Sheikhany et al.

The Egyptian Journal

The Egyptian Journal of Otolaryngology (2022) 38:123
https://doi.org/10.1186/s43163-022-00309-8 of Otolaryngology

ORIGINAL ARTICLE Open Access

Language profile in different kinds of apraxia

in post‑stroke patients
Ayaatallah R. Sheikhany1, Dalia M. Othman1, Omnia Z. Elshebl2*   and Aisha F. Abdelhady1

Abstract
Background: Stroke affects all aspects of communication of patients by causing disorders of motor control (dysar-
thria or apraxia) or language (dysphasia) or both. The aim of this study is to evaluate language skills in patients post-
stroke presented with comorbidity with different types of apraxia.
Methods: An analytical cross-sectional study was carried out, and a number of 58 stroke adults with comorbid
apraxic manifestations of various types were included after assessing them using the protocol of motor programming
skills that was extracted from thesis titled “Assessment protocol of motor programming skills after cerebrovascular
insults” from October 2016 to July 2018. They were subjected to the interview and personal history taking, and a
modified comprehensive aphasia test to determine their language profile.
Results: Patients with verbal apraxia showed difficulty with tasks tapping verbal fluency, repetition, and picture
description. The language deficits in ideational apraxia patients included cognition tasks, verbal fluency, sentence
comprehension, and naming. Constructional apraxia patients showed language deficits in word comprehension,
complex word repetition, and naming. Limb apraxia showed greater deficits on tasks tapping working memory and
processing speed while buccofacial apraxia was accompanied by fewer language deficits in reading and repeating
complex words.
Conclusion: Heterogeneous language profile was found in different types of apraxia.
Keywords: Apraxia, Aphasia, Stroke, Reading, Writing

Background Approximately 2 million patients worldwide every year

Cerebrovascular disease is a general term encompassing suffer from cerebrovascular diseases as a result of cer-
different disturbances of the vascularization of the brain. ebral hemorrhage, cerebral infarction, and subarachnoid
The majority of deaths due to cerebrovascular diseases hemorrhage. Even if the patient’s life is saved, the after-
are due to stroke [1]. effects experienced by stroke victims are a grave problem
Every 2 s, someone in the world has a stroke; there [4]. The residual impairment in a number of functions
were almost 17 million incidences of first-time strokes fundamental for everyday activities, such as movement
worldwide in 2010 [2]. Stroke is the second most com- programming and execution, sensorimotor integration,
mon cause of death in the world, causing around 6.7 mil- language, and other cognitive functions, has a chronic
lion deaths each year, taking a life every 5 s [3]. Almost 1 impact on the overall level of functioning and quality of
in 8 deaths worldwide are caused by stroke [3]. life [5].
Communication may be impaired following cerebro-
vascular insults as a result of disorders of motor control
*Correspondence: [email protected]; [email protected] (dysarthria and dyspraxia) or language (dysphasia) or
2
Department of Otorhinolaryngology, Benha University, Banha, Qalyubia both [6].
13511, Egypt Communication is usually affected after CVI.
Full list of author information is available at the end of the article Communication is affected in the form of aphasia,

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 2 of 17

dysarthria, and apraxia. Each type of communication Methods

disorder may affect the patient separately and may This study was an analytical cross-sectional study that
be combined. This study assesses the combination has been carried out on post-stroke patients aged more
between aphasia and apraxia in post-CVI patients and than 18 years who attended the phoniatric outpatient
if there is an effect of apraxia on the language of the clinic in Kasr Al Aini and Benha university hospitals in
patients in order to put a specified detailed rehabilita- the period from October 2016 to July 2018. After obtain-
tion program that will help improve the quality of life of ing an oral informed consent, fifty-eight post-stroke
this kind of patients. adults with apraxic manifestations that were revealed
The long-term outcomes of strokes have been taught to after being assessed by the protocol of motor program-
be essentially irreversible, and it is a common belief that ming skills [15] were included in the study The assess-
the adult brain has no significant ability for self-repair or ment protocol of motor programming skills is composed
reorganization following injuries resulting in neuronal of different tasks to assess different types of apraxia (limb
death, such as CVAs. However, it is not uncommon in apraxia, verbal apraxia, buccofacial apraxia, ideational
clinical practice to see slow but consistent recovery over and ideomotor apraxias, and constructional, dressing,
a period of weeks and months following lesions underly- and swallowing apraxias). The patients included had dif-
ing seemingly stabilized neurological deficits [7]. ferent types of apraxia in addition to their language and
Aphasia, a term which is used interchangeably with communication impairment. The sample included 54
dysphasia, is defined as an acquired impairment of the patients with verbal apraxia, 23 with ideational apraxia,
components of the language system (semantics, syntax, 13 with constructional apraxia, 26 with limb apraxia, 45
phonology, morphology, and pragmatics). The language with bucco-facial apraxia and less than 4 with ideomotor
limitations include both expressive and receptive modali- apraxia, 2 with dressing apraxia, and 1 with swallowing
ties (comprehension, speaking, reading, and writing) to apraxia. Because of the very few number and percent-
varying degrees [8]. age of patients with ideomotor, swallowing and dressing
Praxis means action which refers to the ability to per- apraxia, they were excluded from the statistical analysis
form complex learned motor actions in response to ver- as it was not expected to reveal any significant findings.
bal command, imitation, or pantomiming [9]. Forty-eight patients of the sample had combined apraxia
The brain’s left hemisphere is responsible for skilled while 10 patients had single type of apraxia.
movement planning of both right and left arms, while Patients were selected from adults who suffered from
corpus callosum mediation occurred in this latter language and speech difficulties after cerebrovascular
limb [10]. insults. Patients with insults of more than 6-month dura-
Apraxia is a higher-order motor disorder impairing the tion were selected to ensure full neurological stabiliza-
ability to correctly perform skilled, purposive movements tion of their condition.
as the result of neurological disorders most commonly The exclusion criteria included were as follows: the
stroke, dementia, and movement disorders. It is increas- presence of other central neurological lesions or demen-
ingly recognized that Apraxia negatively influences activ- tia before the current stroke, addiction, presence of
ities of daily living [11]. severe physical weaknesses that might interfere with
Acquired apraxia consists of various types of apraxia active patient’s participation with the administered tasks,
among them: limb apraxia, ideational and ideomotor severe aphasia patients in the first 6 months of the cer-
apraxias, buccofacial apraxia, dressing and construc- ebrovascular insult in addition to illiterate patients.
tional apraxia, and acquired verbal apraxia [12]. Patients were subjected to the protocol of assessment
There is co-morbidity between dysphasia and apraxia that included the following: interview and personal his-
in post-stroke patients [13]. However, to our knowledge, tory taking including name, age, sex, marital status, hand-
there is no Egyptian study done to clarify if there is an iness, literacy level, and occupation. Then, the patients
effect of the presence of apraxia on the language skills in were subjected to the modified comprehensive aphasia
the population of post cerebrovascular insults. test [16]. It was carried out on the apraxic patients to
The manuscript was extracted from thesis titled assess the receptive and expressive language abilities in
“Assessment protocol of motor programming skills after the patients diagnosed as having apraxic manifestations.
cerebrovascular insults” [14]. The test consists of 34 subtests divided into three parts:
The aim of this study was to determine if there is a the Cognitive screen, the Language Battery, and the Dis-
specific language profile in patients post-stroke pre- ability Questionnaire. The first section is the cognitive
sented with comorbidity with different types of apraxia screen which includes 6 items: line bisection, seman-
in order to help establish the needed program for their tic and recognition memories, word fluency, gesture
rehabilitation. use, and arithmetic. The second section is the language
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 3 of 17

