Praxis and language: The extent and variety of apraxia in aphasia

PRAXIS AND LANGUAGE: THE EXTENT AND VARIETY OF APRAXIA IN APHASIA ASDREM’ KERTESZ and PHILIP HOOPER

bpartment

of

ClinicalNeurological

Sciences. St. Joseph‘s (Receivtd

7 Dewmhrr

Hospital.

London,

Ontario.

Canada,

N6A JV2

198 1 )

Abstract-This quantitative study of apraxia in aphasics establishes the extent and characteristics of apraxia in various aphasic groups, the differences between various categories of praxis. and the correlation between praxis and language parameters. Broca’s aphasics have more severe apraxia than Wernicbe’s aphasics even though their comprehension is significantly better. Apraxia, however, correlates best with comprehension deficit and secondly with the severity of aphasia. Among the nonverbal parameters. drawing shows the highest correlations. Our study confirms the prominence of facial apraxia in Broca’s aphasia. Praxis and language are closely related and appear to share the same neural structures.

INTRODUCTION of a transmodality of cognitive disorder of communicative function has been postulated for more than 100 years. FINKELRURG [l] used the term “asymbolia” for the inability to express or comprehend spoken words, graphic symbols and gestures. GOLDSTEIN [2] regarded apraxia or gestural distrubance in aphasics as a manifestation of impaired abstract behaviour. Many others continued to support the unitary concept of impaired symbolic function encompassing language, performance and praxis. LEIPMANN [3] defined apraxia as a disturbance of purposeful movement despite retained motor power, not due to loss of comprehension or agnosia. In a series of articles from 1900-1920, he described three kinds of apraxia: limb kinetic, ideomotor and ideational. This classification, although often quoted, has confused the issue to some extent because it is difficult to apply to clinical cases. Even though PICK [4] described ideational apraxia and Liepmann adopted this category, it is not described uniformly. Ideomotor apraxia is much more common than ideational apraxia [5]. It is not the purpose of this study to enter the controversy regarding ideomotor vs ideational apraxia, but to elucidate the relationship of gestural and language disturbance. Apraxia is most,often seen in association with aphasia although at times it appears independently. Similarly, not all cases of aphasia are associated with apraxia. Systematic quantitative examination of the relationship of language and gestural disturbances are few. The studies in the area concern only a few selected aphasics [6] or issues such as the differentiation of ideational or ideomotor praxis [7], or the side of the lesion [S]. LIEPMANN [9] himself, surveyed a series of 89 patients and found the incidence of aphasia in 14 out of 20 left hemisphere damaged patients who had left sided apraxia and right hemiplegia. He termed this sympathetic dyspraxia. The impairment was present both to command and imitation THE EXISTENCE

