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The Clinical Neuropsychologist

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Cognitive Approach to the Assessment of

Limb Apraxia
a b c
Angela Bartolo , Roberto Cubelli & Sergio Della Sala
a
Laboratoire URECA, Psychologie, Université Charles-de-Gaulle Lille
III, France
b
Dipartimento di Scienze della Cognizione e della Formazione,
Università di Trento, Italy
c
Human Cognitive Neuroscience, Psychology, University of
Edinburgh, UK

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To cite this article: Angela Bartolo, Roberto Cubelli & Sergio Della Sala (2008): Cognitive Approach to
the Assessment of Limb Apraxia, The Clinical Neuropsychologist, 22:1, 27-45

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 The Clinical Neuropsychologist, 22: 27–45, 2008
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ISSN: 1385-4046 print=1744-4144 online
DOI: 10.1080/13854040601139310

CE COGNITIVE APPROACH TO THE ASSESSMENT

OF LIMB APRAXIA

Angela Bartolo1, Roberto Cubelli2, and Sergio Della Sala3

1
Laboratoire URECA, Psychologie, Université Charles-de-Gaulle Lille III,
France, 2Dipartimento di Scienze della Cognizione e della Formazione,
Università di Trento, Italy, and 3Human Cognitive Neuroscience, Psychology,
University of Edinburgh, UK
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A new instrument for the assessment of the different levels of gesture processing, as iden-
tified by recent cognitive models of apraxia, is presented. The battery comprises thirteen
tasks—eight assess the production of meaningful gestures both on command and on imi-
tation, four tasks assess the ability to recognize and identify gestures, and one task assesses
imitation of meaningless gestures. The battery encompasses a novel test of gesture pro-
duction on visual command. A total of 60 healthy British volunteers were tested with the
entire battery. On the whole, participants made more errors with pantomimes than with
other tasks. Their scores served as norms.

Keywords: Assessment; Cognitive model; Gestures; Limb apraxia

INTRODUCTION
The term limb apraxia was coined by Steinthal (1881) to indicate the difficulty
in planning and executing actions or to move a body part as a consequence of a brain
lesion. Limb apraxia is a specific form of apraxia defined as the deficit of purposive
movements, which cannot be explained by elementary motor or sensory defect, by
task comprehension problems, or inattention to command (De Renzi & Faglioni,
1999). Purposive movements can be classed in two categories: meaningless and
meaningful gestures. Meaningless gestures are gestures that carry no meaning for
the examinee (e.g., fist under the chin). In the realm of meaningful gestures, three
different kinds can be identified: transitive gestures, involving the actual manipu-
lation and use of tools; intransitive gestures, or symbolic gestures such as the
‘‘military salute’’; and pantomimes, the miming of tool use.
Limb apraxia usually affects all types of gestures. However, dissociations
across types of gestures have been reported. Goldenberg and Hagmann (1997)

Address correspondence to: Angela Bartolo, Laboratoire URECA, Université Charles-de-Gaulle

Lille III, Domaine universitaire du Pont de Bois, BP 149, 59653 Villeneuve d’Ascq Cedex France. E-mail:
angela.bartolo@univ-lille3.fr
Accepted for November 27, 2006. First published online: April 13, 2007.

