Limb apraxia in Parkinson's disease and atypical parkinsonian syndromes: a systematic review

Clinical Snapshot

Key Findings

• P Value: Not reported at review level

• Effect Size: No pooled effect size reported; qualitative severity gradient identified: CBS > PD > PSP ≥ MSA. CBS demonstrated most severe and widespread apraxic impairment affecting meaningless gestures, meaningful transitive and intransitive gestures, action sequencing, and fine motor control. PD showed milder but overlapping deficits with CBS. PSP was characterised by predominantly sequence-related impairments. MSA findings were heterogeneous and less pronounced.

• Primary Outcome: Limb apraxia phenotype and severity across PD, CBS, PSP, and MSA

• Nnt Or Sensitivity: Sensitivity and specificity of apraxia assessment for differential diagnosis not formally calculated; diagnostic utility described qualitatively only

• Confidence Interval: Not reported — narrative synthesis only

Clinical Application

Bedside praxis assessment (gesture imitation, pantomime, tool use) is feasible in routine neurological consultation without specialised equipment. However, the lack of a validated, standardised battery means clinicians must currently rely on heterogeneous assessment approaches. Implementation of structured praxis testing would require clinician training and protocol standardisation. In Australia, differential diagnosis of parkinsonian syndromes is managed primarily within specialist neurology and movement disorder services, consistent with RACGP referral pathways. CBS, PSP, and MSA are not separately listed on the PBS for disease-modifying therapies, as none currently exist; however, accurate diagnosis informs prognosis counselling, allied health referral (occupational therapy for ADL assessment of apraxia), and avoidance of inappropriate levodopa escalation in APS. The TGA has not approved any apraxia-specific diagnostic tool. Australian neurologists may find this review useful for framing praxis assessment within existing cognitive and motor evaluation protocols, pending development of validated standardised tools. Adults presenting to neurology services with suspected or confirmed parkinsonian syndromes, particularly where differential diagnosis between PD, CBS, PSP, and MSA is clinically uncertain. Most relevant in specialist movement disorder clinics and cognitive neurology settings.

Abstract

BACKGROUND: Evidence regarding the clinical manifestations, disease-specific profiles and diagnostic significance of limb apraxia in Parkinson's disease and Atypical Parkinsonian Syndromes (APS) is limited. OBJECTIVES: The present systematic review aims to consolidate current knowledge on limb apraxia across neurodegenerative disorders, including Parkinson's disease (PD), corticobasal syndrome (CBS), Progressive Supranuclear Palsy (PSP) and Multiple System Atrophy (MSA). METHODS: A systematic literature review was conducted in accordance with PRISMA guidelines. Studies were included if they enrolled ≥ 10 patients in at least one of the patient groups and ≥ 10 control subjects with quantitative data on apraxic deficits. Risk of bias assessment was assessed. RESULTS: Twenty-two studies met inclusion criteria (PD n = 11; CBS n = 10; PSP n = 7; MSA n = 3). Across PD and APS, praxis assessment primarily involved gesture imitation, pantomime, action sequencing, actual tool use and measures of fine motor coordination. CBS demonstrated the most severe/widespread apraxic impairment, affecting both meaningless and meaningful (transitive and intransitive) gestures, as well as action sequencing and fine motor control. In PD, apraxic deficits were generally milder but shared overlapping features with CBS. Direct comparative studies between PD and CBS remain scarce. PSP was characterized by less frequent and predominantly sequence-related impairments, whereas findings in MSA were heterogeneous and less pronounced. CONCLUSIONS: Limb apraxia phenotypes differ across PD, CBS, PSP and MSA and may contribute to their differential diagnosis. Future research should adopt standardized, multimodal praxis assessment protocols in larger cohorts including all major neurodegenerative parkinsonian disorders, to facilitate the direct comparison of limb apraxia across these diseases.

References

1. 1.Smaragdaki, E., Stamelos, I., Tsolaki, M., Scarmeas, N., Potagas, C., Stefanis, L., Papageorgiou, S. G., & Constantinides, V. C. (2026). Limb apraxia in Parkinson's disease and atypical parkinsonian syndromes: a systematic review. Neurological Sciences: Official Journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. https://doi.org/10.1007/s11910-024-01391-6