Imitating Gestures
A Quantitative Approach
Ennio De Renzi, MD; Fabrizia Motti, MD; Paolo Nichelli,
\s=b\ The ability to carry out movements on
imitation was assessed with a 24-item test
in uniterally hemisphere-damaged pa-
tients. On the basis of a cutoff score
derived from the performances of 100
control patients, 20% of the right
brain\p=m-\damaged patients and 50% of the
left brain\p=m-\damaged patients were classi-
fied as apraxic. Most right brain\p=m-\damaged
patients were only mildly defective, but a
few showed striking impairment. In left
a
brain\p=m-\damaged patients apraxia was not
only more frequent, but also much more
severe and was nearly always associated
with aphasia. However, the correlation
between the motor and the language
disorder was not particularly high, and the
link between the two symptoms was
thought to be dependent on the contiguity
of the underlying nervous structures.
(Arch Neurol 37:6-10, 1980)
f^ur understanding of apraxic phe-
^ nomena and the neural mecha¬
nisms underlying them is mainly
based on the interpretation of clinical
and pathological data derived from
single case studies, beginning with
Liepmann's1 analysis of his first
patient, the Regierungsrat. Although
Liepmann's interpretation of apraxia2
has received wide consensus and still
provides a sound framework of refer-
Accepted forpublication Jan 7, 1979.
From the Department of Neurology, Modena
University, Italy.
Reprint requests to Clinica Neurologica, Mod-
ena University, Via del Pozzo, 71, 41100 Modena,
Italy (Dr De Renzi).
to Ideomotor Apraxia
MD
for clarifying the nature of the
enee
disorder,3 there remain areas of uncer¬
tainty that cannot be answered from
the examination of individual pa¬
tients. Questions such as the incidence
of apraxia in unselected brain¬
damaged patients, the differential
association of apraxia with disease of
either hemisphere, the differential
occurrence of the disorder according
to the type of movement required, and
its relationship to other neurological
symptoms require the evaluation of
large patient populations with stan¬
dardized tests. To avoid excluding
from ourinvestigation patients with
verbal comprehension deficit
severe
who cannot understand verbal com¬
mands, we have restricted the scope of
our examination to imitation tasks,
although this procedure admittedly
misses patients who fail to carry out
movements on verbal command but do
so well under other circumstances.4
In two studies, imitation tasks have
been administered to unselected sam¬
ples of patients with hemisphere
damage. Adequacy of performance
was quantified by using the least
score obtained by a control patient
without cerebral disease as the cutoff
point for discriminating a normal
from an apraxic performance. In the
first investigation/' in which the
patients were asked to imitate only
conventional gestures (to salute, to
cross oneself, etc), the percentage of
apraxics was 2% in right brain-dam¬
aged patients and 39% in left
brain-damaged patients, but a moder-
ate to severeimpairment in the repro¬
duction of gestures was found only
among aphasies. The second study"
extended the imitation test to include
gestures that have no symbolic mean¬
ing and are usually not practiced: the
percentage of apraxics rose to 9% in
right brain-damaged patients and to
46% in left brain-damaged patients
(all of whom were aphasie). An inter¬
esting finding of this research was
that in the left hemisphere group,
nonsymbolic gestures were performed
more poorly than symbolic gestures,
thus suggesting that apraxia is not
related to the symbolic value of the
gesture and may be more easily
elicited by tasks requiring motor
programs that have not been over-
learned. This point was supported by
Kimura and Archibald/ while Dee et
al" maintained that there was a differ¬
ence between symbolic and nonsym¬
bolic actions, the first being closely
associated with receptive aphasia and
the second being unrelated to the
hemispheric locus of lesion. Kimura
and Archibald7 also made a distinction
between gestures requiring the pa¬
tient to reproduce a given hand posi¬
tion (eg, making a fist) and gestures
calling for the imitation of motor
sequences (eg, closed fist, thumb side¬
ways on table). Only in the second
type of movements were left
brain-damaged patients significantly
impaired in comparison with right
brain-damaged patients, a finding
which led the authors to propose that
the primary deficit in the left hemi-
sphere group was one of motor
sequencing.
Another possibly relevant dimen¬
sion of apraxia is suggested by the
finding that in commissurotomized
patients, difficulty in imitating hand
postures flashed to one visual field
was present in the hand ipsilateral to
the hemisphere receiving the visual
information and was limited to fine
differential movements of thumb or
fingers, whereas fairly good perform¬
ance was obtained with arm or whole
hand movements.9
The present research was undertak¬
en to assess the incidence of impair¬
ment in copying movements in hemi¬
sphere-damaged patients, the relation
of the deficit to the nature of the
movements, and its association with
aphasia.
