Apraxia: Pediatric PT Primer

Apraxia

Apraxia is a neurological disorder characterized by loss of the ability to execute or carry out skilled movements and gestures, despite having the desire and the physical ability to perform them. Typically, most children do not spend time thinking about what is required to catch a ball or to combine sounds to say a word. A child with apraxia has to work at each part of the movement to coordinate a complete task.   

In other words, Apraxia is a condition in which a child experiences a disconnect between what they want to achieve or accomplish, and the ability to plan and coordinate the movements required to reach the end result.

There are several kids of apraxia, which may occur alone or together:

  1. Ideomotor Apraxia: the inability to make the intended movement in response to a verbal command.
    • The most widely recognized type of apraxia is ideomotor apraxia, or impaired performance of skilled motor acts despite intact sensory, motor, and language function.
    • Typically demonstrated when a child is asked verbally to perform a gesture.
    • This also includes the inability to imitate another person’s gesture, to perform the appropriate action in response to a visually presented object, or to carry out a movement using the actual object.
    • Affects timing, sequencing, grading of movement, and limb position in space.
    • Children with apraxia are often able to perform the same acts without difficulty in their daily lives without conscious thought. This phenomenon has been called the “voluntary-automatic dissociation”.
    • Children may exhibit differing degrees of impairment depending on testing conditions. For instance, children typically have greatest difficulty performing gestures elicited by verbal command, with less difficulty imitating a gesture or acting in response to a visual cue. They may be least impaired when asked to use the object itself.
    • Performance may differ depending on gesture type: transitive (involving an object; eg, using a hammer) versus intransitive (eg, waving goodbye); meaningful versus meaningless.
  2. Limb-kinetic Apraxia: characterized by inaccurate or clumsy distal movements; the inability to make fine, precise movement with upper or lower extremity.
    • Often seen in the limb contralateral to the affected hemisphere.
    • Associated with frontal lesions.
    • Limb-kinetic apraxia differs from classical ideomotor apraxia.  For instance, limb-kinetic apraxia tends to be independent of modality (eg, verbal command versus imitation), and there is typically no voluntary-automatic dissociation.
  3. Buccofacial or Orofacial apraxia: characterized by an impairment of skilled movements involving the face, mouth, tongue, larynx, and pharynx (eg, blowing a kiss).
    • Associated with inferior frontal, deep frontal white matter, and basal ganglia lesions.
    • Automatic movements of the same muscles are often preserved.
    • Frequently presents with limb apraxia.
  4. Ideational apraxia: the inability to coordinate activities with multiple, sequential movements, such as dressing, eating, and bathing.
    • Child with ideational apraxia exhibit difficulties carrying out a sequence of actions in performance of a complex, multistep task (eg, putting on shoes).
    • Ideational apraxia is often seen in those with extensive left hemisphere damage.
    • Difficulty sequencing actions may not represent a higher-order motor programming deficit; rather, this deficit may be due to a combination of executive, language, and memory limitations or to a general limitation in cognitive resources

Other categories of Apraxia, are best left to my Pediatric Speech and Occupational Therapy colleagues for their unique expertise and wisdom such as:

  1. Verbal apraxia (difficulty coordinating mouth and speech movements)
  2. Constructional apraxia (the inability to copy, draw, or construct simple figures)
  3. Oculomotor apraxia (difficulty moving the eyes on command)

Apraxia is often associated with:

1. Benign Congenital Hypotonia (decreased muscle tone): Often results in delays in motor milestones such as sitting, crawling, and walking.  Children with hypotonia often sit with a rounded back and/or in a “W”-sitting position due to the laxity of the ligaments of the lower extremities.  Low muscle tone may effect oral motor musculature, impacting feeding and speech.

2. Gross and fine motor coordination deficits: This may manifest in lack of fluidity of gait, awkward running pattern,throwing and catching a ball, or difficulty performing activities of daily living (dressing, toileting, feeding).

3. Motor planning difficulties: A child with motor planning difficulties may have trouble imitating sequences of motor movements like playing pat-a-cake or doing jumping jacks.

