Pusher Syndrome Flashcards by Talia Holze

what three characteristics of pushing must ALL be present to qualify someone as a “pusher”

Spontaneous body posture

ABD and extension of non-paretic extremities

Resistance to passive correction

should be assess in both sitting and standing

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which direction do pushers push towards

involved/hemiparetic side

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true or false: pushers FALL to the hemiparetic side?

false! they actively push themselves over

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are the following sites common or uncommon lesion sites for pushers syndrome?

L and R posterolateral thalamus

Ventral posterior and lateral nucleus

common

the uncommon are

insular cortex
post central gyrus
ACA territory

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do pushers have a normal perception of visual vertical?

yes! They can drop a plumb line just fine

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true or false: pts who push do not align their body w/ visual vertical OR perceived postural vertical

true!

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with eyes closed, when do pushers feel they are “upright”

tilted 18 degrees towards the side with the lesion (non-involved side)

they attempt to correct posture towards upright

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spontaneous body posture is defined as what?

longitudinal body axis tilted toward the paretic side

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how would you document someone with spontaneous posture?

severe, moderate or mild tilt

falling?

if falling “falling to the side contralateral to lesion”

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Hand 
Elbow 
Leg 
hip 
knee

are all doing what on the non-involved side?

hand: ABD
Elbow: extended 
Leg: ABD
Hip: extended 
Knee: extended

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how do you document ABD and extension of limbs?

spontaneous (more severe) or only in response to movement

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Active resistance to movement towards which side

the NON-hemiparetic side

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true or false: often this population has a longer stay in acute rehab

true!

they are also less likely to be discharged home from rehab

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true or false: 6 months post stroke, evidence of pusher syndrome is rarely present?

true!

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true or false: pusher syndrome negatively impacts long term outcome of rehab

false! They are likely to make the same recovery as someone who does not push

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Compare and contrast L and R hemisphere damage when it comes to the following things

Time to recovery
LE weakness
Functional recovery

Time to recovery: L hemisphere damage faster

LE weakness: R hemisphere damage weaker

Functional recovery: L hemisphere damage better

REMEMBER YOURE TALKING ABOUT HEMISPHERE SIDE HERE SO THE AFFECTED BODY SIDE IS THE OPPOSITE

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Overall would you expect someone with R or L hemiparesis to recover more optimally?

R hemiparesis because that is L hemisphere damage which has more optimal recovery

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true or false: the more impairments you have on top of pusher syndrome and motor impairment the worse the prognosis?

true!

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true or false: pts with pusher syndrome are more resource intensive?

true:

early identification is key!
need to be able to measure change!

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what are the three things you want to make sure you’re doing documentation wise when you have a pusher?

identify: presence of syndrome
quantify: severity of presentation
evaluate: effectiveness of interventions

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Scale for contraversive pushing (SCP) is comprised of what three sections?

spontaneous body posture

extension/ABD of nonaffected extremities

resistance to passive correction

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Burke Lateropulsion Scale (BLS) measures what?

if resistance is present during correction of posture, how much and when the resistance began.

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what does BLS assess mobility wise

rolling, sitting, standing, transfers, walking

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what is the preferred measuring tool for pushing?

BLS! has good sensitivity and responsive to measuring progress

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what is the cut off score for BLS

> or = to 3

what does PASS assess by looking at level of assistance required to do low level tasks such as rolling

postural control in pts in the first 3 months post stroke. ALL POST STROKE NOT JUST PUSHER SPECIFIC.

what population is PASS in?