SUBJECTS AND METHODS
Subjects
Two hundred eighty right-handed pa¬
tients from the neurological wards or the
outpatient speech unit of our department
participated in this study. One hundred
were patients free from brain injury; 80
were patients whose history, neurological
signs, and, in most cases, EEG, brain scan,
and neuroradiological data pointed to a
diesease confined to the right hemisphere;
and 100 were patients with damage
restricted to the left hemisphere. Forty
these were nonaphasic and 60 were apha¬
sie, as determined by performance on a
standard aphasia battery that also permit¬
ted definition of the type of aphasia: 25
were Wernicke's, 14 Broca's, 12 global, 5
conduction, and 4 anomic aphasies. The
distinction between global and Broca's
aphasies, whose expressive behavior may
be very similar, was made on the basis of
oral comprehension level, as assessed by
the Token Test. Nonfluent aphasies were
diagnosed global if they scored less than 17
on the shortened version of the Token
Test,1" Broca's if they scored 17 or more.
The mean age was 52.6 years for control
patients, 55.9 years for left brain-damaged
patients, and 57.7 years for right
brain-damaged patients. The most fre¬
quent etiology in both hemispheric damage
groups was vascular disease (accounting
for nearly 80% of all diagnoses), followed
by tumor and trauma. The time elapsed
since the onset of illness varied widely,
ranging from a few days to several years,
but tended to be longer in the aphasie
group because of the presence of patients
who were attending the outpatient speech
unit for language rehabilitation. Even in
this group, however, approximately 50% of
patients were examined not later than two
months after onset of illness.
Testing Procedures
Movement Imitation Test.-The test con¬
sisted of 24 movements which the examin¬
er performed slowly in front of the patient,
who was required to reproduce them imme-
diately afterwards from memory. Each Token Test.—This oral comprehension
item classifiable according to the test was administered in the version
was
De Renzi and
following three dimensions: (1) indepen¬ published by Paglioni.1"
dent finger movements vs whole hand
movements, (2) holding a position vs carry¬ RESULTS
ing out motor sequences, and (3) symbolic
vs nonsymbolic gestures. The possible com¬
Since there was no difference
bination of the three dimensions yielded between the performance of the
eight conditions, which are given in Table control patients who used the right
1. There were three items for condition and limb and those who used the left limb,
12 items for either alternative of a given the control patients' scores were
dimension (namely, 12 movements were pooled. Their distribution, together
symbolic and 12 nonsymbolic, 12 were posi¬ with that of the three brain-damaged
tions and 12 sequences, 12 involved fingers
and 12 the hand). If an item was not groups, is given in Table 2. It ranges
from 72 to 62, with the exception of
correctly reproduced on the first presenta¬ one subject who performed very poor¬
tion, a second trial was given, and, when
necessary, a third one. The patient's per¬ ly (52). Because of the large number of
formance was credited 3, 2, 1, or 0 points, control patients examined, it was
depending on whether it was flawless on thought appropriate to disregard the
the first, second, or third trial, or if all performance of this patient and to set
three trials were unsatisfactory. Conse¬ the cutoff score at the level of the
quently, the maximum score a patient last-but-one control patient: brain¬
could obtain was 9 for each condition, 36 for
either alternative of a given dimension, damaged patients scoring less than 62
were considered apraxic. Sixteen
and 72 for the whole test. Motor sequences
were always repeated three times on each (20%) right brain-damaged patients,
presentation and the patient was re¬ two (5%) nonaphasic left brain-dam¬
quested to reproduce them three times in aged patients, and 48 (80%) aphasie
succession. left brain-damaged patients were
Brain-damaged patients used the limb found to perform in the apraxic range.
