logo logo
The association between neuroimaging data and presence of lateropulsion after stroke. Topics in stroke rehabilitation BACKGROUND:Post-stroke lateropulsion is prevalent and has been associated with varied lesion locations, but existing imaging studies are limited by small participant cohorts. Evidence to guide lateropulsion rehabilitation is also limited. Improved understanding of lesion localization associated with lateropulsion post-stroke may inform more targeted intervention approaches. OBJECTIVES:This study investigated the associations between stroke neuroimaging data and presence of lateropulsion at inpatient rehabilitation admission. METHODS:This prospective, observational study included participants aged ≥65 years, admitted for inpatient stroke rehabilitation. Using routinely collected clinical neuroimaging data, stroke type, location, and volume were reported, and their association with lateropulsion presence (Four-Point Pusher Score - 4PPS) at admission was explored. RESULTS:Of 144 included participants, 82 (56.9%) had lateropulsion (4PPS ≥1). Lateropulsion presence was univariately associated with hemorrhagic stroke ( = 0.002), frontal cortical involvement (OR = 2.17, 95%CI 1.02-6.46), and white matter involvement (OR = 2.45, 95%CI 1.24-4.85), particularly frontal white matter ( = 0.021). Lesions involving the posterior limb of the internal capsule (OR = 2.88, 95% CI 1.14-7.27) and those involving the entire thalamus (OR = 1.0,  = 0.03) were associated with lateropulsion presence. When stratified by stroke type, no specific location was significantly associated with lateropulsion presence in hemorrhagic strokes. Among participants with ischemic stroke, involvement of the pre-central gyrus (OR = 2.45, 95%CI 1.05-5.76), post-central gyrus (OR = 2.76, 95%CI 1.15-6.60), inferior parietal cortex (OR = 3.95, 95%CI 1.43-10.90), and supramarginal gyrus (OR = 3.73, 95%CI 1.25-11.13) were associated with lateropulsion presence. The stroke laterality and size were not significantly associated with lateropulsion presence. CONCLUSIONS:The findings indicate a role of network disconnection in the post-stroke lateropulsion presence. Future, larger-cohort lesion-network mapping studies are recommended. 10.1080/10749357.2024.2340339
Early incidence and factors affecting recovery from lateropulsion after acute hemispheric stroke. Annals of physical and rehabilitation medicine 10.1016/j.rehab.2022.101706
Recovery process of vertical perception and activities of daily living in stroke patients: A retrospective cohort study. Brain and behavior INTRODUCTION:Clarifications regarding the recovery process of the subjective postural vertical (SPV) and activities of daily living in stroke patients are required to help clinicians determine treatment plans. Therefore, we aimed to investigate the characteristics of the longitudinal recovery process of SPV and activities of daily living after stroke. METHODS:Overall, 109 patients with stroke were enrolled. Clinical assessments included the SPV and total functional independence measure (FIM), initially and after 1 month. The mean and standard deviation of SPV indicated the directional and variability errors, respectively. Participants were categorized as follows: nondeviation group comprised directional and variability errors within the standard values, deviation of variability errors group comprised directional errors within the standard value and variability errors greater than the standard value, and deviation of both directional and variability errors group comprised directional and variability errors greater than the standard values. In addition, a two-way analysis of variance was performed for initial pre- and post-SPV, and pre- and posttotal FIM scores (p < .05). RESULTS:The deviation of variability errors group, and deviation of both directional and variability errors group, had larger SPV variability errors than did the nondeviation group. Furthermore, the deviation of variability errors group showed a significant improvement in variability errors after 1 month. There was a correlation between the initial SPV with eyes opened variability error and total FIM after 1 month in Pusher patients with unilateral spatial neglect in the deviation of both directional and variability errors group. CONCLUSIONS:SPV with eyes opened variability errors and initial FIM score may influence the independence of activities of daily living after 1 month in the recovery of patients with stroke with Pusher and unilateral spatial neglect. 10.1002/brb3.3001
Is Lateropulsion Really Related with a Specific Lesion of the Brain? Brain sciences Lateropulsion (pusher syndrome) is an important barrier to standing and gait after stroke. Although several studies have attempted to elucidate the relationship between brain lesions and lateropulsion, the effects of specific brain lesions on the development of lateropulsion remain unclear. Thus, the present study investigated the effects of stroke lesion location and size on lateropulsion in right hemisphere stroke patients. The present retrospective cross-sectional observational study assessed 50 right hemisphere stroke patients. Lateropulsion was diagnosed and evaluated using the Scale for Contraversive Pushing (SCP). Voxel-based lesion symptom mapping (VLSM) analysis with 3T-MRI was used to identify the culprit lesion for SCP. We also performed VLSM controlling for lesion volume as a nuisance covariate, in a multivariate model that also controlled for other factors contributing to pusher behavior. VLSM, combined with statistical non-parametric mapping (SnPM), identified the specific region with SCP. Lesion size was associated with lateropulsion. The precentral gyrus, postcentral gyrus, inferior frontal gyrus, insula and subgyral parietal lobe of the right hemisphere seemed to be associated with the lateropulsion; however, after adjusting for lesion volume as a nuisance covariate, no lesion areas were associated with the SCP scores. The size of the right hemisphere lesion was the only factor most strongly associated with lateropulsion in patients with stroke. These results may be useful for planning rehabilitation strategies of restoring vertical posture and understanding the pathophysiology of lateropulsion in stroke patients. 10.3390/brainsci11030354
The association between contraversive lateropulsion and outcomes post stroke: A systematic review. Topics in stroke rehabilitation BACKGROUND:Contraversive lateropulsion is a common post-stroke impairment. Rehabilitation outcomes in stroke survivors exhibiting lateropulsion may differ from those without lateropulsion. OBJECTIVES:To systematically review evidence regarding associations between:1. Presence/severity of lateropulsion after stroke and functional outcome, rehabilitation length of stay, and discharge destination;2. Stroke-related factors and resolution of lateropulsion, functional outcome, rehabilitation length of stay, and discharge destination in affected stroke survivors. METHODS:Medline, CINAHL, and Embase databases were searched. Journal articles published in English reporting on resolution of lateropulsion, length of stay, functional outcome, and/or discharge destination associated with post-stroke lateropulsion were included for review. Studies that did not include a comparison group (stroke survivors without lateropulsion, or sub-groups of participants with lateropulsion based on stroke-related factors), animal studies, and studies reporting only on ipsiversive lateropulsion and/or lateral medullary syndrome were excluded. Two authors independently assessed studies for inclusion. Included studies were evaluated using the Risk of Bias Assessment Tool for Nonrandomized Studies. RESULTS:Screening identified 133 articles. Seven articles met inclusion criteria. People with contraversive lateropulsion after stroke can achieve similar improvements in function as those without lateropulsion, increasing likelihood of discharge home, but require longer rehabilitation durations to do so. CONCLUSIONS:The finding that longer rehabilitation durations are required for people with post-stroke lateropulsion to achieve their functional potential and increase likelihood of discharge home has implications for resourcing rehabilitation services. Given an additional three to four weeks in rehabilitation, people with post-stroke lateropulsion can achieve functional improvements function similar to those without lateropulsion. 10.1080/10749357.2021.1886640
Scale for contraversive pushing: cutoff scores for diagnosing "pusher behavior" and construct validity. Baccini Marco,Paci Matteo,Nannetti Luca,Biricolti Claudia,Rinaldi Lucio A Physical therapy BACKGROUND AND PURPOSE:Considerable disagreement exists among researchers with regard to the prevalence, pathophysiology, and treatment of "pusher behavior" (PB), partly because of different testing procedures. This study was primarily aimed at establishing cutoff scores for and the construct validity of the Scale for Contraversive Pushing (SCP). The prevalence of PB in people with right- and left-brain lesions also was investigated. SUBJECTS AND METHODS:The study subjects were 105 consecutive patients with recent stroke. Two methods were used to diagnose PB: clinical examination and SCP score with 3 different cutoff points--an SCP total score of greater than 0 (Crit_1), subscores in each section of the scale of greater than 0 (Crit_2), and subscores in each section of the scale of > or =1 (Crit_3). Clinical and SCP diagnoses were independently made by different examiners. The Cohen kappa coefficient was used to determine the agreement between clinical and SCP diagnoses. The construct validity of the SCP was estimated by calculation of Spearman rank correlation coefficients for SCP and balance, mobility, and functional scores. RESULTS:The agreement between clinical and SCP diagnoses was low (kappa=.212) when Crit_1 was used. Crit_2 led to the highest agreement with the clinical diagnosis (kappa=.933). However, only Crit_3, although globally less accurate (kappa=.754), ensured no false-positive results. The construct validity of the SCP was demonstrated by significant (P<.001) moderate to high correlations with mobility (rho=.595), functional (rho=.632), and balance (rho=.666) scores. The prevalence of PB was not influenced by the side of the lesion. A limitation of the study was that the reliability of the clinical examination method was not investigated. DISCUSSION AND CONCLUSION:The results support the validity of the SCP and suggest the need to choose different SCP cutoff criteria (Crit_2 or Crit_3) according to the aim of the evaluation. 10.2522/ptj.20070179
Effects of galvanic vestibular stimulation combined with physical therapy on pusher behavior in stroke patients: a case series. Nakamura Junji,Kita Yorihiro,Yuda Tomohisa,Ikuno Koki,Okada Yohei,Shomoto Koji NeuroRehabilitation BACKGROUND:A recent study investigated the effects of galvanic vestibular stimulation (GVS) on pusher behavior (PB) in post-stroke patients. However, there have been no reports about the effects of multisession GVS on PB. OBJECTIVE:The purpose of this study was to investigate the feasibility and effects of multisession GVS combined with physical therapy for PB in stroke patients. METHODS:Two stroke patients who showed PB were enrolled. The ABAB single-case design was used. Each phase lasted 1 wk. In phases A1 and A2, the patients underwent a 60-min-long physical therapy session 5 days a week. In phases B1 and B2, they underwent GVS for 20 min before each physical therapy session, and then the same physical therapy program as in phases A1 and A2 were performed. PB was evaluated using the Scale for Contraversive Pushing (SCP) and the Burke Lateropulsion Scale (BLS). Outcomes were tested at the baseline and after each phase. RESULTS:In both patients, the SCP scores were reduced only during phase B2. Although the BLS scores improved at the A1 phase, a larger improvement was seen at the two B phases. CONCLUSIONS:Multisession GVS combined with physical therapy may have positive effects on PB in clinical setting. 10.3233/NRE-141094
Prognosis of contraversive pushing. Karnath H-O,Johannsen L,Broetz D,Ferber S,Dichgans J Journal of neurology Stroke patients with 'pusher syndrome' actively push away from the non-hemiparetic side leading to a loss of postural balance and falling towards the paralysed side. The behaviour is due to an altered perception of the body's orientation in relation to gravity. Here, we studied the prognosis of the disorder. Twelve pusher patients first investigated immediately after the stroke were re-examined 6 months later. Pusher symptoms had nearly completely recovered. The aim for physiotherapy of patients with contraversive pushing thus is to shorten the period of necessary treatment and enable earlier discharge from residential care. 10.1007/s00415-002-0824-z
Pushing behavior and hemiparesis: which is critical for functional recovery in pusher patients ? Case report. Santos-Pontelli Taiza E G,Pontes-Neto Octávio M,Colafêmina José Fernando,Araújo Dráulio B de,Santos Antônio Carlos,Leite João P Arquivos de neuro-psiquiatria We report a sequential neuroimaging study in a 48-years-old man with a history of chronic hypertension and lacunar strokes involving the ventral lateral posterior nucleus of the thalamus. The patient developed mild hemiparesis and severe contraversive pushing behavior after an acute hemorrhage affecting the right thalamus. Following standard motor physiotherapy, the pusher behavior completely resolved 3 months after the onset and, at that time, he had a Barthel Index of 85, although mild left hemiparesis was still present. This case report illustrates that pushing behavior itself may be severely incapacitating, may occur with only mild hemiparesis and affected patients may have dramatic functional improvement (Barthel Index 0 to 85) after resolution pushing behavior without recovery of hemiparesis.
