background and treatment of post-stroke lateropulsion

what are other names for lateropulsion

-Pusher behavior (PB)

-contraversive pushing

-ipsilateral pushing

-pusher syndrome

what is pusher behavior/lateropulsion

tilt or active pushing towards hemiparetic side with active resistance to passive correction

what areas of the body do you see pusher behavior/lateropulsion

trunk

unaffected extremities (extension and abduction, overactive hip hike)

affected LE (flexion and ADD)

what is the incidence in stroke patients of pusher behavior/lateropulsion

-most commonly reported to be around 10-20%

-some studies have reported up to 60%

what areas is there a disconnect between, that creates pusher behavior/lateropulsion

disconnect between Subjective Visual Vertical (SVV) and Subjective Postural Vertical (SPV)

what side cerebral involvement is seen in lateropulsion

left or right cerebral involvement

what is lateropulsion often seen in conjunction with

aphasia or neglect

what areas could be linked to pusher behavior

no one specific area

-posterolateral thalamus

-insular cortex

-postcentral gyrus

what size of lesion does there tend to be with lateropulsion

patients tend to have larger lesion size

what are the 3 different outcome measures for lateropulsion

-Burke lateropulsion scale

-Four Point Pusher Scale (4PPS)

-Scale for contraversive pushing

what is the scoring for Burke Lateropulsion Scale

GOLD STANDARD

-looks at full range (sit, stand, transfer, walking)

-score >2 to diagnose

-MDC = 2.18 in acute stroke

what is the scoring for 4 Point Pusher Scale (4PPS)

-score >0 to diagnose

-MDC not established

what is the scoring for Contraversive Pushing

-looking at spontaneous body posture in sitting/standing

-Score >0 on any subset to diagnose

-MDC not established

what is the Burke Lateropulsion Scale looking at

supine→ logroll (looking at resistance to rolling on affected/unaffected)

sitting (response to attempts to bring pt back to vertical)

standing (pt position 15-20 toward affected side and look at response, then 5-10 toward intact side and look at response)

transfers (resistance to transferring to affected side)

walking(lateropulsion after PT support with walking)

what is the Scale for Contraversive Pushing looking at

spontaneous body posture (contraversive tilt/fall)

Use of non-paretic extremities (abd and ext)

resistance to passive correction of tilted posture

what is the 4 Point Pusher Scale looking at

3: severe pushing in sitting, over-activity in less affected side

2:moderate pushing in sitting, no visible lean in sitting, resistance to weight shift, visible lean in standing

1: mild pushing in sitting, no resistance to shift/no visible lean. resistance to weight shift in standing

0: No pushing during sitting, standing, or walking. No resistance to passive weight shift. No overactivity of less affected side

what are the prognostic indicators of lateropulsion

-postural control systems involved (motor, hemianopic/visual-spatial, proprioception/sensation)

-side of lesion (R<L)

-initial stroke severity

-age

-pts with lateropulsion overall tend to have worse prognosis

-lateropulsion at day 30 correlated to long term walking prognosis

what is lateropulsion prognosis based on study

pts with PB required 3.6 weeks longer than patients without to reach same final outcome

pts with PB tend to have more severe strokes

no correlation between PB and functional outcome, strongly correlated with recovery period and length of rehab

pts with PB have significantly longer hospital stays

motor recovery and functoinal ability significantly worse for pt with PB

what are the classic approaches to lateropulsion

Davies

Broetz and Karnath

what is the Davies approach to lateropulsion

passive correction of head tilt

flexor activity stimulated on paretic side of trunk

pts learn to place weight on both affected and unaffected sides

use of knee extension splint for standing midline

promote early stair navigation

what is the Broetz and Karnath approach to lateropulsion

promote pts active movement to shift toward affected side

decrease fear of movement

start with low transfer to paretic side

promote good wheelchair positioning

what are treatment approach categories for lateropulsion

visual feedback

somatosensory cues

visual-somatosensory integration

brain stimulation

what are some treatment techniques for lateropulsion

robot assisted gait training

standing frame

BWSTT -lateral stepping

prone relaxation

interactive visual feedback

lateral-reaching from tilted sitting surface

prism glasses

PUSH (Prioritizing Upright, Standing, and Higher-level activities)

what are characteristics of lateropulsion

-behaviors exhibited by affected side include overactivity of less affected, actively leaning across midline toward more affected, resistance to passive correction

-altered perception of vertical/midline, misorientation with respect to gravity, perception of upright when leaning toward more affected, sense of falling toward less affected

-behavior is involuntary

-unaware of deficits

what is the impact of lateropulsion

increased risk of falling

what are elements of rehab and strategies for managing lateropulsion

-practical hands-on guidance for mobility and transfer training including positioning, re-positioning, and postural support

-need for clear, simple instructions

-appropriate tactile cues and verbal feedback

-guide to see/feel they aren’t upright

-passive attempts at correction increase lateropuslion, pt encouraged to move actively toward midline

approach to rehab

-training in managing lateropulsion

-safety and falls prevention

-interdisciplinary approach

-cueing and strategies for transfers remain consistent among team

-individualized

what are specific rehab strategies

-task specific training (sitting, transfers, standing, walking) should be provided as appropriate, considering individual mobility status

-early orientation to upright should be prioritized

-practice incorporating repeated weight-shifting tasks toward less affected side

interventions for lateropulsion in therapy

-finding midline

-transfers

-gait

-stairs

interventions for lateropulsion outside of therapy

increase time in midline

wheelchair positioning

nursing/family

what are key principals to finding midline

-education

-set up for success (anchors→ physical, visual)

-targets

-positioning (pt, PT)

-don’t push a pusher

-make them feel safe

-just right challenge

-provide stability only where needed (support seekers)

finding midline progression

-static to dynamic (calm pushing)

-seated to standing

-weight acceptance (unaffected side, midline, affected side)

-small transitions

-decrease fear

-training midline

-dealing with increased pushing behaviors (facilitation, task, environment)

early/low level of finding midline

-visual cues (mirror, feet at tape)

-bolster (sliding to end and pausing at midline)

items in front to decrease fear

-reaching for targets (overhead reach)

-elevator leg technique

-shake tail feather

-tactile cue of wall when walking, quiet

transfers in lateropulsion

start small

-hip lifts, scooting, sit>flexed>stand pivot

direction of transfers

-less affected side first

-more affected side once pushing has calmed down

cues

-concise and consistent

tips and tricks for transfers with lateropulsion

hand placement

foot placement

therapist positions

special considerations for transfers in lateropulsion

toilet, car

hand position in transfers

IR rotating arm to shift weight

gait in lateropulsion

-AD/environmental considerations (NO QUAD CANES=unstable)

-facilitation/hand placement

-common deficits (early, chronic)

tips/tricks in gait in lateropulsion

decrease fear

treatment ideas

dealing with increased pushing behaviors (facilitation, task, environment)