Pusher Syndrome Research Articles

Influence of Subjective Postural Vertical with Closed and Open Eyes in Patients with Hemiplegic and Pusher Behavior with Unilateral Spatial Neglect After Stroke: A Cross-Sectional Study

Background: When integrating visual and somatosensory processing into the subjective postural vertical using the Romberg test, patients with hemiplegic can be sorted into either post-stroke or pushers with unilateral spatial neglect (USN). This study aimed to clarify the characteristics of the integrated processing of the integrated subjective postural vertical (ISPV) with open or closed eyes in patients with hemiplegic and/or pusher with USN. Methods: This cross-sectional study included 91 patients with hemiplegic and 45 with pusher and USN. The outcomes included the ratio and sum of SPV with the eyes closed and open. Statistical analyses were performed using the parametric and/or non-parametric Wilcoxon rank-sum test, Mann–Whitney U test, or chi-square test after the Shapiro–Wilk test. Results: The outcomes in the 91 patients with hemiplegic were as follows: moderate-to-severe ISPV with ratio, 1.64°; ISPV sum (ISPVS), 9.41°. The outcomes in the 45 patients with pusher and USN were as follows: moderate-to-severe, ISPV: 1.35°, and ISPVS: 13.96°. No significant differences were observed between the two groups in terms of demographic data or ISPV. However, the number of patients with pusher syndrome was significantly higher in the ISPVS group than in stroke patients with hemiplegic. Conclusions: Adaptation occurs by integrating sensory modalities, and the pusher behavior in patients with USN is characterized by the specific pathophysiology of a two-modality disorder with visual and somatosensory deficits. This study provides key insights into the pathophysiological characteristics of patients with pusher syndrome and USN.

Validation of a laser visual feedback and core stability exercise programme to improve lateropulsion reduction and pushing intensity in stroke patients with pusher syndrome: A Delphi study.

The patient with pusher syndrome (PS) is characterized by showing postural control alterations due to a lack of perception of his own body in the space. It appears when the patient actively pushes with his unaffected limbs towards the injured side, reacting with resistance to passive straightening towards the midline. Between 10% and 50% of strokes present PS. Nowadays, there is no clearly defined treatment for PS. To design and validate an exercise program using visual feedback and specific core stability exercises (FeViCoS) for the treatment of patients with PS. Validation was conducted by expert consensus using the Delphi method. Thirteen neurorehabilitation experts participated in the process. An online questionnaire with 18 Likert-type questions was used to evaluate the designed program. Consensus was considered reached if there was convergence between the quartile 1 and 3 values (RIQ=Q1-Q3) or if the relative interquartile range (RIR) was less than 20%. The degree of agreement between experts was measured by calculating the Fleiss' kappa coefficient. A total of 2 rounds were required to achieve 97.44% consensus with 100% participation. The RIR was less than or equal to 20% for all questions. The Fleiss' kappa index (0.831) showed that the degree of agreement between experts was excellent. Neurorehabilitation experts considered FeViCoS valid for the therapeutic approach to patients with PS. Expert consensus suggests a novel strategy in physical therapy clinical practice to improve balance and postural orientation in patients with subacute stroke and PS.

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.

Misperception of body verticality in neurological disorders: A systematic review and meta-analysis.

The internal representation of verticality could be disturbed when a lesion in the central nervous system (CNS) affects the centers where information from the vestibular, visual, and/or somatosensory systems, increasing the risk of falling. The aim was to evaluate the vestibular and somatosensory contribution to the verticality pattern in patients with stroke and other neurological disorders. A literature search was performed in PubMed, Scopus, Web of Science, and CINAHL databases. Cross-sectional, case-control, and cohort studies comparing body verticality in patients with stroke or CNS diseases (CNSD) versus healthy controls were selected. Subjective postural vertical (SPV) in roll and pitch planes was used as the primary variable. Ten studies reporting data from 390 subjects were included. The overall effect for CNSD patients showed a misperception of body verticality in roll (standardized mean difference [SMD]=1.05; 95% confidence interval [CI].84-1.25) and pitch planes (SMD=1.03; 95% CI.51-1.55). In subgroup analyses, a high effect was observed in the perception of SPV both in roll and pitch planes in stroke (p=.002) and other CNSD (p<.001). These findings suggest a potential misperception of SPV in patients with stroke and other neurological disturbances. Patients with CNSD could present an alteration of vestibular and somatosensory contribution to verticality construction, particularly stroke patients with pusher syndrome (PS), followed by those with PS combined with hemineglect.