Soehendra's Stent Retriever as a pusher. Navarrete C Endoscopy
Recovery of an injured medial lemniscus with concurrent recovery of pusher syndrome in a stroke patient: a case report. Jang Sung Ho,Lee Han Do Medicine RATIONALE:A 67-year-old, right-handed male patient underwent craniotomy and drainage for hematoma removal related to an intracerebral hemorrhage (ICH) in the right thalamus and basal ganglia at the neurosurgery department of a university hospital. PATIENT CONCERNS:He presented with severe motor weakness of left extremities, impairment of proprioception, and severe pusher syndrome at the start of rehabilitation. DIAGNOSES:He was diagnosed as ICH in the right thalamus and basal ganglia. INTERVENTIONS:The patient received comprehensive rehabilitative therapy, movement therapy, and somatosensory stimulation. OUTCOMES:Four months after onset, left leg motor function (Motricity Index [MI] = 51) did not show significant recovery from that at two months after onset (MI = 41); however, in the same period, Nottingham Sensory Assessment and scale for contraversive pushing significantly improved. At four months, the patient was able to stand independently but required manual contact of one person during independent walking on an even floor. At seven months after onset, he was able to walk independently on an even floor. LESSONS:Recovery of a severely injured medial lemniscus with concurrent recovery of impaired proprioception and pusher syndrome. 10.1097/MD.0000000000010963
Lateropulsion Prevalence After Stroke: A Systematic Review and Meta-analysis. Neurology BACKGROUND AND OBJECTIVES:Lateropulsion is a deficit of active body orientation with respect to gravity in the frontal plane, mostly observed after a stroke. It magnifies mobility limitations and represents an emerging target in rehabilitation. Efforts to design specific interventional studies require some basic knowledge of epidemiology, which is insufficient today because many studies have focused on a few severe forms in individuals called pushers. The objectives of this study were to bridge this gap. METHODS:We systematically searched MEDLINE, EMBASE, CINAHL, and Cochrane Clinical Trials up to 31 May 2021 for original research reporting a prevalence or incidence of poststroke lateropulsion. We followed MOOSE and PRISMA guidelines. Eligibility for inclusion, data extraction, and study quality (Joanna Briggs Institute guidelines) were evaluated by 2 reviewers who used a standardized protocol (PROSPERO; CRD42020175037). A random-effects meta-analysis was used to obtain the pooled prevalence, whose heterogeneity was investigated by subgroup analysis (stroke locations and poststroke phases) and metaregression. RESULTS:We identified 22 studies (5,125 individuals; mean age 68.5 years; 42.6% female; assessed 24 days, on average, after stroke), most published after 2000. The studies' quality was adequate, with only 8 (36.4%) showing risk of bias. The pooled lateropulsion prevalence was 55.1% (95% CI 35.9-74.2) and was consistent across assessment tools. After supratentorial stroke, lateropulsion prevalence was 41% (95% CI 33.5-48.5), and only 12.5% (95% CI 9.2-15.9) in individuals with severe lateropulsion, called pushers. Metaregression did not reveal any effect of age, sex, geographic region, publication year, or study quality. Lateropulsion prevalence progressively decreased from 52.8% (95% CI 40.7-65) in the acute phase to 37% (95% CI 26.3-47.7) in the early subacute phase and 22.8% (95% CI 0-46.3) in the late subacute phase. The ratio of right to left hemispheric stroke with lateropulsion increased as a function of time: 1.7 in the acute phase to 7.7 in the late subacute phase. After infratentorial stroke, lateropulsion prevalence was very high, reaching 83.2% (95% CI 63.9-100.3). DISCUSSION:Poststroke lateropulsion prevalence is high, which appeals for its systematic detection to guide early interventions. Uprightness is predominantly controlled from the right hemisphere. 10.1212/WNL.0000000000200010
Progress in neuro-otology research in the last year. Tarnutzer Alexander A,Straumann Dominik Journal of neurology Herein, we summarize articles in the field of neuro-otology published in the Journal of Neurology over the last year. Topics included acute and chronic vertigo as well as auditory and ocular motor disorders. Characteristic lesion locations in Pusher syndrome are reported and the usefulness of bedside ocular motor tests in vertebrobasilar stroke is revisited. Probing the vestibular system and its value in predicting the outcome in vegetative state is discussed. Several articles address new diagnostic and therapeutic approaches in different disorders associated with chronic vestibular, auditory or gait deficits. In a series of case reports, we focus on different eye movement disorders in the vertical plane, which are often difficult to assess. 10.1007/s00415-012-6670-8
Post-stroke lateropulsion terminology: pushing for agreement amongst experts. Annals of physical and rehabilitation medicine Post-stroke lateropulsion is prevalent. The global inconsistency in terminology used to describe the condition presents obstacles in accurately comparing research results, reaching consensus on use of measurement tools, agreeing upon a consistent approach to rehabilitation, and translating research to clinical practice. Commencing in 2021, 20 international experts undertook a Delphi Process that aimed to compile clinical practice recommendations for the rehabilitation of lateropulsion. As a part of the process, the panel agreed to aim to reach consensus regarding terminology used to describe the condition. Improved understanding of the condition could lead to improved management, which will enhance patient outcomes after stroke and increase efficiency of healthcare resource utilisation. While consensus was not reached, the panel achieved some agreement that 'lateropulsion' is the preferred term to describe the phenomenon of 'active pushing of the body across the midline toward the more affected side, and / or actively resisting weight shift toward the less affected side'. This group recommends that 'lateropulsion' is used in future research and in clinical practice. 10.1016/j.rehab.2022.101684
Post-stroke lateropulsion and rehabilitation outcomes: a retrospective analysis. Disability and rehabilitation PURPOSE:A person with post-stroke lateropulsion actively pushes themselves toward their hemiplegic side, or resists moving onto their non-hemiplegic side. This study aimed to determine the association of lateropulsion severity with: • Change in function (Functional Independence Measure - FIM) and lateropulsion severity (Four-Point Pusher Score - 4PPS) during inpatient rehabilitation; • Inpatient rehabilitation length of stay (LOS); • Discharge destination from inpatient rehabilitation. METHODS:Retrospective data for 1,087 participants (aged ≥65 years) admitted to a stroke rehabilitation unit (2005-2018) were analysed using multivariable regression models. RESULTS:Complete resolution of lateropulsion was seen in 69.4% of those with mild lateropulsion on admission ( = 160), 49.3% of those with moderate lateropulsion ( = 142), and 18.8% of those with severe lateropulsion ( = 181). Average FIM change was lower in those with severe lateropulsion on admission than those with no lateropulsion ( < 0.001). Higher admission 4PPS was associated with reduced FIM efficiency ( < 0.001), longer LOS ( < 0.001), (adjusted mean LOS: 35.6 days for those with severe lateropulsion versus 27.0 days for those without), and reduced likelihood of discharge home ( < 0.001). CONCLUSION:Post-stroke lateropulsion is associated with reduced functional improvement and likelihood of discharge home. However, given a longer rehabilitation duration, most stroke survivors with moderate to severe lateropulsion can achieve important functional improvement.Implications for RehabilitationWhile people with post-stroke lateropulsion can be difficult to treat and require more resources than those without lateropulsion, the majority of those affected, even in severe cases, can make meaningful recovery with appropriate rehabilitation.Although those with moderate to severe post-stroke lateropulsion may have poorer outcomes (longer LOS and reduced likelihood of discharge home) it is still important to advocate for access to rehabilitation for this patient group to give them the opportunity for optimal functional recovery. 10.1080/09638288.2021.1928300
Subjective visual vertical (SVV) determined in a representative sample of 15 patients with pusher syndrome. Johannsen Leif,Fruhmann Berger Monika,Karnath Hans-Otto Journal of neurology 10.1007/s00415-006-0216-x
Measuring verticality perception after stroke: why and how? Pérennou D,Piscicelli C,Barbieri G,Jaeger M,Marquer A,Barra J Neurophysiologie clinique = Clinical neurophysiology About 80 papers dealing with verticality after stroke have been published in the last 20years. Here we reviewed the reasons and findings that explain why measuring verticality perception after stroke is interesting. Research on verticality perception after stroke has contributed to improve the knowledge on brain mechanisms, which build up and update a sense of verticality. Preliminary research using modern techniques of brain imaging has shown that the posterior lateral thalamus and the parietal insular cortex are areas of interest for this internal model of verticality. How they interact and are critical remains to be investigated. From a clinical standpoint, it has now been clearly established that biases in verticality perception are frequent after a stroke, causing postural disorders. Measuring the postural vertical with the wheel paradigm has allowed elucidating the mechanisms of lateropulsion, leading or not to a pushing. Schematically, patients with a hemispheric stroke align their erect posture with an erroneous reference of verticality, tilted to the side opposite the lesion. In patients with a brainstem stroke lateropulsion is usually ipsilesional, and results rather from a pathological asymmetry of tone, through vestibulo-spinal mechanisms. These evolutions of concepts and measurement standards of verticality representation should guide the emergence of rehabilitation programs specifically dedicated to the sense of verticality after stroke. Indeed, several pilot studies using appropriate somatosensory stimulation suggest the possibility to recalibrate the internal model of verticality biased by the stroke, and to improve uprightness. Vestibular stimulations seem to be less relevant and efficient. 10.1016/j.neucli.2013.10.131