battery which is subdivided into 2 parts; the first part the ability to extract the idea of performance from the
assesses language comprehension as regards under- task.
standing spoken words, sentences, and paragraphs and Ideomotor apraxia tasks assessed d the patient’s ability
understanding written words and sentences. The second to translate the idea into a motor act in the three condi-
part assesses the expressive abilities as regards repetition tions: at rest, imitation, and in passive manner. It con-
(repetition of words, complex words, pseudowords, num- sisted of two parts:
bers, and sentences), naming pictures and actions, spo-
ken picture description, reading (words, complex words, • The first part consisted of five gestures in which the
function words and non-words), and writing (copying, patient was asked to imitate immediately the asses-
writing picture names, dictation, and picture description sor. For example: raising one’s hand.
by writing). • The second part included multiple object use where
The protocol of motor programming skills that was the patient was asked to operate; two objects, e.g., a
used to pick up the post-stroke patients with apraxic torch.
manifestations included the following: limb apraxia tasks
that were divided to receptive tasks which assess the abil- Constructional apraxia tasks assessed the ability of the
ity of the patient to understand gestures produced by the patient to assemble two shapes using matches. The first
assessor and the patient was asked to explain the purpose one is a simple square and the second is a more complex
of the gesture or explains verbally what the assessor was one which is a square with diagonals.
doing, and expressive tasks which assess the ability of the Dressing apraxia task assessed the ability of the patient
patient to perform a gesture either by imitation or panto- to dress. In addition to swallowing apraxia which was
miming (giving the orders to the patient verbally). assessed by bedside assessment. The bedside assessment
The gestures included were divided into meaningless included 2 parts:
such as “Put your thumb on your nose,” intransitive (com-
municative) such as “Use a phone in the absence of the • Dry assessment: which is an observational checklist
tool itself,” and transitive (tool related) such as “use a key.” that included 7 items: if the patient had normal pos-
Verbal apraxia was assessed by various tasks including: ture, had the ability to control his own secretions, did
not show drooling, had the ability to chew and ingest
• Diadochokinesis that consists of two items: the rate food smoothly, had completed oral evacuation and
and accuracy with increasing speed. clearing of the oral cavity post swallow, was safe and
• The ability to repeat words that measures the abil- had no signs of aspiration such as cough and gurgly
ity of the patient to repeat certain words (6 words voice after swallow, and had normal tongue move-
divided into three groups with 2 words in each ment with no searching movement.
group) heard from the assessor. These words were • Meal eating and self-feeding: introducing the three
graded in difficulty from simple monosyllabic words, different food consistencies which are the fluids,
bisyllabic words, then to tri- and tetrasyllabic words. semisolids, and solids. Each consistency was tested
• The ability to repeat words of increasing length which spontaneously, with elicitation and upon imitation.
were assessed by asking the patient to repeat a series
of words increasing in length. The patient was given During the assessment, the patient was put under sev-
two series that were the most sensitive series found eral challenges such as doing the action spontaneously,
while applying the pilot study. on imitation and on command, and to perform unpur-
• Latency time which measured the time taken by the poseful and purposeful tasks. The purposeful tasks were
patient to name familiar objects or pictures like scis- divided into transitive (tool related) and intransitive
sors and a cup. (communicative) tasks that might help to induce apraxic
• Inventory of articulation characteristics of apraxia errors.
which assessed the patient’s spontaneous speech, pic- The assessment was done in two settings about 30–45
ture description, reading, and automatic speech. min each.
Patients who showed apraxic manifestations were
Buccofacial apraxia assessed the non-speech non- included in the study.
swallowing oral motor function of the patient includ-
ing the functions of the following structures: lips, face, Results
tongue, jaw, soft palate and pharynx. The current study was conducted on the 58 selected
Ideational apraxia tasks assessed the ability of the Egyptian post-stroke adults who had apraxic manifes-
patient to plan the sequence of a multi-task and assesses tations in addition to language and communication
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 4 of 17

deficits. The males constitute 55.2% while females con- Demographic data
stitute 44.8% of normal subjects. In post-CVI patients, Figure 1 shows that 82.8% of patients had combined
males constitute 65.5% while females constitute 34.5%. apraxia while 17.2% had single type of apraxia.
The lesion was left-sided in 89.7% of post CVI cases Figure 2 shows that the common combination is
while 6.9% were right-sided with left handedness and the between verbal apraxia and buccofacial apraxia.
lesion was bilateral in 3.4% of cases. 5.2% of cases had Figure 3 shows that 93.1% of patients had verbal
both expressive aphasia and dysarthria while the rest had apraxia, 39.7% of patients had ideational apraxia, 22.4%
expressive aphasia. had constructional apraxia, 44.8% had limb apraxia,

Fig. 1 Distribution of combined and single types of apraxia in the group of cases. 82.8% of patients had combined apraxia while 17.2% had a single
type of apraxia

Fig. 2 Demonstration of combined types of apraxia among cases. The most frequent combination was of verbal apraxia and buccofacial apraxia
which constitutes 41.67%
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 5 of 17

Fig. 3 Distribution of different types of apraxia among cases. 93.1% of patients had verbal apraxia, 39.7% of patients had ideational apraxia, 22.4%
had constructional apraxia, 44.8% had limb apraxia, and 77.6% had buccofacial apraxia.

