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Pusher Behaviour

Lara Huxley

Band 5 Physiotherapist

INTRODUCTION

  • Choosing a topic: Stroke & Neurosurgery

COMMON THEMES FOUND

  • Research availability & specificity
  • Differences between literature

RESEARCH

Limitations of research

Often low grade (III) evidence for practice & high risk of bias

Lack of applicable research

Agniezka & Rafal 2013

Paci & Nannetti 2004

Remains poorly understood & findings are inconsistent

MENTIMETER

What do you already know?

ABOUT

1. Spontaneous body posture tilted towards paretic side

2. Pushing towards paretic side

3. Resistance to passive correction

Geissert, 2019

Patricia Davies, 1985

HISTORY

"Contraversive pushing"

"Lateropulsion"

Initially termed "syndrome"

Later determined not a true syndrome

"Ipsilateral pushing"

Occurs with right and left sided lesions (higher incidence R side)

Davies, 1985

Geissert, 2019

ETIOLOGY

INCIDENCE OF PUSHER BEHAVIOUR

5-10%

5-63%

Paci & Nanetti (2004)

Krewer et al. 2013

Heterogenous diagnostic criteria

Diversity in patient groups

MECHANISM

A posture disorder

Fujino et al. 2019

An incorrect perception of the verticality of the body

Due to a loss of sensory stimuli & spatial neglect

Carota 2015

Typically associated with posterior thalamic stroke / extra-thalamic lesions

Krewer et al. 2013

Perception as "upright" when tilted an average of 18 degrees

Paci et al. 2011

Associated with neglect (for right sided lesions) & aphasia (for left sided lesions)

Geissert et al. 2019

What is it?

SHORT-TERM

Increased difficulty with transfers

Increased risk of pressure areas due to repositioning challenges

Chitambira & Evans 2018

3.6 additional weeks to achieve same functional outcome

Pedersen et al. 1996

Reduced FIM initially & increased likelihood to discharge to sub-acute setting

Babyar et al. 2008

SHORT-TERM OUTCOMES

LONG-TERM

LONG- TERM OUTCOMES

Negative predictor for recovery time but not functional gain

Krewer et al. 2013

Karnath et al. 2002

21%

67%

Pushing behaviour rarely evident after 6 months

TREATMENT

Patient Goals

1. Improve awareness of upright body position

2. Learn movements to achieve verticality

3. Maintain these while performing other tasks

Karnath & Broetz 2003

PHYSIOTHERAPY

Graded activities e.g.

  • Lateral pelvic tilt in sitting
  • Standing using unaffected arm as support
  • Vocal feedback from therapist
  • Visual feedback from mirror with drawn midline

Visual feedback therapy used for 3.5 weeks with significant improvements on SCP

Primarily visual cues, somesthetic information also important

Outcome: Leaning towards affected side did not change, but patient learnt important compensatory strategies

Paci & Nannetti (2004)

Agniezka & Rafal (2013)

Motor learning principles, use of visual cues, blocking use of "pushing" limb

PHYSIOTHERAPY

Broetz et al. 2004

Investigate fear of falling

Active rather than passive correction where possible

Paci et al. 2011

TOP TIPS

  • DO NOT push / pull patient to midline
  • Use sternum and back as key points
  • Stand / sit with non-paretic side against a wall
  • If pushing severe t/f to paretic side, if mild towards non-paretic
  • Use tactile cues to ischial tuberosity to improve weight shift
  • Distract non-paretic arm (cup, reaching)

Outcome Measures

OUTCOME MEASURES

1. The Pusher index

2. The Melbourne Index Scale

3. The scale for Contraversive Pushing

4. The Lateropulsion Scale

Carota, 2015

NEW TREATMENT OPTIONS

Prone Positioning

Vestibular Stimulation & Machine Supported Gait Training

Conventional therapy plus relaxation therapy in prone 10 mins/day

Results: SCP scores improved post treatment

*Influencing motor output > vertical perception

To determine the effects of

  • Galvanic vestibular stimulation
  • Gait training with Lokomat
  • PT with visual feedback

Results: Significant improvement found after Lokomat training vs PT

Fujino et al. 2016

Krewer et al. 2012

Electrical Stimulation

Interactive Visual Feedback Training

Activation of biceps & triceps

Results: SCP & BLS scores reduced immediately post e-stim

Fujino et al. 2019

2 groups: Physically assisted in sitting or standing on Nintendo Wii balance board vs full body mirror

Results: Both significant improvments, more so in Wii group

Yang et al. 2014

REFERENCES

References

Krewer et al. 2013. Immediate effectiveness of single-session therapeutic interventions in pusher behaviour. Gait & Posture 37(2), pp. 246-250.

Paci, M. & Nannetti, L. 2004. Physiotherapy for pusher behaviour in a patient with post-stroke hemiplegia. Journal of Rehabilitation Medicine 36(4), pp. 183-185.

Pedersen, P. et al. 1996. Ipsilateral pushing in stroke: Incidence, relation to neuropsychological symptoms, and impact on rehabilitation . The Copenhagen Stroke Study. Archives of Physical Medicine and Rehabilitation 77, pp. 25-28.

Primoselli, S et al. 2001. Pusher syndrome in stroke: clinical, neuropsychological and neurophysiological investigation. Eur Med Phys 37, pp. 143-151.

Yang, Y. et al. 2014. Effects of interactive visual feedback training on post-stroke pusher syndrome: a pilot randomized controlled study. Clinical Rehabilitation 29(10), pp. 987-993.

Agnieszka, S. & Rafal, P. 2013. Pusher Syndrome in stroke patients : the current state of knowledge on methods and physiotherapy. Rehabilitatacja Medyczna 17(4), pp. 19-28.

Babyar, S. 2008. Outcomes with stroke and lateropulsion: a case-matched controlled study. Neurorehabil Neural Repair 4, pp. 415-423.

Burness, M. 2018. Identification and Treatment of Pusher Syndrome. Pusher Syndrome 2018 Handout Version (memberclicks.net)

Broeta, D. 2004. Time course of “pusher syndrome” under visual feedback treatment. Physiother Res Int 9(3), pp. 138-143.

Carota, A. 2015. Pusher Syndrome. Available from: Pushersyndrome | Dr Antonio Carota MD, Neurologist (neuro-la-cote.info) [Accessed 1/2/2022].

Chitambira, B. & Evans, S. 2008. Repositioning stroke patients with pusher syndrome to reduce incidence of pressure ulcers. British Journal of Neuroscience Nursing 14(1), pp. 16-21.

Davies, P. (1985). Steps to follow. Berlin: Springer-Verlag .

Fujino, Y. et al. 2016. Prone positioning reduces 292 severe pushing behavior: Three case studies. Journal of Physical Therapeutic Science 28, pp. 2690-2693.

Fujino, Y. et al. 2019. Electromyography-guided electrical stimulation therapy for patients with pusher behaviour: A case series. Neuro Rehabilitation 45(4), pp. 537-545.

Geissert, J. 2019. Rehabilitation Strategies for Pusher Syndrome. Available from: https://www.heart.org/-/media/Files/Affiliates/MWA/Kansas-City/BiStateStrokeConsortium/23rd-Annual-Stroke-Symposium/Rehabilitation-Strategies-for-Pusher-Syndrome.pdf [Accessed 31/1/22].

Karnath, H. 2002. Prognosis of contraversive pushing. J Neurol 249(9), pp. 1250-1253.

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