Rehabilitation procedures in the management of postural orientation deficits in patients with poststroke pusher behavior: a pilot study. Gandolfi Marialuisa,Geroin Christian,Ferrari Federico,LA Marchina Elisabetta,Varalta Valentina,Fonte Cristina,ìPICELLI Alessandro,Dimitrova Eleonora,Munari Daniele,Valè Nicola,Waldner Andreas,Smania Nicola Minerva medica BACKGROUND:Pusher behavior (PB) is a little-known postural control disorder characterized by alterations in the perception of body orientation in the coronal (roll) plane. Poststroke PB poses many short- and long-term concerns in clinical practice leading to the longer length of hospital stay and slower functional recovery. The literature on specific rehabilitation training in PB is scant. The aim of this pilot study was to compare the outcomes after postural orientation training using visual and somatosensory cues versus conventional physiotherapy in patients with poststroke PB. METHODS:Sixteen patients with PB were enrolled. Eight patients received postural orientation training employing visual and somatosensory cues. Seven patients received conventional physiotherapy. Each patient underwent 20 (50 min/d) individual treatment sessions (5 d/week for 4 weeks). Primary outcome measure was the Scale for Contraversive Pushing (SCP). Secondary outcome measures were the European Stroke Scale (ESS), and the Postural Assessment Scale for Stroke (PASS). Outcomes were assessed at admission, after 1 week, post-treatment, and at 1-month follow-up. RESULTS:No significant between-group differences were measured on primary and secondary outcome measures. Significant within-group changes in performance were noted in both groups. The magnitude of the differences between the postural orientation training and the conventional physiotherapy effects, as measured on the SCP and the PASS, suggests the value of the former approach. CONCLUSIONS:Training employing visual and somatosensory cues might reduce pusher behavior severity and improve postural control in poststroke pusher behaviour.
The visual vertical in the pusher syndrome: influence of hemispace and body position. Saj Arnaud,Honoré Jacques,Coello Yann,Rousseaux Marc Journal of neurology The subjective visual vertical (SVV) was investigated in right brain-damaged (RBD) patients with pusher syndrome (PS) which is thought to stem from an erroneous perception of body orientation. The participants, sitting or lying, had to align a luminous rod with gravity. The task was performed in darkness with the rod centred to the body, or placed in the left (neglected) or in the right hemispace. The error, negligible in the control group (+0.3 degrees; n = 6) and mild in the nonneglect non-pusher patients (-1.8 degrees; n = 6), was clearly clockwise in the pusher neglect patients (N+P+; +7.2 degrees; n = 4), but anticlockwise in the non-pusher neglect patients (-6.6 degrees; n = 6). In both neglect groups, error was greater when the rod was in the left space. In N+P+ patients, the performance was strongly affected by posture (lying: +5.2 degrees ; sitting: +9.2 degrees ). Intra-individual variability was also much greater in this group. This study confirms the contralesional deviation of SVV in RBD patients without PS and suggests the presence of an opposite bias in RBD patients affected by PS. 10.1007/s00415-005-0716-0
[Spanish translation and validation of the Burke Lateropulsion Scale to measure pusher behaviour]. Martin-Nieto A,Martin-Casas P,Bravo-Llatas C,Moreno-Bermejo M I,Atin-Arratibel M A Revista de neurologia INTRODUCTION:Pusher behaviour is an alteration of postural control and the perception of the midline which occurs in some patients after suffering a stroke and it has important functional consequences, so its evaluation is essential. AIM:To translate into Spanish and to validate the Burke Lateropulsion Scale (BLS), used to evaluate the signs of pusher behaviour in patients. PATIENTS AND METHODS:To achieve the proposed objectives, a translation-back translation into Spanish of the scale was performed and the validity and reliability of a sample of post-stroke patients was evaluated. In addition, sensitivity to change was evaluated in patients who turned out to be pushers and received physiotherapy treatment. RESULTS:The experts' answers indicated that the scale was valid in terms of its content to evaluate pusher behaviour in a sample of patients. Cronbach's alpha obtained a result of 0.91. The evaluation of inter-observer and intra-observer reliability gave an overall intraclass correlation coefficient result of 0.99. When the reliability of each item was evaluated by means of the weighted kappa coefficient, most of the results exceeded 0.9. Finally, on evaluating the sensitivity to change on the scale in the sample of pusher patients, the results showed that the BLS is sensitive to the changes which occur after receiving neurological physiotherapy treatment for items related to standing, transfers and walking. CONCLUSIONS:The BLS scale is valid and reliable for measuring pusher behaviour in patients who have suffered a stroke and is sensitive to changes after neurological physiotherapy treatment.
Clinical Outcome Measures for Lateropulsion Poststroke: An Updated Systematic Review. Koter Ryan,Regan Sara,Clark Caitlin,Huang Vicki,Mosley Melissa,Wyant Erin,Cook Chad,Hoder Jeffrey Journal of neurologic physical therapy : JNPT BACKGROUND AND PURPOSE:Contraversive Lateropulsion, also referred to as contraversive pushing, pusher behavior, and pusher syndrome, can be associated with increased hospital length of stay, increased health care costs, and delayed outcomes in persons with stroke. The purpose of this updated systematic review was to identify scales used to classify contraversive lateropulsion, investigate literature that addresses their clinimetric properties, and create a resource for clinicians recommending use in clinical practice. METHODS:Three databases were searched for articles from inception to March 2017. The search strategy followed Cochrane Collaboration guidelines. The Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was applied to evaluate methodological quality. RESULTS:Four hundred three records were screened. Seven studies met inclusion criteria. Four scales were identified: the Scale for Contraversive Pushing (SCP), the Modified Scale for Contraversive Pushing (M-SCP), the Burke Lateropulsion Scale (BLS), and the Swedish Scale for Contraversive Pushing (S-SCP). Psychometric property investigation was most robust for the SCP and the BLS. Cross-cultural validity has not been fully investigated in scales used outside of their country of origin. DISCUSSION AND CONCLUSIONS:The BLS is recommended for identifying contraversive lateropulsion. The scale assesses the presence of contraversive lateropulsion across several functional tasks, from rolling to walking, and is the only scale originally written in English. The BLS is the only tool to receive ratings greater than poor for reliability and responsiveness. The BLS should be implemented as soon as contraversive lateropulsion is suspected to guide frontline clinicians' initial plan of care, allow objective identification of change over time, and facilitate easier investigation of interventional efficacy.Video Abstract available for additional insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A177). 10.1097/NPT.0000000000000194
Perception of Verticality and Vestibular Disorders of Balance and Falls. Dieterich Marianne,Brandt Thomas Frontiers in neurology To review current knowledge of the perception of verticality, its normal function and disorders. This is based on an integrative graviceptive input from the vertical semicircular canals and the otolith organs. The special focus is on human psychophysics, neurophysiological and imaging data on the adjustments of subjective visual vertical (SVV) and the subjective postural vertical. Furthermore, examples of mathematical modeling of specific vestibular cell functions for orientation in space in rodents and in patients are briefly presented. Pathological tilts of the SVV in the roll plane are most sensitive and frequent clinical vestibular signs of unilateral lesions extending from the labyrinths via the brainstem and thalamus to the parieto-insular vestibular cortex. Due to crossings of ascending graviceptive fibers, peripheral vestibular and pontomedullary lesions cause ipsilateral tilts of the SVV; ponto-mesencephalic lesions cause contralateral tilts. In contrast, SVV tilts, which are measured in unilateral vestibular lesions at thalamic and cortical levels, have two different characteristic features: (i) they may be ipsi- or contralateral, and (ii) they are smaller than those found in lower brainstem or peripheral lesions. Motor signs such as head tilt and body lateropulsion, components of ocular tilt reaction, are typical for vestibular lesions of the peripheral vestibular organ and the pontomedullary brainstem (vestibular nucleus). They are less frequent in midbrain lesions (interstitial nucleus of Cajal) and rare in cortical lesions. Isolated body lateropulsion is chiefly found in caudal lateral medullary brainstem lesions. Vestibular function in the roll plane and its disorders can be mathematically modeled by an attractor model of angular head velocity cell and head direction cell function. Disorders manifesting with misperception of the body vertical are the pusher syndrome, the progressive supranuclear palsy, or the normal pressure hydrocephalus; they may affect roll and/or pitch plane. Clinical determinations of the SVV are easy and reliable. They indicate acute unilateral vestibular dysfunctions, the causative lesion of which extends from labyrinth to cortex. They allow precise topographical diagnosis of side and level in unilateral brainstem or peripheral vestibular disorders. SVV tilts may coincide with or differ from the perception of body vertical, e.g., in isolated body lateropulsion. 10.3389/fneur.2019.00172
