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Lara Huxley
Band 5 Physiotherapist
COMMON THEMES FOUND
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
What do you already know?
1. Spontaneous body posture tilted towards paretic side
2. Pushing towards paretic side
3. Resistance to passive correction
Geissert, 2019
"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
5-10%
5-63%
Paci & Nanetti (2004)
Krewer et al. 2013
Heterogenous diagnostic criteria
Diversity in patient groups
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?
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
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
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
Graded activities e.g.
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
Broetz et al. 2004
Investigate fear of falling
Active rather than passive correction where possible
Paci et al. 2011
1. The Pusher index
2. The Melbourne Index Scale
3. The scale for Contraversive Pushing
4. The Lateropulsion Scale
Carota, 2015
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
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
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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