Educate People On Pusher Syndrome

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4th May 2017 Health And Social Care Reference this

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The brain is a very complex organ. Everything we do or think takes place in a very confined, small space. Any injury that occurs in the brain can affect the whole body. Pusher syndrome is a disorder following right or left brain damage. Pusher syndrome occurs when the patient pushes away from the nonhemiparetic side.2 Pusher syndrome is observed in about 10 percent of acute stroke patients that has hemiparesis.10 Typically, pusher syndrome occurs in strokes, but may also occur in trauma, tumors, or other kinds of brain damage.11 Pusher syndrome usually occurs when the posterolateral portion of the thalamus, that is located deep within the cerebral hemispheres beneath the cortex and is the relay center for sensory and motor mechanisms and the suprathalamic white matter is involved.1,12,13 The damage is caused by higher pressure, swelling, and other secondary pathologies.10 Pusher syndrome is usually caused by a hemorrhagic stroke rather than a cerebral infarction.10 A posterior thalamic hemorrhage causes bigger lesions than thalamic infarctions, which frequently leads to pusher syndrome.7

Stroke

Since pusher syndrome is usually the result of a stroke, it is important to know some basic facts about strokes. One of the most common causes of death in the United States is due to a stroke.14 The long term cause of disability is also due to a stroke.15 Strokes can cause an increased dependence for many survivors.16 A stroke is one of the most expensive and life changing syndromes keeping people from fully participating in their lives.17 Stroke occurs when there is an interruption of blood flow to the brain and it causes sudden severe neurologic loss of function. Hypertension, heart disease, and diabetes are major risk factors for having a stroke.5 The age of people having strokes are starting to decrease.17

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There are two different classifications of stroke, which are hemorrhage and ischemic strokes. Ischemic strokes are caused by thrombosis, embolism, or systemic hypoperfusion, while hemorrhage strokes are caused by intracerebral or subarachnoid hemorrhage. A thrombotic stroke is caused when a disease causes a thrombus and reduces blood flow distally. An embolic stroke is caused when debris breaks off and travels elsewhere to block arterial access to a particular region of the brain. Intracerebral hemorrhage stroke is usually from small arteries bleeding directly into the brain. This bleeding causes a localized hematoma that spreads along white matter pathways. The accumulation of blood can occur within minutes or hours. The hematoma grows until the pressure increases to its limit or until the hemorrhage decompresses by emptying into the ventricular system or into the cerebrospinal fluid on the surface of the brain. Subarachnoid hemorrhage stroke is usually caused by a rupture of arterial aneurysms that are located at the base of the brain. Subarachnoid hemorrhage strokes can be also caused by bleeding from vascular formations that lie near the pial surface of the brain. Ischemic cerebral infarctions are responsible for 80 percent of strokes and brain hemorrhage is responsible for 20 percent of strokes.18

Strokes can cause many neurological deficits. Those deficits include deficits in motor control, abnormal synergistic patterns of movement, muscle weakness, sensory deficits, and a loss of range of motion.14 People having symptoms of a stroke should have a MRI or CT scan within 24 hours of onset.19 Symptoms of stroke include: sudden numbness or weakness in the arm, leg, or face on one side of body, sudden confusion or trouble speaking, sudden trouble seeing, sudden difficulty with walking, dizziness, loss of balance, and sudden headaches.5

Characteristics of Pusher Syndrome

Pusher syndrome is characterized by pushing toward the hemiparetic side. A patient with pusher syndrome strongly resists the vertical upright position. They align their longitudinal axis of their bodies with what they perceive as vertical, which is toward their hemiparetic side.3 A patient with pusher syndrome usually tilts their body 20 degrees to their hemiparetic side.4 Pushing varies in severity and increases with postural challenges. In sitting, the patient leans toward the weaker side. In standing, the patient has a high risk for falls because they are unbalanced and the hemiparetic lower extremity cannot support the weight of their body. The patient shows no fear of pushing to the weak side.5 These patients actually show fear of falling toward their nonparetic side and that is why they push toward the hemiplegic side.20 Normally, a patient with a stroke increases their weight bearing on their stronger side, so this syndrome is opposite of the expected tendency’s.5 Pusher syndrome is more prominent when patients are upright rather than lying down.21 Patients with pusher syndrome has paresis of the contralesional extremities more frequently and more severe than patients without pusher syndrome13 These patients also have an unstable gait because they continuously fall to their paretic side. The inability to bear weight on the paretic lower extremity also causes gait disturbances. Part of the underlining mechanism of pusher syndrome is the mismatch between the visual vertical and tilted orientation of the body.14