275

276

;\VDREL+ KERTESZ and PHILIP HIXIPER

although it improved on the latter. He pointed auf that impaired comprehension was not a cause of apraxia. The incidence of apraxia was much less in right hemiplegics without aphasia (capsular lesions) and he did not find right sided apraxia in left hemiplegics although there were quite a few cases of bilateral apraxias. He concluded that the left hemisphere was dominant for purposeful movements for both sides of the body and called attention to the importance of the corpus callosum in the neural mechanisms of apraxia. The relationship between aphasia and ideational apraxia [7. S], and between the expressive difficulties in aphasia and apraxia was emphasized by several studies [IO. 11, 121. GWDLASS and K.APLAS [6] examined 20 moderate to mild aphasics and did not find significant correlation between the severity of aphasia and gestural scores. Their control group of 19 patients had diffuse or right hemisperic damage and they were clearly better on gestural tasks even though they were matched on the WAIS performance scores. They suggested that although there is no causal relationship, the association of language and praxis is related to the contiguity of the neural structures involved. Conventional, symbolic, intransitive movements such as saluting or transitive movements such as pretending to use a hammer have been used to test praxis, a distinction made by Liepmann. They are all part of “pantomime” which is gestural expression in lieu of speech. Some authors consider imitation of gestures. complex sequential actions, or the use of objects, distinct phenomena while others like Liepmann as part of a continuum of skilled movements. It is also recognized that the sign language of the deaf is unique in that it parallels the linguistic complexities of spoken languages [13]. The relationship of the traditional gestural tests of aprnxia to more elementary, repetitive. or meaningless movements have also been explored [14, IS]. Facial (oral) apraxia has special importance because of its relationship to speech movements. The oral and limb gestures of 105 aphasics were studied by DE REXZI et al. [ 121 who found oral apraxia in the majority of Broca’s aphasics and also with phonemic jargon. Oral apraxia correlated more with articulatory phonemic disorders than with limb apraxia, but at times a clear dissociation was observed. Articulatory-phonemic disorders are also called verbal apraxia by some and considered distinct particularly from the therapeutic point of view [16]. In this study, we chose an empirical classification of gesture, that involves a description of either the actual movement such as facial or limb, the use of objects such as transitive and intransitive or the complexity of a sequence of movements. We attempted to test axial movements systematically because of the suggestion that these may be spared in certain lesions. However, this could not be applied to a great number of global, Broca’s, and Wernicke’s aphasics, because of their hemiplegia. Most hemiplegics had variable difficulty standing and the axial movements that can be applied in a sitting position are limited. The complexity of movement was introduced as a variable to investigate ideational apraxia, as a failure of sequential, complex actions. Transitive movements were used to study the frequency of the failure of object use, and to determine if this was a distinct abnormality underlying ideational apraxia as advocated in literature [7]. We chose simple, familiar, common movements to avoid intellectual and memory factors. These movements represented no difficulty whatever to control patients. Our hypothesis was that apraxia is closely correlated with language impairment; that there is significant difference in the extent of apraxia between the types of aphasia and also that the categories of movement disorders are different in their difficulty level and distribution across aphasic types.

METHODS

Two hundred and thirty consecuttvely examined aphasic patients who completed the Western Aphasia Battery (WAB) language subtests [17] and the praxis subtests were the subjects of this study. This is predommantly a stroke population with a small number of patients with turnours. trauma and degenerative disease mcluded. Most were examined ut the first month of their tllness, a smaller number at 3 months and a few in a morechronic stage. Left-handed and ambidextrous pattents were excluded. One hundred and twenty-five controls were also examined with the same tests of language and praxis. These consisted of2 1 normal age matched hospital patients without brain disease from the neurologtcal and medtcal wards. 71 nonaphasic patients with right hemisphere lesions and 32 nonaphasic left hemisphere damaged patients. Ibl

.dprasia

tet

Our test consists of :i) items tn four descriptive cstegortrs [IS]. for object use. (i I “Facial”

(ii) “Upper

I. 2. 3. ‘4. ‘5. limb”

1. 2. 3. 4. 5.

The items marked with an astertsk provide a test

Put out your tongue Close your eyes Whistle Sniff a llowzr Blow out a match Make a fist Salute Wave goodbye Scratch your head Snap your hnfzrs

tiit) “Transitive”

* I. *2. ‘3. *A. ‘5.

Use Use Use Use Use

a a a a a

comb toothbrush spoon to eat hammer key

(iv) “Complex”

I. 2. ‘3. 4. 5.

Pretend Pretend Pretend Pretend Pretend

to to to to to

drive a car knock at the door fold a paper light a cigarette play the piano

The patient is asked to carry out each movement. If no response or only amorphous. approximate response is given the patient is then shown the movement by the examiner and he is verbally and gesturally encouraged to imitate. In order to eliminate comprehension difticulty, we deviated from the usual scoring method of the WAB which gives less credit for performance on imitation than on command. If good, standard performance was achieved by either method, the patient received a score of three. Impaired but recognizable performance was scored two and poor, but approximate performance, one. If the patient performed the item with an object only, a credit of one was given. No performance, unrecognizable or unrelated gesturing or completely erroneous use of objects were scored zero. Maximum score for all the items was 60. (c) Lanyuaye rest The oral subtests of the Wcstcrn Aphasia Battery (W’AB) were given in every instance. as well as reading. writing. calculation and nonverbal tests of drawing. block design and Raven’s Coloured Progressive Matrices with a few exceptions. The standardization and rationale of the test has been described elsewhere [l9.20]. The patients were grouped into eight diagnostic categories according to taxonomic criteria published previously [ 17, 191: global, Broca’s tramcortical motor, isolation, Wernicke’s, transcortical sensory, conduction and anemic.

