Scale For Contraversive Pushing Research Articles

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

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.

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.

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.

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.

The severity of unilateral spatial neglect was positively correlated with that of Pusher syndrome

While previous studies have reported that unilateral spatial neglect (USN) and pusher syndrome are related but independent symptoms, their relationship has not been investigated using a quantitative scale and causative lesions using brain imaging. This study aimed to clarify the relationship between evaluation scores and the extent of the damaged area revealed by brain imaging. We evaluated twenty patients with first-ever stroke and pusher syndrome (14 right and 6 left hemispheric patients). First, we analyzed the relationship between the Catherine Bergego Scale (CBS) and Scale for Contraversive Pushing (SCP). We also introduced a new way of quantifying the affected brain lesions at two levels of horizontal brain imaging slice. At each level, a brain hemisphere was divided into 3 areas, and the total number of damaged areas from these two levels was used as an indication of the extent of the damaged lesion, ranging 0 to 6 ( Fig. 1 ). By using this score, the relationship between the CBS and SCP scores was further examined. All patients with pusher syndrome had USN based on CBS. In each subject, the CBS score was positively correlated with the SCP score (Spearman = 0.805, P < 0.001) ( Fig. 2 ). Brain imagining showed that six patients had damage in both slice 1 and slice 2, while the fourteen patients had damage only in slice 2. The imaging score at slice 1 was correlated with the CBS score in the first group. The severity of USN was positively correlated with that of pusher syndrome with clinical scales. The location and extent of the damaged area in relation to SCP and CBS needs to be examined with a larger sample size in future.

Postural and gait disorders in subacute stroke patients: Lateropulsion is the key

Recent researches suggested that postural disorders after stroke may be partly caused by a wrong referential of verticality, expressed by a lateropulsion behavior. The role played by lateropulsion in the postural and gait disorders after stroke remained to be investigated, which was the objective of the present study. Retrospective cohort study (2012–2017) of 147 consecutive patients investigated in a neurorehabilitation ward in average at 32.7 days after a first hemispheric stroke: age 62.8 ± 12.6 years, 41 females, 120 with infarction, 57 with right lesion. Trained physiotherapists assessed: lateropulsion with the Scale for Contraversive Pushing (SCP, 0-6), Balance disorders with the Postural Assessment Scale for Stroke (PASS, 0-36) and gait disorders with Lindmark Scale (0–6). Brain imaging was carefully checked (138 MRI, 9 CT). Patients with a malignant stroke, dementia, instable medical status that could interfere with balance and gait recovery, or those who refused the assessments were not included. Descriptive data are given in the form median (first-third quartile). One month poststroke, postural and gait data were: SCP 0 (0–0.25), PASS 32 (25–35) and Gait score 4 (2–6). Fifteen patients were pushers (10%), among them 80% had a right hemisphere stroke. A first result was to confirm that lateropulsion was more severe in right hemisphere stroke than in left (right 46% vs. left 10%, χ2 =47.7; P < 0.001). As a corollary postural disorder and gait disorder were also more severe after right hemisphere stroke. In patients with a right hemisphere stroke, lateropulsion explained 77% of the variance of postural disorders (P < 0.001) and 76% of the variance of gait disorders (P < 0.001). Postural disorders explained 81% of the variance of gait disorders (P < 0.001). Lateropulsion, which is a sign of biased representation of the vertical, is a primary cause of postural and gait disorders at the subacute phase after right hemisphere stroke, explaining almost 80% of balance and gait disabilities. A greater attention should be focused on the assessment and the rehabilitation of the poststroke lateropulsion.

Novel Treatment Approach to Contraversive Pushing after Acute Stroke: A Case Report.

Purpose: The purpose of this case report is to provide an alternative treatment approach to pushing behavior (PB), adapting widely used equipment for persons with stroke demonstrating such behaviour. The aim is to change their graviceptive experience during interventions while performing repeated stepping and righting practice to resolve PB more quickly. Client Description: The subject is a man aged 56 years who sustained a right middle-cerebral-artery ischemic stroke. He entered in-patient rehabilitation from an acute care hospital 7 days post-stroke. Intervention: Lateral stepping with body weight-supported treadmill training (LS-BWSTT) was used such that the subject stepped laterally toward the uninvolved side. Measures and Outcome: Scores on the Scale for Contraversive Pushing and the FIM were recorded at regular intervals. After intervention, the subject demonstrated decreased PB and improved function. Implications: The individual's PB improved after LS-BWSTT. LS-BWSTT is a novel treatment intervention that could be considered in future clinical decision making using evidence-based principles.

Postural and gait disorders in subacute stroke patients: Lateropulsion is the key