# 2007 Psychology Press, an imprint of the Taylor & Francis group, an Informa business
 28 ANGELA BARTOLO ET AL.

described two patients who were able to imitate meaningful gestures but showed dif-
ficulties in the imitation of meaningless gestures. The opposite pattern has been
observed by Bartolo, Cubelli, Della Sala, Drei, and Marchetti (2001): their patient
flawlessly imitated meaningless gestures, yet she performed well below cut-off in
tasks assessing the imitation of meaningful gestures. Furthermore, cases of selective
deficit in the production of pantomimes (Bartolo, Cubelli, Della Sala, & Drei, 2003),
object use (Fukutake, 2003; Heath, Almeida, Roy, Black, & Westwood, 2003;
Motomura & Yamadori, 1994), and intransitive gestures (Cubelli, Marchetti,
Boscolo, & Della Sala, 2000) have been reported.
Liepmann (1920) was the first to investigate the nature of limb apraxia (for a
review see Goldenberg, 2003). He singled out two forms of limb apraxia: ideational
(IA) and ideomotor apraxia (IMA). According to Liepmann, patients with IA fail to
retrieve the formula of the movements to carry out actions with an object. Under
these circumstances, a patient with IA who is required to perform a gesture would
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not know what to do. On the contrary, patients are said to be suffering from
IMA if they do know what to do, but do not know how to implement the gestures
(Morlaas, 1928).
The IA=IMA dichotomy suggests that limb apraxia has to be conceived as a
gesture production deficit (for further discussion see Cubelli & Della Sala, 1996).
However, several cases have been reported of patients showing difficulties in tasks
where gesture production is not required. These non-production deficits encompass
difficulties in ordering pictures depicting the correct object use sequence (Lehmkuhl
& Poeck, 1981) as well as problems in categorizing objects according to their manner
of manipulation (Buxbaum & Saffran, 2002; Buxbaum, Veramonti, & Schwartz,
2000). Moreover, non-production deficits have been demonstrated as impairments
of selection, including choosing among four alternatives the picture representing
the correct object manipulation (Bergego, Pradat-Diehl, Deloche, & Lauriot-
Prevost, 1992; Cubelli et al., 2000; Seron, Van Der Kaa, Remitz, & Van Der Linden,
1979), selecting the correct object corresponding to a pantomime (Ferro, Santos,
Castro-Caldas, & Mariano, 1980; Gainotti & Lemmo, 1976), matching a pantomime
to an object (‘‘pantomime agnosia’’, Bartolo, 2002; Rothi, Mack, & Heilman, 1986),
or attributing a meaning to a gesture (‘‘conceptual apraxia,’’ Ochipa, Rothi, &
Heilman, 1992).
Roy (1983) proposed a cognitive model of praxis processing comprising of a
conceptual and a production system. Similarly, De Renzi (1985) posited a step within
the praxis processing that specifies the semantic knowledge of familiar gestures and
contains the long-term representations of learned gestures. He also proposed a
second level; i.e., the motor control for the action to be executed. A deficit at the first
level would result in a semantic impairment, the patients’ ability to retrieve concep-
tual information would be damaged, yet patients would be able to imitate gestures.
This deficit would correspond to IA and it would be assessed by means of tasks
investigating the production of meaningful gestures on command (De Renzi,
Pieczuro, & Vignolo, 1968). A deficit at the second level would affect the perform-
ance of tasks requiring the production of gestures, but the ability to recognize and
identify gestures would be spared. This would correspond to IMA and it could be
assessed with tasks investigating gesture imitation (De Renzi, Motti, & Nichelli,
1980). This approach reiterated the existence of two forms of limb apraxia and
 ASSESSMENT OF LIMB APRAXIA 29

accrued the habit of assessing it by using two sets of tasks (transitive gestures to
assess IA and intransitive to assess IMA). This approach cannot account for all
the patterns of spared and impaired abilities one can glean from the literature, such
as imitation more affected than production of gestures on command (Ochipa,
Rothi, & Heilman, 1994; Poncet, Pelissier, Sebahoun, & Nasser, 1971), the difficulty
in distinguishing well-executed from awkward gestures (Heilman, Rothi, &
Valenstein, 1982; Sirigu et al., 1995), or impaired production of transitive gestures
coupled with spared ability in identifying gestures (Bergego et al., 1992).
To do justice to the complexity of limb apraxia, Rothi, Ochipa and Heilman
(1991, 1997) proposed a model of praxis processing, mapped onto the cognitive
model of language processing (Patterson & Shewell, 1987). Subsequently, Cubelli
et al. (2000) modified Rothi at al.’s model focusing only on the cognitive aspects
of praxis deficit (Figure 1). This cognitive model of praxis process presents the
following features:
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. A route for the processing of familiar gestures (lexical route) and one for meaning-
less gestures (non-lexical route).

Figure 1 Outline of the cognitive model of limb praxis (from Rothi et al., 1997 as modified by Cubelli et al.,
2000). On the left, the input and output lexicon and the action semantic, composing the lexical route; on
the right the visuo-motor conversion mechanism characterizing the non-lexical route.
 30 ANGELA BARTOLO ET AL.

. The lexical route includes a mechanism for gesture identification (‘‘action seman-
tic’’), which specifies gestures’ meaning, the context in which they have to be exe-
cuted, the functional properties of the objects, and all the encyclopedic knowledge
related to the objects (for a discussion see Mahon & Caramazza, 2005). It also
includes a lexical system (‘‘gestural lexicon’’) that processes learned gestures and
constitutes the repertoire of their motor programs.
. The lexical system is further divided into an ‘‘input’’ stage for gesture recognition
and an ‘‘output’’ stage for gesture production.
. The non-lexical route includes a visuo-motor conversion mechanism, which trans-
forms the visual information into motor action.
. Both the lexical and the non-lexical route converge in a gestural buffer that holds
the motor program information on-line until the gesture is reproduced.

