Review Article

Therapeutic approaches for pusher syndrome after a stroke: a literature review

Sayu Aryantari Putri Thanaya , Putu Eka Mardhika

Sayu Aryantari Putri Thanaya
Department of Physiotherapy, Faculty of Medicine, Universitas Udayana, Bali, Indonesia. Email: sayuthanaya@unud.ac.id

Putu Eka Mardhika
Department of Neurosurgery, Faculty of Medicine, Universitas Udayana, Sanglah General Hospital, Bali, Indonesia
Online First: August 01, 2019 | Cite this Article
Thanaya, S., Mardhika, P. 2019. Therapeutic approaches for pusher syndrome after a stroke: a literature review. Intisari Sains Medis 10(2). DOI:10.15562/ism.v10i2.507


Introduction: Pusher syndrome is a disorder that is clinically present in 5-52% of stroke patients, characterized by active pushing using the non-paretic side towards the paretic side, and resistance to the passive correction of posture. This disorder can pose an unfavorable effect on the rehabilitation of stroke patients. Hence, finding effective therapeutic approaches for pusher syndrome is crucial. This study aimed to identify the existing therapeutic approaches for pusher syndrome and investigate their effectiveness.

Methods: A literature review was carried out, where studies were identified through searching the PubMed database from database inception to 2019 using the keywords: “pusher syndrome”, “pusher behaviour”, “contraversive pushing”, “ipsilateral pushing”, “lateropulsion”, “physiotherapy”, “physical therapy”, “treatment”, “therapeutic approach”, “therapy” and “training”.  The literatures were analyzed systematically based on the results of previous studies.

Results: Several approaches were identified for treating pusher syndrome post-stroke, including robot-assisted gait training (RAGT), galvanic vestibular stimulation (GVS), visual feedback (VF), and physiotherapy with additional components such as relaxation therapy in the prone position and lateral stepping with body weight–supported treadmill training (LS-BWSTT). RAGT and VF training appear to be promising adjunctive approaches for treating pusher syndrome. Conventional physiotherapy with additional components such as relaxation therapy and LS-BWSTT have also led to positive effects. However, the effect of GVS has not been established.

Conclusion: There is evidence that some therapeutic approaches can be beneficial for improving pusher syndrome and outcomes of stroke patients, in particular when combined with conventional physiotherapy. However, the number of studies is still very limited. Further research with methodological rigor is needed.

References

Karnath HO, Johannsen L, Broetz D, Ferber S, Dichgans J. Prognosis of contraversive pushing. J Neurol. 2002;249(9):1250-3.

Pérennou DA, Amblard B, Laassel EM, Benaim C, Hérisson C, Pélissier J. Understanding the pusher behavior of some stroke patients with spatial deficits: A pilot study. Arch Phys Med Rehabil. 2002;83(4):570-5.

Bohannon RW. Ipsilateral pushing in stroke. Archives of physical medicine and rehabilitation. 1996;77(5):524.

Roller ML. The ‘pusher syndrome’. J Neurol Phys Ther. 2004;28(1):29.

Davies PM. Steps to Follow: A Guide to the Treatment of Adult Hemiplegia. New York: NY: Springer; 1985.

Karnath H-O, Broetz D. Understanding and Treating “Pusher Syndrome”. Phys Ther. 2003;83(12):1119-25.

Karnath HO, Ferber S, Dichgans J. The origin of contraversive pushing: Evidence for a second graviceptive system in humans. Neurology. 2000;55(9):1298-304.

Pedersen PM, Wandel A, Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS. Ipsilateral pushing in stroke: Incidence, relation to neuropsychological symptoms, and impact on rehabilitation. The Copenhagen Stroke Study. Arch Phys Med Rehabil. 1996;77(1):25-8.

Pérennou DA, Mazibrada G, Chauvineau V, Greenwood R, Rothwell J, Gresty MA, et al. Lateropulsion, pushing and verticality perception in hemisphere stroke: A causal relationship? Brain. 2008;131(9):2401-13. DOI: 10.1093/brain/awn170.

Lafosse C, Kerckhofs E, Troch M, Vereeck L, Van Hoydonck G, Moeremans M, et al. Contraversive pushing and inattention of the contralesional hemispace. J Clin Exp Neuropsychol. 2005;27(4):460-84. DOI: 10.1080/13803390490520463.

Abe H, Kondo T, Oouchida Y, Suzukamo Y, Fujiwara S, Izumi SI. Prevalence and length of recovery of pusher syndrome based on cerebral hemispheric lesion side in patients with acute stroke. Stroke. 2012;43(6):1654-6. DOI: 10.1161/strokeaha.111.638379.

Lagerqvist J, Skargren E. Pusher syndrome: Reliability, validity and sensitivity to change of a classification instrument. Adv Physiother. 2006;8(4):154-60. DOI: 10.1080/14038190600806596.

