Cognition in action: testing a model of limb apraxia

Visuo-spatial complexity potentiates the body-part effect in intransitive imitation of meaningless gestures

Recent studies on the imitation of intransitive gestures suggest that the body part effect relies mainly upon the direct route of the dual-route model through a visuo-transformation mechanism. Here, we test the visuo-constructive hypothesis which posits that the visual complexity may directly potentiate the body part effect for meaningless gestures. We predicted that the difference between imitation of hand and finger gestures would increase with the visuo-spatial complexity of gestures. Second, we aimed to identify some of the visuo-spatial predictors of meaningless finger imitation skills. Thirty-eight participants underwent an imitation task containing three distinct set of gestures, that is, meaningful gestures, meaningless gestures with low visual complexity, and meaningless gestures with higher visual complexity than the first set of meaningless gestures. Our results were in general agreement with the visuo-constructive hypothesis, showing an increase in the difference between hand and finger gestures, but only for meaningless gestures with higher visuo-spatial complexity. Regression analyses confirm that imitation accuracy decreases with resource-demanding visuo-spatial factors. Taken together, our results suggest that the body part effect is highly dependent on the visuo-spatial characteristics of the gestures.

A preliminary study of white matter disconnections underlying deficits in praxis in left hemisphere stroke patients

Limb apraxia is a higher-order motor disorder often occurring post-stroke, which affects skilled actions. It is assessed through tasks involving gesture production or pantomime, recognition, meaningless gesture imitation, complex figure drawing, single and multi-object use. A two-system model for the organisation of actions hypothesizes distinct pathways mediating praxis deficits via conceptual, 'indirect', and perceptual 'direct' routes to action. Traditional lesion- symptom mapping techniques have failed to identify these distinct routes. We assessed 29 left hemisphere stroke patients to investigate white matter disconnections on deficits of praxis tasks from the Birmingham Cognitive Screening. White matter disconnection maps derived from patients' structural T1 lesions were created using a diffusion-weighted healthy participant dataset acquired from the human connectome project (HCP). Initial group-level regression analyses revealed significant disconnection between occipital lobes via the splenium of the corpus callosum and involvement of the inferior longitudinal fasciculus in meaningless gesture imitation deficits. There was a trend of left fornix disconnection in gesture production deficits. Further, voxel-wise Bayesian Crawford single-case analyses performed on two patients with the most severe meaningless gesture imitation and meaningful gesture production deficits, respectively, confirmed distinct posterior interhemispheric disconnection, for the former, and disconnections between temporal and frontal areas via the fornix, rostrum of the corpus callosum and anterior cingulum, for the latter. Our results suggest distinct pathways associated with perceptual and conceptual deficits akin to 'direct' and 'indirect' action routes, with some patients displaying both. Larger studies are needed to validate and elaborate on these findings, advancing our understanding of limb apraxia.

The neural correlates of limb apraxia: An anatomical likelihood estimation meta-analysis of lesion-symptom mapping studies in brain-damaged patients

Limb apraxia is a motor disorder frequently observed following a stroke. Apraxic deficits are classically assessed with four tasks: tool use, pantomime of tool use, imitation, and gesture understanding. These tasks are supported by several cognitive processes represented in a left-lateralized brain network including inferior frontal gyrus, inferior parietal lobe (IPL), and lateral occipito-temporal cortex (LOTC). For the past twenty years, voxel-wise lesion symptom mapping (VLSM) studies have been used to unravel the neural correlates associated with apraxia, but none of them has proposed a comprehensive view of the topic. In the present work, we proposed to fill this gap by performing a systematic Anatomic Likelihood Estimation meta-analysis of VLSM studies which included tasks traditionally used to assess apraxia. We found that the IPL was crucial for all the tasks. Moreover, lesions within the LOTC were more associated with imitation deficits than tool use or pantomime, confirming its important role in higher visual processing. Our results questioned traditional neurocognitive models on apraxia and may have important clinical implications.

The Neurocognitive Bases of Meaningful Intransitive Gestures: A Systematic Review and Meta-analysis of Neuropsychological Studies

Researchers and clinicians have long used meaningful intransitive (i.e., not tool-related; MFI) gestures to assess apraxia-a complex and frequent motor-cognitive disorder. Nevertheless, the neurocognitive bases of these gestures remain incompletely understood. Models of apraxia have assumed that meaningful intransitive gestures depend on either long-term memory (i.e., semantic memory and action lexicons) stored in the left hemisphere, or social cognition and the right hemisphere. This meta-analysis of 42 studies reports the performance of 2659 patients with either left or right hemisphere damage in tests of meaningful intransitive gestures, as compared to other gestures (i.e., MFT or meaningful transitive and MLI or meaningless intransitive) and cognitive tests. The key findings are as follows: (1) deficits of meaningful intransitive gestures are more frequent and severe after left than right hemisphere lesions, but they have been reported in both groups; (2) we found a transitivity effect in patients with lesions of the left hemisphere (i.e., meaningful transitive gestures more difficult than meaningful intransitive gestures) but a "reverse" transitivity effect in patients with lesions of the right hemisphere (i.e., meaningful transitive gestures easier than meaningful intransitive gestures); (3) there is a strong association between meaningful intransitive and transitive (but not meaningless) gestures; (4) isolated deficits of meaningful intransitive gestures are more frequent in cases with right than left hemisphere lesions; (5) these deficits may occur in the absence of language and semantic memory impairments; (6) meaningful intransitive gesture performance seems to vary according to the emotional content of gestures (i.e., body-centered gestures and emotional valence-intensity). These findings are partially consistent with the social cognition hypothesis. Methodological recommendations are given for future studies.

Actions are characterized by 'canonical moments' in a sequence of movements

Understanding what others are doing is an essential aspect of social cognition that depends on our ability to quickly recognize and categorize their actions. To effectively study action recognition we need to understand how actions are bounded, where they start and where they end. Here we borrow a conceptual approach - the notion of 'canonicality' - introduced by Palmer and colleagues in their study of object recognition and apply it to the study of action recognition. Using a set of 50 video clips sourced from stock photography sites, we show that many everyday actions - transitive and intransitive, social and non-social, communicative - are characterized by 'canonical moments' in a sequence of movements that are agreed by participants to 'best represent' a named action, as indicated in a forced choice (Exp 1, n = 142) and a free choice (Exp 2, n = 125) paradigm. In Exp 3 (n = 102) we confirm that canonical moments from action sequences are more readily named as depicting specific actions and, mirroring research in object recognition, that such canonical moments are privileged in memory (Exp 4, n = 95). We suggest that 'canonical moments', being those that convey maximal information about human actions, are integral to the representation of human action.1.