This model predicts five clinical pictures of limb apraxia, according to the dif-
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ferent loci of impairment (see Figure 1). A deficit of the action input lexicon would
be characterized by the difficulty in recognizing and identifying seen gestures coupled
with a spared ability to imitate and execute gestures on verbal command. A deficit of
the action semantic system would result in spared imitation of meaningless gestures
but impaired execution of meaningful gestures coupled with problems in attributing
meaning to gestures. Patients should be able to disentangle familiar from unfamiliar
gestures and to differentiate well-executed from clumsy gestures (these abilities are
stored in the spared action input lexicon). A deficit at the level of the action output
lexicon should impair the production of meaningful gestures, with a spared ability to
attribute meaning to gestures. Since patients would have access to a spared visuo-
motor conversion mechanism, the imitation of meaningless gestures will be normal.
Deficits of the visuo-motor conversion mechanism should affect the imitation of
meaningless gestures, with spared ability in producing and comprehending meaning-
ful gestures. A deficit at the level of the gestural buffer would impair the production
of both meaningful and meaningless gestures, including imitation, but would not
weaken the ability to perform judgment and categorization tasks.
The lexical route processes familiar gestures, both transitive and intransitive.
However, working memory is necessary for the production of pantomimes. In this
context working memory is conceived as a complex system (Logie & Della Sala,
2006) which permits the creation of new motor programs drawing from both the
semantic system and the output lexicon (Bartolo et al., 2003). Hence, a further form
of limb apraxia that the model predicts is the isolated deficit of the production of
pantomimes, caused by an impairment of this integration mechanism.
The upsurge of such a complex cognitive model of praxis processing calls for
the development of a new instrument for the assessment of the different stages fore-
seen by the model and the relative patterns of limb apraxia following specific lesion
to each of these stages.

AIMS OF THE PRESENT STUDY

The main aim of the current study is to present a new battery of tasks assessing
the different stages of praxis processing (Cubelli et al., 2000). This battery comprises
of tasks for gesture recognition and identification (taxing input lexicon and action
 ASSESSMENT OF LIMB APRAXIA 31

semantic), as well as tasks for the assessment of gestures production (familiar and
meaningless) in different modalities of gesture presentation, i.e., on command
(e.g., verbal and visual) or on imitation. The tasks included in this battery move
away from those used in the other available test batteries assessing limb apraxia
(e.g., Le Gall, Dupont, & Forgeau, 1994; Rothi et al., 1992; Viggiano, 2004) in
several respects:

1. Intransitive gestures are usually elicited under verbal modality (Spinnler &
Tognoni, 1987). Nevertheless, since many apraxic patients are also aphasic, it
is not always possible to disentangle whether impairment of gesture processing
is due to apraxia or is caused by comprehension problems. Therefore, a task
has been added assessing the production of gestures under visual modality (fam-
iliar situations eliciting a specific gesture).
2. The imitation of familiar gestures is usually assessed only by means of intransitive
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gestures (Spinnler & Tognoni, 1987). However, it is not clear whether a deficit in
the imitation of familiar gestures is caused by a specific deficit in processing
intransitive gestures or by a general deficit in the imitation of familiar gestures.
Therefore, in the current battery a task for the imitation of pantomimes has been
included. Moreover, to determine whether imitation is stimulus independent, a
task assessing the imitation of transitive gesture has also been included.
3. De Renzi et al. (1980) proposed a task for gesture imitation whereby meaningful
and meaningless gestures are mixed up. Imitation tasks are susceptible to list
composition effect, in particular mixed lists elicit more errors than ‘‘pure’’
lists and might obscure the nature of the deficit (Cubelli, Bartolo, Nichelli, &
Della Sala, 2006; Cubelli et al., 2000; Tessari & Rumiati, 2004). Therefore, sep-
arate tasks have been used, each assessing a different aspect of gesture imitation,
i.e., homogeneous lists of intransitive gestures, pantomimes, and meaningless
gestures.
4. There is still little agreement on the best way to assess pantomimes. Some authors
(Dumont, Ska, & Schiavetto, 1999), ask patients to perform given actions (e.g.,
‘‘Show me how you would brush your teeth’’) rather than asking the participant
to demonstrate the object’s use (e.g., ‘‘Show me how you would use the tooth-
brush’’), with the risk of assessing the semantic and encyclopedic knowledge
rather than praxis abilities. Under these experimental conditions, errors such as
‘‘body part as object’’ (BPO) could occur: for instance patients would use their
index finger as if it is a toothbrush (moving their fingers in the act to brush their
teeth, as required by the task), instead of closing their hand as if they were hold-
ing the toothbrush in their hand (demonstration of object use). BPO errors are
frequent also among normal volunteers (Duffy & Duffy, 1989), and usually
consist of iconic gestures, performed to represent an object and its functional
properties. Nevertheless, when healthy individuals are asked to avoid BPO errors,
they can perform the pantomime correctly, whereas left-brain-damaged patients
cannot, indicating that BPO error is a sign of limb apraxia (Raymer, Maher,
Foundas, Heilman, & Rothi, 1997). Some authors (Buxbaum & Saffran, 2002)
give a full score to pantomimes which have a ‘‘global recognisability’’ (Buxbaum
& Saffran, 2002, p. 184)—that is to say that the gesture is an acceptable approxi-
mation or it is similar enough to the target gesture to be recognized, regardless of
 32 ANGELA BARTOLO ET AL.

the quality of production—and do not consider BPO as errors (Buxbaum &

Saffran, 2002; Buxbaum et al., 2000). However, pantomimes should be conceived
as gestures without object, coherent with the characteristics of the object, the use
of which has to be represented. To execute a pantomime correctly, it is necessary
to consider the configuration of one’s own fingers and hand orientation, together
with the distance between the hand and the goal of action, e.g., the table for
hammering or the lips for drinking.

