1. itiertrui~n~uistic,.~, Volume 4, Number i. pp. I f3- 122. t 989. I?91 l-6044/89 $3.00 i .W Printed in Great Britain Q 1989 Pergamon Press plc

Constructional Apraxia in Luria’s Theory

ABSTRACT

A short discussion of the meanings of the term ‘“constructional apraxia” is made in order to understand better the significance of Luria’s findings. Investigations which have followed Lurk’s distinction between a frontal type and a parietai type of Constr~Ictio~a~ impairment have consistently obtained positive results. Studies which have transposed the opposition between a “planning” and a “visual-spatiat” type of constructional apraxia from the anterior vs posterior to the left vs right side of brain damage have, in general, obtained negative results. Luria’s hypothesis that the main function of the frontal lobes consists in the temporal organization of non-automatized goal directed behaviour is strongly supported by clinical and experimental studies.

AIthough the problem of constructional apraxia has never been particuIarly

relevant in Luria’s work, some observations and experimental results reported in a

paper by Lucia and Tsvetkova (1964) have been very influential in this field, As a

matter of fact, concepts and methods reported in that paper were important for at

least three reasons:

(1) they added further support to Luria’s theory viewing the frontat lobe as a

system specialized for the planning, regulation and verification of inrellectuai

activities;

(2) they provided investigators aiming to check Luria’s views aboutthe nature af

frontal Iobe functions with a nice and replicable experimental paradigm; and

(3) they supplied authors interested in clarifying the meaning of constructional

disorders resulting from right and left hemispheric lesions with a new and testable

dichotomic interpretation,

The discussion of Luria’s contribution to the advancement of ideas about

114 Journal of Neurolinguistics, Volume 4, Number 1 (1989)

constructional apraxia wiil. therefore, be organized along these three main points.

However, since the concept of coIlstructiona1 apraxia is rather “fuzzy” and lends

itself to non-univocal interpretations, the first section of this paper wili be devoted

to a short discussion of the meanings of the term “constructional apraxia”. It is

hoped that this terminological discussion will serve to understand better the

significance of Luria’s findings and the results of the subsequent experimental

investigations.

ACCEPTATIONS AND USES OF THE TERM

“CQNSTRUCTIONAI. APRAXIA”

There is a certain agreement among the authors who have recently reviewed the

subject of c{~nstructional apraxia (e.g. De Kenzi 1982; Gainotti 1985) to acknow-

ledge that the expression “constructional apraxia” is generally used as a sort 01

“umbrella term” which covers a rather heterogeneous set of clinical phenomena,

Within this general context, two distinctions might be particularly relevant with

respect to the specific subject of our discussion. The first distinction concerns the

opposition between the two senses in which the term constructional apraxia can be

used: (i) a broad behavioural sense, considering constructional apraxia (CA) as an

area of behavioural impairment which can be described independently from the

underlying pathophysiological mechanisms; and (ii) a narrower pathophysio-

logical sense, stressing, within the area of the observed constructional impairment,

a particular (apraxic) pathophysiolog~cal mechanism. From the behavioural point

of view, the term CA denotes a disorder of formative activities (such as drawing,

building, assembling and so on) “in which the relationships among the component

parts of the entity must be apprehended, if the desired synthesis of them is to be

achieved” (Benton 1967). From the pathophysiological point of view. the same

term denotes a subset of these constructive disorders, namely those resulting from

an executive (praxic) and not from a receptive (~~isuo-perceptual) impairnlent

(Kleist 1934; McFie and Zangwill 1960).

The second distinction refers to the complexity of the task operationally used to

define a patient as affected or non-affected by constructional apraxia, making an

opposition between elementary constructive tasks, that can be performed even by

individuals poorly endowed from the intellectual pomt of view and complex

constructive tasks, that are so strongly interconnected with the general cognitiv:e

abilities of the individual to be sometimes used as “intelligence tests”.