RESULTS 1. The extent of apraxia

in aphasic

types and control groups

The mean scores and standard deviations of the total praxis scores for all aphasic and control groups are summarized in Table 1. The significance of the differences between the

deviation stntisticdy

50.71-6.36

Mean----SD

The mean and stnndmd horizolital line) is similar

0

Group

(I’C~M)

4 (Wclnicke’s) 48.90. ..-8.03

Subset 4 Group Mean --SD

Sllbscl 5

3 ( PJocu’s) 43.27 --13.07

Subset 3 Group Meiu--SD

(Global) 15.53 .- 14.44

I

2 (Isolation) 33.0~-19.63

SD

1

Subset 2 Group Mean--SD

Mean.

Group

Subset

8 (Anemic) 57.28-3.99

6 (TCM) 50.71--6.36

5 (TCS) 50.70-a.49

9 (Nonaphasic 58.3% -2.87

7 (Conduction) 5?.9?_ I - 7.11

6 (TCM) 50.71-6.36

I,)

of the total praxis scores in each apraxic type is grouped in subsets by the Newman to the other types in that group. Some types are members of severd subsets.

7 (C’onduction) 52.92-7.11

5 (TCS) 50.70.- 8.49

4 (Wernicke’s) 48.90---8.03

Keuls

Student

10 (R lesion) 59.12 ---1.26

method.

linch type (in the same

II (Norm:d) 59.7 1. 0.78

PR41S

%ND LANGL’\GE

'19

praxis scores was analysed by the Student-Newman-Keuls procedure for a probability level of 0.05. The homogeneous subsets. where the means of the first and last groups (aphasic types) differ less than the critical value for a subset of that size, are represented in each horizontal line. Table 2 indicates these subsets in the upper case above the mean scores. For instance, if group one has a mean value with a subset number one and this is the only group with that subset number, then this means that for the value, thegroup is different from all the others. However, if another group shares subset number three with four other groups, then these are all similar but significantly differ from other groups with different numbers. Some group values may have more than one subset numbers above them indicating that they do not differ significantly from either of these subsets. The scores of all categories of praxis in each aphasic group are summarized in Table 2. The Aphasia Quotient (the total language score and a measure of the severity of the aphasia) and the comprehension section means are also included. Global aphasics (n=32) are the most apractic with complex and transitive movements being more affected than facial and intransitive upper limb movements. This pattern was similar in other aphasic groups as well. Isolation aphasics (ti=6). albeit a smaller group, seemed to do significantly better on the praxis task than globals even though their comprehension is not much better than global aphasics. However, they had significantly poorer praxis than Broca’s aphasics even though their AQ was higher than the Broca’s group. Broca’s aphasics (ti=48) showed a similar pattern and only slightly lower praxis scores across the praxis subtests than Wernicke’s (n=20) even though they had better comprehension. Transcortical motor (n = 7) transcortical sensory (n = 17) and conduction aphasics (n = 24) have similar praxis scores even though their fluency, comprehension and repetition scores differ significantly. Anemic aphasics had high scores, only slightly below the right hemisphere damaged and the other control groups. Their differences from controls is most significant in the complex bimanual movements. It is notable that left hemsiphere nonaphasic controls have slightly higher total praxis than right hemisphere damaged patients. 2. Categories of npraxin in aphasic groups The general pattern across all groups indicated a hierarchy of difficulty for the various categories of praxis. The data in Table 1 show that intransitive conventional movements are usually the best performed followed by facial movements then transitive movements and finally the most difficult of all the categories, complex movements. Isolation aphasics were the only exception with slightly better facial praxis than the other categories. The differences between the categories were more marked at levels of greater impairment such as in global, isolation and to a lesser extent in Broca’s aphasia. This trend existed in the milder aphasic and control groups as well; the complex movements were most difficult. 3. The correlation of apraxia with language and nonverbal impairment Apraxia correlated best with comprehension deficit and the severity of aphasia (AQ). These two parameters correlated highly with all categories of praxis (Table 3). The next highest correlation was seen with the drawing subtest, but the block design subtest achieved the lowest coefficients of correlation of all the parameters. Raven’s Coloured Progressive Matrices correlated less than the language parameters. Table 3 also indicates that facial praxis scores correlated best with measures of verbal output such as fluency and repetition.

___---_-

r.,\om-FP*v, l--l

-

-

?

