pusher behaviour

[noemigaudenzi]

What about pusher behaviour in the last 3 yars? Last comment was in 2007, and there are a lot of news in Karnath, Perennou, ...studies
Who is interested in this problem?
I hope to understand what physiotherapists are doing in the world, and their teaching authors (not only Davies!)

Similar Threads:

• Pusher syndrome
• Inappropriate Behaviour
• Cognitive-behaviour Therapy & Physio

[gcoe]

Ciao noemigaudenzi

I find Karnath's work helpful. In this part of the world there has remained some controversy over whether it really is a distinct entity (Carr & Shepherd) however Karnath and associates have greatly improved our understanding about PS as a distinct entity. Have you got his review of 2007:

Karnath, H. O. (2007). Pusher syndrome - A frequent but little-known disturbance of body orientation perception. Journal of Neurology, 254(4), 415-424.

Do you use the The scale for contraversive pushing? While it may not be perfect I think this goes some way to diagnosing PS a distinct entity and is useful for treatment planning:


Baccini, M., Paci, M., Nannetti, L., Biricolti, C., & Rinaldi, L. A. (2008). Scale for contraversive pushing: Cutoff scores for diagnosing "pusher behavior" and construct validity. Physical Therapy, 88(8), 947-955.

Baccini, M., Paci, M., & Rinaldi, L. A. (2006). The scale for contraversive pushing: A reliability and validity study. Neurorehabilitation and Neural Repair, 20(4), 468-472.

There isn't much in clinical trials on effective treatments. Now with a better understanding of the what PS is hopefully we should see some well conducted trials over the next few years. Until then I think it is best to use common sense type approaches. As for what we use, visual cues for orientation (gridlines in front of the patient while practicing sitting & standing etc), conscious strategies of correction combined with positive reinforcement and shaping. These seem to be the most plausible based on Karnaths review. Have you had a look at this paper in Neurologic PT?

'Pusher Syndrome', The | Journal of Neurologic Physical Therapy | Find Articles at BNET

I have never tried Perennou's the TENS treatment. Have you?

the trouble with treatments as these patients generally get better anyway so based on clinical practice it is hard to tell if we are actually being effective or if they would be responding anyway without out the treatment.

One more thing I wanted to ask: Do you speak German. There are two recent papers in that I don't have access and I don't speak German. Have you seen them?

Bohm, C. (2009). Movement therapy - Classic or modern? Why are pushers different? New approaches in the pusher syndrome. [German]. Neurologie und Rehabilitation, 15(1), 43-45.
Urquizo, V. H., & Hundsdorfer, N. (2009). Push or pull? Controversy of the pusher-behaviour. [German]. Neurologie und Rehabilitation, 15(6), 365-372.

I was wondering if you did speak German if you could review them?

[noemigaudenzi]

My English is bad, but I know all you say.
I use SCP of Karnath, I think cut off validated by Baccini-Paci (score >0 in each section) is good only in the early stages post stroke, because I think resistance to passive correction is the first symptom to disappear. Lateropulsion Scale by D'aquila e c. is better, but it is too long to do...
I hope to know Shepherd and Carr experiences, I have Guidelines ....2002: are there their opinions?

[gcoe]

I hope to know Shepherd and Carr experiences

Do you know of them? They were two pioneer academics and University of Sydney, Australia. They didn't write extensively on the subject but they were critical of Pat Davies' criteria for pushers syndrome and contended there was no evidence to substantiate a unique syndrome. I think they were skeptical because of the lack of validation research behind the concept. So I wouldn't worry about it now - this goes back to 1998. I think Karnath and others has done a great job of showing that such a syndrome can be identified.

Lateropulsion Scale by D'aquila e c. is better, but it is too long to do...

. I haven't tried this scale so I looked it up. Have you seen this review of these scales?

Babyar, S. R., Peterson, M. G., Bohannon, R., Perennou, D., & Reding, M. (2009). Clinical examination tools for lateropulsion or pusher syndrome following stroke: a systematic review of the literature. Clin Rehabil, 23(7), 639-650.

Both seem good scales with good reliability and validity but they make the point that Lateropulsion scale covers more grounds. the name is confusing however. Karnath makes a distinction that lateropulsion is quite a different balance disorder whereas Burkes Lateroplusion scale is measuring Pushers syndrome. I think I will try it as it seems to be a better outcome measure for capturing progress and function improves - maybe less floor and ceiling effects.

I have Guidelines ....2002

are these Italian or European guidelines?

I see you work in Bologna. Do you work for one of the hospitals there? I really like Bolonga - it is a great ctiy!