Lower limb muscle strength of the affected side in stroke patients is an accurate predictor of the need for a KAFO.

Accurate prediction of recovery is essential to determine whether a knee-ankle-foot orthosis (KAFO) is required in the subacute phase of stroke. However, there are currently no reliable methods to predict such recovery. This study aimed to determine whether muscle strength of the affected lower limb (affected side LL strength) in stroke patients in the subacute phase who cannot walk without a KAFO can be used to predict the continuous need for a KAFO, using a hand-held dynamometer. We enrolled patients with severe hemiplegia (n = 51) who were unable to walk without a KAFO for 10 days after stroke onset. They were divided into two groups depending on the continuous need for a KAFO at 1 month after onset; the KAFO and non-KAFO groups. Logistic regression analysis was used to investigate whether the affected side LL strength was a predictor of the continuous need for a KAFO at 1 month after onset. In addition, significant predictors were analyzed using receiver operating characteristic (ROC) curves. The KAFO and non-KAFO groups included 23 (45.10%) and 28 (54.90%) patients, respectively. The affected side LL strength and pusher syndrome severity were identified as predictors of the continuous need for a KAFO. The predictor with the highest predictive ability was the affected side LL strength, with an area under the ROC curve of 0.80 (95% CI, 0.68-0.93). Affected side LL strength may be a highly accurate predictor of the need for a KAFO in the subacute phase of stroke.

Predictors indicating the continuous need for a knee-ankle-foot orthosis in stroke patients at 1 month after onset

ObjectivesTo investigate predictors indicating the continuous need for a knee-ankle-foot orthosis (KAFO) at 1 month after stroke onset in patients who cannot walk without a KAFO in the acute period. Materials and methodsWe enrolled patients with severe hemiplegia (n = 139) who were unable to walk without a KAFO on day 10 from stroke onset. The patients were divided into two groups depending on the need for a KAFO at 1 month after the onset: the KAFO group and non-KAFO group. Logistic regression analysis was used to identify predictors of the continuous need for a KAFO at 1 month after stroke onset. In addition, significant predictors were analyzed using receiver operating characteristic curves. ResultsThe number of patients in the KAFO group and non-KAFO group was 72 (51.8 %) and 67 (48.2 %), respectively. Motor deficit, sensation disorder, severity of pusher syndrome, and body mass index were identified as predictors of the continuous need for a KAFO. Moreover, active range of motion of knee extension on the affected side was found to have the highest predictive ability, with an area under the receiver operating characteristic curve of 0.89 (95 % confidence interval, 0.83–0.94). ConclusionsIn this study, multiple factors were associated with the continuous need for a KAFO at 1 month after stroke onset. In particular, active range of motion of knee extension on the affected side is suggested to be a highly accurate predictor for the need for a KAFO in the subacute phase.

Possibilities of physiotherapeutic treatment in the case of patients with pusher syndrome

The consequences of damage to brain structures often includes various types of perceptual and motor disorders. One of them is Pusher Syndrome (PS). It is defined as a disturbance in the perception of the body position in the frontal plane, which in turn makes it difficult to maintain a correct vertical posture. It occurs most often in patients after a stroke of the right hemisphere of the brain, in the posterolateral region of the thalamus, and its frequency is estimated at about 9–50%. However, it is still a little-known syndrome and too rarely diagnosed. Correct, early diagnosis of pusher syndrome and the introduction of appropriate physiotherapy allows us to shorten the patient’s rehabilitation time and speed up his/her recovery. The objective of the study is to present the principles and possibilities of therapy for patients with pusher syndrome.

Thalamocortical disconnection involved in pusher syndrome.