METHOD AND PROCEDURES

Participants
The battery has been calibrated by testing a group of 60 British participants
(M ¼ 25, F ¼ 35; range age ¼ 17–81, mean ¼ 47.9, SD ¼ 21.3; education
range ¼ 9–17, mean ¼ 12.4, SD ¼ 2.3). All were right-handed, with a normal or cor-
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rect to normal sight, and with no history of neurological or psychiatric disease. They
were selected from a panel of volunteers from the general public, available from
Aberdeen’s Psychology Department. Only adults and the elderly with a score above
the cut-off at the Mini Mental State Examination were included (cut-off ¼ 24;
Folstein, Folstein, & McHugh, 1975). All participants executed gestures with their
right hand. Previous studies did not show any difference between the two hands in
the imitation (De Renzi et al., 1980; Goldenberg & Strauss, 2002) or production
of gestures in healthy participants (Bartolo, Drei, Cubelli, & Della Sala, in press).

Materials
To calibrate the tasks assessing gesture production, 21 objects, 20 familiar ges-
tures, and 20 meaningless gestures were included. The material also comprised of 20
tables for the production of intransitive gestures on visual modality. The tasks for
gesture recognition included 20 familiar and 20 meaningless gestures, both
for intransitive gestures and pantomimes. The tasks for gestures identification
comprised of the same stimuli used in the production tasks. For the identification
of intransitive gestures task, 20 tables with four situations in each table were
included. The line drawing pictures of objects were taken from the set of Dell’Acqua,
Lotto, and Job (2000) and Snodgrass and Vanderwart (1980). In all, 20 tables con-
taining four objects each were included.
Description of the test battery. The battery of tasks administered com-
prised of a total of 13 tests (see also Bartolo et al., in press), which were devised
to assess the different stages of gesture processing depicted in Cubelli et al.’s cogni-
tive model (Bartolo et al., 2003; Cubelli et al., 2000) (see Table 1). For each task the
gestures employed in the battery have been vetted through a series of pilot studies,
which also addressed the issue of meaning in the specific population under study.
Through this careful selection process several gestures have been refined or eventu-
ally dropped from the final list. Inter-rater reliability was not formally checked in
this study; however it had been checked in previous investigations with the same
instruments and no discrepancy was noted between the scores of two independent
examiners (Bartolo et al., in press; Cubelli et al., 2006).
 ASSESSMENT OF LIMB APRAXIA 33

Table 1 The 13 tasks composing the battery

Levels of processing Types of gestures TASKS (input)

Production level Lexical=semantic route Intransitive 1. Command (Verbal)

2. Command (Visual)
3. Imitation
Transitive 4. Use
Pantomime 5. Command (Verbal)
6. Command (Visual)
7. Command (Tactile)
8. Imitation
Visuo-motor conversion Meaningless 9. Imitation
mechanism
Receptive level Input Lexicon Intransitive 10. Recognition
Pantomime 11. Recognition
Action semantic Intransitive 12. Identification
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Pantomime 13. Identification

Tasks for the production of familiar gestures. Eight tasks were included,
assessing the production of familiar gestures both on command and on imitation (see
Appendix for instructions and classification of errors). Participants were instructed
to keep their hand on the testing desk before the presentation of each item. If neces-
sary, items could be shown a second time. In the imitation tasks, participants were
instructed to wait until the gesture to be copied had been completely executed by
the examiner. The same 21 objects and 20 intransitive gestures were used in all tasks
assessing meaningful gestures.

. Intransitive gestures (Table 2) were assessed by means of three tasks: (i) on verbal
command, whereby the examiner gave the name of the gesture to be performed
(e.g., ‘‘Please execute the military salute’’, Test 1); (ii) on visual modality, whereby
participants were presented with a scene describing a situation and were invited
to perform the gesture elicited by the scene (e.g., ‘‘Please show me the gesture that
the person indicated by the arrow should execute’’, Test 2, see Figure 2); (iii) on
imitation modality (Test 3).
. One task assessed the ability to produce transitive gestures. Participants were
required to use the 21 objects given by the examiner one at a time (Test 4).
. Four tasks including the same items adopted for the production of transitive
gestures assessed the production of pantomimes. Since we defined the pantomimes
as the demonstration of objects use, in three tasks the participants were asked to
pretend to use the object as if they were holding the object in their hand with three
modalities of presentation: verbal (‘‘Show me how you would use a pen if you
were holding it in your hand’’, Test 5), visual (‘‘Show me how you would use this
object if you were holding it in your hand’’, Test 6), and on tactile modality
(Test 7). In the latter condition, participants were asked to identify but not to
name the objects they were manipulating. Once the object was out of touch, part-
icipants were asked to ‘‘Show me how you would use the object you have
just touched’’. In a fourth task, participants were instructed to reproduce the
pantomime executed by the examiner (Test 8).
 34 ANGELA BARTOLO ET AL.