A fist bump in a political meeting? The influence of social context on affordance selection

Historically, understanding human cognition such as action processing has been a challenging issue in cognitive neuropsychology and the more we know about cognition, the more we shape it as a complex, multi-determined phenomenon that is embedded in a social context. The present study aimed at understanding how the social context could influence affordance selection. We hypothesized that affordance selection would be modulated by social context and that a given hand configuration would be considered appropriate or not, as a function of the presence or absence of social context. Twenty-six healthy participants were asked to judge the appropriateness of three variants of 10 hand-object interactions based on photographs presented with or without a visual, social context. In our results, hand configurations were intrinsically acceptable or not, but this effect was modulated by the social context. A three-step model of the influence of social context on affordance selection was proposed, according to which selection depends on social norms, in the form of social knowledge and social context analysis.

An active inference model of hierarchical action understanding, learning and imitation

We advance a novel active inference model of the cognitive processing that underlies the acquisition of a hierarchical action repertoire and its use for observation, understanding and imitation. We illustrate the model in four simulations of a tennis learner who observes a teacher performing tennis shots, forms hierarchical representations of the observed actions, and imitates them. Our simulations show that the agent's oculomotor activity implements an active information sampling strategy that permits inferring the kinematic aspects of the observed movement, which lie at the lowest level of the action hierarchy. In turn, this low-level kinematic inference supports higher-level inferences about deeper aspects of the observed actions: proximal goals and intentions. Finally, the inferred action representations can steer imitative responses, but interfere with the execution of different actions. Our simulations show that hierarchical active inference provides a unified account of action observation, understanding, learning and imitation and helps explain the neurobiological underpinnings of visuomotor cognition, including the multiple routes for action understanding in the dorsal and ventral streams and mirror mechanisms.

Visual Form and Event Semantics Predict Transitivity in Silent Gestures: Evidence for Compositionality

Silent gesture is not considered to be linguistic, on par with spoken and sign languages. It is claimed that silent gestures, unlike language, represent events holistically, without compositional structure. However, recent research has demonstrated that gesturers use consistent strategies when representing objects and events, and that there are behavioral and clinically relevant limits on what form a gesture may take to effect a particular meaning. This systematicity challenges a holistic interpretation of silent gesture, which predicts that there should be no stable form-meaning correspondence across event representations. Here, we demonstrate to the contrary that untrained gesturers systematically manipulate the form of their gestures when representing events with and without a theme (e.g., Someone popped the balloon vs. Someone walked), that is, transitive and intransitive events. We elicited silent gestures and annotated them for manual features active in coding transitivity distinctions in sign languages. We trained linear support vector machines to make item-by-item transitivity predictions based on these features. Prediction accuracy was good across the entire dataset, thus demonstrating that systematicity in silent gesture can be explained with recourse to subunits. We argue that handshape features are constructs co-opted from cognitive systems subserving manual action production and comprehension for communicative purposes, which may integrate into the linguistic system of emerging sign languages. We further suggest that nonsigners tend to map event participants to each hand, a strategy found across genetically and geographically distinct sign languages, suggesting the strategy's cognitive foundation.

Shared and distinct routes in speech and gesture imitation: Evidence from stroke

Dual-route models of high-level (praxis) actions distinguish between an "indirect" semantic route mediating meaningful gesture imitation, and a "direct" sensory-motor route mediates meaningless gesture imitation. Similarly, dual-route language models distinguish between an indirect route mediating production and repetition of words, and a direct route mediating non-word repetition. Although aphasia and limb apraxia frequently co-occur following left-hemisphere cerebrovascular accident (LCVA), it is unclear which aspects of these functional-neuroanatomic dual-route architectures are shared across praxis and language domains. This study focused on gesture imitation to test the hypothesis that semantic information (and portions of the indirect route) are shared across domains, whereas two distinct dorsal routes mediate sensory-motor mapping. Forty chronic LCVA and 17 neurotypical controls completed semantic memory and language tasks and imitated 3 types of gesture stimuli: (1) labeled/"named" meaningful, (2) unnamed meaningful, and (3) meaningless gestures. The comparison of accuracy between meaningless versus unnamed meaningful gestures examined the benefits of semantic information, while the comparison of unnamed meaningful versus named meaningful imitation examined additional benefits of linguistic cueing. Mixed-effects models examined group by task interaction effects on gesture ability. We found that for patients with LCVA, unnamed meaningful gestures were imitated more accurately than meaningless gestures, suggesting that semantic information was beneficial, but there was no benefit of labeling. Reduced benefit of semantic information on gesture accuracy was associated with lesions to inferior frontal and posterior temporal regions as well as semantic memory performance on a pictorial (non-gesture) task. In contrast, there was no relationship between meaningless gesture imitation and nonword repetition, indicating that measures of direct route performance are not associated across language and action. These results provide preliminary evidence that portions of the indirect semantic route are shared across the language and action domains, while two direct sensory-motor mapping routes mediate word repetition and gesture imitation.

Paradoxical decrease of imitation performance with age in children

Imitation development was studied in a cross-sectional design involving 174 primary-school children (aged 6-10), focusing on the effect of actions' complexity and error analysis to infer the underlying cognitive processes. Participants had to imitate the model's actions as if they were in front of a mirror ('specularly'). Complexity varied across three levels: movements of a single limb; arm and leg of the same body side; or arm and leg of opposite body sides. While the overall error rate decreased with age, this was not true of all error categories. The rate of 'side' errors (using a limb of the wrong body side) paradoxically increased with age (from 9 years). However, with increasing age, the error rate also became less sensitive to the complexity of the action. This pattern is consistent with the hypothesis that older children have the working memory (WM) resources and the body knowledge necessary to imitate 'anatomically', which leads to additional side errors. Younger children might be paradoxically free from such interference because their WM and/or body knowledge are insufficient for anatomical imitation. Yet, their limited WM resources would prevent them from successfully managing the conflict between spatial codes involved in complex actions (e.g. moving the left arm and the right leg). We also found evidence that action side and content might be stored in separate short-term memory (STM) systems: increasing the number of sides to be encoded only affected side retrieval, but not content retrieval; symmetrically, increasing the content (number of movements) of the action only affected content retrieval, but not side retrieval. In conclusion, results suggest that anatomical imitation might interfere with specular imitation at age 9 and that STM storages for side and content of actions are separate.