Luria stands apart from the majority of authors working in the field of

constructive disabilities with respect to both of these distinctions. As a matter of

fact. most authors use the term constructional apraxia in its loose descriptive sense

(since the exact nature of the mechanisms underlying the observed constructive

Constructional Apraxia in Luria’s Theory 11.5

disorders still remains hypothetical and largely controversial), whereas Luria offers

a mechanism which could specifically subsume a properly apraxic form of cons-

tructive disorder. Furthermore, most authors use elementary (drawing or assemb-

ling) constructive tasks to assess CA, whereas the type of constructional impair-

ment described by Luria is only observed when the patient is faced with a mentally

demanding constructional task. Obviously, in this, Luria’s particular position

depends on the fact that he aimed to achieve a goal different from that pursued by

most authors working in this field. The current trend in this area consists, indeed, in

considering CA (taken in its loose descriptive sense) as a discrete behavioural

disorder capable of giving important information about the functioning of the

parietal lobe (in particular of the right parietal lobe) and of assessing the visual-

spatial abilities of the patient. Elementary constructive tasks are deemed as

particularly useful from this point of view, to avoid the influence of more global

cognitive disturbances and to selectively explore the disruption of a discrete

(visual-spatial) ability and the level of functioning of the lobe which critically

subsumes this discrete cognitive ability.

The goal pursued by Luria and Tsvetkova (1964) was very different: they took for

granted that the functions of visual-spatial analysis are mainly subsumed by the

posterior (parieto-occipital) parts of the brain and were not particularly interested

in the differences between right-sided and left-sided lesions. They observed,

however, that a particular form of constructional disturbance, that could be put in

evidence only with high-level constructive tasks, but not with elementary drawing

or assembling tests, could also be noticed in patients with frontal lobe lesions. Their

suggestion was that this form of constructional impairment (that they cautiously

called “quasi-constructional apraxia”) might be due to a different mechanism from

that subsuming the visuo-constructive disturbances of patients affected by parieto-

occipital lesions. The basic defect consisted in the latter of an inability to appreciate

the spatial relations among the components of the pattern, whereas in frontal lobe

patients the main impairment seemed to consist of an inability to plan the

constructive activity and to compare the results obtained with the corresponding

stages of the plan. From this point of view, the constructive disturbances of frontal

lobe patients constituted a further example of the inability to plan, regulate and

check the results of an intellectual activity which, according to Luria (1966) results

from damage to the frontal lobes. To check this hypothesis, Luria and Tsvetkova

(1964) conducted a series of experiments in a patient with a large and stabilized

frontal lobe lesion, to see whether the patient’s constructional defect could be

compensated by breaking down his constructive behaviour into a series of succes-

sive stages, substituting his lost planning ability by a sort of external programme

ensuring the necessary sequence of actions.

I16 Journal of Keurolinguistics, Volume 4, Number I (1989)

THE STRUCTURE OF THE DEFECT IN FRONTAL LOBE

CONSTRUCTIONAL APRAXIA AND THE INFLUENCE OF AN

EXTERNAL CONSTRUCTIVE PROGRAMME

According to Luria and Tsvetkova (1964) it is possible to distinguish twoformsof

constructive actions according to clear differences in their psychological structure.

In one of them (called “immediate” or “reproductive” form) the process of

construction results directly.from the perceived pattern. In the other type of

constructive action (called “indirect” or “productive” form) the elements with

which the construction must be accomplished do not coincide with the parts of the

pattern immediately perceived by the subject. The constructive action. therefore,

requires a preliminary analysis of the perceived pattern, a breaking down of it into

elementary constructive units and a synthesis of the intended form from these

elementary units. A typical example of these kinds of indirect constructive actions

is given by the less simple items of the Kohs’ blocks task.

According to Luria. frontal lobe patients, although perfectly able to perform the

immediate constructive actions, are much more impaired with the indirect ones.