Effects of interactive visual feedback training on post-stroke pusher syndrome: a pilot randomized controlled study. Yang Yea-Ru,Chen Yi-Hua,Chang Heng-Chih,Chan Rai-Chi,Wei Shun-Hwa,Wang Ray-Yau Clinical rehabilitation OBJECTIVE:We investigated the effects of a computer-generated interactive visual feedback training program on the recovery from pusher syndrome in stroke patients. DESIGN:Assessor-blinded, pilot randomized controlled study. PARTICIPANTS:A total of 12 stroke patients with pusher syndrome were randomly assigned to either the experimental group (N = 7, computer-generated interactive visual feedback training) or control group (N = 5, mirror visual feedback training). MAIN OUTCOME MEASURES:The scale for contraversive pushing for severity of pusher syndrome, the Berg Balance Scale for balance performance, and the Fugl-Meyer assessment scale for motor control were the outcome measures. Patients were assessed pre- and posttraining. RESULTS:A comparison of pre- and posttraining assessment results revealed that both training programs led to the following significant changes: decreased severity of pusher syndrome scores (decreases of 4.0 ± 1.1 and 1.4 ± 1.0 in the experimental and control groups, respectively); improved balance scores (increases of 14.7 ± 4.3 and 7.2 ± 1.6 in the experimental and control groups, respectively); and higher scores for lower extremity motor control (increases of 8.4 ± 2.2 and 5.6 ± 3.3 in the experimental and control groups, respectively). Furthermore, the computer-generated interactive visual feedback training program produced significantly better outcomes in the improvement of pusher syndrome (p < 0.01) and balance (p < 0.05) compared with the mirror visual feedback training program. CONCLUSIONS:Although both training programs were beneficial, the computer-generated interactive visual feedback training program more effectively aided recovery from pusher syndrome compared with mirror visual feedback training. 10.1177/0269215514564898
Role of diffusion tensor imaging in analyzing the neural connectivity of the parieto-insular vestibular cortex in pusher syndrome: As case report. Medicine RATIONALE:Pusher syndrome is a disorder of postural control. It is associated with unilateral lesions on central vestibular system. In the current study, we attempted to identify and investigate neural connectivity of the parieto-insular vestibular cortex in a patient with pusher syndrome, using diffusion tensor imaging. PATIENT CONCERNS:A 60-year-old male patient had left hemiplegia due to an infarction on right premotor cortex, primary motor cortex, corona radiata and temporal and occipital lobe. The patient had severe motor weakness in left upper and lower limb, left side neglect and significant pusher syndrome. DIAGNOSIS:Patient was diagnosed with left hemiplegia due to an infarction in the right middle cerebral artery territory at the neurology department of a university hospital. INTERVENTIONS:One patient and 5 control subjects of similar age participated. Diffusion tensor imaging data were acquired at 4-month and 12-month after the initial injury. OUTCOMES:Fractional anisotropy, mean diffusivity, and tract volume (TV) were measured. TV values in both affected and unaffected hemispheres of the patient were significantly decreased at 4-month compared to those of control subjects. In the unaffected hemisphere of the patient, TV value showed significant increase at 12-month compared to that at 4-month. Although the TV value at 12-month of the affected hemisphere was out of reference range, TV was considerably increased compared to that at 4-month. Mean values for fractional anisotropy or mean diffusivity in 2 hemispheres did not show significant difference compared to those of control subjects regardless of month. LESSONS:Restoration of an injured projection pathway between the vestibular nuclei and parieto-insular vestibular cortex with recovery of pusher syndrome was found in a patient with stroke. 10.1097/MD.0000000000019835
Reliability and Validity of the Four-Point Pusher Score: An Assessment Tool for Measuring Lateropulsion and Pusher Behaviour in Adults after Stroke. Chow Emmanuelle,Parkinson Stephanie,Jenkin Joanna,Anderson Alisha,King Andrea,Maccanti Heidi,Minaee Novia,Hill Kylie Physiotherapy Canada. Physiotherapie Canada The authors determined the reliability and validity of the Four-Point Pusher Score (4PPS) among stroke survivors. Stroke survivors were invited to participate within 48 hours of admission to a stroke rehabilitation unit in a tertiary hospital. Intrarater reliability was determined by examining scores assigned to the same patient by the same physiotherapist. Interrater reliability was determined by examining scores assigned to the same patient by two other physiotherapists. Validity was determined by examining associations with the Burke Lateropulsion Scale (BLS), Scale for Contraversive Pushing (SCP), and functional scales. A total of 85 participants who were a median of 13 (interquartile range 9-21) days post-stroke completed this study. The weighted κ statistic for 4PPS intra- and interrater reliability was 0.97 ( < 0.001). Scores on the 4PPS were very strongly associated with scores on the BLS ( = 0.95) and the SCP ( = 0.86). Strong associations were evident between the 4PPS and the Berg Balance Scale ( = -0.77), Chedoke-McMaster Stroke Assessment postural control scale ( = -0.76), and FIM Motor sub-scale ( = -0.64; all s < 0.001). The 4PPS is a reliable and valid scale to assess lateropulsion and pusher behaviour in stroke survivors in an in-patient rehabilitation setting. 10.3138/ptc.2017-69
A new cutoff score for the Burke Lateropulsion Scale improves validity in the classification of pusher behavior in subactue stroke patients. Bergmann Jeannine,Krewer Carmen,Müller Friedemann,Jahn Klaus Gait & posture BACKGROUND:Pusher behavior substantially hampers balance during sitting, standing, and posture transitions in stroke patients. The Burke Lateropulsion Scale (BLS) was recommended to evaluate pusher behavior. However, its cutoff score has not been validated and recent studies found evidence for a need to modify it. As there is no gold standard for the diagnosis of pusher behavior, functions that are typically disturbed in these patients should be used for the validation of the cutoff score. RESEARCH QUESTION:To investigate whether pusher behavior correlates with balance performance during sitting, standing and posture transitions, and to validate the BLS cutoff score. METHODS:44 subacute stroke patients with pusher behavior (BLS ≥ 2) were included in this study. The BLS and the Performance-Oriented Mobility Assessment Balance subscale (POMA-B) were assessed several times at intervals of two weeks resulting in a total of 137 data sets. RESULTS:Correlation analysis between the BLS score and the POMA-B score revealed a moderate negative correlation (r=-0.602, p < 0.001): The lower the BLS score, the higher the balance performance. The maximum Youden Index (J=0.864) was found for a cutoff score ≥2.5. Patients with a BLS score ≥2 scored ≥1 on the POMA-B, while patients with a BLS score ≥3 scored at no item or only at the sitting balance task. SIGNIFICANCE:In line with previous findings, the results of this study support using a BLS cutoff score of ≥3 instead of ≥2 to diagnose PB for research purposes and intervention planning. A score ≥3 correlates with severe balance impairments and with an impaired verticality perception in the frontal plane, and it improves the agreement with the Scale for Contraversive Pushing. 10.1016/j.gaitpost.2018.12.034
Electromyography-guided electrical stimulation therapy for patients with pusher behavior: A case series. Fujino Yuji,Takahashi Hidetoshi,Fukata Kazuhiro,Inoue Masahide,Shida Kohei,Matsuda Tadamitsu,Makita Shigeru,Amimoto Kazu NeuroRehabilitation BACKGROUND:Pusher behavior (PB) is a posture disorder due to a subjective bias in verticality perception. However, muscle activity characteristics in this disorder and the effective treatments are not known. OBJECTIVE:To investigate electromyographic (EMG) activity and the effect of electrical stimulation (ES) in PB. METHODS:Two PB patients were enrolled. The EMG activity was measured over the upper and lower limb muscles on the non-paretic side, and over the trunk muscles on both sides during sitting. We used a modified ABA single-case design consisting of consecutive baseline, intervention, and follow-up, each phase lasting 2 d. During the intervention, together with conventional treatment, the patient received ES for 5 min/d on the muscle antagonist to the muscle where excessive activity was observed. PB was assessed before and after each phase using the scale for contraversive pushing and the Burke lateropulsion scale. Truncal balance was evaluated using the trunk control test. RESULTS:In both patients, electromyography of the non-paretic triceps brachii muscle revealed excessive activity. To inhibit the excessive activity, ES was applied to the non-paretic biceps muscle. All scores improved after the intervention and follow-up phases. CONCLUSION:ES based on EMG activity is therapeutic for PB. 10.3233/NRE-192911
Physiotherapy for pusher behaviour in a patient with post-stroke hemiplegia. Paci Matteo,Nannetti Luca Journal of rehabilitation medicine OBJECTIVE:This case report describes a specific, literature-based physiotherapy treatment and the outcome for a stroke patient with pusher behaviour. Pusher behaviour is characterized by pushing strongly towards the hemiplegic side in all positions and resisting any attempt at passive correction of posture to bring the weight towards or over the midline of the body. METHODS:The patient was a 71-year-old man with clear pusher behaviour due to a stroke. Therapy for the pushing behaviour was performed over a 3-week period. Motor function, mobility, disability, tone anomalies and pusher behaviour were assessed before and after the study period. Immediate effects of a single training session were assessed by clinical observation. RESULTS AND CONCLUSION:Immediate effects on the pusher behaviour were observed when using visual and auditory feedback, but not when somatosensory input was used. These results were not maintained to the end of the treatment period. Treatment makes the patient able to use compensatory strategies for functional activities. The long-term effects should be investigated in more depth in the future. 10.1080/16501970410029762