[noemigaudenzi]

I don't speak German, but in my town there are a few German physiotherapists. I don't know the two German texts you say, but I can find them and perhaps I can have a translation, but it's a long work...
I work in a big hospital and I saw pusher patients that did not get better, I saw a lot! And I saw pusher using a lot of time to get better, and national health system has a problem about long stay as inpatient...
Perennou and Lafosse have done a big work about pusher and neglect, and about pusher and lateropulsion as a different grade of the same problem

[gcoe]

Hi Noemigaudenzi

I don't speak German, but in my town there are a few German physiotherapists. I don't know the two German texts you say, but I can find them and perhaps I can have a translation, but it's a long work...

That is ok. Fyzzio, one of the other posters here speaks German and she has kindly offered to translate and review the articles. However I don't have electronic access to the journal Neurologie und Rehabilitation through our library. I wondered if you may have access to the electronic files through your library? If so could you send me the PDF files of the two articles? This would save us some time and money as we will have to order them in from Europe. I can send you my email if you do.

I work in a big hospital and I saw pusher patients that did not get better, I saw a lot! And I saw pusher using a lot of time to get better

That is interesting about seeing patients that don't get better. This is not our experience so it is interesting. Did these patients who didn't do well have anything additional to the PS that may account for the poor prognosis? (eg other perceptual, cognitive or distinctive motor problems other than your typical hemiparesis?) It would make a great study to publish as the accepted wisdom is that PS generally does resolve.

Perhaps other clinicians out there have an opinion?

Perennou and Lafosse have done a big work about pusher and neglect, and about pusher and lateropulsion as a different grade of the same problem

Yes I wasn't really aware of this and I can see how they are using the term. However I think the term is confusing and is actually a bit of a problem. Here is what Hans-Otto Karnath
describes:

Lateropulsion
Active pushing away with non-paretic extremities also distinguishes pusher patients from patients with ‘lateropulsion’, a phenomenon commonly observed in Wallenberg’s syndrome . Dieterich and Brandt investigated 36 such patients with acute unilateral medullary brainstem infarctions and found that they had lateropulsion (defined as a tendency to fall sideways) with an ipsiversive deviation of the center of gravity (determined by means of posturography), i.e. with a deviation towards the side of the brain lesion. By contrast, patients with pusher syndrome tilt their body contraversively (towards the side opposite to the brain lesion), i.e., they use their unaffected arm to push towards the side of the hemiparesis. Thus, patients with lateropulsion and patients with pushing behavior tend to fall to opposite sides (ipsiversively in the case of lateropulsion and contraversively in the case of pusher syndrome). Moreover, patients with brainstem lesions and lateropulsion do not use their non-paretic extremities to actively push away from and to resist passive correction towards the earth-vertical upright orientation.

from: Karnath, H. O., & Karnath, H.-O. (2007). Pusher syndrome--a frequent but little-known disturbance of body orientation perception. [Review]. Journal of Neurology, 254(4), 415-424.

This is really quite different to the concept of Perennou et al :

‘lateropulsion’; that is, an active lateral tilt of the body which is usually ipsilesional in caudal brainstem strokes (Bjerver and Silfverskiold, 1968; Dieterich and Brandt, 1992; Brandt and Dieterich, 1994) and contralesional in rostral brainstem strokes (Brandt and Dieterich, 1994; Yi et al., 2007) as well as in hemisphere strokes (Bohannon et al., 1986; Beevor, 1909; Pérennou et al., 1998; D’Aquila et al., 2004).

and

In some hemispheric strokes lateropulsion is associated with ‘pushing behaviour’ which is characterized by patients resisting any attempt to correct their posture

. From: Perennou, D. A., Mazibrada, G., Chauvineau, V., Greenwood, R., Rothwell, J., Gresty, M. A., et al. (2008). Lateropulsion, pushing and verticality perception in hemisphere stroke: a causal relationship? [Research Support, Non-U.S. Gov't]. Brain, 131(Pt 9), 2401-2413.

It seems to me that Karnath's distinction is clearer where as Perennou' et al is more ambiguous. Anyway there are obviously differences of opinions amongst the research teams. However ideally we should all be talking about the same diagnostic group so these definitions really matter. Otherwise how make comparisons with each other or define who will benefit from what treatment?

national health system has a problem about long stay as inpatient

Just out of interest how long is the average stay for patients in rehabilitation post stroke in Italy? In our state system selected patients go to rehab if they have marked disability and then receive 3-6 weeks of rehab. There are exceptions. Generally the rehab teams accept the PS patients will take longer.

[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