Diagnosing Pusher Syndrome

To diagnose pusher syndrome, the Standardized Scale of Contraversive Pushing (SCP) is used on the same day of the MRI acquisition. The SCP analyzes three different areas. The first area to be assessed is symmetry of spontaneous body posture. The next is the use of the nonparetic arm or leg to increase pushing force by abduction and extension of extremities. Last is the resistance to passive correction of posture. These tests are determined when the patient is sitting with feet on the ground and standing. For a patient to be diagnosed with pusher syndrome, all three analyzed areas have to be present and with a score of at least one with respect to their spontaneous postures and at least a score of one with respect to the use of the nonparetic arm and leg to increase pushing force by abduction and extension. Also the patient has to show a resistance to the correction of the posture.6 The SCP is a simple and fast test but it is not suitable when symptoms are slight and only show up in dynamic activities like walking. Another way to diagnose pusher syndrome is a four-point scale that assesses the presence of pusher syndrome by examining different postures. If a patient does not have pusher syndrome they will receive a score of zero. If pusher syndrome is only present in standing, the patient receives a score of one. If pusher syndrome is also present in sitting the patient receives a score of two. If pusher syndrome is also present while lying down the patient receives a score of three.7

Treatment of Pusher Syndrome

Physical therapy is a very important part of recovery for a patient with pusher syndrome. Patients with hemiplegia and pusher syndrome will be admitted to inpatient rehabilitation more frequently than patients with less severe symptoms.7 Pusher syndrome causes impairments on postural balance.8 One of the first goals of physical therapy should be to demonstrate and align posture.2 Visual cues may be helpful for patients to try to align their body axis to the earth vertical.14 The therapist can sit next to their less involved side or have the patient sit against a wall with their less involved side and tell the patient to lean toward the therapist or against the wall. To help with sitting posture, physical therapy can include sitting on a therapy ball to promote symmetry and sitting. While the patient is on the ball, the weaker lower extremity should cross over the stronger lower extremity. To help get the weak lower extremity out of flexion, which is often the position of the weaker lower extremity; the patient can wear an air splint or a leg splint. The therapists can actually tap directly over the quadriceps muscle to promote extension. A modified plantigrade position is a great position to begin early standing. In this position, the therapists can focus on using the weaker lower extremity to work on unilateral support. The weaker upper extremity may also be in a position of flexion, so an air splint can be used to promote extension of that upper extremity. A patient can stand in a corner or doorway to promote symmetrical standing. The therapist should block the stronger extremities from moving into abduction and extension and pushing. The therapist should provide constant feedback about body orientation and have the patient practice correcting orientation and weight shifting.5 When a patient begins gait training, the therapist can lower the height of the assistive device so the patient has to bear weight on the uninvolved side.22 If a patient requires transferring, they should be transferred to their weaker side. Transferring this way is much more convenient since the patient is already pushing in that direction.

Also, since pusher syndrome is the result of a stroke, the treatment of a patient with a stroke should also be discussed. The level of the patient with a stroke must be part of consideration when a patient begins therapy. There are many tests to measure the independence in activities of daily living. These tests include the Functional Independence Measurement (FIM), Glasgow Outcome Scale (GOS), modified Rankin Scale (mRS), and the Barthel Index (BI).23 A therapist will examine the patient and make a decision on the level that the patient is on in order to see which direction to begin therapy. Another scale that needs to be evaluated for a patient with a stroke is the Brunnstrom stages of recovery. This scale rates the patient in the progression of the typical characteristics of stroke behaviors. This scale goes through seven stages of recovery. The stages begin with stage one as the patient is flaccid, stage two as the patient begins to develop spasticity, stage three as spasticity is at its greatest, stage four and five as the spasticity decreases, stage six as spasticity is completely gone and stage seven as the patient is back to normal function. The therapist should also be aware of synergy patterns and help the patient to work out of these patterns.22 The stages of motor control and the stages of developmental posture are very important aspects of therapy for stroke patients. A therapist should be aware of these sequences and follow them in the treatment of a stroke patient.5