since they are unable to make a preliminary analysis of the task conditions and to

elaborate, starting from this preliminary analysis, a synthetic scheme for perform-

ing the task. Observation of these patients shows, in fact, that these patients

undertake. in general, isolated, impulsive operations, arising from an immediate

incorrect perceptual impression, instead of organizing a strategic solution of the

task resulting from a correct decoding of the task conditions. The same patients

also show an inability to match the results of their actions with the original model

and are, therefore, unable both to recognize and to correct their errors. In order to

demonstrate that the constructional disturbances of frontal lobe patients are due to

an inability to decode the perceived pattern into the constituent units (and are not

due to a defect of visual-spatial analysis, as in patients with parieto-occipital

lesions) Luria and Tsvetkova conducted a series of experiments, worked out

according to the principles of programmed learning in a patient with massive

bilateral injury of the frontal lobes. During these experiments, the patient was

presented with a programme (i.e. with an extended table of successive instructions)

breaking down the constructive behaviour into a series of stages, but giving him no

assistance in the spatial analysis of the constructive elements. The prediction was

that if the patient’s defect was due to a specific planning impairment, then this

defect could be compensated by the provision of this external programme. but that

this programme would not change the patient’s behaviour if his basic impairment

consisted in a defect of spatial analysis and synthesis. The outcome of the

experiment showed that the first hypothesis was correct, since with the help of the

Constructional Apraxia in Luria’s Theory 117

external programme the patient became able to perform, almost without errors,

constructions much more complex than the ones he had unsuccessfully attempted

just before the experiment.

These results confirm, in agreement with Luria’s general theory about the

functions of the frontal lobes, that defects in performing constructive activities

observed in patients with severe frontal lobe damage are due to a planning

impairment, that is, to an inability to secure the preliminary “orientation basis” of

his activity and to preserve the programme of actions necessary for correctly

performing the task.

Luria and Tsvetkova (1964) contrasted this form of “quasi-constructional

apraxia” with the constructional apraxia observed in patients with injury to the

parieto-occipital parts of the cortex, claiming that in the latter the provision of an

external programme is of no help. These patients, in fact, usually try to make a

preliminary analysis of the model and produce a seyuential plan of behaviour. but

are unable to perform the task because of a basic visual-spatial impairment.

Two main lines of research have been prompted by Luria and Tsvetkova’s ( 1974)

paper:

(1) the first line of research has consisted of checking, in a more rigorously

controlled experimental situation, Luria’s claim that two different neurodynamic

mechanisms subsume the frontal and the parietal type of constructional apraxia;

and

(2) the second line of research has tried to transpose the distinction between a

“planning” and a “visual-spatial” type of constructional apraxia from the dicho-

tomy proposed by Luria (namely the frontal vs parietal locus of lesion) to another

current dichotomy in neuropsychological research (namely the left vs right side of

cerebral injury).

A short account of results obtained following each of these lines of research will,

therefore, be given in the sections below.

INVESTIGATIONS DEVISED TO CONTROL LURIA’S HYPOTHESIS

ABOUT THE NATURE OF CONSTRUCTIONAL DISORDERS

RESULTING FROM FRONTAL LOBE DAMAGE

Two main objections could be addressed to Luria and Tsvetkova’s (1974) paper.

(1) The first objection is a very general one and refers more to the detailed clinical

method followed by Luria in most of his work than to the specific content of this

paper. This objection maintains that it is somewhat dangerous to infer from results

obtained in a single case (selected as typical of a certain kind of pathology) to the

general effects of that kind of pathology. It is possible, in fact, that the pattern of

results obtained comparing one frontal with one parietal lobe patient may be due

118 Journal of Neurolinguistics, Volume 4, Number I (lY89)

not so much to the variable taken into account (namely the intra-hcmisphei-ic locus

of lesion) as to other concomitant variables (such as. for example, the ext<nt of the

cerebral lesion).

This objection is surmounted in today’s neuropsychology b!, matchlllg. not

individual cases, but unselected samples of patients taken as rcpr-eaentatiie o! ;I

certain kind of pathology and by testing with statistical methods the risk O! ~I’I-(11

taken in drawing general inferences from the actual rcsult’r.

(2) The second objection is a more specific one and concern5 the fact that OII!\,

one type of constructional task (namely the Kohs’ cubes) >I reusing one stage of t hc

planning ability. i.e. the preliminary analysis of the task conditions. had hocn u~d

by Luria and Ts\,etkova (1964).