The presence of both isolated thalamic and isolated cortical lesions have been reported in the context of pusher syndrome-a disorder characterized by a disturbed perception of one's own upright body posture, following unilateral left- or right-sided stroke. In recent times, indirect quantification of functional and structural disconnection increases the knowledge derived from focal brain lesions by inferring subsequent brain network damage from the respective lesion. We applied both measures to a sample of 124 stroke patients to investigate brain disconnection in pusher syndrome. Our results suggest a hub-like function of the posterior and lateral portions of the thalamus in the perception of one's own postural upright. Lesion network symptom mapping investigating functional disconnection indicated cortical diaschisis in cerebellar, frontal, parietal and temporal areas in patients with thalamic lesions suffering from pusher syndrome, but there was no evidence for functional diaschisis in pusher patients with cortical stroke and no evidence for the convergence of thalamic and cortical lesions onto a common functional network. Structural disconnection mapping identified posterior thalamic disconnection to temporal, pre-, post- and paracentral regions. Fibre tracking between the thalamic and cortical pusher lesion hotspots indicated that in cortical lesions of patients with pusher syndrome, it is disconnectivity to the posterior thalamus caused by accompanying white matter damage, rather than the direct cortical lesions themselves, that lead to the emergence of pusher syndrome. Our analyses thus offer the first evidence for a direct thalamo-cortical (or cortico-thalamic) interconnection and, more importantly, shed light on the location of the respective thalamo-cortical disconnections. Pusher syndrome seems to be a consequence of direct damage or of disconnection of the posterior thalamus.

Pusher Syndrome: Not a Rare, But a Little-known Phenomenon in Stroke Survivors: A Review of the Literature with Report of a Typical Case

Pusher Syndrome: Not a Rare, But a Little-known Phenomenon in Stroke Survivors: A Review of the Literature with Report of a Typical Case

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...

Is lateropulsion really related with specific lesion of brain?

The 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 the 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.

Lateropulsion After Hemispheric Stroke: A Form of Spatial Neglect Involving Graviception.

To test the hypothesis that lateropulsion is an entity expressing an impaired body orientation with respect to gravity in relation to a biased graviception and spatial neglect. Data from the DOBRAS cohort (ClinicalTrials.gov: NCT03203109) were collected 30 days after a first hemisphere stroke. Lateral body tilt, pushing, and resistance were assessed with the Scale for Contraversive Pushing. Among 220 individuals, 72% were upright and 28% showed lateropulsion (tilters [14%] less severe than pushers [14%]). The 3 signs had very high factor loadings (>0.90) on a same dimension, demonstrating that lateropulsion was effectively an entity comprising body tilt (cardinal sign), pushing, and resistance. The factorial analyses also showed that lateropulsion was inseparable from the visual vertical (VV), a criterion referring to vertical orientation (graviception). Contralesional VV biases were frequent (44%), with a magnitude related to lateropulsion severity: upright -0.6° (-2.9; 2.4), tilters -2.9° (-7; 0.8), and pushers -12.3° (-15.4; -8.5). Ipsilesional VV biases were less frequent and milder (p < 0.001). They did not deal with graviception, 84% being found in upright individuals. Multivariate, factorial, contingency, and prediction analyses congruently showed strong similarities between lateropulsion and spatial neglect, the latter encompassing the former. Lateropulsion (pusher syndrome) is a trinity constituted by body tilt, pushing, and resistance. It is a way to adjust the body orientation in the roll plane to a wrong reference of verticality. Referring to straight above, lateropulsion might correspond to a form of spatial neglect (referring to straight ahead), which would advocate for 3D maps in the human brain involving the internal model of verticality.

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.

Improvement of ADL performance by occupational therapy for a stroke patient with pusher syndrome:

Improvement of ADL performance by occupational therapy for a stroke patient with pusher syndrome:

The importance of the insular cortex for vestibular and spatial syndromes.

The aim of the study was to identify the neuroanatomical correlates and associations of neuropsychological syndromes after acute unilateral right-hemisphere brain lesions. The neuropsychological syndromes considered were orientation in three-dimensional space such as tilts of the subjective visual vertical or of the subjective haptic vertical, pusher syndrome, visual neglect and unawareness of paresis (anosognosia for hemiparesis). These neuropsychological phenomena have been found to occur separately or in different combinations after lesions to the right insular cortex. Magnetic resonance imaging scans were obtained from 82 patients with acute right-hemispheric stroke. A lesion-behavior mapping analysis was conducted to specify the neuroanatomical correlates of the above-mentioned neuropsychological syndromes. In all analyses of the individual neuropsychological syndromes the insular cortex was affected. Thus, the insular cortex is involved in (self-)perception and orientation within a three-dimensional space. Since isolated lesions of the insular cortex did not induce the above neuropsychological phenomena, there have to be other regions involved.

