Pusher syndrome

[Robyn]

Hi, Could anyone tell me if they have any advice in the treatment of pusher syndrome.

I have tried visual prompts for posture correction with good effect in sitting and supported standing. I'm working on righting head movement and active weight bearing to non affected side which seems to be improving with some carry over. The problem I'm having is correction with activity, having to stop activity due to pushing and leaning to affected side as soon as we start the activity i.e cones, reaching for cup. The only success we've had is rolling a ball with affected hand?

If you have any ideas or good journal recommendations please tell! P.S. my patient had right CVA 3/52 ago, no weakness on the left

Thank you, Robbie

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[Pindara]

Place a table on the unaffected side of the patient in sitting. During sit to stand training prompt the patient to stay close to the table (often need lots of verbal prompting, with lots of repetition, aiming to retrain the patients sense of vertical and balance).

During standing balance have the patient keep their unaffected hip close to the table, again with lots of prompting.

And when mobilising, stand on the patients unaffected side, continually prompting the patient with "stay close to me" to ensure adequate weight shift to the unaffected side.

Expect this to take time for the patient's sense of balance to retrain, probably over a number of weeks.

[Robyn]

Thank you for you advice. It is helpful and working a treat. Still have a little problem with activity but I'll keep trying.

If anyone has some handy articles for this subject i would be very appreciative.

Robbie

[neurospast]

I will give you some theory regarding a view on pusher syndrome which might help you to develop ideas.
It is thought that with pusher syndrome the patient has a huge difference in sensory output. which means in order to level this he will push towards the affected side and therefor overbalance in sitting, standing, lying, walking and so on. also sight can be affected because of a disbalance (the head can be turned towards the affected side). Good books about this are from shepperd and carr (their first book has at least one chapter about the subject).
Put a lot of emphasis on retraining the affected sensory, talk with the occupational therapist about this and make a joint plan (they are in principle experts on the subject).
I have always found it helpful to train on walking sideways (In the bars to start of with!) walking backwards, cross over, stepping up and down. In general bars can be very helpful with pusher syndrome since it will give a lot of feedback and you can little by little ask them to take less and less support from the affected side (I am under the impression that your patient has to a certain extend the use of this side).since this means that you will train the sensory part of the affected side.

[sw733]

"No weakness on his affected side" but has "pusher syndrome"??? Without seeing or assessing your patient, it's hard to really give you advice on treating this patient with "pusher" characteristics. However, neurospast has given you some good ideas and I'll add some to it... Sometimes going back to basic is the key. As you mentioned previously, this patient seems to lean towards the affected side during activity --> classic pusher characteristic due to overuse of the unaffected side. Typically I like to start with sit to stand with functional reaching (of course you need to assess and play around with this pending on what the patient is capable of). First, you place a mirror in front of the patient to provide visual cueing. You begin with both legs on level surface and higher seat height while you sit on his affected side. You start it out with sit to stand or/and reaching in the centre. Then you slowly take the client reaching towards his affected side or/ and towards up to force weight bearing on his affected side. If necessary, you may also provide some tactile cueing on hip extensors and quads (if they are weak and not firing but remember to gradually back off as the client improves his/her activation). You progress that with decreasing seat height and also adding height (e.g. a book --> phone book --> step) to the unaffected leg during functional reaching and sit to stand to force weight bearing on the affected side. The key is that you need to constantly challenge your client by taking the client to edge of his comfort zone with emphasis to weight bearing on the affected side but also make it achievable to increase confidence. Hopefully, this helps.
p.s. Did the presentation go well?

[Robyn]

Ah Thank you, yes, I thought beginning with basics was best for this patient, although I'm on placement and the physio's there like to walk patient's straight away, more for the patient's morale. learning at uni that it isn't good to mobilise patient's who are compensating or over using and adopting incorrect patterns, i get a bit confused. I have been doing sit to stand and functional reaching in sitting and standing. I've also be walking between the bars and with the frame. He mobilises better with the "hip over prompt" but hope I'm not rushing into walking too quickly. My educator says the patient is progressing well but it is hard for a student to judge without the experience I suppose.

As for my presentation its all set for tomorrow, I think it will be ok, public speaking isn't my strong point, the only thing I don't like about studying physio so far, but gonna have to get used to it, lots more presentations in my career to look forward to!!

Thanks for the Rx ideas I'll give the book a go!

Robbie

[Robyn]

ps to explain the "no weakness on affected side" compared to the non affected side there is no significant difference in individual muscle group power, ie hip flex, extn, abd- tested in sitting and supine.

Robbie

[asha]

Two exercises you could try in the initial stages are:
1-Let the patient lie on the affected side, ensure that the weight is not borne at the shoulder, but over scapula. For this the shoulder is abducted and in Ext. Rot'ed position, with elbow in flexion. The affected LL is in flexion at knee. Now abduct the unaffected LL & UL at same time.
2-While working on the trunk, even before you have started with standing, ask the patient to flex the unaffected LL & UL at the same time.
These two exercises can be used prophylactically. Most (L) Hemi's are pushers. During ambulation, You could ask a relative to stay close to the patients unaffected side.
asha