NOT just pushers, all stroke. LOW LEVEL

true or false: it is appropriate to treat these patients in supine or quadriped?

false! should be treated in an "earth vertical position" seated, standing or walking

true or false: it is okay to let the patient safely fall

yes! we want to recognize they are not straight. Once they have fallen as them to fix it!

what is super important when it comes to intervention for these patients?

visual feedback!

once a pt has safely fallen what do you ask them to do

ask them to actively fix their own posture! and try to see if they maintain it!

what are some key points to intervention with these patients

visual feedback repetition allow them time to problem solve being upright passive movements are NOT helpful patience

if pushing is present in sitting it is appropriate to take them right to standing

no! address it in sitting first

Explain a sitting intervention involving a wedge

to get them to weight bear on their non involved/strong pelvis, put the wedge next to them with the tall side close and have them move their uninvolved arm down the wedge so they have to weight bear on that side. Maybe even coming all the way down to strong elbow

if you were sitting a pusher on a wedge in their WC or during therapy, would the hemiparetic or normal side be on the tall part of the bolster?

hemiparetic, so they have to lean onto their strong side

if you're doing a reaching task which side do you want to be reaching towards?

reach towards the uninvolved/strong side to get them to wt shift this direction

what do you want to avoid in sitting with tx interventions

avoid elbow extension on the intact side! elevate the arm rest on the strong side, place it in their lap, put their strong side against a wall.

where do you want the wall for a SEVERE pusher, on the strong/pushing or weak side

strong/pushing side!

when first performing transfers which direction do you want to go?

towards the hemiparetic side, let the pushing help you eventually train the other direction

what kind of transfer do you want to initially avoid?

stand pivot

what are some tips for assisting with transfer of a pusher

anterior leaning w/their hands in supination PT feet outside the pts (prevents ABD) Over the back technique!

what does the over the back technique allow

controls their trunk from excessively leaning towards involved side

standing interventions should initially be performed with the involved or ininvolved side next to a wall.

uninvolved/pushing side: decreases fear of falling

when doing standing with a pusher, you want to encourage them to achieve and _____ contact with the wall with what two body parts

achieve and MAINTAIN contact with the HIP and SHOULDER

we know that using a mirror is super important in pushers but what do you want to progress to

progress from an external mirror cue to an internal postural cue

what hand do you put an NDT pole in? what does an NDT pole encourage? reduces what motion: provides what reference point?

Put NDT pole in uninvolved/strong side Encourages: chest extension and upright posture reduces pushing motion due to UE being in elevated position provides vertical reference point

what position do you want someones arm on if you are going to use a bedside table or bolster?

pushing arm should be elevated, flexed elbow and supinated

if you are using a railing what side should it be on

strong/intact side: helpful to have a structure to move towards, may decrease their fear of falling

what does the bedside table allow that other assistive tx may not

stops them from pushing due to the dynamic nature of the table.

weight shifting to the strong side is a great dynamic standing intervention, what do you want to make sure you focus on while doing this

returning to midline!

when doing a reaching activity which direction do you want to reach?

toward the intact side! force the weight shift this direction

pregait activities done with the hemiparetic or noninvolved side

hemiparetic leg! this makes them shift weight on their pushing/strong side

what do you always want to be cueing these patients of during tx

check in with their posture

True or false: use of body weight support during gait is indicated in this population

true! decreasing the weight on the hemiparetic side may decrease active pushing and decrease the fear of falling

what is the caveat to using and NDT pole

they need to hold it super high up and they will probably need help advancing it

who would HHA be used for? what side would HHA be on?

a patient who needs less trunk support HHA would be on strong side

if you put a lift in the pts shoe which side would you put it on to achieve your goal

put lift in the patients hemiparetic side so they have to bear weight through uninvolved/strong side

if you put a wedge in the forefoot to achieve your goal which leg would that be on

on the uninvolved side: this increases DF and decreases their ability to push

if you put a wedge on the heel to achieve your goal which leg would that be on

involved side: increases PF which promotes quicker contact and increases feeling of stability

what is the word on VR and this patient population?

better than just mirror alone! Get quantifiable postural information DURING training

lokomat gait training in pushers? good or bad three reasons why

good: evidence there is a reduction of pushing behavior compared to standard intervention - more time upright - implicit learning of upright - central sensory information processing

lokomat is what kind of learning implicit or explicit. realizing you're falling and fixing it getting it to midline etc is which?

lokomat is implicit: unintentional realizing and fixing is explicit: intentional

remediation of pushing requires _____ and _____ correction of impaired posture

REPETITION and ACTIVE correction