The pusher syndrome reverses the orienting bias caused by spatial neglect. Honoré Jacques,Saj Arnaud,Bernati Thérèse,Rousseaux Marc Neuropsychologia Spatial neglect can be accompanied by a pusher syndrome (PS) which is characterized by a postural deviation towards the contralesional side. In this study, the representation of the body orientation in the horizontal plane was evaluated in neglect patients with and without PS. The participants had to align a luminous rod with the straight ahead direction, a method allowing the measure of both horizontal components of subjective straight ahead, i.e. lateral shift and yaw rotation. Eighteen patients with a lesion of the right hemisphere were compared with ten healthy participants. Patients had neglect and PS (P+N+; n=3), neglect only (P-N+; n=10), or neither neglect nor PS (P-N-; n=5). P+N+ patients showed a significant leftward shift contrasting with the rightward shift of P-N+. No shift occurred in patients without neglect and controls. No significant yaw error was recorded in any groups. The original result of this study was an inversion of the sign of the bias in neglect patients with PS. This could be related to the postural disorders characterizing this syndrome, and which are opposite to those usually observed in spatial neglect. Thus, these data suggest a link between disorders of spatial representations and disorders of posture. 10.1016/j.neuropsychologia.2008.11.008
Spanish translation and validation of the Scale for Contraversive Pushing to measure pusher behaviour. Martín-Nieto A,Atín-Arratibel M Á,Bravo-Llatas C,Moreno-Bermejo M I,Martín-Casas P Neurologia (Barcelona, Spain) INTRODUCTION:The aim of this study was to develop and validate a Spanish-language version of the Scale for Contraversive Pushing, used to diagnose and measure pusher behaviour in stroke patients. METHODS:Translation-back translation was used to create the Spanish-language Scale for Contraversive Pushing; we subsequently evaluated its validity and reliability by administering it to a sample of patients. We also analysed its sensitivity to change in patients identified as pushers who received neurological physiotherapy. RESULTS:Experts indicated that the content of the scale was valid. Internal consistency was very good (Cronbach's alpha of 0.94). The intraclass correlation coefficient showed high intra- and interobserver reliability (0.999 and 0.994, respectively). The Kappa and weighted Kappa coefficients were used to measure the reliability of each item; the majority obtained values above 0.9. Lastly, the differences between baseline and final evaluations of pushers were significant (paired sample t test), showing that the scale is sensitive to changes obtained through physical therapy. CONCLUSIONS:The Spanish-language version of the Scale for Contraversive Pushing is valid and reliable for measuring pusher behaviour in stroke patients. In addition, it is able to evaluate the ongoing changes in patients who have received physical therapy. 10.1016/j.nrleng.2018.03.018
Inconsistent classification of pusher behaviour in stroke patients: a direct comparison of the Scale for Contraversive Pushing and the Burke Lateropulsion Scale. Bergmann Jeannine,Krewer Carmen,Rieß Katrin,Müller Friedemann,Koenig Eberhard,Jahn Klaus Clinical rehabilitation OBJECTIVE:To compare the classification of two clinical scales for assessing pusher behaviour in a cohort of stroke patients. DESIGN:Observational case-control study. SETTING:Inpatient stroke rehabilitation unit. SUBJECTS:A sample of 23 patients with hemiparesis due to a unilateral stroke (1.6 ± 0.7 months post stroke). METHODS:Immediately before and after three different interventions, the Scale for Contraversive Pushing and the Burke Lateropulsion Scale were applied in a standardized procedure. RESULTS:The diagnosis of pusher behaviour on the basis of the Scale for Contraversive Pushing and the Burke Lateropulsion Scale differed significantly (χ2 = 54.260, p < 0.001) resulting in inconsistent classifications in 31 of 138 cases. Changes immediately after the interventions were more often detected by the Burke Lateropulsion Scales than by the Scale for Contraversive Pushing (χ2 = 19.148, p < 0.001). All cases with inconsistent classifications showed no pusher behaviour on the Scale for Contraversive Pushing, but pusher behaviour on the Burke Lateropulsion Scale. 64.5% (20 of 31) of them scored on the Burke Lateropulsion Scale on the standing and walking items only. CONCLUSIONS:The Burke Lateropulsion Scale is an appropriate alternative to the widely used Scale for Contraversive Pushing to follow-up patients with pusher behaviour (PB); it might be more sensitive to detect mild pusher behaviour in standing and walking. 10.1177/0269215513517726
Effects of performing a lateral-reaching exercise while seated on a tilted surface for severe post-stroke pusher behavior: A case series. Fukata Kazuhiro,Amimoto Kazu,Inoue Mamiko,Shida Kohei,Kurosawa Saki,Inoue Masahide,Fujino Yuji,Makita Shigeru,Takahashi Hidetoshi Topics in stroke rehabilitation : For patients with severe post-stroke pusher behavior (PB), acquiring a vertical posture involves correcting paretic-sided body tilt to the non-paretic side. Active lateral sitting training may facilitate improvement in postural orientation for patients with PB. However, its effect on patients with severe PB remains unclear.: To determine the effect of performing a lateral-reaching exercise in patients with severe PB seated on a tilted surface: Three patients with severe PB due to right hemispheric stroke participated in our study. Using a single-case design, the intervention's effect was verified using the applied behavior analysis method. Conventional physical therapy was performed for 1 h at baseline and at follow-up. During the intervention, lateral sitting training on a tilted surface was performed 40 times per session (total, 2 sessions). PB was assessed using the Scale for Contraversive Pushing and the Burke Lateropulsion Scale, and patient-reported fear of falling. The Function in Sitting Test (FIST) and the Trunk Control Test (TCT) were administered.: PB improved in all patients post-intervention and persisted at follow-up. Fear of falling during the passive sitting task while moving toward the non-paretic side disappeared post-intervention and at follow-up. FIST and TCT scores improved in 2 patients.: The lateral sitting exercise reduced severe PB in all patients; however, sitting balance and trunk performance did not improve in 1 patient. Future studies to examine the adaptability of this task and long-term effects are needed. 10.1080/10749357.2020.1861718
Lesion Localization of Poststroke Lateropulsion. Babyar Suzanne R,Smeragliuolo Anna,Albazron Fatimah M,Putrino David,Reding Michael,Boes Aaron D Stroke Background and Purpose- Hemispheric stroke studies associating lateropulsion (pusher syndrome) with the location of brain lesions have had mixed results from small, unmatched samples. This study was designed to determine whether lateropulsion localizes to specific brain regions across patients with stroke using a case-control design. Methods- Fifty patients with lateropulsion after stroke were matched with 50 stroke patients without lateropulsion using age, time since onset of stroke, admission motor Functional Independence Measure score, lesion side, and gender. The primary analysis included multivariate lesion symptom mapping using sparse canonical correlations to identify regions most associated with lateropulsion as assessed with the Burke Lateropulsion Scale. Secondary analyses included evaluating paired comparisons for lesion volume, degree of motor impairment, motor and cognitive Functional Independence Measure scores. Results- The lesion symptom mapping analysis of all lesions mapped onto a common hemisphere produced an overall significant model ( P<5×10) with a regional peak at the inferior parietal lobe at the junction of the post-central gyrus (Brodmann Area 2) and Brodmann Area 40 as the lesion location most associated with lateropulsion. Lesion volume was larger for patients with lateropulsion. Despite adequate matching, motor performance and total Functional Independence Measure scores differed at a group level between patients with and without lateropulsion. Conclusions- This analysis implicated lesion involvement of the inferior parietal lobe as a key neuroanatomical determinant of developing lateropulsion. A better understanding of the anatomic underpinnings of lateropulsion may improve rehabilitation efforts, including the potential for informing noninvasive neuromodulation approaches. 10.1161/STROKEAHA.118.023445
Neuroimaging in stroke and non-stroke pusher patients. Santos-Pontelli Taiza Elaine Grespan,Pontes-Neto Octavio Marques,Araujo Draulio Barros de,Santos Antonio Carlos dos,Leite João Pereira Arquivos de neuro-psiquiatria Pusher behavior (PB) is a disorder of postural control affecting patients with encephalic lesions. This study has aimed to identify the brain substrates that are critical for the occurrence of PB, to analyze the influence of the midline shift (MS) and hemorrhagic stroke volume (HSV) on the severity and prognosis of the PB. We identified 31 pusher patients of a neurological unit, mean age 67.4 ± 11.89, 61.3% male. Additional neurological and functional examinations were assessed. Neuroimaging workup included measurement of the MS, the HSV in patients with hemorrhagic stroke, the analysis of the vascular territory, etiology and side of the lesion. Lesions in the parietal region (p=0.041) and thalamus (p=0.001) were significantly more frequent in PB patients. Neither the MS nor the HSV were correlated with the PB severity or recovery time.