The social cognitive dimension of pantomime

Pantomime production is commonly interpreted as reflecting tool-use-related cognitive processes. Yet, in everyday life, pantomime deserves a communication function and the exaggeration of amplitude found during pantomime compared to real tool use may reflect the individual's attempt to communicate the intended gesture. Therefore, the question arises about whether pantomime is a communicative behavior that is nevertheless supported only by non-social cognitive processes. We contribute to answering this question by using kinematic analyses. Participants performed the pantomime of using a saw or a hammer from visual presentation in three conditions: Free (no specific instructions), Self (focus on the real tool-use action), and Others (focus on the communicative dimension). Finally, they used the tool with the corresponding object (Actual condition). Participants' social cognition were assessed using gold standard questionnaires. Our results indicated that the manipulation of instructions had a minor effect on the exaggeration of amplitude during pantomime. We reported a link between the social cognition score and the amplitude in the Others condition for the hammer, which suggests that social cognitive processes could take part in pantomime production in some conditions. Nevertheless, this result does not alter our conclusion that social cognitive processes might be far from necessary for pantomime production.

Physical understanding in neurodegenerative diseases

This quantitative review gives an overview of physical understanding (i.e., the ability to represent and use the laws of physics to interact with the physical world) impairments in Alzheimer's disease (AD), semantic dementia (SD), and corticobasal syndrome (CBS), as assessed mainly with mechanical problem-solving and tool use tests. This review shows that: (1) SD patients have apraxia of tool use because of semantic tool knowledge deficits, but normal performance in tests of physical understanding; (2) AD and CBS patients show impaired performance in mechanical problem-solving tests, probably not because of intrinsic deficits of physical understanding, but rather because of additional cognitive (AD) or motor impairments (CBS); (3) As a result, the performance in mechanical problem-solving tests is not a good predictor of familiar tool use in dementia; (4) Actual deficits of physical understanding are probably observed only in late stages of neurodegenerative diseases, and associated with functional loss.

Pantomime of tool use: looking beyond apraxia

Pantomime has a long tradition in clinical neuropsychology of apraxia. It has been much more used by researchers and clinicians to assess tool-use disorders than real tool use. Nevertheless, it remains incompletely understood and has given rise to controversies, such as the involvement of the left inferior parietal lobe or the nature of the underlying cognitive processes. The present article offers a comprehensive framework, with the aim of specifying the neural and cognitive bases of pantomime. To do so, we conducted a series of meta-analyses of brain-lesion, neuroimaging and behavioural studies about pantomime and other related tasks (i.e. real tool use, imitation of meaningless postures and semantic knowledge). The first key finding is that the area PF (Area PF complex) within the left inferior parietal lobe is crucially involved in both pantomime and real tool use as well as in the kinematics component of pantomime. The second key finding is the absence of a well-defined neural substrate for the posture component of pantomime (both grip errors and body-part-as-tool responses). The third key finding is the role played by the intraparietal sulcus in both pantomime and imitation of meaningless postures. The fourth key finding is that the left angular gyrus seems to be critical in the production of motor actions directed towards the body. The fifth key finding is that performance on pantomime is strongly correlated with the severity of semantic deficits. Taken together, these findings invite us to offer a neurocognitive model of pantomime, which provides an integrated alternative to the two hypotheses that dominate the field: The gesture-engram hypothesis and the communicative hypothesis. More specifically, this model assumes that technical reasoning (notably the left area PF), the motor-control system (notably the intraparietal sulcus), body structural description (notably the left angular gyrus), semantic knowledge (notably the polar temporal lobes) and potentially theory of mind (notably the middle prefrontal cortex) work in concert to produce pantomime. The original features of this model open new avenues for understanding the neurocognitive bases of pantomime, emphasizing that pantomime is a communicative task that nevertheless originates in specific tool-use (not motor-related) cognitive processes.

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Brain Dynamics of Action Monitoring in Higher-Order Motor Control Disorders: The Case of Apraxia

Limb apraxia (LA) refers to a high-order motor disorder characterized by the inability to reproduce transitive actions on commands or after observation. Studies demonstrate that action observation and action execution activate the same networks in the human brain, and provides an onlooker’s motor system with appropriate cognitive, motor and sensory-motor cues to flexibly implementing action-sequences and gestures. Tellingly, the temporal dynamics of action monitoring has never been explored in people suffering from LA. To fill this gap, we studied the electro-cortical signatures of error observation in human participants suffering from acquired left-brain lesions with (LA+) and without (LA–) LA, and in a group of healthy controls (H). EEG was acquired while participants observed from a first-person perspective (1PP) an avatar performing correct or incorrect reach-to-grasp a glass action in an immersive-virtual environment. Alterations of typical EEG signatures of error observation in time (early error positivity; Pe) and time-frequency domain (theta band-power) were found reduced in LA+ compared with H. Connectivity analyses showed that LA+ exhibited a decreased theta phase synchronization of both the frontoparietal and frontofrontal network, compared with H and LA–. Moreover, linear regression analysis revealed that the severity of LA [test of upper LA (TULIA) scores] was predicted by mid-frontal error-related theta activity, suggesting a link between error monitoring capacity and apraxic phenotypes. These results provide novel neurophysiological evidence of altered neurophysiological dynamics of action monitoring in individuals with LA and shed light on the performance monitoring changes occurring in this disorder.

Bottom-up and top-down modulation of route selection in imitation

The cognitive system selects the most appropriate action imitative process: a semantic process - relying on long-term memory representations for known actions, and low-level visuomotor transformations for unknown actions. These two processes work in parallel; however, how context regularities and cognitive control modulate them is unclear. In this study, process selection was triggered contextually by presenting mixed known and new actions in predictable or unpredictable lists, while a cue on the forthcoming action triggered top-down control. Known were imitated faster than the new actions in the predictable lists only. Accuracy was higher and reaction times faster in the uncued conditions, and the predictable faster than the unpredictable list in the uncued condition only. In the latter condition, contextual factors modulate process selection, as participants use statistical regularities to perform the task at best. With the cue, the cognitive system tries to control response selection, resulting in more errors and longer reaction times.

Gesture errors in left and right hemisphere damaged patients: A behavioural and anatomical study

OBJECTIVE

Erroneous gesture execution is at the core of motor cognition difficulties in apraxia. While a taxonomy of errors may provide important information about the nature of the disorder, classifications are currently often inconsistent. This study aims to identify the error categories which distinguish apraxic from non-apraxic patients.

