Pusher Flashcards
(86 cards)
1
Q
What is pusher syndrome?
A
strong pushing toward the weak side ,
resistance to passive corrections of posture —to the vertical upright: they push back
2
Q
Is Pusher Syndrome a true Syndrome?
Davies used her experience and documented characteristics of a typical patient with pusher syndrome: she says it is a syndrome
A
hemineglect
Hemianopsia
Hemiplegia
Hemihypaesthesia
Right Brain Damage
3
Q
Is Pusher Syndrome a true Syndrome?
Peterson 1996: Copenhagen Stroke Study: he disagrees and says it is not a true syndrome
A
Distribution of right vs left brain lesion in pushing group not different from distribution in non-pushing group
Higher incidence of brain damage in posterior crus of the internal capsule (sensory)
Not necessarily associated with neglect, hemianopsia, etc.
Not a true syndrome , not a constellation of signs and symptoms together to make one syndrome
4
Q
Alternate Terminology for pusher syndrome
A
Ipsilateral pushing-pedersen et al
Contraversive pushing -Karnath
Contralesional Pushing: Perennon
Listing-Behannon
lateropulsion-Brandt-pushing in the frontal plane (vs sagittal or transverse)
5
Q
Name of pushing syndrome
Karnath
A
Contraversive pushing
6
Q
Name of pushing syndrome
Perennon
A
Contralesional Pushing
7
Q
Contralesional Pushing
Behannon
A
Listing
8
Q
Contralesional Pushing
Brandt
A
lateropulsion-
pushing in the frontal plane (vs sagittal or transverse)
9
Q
Pushing Syndrome:
Characteristic Behaviors:
Supine
A
rolling: resist rotation to unaffected side
10
Q
Pushing Syndrome:
Characteristic Behaviors:
Sitting
A
pushing to weak side
- Strong Pelvic Tilts
- Head may be rotated toward strong side
- Extreme cases, eyes also fixed to strong side
11
Q
Pushing Syndrome:
Characteristic Behaviors:
Transfer
A
resist transfer toward strong side
-Safety issue
12
Q
Pushing Syndrome:
Characteristic Behaviors:
Standing
A
active pushing to weak side
-Strong resistance to correct posture
13
Q
Pushing Syndrome:
Characteristic Behaviors:
Walking
A
Active pushing to weak side
- note strong foot plantarflexion and eversion
- dig that foot to get over to the weak side
14
Q
Pushing Syndrome
Range of Symptoms:
- degree of pushing
- is there unilateral neglect?
- what occurs with more experience in upright positions?
A
- Mild to Moderate to Severe pushing
- May or may not co-exist with unilateral neglect
- Usually decreases with more experience in upright positions, practice
Pushing can decrease with time if practice upright activities with the patient
15
Q
Pusher’s Syndrome: Implications for Rehab:
A
Will Delay Functional Recovery:
16
Q
By how much will pushers syndrome delay functional recovery:
Time for 95% of patients with lateropulsion to achieve their maximal Barthel Index Score is ____
A
Time for 95% of patients with lateropulsion to achieve their maximal Barthel Index Score is 6 WEEKS LONGER than 95% of patients without laterpopulsion
17
Q
By how much will pushers syndrome delay functional recovery:
Time for discharge from hospital?
A
Time for Discharge from hospital approximately 3.6 WEEKS LONGER than for patients without lateropulsion, controlling for differences between stroke severity
18
Q
By how much will pushers syndrome delay functional recovery:
What adds to the therapy time?
A
Patient must spend more time with basic balance before functional training starts
19
Q
What causes Lateropulsion?
options
A
1) PARIETAL-INSULAR VESTIBULAR CORTEX
Brandt says it is the insula
Between the frontal lobe and the parietal lobe and separate them and look straight down
2) POSTERIOR > Anterior CRUS OF INTERNAL CAPSULE
Peterson says it is sensory: from the internal capsule -the posterior arm of the internal capsule
3) VENTRAL-LATERAL POSTERIOR THALAMUS
Karnath
Thalamus is sensory relay station
4) MEDIAL LONGITUDINAL FASICULUS
20
Q
What causes Lateropulsion?
Pederson
A
Posterior arm of internal capsule (sensory)
21
Q
What causes Lateropulsion?