77.6% had bucco-facial apraxia, and less than 1% had ide- without constructional apraxia in the scores of aphasia
omotor, dressing, and swallowing apraxia test in word fluency, spoken word and paragraph com-
Table 1 that was statistically analyzed using the median prehension, repetition of complex words, digit strings
shows that there was significant difference between and sentences, naming sub-items, and spoken picture
patients with verbal apraxia and patients without verbal description. Table 3 that was statistically analyzed using
apraxia in the following scores of aphasia test word flu- the mean reveals that there was a significant differ-
ency, repetition of digit strings, sentence repetition, and ence between patients with constructional apraxia and
spoken and written picture description. Table 1 that was patients without constructional apraxia in the scores of
statistically analyzed using the mean reveals that there aphasia test in spoken word comprehension, spoken sen-
was no significant difference between patients with ver- tence, and spoken paragraph comprehension repetition
bal apraxia and patients without verbal apraxia in the of digit string, sentence repetition, naming objects and
scores of aphasia test except for repetition of words. actions, spoken picture description, reading words, writ-
Table 2 that was statistically analyzed using the median ing copying and words, and dictation.
shows that there was a significant difference between Table 4 that was statistically analyzed using the median
patients with ideational apraxia and patients without shows that there was a significant difference between
ideational apraxia in the scores of aphasia test in word patients with limb apraxia and patients without limb
fluency, semantic and recognition memories, arithme- apraxia in the scores of aphasia test in word fluency,
tic, spoken word, sentence and paragraph comprehen- semantic and recognition memories, arithmetic, spoken
sion, written word comprehension, repetition of digit word, sentences and paragraph comprehension, nam-
strings, sentence repetition, naming tasks, spoken pic- ing tasks, spoken picture description, and writing tasks.
ture description, and reading and writing tasks. Table 2 Table 4 that was statistically analyzed using the mean
that was statistically analyzed using the mean reveals revealed that there was a significant difference between
that there was a significant difference between patients patients with limb apraxia and patients without limb
with ideational apraxia and patients without ideational apraxia in the scores of aphasia test in semantic and rec-
apraxia in the scores of aphasia test in sematic and rec- ognition memories, arithmetic, spoken word, sentence
ognition memories, arithmetic, spoken word, sentence and paragraph comprehension, and naming and writing
and paragraph comprehension, repetition of digit strings, tasks.
sentence repetition, naming tasks, reading words, and Table 5 that was statistically analyzed using the median
writing tasks. shows that there was a significant difference between
Table 3 that was statistically analyzed using the median patients with buccofacial apraxia and patients without
shows that there was a significant difference between buccofacial apraxia in the scores of aphasia test in gesture
patients with constructional apraxia and patients object use, written sentences comprehension, reading
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 6 of 17

Table 1 Comparison between patients with verbal apraxia and without verbal apraxia regarding scores of aphasia test. Table 1 (a) that
was statistically analyzed using the median shows that there was a significant difference between patients with verbal apraxia and
patients without verbal apraxia in the scores of aphasia test except for word fluency, repetition of digit strings, sentence repetition, and
spoken and written picture description. Table 1 (b) that was statistically analyzed using the mean reveals that there was a significant
difference between patients with verbal apraxia and patients without verbal apraxia in the scores of aphasia test except for repetition
of words
a.
Items of aphasia test Results of cases Mode Results of cases without Mode
with verbal apraxia verbal apraxia
Median Range Median Range P value
Bisection of line 0 (0–1) 4 0 (0–0) 0 0.965
Semantic memory 10 (0–10) 2 10 (10–10) 10 0.261
Verbal fluency for words 4 (0–25) 0 13 (9–18) 13 0.013*
Recognition memory 10 (0–10) 3 10 (10–10) 10 0.288
Gesture object use 12 (2–12) 4 12 (12–12) 12 0.824
Arithmetic skill 2 (0–6) 11 5 (3–6) 5 0.161
Comprehension of spoken words 30 (0–30) 4 30 (30–30) 30 0.236
Comprehension of spoken 32 (0–32) 2 32 (32–32) 32 0.189
sentences
Comprehension of spoken para- 2 (0–4) 0 3 (2–4) 3 0.543
graphs
Comprehension of written words 30 (0–30) 3 30 (30–30) 30 0.239
Comprehension of written 32 (0–32) 4 24 (16–32) 24 0.953
sentences
Words repetition 32 (0–32) 11 32 (32–32) 32 0.524
Repetition of complex words 6 (0–6) 4 6 (6–6) 6 0.348
Non-word repetition 6 (0–10) 2 6 (6–6) 6 0.646
Repetition of digits 6 (0–14) 0 9 (8–10) 9 0.035*
Repetition of sentences 6 (0–12) 3 11 (10–12) 11 0.029*
Naming (objects) 10 (0–48) 4 30 (12–48) 30 0.236
Naming (actions) 5 (0–10) 11 10 (10–10) 10 0.089
Spoken description of pictures 7 (0–28) 4 28 (4–28) 28 0.018*
Reading at level of words 20 (0–48) 2 34 (20–48) 34 0.384
Reading at level of complex 6 (0–6) 0 4 (2–6) 4 0.658
words
Reading at level of function words 6 (0–6) 3 3 (0–6) 3 0.863
Reading at level of non-words 6 (0–10) 4 3 (0–6) 3 0.686
Writing by copying 27 (0–27) 11 27 (27–27) 27 0.189
Writing of picture names 21 (0–21) 4 21 (21–21) 21 0.285
Dictation 28 (0–28) 2 28 (28–28) 28 0.207
Picture description by writing 7 (0–28) 0 24 (10–26) 24 0.02*
b.
Items of aphasia test Results of cases Results of cases without verbal apraxia Independent t test
with verbal apraxia
Mean SD Mean SD T P value
Bisection of line 0.02 0.15 0 0 0.61 0.54
Semantic memory 8.36 3.237 7.6 3.519 0.75 0.455
Verbal fluency for words 6.4 6.23 3.9 4.89 1.42 0.16
Recognition memory 7.79 3.848 7 4.195 0.678 0.50
Gesture object use 11.86 0.52 11.38 2.5 1.199 0.236
Arithmetic skill 2.8 2.597 2.4 2.58 0.53 0.61
Comprehension of spoken words 26.4 5.456 24.5 8.779 1.008 0.318
Comprehension of spoken 26.05 8.04 25.13 10.275 0.36 0.719
sentences
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 7 of 17