Effectiveness of visual feedback and postural balance treatment of post-stroke pusher syndrome. A systematic review

IntroductionPusher syndrome is characterised by the patient pushing towards the hemiparetic side with the contralateral side, in a sitting position, standing and during movement, surpassing the gravitational mean line, which produces inappropriate adjustment and postural control. ObjectiveTo determine the effectiveness of physiotherapy treatment in post-stroke pusher syndrome and to extract guidelines for its correct identification and interdisciplinary approach. MethodA systematic review was carried out (2000–2019), using the specialised databases MEDLINE, Scopus, PEDro and Web of Science. The descriptors used in the search strategies were “pusher syndrome”, “pushing behaviour”, “controversial pushing”, treatment, “physical therapy”, physiotherapy. ResultsAlthough the evidence is still limited, the intensive intervention of Physiotherapy in the patient with pusher syndrome post-stroke seems to improve the clinical symptoms in terms of severity and postural control. Among the different forms of treatment, training through visual feedback seems to be effective, especially using the Nintendo Wii balance platform. ConclusionAn individualised physiotherapeutic intervention with each patient is necessary to facilitate and guide the most effective motor strategies, work synergies between the members of the interdisciplinary team are essential (with specific guidelines on transfers and functional activities between sessions) to ensure continuity of care that guarantees achievements are maintained.

Efectividad del feedback visual y tratamiento del equilibrio postural en el síndrome del empujador postictus. Revisión sistemática

IntroductionPusher syndrome is characterized by the patient pushing towards the hemiparetic side with the contralateral side, in a sitting position, standing and during movement, surpassing the gravitational mean line, which produces inappropriate adjustment and postural control. ObjectiveTo determine the effectiveness of physiotherapy treatment in post-stroke pusher syndrome and to extract guidelines for its correct identification and interdisciplinary approach. MethodA systematic review was carried out (2000-2019), using the specialized databases MEDLINE, Scopus, PEDro and Web of Science. The descriptors used in the search strategies were “pusher syndrome”, “pushing behaviour”, “controversial pushing”, treatment, “physical therapy”, physiotherapy. ResultsAlthough the evidence is still limited, the intensive intervention of Physiotherapy in the patient with pusher syndrome post-stroke seems to improve the clinical symptoms in terms of severity and postural control. Among the different forms of treatment, training through visual feedback seems to be effective, especially using the Nintendo Wii balance platform. ConclusionAn individualized physiotherapeutic intervention with each patient is necessary to facilitate and guide the most effective motor strategies, work synergies between the members of the interdisciplinary team are essential (with specific guidelines on transfers and functional activities between sessions) to ensure continuity of care that guarantees achievements are maintained.

Effect Analysis on Suspension Exercise Training Combined with Repetitive Transcranial Magnetic Stimulation in the Treatment of Post-stroke Pusher Syndrome

Effect Analysis on Suspension Exercise Training Combined with Repetitive Transcranial Magnetic Stimulation in the Treatment of Post-stroke Pusher Syndrome

Therapeutic approaches for pusher syndrome after a stroke: a literature review

Introduction: Pusher syndrome is a disorder that is clinically present in 5-52% of stroke patients, characterized by active pushing using the non-paretic side towards the paretic side, and resistance to the passive correction of posture. This disorder can pose an unfavorable effect on the rehabilitation of stroke patients. Hence, finding effective therapeutic approaches for pusher syndrome is crucial. This study aimed to identify the existing therapeutic approaches for pusher syndrome and investigate their effectiveness.Methods: A literature review was carried out, where studies were identified through searching the PubMed database from database inception to 2019 using the keywords: “pusher syndrome”, “pusher behaviour”, “contraversive pushing”, “ipsilateral pushing”, “lateropulsion”, “physiotherapy”, “physical therapy”, “treatment”, “therapeutic approach”, “therapy” and “training”.  The literatures were analyzed systematically based on the results of previous studies.Results: Several approaches were identified for treating pusher syndrome post-stroke, including robot-assisted gait training (RAGT), galvanic vestibular stimulation (GVS), visual feedback (VF), and physiotherapy with additional components such as relaxation therapy in the prone position and lateral stepping with body weight–supported treadmill training (LS-BWSTT). RAGT and VF training appear to be promising adjunctive approaches for treating pusher syndrome. Conventional physiotherapy with additional components such as relaxation therapy and LS-BWSTT have also led to positive effects. However, the effect of GVS has not been established.Conclusion: There is evidence that some therapeutic approaches can be beneficial for improving pusher syndrome and outcomes of stroke patients, in particular when combined with conventional physiotherapy. However, the number of studies is still very limited. Further research with methodological rigor is needed.