Contraversive Pushing Research Articles

RTMS for Poststroke Pusher Syndrome: A Randomized, Patient-Blinded Controlled Clinical Trial

Background Patients with poststroke pusher syndrome (PS) require longer duration of rehabilitation and more supplemental care after discharge. Effective treatment of PS remains a challenge. The role of repetitive transcranial magnetic stimulation (rTMS) for PS has not been examined. Objective Assess the efficacy of rTMS for patients with poststroke PS in reducing pushing behavior, enhancing motor recovery and improving mobility. Methods A randomized, patient- and assessor-blinded sham-controlled trial with intention-to-treat analysis was conducted. Thirty-four eligible patients with poststroke PS were randomly allocated to receive either rTMS or sham rTMS for 2 weeks. Pushing behavior on the Burke lateropulsion scale and scale for contraversive pushing, motor function on Fugl-Meyer assessment scale-motor domain (FMA-m) and mobility on modified Rivermead mobility index were measured at baseline, 1 and 2 weeks after intervention. Repeated-measures analysis of covariance was used for data analysis. Results There was no significant interaction between intervention and time on Burke lateropulsion scale (F = 2.747, P = .076), scale for contraversive pushing (F = 1.583, P = .214), or change of modified Rivermead mobility index (F = 1.183, P = .297). However, a significant interaction between intervention and time was observed for FMA-m (F = 5.464, P = .019). Post hoc comparisons of FMA-m show better improvement in rTMS group with mean differences of 12.7 (95% CI −7.3 to 32.7) and 15.7 (95% CI −4.6 to 36.0) at post-treatment week 1 and week 2 respectively. Conclusions rTMS did not demonstrate significant efficacy in improving pushing behavior and mobility in patients with PS. However, rTMS might have potential effect in enhancing motor function for patients with PS. Registration: The study was registered in the Chinese Clinical Trial Registry (registration No. ChiCTR2200058015 at http://www.chictr.org.cn/searchprojen.aspx) on March 26, 2022.

Improving orientation with respect to gravity enhances balance and gait recovery after stroke: DOBRAS cohort

BackgroundLateropulsion is a deficit in body orientation with respect to gravity, frequent after stroke. Although it is a primary factor affecting mobility, the impact of its attenuation on balance and gait recovery has never been investigated. Moreover, most studies on the lateropulsion time-course focus on severe forms suspected to have a poor recovery, which is not proven. ObjectivesTo investigate lateropulsion attenuation and test 2 hypotheses: 1) lateropulsion attenuation greatly contributes to balance and gait recovery and 2) severe forms of lateropulsion recover slower than moderate forms. MethodsThis longitudinal study involved individuals included in the Determinants of Balance Recovery After Stroke (DOBRAS) cohort, after a first-ever hemispheric stroke, with data collected on day 30 (D30), D60 and D90 post-stroke. Body orientation with respect to gravity was assessed using the Scale for Contraversive Pushing (both scores and severity grouping), in parallel with balance (Postural Assessment Scale for Stroke) and gait (modified Fugl-Meyer Gait Assessment). ResultsAmong the 106 eligible individuals (mean age 66.5 [SD 9.7] years), on D30, 43 (41%) were considered upright and 63 (59%) showed lateropulsion: 30 (28%) moderate and 33 (31%) severe. Most individuals with lateropulsion (73%) improved their body orientation, progressing from severe to moderate lateropulsion, or becoming upright. However, half were still not upright on D90. The improvement in body orientation had a large impact on mobility, especially in individuals with severe lateropulsion, in whom it explained about 50% of balance and gait recovery between D30 and D60, then 20% (D60-D90). For moderate lateropulsion, its attenuation explained about 20% of balance and gait recovery until D90. Lateropulsion attenuation was not slower in individuals with severe forms. ConclusionsLateropulsion attenuation enhances balance and gait recovery in individuals after stroke suggesting that specific rehabilitation of body orientation with respect to gravity might help to recover mobility. RegistrationNCT03203109