Table 2 Stimuli used in the present study

TASKS FOR GESTURE PRODUCTION
Intransitive gestures: clapping (example), military salute, waving, stop, mopping one’s brow, silence,
exultation, giving a punch, hitchhiking, call someone, removing an annoying fly, hands up, blind man’s
bluff, being cold, point to someone, tapping one’s nose, showing muscles, sign of the cross
, gesture of
craziness
, looking at a distance
, money

Objects: hat (example), knife (example), comb, hammer, pen, key, cigarette, ring, needle, tennis racket,
saline, piano, watering can, telephone, bottle, iron, glass, toothbrush, pair of glasses
, spoon
, tea-cup
,
gun
, scissors

Meaningless gestures: index and middle finger on the forehead (example), open hand and thumb under the
chin (example), hand as a fist flexion and extension; thumb between the little and the ring finger; index
finger horizontal to the nose; move index and middle finger on the cheek; thumb and index finger toward
the ipsilateral shoulder; hand under the chin; back hand on the opposite ear; palm hand on the opposite
ear; fingers walking on the head; hand on shoulder sternum shoulder; link thumb and little finger; fist and
thumb on index finger; fist under the chin; hand parallel to nose; index and middle finger on the cheek;
hand above the head; fist rotation; showing the back hand and thumb on the index finger; index on middle
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finger and vice versa; arm lifted and index finger extended
RECOGNITION TASKS
Pantomimes: hat on the head (example); index and middle finger on the head (example); comb; hammer;
fists alternate movements; spoon; smoking a cigarette on the opposite shoulder; drink on the same shoulder;
index and middle fingers moving alternatively; pen; key; phone on the sternum; watering own body; iron;
moving index fingers ahead; fist rotation; thumb lifted, open and close hand; pair of glasses; sew with thumb
and little finger; toothbrush; ring; saline; drive with index fingers; ring on the head; sew; gun; cutting own
shoulder; index and middle finger moving horizontally; showing the palm and the back hand opening and
closing fingers; turning key behind the own body; tennis racket; scissors; watering can; writing turning the
wrist; telephone; tea-cup; spoon using inversely; glass; hammering own shoulder; cigarette; bottle; comb
own face
Intransitive gestures: clap (example); open hand and thumb under the chin (example); military salute; sign
of the cross; hand as a fist flexion and extension; waving; thumb between the little and the ring finger;
index finger horizontal to the nose; money; showing the back hand and thumb on the index finger; move
index and middle finger on the cheek; mopping one’s brow; thumb and index finger toward ipsilateral
shoulder; silence; stop; back hand on the opposite ear; fist rotation; exultation; fist under the chin; index
and middle finger on the cheek; palm hand on the opposite ear; fingers walking on the head; blind man’s
bluff; being cold; hand on shoulder sternum shoulder; hitchhiking; call someone; giving a punch; index
on middle finger and vice versa; showing muscles; fist and thumb on index finger; link thumb and little
finger; arm lifted and index finger extended; looking at a distance; point to someone; fist under the chin;
hand parallel to nose; removing an annoying fly; hand up; hand above the head; tap one’s nose; gesture
of craziness

The stimuli with asterisks are not included in the final version of the battery.

Test for the production of meaningless gestures. Meaningless gestures

(Table 2) were assessed via imitation modality only (Test 9). Stimuli were video-
recorded and presented on a TV screen, one at a time, every 5 seconds. If requested
by the examinee, gestures could be shown a second time.

Test of recognition of gestures and pantomimes. Two tasks assessing

gesture recognition were included, one assessing intransitive gestures recognition
(Test 10) and one pantomime recognition (Test 11). False pantomimes were made
up by familiar gestures containing some apparent errors (e.g., ‘‘use a needle with
the thumb and the little finger’’). Stimuli were video-recorded and presented on a
TV screen, one at a time, every 5 seconds. If requested by the examinee, gestures
could be shown a second time.
 ASSESSMENT OF LIMB APRAXIA 35
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Figure 2 Example of a stimulus used in the task eliciting the production of intransitive gestures.

Test for the identification of gestures and pantomimes. Two tasks for
the identification of intransitive gestures (Test 12) and pantomimes (Test 13) have
been included to assess the semantic system. In Test 12 participants were ask to indi-
cate the scene consistent with the gesture executed by the examiner among four alter-
natives (Figure 3). In Test 13 participants were asked to select, among four
alternatives, the image of the object that the examiner is pretending to use (Figure 4).
Times and modalities of administration. The gestures to be executed and
the objects were the same in all tasks. Therefore, to reduce learning effects, the bat-
tery was administered in two sessions on two separate days. For the same reason half
of the participants were administered the identification tasks first, while the other
half received the production tasks first. Overall, it took 1 hour to administer the
whole battery. Instructions for all tasks are reported in the Appendix. The tasks
and videos for the administration of the battery are available on-line: http://
psy-web.psy.ed.ac.uk/people/sdsala/tests (APRAXIA BATTERY).

Scores
The tasks were administered by one of the authors (AB), who scored the
answers. To avoid spurious scores, one point was attributed to each correct answer,
with no penalty if the stimulus was repeated, or if the participant corrected
her=himself.

