Week 3.3.5 Pusher Syndrome Handouts PDF

DPT 6410 Neuromuscular Practice – Adult Contraversive Pushing Objectives Define contraversive pusher and identify the clinical presentation of someone with this disorder Identify location of pathology and systems involved in contraversive pushing Discuss prognosis and examination of contraversive pu...

DPT 6410 Neuromuscular Practice – Adult Contraversive Pushing Objectives Define contraversive pusher and identify the clinical presentation of someone with this disorder Identify location of pathology and systems involved in contraversive pushing Discuss prognosis and examination of contraversive pushing Identify treatment strategies for recovery from contraversive pushing Pusher 2,4-5 Syndrome Observed in those with Right or Left hemisphere lesions No evidence of co-occurrence with spatial neglect, anosognosia, aphasia, or apraxia Neglect and Aphasia – NOT underlying cause of pusher syndrome Neglect highly associated with pushing after Right hemisphere damage Aphasia highly associated with pushing after Left hemisphere damage Pusher syndrome incidence is significantly higher in those with Right CVA Posterolateral Thalamus Anatomy associated with pusher syndrome: Left or Right Posteriolateral thalamus “Fundamentally involved in control of upright body posture”4 Lesions of thalamic nuclei found to be affected in those with CP Posterolateral Thalamus Vision: provides info about movement and cues for judging upright posture Vestibular: informs person about head position relative to gravity and about head movement Somatosensation: provides information about weight bearing and relative position of body parts Sorting out all the systems Visual and vestibular processing not necessarily disturbed A lesion of vestibular cortex leads to tilt of perceived visual vertical but NOT to contraversive pushing Normal perception of visual vertical Problems integrating visual and vestibular information Somatosensation is not associated Graviception Perception of body position, equilibrium, and direction of gravitational forces Pusher Syndrome = DISTORTION of subjective postural vertical Karnath HO et al 3 The 3 Conflict Mismatch between visual and postural vertical Visual vertical based on vestibular AND visual inputs Pushing behavior is effort to compensate 1, 2, 6 Prognosis Does not affect functional outcomes Rarely still evident at 6 months BUT.. It does slow process significantly Need 3.6 weeks longer to reach same functional outcome as those without pusher syndrome Goal should be to shorten rehab time Pushing can be fairly well compensated for by brain, as compared with aphasia or neglect 7, 8 Prognosis 7 8 83% of patients resolved at 3 months Motor recovery and function significantly lower compared to non-pushers at 3 months Longer LOS FIM efficiency and d/c FIM scores worse in pusher group Similar LOS Those with R CVA and pusher syndrome significantly worse Discharge to more dependent living locations Clinical Scale for Contraversive Pushing 13 12, (SCP) Modified SCP (M-SCP) Based on original scale Score 0-2, max 8 4 test conditions Static sitting at bedside, feet on floor Static standing with a full erect posture Transferring from bed to chair or wheelchair with squat pivot Transferring from bed to chair or wheelchair using stand pivot Burke Lateropulsion Scale 14-15 (BLS) Postural alignment and degree of resistance when moving patient passively: Supine (0-3) Sitting (0-3) Standing (0-4) Transfers (0-3) Walking (0-3) Sum scores, max of 17 Babyar et al, 200916 Recommended 17 Measure BLS recommended for identifying contraversive lateropulsion Across several functional tasks (rolling to walking) Only scale originally written in English Best reliability and responsiveness More Current 3,18 Evidence Treat in earth vertical positions (sitting, standing, walking) Allow pushing to occur so pt experiences falling Make pts visually aware of tilted position Assist with active correction Reaching vertical position actively Trained to use visual orientation Are you upright? Visual Feedback 18, 19 Treatment Realize the disturbed perception of erect body position Visually explore the surroundings and the body’s relation to the surroundings Learn the movements necessary to reach a vertical body position Maintain the vertical body