“Pusher

Syndrome”
Understanding
and Treating

Bambang W
Introduction
1985 (Patricia Davies), stroke patients use their non
paretic extremities to push toward the paretic side,
loss lateral postural balance fall toward the
hemiparetic side
Disruption of body posture in relation to gravity
(Karnath & Broetz, 2003)
reports fear of falling towards the non hemiplegic
side.
 actively pushes towards the hemiplegic side
 More common in stroke right side hemisphere
Karnath & Broetz, 2003
Displayed in 5% of all patients post-stroke, 10% of
patients referred for neurologic rehabilitation.
These are the most severely impaired patients with
profound functional limitations in transfers,
standing, and gait.
Individuals with pusher syndrome take 63% longer
than average time to recover independence post-
stroke.
80% of patients with right brain lesions and pushing
displayed spatial neglect and somatosensory
impairment.
 Differential Diagnoses:

. Listing phenomenon
. Ipsilesional Lateropulson
. Thalamic astasia
 LISTING PHENOMENON

 Loss of lateral balance towards

hemiparetic side
 Without assistance, patient’s trunk will
“list”toward the affected side
 CONTRAST: Patient will attempt to hold
onto something or use non-paretic hand to
prevent a loss of balance towards paretic
side
 LATEROPULSION

“A tendency to fall sideways”

 Frequently seen in Wallenberg’s
syndrome (acute unilateral medullary
brainstem infarcts)
CONTRAST: Patient falls towards the
side of the lesion, no active pushing or
resistance to passive correction
 THALAMIC ASTASIA

 Patients are unable to stand unsupported, fall

backward or to affected side when left
unsupported
 During supine>sit, patients don’t use trunk
muscles but attempt to use hands to pull
themselves up
 CONTRAST: No pushing or active resistance to
correction
 Pusher
Syndrome

Karnath et al 2000:
• 20% patients with right-sided lesions with pusher syndrome
did not have spatial neglect
• All patients with pusher syndrome with left-sided lesions
had aphasia (none had spatial neglect)

Aphasia Spatial
Neglect

Hemispatial neglect is NOT the cause of contraversive pushing, but…

. High association with spatial neglect in patients with right hemisphere lesions
. High association with aphasia in patients with left hemisphere lesions
 *Location & Cause
* Study conducted by Karnath et al- looked at the MRI scans
of 23 patients with severe pusher syndrome
* Overlapping area of these infarctions centered on that of
the posterolateral thalamus (anatomically distinct from the
vestibular cortex in the posterior insula, but similar to the
area of patients with thalamic astasia), extensions including
the ventral posterior nucleus, lateral posterior nucleus and
its cortical projections.
* All seem to be involved in the neural representation of the
graviceptive system which is critical for our control of
upright body posture.
Sensory
Input

14
Posterior thalamus + extra-thalamic structures are
needed for intact processing of gravity and control of
upright body posture
 inferior frontal gyms
 middle temporal gyrus
 precentral gyms
 inferior parietal lobe
 parietal white matter
 superior longitudinal fasciculus
Kenapa kerusakan di area ini
bisa menyebabkan PS ?
Hipotesis 1 : DISTURBANCE OF THE VISUAL-VESTIBULAR SYSTEM

Subyektive visual vertical : “earth Vertical” dependent on visual

and vestibular processing
Hipotesis 2 : SUBJECTIVE POSTURAL VERTICAL DISTURBANCE
Subjective postural vertical: perceived upright orientation
of body
HYPOTHESES 3:

 Conflict between two reference systems ( Less

pushing with eyes closed)
 Secondary response to unexpected experience of loss
of balance
 Disturbed spontaneous postural responses
Patient with PS
Experience a mismatch between visual vertical,
based on vestibular and visual inputs on the one
side, and their perception of tilted body
orientation relative to the vertical

Karnath and Broetz, 2003

 Diagnosis of Pushing Behavior
1. Spontaneous lateral tilt towards weak side in sitting
and standing
2. Abduction and extension of nonparetic extremities
when in physicalcontact with a surface
3. Resistance to any attempt at passive correction
Outcome Measures
1. Burke Lateropulsion Scale:

This scale assesses the patient’s resistance to:

1.Passive supine rolling
2.Passive postural correction when sitting and standing
3.Assistance during transferring and walking.