Error Analyses
The answers given by each participant were classified on the basis of the errors
listed in the Appendix. We made this decision to ensure inclusion in the final version
of the task battery of only those stimuli that were correctly performed by the 80% of
 36 ANGELA BARTOLO ET AL.
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Figure 3 Example of a four-picture array used for the identification of intransitive gestures.

Figure 4 Example of a four-object array used for the identification of pantomimes.

 ASSESSMENT OF LIMB APRAXIA 37

participants. This is to make sure that the stimuli comprising the final battery of
tasks are unambiguous for patients.

RESULTS
The effect of gender did not play any significant role in any of the tests of the
battery. Moreover, correlations between age and task performance were not signifi-
cant (in all comparisons, p > .1). Therefore, for all tasks the cut-off score has been
calculated considering the performance of the entire group of 60 participants.
Participants performed at ceiling in the production of transitive gestures, and in
the imitation of familiar and meaningless gestures. Similarly, identification of both ges-
tures and pantomimes was executed flawlessly by all participants. In the recognition of
intransitive gestures and pantomimes, no participant committed more than six errors.
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Production of Familiar Gestures

Intransitive gestures. The mean of correct answers was 19.2 (96%,
SD ¼ 0.9) for the verbal modality and 16.2 (81%, SD ¼ 1.5) for the visual modality.
The plausibility of answers that had not been anticipated was determined by a panel
of four independent judges. In particular, the gesture of ‘‘stop’’ was considered a
plausible alternative for the stimulus ‘‘hitchhiking’’ both ‘‘clap one’s hands’’ and
‘‘putting hands on head’’ were considered plausible solutions for the table depicting
the stadium; finally, the gesture of wiping was considered a plausible alternative for
the table representing a man in a gym. Four gestures that were not correctly executed
by at least 80% of the participants in the verbal or the visual modalities of presen-
tation were excluded from the final list of stimuli, which therefore comprised of 16
gestures (see Table 2).
Pantomimes. The pantomime of five objects was not correctly performed by
the 80% of participants on the verbal, the visual, or the tactile modality (Table 3).
These stimuli have been excluded in all tasks requiring the use of objects. For the
sake of symmetry, the final list of stimuli included 16 objects, also for the imitation
task, and the production of transitive gesture task (see Table 2). The errors commit-
ted in the production of pantomimes are detailed in Table 3.

Cut-Off Scores Used in the Tasks

The purpose of this work is to allow both clinicians and researchers to assess
performances that are deviant from normality for the different levels of praxis com-
petence. To this end, the stimuli that have been selected for each task were those eli-
citing the least errors in the healthy participants, resulting in a quasi-ceiling
performance. This choice, of course, favors specificity over sensitivity. For each task,
cut-off score is given by the following formula:

M  3 SD  1 ðthe score achieved rounded to the closest numberÞ

in which M ¼ mean score and SD ¼ standard deviation score. For tasks in which
no error was committed, such as the imitation tasks, the production of transitive
gestures, and the tasks for the identification of gestures, the cut-off scores were
 38 ANGELA BARTOLO ET AL.

Table 3 Errors

Participants
producing
Body part as Distance Total at least
Objects object (BPO) error Unrecognizable errors one error (%)

Comb 2 0 0 2 3
Hammer 2 0 0 2 3
Pen 0 1 0 1 2
Key 0 0 0 0 0
Cigarette 0 0 0 0 0
Ring 3 0 0 3 3
Needle 0 0 0 0 0
Racket 0 0 2 2 2
Saline 2 0 0 2 2
Piano 0 0 0 0 0
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Watering can 0 0 0 0 0
Bottle 0 5 3 8 7
Iron 0 0 0 0 0
Glass 0 0 0 0 0
Telephone 20 0 0 20 15
Toothbrush 18 10 0 0 15
Pair of glasses
36 0 0 36 27
Spoon
0 70 0 70 32
Tea cup
0 64 2 66 28
Gun
105 0 0 0 32
Scissors
60 0 2 0 30

Number of errors produced by the 60 participants in pantomiming on command (with verbal, visual, or
tactile input) the use of the stimulus objects. The stimuli with asterisks are excluded from the final version
of the battery.

Table 4 Range, means, and SD

Intransitive gestures Pantomimes

Tasks Verbal Visual Verbal Visual Tactile

Group (17–81 yrs) Production Range 15–16 13–16 14–16 14–16 14–16
(max 16) Mean (SD) 15.95 (0.2) 15.5 (0.8) 15.6 (0.6) 15.7 (0.5) 15.6 (0.6)
Cut-off 14 12 13 13 13
Recognition Range 36–40 34–40
(max 40) Mean (SD) 39.2 (1.1) 39.0 (1.2)
Cut-off 35 34

Range, means, and standard deviations of the scores achieved by the 60 participants in tasks assessing
the production and the recognition of intransitive gestures and pantomimes. Cut-off scores are in bold.
For the remaining tasks, all the 60 participants performed at ceiling in the production of transitive gestures
(16=16), and in the imitation of intransitive gestures (16=16), pantomimes (16=16), and meaningless
gestures (20=20). The tasks assessing the identification of both intransitive gestures and pantomimes were
also executed at ceiling (16=16 for each type of gesture).
 ASSESSMENT OF LIMB APRAXIA 39

calculated as the maximum score achieved minus 1. A score below cut-off could
therefore be confidently considered pathologic. Range, means, standard deviations,
and cut-off scores achieved by the 60 participants in the tasks assessing the
production and the receptive level are reported in Table 4.