ipsilateral to the side of the lesion, while A 2 4 contingency table (including
half the control patients performed the the control patients) can be derived
task with the right limb and half with the from these data. Its three degrees of
left limb. freedom were utilized for orthogonal
Demonstration-of-Use Test.—This test
wasnot originally planned for this experi¬ comparisons, contrasting the two left
of ment and has been subsequently intro¬ brain-damaged groups to the control
duced as part of a separate study. Data are plus the right brain-damaged group
consequently available for a limited num¬ (x--> 58,
= < .001), the right
ber of patients. Ten common objects (ham¬ brain-damaged group to the control
mer, fan, glass, revolver, eraser, screwdriv¬ group ( =
8, 81, P< .05), and the
er, fork, saw, comb, key) were presented nonaphasic, left brain-damaged
singly and the patient was asked to show group to the aphasie, left brain-dam¬
how he would use them without, however,
being permitted to hold them. A flawless aged group ( - =
74, < .001). It
follows from this
analysis that a poor
performance was scored 2; if the perform¬
ance was totally or partially incorrect, a performance on imitating move¬
second trial was given and was scored 1 if ments, although occurring in a non-
correct, 0 if wrong. negligible minority (20%) of right
Required for Each Condition
Table 1.—Examples of Movements
No. of Maximum
Condition Example Items Score
Finger, position, symbolic Forefinger and middle
finger raised to rep¬
resent letter V
Finger, position, nonsymbolic Middle finger arched
on forefinger
Finger, sequence, symbolic Snapping one's finger
Finger, sequence, nonsym¬ Flexing and extending
bolic alternately the
forefinger and mid¬
dle finger on bent
thumb
Hand, position, symbolic Saluting
Hand, position, nonsymbolic Hand, palm down, ho¬
rizontally held under
chin
Hand, sequence, symbolic Crossing oneself
Hand, sequence, nonsymbolic Fist on forehead; tip
of fingers, vertically
held, on lips
 Table 2.—Score Distribution of the Four
brain-damaged patients, is far more
Groups* frequent among left brain-damaged
Hemisphere
Left Lett Hemi- patients, being usually associated
Control Right Hemisphere Nonaphasic sphere Aphasie with aphasia and very rarely present
Score (N =
100)_(N 80)_(N = =
40)_(N = 60) in the absence of this symptom.
72 22 9 2 1 If the exceptionally low score of the
worst performance by a control
70
patient is taken as the cutoff point to
69 17 define a severe praxic impairment,
68 8 12 the outcome of the analysis does not
67 6 10 substantially change. There are still
66 three right brain-damaged patients
65 who fail, and in the group with left-
64 sided lesion, apraxia is found only
63 among aphasies, 32 (53%) of whom fall
62 below the cutoff point.
61
The score distributions given in
60
Table 2 show that most of the
59 "apraxic" right brain-damaged pa¬
tients were only mildly defective, with
58
scores 1 to 5 points below the cutoff
57
score. There were, however, four
56
55 patients whose performance was re¬
54 markably poor. They were complete
right-handers suffering from a stroke
51
that in three cases was likely to have
50 produced a large infarct in the middle
48
cerebral artery distribution, as sug¬
47 gested by the presence of left hemi¬
46 plegia, hemianesthesia, and hemiano¬
pia, and by the brain scan findings.
43
Left visual field defects were present
42
in all four patients, but a sensory
deficit can be ruled out, because
40 special care was taken to present the
36
movements in the intact visual field,
35
and the quality of the errors revealed
that the examiner's gestures had been
33
seen. Neither in the patients' histories
32
nor in the neurological examinations
31
were there symptoms or signs point¬
24
23 ing to left hemisphere damage, and on
verbal tasks the patients did not
21
14 appear impaired. The errors they
made bore a certain resemblance to
the model, were not due to persevera¬
ron of movements carried out in the
'Broken line Indicates cutoff
previous items, and were not specifi¬
score.
cally characterized by a spatial deficit.
The following are examples of dis¬
rupted performance: instead of arch¬
ing the middle finger on the forefin¬
ger, one patient pressed the forefin¬
ger on the dorsal surface of the thumb
in each of the three trials; instead of
putting the fist on the forehead and
Table 3.—Number of Patients With Scores Below Cutoff Score for Each the tips of the fingers on the lips,
another patient put the tips of the
Type of Movement
fingers on both the forehead and the
Lett Hemisphere Lett Hemisphere lips. We were unable to find consist¬
Cutoff Score Right Hemisphere Nonaphasic Aphasie ent differences between the types of
(Maximum, 36) (N = 80) (N = 40) ( = 60) errors made by these patients and
Fingers 28 14 42 those made by left brain-damaged
Hand 32 10 39
Postures 32 36
patients of comparable impairment.
The relationship of apraxia on
Sequences 27 42
imitation to aphasia was further
Symbolic 30 41
investigated by examining the inci¬
Nonsymbolic 29 40
dence of the motor deficit in different
aphasie subtypes. The 60 aphasies
were subdivided into the following
categories: global aphasia (N 12),
Wernicke's aphasia (N 25), Broca's
= native of a given dimension to
aphasia (N 14), conduction aphasia
= discriminate apraxic from nonapraxic
(N 5), and anomic aphasia (N 4).