METHOD

Two groups of mixed (bucco-facial and limb) and bucco-facial apraxic patients suffering from stroke were compared to non-apraxic, left and right hemisphere damaged patients in tasks tapping the ability to perform limb and bucco-facial actions. The errors were analysed and classified into 6 categories relating to content, configuration or movement, spatial or temporal parameters and unrecognisable actions. Furthermore, an anatomical investigation (VLMS) was conducted in the whole group of left hemisphere damaged patients to investigate potential correlates of the various error categories.

RESULTS

Although all the above error typologies may be observed, the most indicative of mixed apraxia is the content-related one in all the typologies of actions (transitive and intransitive), and configuration errors in transitive ones. Configuration and content errors in mouth actions seem to be typical of bucco-facial apraxia. Spatial errors are similar in both apraxic and right brain damaged, non-apraxic patients. A lesion mapping analysis of left-brain damaged patients demonstrates that all but the spatial error category are associated with the fronto-parietal network. Moreover, content errors are also associated with fronto-insular lesions and movement errors with damage to the paracentral territory (precentral and postcentral gyri). Spatial errors are often associated to ventral frontal lesions.

CONCLUSIONS

Bucco-facial and mixed apraxic patients make different types of errors in different types of actions. Not all errors are equally indicative of apraxia. In addition, the various error categories are associated with at least partially different neural correlates.

100 years after Liepmann-Lesion correlates of diminished selection and application of familiar versus novel tools

100 years ago, Liepmann highlighted the role of left ventro-dorsal lesions for impairments in conceptual (rather ventral) and motor (more dorsal) related aspects of apraxia. Many studies thereafter attributed to an extended left fronto-temporo-parietal network. Yet, to date there are only few studies that looked at apraxic performance in the selection and application of familiar versus novel tools. In the current study we applied modern voxel-based lesion-symptom mapping (VLSM) to analyze neural correlates of impaired selection and application of familiar versus novel tools. 58 left (LBD) and 51 right brain damaged (RBD) stroke patients participated in the Novel Tools Test (NTT) and the Familiar Tools Test (FTT) of the Diagnostic Instrument for Limb Apraxia (DILA-S). We further assessed performance in control tasks, namely semantic knowledge (BOSU), visuo-spatial working memory (Corsi Block Tapping) and meaningless imitation of gestures (IML). Impaired tool use was most pronounced after LBD. Our VLSM results in the LBD group suggested that selection- versus application-related aspects of praxis and semantics of familiar versus novel tool use can be behaviorally and neuro-anatomically differentiated. For impairments in familiar tool tasks, the major focus of lesion maps was rather ventral while deficiencies in novel tool tasks went along with rather dorsal lesions. Affected selection processes were linked to rather anterior lesions, while impacted application processes went along with rather posterior lesion maps. In our study, particular tool selection processes were rather specific for familiar versus novel tools. Foci for lesion overlaps of experimental and control tasks were noticed ventrally for semantic knowledge and FTT, in fronto-parietal regions for working memory and NTT, and ventro-dorsally for imitation of meaningless gestures and the application of NTT and FTT. We visualized our current interpretation within a neuroanatomical model for apraxia of tool use.

Treating limb apraxia via action semantics: a preliminary study

Limb apraxia is evident in approximately 50% of patients after left hemisphere cerebral vascular accident (LCVA) and increases disability and caregiver dependence. Individuals with apraxia exhibit abnormalities in spatio-temporal aspects of gesture production and/or in knowledge of tool-related actions (action semantics). This preliminary study of three LCVA participants aimed to (i) explore the efficacy of a novel Action Network Treatment (ANT) that focused on improving the semantic association between tool actions and other types of tool knowledge, an intervention inspired by successful semantic network treatments in aphasia (e.g., Edmonds et al., 2009), and (ii) explore whether there are individuals with apraxia who benefit from ANT relative to a version of a comparatively well-studied existing apraxia treatment (Smania et al., 2006; Smania et al., 2000) that shapes gesture via focus on practicing the spatio-temporal aspects of gesture production (Tool Use Treatment or TUT). One participant demonstrated treatment benefits from both ANT and TUT, while another only benefited from TUT. These findings indicate that our novel semantic network strengthening approach to gesture training may be efficacious in at least some individuals with apraxia, and provide a foundation for future study of the characteristics of people with apraxia who benefit from each approach.

The Effect of Structured Exercise on Short-Term Memory Subsystems: New Insight on Training Activities

It has been shown that exercise positively affects cognitive abilities, such as frontal functions and long-term memory processes. We tried to understand whether different exercises (i.e., an open-skill activity, a team game, vs. a closed-skill activity, a circuit) might specifically influence different short-term-memory (STM) subsystems of working memory. We examined the effect of a single bout of open- and closed-skill exercises on three STM tasks (i.e., verbal, visuo-spatial, and motor) in children attending the 3rd and 4th classes at primary school. One group was tested before and after (T0 and T1) an Italian class (control group), one group before and after 30-min exercise on a circuit, and one group before and after 30-min of a team game. The control group presented no improvement. The open-skill activity improved short-term memory performance in all the participants at T1 (p < 0.001 for children attending the 3rd class, and p = 0.007 for children attending the 4th class). In contrast, closed-skill activity improved short-term memory performance in older children (those attending the 4th class; p = 0.046) at T1. Importantly, this finding was found in a school setting and might have ecological validity. Therefore, the exercise protocol here used might help to structure specific training activities for both normal children and those with learning deficits to positively improve short-term memory abilities.

Anatomical correlates of recovery in apraxia: A longitudinal lesion-mapping study in stroke patients

OBJECTIVE

This study investigates the clinical course of recovery of apraxia after left-hemisphere stroke and the underlying neuroanatomical correlates for persisting or recovering deficits in relation to the major processing streams in the network for motor cognition.

METHODS

90 patients were examined during the acute (4.74 ± 2.73 days) and chronic (14.3 ± 15.39 months) stage after left-hemisphere stroke for deficits in meaningless imitation, as well as production and conceptual errors in tool use pantomime. Lesion correlates for persisting or recovering deficits were analyzed with an extension of the non-parametric Brunner-Munzel rank-order test for multi-factorial designs (two-way repeated-measures ANOVA) using acute images.