CONCLUSION
Assessing apraxia is clinically relevant, as praxis deficits can impair everyday
activities (Cubelli & Della Sala, 1996; Foundas et al., 1995). Indeed, the pattern of
spared and impaired praxis skills can assist clinicians and researchers in understand-
ing the observed tool use problems in daily activities presented by brain-damaged
patients (Buxbaum, Kyle, Grossman, & Coslett, in press; Goldenberg & Iriki,
in press; Sunderland & Shinner, in press). Different studies have demonstrated a
close relationship between severity of apraxia and levels of functional dependency
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(Sundet, Finset, & Reinvang, 1988), as well as the clear effect of apraxia on com-
munication skills (Borod, Fitzpatrick, Helm-Estabrooks, & Goodglass, 1989). Since,
like aphasia or unilateral neglect, apraxia is a fractionable cognitive deficit, a sound
assessment should allow for a detailed analysis of the different components of praxis.
Such cognitive approach to the assessment of limb apraxia may also assist clinicians
to devise a more focused rehabilitation program. Once the screening battery has
shown a potential problem at one level of the cognitive processing of praxis, the
diagnosis may be further refined with further ad hoc testing and appropriate stat-
istics (e.g., Crawford & Garthwaite, 2002).
Limb apraxia is not caused only by a deficit at the level of the production sys-
tem, since the praxis components are represented in a complex system (Cubelli et al.,
2000). The battery of tasks administered to this group of healthy British participants
led to the selection of stimuli different than those considered in a sibling study
reporting norms on the Italian population (Bartolo et al., in press). For instance,
in the UK group the sign of the cross, a gesture that achieved the highest scores
in the Italian population (Bartolo et al., in press), had to be excluded. These data
confirm that cultural differences have to be taken into consideration in choosing
an instrument for praxis assessment. Moreover, the current results did not show
any age effect, yet it is worth noticing that in the Italian version of the battery differ-
ences between an older and a younger group of participants were observed, though
only in the production of intransitive gestures. Many variables could account for this
difference, including the possibility that Italian elderly may be less experienced in
extracting meaning from vignettes.
The battery of tasks that we have presented along with its calibration for UK use
will allow the clinician and the researcher to test limb apraxia according to a multi-
stage cognitive model of praxis processing (Cubelli et al., 2000). Since the same objects
have been used as stimuli in each task, it would be relatively straightforward to make a
comparison across tasks. The administration of this limb apraxia battery would allow
one to identify the clinical pictures predicted by the cognitive model. In particular, the
patterns of spared and impaired praxis skills will identify the following syndromes:

1. Gesture agnosia: impaired familiar gesture recognition, normal gesture imitation,

and normal gesture production on command.
 40 ANGELA BARTOLO ET AL.

2. Ideational apraxia (semantic type): impaired gesture comprehension, impaired

production of familiar gestures, normal recognition of familiar gestures, and
normal imitation of meaningless gestures.
3. Ideational apraxia (procedural type): impaired production of familiar gestures,
normal recognition of familiar gestures, normal gesture comprehension, normal
imitation of meaningless gestures.
4. Ideomotor apraxia: impaired imitation of meaningless gestures, normal gesture
recognition, normal gesture comprehension, normal production of familiar
gestures.
5. Ideomotor apraxia and ideational apraxia: impaired imitation and production on
command, normal recognition and identification of gestures.

This battery successfully demonstrated its soundness in showing dissociations

among gestures and tasks, which would otherwise have gone undetected. In parti-
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cular, we have demonstrated a selective impairment of the imitation of meaningful

gestures (Bartolo et al., 2001); or that the correct execution of pantomimes requires
spared working memory abilities (Bartolo et al., 2003).
In conclusion, the battery of tasks described in the current manuscript repre-
sents a step toward a cognitive diagnosis of praxis deficits allowing clinicians and
researchers a fine-grained diagnosis building on a precise taxonomy of possible
praxis impairments. As such, it should be conceived as a flexible instrument available
to clinicians and researchers.

ACKNOWLEDGEMENTS
We are extremely grateful to Claudio Villa who drew all the pictures used in the
test battery. We also thank Claire Spivey for amending the English.