_--

P‘

-

-

?-I -1

r-

The

lolaIpraxis

All signifiwnt

and

PjO.001. praxis

subtests

art’ correlated

0.71 0.74 0.76

0.56 0.59 0.63

0.65 0.69 0.73

other

0.69 0.65

0.55 0.64

0.63 0.7 I

with

Comprehension

Fluency

AQ

nonverbal

paramrtcrs

0.57 0.62 0.64

0.53 0.54 0.60

and

0.53 0.62

0.51 0.6-l

language

Naming

Kqdtion

in al1 aph;rGcs.

0.6-t 0.64 0.66

0.57 0.56

Drawing

KC’I’M 0.52 0.3:! 0.55 0.51 0.55

Mock\ 0.34 0.27 0.33 ii.32 1b.35

0.59 O.fI?. 0.0 I

0.44 0.53

Writing

i’ m

:: ;t: (1 5

5 cl

2 : G

37

ANDREU

KERTESZ

and PHILIPHOOPER

On the other hand, instrumental and complex praxis showed higher correlations with comprehension and drawing. When the correlation was studied in each aphasic and control group (Table 4), the results were similar although some differences appeared. Comprehension again correlated with praxis the most significantly especially in global, Broca’s. Wernicke’s. anemic and transcortical motor groups. Drawing and praxis correlated well in Broca’s and global aphasia, but less well in other groups. The correlations reached significant levels in all the language but not in the performance parameters for the anemic group, which is the largest of the aphasic types. Although some of the smaller groups show higher correlations, these do not reach levels of significance. DISCUSSION Our results indicate a close relationship between language impairment and apraxia. The severity of aphasia and the comprehension deficit especially show a high correlation with deficits of purposeful movements. This is in variance with some conclusions reached by GOODGLASS and KAPLAN [6]. A possible reason for their lack of correlation between language and praxis scores is their relatively small sample of mildly affected aphasics in contrast to the large and representative population in ours. This is not to be taken as evidence however, that language impairment and praxis always coincide. There are cases when the patient is clearly apractic but language is not significantly impaired and vice versa. The former situation is seen especially with lesions of the corpus callosum. Emphasis on callosal mechanisms in the interpretation of apraxia diverted attention from the fact that apraxia is most commonly seen with left hemisphere lesions that produce aphasia as well. H~CAEN[21] correlated varieties of apraxia (examined with similar items, as in this study) with language parameters, and found significant correlations especially for the items performed on verbal commands. He also noted several dissociations which suggested that gesture may be impaired without direct relationship to the degree of language disturbance. The slightly better praxis scores in left hemisphere damaged nonaphasics as compared to the right hemisphere damaged patients is interesting and contrary to other suggestions in the literature. This may be related, of course, to the relatively smaller lesions of the nonaphasic left hemisphere group sparing the speech areas in contrast to some of the large lesions involving the whole middle cerebral artery distribution of the right hemisphere damaged patients. A more likely possibility, suggested by the high correlation between praxis and language scores, is that apraxia is closely related to those areas of the brain that are involved in language and inversely spared in left hemisphere lesions which are outside the language areas. These findings caution against considering the left hemisphere being dominant for purposeful movements in its entirety. There is no significant difference, however, between aphasics with presumably anterior and posterior lesions within the speech area, when the groups are matched for severity such as the Broca’s, Wernicke’s and transcortical motor-transcortical sensory aphasics. Posterior left hemisphere mechanisms were suggested to be responsible for complex sequential patterns of movements and anterior regions for single acts [ 151. Our results indicate that apraxia occurs with anterior and posterior lesions alike, as long as they produce aphasia. If the above hypothesis was valid, one would expect Broca’s aphasics to be more affected for simple intransitive movements than for complex sequences and the reverse true for Wernicke’s aphasia. The results of this study do not show such a differentiation. In fact, single intransitive movements are somewhat less affected

with language and nonverbal

lP
0.67* * 0.40’ 0.15 -0.9211 0.20 -0.01 0.56’ 0.35**

Comprehension

230

motor sensory

- 0.02 0.09 -0.55 0.00 -0.01 - 0.08 - 0.07 0.04

32 48 6 I I7 24 21 75

Fluency

N

0.02 0.17 - 0.29 0.88’ 0.49. 0.17 0.29 0.48**

Naming

AQ

0.45’ 0.45** 0.26 0.40 0.46* 0.44 0.56’ 0.1 1

Writing

tests in each group

0.28 0.2 I -0.37 0.88’ 0.29 0.19 0.4 I * 0.44**

in various aphasic groups

0.06 0.13 - 0.79* 0.56 0.05 0.15 0.23 0.33”

