Pusher Behavior Research Articles

Analysis of the recovery process and activities of daily living independence in pusher behavior and unilateral spatial neglect

ObjectiveTo investigate the recovery processes of pusher behavior (PB) and unilateral spatial neglect (USN) based on the severity of PB and USN, to determine the relationship between activities of daily living (ADL) independence levels. DesignThis retrospective study aimed to examine the temporal changes and their association with ADL independence levels based on the severity of PB and USN. SettingRecovery ward of Moriyama Neurological Center Hospital between March 2017 and October 2022. ParticipantsWe included all patients with cerebrovascular disease admitted to the recovery ward of Moriyama Neurological Center Hospital between March 2017 and October 2022. A total of 174 patients with PB and USN were classified into four groups as follows; severe PB and severe USN (Group A), severe PB and mild USN (Group B), mild PB and severe USN (Group C), and mild PB and mild USN (Group D). InterventionsNot applicable. Main Outcome MeasuresKaplan–Meier survival analysis was used to determine whether the time to recovery from PB or USN (SCP: ≤1.75 points; CBS: 0 points) differed between groups. Additionally, group differences in Functional Independence Measure (FIM) scores and efficiencies were examined. ResultsThere were significant differences among Groups A and B and Groups A and C, as determined by the log-rank test (P<0.05), and recovery was prolonged when both PB and USN were severely impaired. Similarly, FIM scores and efficiencies were lower in Group A (P<0.05). When PB and USN were severely impaired, ADL was adversely affected, and the recovery process was prolonged. In addition, when one of the two symptoms was severe and the other was mild, each recovery course tended to show improvement, suggesting that they exerted a mutual influence on each other. ConclusionsThese findings indicate that severity classification may help to determine functional prognosis in patients with PB and USN.

Body Lateropulsion and Pusher Behavior

The relationship between postural disturbance and vertical perception after cerebrovascular disease remains unclear and studies have only recently begun to be conducted. On the other hand, the symptomatic aspect is evident: body lateropulsion is ipsilateral in the case of caudal brainstem lesions and contralateral in the case of rostral brainstem and cerebral hemispheric lesions. In addition, patients with cerebral hemispheric lesions sometimes show“pusher behavior” in which they resist any attempt to correct their posture and push the body back to the paralyzed side using the healthy limbs, as they have a fear of deviation to the healthy side. The pusher behavior is always accompanied by hemiplegia and is detected in about 10% of cases of hemispheric vascular lesions.

Factors associated with clinical severity of pusher behavior

Factors associated with clinical severity of pusher behavior

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.

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.

Starting position effects in the measurement of the postural vertical for pusher behavior.

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.

Perception of postural verticality in roll and pitch while sitting and standing in healthy subjects

Assessment of verticality perception is increasingly used in patients with disorders of upright body orientation, e.g. in pusher behavior after hemispheric stroke or in retropulsion in neurovascular or degenerative diseases. The subjective postural vertical (SPV) assesses the individual’s perceived upright body orientation in space and can be determined in a sitting or a standing position. As somatosensory input differs between sitting and standing, we suppose a different representation of verticality. Thus, the aim of this study was to compare the SPV while sitting and while standing, and to determine the influence of proprioceptive and visual stimulations on the SPV in both positions.Twenty healthy subjects (18–40 years, 9 female) participated in two experiments. In experiment 1 the SPV was assessed in the pitch and roll planes while sitting and standing. In experiment 2 we additionally applied somatosensory Achilles tendon vibration and visual optokinetic stimulation.Results of experiment 1 revealed no difference of the SPV error between sitting and standing. Though, we found an increased SPV variability while sitting. Experiment 2 showed no effect of sensory manipulation in the pitch plane, but an effect of optokinetic stimulation in the roll plane. The tilt in direction of the visual stimuli was more pronounced while sitting. Optokinetic stimulation also resulted in a larger SPV variability in roll, indicating larger insecurity in verticality estimation during stimulation.In conclusion, even though the SPV assessment while sitting and standing resulted in similar mean values, the larger variability and the higher sensitivity to visual stimuli while sitting suggest different strategies for verticality estimation while sitting and while standing.

Effects of galvanic vestibular stimulation combined with physical therapy on unilateral spatial neglect and pusher behavior in stroke patient.

Effects of galvanic vestibular stimulation combined with physical therapy on unilateral spatial neglect and pusher behavior in stroke patient.

Influence of unilateral spatial neglect on vertical perception in post-stroke pusher behavior

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.

Effects of Game-based Postural Vertical Training on Pusher Behavior, Postural Control, and Activity of Daily Living in Patients With Acute Stroke: A Pilot Study

Effects of Game-based Postural Vertical Training on Pusher Behavior, Postural Control, and Activity of Daily Living in Patients With Acute Stroke: A Pilot Study

Brain imaging studies in pusher behavior: a narrative review

Brain imaging studies in pusher behavior: a narrative review

Comparing and contrasting clinical outcome measures for pusher behavior

Comparing and contrasting clinical outcome measures for pusher behavior

Robot assisted gait training for pusher behavior

Robot assisted gait training for pusher behavior

Comparing and contrasting clinical outcome measures for pusher behavior

Comparing and contrasting clinical outcome measures for pusher behavior

Pusher behavior visual feedback training is helpful

Pusher behavior visual feedback training is helpful

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.

Analysis of Subjective Postural Vertical in Pitch Plane in Patients with Pusher Behavior

Analysis of Subjective Postural Vertical in Pitch Plane in Patients with Pusher Behavior