RESULTS

Meaningless imitation and tool use production deficits persisted into the chronic stage. Conceptual errors in tool use pantomime showed an almost complete recovery. Imitation errors persisted after occipitotemporal and superior temporal lesions in the dorso-dorsal stream. Chronic pantomime production errors were related to the supramarginal gyrus, the key structure of the ventro-dorsal stream. More anterior lesions in the ventro-dorsal stream (ventral premotor cortex) were additionally associated with poor recovery of production errors in pantomime. Conceptual errors in pantomime after temporal and supramarginal gyrus lesions persisted into the chronic stage. However, they resolved completely when related to angular gyrus or insular lesions.

CONCLUSION

The diverging courses of recovery in different apraxia tasks can be related to different mechanisms. Critical lesions to key structures of the network or entrance areas of the processing streams lead to persisting deficits in the corresponding tasks. Contrary, lesions located outside the core network but inducing a temporary network dysfunction allow good recovery e.g., of conceptual errors in pantomime. The identification of lesion correlates for different long-term recovery patterns in apraxia might also allow early clinical prediction of the course of recovery.

U-Limb: A multi-modal, multi-center database on arm motion control in healthy and post-stroke conditions

BACKGROUND

Shedding light on the neuroscientific mechanisms of human upper limb motor control, in both healthy and disease conditions (e.g., after a stroke), can help to devise effective tools for a quantitative evaluation of the impaired conditions, and to properly inform the rehabilitative process. Furthermore, the design and control of mechatronic devices can also benefit from such neuroscientific outcomes, with important implications for assistive and rehabilitation robotics and advanced human-machine interaction. To reach these goals, we believe that an exhaustive data collection on human behavior is a mandatory step. For this reason, we release U-Limb, a large, multi-modal, multi-center data collection on human upper limb movements, with the aim of fostering trans-disciplinary cross-fertilization.

CONTRIBUTION

This collection of signals consists of data from 91 able-bodied and 65 post-stroke participants and is organized at 3 levels: (i) upper limb daily living activities, during which kinematic and physiological signals (electromyography, electro-encephalography, and electrocardiography) were recorded; (ii) force-kinematic behavior during precise manipulation tasks with a haptic device; and (iii) brain activity during hand control using functional magnetic resonance imaging.

Knowing how to do it or doing it? A double dissociation between tool-gesture production and tool-gesture knowledge

Deciding how to manipulate an object to fulfill a goal requires accessing different types of object-related information. How these different types of information are integrated and represented in the brain is still an open question. Here, we focus on examining two types of object-related information-tool-gesture knowledge (i.e., how to manipulate an object), and tool-gesture production (i.e., the actual manipulation of an object). We show a double dissociation between tool-gesture knowledge and tool-gesture production: Patient FP presents problems in pantomiming tool use in the context of a spared ability to perform judgments about an object's manipulation, whereas Patient LS can pantomime tool use, but is impaired at performing manipulation judgments. Moreover, we compared the location of the lesions in FP and LS with those sustained by two classic ideomotor apraxic patients (IMA), using a cortical thickness approach. Patient FP presented lesions in common with our classic IMA that included the left inferior parietal lobule (IPL), and specifically the supramarginal gyrus, the left parietal operculum, the left premotor cortex and the left inferior frontal gyrus, whereas Patient LS and our classic IMA patients presented common lesions in regions of the superior parietal lobule (SPL), motor areas (as primary somatosensory cortex, premotor cortex and primary motor cortex), and frontal areas. Our results show that tool-gesture production and tool-gesture knowledge can be behaviorally and neurally doubly dissociated and put strong constraints on extant theories of action and object recognition and use.

The challenge of apraxia: Toward an operational definition?

The diagnosis of limb apraxia relies mainly on exclusion criteria (e.g., elementary motor or sensory deficits, aphasia). Due to the diversity of apraxia definitions and assessment methods, patients may or may not show apraxia depending on the chosen assessment method or theory, making the definition of apraxia somewhat arbitrary. As a result, "apraxia" may be diagnosed in patients with different cognitive impairments. Based on a quantitative and critical review of the literature, it is argued that this situation has its roots in the evolution from a task-based approach (i.e., the use of gold standard tests to detect apraxia) toward a process-based approach, namely, the deconstruction of the conceptual or production systems of action into multiple cognitive processes: language, executive functions, working memory, semantic memory, body schema, body image, visual-spatial skills, social cognition, visual-kinesthetic engrams, manipulation knowledge, technical reasoning, structural inference, and categorical apprehension. The coexistence of both approaches in the current literature is a major challenge that stands in the way of a scientific definition of apraxia. As a step toward a solution, we suggest to focus on symptoms, and on two complementary definition criteria (in addition with traditional exclusion criteria): Specificity (i.e., is apraxia explained by the alteration of cognitive processes specifically dedicated to gesture production?), and consistency (i.e., is the gesture production impairment consistent across tasks?). Two categories of limb apraxia are proposed: symptomatic apraxia (i.e., gesture production deficits that are secondary to more general cognitive impairments) and idiopathic apraxia (i.e., gesture production deficits that can be observed in isolation). It turns out that the only apraxia subtype that fulfills exclusion, specificity, and consistency criteria is limb-kinetic apraxia. A century after Liepmann's demonstration of the autonomy of apraxia toward language, the autonomy of this syndrome toward the rest of cognition remains an open question, while it poses new challenges to apraxia studies.

The autocracy of meaning: Intact visuo-imitative processes may not compensate for meaningful gestures

The dual-route models of action distinguish between a semantic and a non-semantic visuo-motor route to execute different types of gestures. Despite the large amount of evidence in support to the model, some aspects are debated. One issue concerns the recruitment of the visuo-motor route to correctly execute meaningful gestures when the semantic route is damaged. Debated predictions of the dual-route model were investigated in a sample of 32 patients with left hemisphere stroke lesions compared to 27 healthy controls. Group analysis showed that patients were equally impaired on meaningful and meaningless gestures. Single-case analysis demonstrated that most cases were more impaired on meaningful than on meaningless gestures both when they are given in separate lists and when they are intermingled. Impaired performance on the imitation of meaningful gestures in both the separate and mixed list but spared performance on meaningless gestures in the separate list is against the hypothesis that the intact visuo-motor route compensates for damage to the semantic route. These results suggest that the damaged semantic route interferes with the visuo-motor route and prevents the processing of meaningful gestures along the visuo-motor route. Furthermore, an explorative analysis was conducted to investigate the relationship between gestures imitation and pantomime of object use on verbal command and between gestures imitation and performance on linguistic tasks. Although no significant correlation emerged, patients with moderate/severe impairment on the AAT performed significantly worse on meaningful, but not on meaningless gestures than patients with mild/minimal language impairment, suggesting that praxis and language systems are independent but dynamically interact.