Repetition

of total praxis with language and nonverbal

Total

Global Broci’s ‘ Isolation Transcortical Transcortical Conduction Wernicke’s Anemic

Subtests Group

Table 4. Correlation

0.5X** 0.45** 0.64 0.16 0.17 0.52’ 0.47* 0. IO

Drawing

0.20 OM

0.0 I

0.47. 0.27 0.x I O.ll --0.X 0.52

RCI’M

0.0 I

-0.19 0.24

-0.6X

0.30 0.08 0.7x

Blocks

2 a

5

5 u $I

2

> -g

3-i

~\IDRFH KERTESZand PHILIP HiwPER

(easier) than complex bimanual acts in all types of aphasics. it is not evident from our clinical data that anteroposterior lesion location within the speech area will differentiate between the types or severity of apractic disorders accompanying aphasia with the exception of facial apraxia which is somewhat more prominent than limb apraxia in Broca’s and transcortical motor aphasia. A recent study suggested the preponderance of anterior and central lesions in oral apraxia [21]. although another study differentiating between types of aphasia did not find a significant difference [23]. The most severe apraxia in global aphasics is not surprising considering their severe comprehension and speech deficits and their large lesions. However, the severe apraxia of the isolation syndrome patients is noteworthy in view of their lesser overall language impairment. Their .AQ was higher than Broca’s aphasics even though their praxis scores were definitely lower. Broca’s aphasics on the other hand have slightly more facial apraxia than Wernicke’s even though their comprehension is significantly better. G~sctrw~~uv [Z-I] predicted that conduction aphasia which is seen with supramarginal gyrus lesions would have a high association with apraxia. Our data failed to show tnore apraxia in conduction aphasia, in fact, conduction aphasics as a group seemed to have milder apraxia than some other aphasic groups with better overall language scores such as the transcortical aphasias. A notable feature of apraxia associated with Broca’s aphasia is the severity of facial or oral apraxia. This confirms previous observations such as DE RESTI ~‘t al. [ 121 who found oral apraxia in 90”,;, of Broca’s aphasics but only in 33”;, of conduction aphasics. Geschwind thought that facial apraxia represented a special form of sympathetic dyspraxia, with selective sparing ofthe pathways for limb praxis but specific involvement of the inferior paths to the face area closer to Broca’s region. On the other hand, in cases ofcallosal apraxia, facial and truncal movements are usually spared. Other apractic categories appear to represent similar difficulty levels for all aphasic groups. Complex sequences are most difficult. followed by transitive movements and the easiest, or least affected category seems to be intransitive movements similar to other studies [6, 151. Our clinical experience indicated that meaningless movements are as much affected as the purposeful ones and for some patients they are more difficult. There is no obvious clinical advantage in testing for them, although their impairment indicated that symbolic content is not the reason why purposeful movements are impaired [14]. Aphasic comprehension disturbance has confounded the interpretation of the mechanisms of apraxia. Initially. there was a tendency among investigators, and this persists among less experienced clinicians, to attribute difficulties of purposeful movements to comprehension deficit. This has been refuted by Liepmann who showed that the majority of cases with apraxia have difficulty on imitation as well. We have used this fact to design our study to overcome the severe comprehension deficit ofsome of our aphasics, rather than exclude them as GOODGLASS and KAPLAS have done from their study [63. This enabled us to assess the apractic disturbance without the direct interference of the aphasic comprehension difficulty, yet, establish independently and confirm previous observations about the high correlation between the comprehension deficit and apraxia. What is then, the role of comprehension in apraxia, if not a direct one? Is there an underlying general factor of cognitive processing, that is needed for language comprehension, and language output as well as for skilled movements meaningful or not? Is this general factor more than just the sharing of neural structures around the sylvian fissure of the dominant hemisphere for speech and handedness, or is it an underlying commonality in processing? The fact remains that disturbances of language and