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After a patient suffers a stroke, balance ability can be improved by physical therapy interventions. After a stroke, early impaired balance is strongly associated with future function and recovery.15 The Bobath concept of Neuromuscular Developmental Treatment (NDT) is one of the many tools that therapist can use to deal with individual deficits and opportunities for stroke survivors. NDT is especially useful for those patients with a good prognosis for recovery. Bobath explained that a patient suffering from hemiplegia should be active while the therapist assists them in moving by using key points of control and reflex inhibiting reflexes.9 The key points of control are head, shoulders, hips, or distal extremities. The shoulder and pelvic girdle is the most important points to influence postural alignment. A therapist would apply manual contact to the shoulder and pelvis to influence muscle tone distribution and distal movements. The distal key points are the elbows, hands, knees, and feet. The distal key points affect the movement of the trunk. Once a patients’ tone is manageable, the therapist superimposes normal movements and posture. When a therapist superimposes normal movement and posture, it is done within the context of a functional activity. NDT is a great way to inhibit abnormal postural reflex activity and movements and facilitate normal patterns. Normal motor patterns include head and trunk control, upper extremity support, and balance reaction. NDT is also a good approach to align posture.22

Proprioceptive Neuromuscular Facilitation (PNF) is reported as being the most effective protocol for achieving the greatest increase in range of motion.24 PNF is also used to increase strength, flexibility, and range of motion. By increasing these things and integrating these gains, the patient can establish head and trunk control, iniate and maintain movements, control shifts in the center of gravity, and control their pelvis and trunk while the extremities move. PNF is unique diagonal patterns of movement. Most movements do not occur only in the cardinal plane but also occur as triplanar. PNF patterns simulate the demands incurred during functional movements.22

Another good approach to physical therapy is to strengthen the weak muscles. Tone is another issue that must be addressed in physical therapy in a patient with a stroke and pusher syndrome. Patients can either have low tone (flaccid) or high tone (spastic). Low tone can be corrected by using facilitory techniques, and high tone can be corrected by using inhibitory techniques.5 Some facilitory techniques include quick stretching, tapping, vibration, approximation, and weight bearing. Some inhibitory techniques include slow, rhythmic rotation, weight bearing, prolonged icing, and static stretch.22

Occupational and Speech Therapy

Occupational therapy is also required to expand rehabilitation to address participation in work, family, and community life.17 Upper extremity weakness also needs to be strengthened by the occupational therapist to perform activities of daily living.25 Although speech therapy may not be needed to treat pusher syndrome patients specifically, the injuries that result in this condition will require speech therapy, such as stroke or brain injury. Speech therapy may be needed to address aphasia, global or expressive.

Prognosis of Pusher Syndrome

Even though progress of a patient with pusher syndrome is based on a patient by patient case, they usually have good results. With effective training, the potential for minimizing the impact of pusher syndrome is good. Motor learning strategies are also very effective in reducing the effects of pusher syndrome and enhancing recovery.5 The functional recovery process may be very slow and require a longer stay in the hospital but usually a patient with pusher syndrome makes a full recovery. Recovery is usually completed by six months after the stroke.7

Conclusion

Pusher syndrome can be a very devastating symptom after a hemorrhagic stroke. Ten percent of acute stroke patients suffer from pusher syndrome. A patient with pusher syndrome can have greater challenges with function and mobility. They have difficulties with standing and sitting as they push to their hemiparetic side and resist correction of posture. The Standardized Scale of Contraversive pushing (SCP) and a four-point scale are two ways to diagnose a patient with pusher syndrome. The treatment of pusher syndrome is dependent on physical therapy. Initially, correcting posture is the main focus of therapy. Then balance, strengthening weak muscles, and correcting abnormal movements are the focus of therapy. Neuromuscular Developmental Treatment (NDT) and proprioceptive Neuromuscular Facilitation (PNF) are great tools that help with physical therapy. Patients with pusher syndrome may have a slower recovery and a longer hospital stay, but usually make a full recovery within six months.