Application of ‘the PUSH strategy’ to reduce contraversive pushing after stroke during inpatient rehabilitation

OBJECTIVE: Given the poor functional outcomes associated with contraversive pushing after stroke and lack of evidence guiding physical therapy interventions, the PUSH (Prioritizing Upright, Standing, and Higher-level stepping activities) Strategy was designed to address unmet needs. The aim of this paper is to describe the clinical application of the PUSH Strategy delivered during the physical therapy plan of care within inpatient rehabilitation. METHODS: The PUSH Strategy was applied during clinical practice in a large, urban inpatient rehabilitation hospital for patients demonstrating contraversive pushing after stroke with the goals to (1) reduce contraversive pushing, (2) contribute to facilitation of a community discharge, and (3) improve functional outcomes. Subsequently, outcomes [Burke Lateropulsion Scale (BLS), discharge disposition, and the Mobility and Walk portions of the Continuity Assessment and Record Evaluation (CARE) Tool] were collected at admission and discharge to assess patient progress. RESULTS: Between 2018 and 2020, 11 patients participated in the PUSH Strategy with 73% of patients achieving all three Strategy goals. On average, patients saw improvement in pushing [admit, 7.73 ± 3.3 (moderate pushing); discharge, 1.55 ± 2.4 (no pushing)] and function (admit mobility, 9.9 ± 4.4; discharge, 21.5 ± 5.3 and admit walking 8.1 ± 0.3, discharge 9.6 ± 2.7) during their inpatient rehabilitation stay. Nine were discharged to the community (82%). CONCLUSIONS: The PUSH Strategy was successfully applied for patients with post-stroke contraversive pushing during inpatient rehabilitation. Overall, patients demonstrated reduced pushing and improved functional outcomes during their rehabilitation and most were discharged to a community setting.

IMPAIRED VERTICALITY PERCEPTION AND POSTURAL BALANCE AT 1 MONTH AFTER HEMISPHERIC STROKE

Introduction. In some patients with hemispheric strokes the internal model of verticality is shifted to the opposite side, so patients actively tilt the body axis in the opposite direction from the affected hemisphere. Disturbances of verticality perception are associated with worse functional conditions and slower dynamics of their recovery, with the need for longer rehabilitation treatment, etc. Objective: to investigate the relationships between impaired perception of verticality and indicators of postural balance during the 1st month after hemispheric strokes. Material and methods. There were examined 205 patients with hemispheric strokes that occurred during the last month. The Scale for Contraversive Pushing was used to assess the orientation of the body axis in relation to the force of gravity in the frontal plane. For evaluating of static and dynamic balance we used Berg Balance Scale, Postural Assessment Scale for Stroke, Trunk Impairment Scale, Test Timed Up and Go. Results. Depending on the presence (absence) of verticality perception disorders it had been revealed significant differences in postural balance scales and tests. Severity of verticality perception impairment was associated with significant changes in postural balance: patients with pushing syndrome had reliably worse indicators of postural balance compared to patients with lateropulsion. Moreover, even minimal lateropulsion was associated with significant deterioration of postural balance indicators, compared to normal perception of verticality. In addition, increasing severity of lateropulsion was associated with significant deterioration of postural balance indicators, regardless of spatial hemineglect and hemiparesis severity. Conclusions. 1. Impaired verticality perception in the recovery period of hemispheric strokes was associated with reliable negative changes in postural balance status. 2. Increasing severity of verticality perception disorders corresponded to a reliable deterioration of postural balance indicators.

Dynamic changes of the direction and angle of radiographic ocular lateral deviation in patients with lateropulsion after stroke onset.