Grant
A
Insula (btwn frontal and parietal lobe)
22
Q
What causes Lateropulsion?
Pereneou
A
Temporal-Parietal junction
high integrative center visual form occiput motor from parietal and vestibular from temporal
23
Q
What causes Lateropulsion?
Karnath
A
Thalamus (sensory relay station)
24
Q
What causes Lateropulsion?
Middlestadt
A
in the kidneys, innervated by vagus nerve, interpretation of information from the level is the issue: graviceptive neglect: cannot feel they are not upright
25
What causes Lateropulsion? Why is Karnath wrong?
Can have pushers with thalamic lesions and pushers with extrathalamic lesions, so thalamus is not the answer
26
Why Perennou says lateropulsion is temperopatietal junction?
Correlational findings from a balance task to brain imaging studies
Temperoparietal Junction most common in individuals who have difficulty with their balance task: LP and or neglect
They viewed this area as the polymodal sensory integration area for body balance center of VISUAL, MOTOR (parietal) and VESTIBULAR
27
Golden, D’Aquila and Reding 2001
Location to get pushing syndrome (3)
PIVC: Parietal Insular Vestibular Cortex may be
the one that is more affected
Temporal Eperculum
Thalamus
28
Graviceptive Input:
Mittelstaedt: [kidneys]
=> receptors in viscera transmit information to brain via vagus
It is in the kidneys
Perenneu, Amblard: [Temporal-Parietal junction]
=>lateropulsion may be a high order disruption in the processing of somesthetic information originating in the left hemibody, which could be a form of graviceptive neglect (extinction)
---->Altered ego-centric reference system for posture and balance
29
Patients with left brain lesions and lateropulsion showed a trend for greater involvement of:
(2)
1. Anterior insula extending to the eperculum
| 2. Internal Capsule extending to the thalamus
30
Those with right brain lesions and lateropulsion had trend for lesions near the
(2)
1. Posterior Insula (long insula gyrus)
| 2. Superior temporal gyrus, eperculum, and white matter
31
Anterior insula extending to the eperculum
Patients with ____ brain lesions and lateropulsion showed a trend for greater involvement
Patients with LEFT brain lesions and lateropulsion showed a trend for greater involvement
32
Internal Capsule extending to the thalamus
Patients with ____ brain lesions and lateropulsion showed a trend for greater involvement
Patients with LEFT brain lesions and lateropulsion showed a trend for greater involvement
33
Posterior Insula (long insula gyrus)
Patients with ____ brain lesions and lateropulsion showed a trend for greater involvement
Those with RIGHT brain lesions and lateropulsion had trend for lesions
34
Superior temporal gyrus, eperculum, and white matter
Patients with ____ brain lesions and lateropulsion showed a trend for greater involvement
Those with RIGHT brain lesions and lateropulsion had trend for lesions
35
How does the graviceptive system work?
Graviceptive system exists which feeds back information from the body about its position in space
This system is the foundation for an egocentric coordinate (reference) system
When graviceptive information is altered, the egocentric system is incorrect resulting in altered postural alignment
Graviceptive neglect (Perennou, et all)
36
Which system is the foundation for an egocentric coordinate (reference) system ?
graviceptive system
37
What causes altered postural alignment in the graviceptive system?
When graviceptive information is altered, the egocentric system is incorrect resulting in altered postural alignment
38
Who formed the idea of graviceptive neglect?
Perennou
39
Central postural control center
how it explains lateropulsion
(CPCS) either is not receiving correct information from graviceptive system
OR
it is getting the information but is not interrupting this information symmetrically
==> improper signals from VESTIBULAR centers, SEMATOSENSORY areas, or OCULAR MOTION centers
==>Result of this imbalance of information is lateropulsion
40
3 types of verticals
subjective VISUAL vertical (SVV)
is determined by having subjects adjust a visible luminus line in complete darkness to what they consider to be upright, earth vertical
```
HAPTIC vertical (HV)
is assessed by manipulation of a rod to the earth-vertical position with both eyes, while the subject's eyes are closed—put rod in vertical
```
subjective POSTURAL vertical (SPV)
is the position of the head or body with respect to true vertical—body in vertical
41
subjective VISUAL vertical (SVV)
[online]
is determined by having subjects adjust a visible luminus line in complete darkness to what they consider to be upright, earth vertical
42
HAPTIC vertical (HV)
[online]
is assessed by manipulation of a rod to the earth-vertical position with both eyes, while the subject's eyes are closed—put rod in vertical
43
subjective POSTURAL vertical (SPV)
[online]
is the position of the head or body with respect to true vertical—body in vertical
44
What is the Subjective Visual Vertical:
Ability to ascertain vertical through visual information
--Look at a dial and see it is 6:00
--intact with patients with lateropulsion
45
Is Subjective visual vertical intact or impaired in lateropulsion?