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APPENDIX
Production of Intransitive Gestures: Instructions and Errors Analysis

Test 1: Verbal modality

‘‘Now I will ask you to perform some gestures for me, such as clapping your hands.’’
Test 2: Visual modality
‘‘Now, I will show you some scenes. Once you have studied each scene, please perform the gesture that the
person indicated by the arrow should execute. For instance, what gesture should this person carry out?’’
Test 3: Imitation
‘‘Now, I will perform a gesture, you should copy it, please pay attention to my fingers and my
movements.’’
Note: The gesture of ‘‘clapping’’ will be used in all tasks as an example. In tasks 1 and 2 the following
answers are correct:
– ‘‘exultation’’: clapping, or putting hands on head (for Test 2).
– ‘‘hitchhiking’’: stop.
– ‘‘showing muscles’’: wiping (for Test 2)
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Error Analysis
C - content: execute a gesture instead of another (e.g., gesture of ‘‘waving’’ instead of ‘‘hitchhiking’’).
M - movement=sequence: movement or motor sequence incorrectly executed (e.g., no movement in the
gesture of driving away an annoying fly).
O - orientation: hand with fingers incorrectly oriented (e.g., hitchhiking with the thumb toward the left
side of the body rather than the right).
UR - unrecognizable gesture: performance that does not lead to a clear classification of the gesture.

Production of Transitive Gestures: Instructions and Error Analysis

Test 4: Use
‘‘Now, I will give you some objects, one at a time, you should simply show me how you’d use them.’’

Error Analysis
G - grasping: object grasped incorrectly or with the wrong part of the body (e.g., the toothbrush between
index and middle fingers).
O - orientation: object incorrectly oriented (e.g., the head of the pen pointing upwards rather than toward
the sheet of paper).
M - movement: incorrect movement of one or more body segments (e.g., sliding fingers on a keyboard).
S - semantic: use of one object instead of another (e.g., use a pen as if it was a cigarette).
UR - unrecognizable gesture: performance that does not allow a clear classification.

Production of Pantomimes: Instructions and Error Analysis

Test 5: Verbal modality

‘‘Now I will give you the name of some objects, you should show me how you would use them if you were
to hold the real object. For instance, could you show me how you would use a knife if you were holding
it in your hand?’’
Test 6: Visual modality
‘‘Now I will show you some objects, you should show me how you would use them if you were to hold the
real object. For instance, how would you use this object if you were holding it in your hand?’’ [ The
object is left on the table until the pantomime is fully executed. The examinee is asked not to touch or
name the object.]
 ASSESSMENT OF LIMB APRAXIA 45

Test 7: Tactile modality

‘‘Now I will blindfold you and I will ask you to touch some objects, one at a time. Once you have
recognized the object, without telling me what it is, please show me how you would use the object if you
were holding it in your hand. For instance, touch this object and let me know when you have
recognized it.’’ Once the object is recognized: ‘‘Show me how you would use it if you were holding it in
your hand’’. [The examinee is asked not to name the object.]
Test 8: Imitation
‘‘I will perform a gesture, you should copy exactly the gesture that I have performed paying attention to
my fingers and movement.’’ [ If requested, the gesture can be repeated.]

Error Analysis
C - configuration: incorrect shaping of the hand or fingers that do not reproduce the posture of prehension
(e.g., hand like a fist in the pantomime of drinking).
BPO - body parts as object: reproduction of the shape or the movement of the object using body parts
(e.g., move index and middle fingers as if they are the blades of scissors).
D - distance: wrong distance between the hand and the target of the action (e.g., thumb and index finger
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shaped as a circle and put in the mouth, in the gesture of drinking).

O - orientation: incorrect orientation of one or more parts of the body (e.g., index and medium fingers
oriented toward the lips in showing the action of smoking a cigarette).
D þ O - a combination of distance and orientation errors.
M - movement: incorrect movement of one or more parts of the body (e.g., in pantomiming the use of
a hummer, execute the movement parallel to the surface of the table rather than perpendicular to it).
S - semantic: pantomime of another object (e.g., instead of executing the pantomime of the use of a key,
perform the pantomime of the use of a spoon).
UR - unrecognizable gesture: performance that does not allow a clear classification.

Production of Meaningless Gestures: Instructions and Error Analysis

Test 9: Imitation
‘‘On the screen you will see a person executing a gesture. You should copy the gesture exactly as you saw
it, paying attention to fingers and movement.’’

Error Analysis
P - incorrect position of the hand or fingers with respect to the model (e.g., hand under the nose instead
of under the chin).
M - movement=sequence: incorrect movement of the hand or fingers or incorrect sequence of movements.
UR - unrecognizable: performance that does not allow a clear classification.

Recognition and Identification of Gestures: Instructions

Test 12: Recognition of intransitive gestures

‘‘Now, you will see a person executing a movement. Please tell me if the gesture is familiar to you.’’
Test 13: Recognition of pantomimes
‘‘Now, you will see a person miming the use of some objects. You should tell me if this action is familiar
to you.’’
Test 14: Identification of intransitive gestures
‘‘Now, I will execute a gesture. You should point to the situation coherent with the gesture that I have
executed.’’
Test 15: Identification of pantomimes
‘‘Now, I will mime the use of some objects. You should point to the one that I have pretended to use’’.