Table 1 (continued)
Comprehension of Spoken 2.29 1.566 2.6 1.89 −0.696 0.489
paragraph
Comprehension of written words 23.39 10.857 22.91 12.534 0.12 0.902
Comprehension of written 23.45 11.77 23.82 13.43 −0.086 0.93
sentences
Word repetition 29.81 7.306 23.13 14.028 2.375 0.021*
Repetition of complex words 5.1 1.985 3.88 2.579 1.923 0.060
Non-word repetition 6.79 3.36 5.13 3.86 1.614 0.112
Digits repetition 6 3.155 5.38 4.77 0.581 0.56
Repetition of sentences 7.24 3.9 6.25 4.78 0.810 0.42
Naming (objects0 21 21.999 18.75 23.58 0.341 0.734
Naming (actions) 5.71 4.89 4.38 5.123 0.920 0.361
Spoken description of pictures 12.79 11.503 6.81 9.347 1.854 0.069
Reading at level of words 24.45 22.547 25.67 23.967 −0.157 0.876
Reading at level of complex 3.58 2.905 3.17 2.887 0.418 0.678
words
Reading at level of function words 3.45 3.01 3.17 2.887 0.287 0.776
Reading at level of non-words 4.18 3.917 3.17 2.887 0.818 0.418
Writing by copying 16.55 12.173 22.5 10.5 −1.501 0.141
Writing of picture names 13.6 9.924 17.5 8.17 −1.206 0.235
Dictation 18.03 12.785 23.33 10.899 −1.272 0.211
Picture description by writing 10.88 10.597 12 8.893 −0.326 0.746

complex, and function words. Table 5 that was statisti- of manual praxis, known as action lexicon or praxicon,
cally analyzed using the mean revealed that there was a is generally stored in the left hemisphere. If praxicons
significant difference between patients with buccofacial are stored in the left hemisphere as a result of right-
apraxia and patients without buccofacial apraxia in the handedness, the praxicons of left-handers should be
scores of aphasia test in complex word repetition, reading stored in the right hemisphere. In fact, the incidence
complex words, and reading non-words. of apraxia in left-handers is not high after right-hem-
Data management and statistical analysis were done isphere injuries. Thus, based on clinical observations,
using SPSS vs.25. Numerical data was summarized using praxis usually appears to be represented in the left
means and standard deviations. Categorical data was hemisphere, irrespective of handedness, and only in
summarized as numbers and percentages. All apraxia less cases is represented bilaterally, or lateralized to
scores were compared between two groups using Mann- the right hemisphere [18].
Whitney U test. Categorical data was compared using In the current study, the most frequent combination
chi-square test. was the combination between verbal apraxia and bucco-
All P values were two sided. P values less than 0.05 facial apraxia as they share the same muscles and it con-
were considered significant. stitutes 41.67% of cases. New et al. [19] also found that
many patients with verbal apraxia also have buccofacial
Discussion apraxia and this co-occurrence is mostly indicating that
Language and praxis are the most lateralized functions in verbal and buccofacial apraxia share the same control
the human brain. There is a striking overlap involving the mechanisms [20].
left frontal and parietal lobes. Their co-occurrence is very Many studies reported various combinations such
frequent [17]. as Ozsancak et al. [21] who found orofacial apraxia fre-
In this study, the lesion was left-sided in 89.7% of quently coexists with limb apraxia. However, orofacial
the included post CVI cases. Meador et al. [18] found and limb apraxia can be dissociated, suggesting that the
that among the right-handed population, apraxia is neural systems underlying these disorders are at least
mostly caused by injury to the left hemisphere. The partially separable.
incidence of apraxia is reportedly 34–51% after left- Vanbellingen et al. [22] showed that ideational and
hemisphere stroke and 6–10% after right-hemisphere ideomotor apraxia usually co-exists with limb apraxia
stroke. This led to the notion that acquired memory because of the same parietal representation.
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 8 of 17

Table 2 Comparison between patients with ideational apraxia and without ideational apraxia regarding scores of aphasia test. Table 2
(a) that was statistically analyzed using the median shows that there was a significant difference between patients with ideational
apraxia and patients without ideational apraxia in the scores of aphasia test in word fluency, semantic and recognition memories,
arithmetic, spoken word, sentence and paragraph comprehension, written word comprehension, repetition of digit strings, sentence
repetition, naming tasks, spoken picture description, and reading and writing tasks. Table 2 (b) that was statistically analyzed using the
mean revealed that there was a significant difference between patients with ideational apraxia and patients without ideational apraxia
in the scores of aphasia test in sematic and recognition memories, arithmetic, spoken word, sentence and paragraph comprehension,
repetition of digit strings, sentence repetition, naming tasks, reading words, and writing tasks
a.
Results of cases with Mode Results of cases without ideational Mode
ideational apraxia apraxia
Median Range Median Range P value
Bisection of line 0 (0–1) 0 0 (0–0) 0 0.217
Semantic memory 8 (0–10) 8 10 (0–10) 10 0.003*
Verbal fluency for words 0 (0–15) 0 7 (0–25) 7 0.024*
Recognition memory 6 (0–10) 6 10 (0–10) 10 0.001*
Gesture object use 12 (2–12) 12 12 (10–12) 12 0.575
Arithmetic skill 0 (0–6) 0 4 (0–6) 4 0.002*
Comprehension of spoken 20 (0–30) 20 30 (18–30) 30 <0.001**
words
Comprehension of spoken 18 (0–32) 18 32 (16–32) 32 <0.001**
sentences
Comprehension of spoken 2 (0–4) 2 4 (0–4) 4 0.002*
paragraphs
Comprehension of written 22 (0–30) 22 30 (0–30) 30 0.044*
words
Comprehension of written 20 (0–32) 20 32 (0–32) 32 0.186
sentences
Word repetition 32 (0–32) 32 32 (0–32) 32 0.798
Repetition of complex 6 (0–6) 6 6 (0–6) 6 0.163
words
Repetition of non-word 6 (0–10) 6 6 (0–10) 6 0.511
Digit repetition 4 (0–10) 4 8 (0–14) 8 0.007*
Repetition of sentences 6 (0–12) 6 10 (0–12) 10 0.022*
Naming (objects) 0 (0–48) 0 48 (0–48) 48 0.001*
Naming (actions) 0 (0–10) 0 10 (0–10) 10 <0.001**
Spoken description of 0 (0–23) 0 22 (0–28) 22 0.001*
pictures
Reading at level of words 0 (0–48) 0 48 (0–48) 48 0.036*
Reading at level of complex 0 (0–6) 0 6 (0–6) 6 0.095*
words
Reading at level of function 0 (0–6) 0 6 (0–6) 6 0.143
words
Reading at level of non- 0 (0–6) 0 6 (0–10) 6 0.072*
words
Writing by copying 13 (0–27) 13 27 (0–27) 27 0.035*
Writing of picture names 3 (0–21) 3 21 (0–21) 21 0.007*
Dictation 4 (0–28) 4 28 (0–28) 28 0.014*
Picture description by 1 (0–20) 1 19 (0–28) 19 0.005*
writing
b.
Results of cases with Results of cases without ideational apraxia Independent t test
ideational apraxia
Mean SD Mean SD T P value
Bisection of line 0.04 0.21 0.00 0.00 1.239 0.220
Semantic memory 6.35 4.07 9.3 1.97 −3.745 0.001**
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 9 of 17