The brain is a very complex organ. Everything we do or think takes place in a very confined, small space. Any injury that occurs in the brain can affect the whole body. Pusher syndrome is a disorder following right or left brain damage. Pusher syndrome occurs when the patient pushes away from the nonhemiparetic side.2 Pusher syndrome is observed in about 10 percent of acute stroke patients that has hemiparesis.10 Typically, pusher syndrome occurs in strokes, but may also occur in trauma, tumors, or other kinds of brain damage.11 Pusher syndrome usually occurs when the posterolateral portion of the thalamus, that is located deep within the cerebral hemispheres beneath the cortex and is the relay center for sensory and motor mechanisms and the suprathalamic white matter is involved.1,12,13 The damage is caused by higher pressure, swelling, and other secondary pathologies.10 Pusher syndrome is usually caused by a hemorrhagic stroke rather than a cerebral infarction.10 A posterior thalamic hemorrhage causes bigger lesions than thalamic infarctions, which frequently leads to pusher syndrome.7

Stroke

Since pusher syndrome is usually the result of a stroke, it is important to know some basic facts about strokes. One of the most common causes of death in the United States is due to a stroke.14 The long term cause of disability is also due to a stroke.15 Strokes can cause an increased dependence for many survivors.16 A stroke is one of the most expensive and life changing syndromes keeping people from fully participating in their lives.17 Stroke occurs when there is an interruption of blood flow to the brain and it causes sudden severe neurologic loss of function. Hypertension, heart disease, and diabetes are major risk factors for having a stroke.5 The age of people having strokes are starting to decrease.17

There are two different classifications of stroke, which are hemorrhage and ischemic strokes. Ischemic strokes are caused by thrombosis, embolism, or systemic hypoperfusion, while hemorrhage strokes are caused by intracerebral or subarachnoid hemorrhage. A thrombotic stroke is caused when a disease causes a thrombus and reduces blood flow distally. An embolic stroke is caused when debris breaks off and travels elsewhere to block arterial access to a particular region of the brain. Intracerebral hemorrhage stroke is usually from small arteries bleeding directly into the brain. This bleeding causes a localized hematoma that spreads along white matter pathways. The accumulation of blood can occur within minutes or hours. The hematoma grows until the pressure increases to its limit or until the hemorrhage decompresses by emptying into the ventricular system or into the cerebrospinal fluid on the surface of the brain. Subarachnoid hemorrhage stroke is usually caused by a rupture of arterial aneurysms that are located at the base of the brain. Subarachnoid hemorrhage strokes can be also caused by bleeding from vascular formations that lie near the pial surface of the brain. Ischemic cerebral infarctions are responsible for 80 percent of strokes and brain hemorrhage is responsible for 20 percent of strokes.18

Strokes can cause many neurological deficits. Those deficits include deficits in motor control, abnormal synergistic patterns of movement, muscle weakness, sensory deficits, and a loss of range of motion.14 People having symptoms of a stroke should have a MRI or CT scan within 24 hours of onset.19 Symptoms of stroke include: sudden numbness or weakness in the arm, leg, or face on one side of body, sudden confusion or trouble speaking, sudden trouble seeing, sudden difficulty with walking, dizziness, loss of balance, and sudden headaches.5

Characteristics of Pusher Syndrome

Pusher syndrome is characterized by pushing toward the hemiparetic side. A patient with pusher syndrome strongly resists the vertical upright position. They align their longitudinal axis of their bodies with what they perceive as vertical, which is toward their hemiparetic side.3 A patient with pusher syndrome usually tilts their body 20 degrees to their hemiparetic side.4 Pushing varies in severity and increases with postural challenges. In sitting, the patient leans toward the weaker side. In standing, the patient has a high risk for falls because they are unbalanced and the hemiparetic lower extremity cannot support the weight of their body. The patient shows no fear of pushing to the weak side.5 These patients actually show fear of falling toward their nonparetic side and that is why they push toward the hemiplegic side.20 Normally, a patient with a stroke increases their weight bearing on their stronger side, so this syndrome is opposite of the expected tendency’s.5 Pusher syndrome is more prominent when patients are upright rather than lying down.21 Patients with pusher syndrome has paresis of the contralesional extremities more frequently and more severe than patients without pusher syndrome13 These patients also have an unstable gait because they continuously fall to their paretic side. The inability to bear weight on the paretic lower extremity also causes gait disturbances. Part of the underlining mechanism of pusher syndrome is the mismatch between the visual vertical and tilted orientation of the body.14