Preexisting brain lesions in patients with post stroke pusher behavior and their association with the recovery period: A one year retrospective cohort study in a rehabilitation setting. Sue Keita,Usuda Daiki,Moriizumi Shutaro,Momose Kimito Neuroscience letters The presence of preexisting brain lesions due to previous stroke and cerebral small vessel disease has been reported to influence stroke related disability or rehabilitation outcomes. However, there is no data about the impact of such lesions on the recovery period after pusher behavior (PB). This retrospective cohort study aimed to determine the influence of preexisting brain lesions on PB recovery time. Nineteen patients who were suffering from PB were included in the study. The presence of preexisting brain lesions, including previous stroke, silent brain infarcts, microbleed, white matter hyperintensity, and enlarged perivascular spaces were assessed using medical history reports, radiological reports, and magnetic resonance imaging data. The lesion score, ranging from 0 to 5, was calculated based on each preexisting brain lesion. The time to recovery from PB was assessed using the Scale for Contraversive Pushing. Based on the median value of the lesion score, we divided patients into those with a lesion score < 2 and those with a lesion score ≥ 2. A Kaplan Meier survival analysis was performed between these two groups. A multivariable Cox proportional hazards analysis was also performed using the side with hemiparesis and the score of preexisting brain lesions as covariates to determine the hazard ratio. The results showed that the group with a lesion score ≥ 2 had significantly delayed recovery from PB and the hazard ratio of preexisting brain lesions score was 0.458 (95% confidence interval: 0.221, 0.949), while the side of hemiparesis was not identified a significant covariate. Our results indicated that patients with PB having higher score of preexisting brain abnormalities might require a longer time to recover, and this might be useful in planning inpatient rehabilitation and treatment goals for patients with PB. 10.1016/j.neulet.2021.136323
Scale for contraversive pushing in stroke patients: pusher behavior vs Thalamic astasia differential diagnosis and psychometric properties. Topics in stroke rehabilitation BACKGROUND:: Few studies have investigated the psychometric properties of the Scale for Contraversive Pushing (SCP) in depth, and none have evaluated its ability to establish differential diagnosis between pusher behavior (PB) and thalamic astasia (TA). OBJECTIVES:: To study the ability of the SCP to establish differential diagnosis, its reliability, content, construct, and internal validity in the assessment of subacute stroke patients. METHODS:: 120 individuals were evaluated using the SCP over a four-week period of treatment. Intra- and inter-observer reliability, floor and ceiling effects, minimum detectable change (MDC), internal validity and sensitivity to change were explored. In addition, the Barthel Index and the Trunk Control Test were used to study their correlations with the SCP. RESULTS:: Discriminant validity provides evidence that the correlation between SCP items was large or moderate. Convergent validity demonstrated that the correlation of each item with the total score of the scale was high (at around 0.8). Sensitivity to change was large (W = 0.274). Intra- and inter-observer reliability were excellent (Intraclass Correlation Coefficient > 0.9; k > 0.8), except for items B standing and C sitting (k > 0.7). The MDC was 1.39, and ceiling (8.333%) and floor (15.833%) effects were adequate. Cronbach's alpha (α) was equal to 0.901 (0.874-0.924) and McDonald's Omega (ω) was equal to 0.883 (0.856-0.973), showing excellent internal consistency. CONCLUSIONS:: The SCP is a reliable and valid tool which can successfully establish differential diagnosis between PB and TA and evaluate the changes generated by physiotherapy treatment. 10.1080/10749357.2021.1950986
Persistent pusher behavior after a stroke. Clinics (Sao Paulo, Brazil) 10.1590/s1807-59322011001200025
A Chinese patient with pusher syndrome and unilateral spatial neglect syndrome. Chen Xiao-Wei,Lin Cheng-He,Zheng Hua,Lin Zhen-Lan The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques OBJECTIVE:To observe clinical manifestations, behavioral characteristics, and effects of rehabilitation on a patient with pusher syndrome and unilateral spatial neglect caused by right thalamic hemorrhage. METHODS:Assessment of pusher syndrome was made by the Scale for Contraversive pushing (SCP), and unilateral spatial neglect syndrome was diagnosed using line cancellation, letter and star cancellation, line bisection tests and copy and continuation of graphic sequence test. Behavioral therapy, occupational therapy, reading training and traditional Chinese medicine methods were adopted for treatment of pusher syndrome and unilateral spatial neglect. RESULTS:The patient showed typical pusher syndrome and unilateral spatial neglect symptoms. The pusher syndrome and unilateral spatial neglect symptoms were significantly improved following rehabilitation treatments. CONCLUSIONS:Pusher syndrome and unilateral spatial neglect syndrome occurred simultaneously after right thalamic hemorrhage. Early rehabilitation therapy can reduce the symptoms of pusher syndrome and unilateral spatial neglect syndrome and improve motor function.
"Pusher syndrome" following cortical lesions that spare the thalamus. Johannsen Leif,Broetz Doris,Naegele Thomas,Karnath Hans-Otto Journal of neurology Stroke patients with "pusher syndrome" show severe misperception of their own upright body orientation although visual-vestibular processing is almost intact. This dissociation argues for a second graviceptive system in humans for the perception of body orientation. Recent studies revealed that the posterior thalamus is an important part of this system. The present investigation aimed to study the cortical representation of this system beyond the thalamus. We evaluated 45 acute patients with and without contraversive pushing following left-or right-sided cortical lesions sparing the thalamus. In both hemispheres, the simple lesion overlap associated with contraversive pushing typically centered on the insular cortex and parts of the postcentral gyrus. The comparison between pusher patients and controls who were matched with respect to age, lesion size, and the frequency of spatial neglect, aphasia and visual field defects revealed only very small regions that were specific for the pusher patients with cortical damage sparing the thalamus. Obviously, the cortical structures representing our control of upright body orientation are in close anatomical proximity to those areas that induce aphasia in the left hemisphere and spatial neglect in the right hemisphere when lesioned. We conclude that in addition to the subcortical area previously identified in the posterior thalamus, parts of the insula and postcentral gyrus appear to contribute at cortical level to the processing of the afferent signals mediating the graviceptive information about upright body orientation. 10.1007/s00415-005-0025-7
Pusher syndrome after ACA territory infarction. Karnath H-O,Suchan J,Johannsen L European journal of neurology 10.1111/j.1468-1331.2008.02187.x
Influence of unilateral spatial neglect on vertical perception in post-stroke pusher behavior. Fukata Kazuhiro,Amimoto Kazu,Fujino Yuji,Inoue Masahide,Inoue Mamiko,Takahashi Yosuke,Sekine Daisuke,Makita Shigeru,Takahashi Hidetoshi Neuroscience letters Pusher behavior (PB) impairs verticality in the frontal plane and is often associated with unilateral spatial neglect (USN). However, it is unclear whether USN affects verticality among patients with PB. We aimed to clarify the characteristics of verticality among PB, with and without USN. The study included 43 patients with right hemisphere stroke, including 12 without PB or USN, 10 with only USN, 10 with PB only, and 11 with PB and USN, and 15 age-matched healthy individuals. The subjective visual vertical (SVV), subjective postural vertical with eyes closed (SPV), and subjective postural vertical with eyes open were assessed. Under each condition, the mean (tilt direction) and standard deviation (variability) across trials were calculated. The variability of SVV was significantly greater among patients with only USN (6.9°±5.9°) or those with PB and USN (7.6 ± 4.3°). On SPV, the contralesional tilt was significantly greater, with higher variability, in patients with only PB (-2.2°±1.1° and 6.3°±1.4°, respectively) and those with PB and USN (-2.1°±2.0° and 6.6°±2.0°, respectively) than in the other groups. In patients with PB, SVV differed depending on the presence of USN, but it was suggested that SPV might not be affected by USN. These findings are important to plan PB treatment. 10.1016/j.neulet.2019.134667
Case Report: Visual Deprivation in Pusher Syndrome Complicated by Hemispatial Neglect After Basal Ganglia Stroke. Zhang Qian,Zhang Lixia,He Wei,Zheng Xuemei,Zhao Zhengrui,Li Yuanli,Xu Shutian,Zheng Juan,Zhuang Xin,Jia Wenting,Zhu Chengyuan,Xu Hua,Shan Chunlei,Chen Wenhua,Zhao Jingpu,Chen Sijing Frontiers in neurology We aimed to explore whether motor function and activities of daily life (ADL) could be improved with the application of visual deprivation in two patients with Pusher syndrome complicated by hemispatial neglect after right basal ganglia stroke. We assessed two stroke patients suffering from severe motor disturbances, both tilting heavily to the left, with diagnoses of Pusher syndrome and left hemispatial neglect. Vision in the left eye was deprived using patches during clinical rehabilitation. Motor function promotion was confirmed using the Burke Lateropulsion Scale (BLS), Fugl-Meyer Balance Scale (FMBS), and Holden grade (HG), while the Barthel index (BI) assessed ADL immediately and 1 week after intervention. Both patients regained standing balance immediately using visual deprivation, as well as walking ability, although both scored 0 on the FMBS and HG. After 1 week of treatment, one patient increased to 11 and 3 on the FMBS and HG, respectively, while the BLS score decreased from 12 to 2, and the ADL increased from 23 to 70. The other patient demonstrated increases to 10 and 3 on the FMBS and HG, respectively, with the BLS decreasing from 13 to 3, and the ADL increasing from 25 to 60. Therefore, in the rehabilitation treatment of Pusher syndrome complicated by hemispatial neglect due to basal ganglia stroke, visual deprivation can significantly improve motor function and shorten the treatment course. 10.3389/fneur.2021.706611
Effects of dynamic supported standing training in a patient with pusher behavior: a case report. Physiotherapy theory and practice BACKGROUND:The effects of task-specific and voluntary exercise in upright positions for pusher behavior remain unclear. In this report, we aimed to describe the effects of dynamic supported standing training using a modified standing frame to correct the alignment in a patient with severe pusher behavior. CASE DESCRIPTION:A 76-year-old man with cardioembolic ischemic stroke demonstrated pusher behavior. The patient underwent 3 days of dynamic supported standing training using a modified standing frame. The Scale for Contraversive Pushing, the Burke Lateropulsion Scale, and the Trunk Control Test were used to assess changes. OUTCOMES:Immediate improvements in sitting balance were observed after the intervention, and the effects persisted to 8 days later. CONCLUSION:Dynamic supported standing training using a modified standing frame may improve pusher behavior with short-term training. The collapsed posture of the patient in the present case was corrected using the modified standing frame. This neutral standing position could have a positive effect on motor learning with respect to holding one's posture. 10.1080/09593985.2021.1978119
