pusher behaviour

[noemigaudenzi]

You are very friendly with me and all you write is very, very interesting, but now I have no time to reply well, I hope to do in the next days
Today I was looking for Neurologie und Rehabilitation, but in Italy this paper is not easy to try!!
Perhaps, I think it is possible doing "foreign request" in library, but it is not free and it is difficult.
Good work

[gcoe]

Hi Noemigaudenzi

No rush! Just answer when you are ready and have the time

[sarahgann]

This is a very useful thread- thank you. I have a quick clinical question about a patient. Left hemiparesis, cognitively intact, full sensory loss on left hand side (visual, perception, sensation etc). Pusher syndrome is particularly apparent during transfering and bed mobility onto unaffected side and especially in standing. She is independently sitting and reaching out of BOS. I'm looking for some ideas to treat her pusher syndrome in standing - she pushes very severely with her right leg in standing and is unable to maintain balance and upright posture as soon as I start to decrease her BOS by getting her to engage in right upper limb activities. Any ideas what else I can do in standing in order to decrease the pushing?

[noemigaudenzi]

Davies said to do stand up with unaffected hip near the table: it's yet a good idea! And she said to walk with unaffected hip near the table before doing walking with a can. And you can reach stand up with weight over unaffected elbow, and then hand, on the table. Do you understand my bad English? Good work!

[Fyzzio]

Hi,
sorry, it took me a while, but have now finally managed to read/ translate the article from the "Neuro Rehab" Journal by V.-H. Urquinzo: Push or Pull? Controversy of the pusher-behaviour (2009); this article is mainly based on the works of P. Davies and H.O. Karnath.

Interesting article, right from the start as the English translation of the German title is not entirely correct (should read: the Pusher behaviour discussed controversially) or is it????? Otherwise some fascinating background informational and some interesting treatment guidelines.
I might, however state that the article doesn't really discuss aspects a lot, just makes a series of summaries, unfortunately, often in rather high tech language. Some noted aspects especially in the second part (therapy) are not thoroughly explained, leaving the reader wondering about the "how". Never mind, it would probably take a whole book to describe everything in detail.

Here's my summary:

- Pusher symptom is a stand-alone type of movement disorder; it is often associated with neglect, however, not caused by it, nor is neglect a consequence of this symptom

- early detection and specific treatment of Pusher symptom are crucial for a good rehab outcome; the occurrence of Pusher symptom is not an indicator for quality of rehab outcome, but for length of stay (= takes longer to rehab)

- Definition: a motor behaviour pattern used as an unconscious compensatory strategy (= automatic), based on a long lasting hypotonus; suspected reaction to the mismatch between visual system and body related postural information (=malalignment) and/or secondary reaction to the unexpected experience of loss of balance when trying to sit/ stand straight; interesting point: they found that in patients with Pusher symptom the subjective experience of postural vertical axis was tilted by ~ 18 degrees to the affected side, whereas the experience of visual vertical axis was nearly intact

- this means that Pusher symptom is
a) caused by postural and limb weakness/ instability
b) follows a typical pattern on the affected side
c) uses specific movement strategies on the un-effected side (flexor fixation)
d) patient is unaware of "problem"

- Diagnosis: main symptoms:
1) malalignment of body position in free space
2) the way in which un-affected limbs are used
3) typical behaviour when attempts are undertaken to passively correct posture/ position
x) recommends the Scale for Contraversive Pushing/ SCP

- Therapy (this is in hierarchical order):
# provide patient with security and support/ stability within the therapeutic setting; this will enable the patient to make changes to the otherwise automatic compensatory strategies (there was at least 2 therapists on each photo)
# assess and treat flexor-fixation on the un-affected side
# work on re-organisation of the internal representation of body position (= leave patient in his chosen position and demonstrate/ create awareness of malalignment)
# work on strengthening of stability on the affected side (= limb weakness and posture); focus on early integration of hemiparetic side, this enables patients to realise their own potential for movement, facilitates plasticity and starts the orientation to midline
# work on the awareness of verticality (use aids)
# work on re-organisation of spatial orientation (stimulate visual, auditory and tactile, which integrates proprioceptive and vestibular aspects); first exploration of space, then movement, followed by integration into functional activities
# adapt the programme to allow for individual maximum tolerance capacity to be used in the rehab setting as well as at home


Hope, this helps a little.
Cheers,
Fyzzio

[gcoe]

Hey Fyzzio

Thanks for your review which is very clear. Good to have a some clear operational definitions of the syndrome for all to see.

[viveksharma607]

Pusher behaviour or pusher syndrome which is commonly seen after stroke is believed to be caused by problems in vertical orientation