To examine if radiographic ocular lateral deviation (rOLD) could be provoked in stroke patients with mild-to-moderate lateropulsion according to vertical perception. In this single-center, retrospective study, acute stroke patients with mild-to-moderate lateropulsion assessed by the Scale for Contraversive Pushing were enrolled. Computed tomography or magnetic resonance imaging was performed on all patients on admission and then according to their conditions. The direction and angle of rOLD were compared among three groups according to the responsible lesion: lateral medullary (LM), pontine (P), and hemispheric (H). Sixty-six patients (male, 47; average age, 67years) were enrolled and divided into the LM (n = 37), P (n = 8), and H (n = 21) groups. All patients had body tilt. Patients in the LM group showed body tilt to the ipsilesional side during hospitalization, while those in the P and H groups tilted to the contralesional side. All patients had rOLD at the final assessment at an average of 13days after onset; patients in the P and H groups showed contralateral rOLD, while those in the LM group showed ipsilateral rOLD if they did not have cerebellar or pontine lesions. Significant decreases in the angle and changes in direction of rOLD according to lesion site were observed during hospitalization. Serial changes in rOLD findings after stroke onset are different according to the responsible lesion. The direction of rOLD in most patients is in accordance with vertical perception after the acute stage of stroke.

IMPAIRED VERTICALITY PERCEPTION IN PATIENTS WITH HEMISPHERIC STROKES: PREVALENCE, ASSOCIATED FACTORS (CROSS-SECTIONAL STUDY)

Introduction. In recent decades, among the causes of post-stroke postural balance disorders, a lot of attention has been paid to disorders of verticality perception. Impairments of verticality perception have different forms: from lateropulsion to pushing syndrome. Aim: to study the prevalence of verticality perception impairments during the 1st month after strokes and to determine the factors associated with this phenomenon. Material and methods. 205 patients with hemispheric strokes that occurred during the last month were examined. The Scale for Contraversive Pushing scale was used to assess the orientation of the body axis in relation to the force of gravity in the frontal plane. We determined socio-demographic factors, clinical and neurological characteristics, cognitive and psycho-emotional characteristics, neuroimaging parameters. Impaired verticality perception was diagnosed in 70 patients (34,2%): lateropulsion – in 61 (29,8%), pushing syndrome – in 9 patients (4,4%). No associations were found between impaired vertical perception and age, gender of patients, level of paresis, presence of apraxias and aphasias, NIHSS scale scores, modified Rankin scale scores, stroke type (ischemic/hemorrhagic), cognitive, anxiety and depressive disorders, fatigue, localization of cerebral infarction, level of leukoaraiosis, morphometric indicators of external and internal cerebral atrophy. On the other hand, patients with impaired verticality perception had significantly more often paresis (in case of lateropulsion - in 96.7%, in pushing syndrome - in 100%, in patients with normal verticality perception - in 75.6%), spatial hemineglect (70.5 %, 88.% and 17.8%, respectively), non-lacunar subtype of ischemic stroke (91.8%, 100% and 73.4%, respectively), lesions of the right hemisphere (73.8%, 77.7% and 57.0%, respectively), also they had significantly larger volumes of cerebral infarctions (20.3 (13.4-28.9) cm3, 24.1 (12.9-27.2) cm3 and 15.8 (8.5 -23.3) cm3, respectively). Conclusions. During the first month after stroke, impaired verticality perception is a common phenomenon associated with certain clinical and neuroimaging characteristics.

Tilted 3D visual scenes influence lateropulsion: A single case study of pusher syndrome

ABSTRACT 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).

RTMS for poststroke pusher syndrome: study protocol for a randomised, patient-blinded controlled clinical trial

IntroductionPoststroke 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...

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

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.

Effects of prismatic adaptation on balance and postural disorders in patients with chronic right stroke: protocol for a multicentre double-blind randomised sham-controlled trial

IntroductionPatients with right stroke lesion have postural and balance disorders, including weight-bearing asymmetry, more pronounced than patients with left stroke lesion. Spatial cognition disorders post-stroke, such as misperceptions of subjective...

Scale for contraversive pushing in stroke patients: pusher behavior vs Thalamic astasia differential diagnosis and psychometric properties

ABSTRACT 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.

Is Lateropulsion Really Related with a Specific Lesion of the Brain?

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.