Tilted 3D visual scenes influence lateropulsion: A single case study of pusher syndrome. Journal of clinical and experimental neuropsychology INTRODUCTION:Hemiparetic stroke patients with so-called "pusher syndrome" (synonyms: contraversive lateropulsion, contraversive pushing) use their non-paretic extremities to push toward their paralyzed side and actively resist external posture correction. The disorder is associated with a distorted perception of postural vertical combined with a maintained, or little deviating perception of visual upright. With the aim of reducing this mismatch, and thus reducing contraversive lateropulsion, we manipulated the orientation of visual input in a virtual reality setup. METHOD:We presented healthy subjects and an acute stroke patient with severe pusher syndrome a 3D visual scene that was either upright or tilted in roll plane by 20°. By moving the sitting participants in roll plane to the left and right, we assessed the occurrence of contraversive lateropulsion, namely the active resistance to external posture manipulation. RESULTS:With the 3D visual scene oriented upright, the patient with pusher syndrome showed the typical active resistance against tilts toward the ipsilesional side. He used his non-paretic arm to block the examiner's attempt to move the body axis toward that side. With the visual scene tilted to the ipsiversive left, his pathological resistance was significantly reduced. Statistically, the tolerated body tilt angles no longer differed from those of healthy subjects. CONCLUSIONS:We conclude that even short presentations of tilted 3D visual input can reduce symptoms of severe contraversive lateropulsion. The technique provides potential for a new treatment method of pusher syndrome and offers a simple, straightforward approach that can be effortlessly integrated in clinical practice. TRIAL REGISTRATION:German Clinical Trials Register (DRKS00026700). 10.1080/13803395.2022.2121382
Somatosensory findings of pusher syndrome in stroke patients. Lee Jong Hwa,Kim Sang Beom,Lee Kyeong Woo,Lee Ji Yeong Annals of rehabilitation medicine OBJECTIVE:To investigate the somatosensory findings of pusher syndrome in stroke patients. METHODS:Twelve pusher patients and twelve non-pusher patients were enrolled in this study. Inclusion criteria were unilateral stroke, sufficient cognitive abilities to understand and follow instructions, and no visual problem. Patients were evaluated for pusher syndrome using a standardized scale for contraversive pushing. Somatosensory finding was assessed by the Cumulative Somatosensory Impairment Index (CSII) and somatosensory evoked potentials (SEPs) at 1 and 14 weeks after the stroke onset. Data of SEPs with median and tibial nerve stimulation were classified into the normal, abnormal, and no response group. RESULTS:In the baseline characteristics (sex, lesion character, and side) of both groups, significant differences were not found. The score of CSII decreased in both groups at 14 weeks (p<0.05), but there were no significant differences in the CSII scores between the two groups at 1 and 14 weeks. There were no significant differences in SEPs between the two groups at 1 and 14 weeks after the stroke onset. CONCLUSION:It appears that somatosensory input plays a relatively minor role in pusher syndrome. Further study will be required to reveal the mechanism of pusher syndrome. 10.5535/arm.2013.37.1.88
Starting position effects in the measurement of the postural vertical for pusher behavior. Experimental brain research Pusher behavior (PB) is a severe lateral postural disorder that involves a disturbed subjective postural vertical (SPV) in the frontal plane. SPV is measured by determining the mean value and standard deviation of several trials beginning on both the contralesional- and ipsilesional-tilted positions. However, the postural representation, when passively tilted to the contralesional versus ipsilesional position, is different between patients with and without PB. Therefore, we hypothesized that SPV dependence on the starting position will be influenced by PB. For 53 patients with hemispheric stroke enrolled, SPV was measured using a non-motorized vertical board with eyes closed. The mean value (tilt direction) and standard deviation (variability) were calculated in four trials, each from two positions, with the patient tilted to the contralesional position (SPV-CL condition) and then to the ipsilesional position (SPV-IL condition). Patients were categorized into the non-pusher (n = 29) and pusher (n = 24) groups. In the SPV-CL trials, the tilt direction was significantly tilted contralesionally for the pusher group (- 6.3° ± 1.6°) compared with that for the non-pusher group (- 2.2° ± 1.8°; p < 0.001), with no significant difference in variability between the groups. In the SPV-IL trials, the tilt direction was not significantly different between the groups, but the variability was significantly higher in the pusher group (4.8° ± 2.0°) than in the non-pusher group (2.2° ± 1.3°; p < 0.001). The dependence of tilt direction and variability of SPV on the starting position in patients with PB differed from those noted in patients without PB. These results may help explain this abnormal posture and optimize neurological rehabilitation strategies for PB. 10.1007/s00221-020-05882-z
Pusher behaviour: a critical review of controversial issues. Paci Matteo,Baccini Marco,Rinaldi Lucio A Disability and rehabilitation Despite an increasing interest by researchers and clinicians, the pusher behaviour (PB) is still a poorly understood disorder, exhibited by some stroke patients, who push with their non-affected limbs towards the contralesional side and resist attempts at correction of their tilted posture. This review is aimed at critically summarizing findings on controversial issues regarding PB, namely correlation with neglect, neural correlates and underlying mechanisms. There is a growing agreement that PB reflects some misrepresentation of verticality. According to different findings, it has been suggested that PB may result from a conflict between an intact visual and an impaired somesthetic perception of vertical, or alternatively that it might result from a high-order disruption of somesthetic information processing from the paretic hemi-body, named graviceptive neglect. Although conflicting data have been reported, the association between PB and neglect seems to be confirmed, when a comprehensive assessment of neglect-related phenomena is performed. Localization of brain lesions is also controversial. Some investigations stressed the role of posterior lateral thalamus, but other findings revealed that different lesional sites may also be present. On the basis of these data we suggest the existence of a multicomponential network reliable for upright posture control. This model might also explain some different results in this area. Clinical implications and requirements for future research are discussed. 10.1080/09638280801928002
[Pusher syndrome]. Jokelainen L,Jokelainen M Duodecim; laaketieteellinen aikakauskirja
The Subjective Postural Vertical Determined in Patients with Pusher Behavior During Standing. Bergmann Jeannine,Krewer Carmen,Selge Charlotte,Müller Friedemann,Jahn Klaus Topics in stroke rehabilitation BACKGROUND:The subjective postural vertical (SPV), i.e., the perceived upright orientation of the body in relation to gravity, is disturbed in patients with pusher behavior. So far, the SPV has been measured only when these patients were sitting, and the results were contradictory as regards the side of the SPV deviation. OBJECTIVE:The objective was to investigate the SPV in patients with different degrees of severity of pusher behavior while standing. METHODS:Eight stroke patients with pusher behavior, ten age-matched stroke patients without pusher behavior, and ten age-matched healthy control subjects were included. The SPV (SPV error, SPV range) was assessed in the pitch and the roll planes. Pusher behavior was classified with the Burke Lateropulsion Scale (BLS). RESULTS:In the pitch plane, the SPV range was significantly larger in pusher patients than in patients without pusher behavior or healthy controls. The SPV error was similar for groups. In the roll plane, the SPV error and the SPV range were significantly larger and more ipsilesionally tilted in the pusher group than in the other two groups. There was a significant correlation between the SPV error in the roll plane and the BLS score. CONCLUSIONS:The study revealed that patients with pusher behavior had an ipsilesional SPV tilt that decreased with decreasing severity of the behavior. The large uncertainty in verticality estimation in both planes indicates that their sensitivity for the perception of verticality in space is generally disturbed. These findings emphasize the importance of specific rehabilitation approaches to recalibrate the impaired inner model of verticality. 10.1080/10749357.2015.1135591
Robot-assisted gait training to reduce pusher behavior: A randomized controlled trial. Bergmann Jeannine,Krewer Carmen,Jahn Klaus,Müller Friedemann Neurology OBJECTIVE:To determine the effects of 2 weeks of intensive robot-assisted gait training (RAGT) on pusher behavior compared to nonrobotic physiotherapy (nR-PT). METHODS:In a single-blind, randomized, controlled trial with 2 parallel arms, we compared 2 weeks of daily RAGT (intervention group) with the same amount of nR-PT (control group). Patients with subacute stroke who had pusher behavior according to the Scale for Contraversive Pushing (SCP) were included. The primary research questions were whether changes in pusher behavior would differ between groups post intervention, and at a follow-up 2 weeks afterward (SCP and Burke Lateropulsion Scale, Class II evidence). Secondary outcomes included the Performance-Oriented Mobility Assessment, the Functional Ambulation Classification, and the Subjective Visual Vertical. RESULTS:Thirty-eight patients were randomized. Thereof, 30 patients received the allocated intervention and were included in the analyses. RAGT led to a larger reduction of pusher behavior than nR-PT at post test (SCP: = 69.00, = -0.33, = 0.037; Burke Lateropulsion Scale: = 47.500, = -0.50, = 0.003) and at follow-up (SCP: = 54.00, = -0.44, = 0.008). Pusher behavior had ceased in 6 of 15 participants in the intervention group and 1 of 15 participants in the control group at post test. At follow-up, 9 of 15 and 5 of 15 participants, respectively, no longer exhibited the behavior. CONCLUSIONS:Two weeks of RAGT seems to persistently reduce pusher behavior, possibly by recalibrating the disturbed inner reference of verticality. The potential benefits of RAGT on pusher behavior and verticality perception require further investigation. TRIAL REGISTRATION:German Clinical Trials Register (registration number: DRKS00003444). CLASSIFICATION OF EVIDENCE:This study provides Class II evidence that RAGT is beneficial to reduce pusher behavior in patients with stroke. 10.1212/WNL.0000000000006276
[Clinical symptoms, origin, and therapy of the "pusher syndrome"]. Karnath H O,Brötz D,Götz A Der Nervenarzt Stroke patients may exhibit the peculiar behavior of actively pushing away from the nonhemiparetic side, leading to lateral postural imbalance and a tendency to fall towards the paralyzed side. These patients use the nonparetic extremities to stem actively against attempts of passive correction towards upright orientation. This phenomenon has been called the "pusher syndrome". Recent findings disclose that the deficit leading to contraversive pushing is an altered perception of the body's orientation in relation to gravity. Pusher patients experience their body as upright when they are actually tilted to the nonhemiparetic side. In contrast, processing of visual and vestibular inputs for the determination of visual vertical was undisturbed. The results argue for a separate pathway in humans for sensing gravity apart from that for perception of the visual world. This second graviceptive system decisively contributes to our control of upright body posture. The present article describes this still largely unknown neurological disease. The clinical examination of contraversive pushing, its underlying disturbance, lesion location, and approaches for therapy are considered. 10.1007/s001150050719
Physiotherapy for pusher behaviour. Paci Matteo,Rinaldi Lucio A NeuroRehabilitation