Ability to ascertain vertical through visual information
--Look at a dial and see it is 6:00
--intact with patients with lateropulsion
46
Subjective Postural Vertical:
know our vertical upright
Ability to ascertain body vertical without visual cues
---Impaired in patients with lateropulsion
47
Is Subjective Postural Vertical intact or impaired in lateropulsion?
know our vertical upright
Ability to ascertain body vertical without visual cues
---Impaired in patients with lateropulsion
48
By how much does Karnath say subjective postural vertical is off in patients with lateropulsion?
Off by as much as 18 degrees towards the ipsilateral side with eyes closed
With eyes open: within 95% confidence interval of controls
49
Where does Perennou and Associates say subjective postural vertical is off in patients with lateropulsion?
off but toward the CONTRALESIONAL SIDE: (to side of the weakness):
--->Patient trying to align themselves to their perceived vertical: even in ex-pushers (even patients who are not pushers have issues with vertical)
SVV (subjective visual vertical) also biased to contralesional side
Both subjective postural vertical and subjective visual vertical: to the side of the weakness (contralesional side)
Tilt thingy to measure where is their perception of vertical
50
What are patients trying to align themselves with according to Perennou?
Patient trying to align themselves to their perceived vertical: even in ex-pushers (even patients who are not pushers have issues with vertical)
Both subjective postural vertical and subjective visual vertical: to the side of the weakness (contralesional side)
51
Central postural control center (CPCS) either is not receiving correct information from graviceptive system
OR
it is getting the information but is not interpreting this information symmetrically
==> improper signals from VESTIBULAR centers, SEMATOSENSORY areas, or OCULAR MOTION centers
==>Result of this imbalance of information is lateropulsion
52
Subjective Visual Vertical
Ability to ascertain vertical through visual information
INTACT in patients with lateropulsion
53
Subjective postural vertical
Ability to ascertain body vertical without visual cues
IMPAIRED in patients with lateropulsion
54
Subjective postural vertical: Karnath and associates
EYES CLOSED: off by as much as 18 degrees toward IPSILATERAL side with
EYES OPEN: within 95% of confidence interval of controls
55
Subjective postural vertical
Perennous
Off toward the CONTRALESIONAL SIDE (to the side of weakness) -pt tries to align with perceived vertical, even non pushers
Subjective Visual Vertical is ALSO biased to contralesional side
56
Positions measured in the Burke Lateropulsion scale
| 5
Test in all postures: check degree of resistance or degree of postural deviation the patient has
1. Supine-Rolling
2. Sitting
3. Transferring
4. Standing
4. Walking
57
What does the Burke lateropulsion scale measure?
Attempts to quantify the POINT IN THE RANGE WHERE RESISTANCE TO PASSIVE CORRECTION is felt
Or attempts to quantify the DEGREE OF PUSHING felt by the examiner during the functional task
review it
58
What are the scores in the burke lateropulsion scale?
Supine to roll: 0-3 (can add one if to both sides)
Sit: 0-3
Transfer: 0-3
STAND: 0-4
Walk: 0-3
59
Burke: lateropulsion Scale
SUPINE
roll to bad side then to good side
```
0 = No resistance to passive rolling
1 = Mild resistance
2 = Moderate Resistance
3 = Strong Resistance
```
+1 = Add one point if resistance noted in both directions x
60
Burke: lateropulsion Scale
SITTING
POSITION: TRUNK 30 DEGREES OFF TRUE VERTICAL TOWARDS THE HEMI SIDE : score attempts to move them to true vertical
0 = No resistance to passive return to true vertical sitting
1= voluntary or reflex resistive movements in trunk, arms, or legs, noted only in the LAST 5 DEGREES approaching VERTICAL
2= resistive movements noted but beginning WITHIN 5-10 DEGREES of VERTICAL
3= resistive movements noted MORE THAN 10 DEGREES OFF VERTICAL
61
Burke: lateropulsion Scale
STANDING
POSITION: TRUNK 15-20 DEGREES OFF TRUE VERTICAL TOWARDS HEMI SIDE: score attempt to bring them to vertical and then 5-10 degrees past vertical to the intact side
0 = pt prefer to place COG over affected leg
1= (resistance) 5-10 degrees past midline
2= (resist/reflex) 5 degrees of approaching vertical
3 = (reflex) beginning 5-10 degrees off vertical
4 = (resistive/reflex) >10 degrees off vertical
62
Burke: lateropulsion Scale
TRANSFERS
Transfer to good side then to bad side.