Table 2 (continued)
Verbal fluency for words 3.61 5.19 7.11 6.09 −2.27 0.027
Recognition memory 5.43 4.50 8.97 2.76 −3.714 0.001**
Gesture object use 11.57 2.09 11.83 0.57 −0.71 0.480
Arithmetic skill 1.57 2.33 3.50 2.47 −2.970 0.004**
Comprehension of spoken 21.65 8.02 28.69 3.07 −4.71 0.001**
words
Comprehension of spoken 20.4 10.1 29.31 5.16 −4.41 0.001**
sentences
Comprehension of spoken 1.57 1.59 2.9 1.48 −3.29 0.002**
paragraphs
Comprehension of written 20.3 10.83 24.52 11.22 −1.147 0.258
words
Comprehension of written 20.00 11.92 25.03 11.98 −1.273 0.210
sentences
Word repetition 28.87 7.55 27.37 11.34 0.557 0.58
Repetition of complex 4.35 2.31 5.03 2.14 −1.15 0.255
words
Non-word repetition 5.9 3.74 6.60 3.45 −0.718 0.476
Digit repetition 4.35 2.87 6.8 3.8 −2.64 0.011*
Repetition of sentences 5.65 3.65 7.8 4.27 −2.009 0.049*
Naming (objects) 9.39 18.4 27.60 21.81 −3.30 0.002**
Naming (actions) 2.35 4.21 7.31 4.42 −4.267 0.001**
Spoken description of 5.26 7.69 15.00 11.54 −3.555 0.001**
pictures
Reading at level of words 14.15 20.63 29.09 22.31 −2.079 0.044*
Reading at level of complex 2.3 3.04 3.94 2.7 −1.766 0.085
words
Reading at level of function 2.3 3.04 3.81 2.85 −1.578 0.122
words
Reading at level of non- 2.3 3.04 4.56 3.7 −1.926 0.061
words
Writing by copying 12.38 12.88 20.47 10.89 −2.141 0.038*
Writing of picture names 8.54 10.3 17.16 8.14 −2.977 0.005**
Dictation 11.38 13.75 22.87 10.24 −3.063 0.004**
Picture description by 4.46 7.3 13.9 9.85 −3.117 0.003**
writing

Apraxia is mainly a production defect: Lipmann [23] sound /S/ in 1 min and that could be attributed to the
assumed that gesture information passes through a con- high linguistic requirements of the test and it was also a
ceptual stage located in the left occipitotemporal cortex, challenging task because of its nature of being time lim-
followed by a production stage where the appropriate ited. The receptive section: apraxic patients showed no
motor programs are selected in the sensory motor areas significant difference in all the subtests and that could be
[24]. So, it is difficult to assess apraxia with sever sen- attributed to the lesser need of coordination in this task
sory/receptive aphasia [25]. This was one of the exclusion than that required in the expressive section. Repetition
criteria for patients in this study. section: apraxic patients showed significant differences
Results of aphasia tests in patients with verbal apraxia in the scores of repetition of sentences and digit strings
with or without other types of apraxia showed the fol- because the patients might have a working memory and
lowing results as compared to patients without verbal a short-term memory deficits. This is in agreement with
apraxia: regarding the cognitive screen: apraxic patients Ortiz and Martins [26]. Regarding the expressive section,
showed only lower performance with significant dif- reading, and writing: apraxic patients showed non-signif-
ference in items of verbal fluency scores which requires icant difference in their scores that means that all cases
recall of items such as animals and things that begin with had impaired expressive language, reading, and writing.
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 10 of 17

Table 3 Comparison between patients with constructional apraxia and without constructional apraxia regarding scores of aphasia
test. Table 3 (a) that was statistically analyzed using the median shows that there was a significant difference between patients
with constructional apraxia and patients without constructional apraxia in the scores of aphasia test in word fluency, spoken word
and paragraph comprehension, repetition of complex words, digit strings and sentences, naming sub-items, and spoken picture
description. Table 3 (b) that was statistically analyzed using the mean reveals that there was a significant difference between patients
with constructional apraxia and patients without constructional apraxia in the scores of aphasia test in spoken word comprehension,
spoken sentence, and spoken paragraph comprehension repetition of digit string, sentence repetition, naming objects and actions,
spoken picture description, reading words, writing copying and words, and dictation
a.
Results of cases with Mode Results of cases without constructional Mode
constructional apraxia apraxia
Median Range Median Range P value
Bisection of line 0 (0–1) 0 0 (0–0) 0 0.063
Semantic memory 10 (0–10) 10 10 (0–10) 10 0.137
Verbal fluency for 0 (0–25) 0 7 (0–18) 7 0.02*
words
Recognition memory 10 (0–10) 10 10 (0–10) 10 0.113
Gesture object use 12 (2–12) 12 12 (10–12) 12 0.848
Arithmetic skill 0 (0–6) 0 3 (0–6) 3 0.07
Comprehension of 20 (0–30) 20 30 (14–30) 30 0.016*
spoken words
Comprehension of 18 (0–32) 18 32 (12–32) 32 0.028
spoken sentences
Comprehension of 0 (0–4) 0 4 (0–4) 4 <0.001**
spoken paragraphs
Comprehension of 21 (0–30) 21 30 (0–30) 30 0.239
written words
Comprehension of 21 (0–32) 21 32 (0–32) 21 0.459
written sentences
Word repetition 32 (0–32) 32 32 (0–32) 32 0.246
Repetition of complex 4 (0–6) 4 6 (0–6) 6 0.027*
words
Non-word repetition 6 (0–10) 6 6 (0–10) 6 0.151
Digit repetition 4 (0–12) 4 6 (0–14) 6 0.026*
Repetition of sentences 4 (0–12) 4 8 (0–12) 8 0.037*
Naming (objects) 0 (0–48) 0 16 (0–48) 16 0.005**
Naming (actions) 0 (0–10) 0 10 (0–10) 10 <0.001**
Spoken description of 0 (0–26) 0 14 (0–28) 14 0.006**
pictures
Reading at level of 0 (0–48) 0 20 (0–48) 20 0.301
words
Reading at level of 0 (0–6) 0 6 (0–6) 6 0.257
complex words
Reading at level of 0 (0–6) 0 6 (0–6) 6 0.317
function words
Reading at level of 0 (0–6) 0 6 (0–10) 6 0.229
non-words
Writing by copying 0 (0–27) 0 27 (0–27) 27 0.092
Picture names by 0 (0–21) 0 21 (0–21) 21 0.074
writing
Dictation 0 (0–28) 0 28 (0–28) 28 0.078
Picture description by 0 (0–21) 0 12 (0–28) 12 0.074
writing
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 11 of 17

