specific exercises tailored to each type of disorder. Here is a methodical progression of practical exercises tested in clinical settings and easily achievable at home or in institutions.
💪 Exercises for ideomotor apraxias
Beginner level (simple ideomotor apraxias)
- Direct imitation in front of a mirror: Military salute, goodbye gesture, thumbs up, "OK" sign
- Common symbolic gestures: Sign of the cross, "shh" gesture, applause
- Facial expressions: Wink, exaggerated smile, pout
- Polite gestures: Shake hands, raise hand to hat, bow
Intermediate level
- Miming actions without objects: Pretending to drink, to phone, to comb hair
- Gesture sequences: Clap twice then snap fingers
- Bilateral gestures: Spread arms in a cross, join hands above the head
- Temporal variations: Same gesture slow then fast
Advanced level
- Gestural games: "Simon says" with complex variations
- Professional gestures: Conductor, police officer directing traffic
- Simple choreographies: Sequences of 4-5 linked gestures
- Contextual adaptation: Same gesture in different positions (sitting/standing)
🍴 Exercises for ideational praxis
Ideational praxies require the use of real objects in functional sequences. Progression goes from simple single-object gestures to complex multi-object sequences.
🥄 Progression with cutlery
Step 1: Isolated use of each utensil (knife alone for spreading, fork alone for picking)
Step 2: Coordination of knife-fork on soft foods
Step 3: Cutting foods of increasing consistency
Step 4: Complete meal with alternating utensils
Step 5: Integration of politeness rules (holding cutlery correctly)
Activities of daily living:
- Preparing a sandwich (progression: bread + butter → bread + butter + ham → complete sandwich)
- Folding laundry (handkerchiefs → towels → shirts → sheets)
- Setting the table (1 place setting → 2 place settings → complete table with decoration)
- Watering plants (1 plant → complete watering circuit)
- Preparing breakfast (simple tea → complete breakfast)
Therapeutic cooking: Following illustrated recipes step by step, starting with very simple preparations (toast, fruit salad) to progress to dishes requiring multiple preparation and cooking steps.
🎨 Exercises for constructive praxies
Constructive praxies engage spatial organization and visuo-motor planning. Rehabilitation progresses from 2D to 3D, from simple to complex.
Week 1-2: Puzzles 4-6 pieces, simple geometric shapes
Week 3-4: Puzzles 12-20 pieces, figure copying
Week 5-6: Simple 3D constructions, guided drawings
Week 7-8: Complex puzzles, free creations
Adjust the pace according to individual progress.
2D Activities:
- Reproduce geometric figures (square → triangle → rhombus → hexagon)
- Copy increasingly complex drawings (simple house → detailed house → landscape)
- Draw by following numbered points (connect the dots)
- Complete symmetrical figures
- Reproduce simple mandalas
3D Activities:
- Assemble Lego constructions according to a model
- Create simple origami with detailed visual instructions
- Play with Kapla by reproducing structures
- Build balance towers with different materials
- Assemble miniature furniture (dollhouses)
👄 Exercises for Orofacial Praxies
Orofacial praxies involve the fine coordination of the facial and mouth muscles. Their rehabilitation also improves articulation and swallowing.
Tongue Mobility:
- Stick the tongue out, then retract it
- Lateral movements: tongue to the right, then to the left
- Vertical movements: tongue towards the nose, then towards the chin
- Slow circular movements around the lips
- Click the tongue against the palate
Lip Control:
- Puff up the cheeks and then slowly deflate them
- Blow bubbles with a closed mouth
- Exaggerated smile then close the mouth
- Pout (duck face)
- Vibrate the lips (make "brrrr" like a horse)
Breath and Coordination:
- Blow out a candle (variable distances)
- Make soap bubbles
- Play the harmonica or recorder
- Inflate balloons
- Blow through a straw to move light objects
Cognitive Stimulation and Digital Praxies
The DYNSEO applications offer exercises specifically designed to stimulate constructive praxies and hand-eye coordination. Puzzle games, image reconstruction, logical sequences, and spatial orientation engage praxic abilities in a fun and progressive way. COCO THINKS and COCO MOVES automatically adapts to the person's level and offers personalized challenges to optimize rehabilitation.
10. Adaptations to facilitate autonomy
In addition to active rehabilitation, practical adjustments allow for overcoming
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