0 = no resistance to good side
1 = mild resistance to good side
2 = moderate resistance to good side (x1)
3 = significant resistance to good side (assist x2 or more)
63
Burke: lateropulsion Scale
WALKING
Measure resistance to PT supporting true vertical
0 = no lateropulsion
1 = mild
2 = moderate
3 = strong lateropulsion, assist x2 or unable due to severity of lateropulsion
64
Max score on the burke lateropulsion scale
17
65
Scale of Contraversive Pushing: Testing positions
1. sitting
| 2. standning
66
Scale of Contraversive pushing: Three components:
1. Postural Deviation
- ->watch the patient
2. Abduction/extension of uninvolved extremities
3. Resistance to Passive Corrections
67
Scale of Contraversive Pushing: Karnath
Who is a pusher?
If the score is >1 on each component in sitting and in standing: “Pusher”
68
Scale of Contraversive Pushing: Baccini scoring
Who is a pusher?
subscore of each component is >0: this gives better validity and reliability
Bacccini has better SENSITIVITY
69
Whose method is more specific and sensitive for the scale of contraversive pushing?
Baccini has more sensitivity (>0 on each component)
Both 100% specific (Baccini >0, Karnath >1)
Internal consistency 0.919
Is it validity or intertest reliability - comparison too an experts clinical diagnosis
70
Modified Scale of Contraversive Pushing
Lagerqvist and Skargren
1. static sitting at the bedside with the feet on the floor
2. Static standing in full erect posture
3. Transferring from bed to chair or wheelchair (with armrests) while maintaining hip flexion
4. Transferring from bed to chair or wheelchair by coming to full standing position and stepping or pivoting 90 degrees
Scored 0-2 = pushes continuously with force enough to fall if not supported, abducts uninvolved arm and or leg spontaneously, even at rest
maximum score = 8
71
Modified Scale of Contraversive Pushing
4 items
1. static sitting at the bedside with the feet on the floor
2. Static standing in full erect posture
3. Transferring from bed to chair or wheelchair (with armrests) while maintaining hip flexion
4. Transferring from bed to chair or wheelchair by coming to full standing position and stepping or pivoting 90 degrees
72
Modified Scale of Contraversive Pushing
scoring
Scored 0-2 = pushes continuously with force enough to fall if not supported, abducts uninvolved arm and or leg spontaneously, even at rest
maximum score = 8
73
Treat Pushers Syndrome:
Sitting
1. MINIMIZE DISTRACTIONS IN THE ROOM
2. MAY NEED TO PU STRONG LEG ON STEP STOOL: flex and inhibit ext
- -if sitting and abducting a lot with the leg put on high step stool to take out of frontal plane pushing mode
3. CUE PELVIS AND ALIGNMENT ON BOTH ISCHIAL TUBEROSITIES
- -You are tilted, you know you are tilted how can I bring you upright
- -I feel your pelvis off the ground how can you ----bring it back down to surface
- -feel my hand under your butt on good side and press into my hand
4. CUE IN VISUAL VERTICAL: TAKE IN INFORMATION FROM ROOM SURROUNDINGS
* **Mirror with central stripe (the tape down the middle of the mirrror)
* **Wall, corners, windows, your alignment, etc.