The score for each component is rated on a scale from 0 to 3 (0 to 4

for standing) and the score is based on the severity of resistance or
the tilt angle when the patient begins to resist the passive
movement. The score for diagnosis of Pusher behaviour is ≥2 points.
Link to PDF:
https://www.burke.org/docs/Burke-
Lateropulsion-Scale.pdf
2. Scale for Contraversive pushing:

This is made up of 3 components:

1.The symmetry of spontaneous body posture (rated with 0, 0.25,

0.75, or 1 point)
2.The use of non-paretic extremities (0, 0.5, or 1 point)
3.The resistance to passive correction of the tilted posture (0 or 1 point).

For a diagnosis of Pusher Syndrome all 3 components need to be present.

COMPARING OUTCOME
MEASURES
1. SCP and BLS are both
reliable and valid measures
2. BLS is more responsive to
small changes
FUNCTIONAL PROGNOSIS

Karnath et al 2002 (N=12)

. Symptoms nearly resolved after 6months post-
stroke

Danells et al 2004 (N=65)

. By 6 weeks, 62% of pushing symptoms resolved
. By 3 months, 79% of pushing symptoms resolved
. Longer hospital LOS (89 vs. 57 days) for patients
with pushing behavior vs. those without pushing
. Used SCP cut-off >0
PROGNOSIS: RECENT RESEARCH

 Babyar et al 2008 (case-matched controlled study)

• FIM efficiency and d/c FIM scores worse in Pusher
Syndrome group
• Pusher syndrome + R CVA required more dependent d/c
living situation

 Abe et al 2012 (N=1660)

•156 (9.4%) had pusher behavior
• Patients with right brain damage had significantly
slower recovery vs. those with left brain damage
•Helpful for discharge planning/goal setting
• Don’t resist the push – allow the patient to recognise the
mistake
• Analyse and treat strategies of fixation through less affected
side
* Upper cervical spine, eyes (head)
* Lower cervical spine
* Thorax, shoulder girdles, arms
* Lumbar spine, pelvis, legs
• Orientation to the less affected side
* Finding stability over the less affected side in sitting and
standing
* Spatial orientation (visual and tactile exploration) on a basis of
stability of the less affected leg
• Orientation to the affected side
* Activate postural muscles on the affected side for stability in
sitting and standing
* Spatial orientation (visual and tactile exploration) on a basis of
stability of the less affected leg
* Avoid non use of the affected side
• Integration into function
* 24 hour care – rehab team, seating, sleep, self training
• Experience of gravity in many postures and postural
transitions
* Spatial exploration (rotation, diagonals, spirals)
• Multimodal sensory integration
TREATMENT GOALS

 Realize the disturbed perception of erect body position

 Visually explore the surroundings and the body’s relation to the
surroundings. Ensure the patient sees whether he or she is
oriented upright (suggest the PT uses visual aids that give
feedback), utilize vertical structures in a room
 Learn the movements necessary to reach a vertical body
position
 Maintain the vertical body position while performing other
activities

Karnath & Broetz 2003

INTERVENTION

 Karnath and Broetz 2004 (case report)

. Realize contraversive tilt
. Explore visual surroundings
. Reach/transfer to non-paretic side
. Add in dual tasking

 Shepherd and Carr 2005

. Visual vertical cues
. Reaching to paretic side
. Focus on sit<>stand first
. Try BWSTT (body weight-supported
treadmill training
SITTING BALANCE

 First goal: achieve midline in static sitting

 Sit on a firm stable surface (mat table)
 Feet should be supported on ground
 Use mirror for visual feedback
• Can add vertical tape line
• Could also put tape on pt’s shirt Perennou 2013
• Utilize other “vertical” references in environment
 Can utilize a physical barrier on non-paretic side
(wall, second person, exercise ball, etc)
 Tactile cues to the ischial tuberosity for weight shift to the
unaffected side
• Sidelying on elbow/forearm of non-paretic arm
 SITTING BALANCE