Diagnosing Pusher Syndrome

To diagnose pusher syndrome, the Standardized Scale of Contraversive Pushing (SCP) is used on the same day of the MRI acquisition. The SCP analyzes three different areas. The first area to be assessed is symmetry of spontaneous body posture. The next is the use of the nonparetic arm or leg to increase pushing force by abduction and extension of extremities. Last is the resistance to passive correction of posture. These tests are determined when the patient is sitting with feet on the ground and standing. For a patient to be diagnosed with pusher syndrome, all three analyzed areas have to be present and with a score of at least one with respect to their spontaneous postures and at least a score of one with respect to the use of the nonparetic arm and leg to increase pushing force by abduction and extension. Also the patient has to show a resistance to the correction of the posture.6 The SCP is a simple and fast test but it is not suitable when symptoms are slight and only show up in dynamic activities like walking. Another way to diagnose pusher syndrome is a four-point scale that assesses the presence of pusher syndrome by examining different postures. If a patient does not have pusher syndrome they will receive a score of zero. If pusher syndrome is only present in standing, the patient receives a score of one. If pusher syndrome is also present in sitting the patient receives a score of two. If pusher syndrome is also present while lying down the patient receives a score of three.7

Treatment of Pusher Syndrome

Physical therapy is a very important part of recovery for a patient with pusher syndrome. Patients with hemiplegia and pusher syndrome will be admitted to inpatient rehabilitation more frequently than patients with less severe symptoms.7 Pusher syndrome causes impairments on postural balance.8 One of the first goals of physical therapy should be to demonstrate and align posture.2 Visual cues may be helpful for patients to try to align their body axis to the earth vertical.14 The therapist can sit next to their less involved side or have the patient sit against a wall with their less involved side and tell the patient to lean toward the therapist or against the wall. To help with sitting posture, physical therapy can include sitting on a therapy ball to promote symmetry and sitting. While the patient is on the ball, the weaker lower extremity should cross over the stronger lower extremity. To help get the weak lower extremity out of flexion, which is often the position of the weaker lower extremity; the patient can wear an air splint or a leg splint. The therapists can actually tap directly over the quadriceps muscle to promote extension. A modified plantigrade position is a great position to begin early standing. In this position, the therapists can focus on using the weaker lower extremity to work on unilateral support. The weaker upper extremity may also be in a position of flexion, so an air splint can be used to promote extension of that upper extremity. A patient can stand in a corner or doorway to promote symmetrical standing. The therapist should block the stronger extremities from moving into abduction and extension and pushing. The therapist should provide constant feedback about body orientation and have the patient practice correcting orientation and weight shifting.5 When a patient begins gait training, the therapist can lower the height of the assistive device so the patient has to bear weight on the uninvolved side.22 If a patient requires transferring, they should be transferred to their weaker side. Transferring this way is much more convenient since the patient is already pushing in that direction.

Also, since pusher syndrome is the result of a stroke, the treatment of a patient with a stroke should also be discussed. The level of the patient with a stroke must be part of consideration when a patient begins therapy. There are many tests to measure the independence in activities of daily living. These tests include the Functional Independence Measurement (FIM), Glasgow Outcome Scale (GOS), modified Rankin Scale (mRS), and the Barthel Index (BI).23 A therapist will examine the patient and make a decision on the level that the patient is on in order to see which direction to begin therapy. Another scale that needs to be evaluated for a patient with a stroke is the Brunnstrom stages of recovery. This scale rates the patient in the progression of the typical characteristics of stroke behaviors. This scale goes through seven stages of recovery. The stages begin with stage one as the patient is flaccid, stage two as the patient begins to develop spasticity, stage three as spasticity is at its greatest, stage four and five as the spasticity decreases, stage six as spasticity is completely gone and stage seven as the patient is back to normal function. The therapist should also be aware of synergy patterns and help the patient to work out of these patterns.22 The stages of motor control and the stages of developmental posture are very important aspects of therapy for stroke patients. A therapist should be aware of these sequences and follow them in the treatment of a stroke patient.5