Table 3 (continued)
b.
Results of cases with Results of cases without constructional apraxia Independent t test
constructional apraxia
Mean SD Mean SD T P value
Bisection of line 0.08 0.28 0.00 0.00 1.903 0.062
Semantic memory 6.62 4.1 8.6 2.9 −1.955 0.056
Word fluency 3.3 7.24 6.4 5.43 −1.688 0.097
Recognition memory 5.85 4.79 8.07 3.55 −1.833 0.072
Gesture object use 11.23 2.77 11.87 0.51 −1.485 0.143
Arithmetic skill 1.69 2.43 3.02 2.57 −1.662 0.102
Comprehension of 21.23 9.58 27.24 4.66 −3.153 0.003**
spoken words
Comprehension of 20.62 11.62 27.29 7.03 −2.574 0.013*
spoken sentences
Comprehension of 0.92 1.32 2.80 1.50 −4.070 0.001**
spoken paragraphs
Comprehension of 17.00 14.90 24.26 10.35 −1.505 0.140
written words
Comprehension of 17.67 16.12 24.47 11.27 −1.297 0.202
written sentences
Word repetition 26.00 11.89 28.53 9.41 −0.805 0.424
Repetition of complex 3.69 2.43 5.07 2.07 −2.027 0.047
words
Non-word repetition 5.08 3.71 6.69 3.46 −1.456 0.151
Digit repetition 4.00 3.65 6.36 3.50 −2.118 0.039*
Repetition of sentences 4.92 4.21 7.56 3.98 −2.076 0.042*
Naming (objects) 7.38 18.03 24.13 22.11 −2.497 0.015*
Naming (actions) 1.08 2.90 6.58 4.74 −3.960 0.001**
Spoken description of 4.00 9.16 13.2 10.96 −2.756 0.008**
pictures
Reading at level of 16.00 24.79 26.1 22.36 −1.020 0.314
words
Reading at level of 2.00 3.10 3.69 2.8 −1.356 0.182
complex words
Reading at level of 2.00 3.10 3.59 2.91 −1.237 0.223
function words
Reading at level of 2.00 3.10 4.21 3.69 −1.386 0.173
non-words
Writing by copying 9.00 13.94 19.54 11.15 −2.089 0.043*
Writing of picture 7.0 10.84 15.85 8.9 −2.201 0.033*
names
Dictation 9.3 14.46 21.08 11.46 −2.255 0.029*
Picture description by 4.8 8.54 12.15 10.04 −1.69 0.098
writing

So the effect of verbal apraxia is mainly on the tasks that ideational apraxia: Regarding the cognitive screen: apraxic
needed processing and co-ordination of the spoken lan- patients showed a significant difference in the scores
guage. This in agreement with Terband et al. [27] who of semantic and recognition memories and arithme-
stated that verbal apraxia mainly affect expression and tic tasks and this can be attributed to the difficulty and
verbal fluency. limitation in their working memory and cognitive abili-
Results of aphasia test in patients with ideational ties after brain insult. This is in agreement with Jackson
apraxia with or without other types of apraxia showed [28] who found that patients with ideational apraxia are
the following results as compared to patients without unable to perform a skilled activity because they have lost
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 12 of 17

Table 4 Comparison between patients with limb apraxia and without limb apraxia regarding scores of aphasia test. Table 4 (a) that
was statistically analyzed using the median shows that there was a significant difference between patients with limb apraxia and
patients without limb apraxia in the scores of aphasia test in word fluency, semantic and recognition memories, arithmetic, spoken
word, sentences and paragraph comprehension, naming tasks, spoken picture description, and writing tasks. Table 4 (b) that was
statistically analyzed using the mean reveals that there was a significant difference between patients with limb apraxia and patients
without limb apraxia in the scores of aphasia test in semantic and recognition memories, arithmetic, spoken word, sentence and
paragraph comprehension, and naming and writing tasks
a.
Results of cases Mode Results of cases without limb apraxia Mode
with limb apraxia
Median Range Median Range P value
Bisection of line 0 (0–1) 0 0 (0–0) 0 0.267
Semantic memory 10 (0–10) 10 10 (0–10) 10 0.026*
Word fluency 0 (0–25) 0 8 (0–18) 8 0.044*
Recognition memory 9 (0–10) 9 10 (0–10) 10 0.009**
Gesture object use 12 (2–12) 12 12 (10–12) 12 0.444
Arithmetic skill 0 (0–6) 0 3 (0–6) 3 0.006**
Comprehension of spoken words 22 (0–30) 22 30 (18–30) 22 <0.001**
Comprehension of spoken sen- 18 (0–32) 18 32 (16–32) 32 <0.001**
tences
Comprehension of spoken para- 2 (0–4) 2 4 (0–4) 4 0.028*
graphs
Comprehension of written words 27 (0–30) 27 30 (0–30) 30 0.208
Comprehension of written sen- 27 (0–32) 27 32 (0–32) 32 0.672
tences
Word repetition 32 (0–32) 32 32 (0–32) 32 0.9
Repetition of complex words 6 (0–6) 6 6 (0–6) 6 0.37
Non-word repetition 6 (0–10) 6 7 (0–10) 7 0.229
Digit repetition 4 (0–14) 4 7 (0–10) 7 0.176
Repetition of sentences 6 (0–12) 6 8 (0–12) 8 0.251
Naming ( objects) 0 (0–48) 0 32 (0–48) 32 0.003**
Naming (actions) 0 (0–10) 0 10 (0–10) 10 0.002**
Spoken description of pictures 0 (0–26) 0 22 (0–28) 22 0.001**
Reading at level of words 0 (0–48) 0 48 (0–48) 48 0.084
Reading at level of complex words 0 (0–6) 0 6 (0–6) 6 0.163
Reading at level of function words 0 (0–6) 0 6 (0–6) 6 0.241
Reading at level of non-words 0 (0–6) 0 6 (0–10) 6 0.099
Writing by copying 13 (0–27) 13 27 (0–27) 27 0.046*
Writing of picture names 3 (0–21) 3 21 (0–21) 21 0.009**
Dictation 4 (0–28) 4 28 (0–28) 28 0.018*
Picture description by writing 1 (0–21) 1 20 (0–28) 20 0.002*
b.
Results of cases Results of cases without limb apraxia Independent t test
with limb apraxia
Mean SD Mean SD T P value
Bisection of line 0.04 0.2 0.00 0.00 1.112 0.271
Semantic memory 7.00 3.89 9.09 2.41 −2.511 0.015*
Word fluency 4.38 6.48 6.81 5.35 −1.564 0.124
Recognition memory 6.19 4.3 8.69 3.24 −2.518 0.015*
Gesture object use 11.62 1.96 11.8 0.59 −0.540 0.591
Arithmetic skill 1.85 2.46 3.45 2.47 −2.446 0.018*
Comprehension of spoken words 22.31 7.85 28.81 2.96 −4.331 0.001**
Comprehension of spoken sen- 21.23 10.01 29.5 4.95 −4.102 0.001**
tences
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 13 of 17