Recent researches suggested that postural disorders after stroke may be partly caused by a wrong referential of verticality, expressed by a lateropulsion behavior. The role played by lateropulsion in the postural and gait disorders after stroke remained to be investigated, which was the objective of the present study. Retrospective cohort study (2012–2017) of 147 consecutive patients investigated in a neurorehabilitation ward in average at 32.7 days after a first hemispheric stroke: age 62.8 ± 12.6 years, 41 females, 120 with infarction, 57 with right lesion. Trained physiotherapists assessed: lateropulsion with the Scale for Contraversive Pushing (SCP, 0–6), Balance disorders with the Postural Assessment Scale for Stroke (PASS, 0–36), and gait disorders with Lindmark Scale (0–6). Brain imaging were carefully checked (138 MRI, 9 CT). Patients with a malignant stroke, dementia, instable medical status that could interfere with balance and gait recovery, or those who refused the assessments were not included. Descriptive data are given in the form median (first-third quartile). One month post-stroke, postural and gait data were: SCP 0 (0–0.25), PASS 32 (25–35) and Gait score 4 (2–6). Fifteen patients were pushers (10%), among them 80% had a right hemisphere stroke. A first result was to confirm that lateropulsion was more severe in right hemisphere stroke than in left (right 46% vs. left 10%, ×2 = 47.7; P < 0.001). As a corollary postural disorder and gait disorder were also more severe after right hemisphere stroke. In patients with a right hemisphere stroke, lateropulsion explained 77% of the variance of postural disorders ( P < 0.001), and 76% of the variance of gait disorders ( P < 0.001). Postural disorders explained 81% of the variance of gait disorders ( P < 0.001). Lateropulsion, which is a sign of biased representation of the vertical, is a primary cause of postural and gait disorders at the subacute phase after right hemisphere stroke, explaining almost 80% of balance and gait disabilities. A greater attention should be focused on the assessment and the rehabilitation of the post-stroke lateropulsion.

Clinical Outcome Measures for Lateropulsion Poststroke: An Updated Systematic Review.

Contraversive Lateropulsion, also referred to as contraversive pushing, pusher behavior, and pusher syndrome, can be associated with increased hospital length of stay, increased health care costs, and delayed outcomes in persons with stroke. The purpose of this updated systematic review was to identify scales used to classify contraversive lateropulsion, investigate literature that addresses their clinimetric properties, and create a resource for clinicians recommending use in clinical practice. Three databases were searched for articles from inception to March 2017. The search strategy followed Cochrane Collaboration guidelines. The Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was applied to evaluate methodological quality. Four hundred three records were screened. Seven studies met inclusion criteria. Four scales were identified: the Scale for Contraversive Pushing (SCP), the Modified Scale for Contraversive Pushing (M-SCP), the Burke Lateropulsion Scale (BLS), and the Swedish Scale for Contraversive Pushing (S-SCP). Psychometric property investigation was most robust for the SCP and the BLS. Cross-cultural validity has not been fully investigated in scales used outside of their country of origin. The BLS is recommended for identifying contraversive lateropulsion. The scale assesses the presence of contraversive lateropulsion across several functional tasks, from rolling to walking, and is the only scale originally written in English. The BLS is the only tool to receive ratings greater than poor for reliability and responsiveness. The BLS should be implemented as soon as contraversive lateropulsion is suspected to guide frontline clinicians' initial plan of care, allow objective identification of change over time, and facilitate easier investigation of interventional efficacy.Video Abstract available for additional insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A177).

Inconsistent classification of pusher behaviour in stroke patients: a direct comparison of the Scale for Contraversive Pushing and the Burke Lateropulsion Scale

Objective: To compare the classification of two clinical scales for assessing pusher behaviour in a cohort of stroke patients. Design: Observational case-control study. Setting: Inpatient stroke rehabilitation unit. Subjects: A sample of 23 patients with hemiparesis due to a unilateral stroke (1.6 ± 0.7 months post stroke). Methods: Immediately before and after three different interventions, the Scale for Contraversive Pushing and the Burke Lateropulsion Scale were applied in a standardized procedure. Results: The diagnosis of pusher behaviour on the basis of the Scale for Contraversive Pushing and the Burke Lateropulsion Scale differed significantly (χ2 = 54.260, p < 0.001) resulting in inconsistent classifications in 31 of 138 cases. Changes immediately after the interventions were more often detected by the Burke Lateropulsion Scales than by the Scale for Contraversive Pushing (χ2 = 19.148, p < 0.001). All cases with inconsistent classifications showed no pusher behaviour on the Scale for Contraversive Pushing, but pusher behaviour on the Burke Lateropulsion Scale. 64.5% (20 of 31) of them scored on the Burke Lateropulsion Scale on the standing and walking items only. Conclusions: The Burke Lateropulsion Scale is an appropriate alternative to the widely used Scale for Contraversive Pushing to follow-up patients with pusher behaviour (PB); it might be more sensitive to detect mild pusher behaviour in standing and walking.

Time Course and Influence of Pusher Behavior on Outcome in a Rehabilitation Setting: A Prospective Cohort Study

Objective: To examine the prevalence and the time course of pusher behavior (PB) among patients with hemiparesis in a rehabilitation setting and the influence of this behavior on rehabilitation outcome. Methods: Over a 1-year period, 448 inpatients with hemiparesis after stroke and nonstroke etiologies were screened in the first week after admission to a neurological rehabilitation hospital. The Clinical Scale for Contraversive Pushing was used to differentiate pusher from nonpusher patients. If PB was present, the patient was examined weekly. The prevalence and duration of PB was assessed, and influence on rehabilitation efficiency and effectiveness according to the Motor Function Assessment Scale and Barthel Index was calculated. Results: PB was present in 16% of all examined, in 17% of the stroke patients, and in 31% of patients (33% of stroke patients) unable to stand erect without support. PB duration within the rehabilitation hospital was 5 ± 4.3 weeks (median = 4; range, 1-20). PB is a negative predictor for the rehabilitation outcome: PB patients are only half as efficient and effective as nonpusher patients. The effect worsened if PB had been present for a longer period of time. Conclusion: The prevalence of PB and its influence on rehabilitation outcome reveal PB as a relevant disorder in stroke rehabilitation. However, the duration of the behavior differed widely among the PB patients. Further studies are needed to establish prognostic criteria for identifying patients with a potential for developing long-term PB.