Clinical examination tools for lateropulsion or pusher syndrome following stroke: a systematic review of the literature. Babyar Suzanne R,Peterson Margaret G E,Bohannon Richard,Pérennou Dominic,Reding Michael Clinical rehabilitation OBJECTIVE:To examine the clinimetric properties and clinical applicability of published tools for 'quantifying' the degree of lateropulsion or pusher syndrome following stroke. DATA SOURCES:Search through electronic databases (MEDLINE, EMBASE, CINAHL, Science Citation Index) with the terms lateropulsion, pushing, pusher syndrome, validity, reliability, internal consistency, responsiveness, sensitivity, specificity, posture and stroke. Databases were searched from their inception to October 2008. REVIEW METHODS:Abstracts were selected by one author. A panel of experts then determined which should be included in this review. Five abstracts were reviewed and the panel agreed to omit one abstract because those authors did not write a full manuscript. The panel critiqued manuscripts according to predetermined criteria about clinical and clinimetric properties. RESULTS:Four manuscripts referencing three tools for examining lateropulsion were found. Validity and reliability data support the clinical use of the Scale for Contraversive Pushing, the Modified Scale for Contraversive Pushing and the Burke Lateropulsion Scale. The Scale for Contraversive Pushing has the most extensive testing of clinimetric properties. The other tools show promising preliminary evidence of clinical and research utility. More testing is needed with larger, more diverse samples. REVIEWERS' CONCLUSIONS:The Scale for Contraversive Pushing, the Modified Scale for Contraversive Pushing and the Burke Lateropulsion Scale are reliable and valid measures with good clinical applicability. Larger, more varied samples should be used to better delineate responsiveness and other clinimetric properties of these examination tools. 10.1177/0269215509104172
Transcranial Direct Current Stimulation Improves Pusher Phenomenon. Yamaguchi Takuya,Satow Takeshi,Komuro Taro,Mima Tatsuya Case reports in neurology An 83-year-old man suffered from cerebral infarction of the right middle cerebral artery territory. In association with severe left hemiparesis and hemispatial neglect on the left side, he showed severe pusher phenomenon (PP), which made rehabilitation difficult. Transcranial direct current stimulation (tDCS) was applied to the parietal area (2 mA × 20 min/day; anode on the right and cathode on the left) for 8 days, which resulted in remarkable improvement of PP and caused prolongation of static sitting time. tDCS of the parietal area could be a novel treatment option of PP following stroke. 10.1159/000497284
Pusher syndrome: its cortical correlate. Baier Bernhard,Janzen Jelena,Müller-Forell Wibke,Fechir Marcel,Müller Notger,Dieterich Marianne Journal of neurology Unilateral stroke can lead to a disorder of postural balance that manifests as a pushing away toward the contralesional side. It is called "pusher syndrome" (PS). The aims of this study were first to assess the anatomical cortical regions that induce PS and second to clarify whether tilt of the subjective visual vertical (SVV)--a sign of vestibular otolith dysfunction--is associated with PS. Sixty-six patients with acute unilateral strokes (28 left-sided lesions, 38 right-sided lesions) were tested for PS, for tilts of the SVV, for hemineglect and for the anatomical lesion site by magnetic resonance imaging (MRI)-based voxelwise lesion-behavior mapping analysis. Our data indicated no significant voxels; however, there was a trend towards an association between lesions of the posterior part of the insula, the operculum and the superior temporal gyrus--key areas of the multisensory vestibular cortical network--and the extent of pushing in patients with right-sided lesions, whereas the rather anterior part of the insula, the operculum as well as the internal capsule reaching to the lateral thalamus seemed to be involved in PS in left-sided lesion patients. These data might point toward a link between the systems responsible for postural control and for processing vestibular otolith information. These findings indicate that vestibular information might be fundamental in right-sided lesion patients for maintaining body posture in space. 10.1007/s00415-011-6173-z
rTMS for poststroke pusher syndrome: study protocol for a randomised, patient-blinded controlled clinical trial. BMJ open INTRODUCTION:Poststroke pusher syndrome (PS) prevalence is high. Patients with PS require longer rehabilitation with prolonged length of stay. Effective treatment of PS remains a challenge for rehabilitation professionals. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation technique that is effective and recommended in the clinical guidelines of stroke rehabilitation. However, the role of rTMS for PS has not been examined. The study is to assess the efficacy of a specific rTMS programme for patients with PS in reducing pushing behaviour, enhancing motor recovery and improving mobility, as well as testing the safety of rTMS for patients with PS. METHODS AND ANALYSIS:A randomised, patient and assessor blinded sham-controlled trial with two parallel groups will be conducted. Thirty-four eligible patients with PS will be randomly allocated to receive either rTMS or sham rTMS for 3 weeks. The primary assessment outcome is the pushing behaviour measured by the Burke Lateropulsion Scale and Scale for Contraversive Pushing. The secondary outcomes are the motor functions and mobility measured by the Fugl-Meyer Assessment Scale (motor domain) and Modified Rivermead Mobility Index, and any adverse events. Assessment will be performed at baseline and 1 week, 2 weeks and 3 weeks after intervention. Repeated-measures analysis of variance will be used for data analysis with the level of significance level set at 0.05. ETHICS AND DISSEMINATION:The protocol has been approved by the Biomedical Ethics Committee of West China Hospital, Sichuan University on 23 March 2022 (2022-133). The trial findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER:Chinese Clinical Trial Registry (ChiCTR2200058015). 10.1136/bmjopen-2022-064905
Pusher syndrome--a frequent but little-known disturbance of body orientation perception. Karnath Hans-Otto Journal of neurology Disturbances of body orientation perception after brain lesions may specifically relate to only one dimension of space. Stroke patients with "pusher syndrome" suffer from a severe misperception of their body's orientation in the coronal (roll) plane. They experience their body as oriented 'upright' when it is in fact markedly tilted to one side. The patients use the unaffected arm or leg to actively push away from the un-paralyzed side and resist any attempt to passively correct their tilted body posture. Although pusher patients are unable to correctly determine when their own body is oriented in an upright, vertical position, they seem to have no significant difficulty in determining the orientation of the surrounding visual world in relation to their own body. Pusher syndrome is a distinctive clinical disorder occurring characteristically after unilateral left or right brain lesions in the posterior thalamus and -less frequently- in the insula and postcentral gyrus. These structures thus seem to constitute crucial neural substrates controlling human (upright) body orientation in the coronal (roll) plane. A further disturbance of body orientation that predominantly affects a single dimension of space, namely the transverse (yaw) plane, is observed in stroke patients with spatial neglect. Apparently, our brain has evolved separate neural subsystems for perceiving and controlling body orientation in different dimensions of space. 10.1007/s00415-006-0341-6
Thalamocortical disconnection involved in pusher syndrome. Brain : a journal of neurology The presence of both isolated thalamic and isolated cortical lesions have been reported in the context of pusher syndrome-a disorder characterized by a disturbed perception of one's own upright body posture, following unilateral left- or right-sided stroke. In recent times, indirect quantification of functional and structural disconnection increases the knowledge derived from focal brain lesions by inferring subsequent brain network damage from the respective lesion. We applied both measures to a sample of 124 stroke patients to investigate brain disconnection in pusher syndrome. Our results suggest a hub-like function of the posterior and lateral portions of the thalamus in the perception of one's own postural upright. Lesion network symptom mapping investigating functional disconnection indicated cortical diaschisis in cerebellar, frontal, parietal and temporal areas in patients with thalamic lesions suffering from pusher syndrome, but there was no evidence for functional diaschisis in pusher patients with cortical stroke and no evidence for the convergence of thalamic and cortical lesions onto a common functional network. Structural disconnection mapping identified posterior thalamic disconnection to temporal, pre-, post- and paracentral regions. Fibre tracking between the thalamic and cortical pusher lesion hotspots indicated that in cortical lesions of patients with pusher syndrome, it is disconnectivity to the posterior thalamus caused by accompanying white matter damage, rather than the direct cortical lesions themselves, that lead to the emergence of pusher syndrome. Our analyses thus offer the first evidence for a direct thalamo-cortical (or cortico-thalamic) interconnection and, more importantly, shed light on the location of the respective thalamo-cortical disconnections. Pusher syndrome seems to be a consequence of direct damage or of disconnection of the posterior thalamus. 10.1093/brain/awad096
Treatment approaches for pusher behaviour: a scoping review. Topics in stroke rehabilitation BACKGROUND:Some individuals with hemiplegia show a postural disorder called pusher behavior. Various underlying theoretical mechanisms have been proposed, thus leading to various treatment approaches. OBJECTIVES:The aim of this scoping review is to identify and analyze the available evidence on the treatment approaches for pusher behavior. METHODS:Two independent reviewers conducted a literature search for original studies reporting on treatments for pusher behavior. Studies were searched in PubMed, Scopus, Web of Science, CINAHL and PEDro from their inception to December 2020. Treatment approaches were grouped in homogeneous areas based on the supposed underlying mechanism. To assess the reporting of the interventions, the Template for Intervention Description and Replication (TIDieR) was used. RESULTS:Thirty-one papers describing 45 interventions were included in the review. Most of the studies were case reports (i.e. including 1 person) (n = 16), followed by randomized controlled trials (n = 5), single subject design trials (n = 5), non-randomized controlled trials (n = 3), and case series (i.e. including more than 1 person) (n = 2). Treatment approaches were grouped into five categories: visual feedback, somatosensory cues, visual-somatosensory integration, brain stimulation, and other nonspecific treatments. The median number of TIDIeR items reported was 7 (range 4 to 10). CONCLUSION:Pusher behavior is still little-known. Five main categories of treatment approaches based on the alleged etiological underlying mechanisms have been identified. Most of studies are case reports; controlled trials should be further conducted. Intervention reporting should be improved to allow treatment replication in larger trials. 10.1080/10749357.2021.2016098
Treatment interventions for pusher syndrome: A case series. Pardo Vicky,Galen Sujay NeuroRehabilitation BACKGROUND:Pusher syndrome (PS) is a clinical disorder that causes decreased postural balance and active pushing away from the non-hemiparetic side in patients with right or left brain damage. Therapists are challenged by needing to manage both the hemiparetic and the pushing/non-hemiparetic sides. There is a minimal amount of evidence about effective treatment interventions for PS. OBJECTIVE:To describe treatment interventions that reduce pushing behavior and improve functional outcomes in patients with PS. METHODS:Five individuals (aged 42-76, admitted 5-16 days post-stroke) with PS participated in this case series. The participants received 90 minutes of physical therapy (5 days/week) with an average length of stay of 27 days. Treatment focused on regaining their sense of midline (balance and transfers), mobility retraining, and neuro re-education activities. Outcome measures examined pushing behavior, transfer ability, and sitting balance. RESULTS:All five participants demonstrated improvements in pushing behavior, balance and transfer status. CONCLUSIONS:These outcomes provide preliminary evidence of decreased pushing behavior, and improved balance and transfers following a program of interventions designed to improve the functional outcomes of patients with PS. Larger studies are needed to confirm these findings, and whether these interventions are effective for patients with less severe pushing behavior. 10.3233/NRE-182549