Table 4 (continued)
Comprehension of spoken para- 1.85 1.69 2.81 1.51 −2.296 0.025
graphs
Comprehension of written words 22.13 10.44 23.93 11.67 −0.512 0.612
Comprehension of written sen- 22.25 11.71 24.29 12.39 −0.535 0.596
tences
Word repetition 29.23 7.15 26.94 11.78 0.870 0.388
Repetition of complex words 4.54 2.23 4.94 2.2 −0.680 0.499
Non-word repetition 5.77 3.4 6.78 3.65 −1.081 0.284
Digit repetition 5.38 3.99 6.19 3.35 −0.834 0.408
Repetition of sentences 6.38 4.0 7.44 4.26 −0.96 0.34
Naming (objects) 12.00 20.37 27.19 21.68 −2.726 0.009*
Naming (actions) 3.08 4.71 7.19 4.40 −3.431 0.001**
Spoken description of pictures 5.42 7.81 15.78 11.48 −3.920 0.001**
Reading at level of words 17.50 22.24 28.79 22.25 −1.630 0.11
Reading at level of complex words 2.63 3.07 3.93 2.7 −1.479 0.146
Reading at level of function words 2.63 3.07 3.79 2.85 −1.281 0.207
Reading at level of non-words 2.63 3.07 4.62 3.82 −1.791 0.08
Writing by copying 13.4 13.04 20.72 10.64 −2.028 0.049*
Writing names of pictures 9.56 10.46 17.48 7.86 −2.872 0.006**
Dictation 12.75 13.95 23.32 9.7 −2.953 0.005**
Picture description by writing 4.88 7.86 14.66 9.57 −3.487 0.001**

the conceptual ability to organize the actions required to constructional apraxia: Regarding the cognitive screen:
achieve their goal. The patients also showed significant apraxic patients showed only significant difference in the
difference in the verbal fluency item. The nature of the verbal fluency item because of the nature of the task being
task was challenging as it is time limited. The receptive time limited causing more challenges in addition to the
section: apraxic patients showed significant difference effect of the combination between constructional apraxia
in the scores of spoken word, sentence, and paragraph and verbal apraxia as shown in the current study Fig. 3.
comprehension. These tasks are negatively impaired by Regarding the receptive and expressive sections: apraxic
the effect of the recognition and working memory. The patients showed significant difference in these tasks. This
expressive section, reading, and writing sections: apraxic could be attributed to that most constructional apraxia
patients showed significant difference in their scores and patients under the study were combined with other
this could be attributed to inability of the patients to find types of apraxia and also attributed to that verbal com-
the idea of the task. Repetition section: apraxic patients mand makes the task more challenging because of the
showed no significant difference in the scores of word more co-ordination needed in addition to the associa-
repetition while they showed lower performance with tion between constructional apraxia and comprehension
significant difference in the items of sentence repetition that was found in the literature as in a study by Laeng
and repetition of digit strings. This could be attributed to [29] who found that in left-hemisphere insult, construc-
the need of integration between the auditory input and tional apraxia is associated with the presence of receptive
spoken outputs which hinder performance in addition to language impairment and affected comprehension, and
the limited working memory skills and verbal reasoning the more severe the receptive disorder, the more likely
present in the ideational apraxia as mentioned in a pre- constructional apraxia will occur. Although the patients
vious study by Ortiz and Martins [26]. So, the effect of under study had predominantly expressive difficulty, but
ideational apraxia on patient’s performance as shown in some degree of comprehension was affected. Correlating
the aphasia test in the current study is mainly in compre- the findings with the radiological results and the brain
hension, reading, writing, and some expressive abilities. lesions is recommended in for future studies.
In contrary to verbal apraxia which did not affect com- Results of aphasia test in patients with limb apraxia
prehension and receptive section. with or without other types of apraxia showed the fol-
Results of aphasia test in patients with constructional lowing results as compared to patients without limb
apraxia with or without other types of apraxia showed apraxia: patients with limb apraxia showed lower perfor-
the following results as compared to patients without mance in tasks of the cognitive screen (scores of semantic,
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 14 of 17

Table 5 Comparison between patients with buccofacial apraxia and without buccofacial apraxia regarding scores of aphasia test.
Table 5 (a) that was statistically analyzed using the median shows that there was a significant difference between patients with
buccofacial apraxia and patients without buccofacial apraxia in the scores of aphasia test in gesture object use, written sentences
comprehension, reading complex, and function words. Table 5 (b) that was statistically analyzed using the mean reveals that there was
a significant difference between patients with buccofacial apraxia and patients without buccofacial apraxia in the scores of aphasia
test in complex word repetition, reading complex words, andreading non-words.
a.
Results of cases with Mode Results of cases without buccofacial Mode
buccofacial apraxia apraxia
Median Range Median Range P value
Bisection of line 0 (0–1) 0 0 (0–0) 0 0.591
Semantic memory 10 (0–10) 10 9 (0–10) 9 0.172
Word fluency 3 (0–25) 3 5 (0–16) 5 0.571
Recognition memory 10 (0–10) 10 10 (0–10) 10 0.891
Gesture object use 12 (2–12) 12 12 (10–12) 12 0.012*
Arithmetic skill 2 (0–6) 2 2 (0–6) 2 0.602
Comprehension of spoken 30 (0–30) 30 30 (14–30) 30 0.531
words
Comprehension of spoken 32 (0–32) 32 22 (10–32) 22 0.386
sentences
Comprehension of spoken 2 (0–4) 2 2 (0–4) 2 0.441
paragraphs
Comprehension of written 30 (0–30) 30 30 (16–30) 30 0.184
words
Comprehension of written 30 (0–32) 30 32 (12–32) 30 0.04*
sentences
Word repetition 32 (0–32) 32 32 (32–32) 32 0.051
Repetition of complex 6 (0–6) 6 6 (4–6) 6 0.055
words
Non-word repetition 6 (0–10) 6 6 (2–10) 6 0.205
Digit repetition 6 (0–12) 6 6 (4–14) 6 0.21
Repetition of sentences 6 (0–12) 6 8 (0–12) 6 0.476
Naming (objects) 0 (0–48) 0 16 (0–48) 0 0.386
Naming (actions) 0 (0–10) 0 10 (0–10) 0 0.104
Spoken description of 12 (0–28) 12 7 (0–28) 12 0.862
pictures
Reading at level of words 34 (0–48) 34 20 (0–48) 34 0.813
Reading at level of com- 3 (0–6) 3 6 (0–6) 3 0.047*
plex words
Reading at level of func- 2 (0–6) 2 6 (0–6) 2 0.044*
tion words
Reading at level of non- 2 (0–10) 2 6 (0–6) 2 0.19
words
Writing by copying 27 (0–27) 27 27 (0–27) 27 0.967
Writing of picture names 21 (0–21) 21 21 (0–21) 21 0.28
Dictation 28 (0–28) 28 28 (0–28) 28 1
Picture description by 18 (0–26) 18 5 (0–28) 18 0.53
writing
b.
Items of aphasia test Results of cases with Results of cases without bucccofacial apraxia Independent t test
buccofacial apraxia
Mean SD Mean SD T P value
Bisection of line 0.02 0.15 0.00 0.00 0.53 0.595
Semantic memory 8.27 3.32 7.77 3.35 0.475 0.637
Word fluency 5.6 6.3 6.08 4.70 −0.240 0.811
Recognition memory 7.53 4.02 7.69 3.73 −0.128 0.899
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 15 of 17