They realize the wall cannot be crooked I must be crooked
- -Strong side into the wall
- -Teach WS to strong side
5. Rest arm/elbow on boslter or ball or bench positioned on their strong side-spend time in this position-look at head righting reactions
6. Allow rest backward, leaning up against you
7. Progress to reaching strong side
- -Cones, rings, playing cards
- -Emphasize, facilitate weight shift to buttocks on strong side with appropriate trunk elongation
74
Treat Pushers Syndrome:
Sit to stand trasnfer
Practice
75
Treat Pushers Syndrome:
Standing
1. Watch for UE pushing
2. Stand with strong side toward wall with or without wall bar and encourage weight shift toward wall
3. Mirror with stripe
4. Spend time experiencing the correct alignment: verbalize it
5. Verbalize strategies to correct any mal-alignment
6. Reaching toward strong side, forward with appropriate weight shift-rings, cones, etc
7. Standing at the foot of the stairs, strong leg on step
76
Treat Pushers Syndrome:
Walking
1) Forward and backward with weak leg—many repetitions to encourage appropriate weight shift
2) Progress to walking along wall
- --shift hips toward wall or toward person standing on strong side or toward quad cane as patient progresses
- --Watch forward trunk
3) Use tactile, verbal, and visual cues liberally without confusing the patient
4) More than one PT in early stages
77
Treat Pushers Syndrome:
Sitting
1. MINIMIZE DISTRACTIONS IN THE ROOM
2. MAY NEED TO PUT STRONG LEG ON STEP STOOL: flex and inhibit ext
3. CUE PELVIS AND ALIGNMENT ON BOTH ISCHIAL TUBEROSITIES
4. CUE IN VISUAL VERTICAL: TAKE IN INFORMATION FROM ROOM SURROUNDINGS
* **Mirror with central stripe
* **Wall, corners, windows, your alignment, etc.
5. Rest arm/elbow on boslter or ball or bench positioned on their strong side-spend time in this position-look at head righting reactions
6. Allow rest backward, leaning up against you
7. Progress to reaching strong side
- -Cones, rings, playing cards
- -Emphasize, facilitate weight shift to buttocks on strong side with appropriate trunk elongation
78
Proposed Pusher syndrome interventions
Perenneu et al
---TENS to SCM region
Schindler, Karnath et al: unilateral neglect
---Vibration to posterior neck muscles
Babyar, Reding, Matuszewski, Smith
---NMES to weak upper trapezius
Past studies
- --EMG of paraspinal muscle
- --Pilot of other interventions
Latest studies: Babyar, Reding, Edwards
- --TMS to determine the correlates of brain activity to pushing behavior
- --TDCS (Transcranial direct-current stimulation) as possible intervention -upregulated the damaged cortex
79
worse outcomes with R hemisphere stroke , lateropulsion and more leg weakness may be the reason
patients with lateropulsion may need more rehab to reach outcome goals
worse outcomes with R hemisphere stroke , lateropulsion and more leg weakness may be the reason
patients with lateropulsion may need more rehab to reach outcome goals
80
Pushers
Time Course Recovery:
what takes shortest --> longest time to recover
Categorized patients with lateropulsion :
strokes that were motor only recovered quickest,
strokes that were motor and sensory next,
strokes that were sensory, motor and vision took the longest to recover
81
Pushers
Time Course Recovery:
what takes shortest --> longest time to recover
Motor only
Motor plus sensory (limb placement error)
Motor plus sensory plus visual
82
Pushers
Recover right vs left:
Right brain lesions with sensory, motor, and visual: the longest to recover
Left brain lesions: chances of recovery are good
83
Recovering pusher: relevance for clinician
CAN get functional gains but need more time because 1st few weeks are just balance
Lateropulsion is a barrier to rehab
extended LOS
Related to degree of LE paresis in Right Brain Damage
Several clinical tools to quantify lateralpulsion with varying clinimetric properties
Intervention involves experience in upright position
Intervention studies needed
84
Scale of Contraversive Pushing
Body Posture
Sitting
Standing
0 = inconspicuous
.25 = mild contraversive tilt without falling
.75 = severe contraversive tilt without falling
1 = severe contraversive tilt with falling to that side
Max = 2 (sit + stand)
85
Scale of Contraversive Pushing
Use of non paretic extremities: abduction/extension
Sitting
Standing
0 = inconspicuous
.5 = only abduct/extend when changing position
1 = abduct/extend spontaneous, even at rest
Max = 2 (sit + stand)
86
Scale of Contraversive Pushing
Resistive to passive correction of tilted position
Sitting
Standing
0 = no resistance
1 = resistance occurs
Max = 2 (sit + stand)