Further studies, aiming to pursue Luria’s lint of thought. have. !herc1orc. e:thct-

attempted a more rigorous control of I.uria’s hypothcxis. by matching le,uiti

obtained in appropriate experimental conditions h) unseiccted groups ot l~(~nt;ri

and of parietal damaged patients or tried to cxtcnd Luria’s data ba\c. 11si11g other

complex constructional tasks, stressing different aspects ol the planning abillt\

In one of these investigation>, I.hermitte CJ/ ul. (1972) ha~e adniini\tercd. la 4

patients suffering from unilateral frontal lobe lesions. a compleu nellrop\!\~trl~-

logical battery. comprising two high le\ el constructional task\: (i) the C\! t\IS Hloch

Design subtest; and (ii) the Rey’s Complex Figure task. The! sho\+cd (ha! p:itlcnL\

were severely impaired on both these tasks, but that their-pert,)r.ltlallct~ ()I-I the Rc\‘t

Complex Figure showed a dramatic improvement if the esamincr decomposed I hc

copy of the figure into several successive stage:,. \o that instead of or,~an~/~n~~ ;L

general plan and of orderly executing its different <tageh. patiilnty LIL’I.>: ()illi

requested to sequentially execute the various stages included in the p~-~~g~;imme

Similar results have been obtained. in a \‘ery well-controlled \tud! h\ 1’1llorl ( 198 1).

who administered the Rey’s Complex Figure to unselected groups of patient\ WI!~?

anterior and posterior cerebral lesions. contrasting the usefulness o!‘!uo c~:rtIpcIl-

satory strategies:

(I) the first consisted in providing the patient with spatial landmark.<: :~rld

(2) the second consisted in breaking the cops in \r\eral succes>ivil stage\. \I) t ha!

patients w’ere not requested to organize a plan for performing th: task

A double dissociation was observed, since patients with postcriol. ~C\IOR\ \: cl-l’

mainly he!ped by the use of spatial landmark>. whereas patients \\ith antcr-l!)r

(frontal) lesions were helped above all by fragmenting the task in three ytagt‘s 01

increasing complexity. These results are quite consistent with Luria’s clainl : ha! tu o

different mechanisms subsume constructional disorders observed in patients \vith

anterior and with posterior brain damage: (i) a \.isual~ spatial impair-ment underlie\

the constructive disabilities of parietal lobe patients, so that the u\e 01 spatiai

landmarks can help to compensate their defect: and (ii) a plarlning di~abiiit:~~

Constructional Apraxia in Luria’s Theory 119

subsumes the constructive disturbances of frontal lobe patients, so that these

difficulties disappear if the constructive plan is provided by the examiner, instead of

being autonomously organized by the patient.

INVESTIGATIONS WHICH HAVE TRANSPOSED FROM THE

“ANTERIOR-POSTERIOR” TO THE “LEFT HEMISPHERE-RIGHT

HEMISPHERE” DAMAGE, THE DISTINCTION BETWEEN A

“PLANNING” AND A “VISUAL-SPATIAL” TYPE OF CONSTRUCTIONAL

APRAXIA

The hypothesis that two different mechanisms may subsume constructional

disturbances observed in patients with left-sided and with right-sided lesions has

been repeatedly advanced in the neuropsychological literature. A number of

authors (see De Renzi 1982; Gainotti 1985, for reviews) have. in fact, suggested that

an executive disorder might subsume constructive disturbances of left brain-

damaged patients, whereas a visual--perceptual impairment might be responsible

for constructive disabilities of right brain-damaged patients. The nature of the

“executive” disorder subsuming left-sided constructional apraxia remained, how-

ever, undetermined, since it was not clear if the term”executive” referred to a motor

impairment at the level of the right hand, to an aspect of ideomotor apraxia or to a

more specific pathophysiological mechanism. In 1966, Warrington PI al. (1966)

inferred from the qualitative features of drawing disabilities observed in these

patients that a “planning” defect might be responsible for left-sided CA. According

to De Renzi (1982), however, the nature of this planning defect was rather vague.