D’Aquilla MA, Smith T, Organ D, Litchman S, Reding M. Validation of a lateropulsion scale for patients recovering from stroke. Clin Rehabil. 2004;18(1):102-9. DOI: 10.1191/0269215504cr709oa.

Babyar SR, Peterson MGE, Bohannon R, Pérennou D, Reding M. Clinical examination tools for lateropulsion or pusher syndrome following stroke: A systematic review of the literature. Clin Rehabil. 2009;23(7):639-50. DOI: 10.1177/0269215509104172.

Paci M, Baccini M, Rinaldi LA. Pusher behaviour: A critical review of controversial issues. Disability and Rehabilitation. 2009;31(4):249-58. DOI: 10.1080/09638280801928002.

Hesse S, Tomelleri C, Bardeleben A, Werner C, Waldner A. Robot-assisted practice of gait and stair climbing in nonambulatory stroke patients. J Rehabil Res Dev. 2012;49(4):613-23. DOI: 10.1682/jrrd.2011.08.0142.

Cho DY, Park S-W, Lee MJ, Park DS, Kim EJ. Effects of robot-assisted gait training on the balance and gait of chronic stroke patients: focus on dependent ambulators. J Phys Ther Sci. 2015;27(10):3053-7. DOI: 10.1589/jpts.27.3053.

Swinnen E, Beckwée D, Meeusen R, Baeyens J-P, Kerckhofs E. Does Robot-Assisted Gait Rehabilitation Improve Balance in Stroke Patients? A Systematic Review. Top Stroke Rehabil. 2014;21(2):87-100. DOI: 10.1310/tsr2102-87.

Bergmann J, Krewer C, Jahn K, Müller F. Robot-assisted gait training to reduce pusher behavior: A randomized controlled trial. Neurology. 2018;91(14):e1319-27. DOI: 10.1212/wnl.0000000000006276.

Yun N, Joo MC, Kim S-C, Kim M-S. Robot-assisted gait training effectively improved lateropulsion in subacute stroke patients: a single-blinded randomized controlled trial. Eur J Phys Rehabil Med. 2019;54(6):827. DOI: 10.23736/s1973-9087.18.05077-3.

Krewer C, Rieß K, Bergmann J, Müller F, Jahn K, Koenig E. Immediate effectiveness of single-session therapeutic interventions in pusher behaviour. Gait Posture. 2013;37(2):246-50. DOI: 10.1016/j.gaitpost.2012.07.014.

Karnath HO. Pusher syndrome - A frequent but little-known disturbance of body orientation perception. Journal of Neurology. 2007;254(4):415-24. DOI: 10.1007/s00415-006-0341-6.

Yang YR, Chen YH, Chang HC, Chan RC, Wei SH, Wang RY. Effects of interactive visual feedback training on post-stroke pusher syndrome: A pilot randomized controlled study. Clin Rehabil. 2015;29(10):987-93. DOI: 10.1177/0269215514564898.

Broetz D, Johannsen L, Karnath HO. Time course of “pusher syndrome” under visual feedback treatment. Physiother Res Int. 2004;9(3):138-43. DOI: 10.1002/pri.314.

Utz KS, Dimova V, Oppenländer K, Kerkhoff G. Electrified minds: Transcranial direct current stimulation (tDCS) and Galvanic Vestibular Stimulation (GVS) as methods of non-invasive brain stimulation in neuropsychology-A review of current data and future implications. Neuropsychologia. 2010;48(10):2789-810. DOI:

Saj A, Honoré J, Rousseaux M. Perception of the vertical in patients with right hemispheric lesion: Effect of galvanic vestibular stimulation. Neuropsychologia. 2006;44(8):1509-12. DOI:

Nakamura J, Kita Y, Yuda T, Ikuno K, Okada Y, Shomoto K. Effects of galvanic vestibular stimulation combined with physical therapy on pusher behavior in stroke patients: a case series. NeuroRehabilitation. 2014;35(1):31-7. DOI: 10.1016/j.neuropsychologia.2010.06.002.

Paci M, Nannetti L. Physiotherapy for pusher behaviour in a patient with post-stroke hemiplegia. J Rehabil Med. 2004;36(4):183-5. DOI: 10.1080/16501970410029762.

Fujino Y, Amimoto K, Sugimoto S, Fukata K, Inoue M, Takahashi H, et al. Prone positioning reduces severe pushing behavior: three case studies. J Phys Ther Sci. 2016;28(9):2690-3. DOI: 10.1589/jpts.28.2690.

Pardo V, Galen S. Treatment interventions for pusher syndrome: A case series. NeuroRehabilitation. 2019;44(1):131-40. DOI: 10.3233/nre-182549.

Romick-Sheldon D, Kimalat A. Novel treatment approach to contraversive pushing after acute stroke: A case report. Physiother Canada. 2017;69(4):313-7. DOI: 10.3138/ptc.2016-28


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