Effects of performing a lateral-reaching exercise while seated on a tilted surface for severe post-stroke pusher behavior: A case series

ABSTRACT Background: 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. Objective: To determine the effect of performing a lateral-reaching exercise in patients with severe PB seated on a tilted surface Methods: 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. Results: 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. Conclusion: 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.

Balance, Lateropulsion, and Gait Disorders in Subacute Stroke.

To test the hypothesis that impaired body orientation with respect to gravity (lateropulsion) would play a key role in poststroke balance and gait disorders. Cohort study of 220 individuals consecutively admitted to a neurorehabilitation ward after a first hemisphere stroke (DOBRAS cohort [Determinants of Balance Recovery After Stroke] 2012-2018, ClinicalTrials.gov: NCT03203109), with clinical data systematically collected at 1 month, then at discharge. Primary outcomes were balance and gait disorders, quantified by the Postural Assessment Scale for Stroke and the modified Fugl-Meyer Gait Assessment, to be explained by all deficits on day 30, including lateropulsion assessed with the Scale for Contraversive Pushing. Statistics comprised linear regression analysis, univariate and multivariate analyses, and receiver operating characteristic curves. Lateropulsion was frequent, especially after right hemisphere stroke (RHS, D30, 48%; discharge 24%), almost always in right-handers. Among all deficits, impaired body orientation (lateropulsion) had the most detrimental effect on balance and gait. After RHS, balance disorders were proportional to lateropulsion severity, which alone explained almost all balance disorders at initial assessment (90%; 95% confidence interval [CI] [86-94], p < 0.001) and at discharge (92%; 95% CI 89-95, p < 0.001) and also the greatest part of gait disorders at initial assessment (66%; 95% CI 56-77, p < 0.001) and at discharge (68%; 95% CI 57-78, p < 0.001). Lateropulsion is the primary factor altering poststroke balance and gait at the subacute stage and therefore should be systematically assessed. Poststroke balance and gait rehabilitation should incorporate techniques devoted to misorientation with respect to gravity.

Factors Influencing Sitting Ability During the Acute Post-Stroke Phase: A Multicenter Prospective Cohort Study in Japan

Objectives: Sitting ability during the acute phase after stroke is a useful indicator of functional outcomes; however, factors that affect this ability have not been evaluated. Therefore, this study aimed to identify and evaluate factors that affect sitting ability in the acute phase after stroke. Materials and Methods: This multicenter prospective cohort study included hemispheric stroke patients who underwent an inpatient rehabilitation program after acute stroke from five acute care hospitals. The effect of age, sex, lesion side, etiology, consciousness disorder, stroke and dementia history, stroke-related complications, National Institutes of Health Stroke Scale score, hemiparalysis, turn-over movement from the supine position and sit-up movement, and Scale for Contraversive Pushing on the “remain sitting” item in the revised version of the Ability of Basic Movement Scale at the time of acute hospital discharge were investigated. Factors affecting sitting ability were identified using binomial logistic regression analysis. Results: We included 293 stroke patients. Age (odds ratio: 0.943, 95% confidence interval: 0.910–0.977, p=0.001), National Institutes of Health Stroke Scale score (odds ratio: 0.862, 95% confidence interval: 0.811–0.916, p<0.001), and Scale for Contraversive Pushing score (odds ratio: 0.543, 95% confidence interval: 0.419–0.705, p<0.001) were identified as independent predictors of sitting ability at the time of hospital discharge (median; 23.0 days). Conclusions: Older patients and those with high Scale for Contraversive Pushing and National Institutes of Health Stroke Scale scores experienced difficulties in regaining sitting ability. These results may guide physical therapy for patients with impaired sitting ability due to hemispheric stroke.

Effect of postural training using a whole-body tilt apparatus in subacute stroke patients with lateropulsion: A single-blinded randomized controlled trial.