Table 5 (continued)
Gesture object use 11.78 1.49 11.5 0.88 0.550 0.585
Arithmetic skill 2.82 2.71 2.3 2.06 0.581 0.564
Comprehension of spoken 26.00 6.7 25.54 5.95 0.223 0.824
words
Comprehension of spoken 26.18 8.8 24.46 8.09 0.628 0.53
sentences
Comprehension of spoken 2.49 1.55 2.00 2.00 0.939 0.352
paragraphs
Comprehension of written 21.94 11.97 28.4 4.67 −1.588 0.120
words
Comprehension of written 21.94 12.65 29.78 6.67 −1.784 0.082
sentences
Word repetition 26.8 11.06 32.00 0.00 −1.684 0.098
Repetition of complex 4.44 2.4 5.85 0.56 −2.071 0.043*
words
Non-word repetition 5.98 3.73 7.5 2.60 −1.408 0.165
Digit repetition 5.38 3.56 7.38 3.60 −1.785 0.080
Repetition of sentences 6.7 4.35 7.85 3.31 −0.868 0.389
Naming (objects) 20.18 23.18 21.08 19.57 −0.127 0.899
Naming (actions) 4.76 5.00 7.38 4.35 −1.716 0.092
Spoken description of 11.78 11.82 8.9 8.73 0.807 0.423
pictures
Reading at level of words 25.11 23.65 23.44 19.39 0.195 0.846
Reading at level of com- 3.00 2.89 5.33 2.00 −2.281 0.028*
plex words
Reading at level of func- 2.89 2.96 5.33 2.00 −2.334 0.024*
tion words
Reading at level of non- 3.56 3.9 5.3 2.00 −1.311 0.197
words
Writing by copying 18.08 12.36 18.33 10.72 −0.056 0.956
Writing names of pictures 13.67 9.92 18.67 7.00 −1.420 0.163
Dictation 18.69 13.1 22.56 9.1 −0.832 0.41
Written description of 12.25 10.3 6.89 8.24 1.444 0.156
pictures

recognition and verbal memories and arithmetic) indi- the co-ordination of the oral muscles that is required for
cating the limited working memory and processing speed reading might be intact. There was no significant differ-
of these patients. They showed also lower performance ence as regards gesture object use. This finding is not
in the receptive and expressive sections. These findings expected. Applying the test on larger scale might clarify
could be explained by the augmented effect of combina- the subtle differences.
tion between aphasia and limb apraxia. Current cogni- Results of aphasia test in patients with buccofacial
tive models for praxis highlighted the close relationship apraxia with or without other types of apraxia showed the
between language and action. Scholars in the field of following results as compared to patients without buc-
language evolution declared the debate about whether cofacial apraxia: regarding the cognitive screen: apraxic
human language evolved from the primitive hand gesture patients showed no significant difference in the scores of
based communication [17]. semantic and recognition memories and arithmetic while
Repetition section: apraxic patients showed no signifi- they showed significant difference only in the scores of
cant difference in the scores of all sub-items due to mini- gesture object use. The receptive section: apraxic patients
mal effect of limb apraxia on repetition. Apraxic patients showed significant difference in the scores of written sen-
showed lower performance and significant difference in tences’ comprehension. These findings are not expected
the scores of writing section due to difficult co-ordination in case of buccofacial apraxia and cannot be attributed to
in hand muscles producing difficult grip, while no sig- the combination with other types as limb apraxia or ver-
nificant difference was found in reading section because bal apraxia. As in case of combination with limb apraxia,
Sheikhany et al. The Egyptian Journal of Otolaryngology (2022) 38:123 Page 16 of 17

no significant difference was found in the current study the Arabic version of Apraxia Battery of Adults is recom-
regarding gesture object use as shown previously in mended [31].
Table 4 and its combination with verbal apraxia does not
Acknowledgements
have any impact on the findings of affected gesture object Thanks to the authors for everything they did to do this work correctly and
use and the written sentences comprehension. Therefore, thanks to the patients who cooperated to give true results.
applying the protocol of assessment on larger sample size
Authors’ contributions
might clarify the current findings. AS shared in the design of the protocol and revised the written manuscript.
However, there is a significant difference between cases DM formulated the idea of the protocol. OE shared in designing the protocol,
of buccofacial apraxia and those without buccofacial formulated and interpreted the results, wrote the manuscript, and is the
corresponding author who contacted the journal. AF shared in designing the
apraxia in reading complex and functional words and in protocol and writing and revision of the manuscript. The author(s) read and
repeating complex words. These findings can be attrib- approved the final manuscript.
uted to the combination between buccofacial and verbal
Funding
apraxia as shown in the current study. This combination This research received no specific grant from any funding agency, commercial,
is common in the literature as in the studies of Whiteside or not-for-profit sectors.
et al. [30] as they shared the same musculature
Availability of data and materials
The datasets used and analyzed during the current study are available from
the corresponding author on reasonable request.
Conclusion
From the research findings, it is concluded that there Declarations
is heterogeneity of language profile in various cases of
Ethics approval and consent to participate
apraxia. The effect of verbal apraxia is mainly on the tasks The study has been approved by the institutional research ethics committee
that needed processing and coordination of the spoken of the Otolaryngology Department of Cairo University in October 2016 with a
language. The language deficits in ideational apraxia unique protocol number of 1-150316 before the experiment was started and
that has been conducted in accordance with the principles set forth in the
patients included limited performance in cognition tasks, Helsinki Declaration. Informed consent was obtained from all patients.
verbal fluency, sentence comprehension, and naming.
Constructional apraxia patients showed language defi- Consent for publication
Not applicable
cits in word comprehension, complex word repetition,
and naming. Limb apraxia showed greater influence on Competing interests
tasks tapping working memory and processing speed. The authors declare no competing interests.

Buccofacial apraxia showed limited performance with Author details

significant difference in reading complex and functional 1
Department of Otorhinolaryngology, Cairo University, Cairo, Egypt. 2 Depart-
words and in repeating complex words. Full appraisal ment of Otorhinolaryngology, Benha University, Banha, Qalyubia 13511, Egypt.

of the co-existence and the specific language profiles in Received: 3 April 2022 Accepted: 25 July 2022
patients with comorbid dysphasia and apraxia may have a
direct impact on the efforts towards setting and tailoring
the patient’s rehabilitation programs and may open the
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