praxis are closely tied together, caused by the same lesions. >-et they are clearly not causative and can occur independently one from another. Careful measurement of both sets of parameters are needed in a \-ariety of lesion localizations to further analyse the underlying neural and psychological factors. The close relationship of language and praxis is supported bl; our study ofaphasia. but the independence of motor dominance from language also has evidence in its favour. That handedness and contralateral hemispheric language dominance do not always coincide is commonly known. There is the report of HEILMXVS er nl. of a left-handcr with right-handed apraxia who did not become aphasic with a right hemispheric stroke suggesting that apraxia and aphasia may be dissociated also [2-i]. We have seen tlvo cases [19] of severe apraxia where single gestural acts were relatively preserved but complex acts showed a bizarre disturbance such as the patient trying to drink from the under surface of a cup or putting the matches in his mouth instead of a cigarcttc. One of these patients had biparietal strokes and the other, Alzheimer’s disease. Seither of them had significant language disturbance! These patients, of course, have what has been described since Pick as ideational apraxia. Clinicians have recognized that movements appear to have conceptual components that can be impaired in a prominent fashion. This gave basis for the continuing differentiation of the disturbances of skilled movements at different levels such as that of the “gesteme” (ideational), “kineme” (ideomotor) and “executive” (melokinetic) [263. The dissociation of ideational apraxia from language disturbance, however, is an important observation underlying language-movement relationship. Although the association of the two has been studied before, its dissociation is evidence against the movement disorder being primary or causative of the language disturbance. A similarly significant observation concerns patients who verbalized the desired movement but can not carry them out [6]. Such patients may forcefully utter “blow” but can not even imitate the movement without the verbalization. This common phenomenon eloquently demonstrates that neither failure ofcomprehension is the cause of apraxia nor is apraxia the cause of verbal impairment.

REFERENCES I. FISKELVDURG. F. Ueber Aphasie und Asymbolie nebst Versuch einer Theorie der Sprachbildung. Arc/~. Psychiar. 6, 1876. 7 GOLDSTEIN, K. Lunguuge nrld Latlguage Disrurbunces. Grunt: Sr Stratton, New York. 1948. i: LIEP~~, H. Das Krankheitsbild der Apraxie (“motorischen asymbolie”). .tfonutsschr. Psychitrtr. N~rurol., Bd VIII, Monographie, Berlin, 1900. 4. PIG, A. Studien iiher Afororische Aphasic. Wien, 1905. 5. H~XAEN, H. et Gw~so, A. L’apraxie ideomotrice unilaterale gauche. Rec. Nertrol. 102, 648-653, 1960. 6. G(x)Dc~LA~, H. and KAPLAV. E. Disturbance of gesture and pantomine in aphasia. Brain 86, 703-720. 1963. 7. DERENZI, E., PIECZCRO, A. et VIGSOLO. L. Ideational apraxia: a quantitative study. Netrropsychologia 6.41-Q 1968. 8. AJIZRIAGUERKA, J. IIF, H~CAEN. H. and ASGELERGUES. R. Les apraxies. varietes cliniques et lateralisation lesionnelle. Rec. Neural. 102, 494-566. 1960. 9. LIEP.MANN, H. iiber Storungen des Handelus be Gehirnkranken. Karger. Berlin. 1905 IO. ALAJOUANINE. T. et LHERSUTTE, F. Les troubles des activities expressive du langage dans l’aphasie, leurs relations avec les apraxies. Rev. Neural. 102, m-629. 1960. 11. NATHAS, P. W. Facial apraxia and apraxic dysarthria. Brain 70, 449, 1947. 12. DERENZI, E., PIECZURO, A. and VIGSOLO. L. A. Oral apraxia and aphasia. Correx 2, 50-73, 1966. 13. BELLCCI, U. and KLIMA, E. S. Language: perspectives from another modality. CIBA Fourtd. sympt. 69.99-I 17, 1979. 14. HEILYAN, K. M. A tapping test in apraxia. Cortex 11, 259-263. 1975. IS. KI~XRA. D. and ARCHIBALD, Y. Motor function of the left hemisphere. Brain 97, 337-350. 1974.