since Warrington et al. (1966) made no reference to Luria’s work in their paper and

since the qualitative feature stressed in their article (namely a tendency to reproduce

simplified versions of the models) could be due to both cognitive and to elementary

motor-executive disorders. Some years later, the hypothesis that left-sided construc-

tional apraxia may be due to a planning disability was re-proposed by Hecaen and

Assal (1970) with explicit reference to Luria’s views and with the suggestion that the

main defect in these patients may essentially lie “in the sequence of various

movements constituting the complete action”. Furthermore, Hecaen and Assal

(1970) put this hypothesis to the test, by requiring patients with left-sided and right-

sided cerebral lesions to copy a cube under two different conditions: (i) simply

presenting the model; and (ii) providing the help of landmarks previously marked

on the paper. Since the presence of landmarks significantly improved the perfor-

mance of left brain-damaged patients, but did not help (or even disrupted) the copy

of right-sided cases, Hecaen and Assal (1970) concluded that a planning disorder

subsumes the constructive disabilities of left (but not of right) brain-damaged

patients.

120 Journal of Neurolinguistics, Volume 4, Number 1 (1989)

Subsequent studies, however, have failed to substantiate these conclusions, since

in a study conducted with a similar methodology on larger samples of right and left

brain-damaged patients, Gainotti et al. (1977) could not replicate the findings

obtained by Hkcaen and Assal (I 970) and since negative results have also been

obtained by Collignon and Rondeaux (1974).

The problem has been taken into account again by Pillon (198 1) in the above-

mentioned study in which a double dissociation was found between patients with

anterior and with posterior cerebral lesions, as for the influence of spatial land-

marks and of fragmenting the task in three stages of increasing complexity on the

copy of the Rey’s Complex Figure. When, in fact, the sample has been split

according to the laterality (and not according to the intra-hemispheric locus) of

lesion, no difference has been found between right and left brain-damaged patients.

Finally, even more recently, Hadano (1984) has shown that the provision of special

visual cues does not differentially improve the performance obtained on the block

design task by right and left brain-damaged patients, confirming that there is no

difference between left-sided and right-sided patients in the pathophysiological

mechanism subsuming constructional disturbances.

CONCLUSIONS

Results of investigations which have pursued and extended Luria’s line of

research about constructional apraxia seem very clear to us.

(1) Studies which have followed Luria’s original distinction between a frontal

type and a parietal type of constructional impairment have consistently obtained

positive results.

(2) By contrast, studies which have transposed the opposition between a “plan-

ning” and a “visual-spatial” type of constructional apraxia from the anterior vs

posterior to the left vs right side of brain damage have, in general, obtained negative

results. These negative results could be due in part to methodological inconsis-

tencies. It might, in fact, be argued that the method of facilitation by the use of

landmarks, proposed by Httcaen and Assal ( 1970). included both programming and

spatial components and was, therefore, not very suitable to test the hypothesis

advanced by these authors. It must be noted. however, that only results obtained

with this method support the hypothesis that a planning defect subsumes the

constructive disturbances of left brain-damaged patients. On the contrary no

laterality effects were observed in Pillon’s (I 98 I) study, which can be considered as

the best attempt to dissociate spatial from temporal (planning) organization of

constructive behaviour.

It can, therefore, be concluded that Luria’s hypothesis cannot be easily disen-

gaged from its original theoretical context. Although the hypothesis that the left

Constructional Apraxia in Luria’s Theory 121

hemisphere may share some general characteristics of the frontal lobes (such as the

control of sequential, temporally ordered organization of behaviour) may be

interesting, this hypothesis remains at present mainly speculative and lacks a strong

empirical support (Gainotti et al. 1986). On the contrary, Luria’s hypothesis, that

the main function of the frontal lobes consists in the temporal organization of non-

automatized goal directed behaviour (decomposing the goal of the planning into

subgoals requiring the sequential execution of specific action patterns and com-

paring these specific operations with the corresponding parts of the programme), is

strongly supported by clinical and experimental studies which have documented

the lack of programming of constructive activities in patients with frontal lobe

damage and the selective compensation of this defect by the external provision of a

plan in substitution of that which could not be autonomously produced by the

patient.

NOTES

1. Please send all correspondence and reprint requests to: Dr. Guido Gainotti,

Clinica Neurologica, Universita Cattolica. Policlinico Gemelli, Largo A.

Gemelli, 8-00168 Roma, Italy.

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