Body representation in people with apraxia post Stroke- an observational study

Objective: To investigate how two types of body representation (body schema and body image) were affected in people with and without apraxia following a supratentorial stroke.Design: Observational cross-sectional studySetting: Level 1 Specialist Neurological Rehabilitation UnitParticipants: 30 participants post-stroke diagnosed with (n = 10) and without apraxia (n = 20) according to a modified version of the short Ideomotor Apraxia Test.Interventions: Not applicableMain Outcome Measures: Body schema assessed using the hand laterality recognition test and body part knowledge test; Implicit body image assessed using the sidedness test.Results: Left-sided lesions were more common in the apraxic group. Compared to people without apraxia post-stroke, those with apraxia showed significantly reduced accuracy and longer reaction times on the hand laterality test and fewer correct responses on the body part knowledge test. There was no between-groups difference in the sidedness test.Conclusions: People with apraxia showed deficits in online body representations (body schema) that are used to plan and execute actions. Future research studies could target body schema deficits as an adjunct in the rehabilitation of apraxia.

Effect of body-part specificity and meaning in gesture imitation in left hemisphere stroke patients

Previous studies showed that imitation of finger and hand/arm gestures could be differentially impaired after brain damage. However, so far, the interaction between gesture meaning and body part in imitation deficits has not been fully assessed. In the present study, we aimed at filling this gap by testing 36 unilateral left brain-damaged patients with and without apraxia (20 apraxics), and 29 healthy controls on an imitation task of either finger or hand/arm meaningful (MF) gestures and meaningless (ML) movements, using a large sample of stimuli and controlling for the composition of the experimental list. Left-brain damaged patients imitated ML finger worse than hand/arm movements, whereas they did not show the same difference in MF gesture imitation. In addition, apraxic patients imitated finger movements worse than hand/arm movements. Furthermore, apraxic patients' imitation performance was equally affected irrespective of the action meaning, whereas non-apraxic patients showed better imitation performance on MF gestures. Results suggest that MF gestures are processed as a whole, as imitation of these gestures relies on the stored motor programs in long-term memory, independently of the body part involved. In contrast, ML movements seem to be processed through direct visuo-motor transformations, with left-brain damage specifically disrupting imitation performance of the more cognitive demanding finger movements.

Distinct fronto-temporal substrates of distributional and taxonomic similarity among words: evidence from RSA of BOLD signals

A class of semantic theories defines concepts in terms of statistical distributions of lexical items, basing meaning on vectors of word co-occurrence frequencies. A different approach emphasizes abstract hierarchical taxonomic relationships among concepts. However, the functional relevance of these different accounts and how they capture information-encoding of lexical meaning in the brain still remains elusive. We investigated to what extent distributional and taxonomic models explained word-elicited neural responses using cross-validated representational similarity analysis (RSA) of functional magnetic resonance imaging (fMRI) and model comparisons. Our findings show that the brain encodes both types of semantic information, but in distinct cortical regions. Posterior middle temporal regions reflected lexical-semantic similarity based on hierarchical taxonomies, in coherence with the action-relatedness of specific semantic word categories. In contrast, distributional semantics best predicted the representational patterns in left inferior frontal gyrus (LIFG, BA 47). Both representations coexisted in the angular gyrus supporting semantic binding and integration. These results reveal that neuronal networks with distinct cortical distributions across higher-order association cortex encode different representational properties of word meanings. Taxonomy may shape long-term lexical-semantic representations in memory consistently with the sensorimotor details of semantic categories, whilst distributional knowledge in the LIFG (BA 47) may enable semantic combinatorics in the context of language use. Our approach helps to elucidate the nature of semantic representations essential for understanding human language.

Structural Disconnection of the Tool Use Network after Left Hemisphere Stroke Predicts Limb Apraxia Severity

Producing a tool use gesture is a complex process drawing upon the integration of stored knowledge of tools and their associated actions with sensory-motor mechanisms supporting the planning and control of hand and arm actions. Understanding how sensory-motor systems in parietal cortex interface with semantic representations of actions and objects in the temporal lobe remains a critical issue and is hypothesized to be a key determinant of the severity of limb apraxia, a deficit in producing skilled action after left hemisphere stroke. We used voxel-based and connectome-based lesion-symptom mapping with data from 57 left hemisphere stroke participants to assess the lesion sites and structural disconnection patterns associated with poor tool use gesturing. We found that structural disconnection among the left inferior parietal lobule, lateral and ventral temporal cortices, and middle and superior frontal gyri predicted the severity of tool use gesturing performance. Control analyses demonstrated that reductions in right-hand grip strength were associated with motor system disconnection, largely bypassing regions supporting tool use gesturing. Our findings provide evidence that limb apraxia may arise, in part, from a disconnection between conceptual representations in the temporal lobe and mechanisms enabling skilled action production in the inferior parietal lobule.

The Verbal Judgement Task: Normative data of verbal abstract reasoning in a sample of 18- to 40-years old

In this study, normative data for the age-range 18-40 years have been provided for the Verbal Judgment Test (VJT), which underpins abstract reasoning on the basis of four subtests: "Differences", "Proverbs", "Absurdities" and "Classifications". 554 participants (280 males and 274 females) were recruited and the following data were provided: means and standard deviations divided by gender, educational level (8, 13 and 18 years) and age group (18-20 years, 21-25 years, 26-30 years, 31-35 years and 36-40 years) for each subtest and the total score; percentiles for each subtest, divided by age group, and, when appropriate, educational level and/or gender; Rho correlations between age group, gender, educational level, intelligence and VJT scores. Age-, education- and gender differences were also assessed carrying out non parametric tests. Results showed that age and education positively affected performance in the subtests of Differences, Proverbs and Classifications, which are mostly based on previous knowledge, experience, and crystallized intelligence, but did not affect performance in the Absurdities subtest, which encompasses to some extent fluid intelligence. In addition, males showed higher scores than females in the subtests of Differences and Proverbs and in the total VJT, probably reflecting higher knowledge acquisition. Implications for future research are briefly discussed.