= =
All global aphasies, 88% of Wernicke's,
and 86% of Broca's aphasies were
apraxic, and all but one global, 56% of
Wernicke's, and 43% of Broca's apha¬
sies were severely impaired (ie, scored
below 52). The rank distributions of
these groups were compared by the
Mann Whitney test. The difference
between Broca's and Wernicke's apha¬
sies was not significant (z —.85), =
while global aphasies were signifi¬
cantly more impaired than Broca's
(z 3.24, < .0006) and Wernicke's
=
aphasies ( =
2.19, < .01). Only
conduction aphasies and no anomic
aphasies were impaired, but the num¬
ber of these patients is too small to
permit drawing firm conclusions.
To obtain a measure of the associa¬
tion linking the apraxic deficit to the
language deficit, the imitation test
scores achieved by aphasies were
correlated with the Token Test scores,
which, not being dependent on articu-
latory proficiency, were considered a
faithful, though partial measure of
the patient's verbal competence. The
correlation coefficient was .56
(P < .01, df =
58).
The imitation test was devised to
allow a separate evaluation of the
various types of gestures and of their
differential impairment following
hemispheric damage. The data for the
single conditions were not analyzed
separately due to the relatively small
scores that would have been involved.
For either alternative of the three
dimensions taken into account by the
test, the 99% cutoff score of the
control patients' distribution was de¬
termined. These scores are given in
Table 3, together with the number of
patients of the three brain-damaged
groups whose scores fall below them.
It is apparent from the data of this
Table that normal control patients
have somewhat more difficulty with
finger movements than with hand
movements and with motor sequences
than with postures, and that a slightly
greater number of right brain-dam¬
aged patients and aphasie patients
have scores below the cutoff score in
imitating finger movements in com¬
parison with hand movements and
motor sequences in comparison with
postures. None of these proportions is,
however, significantly different from
any other either in right hemi¬
sphere-damaged patients or in apha¬
sies. Symbolic and nonsymbolic ges-
tures are practically identical.
A more direct estimate of the
= differential sensitivity of either alter¬
patients was made with the McNe-
mar's test for matched pairs11 in the
aphasie group. Postures and motor
sequences were studied because these
were the alternatives apparently pro¬
ducing the greater discrepancy in the
percentage of patients with failing
scores. Thirty-one patients were
found to be apraxic on both tests; 13
on neither of them; 11 were apraxic on
postures, but not on sequences; and 5
were apraxic on sequences but not on
postures. The - test yielded a value of
1.56, which is not significant.
two A final question concerns the extent
to which the intransitive movements
examined are comparable with move¬
ments requiring the use of objects,
which have been traditionally em¬
ployed to detect apraxia. The correla¬
tion between the imitation test scores
and the scores on the demonstration-
of-use test was computed for the 50
left brain-damaged patients, for
whom both sets of data were avail¬
able. The correlation coefficient was
.80, which suggests that the two tests
assess approximately the same abili¬
ties.
COMMENT
To avoid any interferences with
motor weakness, the hemisphere-
damaged patients of the present ex¬
periment carried out the task with the
limb ipsilateral to the side of the
lesion. Their performance is, there¬
fore, informative of the ability of one
hemisphere to execute the appropriate
motor program with the limb submit¬
ted to its control when the other hemi¬
sphere is injured. Liepmann's- claim
that the left hemisphere plays a domi¬
nant role in programming movements
receives full support by our findings,
which show that failure to initiate
gestures is much more frequent and
severe in the left limb following left-
sided damage than in the right limb
following right-sided damage. When
evaluated with a quantitative proce¬
dure, which makes reference to the
control patients' performance, the
incidence of apraxia on imitation
following left brain damage is re¬
markably high (50%), especially if only
patients with language deficit are
considered (80%), probably higher
than many neurologists would be
inclined to think. The underestima¬
tion of this easily detectable sign is
likely to be due, as Geschwind12
suggests, to the fact that neither the
patient nor the patient's relatives call
the physician's attention to a disorder
that in the great majority of cases
only appears in the testing situation
and does not trouble the patient in
everyday life. No selection was made
in our left hemisphere-damaged sam¬
ple, which comprised a sizable num¬
ber of global aphasies, all of whom
were apraxic. Had they been excluded,
the percentage of apraxics would be
lower.