position while performing other activities. Most Current Evidence Locomat somewhat effective in single Computer generated interactive visual feedback more effective than mirror visual feedback training (but both beneficial)21 20 session Nintendo Wii balance board and customized, interactive visual feedback training program Addresses maintaining vertical body posture and rhythmic body shifting to limits of stability Treatment for Pusher Syndrome - Summary Awareness of perceptional dysfunction Exercises in earth-vertical position Link visual input to reality Involve visual stimulus in motor learning Relearning movements to achieve and maintain vertical Integration into functional tasks Activities for the 19 Pusher Patient needs to see that they are or are not oriented upright Use of vertical structures Active reaching (goal directed) to temporarily extinguish pushing Managing transfers Forward weight shift is key Which side do we go to? Blocking the unwanted movement Finally, the summary… Contraversive pushing can be VERY CHALLENGING to manage in our patients Tends to slow down recovery, but still recoverable If you understand the dysfunction, you can figure out ways to treat More specific treatment strategies in sync and lab. References 1. Karnath HO, Broetz D. Understanding and treating “Pusher Syndrome”. Phys Ther. 2003; 83(12): 1119-25. 2. Pedersen PM, Wandel A, Jorgensen HS, et al. Ipsilateral pushing in stroke: incidence, relation to neurophychological symptoms, and impact on rehabilitation – the Copenhagen stroke study. Arch Phys Med Rehabil. 1996; 77: 25-28. 3. Karnath HO, Ferber S, Dichgans J. The origin of contraversive pushing: evidence for a second graviceptive system in humans. Neurology. 2000; 55: 1298-1304. 4. Karnath HO, Ferber S, Dichgans J. The neural representation of postural control in humans. Proc Natl Acad Sci USA. 2000; 97: 1393113936. 5. Lafosse C, et al. Contraversive pushing and inattention of the contralesional hemispace. J Clin Exp Neuropsych. 2005; 27: 460-84. 6. Karnath HO, Jonannsen I, Broetz D et al. Prognosis of contraversive pushing. J Neurol. 2002; 249: 1250-53. 7. Dannels CJ, Black SE, Gladstone DJ, McIlroy WE. Postroke “pushing”. Natural history and relationship to motor and functional recovery. Stroke. 2004; 35: 2873-2878. 8. Babyar SR, White H, Shafi N et al. Outcomes with stroke and lateropulsion: A case-matched controlled study. Neurorehabil Neural Repair. 2008; 22: 415-23. 9. Babyar SR, Peterson MG, Reding M. Time to recovery from lateropulsion dependent on key stroke deficits: A retrospective analysis. Neurorehabil Neural Repair. 2015; 29: 207-13. 10.Babyar SR, Peterson MG, Reding M. Case-control study of impairments associated with recovery from “pusher syndrome” after stroke: logistic regression analyses. J Stroke Cerbrovasc Dis. 2017; 26: 25-33. References 11. Roller ML. The pusher syndrome. J Neurol Phys Ther. 2004; 28: 29-34. 12.Baccini M, Paci M, Rinaldi L. The scale for contraversive pushing: A reliability and validity study. Neurorehabil Neural Rep. 2006; 20: 46872. 13.Baccini M, Paci M, Nannetti L, Birocolti C, Rinaldi L. Scale for contraversive pushing: cutoff scores for diagnosing pusher behavior and construct validity. Phys Ther. 2008: 88: 947-55. 14.D’Aquila MA, Smith T, Organ D et al. Validation of a lateropulision scale for patients recovering from stroke. Clin Rehabil. 2004; 18: 102109. 15.Bergmann J, Krewer C, Riess K, Muller F, Koenig E, Jahn K. Inconsistent classification of pusher behavior in stroke patients: a direct comparison of the Scale for Contraversive Pushing and the Burke Lateropulsion Scale. Clin Rehabil. 2014: 28: 696-703. 16.Babyar SR, Peterson MGE, Bohannon R, Perennou D, Reding M. Clinical examination tools for lateropulsion or pusher syndrome following stroke: a systematic review of the literature. Clin Rehabil. 2009; 23: 639-50. 17.Koter R, Regan S, Clark C, Huang V, Mosley M, Wyant E, Cook C, Hoder J. Clinical outcome measures for lateropulsion poststroke: An updated systematic review. JNPT. 2017; 41: 145-55. 18.Broetz D, Johannsen L, Karnath HO. Time course of ‘pusher syndrome’ under visual feedback treatment. Physiother Res Intl. 2004; 9: 13843. 19.Broetz D, Karnath HO. New aspects for the physiotherapy of pushing behavior. Neurorehabilitation. 2005; 20: 133-138.