Anosognosia for limb and bucco-facial apraxia as inferred from the recognition of gestural errors

Anosognosia is a multifaceted syndrome characterized by a lack of awareness of motor, cognitive, or emotional deficits. While most studies have focused on basic motor disorders such as hemiplegia, only recently, the issue of whether anosognosia also concerns higher-order motor disorders like apraxia has been addressed. Here, we explore the existence of a specific form of anosognosia for apraxia in forty patients with uni-hemispheric vascular lesions. The patients were requested to imitate actions involving upper limb or bucco-facial body parts and then judge their performance. Successively, they were also asked to observe video recordings of the same actions performed by themselves or by other patients and judge the accuracy of the displayed actions. The comparison of participants versus examiner judgement and between error recognition of others' versus self's actions was considered as an index of awareness deficit for the online and offline conditions, respectively. Evidence was found that awareness deficits occurred both immediately after action execution (online anosognosia) and in the video recording task (offline anosognosia). Moreover, bucco-facial and limb apraxic patients were specifically unaware of their errors in bucco-facial and limb actions, respectively, indicating for the first time a topographical organization of the syndrome. Our approach allowed us to distinguish awareness deficits from more general disorders in error recognition; indeed, anosognosic patients were able to identify errors when the same action was executed by another patient but not when the video showed their own actions. Finally, we provide evidence that anosognosia for apraxia might be associated with frontal cortical and subcortical networks.

Effect of test instructions: The example of the pantomime production task

The production of pantomime is a sensible task to detect praxis deficits. It is usually assessed by presenting objects visually or by verbal command. Verbal instructions are given either by providing the name of the object (e.g., "Show me how to use a pen") or by requiring the object function (e.g., "Show me how to write"). These modes of testing are used interchangeably. The aim of this study is to investigate whether the different instructions generate different performances. Fifty-one healthy participants (17-89 years old) were assessed on three pantomime production tasks differing for the instruction given: two with verbal instructions (Pantomime by Name and Pantomime by Function) and one with the object visually presented (Pantomime by Object). Results showed that Pantomime by Function produced the poorest performance and the highest frequency of Body Parts as Tool (BPT) errors, suggesting that the way the instructions are given may determine the performance in a task. Nuances in test instructions could result in misleading outcome.

A Role for the Action Observation Network in Apraxia After Stroke

Limb apraxia is a syndrome often observed after stroke that affects the ability to perform skilled actions despite intact elementary motor and sensory systems. In a large cohort of unselected stroke patients with lesions to the left, right, and bilateral hemispheres, we used voxel-based lesion-symptom mapping (VLSM) on clinical CT head images to identify the neuroanatomical correlates of the impairment of performance in three tasks investigating praxis skills in patient populations. These included a meaningless gesture imitation task, a gesture production task involving pantomiming transitive and intransitive gestures, and a gesture recognition task involving recognition of these same categories of gestures. Neocortical lesions associated with poor performance in these tasks were all in the left hemisphere. They involved the pre-striate and medial temporal cortices, the superior temporal sulcus, inferior parietal area PGi, the superior longitudinal fasciculus underlying the primary motor cortex, and the uncinate fasciculus, subserving connections between temporal and frontal regions. No significant lesions were identified when language deficits, as indicated via a picture naming task, were controlled for. The implication of the superior temporal sulcus and the anatomically connected prestriate and inferior parietal regions challenges traditional models of the disorder. The network identified has been implicated in studies of action observation, which might share cognitive functions sub-serving praxis and language skills.

Can gesture observation help people with aphasia name actions?

It has been suggested that gesture can play a role in the treatment of naming impairments in aphasia, however investigation is still sparse, especially when compared to research on verbal treatments. Critically, previous studies have included either verbal or gesture production in the training. However, while in speakers without language impairment, action naming is facilitated by gesture observation, no study has yet systematically determined whether gesture observation alone influences word retrieval in people with aphasia. This is the aim of the research presented here. In a gesture priming experiment, participants with aphasia named actions that were preceded by the observation of videos of congruent or unrelated gestures or a non-gesture control condition. At the group-level, action naming was facilitated by observation of congruent gestures. However, single-case analyses revealed variability in the extent to which the participants benefited from gesture cueing. The potential mechanisms underlying the effects of gesture observation on action picture naming in people with aphasia were examined by exploring participant-related and item-related predictors of improvement. It is concluded that gesture observation may facilitate verb retrieval at either semantic or lexical levels. In addition, and despite variability across individuals, gesture observation seems more likely to facilitate action naming in people with spared gesture semantics and mild-moderate deficits in lexical-semantic or post-semantic processing.

To Watch is to Work: a Review of NeuroImaging Data on Tool Use Observation Network

Since the discovery of mirror neurons in the 1990s, many neuroimaging studies have tackled the issue of action observation with the aim of unravelling a putative homolog human system. However, these studies do not distinguish between non-tool-use versus tool-use actions, implying that a common brain network is systematically involved in the observation of any action. Here we provide evidence for a brain network dedicated to tool-use action observation, called the tool-use observation network, mostly situated in the left hemisphere, and distinct from the non-tool-use action observation network. Areas specific for tool-use action observation are the left cytoarchitectonic area PF within the left inferior parietal lobe and the left inferior frontal gyrus. The neural correlates associated with the observation of tool-use reported here offer new insights into the neurocognitive bases of action observation and tool use, as well as addressing more fundamental issues on the origins of specifically human phenomena such as cumulative technological evolution.

EEG Complexity Maps to Characterise Brain Dynamics during Upper Limb Motor Imagery

The Electroencephalogram (EEG) can be considered as the output of a nonlinear system whose dynamics is significantly affected by motor tasks. Nevertheless, computational approaches derived from the complex system theory has not been fully exploited for characterising motor imagery tasks. To this extent, in this study we investigated EEG complexity changes throughout the following categories of imaginary motor tasks of the upper limb: transitive (actions involving an object), intransitive (meaningful gestures that do not include the use of objects), and tool-mediated (actions using an object to interact with another one). EEG irregularity was quantified following the definition of Fuzzy Entropy, which has been demonstrated to be a reliable quantifier of system complexity with low dependence on data length. Experimental results from paired statistical analyses revealed minor topographical changes between EEG complexity associated with transitive and tool-mediated tasks, whereas major significant differences were shown between the intransitive actions vs. the others. Our results suggest that EEG complexity level during motor imagery tasks of the upper limb are strongly biased by the presence of an object.