Lateropulsion after stroke is defined as a postural bias toward the paretic side and push away from the non-paretic side. New rehabilitation techniques and programs should be designed to attenuate lateropulsion and improve functions of balance and gait. This study aimed to determine the effects of whole-body tilting postural training (WTPT) using a Spine Balance 3D on lateropulsion and postural control as compared with general postural training (GPT). Postural training was performed and involved a whole-body tilt apparatus that enables postural training in the tilted position, in multiple directions. This was a pragmatic, single-blind, randomized controlled trial conducted between June 2018 and May 2019. We randomly allocated 30 patients with subacute stroke and lateropulsion based on the Scale of Contraversive Pushing (SCP score>0) to experimental (n=15) and control (n=15) groups. The experimental group received WTPT with a whole-body tilt apparatus, and the control group GPT. WTPT was performed with the Spine Balance 3D and GPT with postural training commonly applied in the clinic. All participants received treatment for 30min/session, 2 times/day, 5 days/week for 3 weeks. The primary outcome measure was lateropulsion assessed with the Burke Lateropulsion Scale (BLS). Secondary outcome measures were postural control ability, activities of daily living, Postural Assessment Scale for Stroke (PASS) score, Berg Balance Scale (BBS) score, Korea-modified Barthel index (K-MBI), and Fugl-Meyer Motor Assessment-Lower Extremity (FMA-L) score. For the primary outcome, after training, BLS scores were decreased more for the experimental than control group (Δ=-5.8 vs. Δ=-4.2, P=0.002). For secondary outcomes, scores were improved more for the experimental than control group: PASS (Δ=13.8 vs. Δ=8.5, P<0.001), BBS (Δ=20.1 vs. Δ=11.1, P=0.001), K-MBI (Δ=27.0 vs. Δ=20.1, P=0.005), and FMA-L (Δ=10.2 vs. Δ=6.3, P=0.002). WTPT is a potentially effective therapeutic intervention for lateropulsion recovery in patients with subacute stroke. It may be useful for improving postural control and activities of daily living.

Spanish translation and validation of the Scale for Contraversive Pushing to measure pusher behaviour

IntroductionThe 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. MethodsTranslation–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. ResultsExperts 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. ConclusionsThe 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.

Reliability and Validity of the Four-Point Pusher Score: An Assessment Tool for Measuring Lateropulsion and Pusher Behaviour in Adults after Stroke.

Purpose: The authors determined the reliability and validity of the Four-Point Pusher Score (4PPS) among stroke survivors. Method: 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. Results: 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 (p < 0.001). Scores on the 4PPS were very strongly associated with scores on the BLS (r s = 0.95) and the SCP (r s = 0.86). Strong associations were evident between the 4PPS and the Berg Balance Scale (r s = -0.77), Chedoke-McMaster Stroke Assessment postural control scale (r s = -0.76), and FIM Motor sub-scale (r s = -0.64; all ps < 0.001). Conclusion: The 4PPS is a reliable and valid scale to assess lateropulsion and pusher behaviour in stroke survivors in an in-patient rehabilitation setting.

A new cutoff score for the Burke Lateropulsion Scale improves validity in the classification of pusher behavior in subactue stroke patients

BackgroundPusher 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 questionTo investigate whether pusher behavior correlates with balance performance during sitting, standing and posture transitions, and to validate the BLS cutoff score. Methods44 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. ResultsCorrelation analysis between the BLS score and the POMA-B score revealed a moderate negative correlation (rSp=-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. SignificanceIn 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.

Robot-assisted gait training to reduce pusher behavior: A randomized controlled trial.

To determine the effects of 2 weeks of intensive robot-assisted gait training (RAGT) on pusher behavior compared to nonrobotic physiotherapy (nR-PT). 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. 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: U = 69.00, r = -0.33, p = 0.037; Burke Lateropulsion Scale: U = 47.500, r = -0.50, p = 0.003) and at follow-up (SCP: U = 54.00, r = -0.44, p = 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. 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. German Clinical Trials Register (registration number: DRKS00003444). This study provides Class II evidence that RAGT is beneficial to reduce pusher behavior in patients with stroke.