The close association between
apraxia and aphasia raises the ques¬
tion of the nature of the bond linking
the two symptoms. Does the language
disorder play a specific role in impair¬
ing the ability to imitate gestures, or
is the relation dependent on the
anatomical contiguity of the neural
substrates subserving the two per¬
formances? The first hypothesis
seems unlikely on an intuitive basis. It
is hard to envisage the reproduction of
visually presented movements as a
language-mediated activity, all the
more so for nonconventional gestures
that cannot be identified with a name.
Also, the size of the correlation
between the imitation test scores and
the Token Test scores (.56), though
significant, is not sufficiently high to
warrant the inference that the severi¬
ty of the movement disorder is strictly
dependent on the severity of the
language disorder, and would seem
more supportive of the view that the
lesion responsible for apraxia very
frequently encroaches on the cerebral
areas specialized for language. The
clinical observations of patients only
mildly defective in their linguistic
performance and who are, neverthe¬
less, severely apraxic, strengthens the
belief that the two functions can be
separately impaired, a conclusion
further borne out by the rare case
reports13-15 of left-handed subjects
with speech centers in the left hemi¬
sphere who become apraxic but not
aphasie following a right hemisphere
lesion.
The frequent association of apraxia
with Broca's aphasia had already been
stressed by Liepmann,2 while Ajuria-
guerra et al10 reported that in patients
with a retro-Rolandic lesion, aphasia
(conceivably, of the Wernicke type)
was present in 90% of apraxics. Our
data concur with these claims and
show that both the frequency and
severity of apraxia are not different
in Wernicke's as compared with Bro¬
ca's aphasia, namely, in two forms
related to the lesion of relatively
distant areas. This finding is in keep¬
ing with a connectionist view, which
suggests discrete neural networks
extending along a wide region of the
lefthemisphere and associating the
posterior temporoparietal cortex with
the frontal premotor cortex. When
large portion of this area is damaged,
as occurs in global aphasia, frequency
and severity of apraxia increase.
An unexpected and not easily
explainable finding was the presence
of apraxia in the right limb of 20% of
right brain-damaged patients. Even
if one maintains that the mild impair¬
ment found in 12 of 16 patients does
not deserve the label of apraxia and
simply reflects an inaccurate behav¬
ior, not specifically related to brain
damage, the issue is not disposed of,
because there are still four patients
whose performance was so poor both
quantitatively and qualitatively as to
make it indistinguishable from that of
clear-cut left hemisphere apraxics. A
possible explanation is that these
patients suffered also from a clinically
undetected left hemisphere lesion that
would be responsible for apraxia.
Though not rejectable on principle,
this ad hoc hypothesis remains entire¬
ly speculative. We feel that at the
present stage of knowledge a definite
conclusion must be suspended, but
future investigators should be aware
1. Liepmann H: Das Krankheitsbild
Apraxie (Motorischen Asymbolie). Monatsschr
Psychiatr Neurol 8:15-44, 102-132, 182-197, 1900.
2. Liepmann H: Die linke Hemisph\l=a"\reund das
Handelns. M\l=u"\nchMed Wochenschr 52:2322-2326,
2375-2378, 1905.
3. Geschwind N: Disconnexion syndromes in
animal and man. Brain 88:237-294, 585-644,
1965.
4. Goodglass H, Kaplan E: Disturbance of
gesture and pantomime in aphasia. Brain 86:703\x=req-\
720, 1963.
5. De Renzi E, Pieczuro A, Vignolo LA: Idea-
tional apraxia: A quantitative study. Neuropsy-
chologia 6:41-52, 1968.
6. Pieczuro A, Vignolo LA: Studio sperimen-
tale sull'aprassia ideomotoria. Sistema Nervoso
of the need tosystematically examine
right brain-damaged patients, since
at least in some cases the contribution
a of theright hemisphere to leading the
motor activity of the left hemisphere
may be greater than formerly
thought. The data of Dee et al" are
supportive of this view, although they
are limited
to the imitation of
nonsymbolic
movements.
The movement categories assessed
in the present research were all found
to be suited to bring out the apraxic
deficit. Kimura and Archibald's7 con¬
tention that motor sequences but not
postures discriminate between right
and left hemisphere lesion was not
upheld by the finding that the
percentage of positive and negative
diagnoses achieved by the two tests
was not significantly different. There
are differences in the clinical charac¬
teristics of patients, test composition,
and evaluation criteria of the two
studies that may in part account for
their conflicting outcome.
It would appear that the features
characterizing the praxic deficit re¬
side not so much in the nature of the
gesture as in the circumstances under
which it is evoked. Whether the move¬
ment is symbolic or nonsymbolic,
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