Understanding Body Language Does Not Require Matching the Body's Egocentric Map to Body Posture: A Brain Activation fMRI Study

Body language (BL) is a type of nonverbal communication in which the body communicates the message. We contrasted participants' cognitive processing of body representations or meanings versus body positions. Participants (N = 20) were shown pictures depicting body postures and were instructed to focus on their meaning (BL) or on the position of a body part relative to the position of another part (body structural description [BSD]). We examined activation in brain areas related to the two types of body representation-body schema and BSD-as modulated by the two tasks. We presumed that if understanding BL triggers embodiment of body posture, a matching procedure between the egocentric map coding the position of one's body segments in space and time should occur. We found that BL (vs. BSD) differentially activated the angular gyrus bilaterally, the anterior middle temporal gyrus, the temporal pole, and the right superior temporal gyrus, the inferior frontal gyrus, the superior medial gyrus, and the left superior frontal gyrus. BSD (vs. BL) differentially activated the superior parietal lobule (Area 7A) bilaterally, the posterior inferior temporal gyrus, the middle frontal gyrus, and the left precentral gyrus. Sensorimotor areas were differentially activated by BSD when compared with BL. Inclusive masking showed significant voxels in the superior colliculus and pulvinar, fusiform gyrus, inferior temporal gyrus, superior temporal gyrus, the intraparietal sulcus bilaterally, inferior frontal gyrus bilaterally, and precentral gyrus. These results indicate common brain networks for processing BL and BSD, for which some areas show differentially stronger or weaker processing of one task or the other, with the precuneus and the superior parietal lobule, the intraparietal sulcus, and sensorimotor areas most related to the BSD as activated by the BSD task. In contrast, the parietal operculum, an area related to the body schema, a representation crucial during embodiment of body postures, was not activated for implicit masking or for the differential contrasts.

Neural correlates of differential finger gesture imitation deficits in left hemisphere stroke

Behavioural studies in apraxic patients revealed dissociations between the processing of meaningful (MF) and meaningless (ML) gestures. Consequently, the existence of two differential neural mechanisms for the imitation of either gesture type has been postulated. While the indirect (semantic) route exclusively enables the imitation of MF gestures, the direct route can be used for the imitation of any gesture type, irrespective of meaning, and thus especially for ML gestures. Concerning neural correlates, it is debated which of the visuo-motor streams (i.e., the ventral steam, the ventro-dorsal stream, or the dorso-dorsal stream) supports the postulated indirect and direct imitation routes. To probe the hypotheses that regions of the dorso-dorsal stream are involved differentially in the imitation of ML gestures and that regions of the ventro-dorsal stream are involved differentially in the imitation of MF gestures, we analysed behavioural (imitation of MF and ML finger gestures) and lesion data of 293 patients with a left hemisphere (LH) stroke. Confirming previous work, the current sample of LH stroke patients imitated MF finger gestures better than ML finger gestures. The analysis using voxel-based lesion symptom mapping (VLSM) revealed that LH damage to dorso-dorsal stream areas was associated with an impaired imitation of ML finger gestures, whereas damage to ventro-dorsal regions was associated with a deficient imitation of MF finger gestures. Accordingly, the analyses of the imitation of visually uniform and thus highly comparable MF and ML finger gestures support the dual-route model for gesture imitation at the behavioural and lesion level in a substantial patient sample. Furthermore, the data show that the direct route for ML finger gesture imitation depends on the dorso-dorsal visuo-motor stream while the indirect route for MF finger gesture imitation is related to regions of the ventro-dorsal visuo-motor stream.

Do Children With Autism Spectrum Disorders Understand Pantomimic Events?

Impairments of motor representation of actions have been reported as a core component of autism spectrum disorders (ASD). Individuals with ASD have difficulties in a number of functions such as assuming anticipatory postures, imitating body movements, producing and understanding gestures, and recognizing motor intentions. Such cognitive-motor abilities are all involved in pantomime. However, the available evidence on the production and comprehension of pantomime in individuals with ASD is still inconclusive. The current investigation assessed pantomime comprehension in 40 children with high-functioning ASD and 40 children with typical development balanced for age, IQ, level of formal education, and cognitive profile. The participants were asked to watch video recordings of pantomimes representing simple transitive events enacted by actors and match them to the corresponding pictorial representations. Such pantomimes were delivered in two conditions with different levels of information content (i.e., lean or rich). The two groups of children performed similarly on these tasks. Nonetheless, children with ASD who were administered the pantomimes in the lean condition performed worse than participants who were administered the informatively richer pantomimes. The methodological implications for interpretation of previous findings and future studies are discussed.

Within the framework of the dual-system model, voluntary action is central to cognition

A new version of the dual-system hypothesis is described. Consistent with earlier models, the improvisational subsystem of the instrumental system, which includes the occipital cortex, inferior temporal cortex, and medial temporal cortex, especially the hippocampus, directs the construction of visual representations of the world and constructs ad-hoc responses to novel targets. The habit system, which includes the occipital cortex; parietal cortex; premotor, supplementary motor, and ventrolateral areas of frontal cortex; and the basal ganglia, especially the caudate nucleus, encodes sequences of actions and generates previously successful actions to familiar targets. However, unlike in previous dual-system models, human cognitive activity involved in task performance is not exclusively associated with one system or the other. Rather, the two systems make it possible for people to learn a variety of skills that draw on the competencies of both systems. The collective effects of these skills define human cognition. So, in contrast with earlier versions of the dual-system hypothesis, which identified the habit system solely with procedural learning and implicit improvements in task performance, the model presented here attributes a direct role in declarative-memory tasks to the habit system. Furthermore, within the model, the computational competencies of the two systems are used to construct purposeful sequences of actions-that is, skills. Human cognition is the result of the performance of these skills. Thus, voluntary action is central to human cognition.

Action Observation for Neurorehabilitation in Apraxia

Neurorehabilitation and brain stimulation studies of post-stroke patients suggest that action-observation effects can lead to rapid improvements in the recovery of motor functions and long-term motor cortical reorganization. Apraxia is a clinically important disorder characterized by marked impairment in representing and performing skillful movements [gestures], which limits many daily activities and impedes independent functioning. Recent clinical research has revealed errors of visuo-motor integration in patients with apraxia. This paper presents a rehabilitative perspective focusing on the possibility of action observation as a therapeutic treatment for patients with apraxia. This perspective also outlines impacts on neurorehabilitation and brain repair following the reinforcement of the perceptual-motor coupling. To date, interventions based primarily on action observation in apraxia have not been undertaken.