16. J~HK~. D. F. and L,+PQIVTE,L. L. Neurologenicdisorders ofspeech. in Sfudiesm .vpurolinyuisrics, Whitaker. H.. Whltakrr, H. A. ieditors). Vol. 1, pp. 161-199. Academic Press, %tv York. 1976. 17. KERTE_SZ..A. and PKILE. E. The aphasia quotient: The taxonomis approach to measurement of aphasic disability. Con. J. Xrurol. Sci. I. 7 ~16, 1974. 18. KERTESZ. A. The Western .Aphasia Battery, L!niversity of Western Ontario. London, 1980. 19. KERTESZ, A. Aphasia ad Associafrd Disorders: Ta.tonomF, Locali:afion ad Recorer_v. Grune 8; Stratton, New York. 1979. 20. SHEWAS, C. hl. and KERTESZ. A. Reliability and validity characteristics of The Western Aphasia Battery (WAB). J. Speech Hear. Dis. 45 308-314, 1980. 2 I. H~.AEN. H. Les apraxies ideomotrices. Essai de dissociation. In Du Conrr6k .!foteur o l+Orgnni;ation du Gesfe. H. H+AEN et hl. JMNSEROD (editors). Masson. Paris, 1978. 22. TXS~LA. G. and VIGS~LO, L. Brain lesions associated with oral apraxia in stroke patients: a cliniconeuroradiological investigation with the CT scan. Neurops)cho/ogia 18, 257-271, 1980. 23. POEUY, K. and KEKSC~IENSTEISER,M. Analysis of the sequential motor events. In Oral Apraxiu in Cerebral Locakarion, ZLL~H. K. J.. CREI.TZFELIX, 0. and GALBRMT~I,G. C. (editors). Springer Verlag, Heidelberg, 1975. 24. GESCHH.IND. N. Disconnexion syndromes in animals and man. Brain 88. 237-294. 585-644, 1965. 25. HEILM.,XSN,K. M., COYLE. J. M.. GOSK~ E. F.. and GESTHWIND, N. Apraxia and agraphia in a left-hander. Bruin 96, 21-28, 1973. 26. SICVORFT, J. L. and NORTH. P. Le.? Apraxirs Gesruelles. hlasson, Paris, 1979.

Cette sa

frlquence

n&e

que

lation ant

les

est

qu’elle

sent

paramPtres

des

montte

Les

que

itroitement

de

Parmi

la

plus

les

hate

la

et

et

langage. de

compcOhension non

de

partager

les

alors

c’est

a une

avec

confirme

la

La praxie

et

mSmes

de la

structures

corr6-

de

que

secondairement

etude Broca.

et

aphasiques

Les

cependant, et

Stablit

d’aphasiques

praxies,

Wernicke

verbaux,

Notre

aphasiques

de

L’apraxie,

l’aphasie

scmblent

du

aphasiques

corr6lation. de

les

groupes

catigories

para&tres

au tours

relics

praxie les

chez

diffPrents

diverses

meilleure.

d0ficits

faciale

l’apraxie dans

de‘la

severe

l’aphasie.

l’apraxie

de

entre

plus

avec

de

quantitative caracteristiques

significativement

corrGlation

de

les

apraxie

hension

v6ritO

ses

diffirences

entre

une

Etude

et

compr+

meilleure avec

le

Broca

leur

la

OS-

drssin

pridwinance le

langage

nerveuses.

Zusammenfassung Diese quantitative

Untersuchung

und die Charakteristika schiede

zwischen

Parametern

verschiedenen

der Praxie

der

am besten

Schwere

h6chsten

Korrelationen.

erscheinen

dieselben

Kategorien

obwohl

der aphasischen

der Praxie

Unsere

Apraxie

neuronalen

waren

starker

signifikant

besser

Untersuchung

Parametern bestatigt

und SprachvermGgen Strukturen

und an zweiter zeigt

die Unterzwischen

apraktisch war.

die Bedeutung

Apraxie

Steele mit

das Zeichnen

sind eng miteinander

zu teilen.

zeigt das AusmaD

Gruppen,

und die Korrelation

im Sprachversttidnis

Bei den nichtverbalen

Patienten

aphasixhen

Broca-Aphasiker

ihr Sprachversttiodnis

mit dem Defizit

der Aphasie.

bei Broca-Aphasic.

Apraxie

bei verschiedenen

und der Sprache.

als Wernicke-Aphasiker. korrelierte

der

der Apraxie

die

der Gesichtsapraxie verbunden

und