Goal: prevent pushing

 PT sitting on paretic side
 Do NOT push/pull patient to midline
 Non-paretic arm placement
• Supinate and externally rotate pushing hand
• Rest arm on exercise ball
• Verbal/tactile cues to relax shoulder
• Second person sits on non-paretic side – hand on their
shoulder or leg
 Place pushing hand up
 Watch positioning of leg
• Block with your foot or give verbal cues
SITTING BALANCE – DYNAMIC

Next goal: move in and out of midline

 Patient should be actively moving (don’t passively correct)
 Dynamic reaching
• Can start with sliding hand on mat (increase distance; raise height
of object)
• Facilitate trunk for return to midline
• Reaching towards unaffected side (may be active-assisted)
• Also want to reach to paretic side (promote UE WB’ing)
• Can work on visual scanning (pt may have visual neglect)
• Incorporate A-P movements as well for midline orientation
 Quadruped
• Add unilateral reaching
 Tall kneeling
• Add bilateral reaching, trunk rotation
SITTING BALANCE

Goal: prevent pushing

 PT sitting on paretic side
 Do NOT push/pull patient to midline
 Non-paretic arm placement
. Supinate and externally rotate pushing hand
. Rest arm on exercise ball
. Verbal/tactile cues to relax shoulder
. Second person sits on non-paretic side – hand on their
shoulder or leg
 Place pushing hand up
 Watch positioning of leg
. Block with your foot or give verbal cues
 Practice weight shifting with elevated mat on
nonparetic side (used as visual/tactile cue)
. Can also use a flat wall or corner
 Add in reaching tasks or pre-gait activities
. Reach for objects (varying heights)
. Stepping forward/backward
. Step up’s
. Visual scanning
https://appliedstrokerehab.wordpress.com/2015/07/
23/strategies-for-the-treatment-of-pusher-syndrome/

Kim, 2017.
Daftar Pustaka

 Abe, H et al, Prevalence and Length of Recovery of Pusher Syndrome Based on Cerebral
Hemispheric Lesion Side in Patients With Acute Stroke, DOI: 10.1161/STROKEAHA.111. 638379.
 Bohannon RW, Smith MB, Larkin PA. Relationship between independent sitting balance and side
of hemiparesis. Phys Ther. 1986;66: 944–945.
 Dettmann MA, Linder MT, Sepic SB. Relationships among walking performance, postural
stability, and functional assessment of the hemiplegic patient. Am J Phys Med. 1987;66:77–90.
 Broetz, D, et al. Time course of “pusher syndrome” under visual feedback treatment.
Physiotherapy Reseacrh International. 2004
 Baccini M, Paci M, Nannetti L, et al. Scale for Contraversive Pushing: cutoff scores for
diagnosing “pusher behavior” and construct validity. Phys Ther. 2008;88: 947–955.
 Chiba, R., et al., Human upright posture control models based on multisensory inputs; in fast
and slow dynamics. Neurosci. Res. (2015), http://dx.doi.org/10.1016/j.neures.2015.12.002 .
 Karnath, HO and Broetz, D. Understanding and Treating “Pusher Syndrome”. Physical Therapy.
2003.
 Kim, Min-Su. (2016). Effect of Robot Assisted Rehabilitation Based on Visual Feedback in Post
Stroke Pusher Syndrome. Journal of the Korea Academia-Industrial cooperation Society. 17.
562-568. 10.5762/KAIS.2016.17.10.562.
 Karnath HO and Broetz, D Understanding and treating Pusher Syndrome, Physical Therapy 83
(2003).
 Saj, N et. al, The visual vertical in the pusher syndrome Influence of hemispace and body
position J Neurol (2005) 252 : 885–891 DOI 10.1007/s00415-005-0716-0.
 Shepard, RB, Carr, JA. New aspects of physiotherapy of pushing behavior. Neurorehabil. 2005.
 Ticini LF, Klose U, Na¨gele T, Karnath H-O (2009) Perfusion Imaging in Pusher Syndrome to
Investigate the Neural Substrates Involved in Controlling Upright Body Position. PLoS ONE 4(5):
e5737. doi:10.1371/journal.pone.0005737.