S.K.

Daniels: Swallowing Apraxia

propulsion. Eleven of 59 patients (19%) in the total

sample presented with lingual discoordination; of these,
seven patients (64%) had RHD, three (27%) had LHD,
and one (9%) had bilateral cortical lesions. Three patients (5% of the total sample) presented with moderate
to severe lingual discoordination defined as 410-sec
periods of disorganized anteriorposterior tongue movement when given the command to swallow a bolus.
These three patients with extended delays of oral transfer
may be similar to those patients described by Shanahan
et al. [3] and by Robbins and Levine and Robbins et al.
[1,2]. All three of the patients with moderate to severe
lingual discoordination had RHD. The periventricular
white matter (PVWM) was the most common site of
involvement for lingual discoordination during swallowing. Furthermore, lingual discoordination during swallowing was not commonly associated with buccofacial
apraxia, apraxia of speech, or limb apraxia.

Similarities and Differences with Other Apraxias

Comparisons of speech, limb, and buccofacial apraxias
have been made by using specific error characteristics
[11]. These error patterns include disturbances in initiation of movement, spatial targeting, coordination of motor subsystems, rate of movement, additive motor behaviors, disturbances of sequencing, and perserverative behavior. Swallowing apraxia will be related to these error
patterns and to other behavioral and neuroanatomic characteristics associated with the traditional forms of
apraxia.

Similarities of Swallowing Apraxia with

Other Apraxias

161

movement system, not with the movement system itself.

The praxis system would be intact.
Occurrence in the Natural Environment
Swallowing apraxia may occur in the natural environment. Continuing with the above focus, if swallowing
apraxia occurred only when given the command to swallow, then swallowing apraxia would be a problem of
disconnection, and not a true problem with motor programming. Although swallowing apraxia has been primarily diagnosed in the radiographic evaluation upon
given command to swallow with resolution in natural
eating settings [1,2], Daniels et al. [17] found evidence of
continued lingual discoordination in natural contexts.
Using palpation to detect lingual propulsion and elicitation of the pharyngeal swallow, Daniels et al. [17] identified 3 of 13 patients with continued deficits in natural
eating setting. This is not unlike what Foundas et al.
noted with limb apraxia and its real world implications
with feeding [20,21]. They noted less efficiency, tool
action errors, and reduced organization in sequencing
mealtime activities in patients with apraxia. Severity of
limb apraxia was related to the degree of mealtime eating
impairment.
Neuroanatomical Patterns
PVWM lesions and anterior cortical left hemispheric lesions may be associated with swallowing apraxia and
lingual discoordination [13,17]. This is not unlike neuroanatomic patterns associated with limb apraxia [22]
and with buccofacial apraxia [23]. However, unlike the
other forms of apraxia, swallowing apraxia has not been
associated with lesions of the posterior parietal lobule,
and unlike limb apraxia, subtypes of swallowing apraxia
associated with lesion site have not been identified.

Degradation upon Command

Delayed initiation and/or oral transfer discoordination
may be evident when patients are given the command to
swallow, but when the same patients are swallowing in a
natural context, these movements may not be degraded.
Some investigators believe that swallowing apraxia is
not a true apraxia as deglutition is a semivegetative function and is not a learned skilled movement. However,
given that swallow to command may demonstrate this
disorder, some investigators may argue that swallowing
is a learned movement that is purposeful. Degraded swallowing movements following command would place
swallowing apraxia in Geschwinds disconnection model
of apraxia that is stimulus specific [18]. However, as
Buckingham [19] pointed out in discussion of apraxia of
speech, the deficit would then be one of engaging the

Dissociation from Other Apraxias

Dissociation from other forms of apraxia is possible. Although speech, limb, and buccofacial apraxia frequently
co-occur, they are dissociable from each other. This dissociation indicates a separateness of the disorders. Although not explicitly defined or studied, with the exception of Daniels et al. [17], swallowing apraxia appears
dissociable from other forms of apraxia. In the initial
study by Robbins and Levine [1], there was 1:1 correspondence of swallowing apraxia with speech and buccofacial apraxias; however, in a second study [2], swallowing apraxia frequently but not exclusively cooccurred with other forms of apraxia. Meadows [14]
found dissociation of buccofacial apraxia and the oral
swallowing incoordination that he described in his three