Appalachian State University
Presented by Jennifer Downs and
November 12, 1997
I. Apraxia-an inability to perform
volitional learned motor acts in the presence of normal comprehension,
muscle strength, sensation, attention, and coordination. Results from a
lesion disconnecting Broca’s area from the motor association area responsible
for organizing intentional actions.
A. Ideational Apraxia- an inability
to carry out a hierarchical complex motor plan as the result of bilateral
cerebral injury (e.g., making a bed). The patient appears to have lost
an overall concept of how to proceed to complete the motor task.
B. Ideomotor Apraxia-inability to
perform previously learned motor acts. This is the most common type of
apraxia. The patient fails to carry out a motor act to the examiner’s verbal
command. Results from damage to the premotor area, motor strip, parietal,
or temporal lobes in the dominant hemisphere.
1. Buccofacial-disturbance of the volitional
movements of the tongue, jaw, and lips during non-speech tasks (e.g., whistling
or drinking through a straw).
2. Limb- inability to carry out acts
upon command. The patient is able to carryout motor acts spontaneously.
Difficulty is not due to muscle weakness or comprehension deficits.
3. Constructional Apraxia-a deficit in
which patients are unable to form a construction in space (e.g., the inability
to copy a shape, complete block design, or match stick designs).
4. Apraxia of Speech-an impaired ability
to execute voluntarily the appropriate movements for articulation of speech
in the absence of paralysis, weakness, or incoordination of the speech
musculature. Errors are inconsistent, involuntary speech is better than
voluntary speech, errors include substitution, repetition, simplification,
distortion, and addition. The errors increase with complexity and word
Rules We Have Lived By: Traditional
Characteristics of Apraxia of Speech
After Darley, 1969.
Phonemic errors are prominent: omissions,
substitutions, distortions, additions, repetitions of phonemes.
Some errors appear to be perseverative,
Errors are seemingly off-target approximations
of the desired production made in an effortful groping for the correct
position or sequence of positions.
Errors are highly inconsistent.
Errors vary with the complexity of the
Errors increase as words increase in length.
There is a discrepancy between the articulatory
accuracy displayed in automatic-reactive speech performance and the inaccuracy
displayed in volitional-purposive performances.
Imitative responses are particularly poor.
The speaker is usually aware of his or
her errors but is typically unable to anticipate or correct them.
Monitoring of speech in anticipation of
errors leads to prosodic disturbances: slowed rate, even stress, even spacing.
Oral apraxia is often, but not always,
observed in association with apraxia of speech.
Articulatory Characteristics in
Apraxia of Speech
Quoted from Rosenbek and
Substitution errors are more frequent than
other error types.
Error sounds are more likely to differ
from the target by one phonetic dimension than by two, three, or four.
Errors are most likely errors of place,
followed by errors of manner, voicing, and oral-nasal.
Voiceless-for-voiced substitutions are
more frequent than voiced-for-voiceless substitutions.
Some errors are anticipatory, some perseverative,
and some metathetic with anticipatory errors probably predominating.
Errors are more likely on consonant clusters
than on singleton consonants.
Apicoalveolar and bilabial sounds are more
often correct than sounds produced at other places.
Affricates and fricatives tend, as classes,
to be more often in error than plosives, laterals, nasals, and vowels,
although order varies with the position in utterance.
Consonant errors are more likely than vowel
errors; however, some patients may make no more consonant errors than vowel
Many substitutions appear to be of more
"difficult" combinations for "easier" ones.
on Articulation in Apraxia of Speech
Within narrow limits, articulator accuracy
is better for automatic-reactive than for volitional-purposive speech.
Articulatory accuracy may be better with
auditory-visual stimulation than with auditory or visual (reading) alone.
Watching verbal production in a mirror
has no effect on the accuracy of single word production.
Imitative accuracy, unless influenced by
the test stimuli, is better than spontaneous accuracy.
Some patients improve if given more than
one consecutive attempt at a production.
Motivating instructions, within very narrow
limits, have no influence on articulatory accuracy.
Response delay intervals of 0, 3, and 6
seconds do not significantly influence articulatory accuracy.
Binaural masking probably has no facilitating
effect on articulation for most patients.
Delayed auditory feedback (DAF) may have
a detrimental effect on articulatory accuracy.
a complete assessment would include
an aphasia battery, oral mechanism exam, and an apraxia assessment.
Oral Apraxia Test
1. Open your mouth.
2. Stick out your tongue.
4. Show me your teeth.
5. Pucker up your lips.
6. Touch your nose with your tongue.
7. Bite your lower lip.
9. Lick your lips.
10. Clear your throat.
11. Move your tongue in and out.
12. Click your teeth together.
14. Click your tongue in top of mouth.
15. Chatter your teeth as if you were
16. Touch your chin with your tongue.
18. Puff out your cheeks.
19. Wiggle your tongue from side to
Failure to perform appropriately in brain-injured
adults suggests a diagnosis of oral apraxia.
III. Treatment for Apraxia of Speech-dependent
upon severity of apraxia and accompanying aphasia. The more severe the
impairment, the poorer the prognosis is for recovery.
Characteristics of Severe AOS
A. Melodic Intonation Therapy- (Sparks and Helm-Estabrooks)
. The idea is to have the patient "sing" an utterance being trained, because
singing an utterance facilitates production for aphasic patients with an
element of verbal apraxia.
Limited repertoire of speech sounds.
Speech may be limited to a few meaningful or unintelligible
Imitation of isolated sounds may be in error, and
errors may be limited in variety.
Errors may be highly predictable.
Automatic speech may not be better than volitional
Error responses may approximate target if stimuli
are chosen carefully.
Muteness may be present, but rarely persists for
more than 1 or 2 weeks if other speech, language, or cognitive deficits
are not present.
Usually accompanied by sever aphasia, but can occur
in the absence of aphasia.
Usually accompanied by nonverbal oral apraxia.
B. Gestures- introduced into speaking as a form of
intersystemic reorganization or deblocking--involves pairing speaking and
gesture. The goal is to maintain the verbal response after the gesture
National Institute of Neurological
Disorders and Stroke
National Aphasia Association
National Stroke Association
American Academy of Neurology
Stroke Support Information
Dana Brain Web
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