Clinical symptoms, origin, and therapy of the "pusher syndrome"

Abstract

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.