4. Sensory Integration/Self-Regulatory issues: Children may have difficulty processing the senses of touch, taste, smell, vision, and hearing. Some children can be sensory seeking, in that they seek out sensory input due to being underresponsive to sensation. For example, a child who is sensory seeking might have decreased attention, crash into objects, and touch other people inappropriately. Other children are sensory-avoiding, and may have a heightened sensitivity to sensory experiences, dislike being touched, dislike loud noises, avoid messy play, and be intolerant to daily tasks like hair washing and tooth brushing. Children may also have a mixed response to sensory input; they can be sensory avoiding as well as sensory seeking to different stimuli. For example, a child may seek out rough play and crave deep input via bear hugs, while at the same time, dislike walking on grass or touching sand. Some children may also display difficulty with self-regulation, difficulty calming themselves and self-soothing, and also often have difficulty establishing regular sleeping and eating patterns.

5. Delayed or mixed hand dominance is often seen in children with apraxia. In typically developing children, hand dominance typically develops around 2 years of age, the time when the brain begins to allocate tasks specifically to the right and left hemispheres. In most individuals, language lateralizes to the left hemisphere, however, in children with apraxia, the emergence of hand dominance is often delayed, or a child will show mixed dominance, indicating a delay in brain specialization.

Assess and Evaluate Each Child’s:

  • Strength
  • Flexibility
  • Posture
  • Motor Control
  • Motor Planning
  • Sensory Processing

Activities to Address Skills May Include:

  • Wheelbarrow Walking
    • These tactile discs are a great addition to the wheelbarrow walking activity! Providing sensory input, encouraging upper body weight bearing and activation of important muscles!
apraxia wheelbarrow walk
  • Animal Walks
apraxia animal walk
  • Heavy work (pushing, pulling, lifting)
apraxia wheelbarrow
apraxia yoga
apraxia climbing ladder
  • Navigating Obstacle Course
apraxia bucket bridge
  • Sports Specific skills (soccer, basketball, swimming, bike riding)

apraxia swimming

When teaching new skills, a problem solving or cognitive approach can be helpful.  Break down tasks into smaller components and use visual cues when possible! Find opportunities for success to build child’s confidence. 

For example, if a child is practicing putting on his or her shoes, encourage practice of the final part of the task, just closing the Velcro strap, so that they experience success. Evaluate any potential deterrents or distractions so that they can focus on task at hand. apraxia

Teaching a New Activity

Example: How to Catch a Ball

apraxia
Break down the activity into steps.  This helps the child with the sequencing of the movement required to accomplish the task.  
  1. Start out with a big beach ball or balloon as these are easier to catch.
  2. Demonstrate task.  Visual modeling helps the child plan and execute the task.
  3. Provide verbal directions for each step.  Give one direction at a time. 
  4. Physically guide the child through each step.
  5. If child has difficulty timing the actual catch, use numbers “1-2-3” or “ready, set and go” as verbal cues to prepare.
  6. A child with poor body awareness or poor spatial perception may benefit from standing on a mat or within a clearly defined space (spot markers are great for this!).
  7. Increase the distance between child and the person throwing the ball.  Start off a few steps away.  Once the catch is mastered from this short distance, gradually increase the distance.
  8. Once distance is mastered, attempt to decrease size of ball.  Try a smaller playground ball, and eventually a tennis ball.
  9. Encourage at each step along the way.  Confidence is key!

Other ideas:

  • Teach children using different modalities, getting sensory systems involved. When learning the letters of the alphabet, use play dough, shaving cream or popsicle sticks to demonstrate and practice how to form letters.
  • Use visual, auditory and tactile models for the child.  Experiment with each, as different children benefit from different types of modeling.
  • Activities which address rhythmic movement can be helpful, as these provide a foundation for coordinated, efficient, automatic movement.
    • Marching in place while singing
    • Stair climbing while counting
    • Jumping on trampoline while clapping or reciting ABC’s
  • Make activities meaningful, tasks with purpose that involve multi-step commands such as baking/cooking building, planting/gardening, etc.

 

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