After a patient suffers a stroke, balance ability can be improved by physical therapy interventions. After a stroke, early impaired balance is strongly associated with future function and recovery.15 The Bobath concept of Neuromuscular Developmental Treatment (NDT) is one of the many tools that therapist can use to deal with individual deficits and opportunities for stroke survivors. NDT is especially useful for those patients with a good prognosis for recovery. Bobath explained that a patient suffering from hemiplegia should be active while the therapist assists them in moving by using key points of control and reflex inhibiting reflexes.9 The key points of control are head, shoulders, hips, or distal extremities. The shoulder and pelvic girdle is the most important points to influence postural alignment. A therapist would apply manual contact to the shoulder and pelvis to influence muscle tone distribution and distal movements. The distal key points are the elbows, hands, knees, and feet. The distal key points affect the movement of the trunk. Once a patients’ tone is manageable, the therapist superimposes normal movements and posture. When a therapist superimposes normal movement and posture, it is done within the context of a functional activity. NDT is a great way to inhibit abnormal postural reflex activity and movements and facilitate normal patterns. Normal motor patterns include head and trunk control, upper extremity support, and balance reaction. NDT is also a good approach to align posture.22

Proprioceptive Neuromuscular Facilitation (PNF) is reported as being the most effective protocol for achieving the greatest increase in range of motion.24 PNF is also used to increase strength, flexibility, and range of motion. By increasing these things and integrating these gains, the patient can establish head and trunk control, iniate and maintain movements, control shifts in the center of gravity, and control their pelvis and trunk while the extremities move. PNF is unique diagonal patterns of movement. Most movements do not occur only in the cardinal plane but also occur as triplanar. PNF patterns simulate the demands incurred during functional movements.22

Another good approach to physical therapy is to strengthen the weak muscles. Tone is another issue that must be addressed in physical therapy in a patient with a stroke and pusher syndrome. Patients can either have low tone (flaccid) or high tone (spastic). Low tone can be corrected by using facilitory techniques, and high tone can be corrected by using inhibitory techniques.5 Some facilitory techniques include quick stretching, tapping, vibration, approximation, and weight bearing. Some inhibitory techniques include slow, rhythmic rotation, weight bearing, prolonged icing, and static stretch.22

Occupational and Speech Therapy

Occupational therapy is also required to expand rehabilitation to address participation in work, family, and community life.17 Upper extremity weakness also needs to be strengthened by the occupational therapist to perform activities of daily living.25 Although speech therapy may not be needed to treat pusher syndrome patients specifically, the injuries that result in this condition will require speech therapy, such as stroke or brain injury. Speech therapy may be needed to address aphasia, global or expressive.

Prognosis of Pusher Syndrome

Even though progress of a patient with pusher syndrome is based on a patient by patient case, they usually have good results. With effective training, the potential for minimizing the impact of pusher syndrome is good. Motor learning strategies are also very effective in reducing the effects of pusher syndrome and enhancing recovery.5 The functional recovery process may be very slow and require a longer stay in the hospital but usually a patient with pusher syndrome makes a full recovery. Recovery is usually completed by six months after the stroke.7

Conclusion

Pusher syndrome can be a very devastating symptom after a hemorrhagic stroke. Ten percent of acute stroke patients suffer from pusher syndrome. A patient with pusher syndrome can have greater challenges with function and mobility. They have difficulties with standing and sitting as they push to their hemiparetic side and resist correction of posture. The Standardized Scale of Contraversive pushing (SCP) and a four-point scale are two ways to diagnose a patient with pusher syndrome. The treatment of pusher syndrome is dependent on physical therapy. Initially, correcting posture is the main focus of therapy. Then balance, strengthening weak muscles, and correcting abnormal movements are the focus of therapy. Neuromuscular Developmental Treatment (NDT) and proprioceptive Neuromuscular Facilitation (PNF) are great tools that help with physical therapy. Patients with pusher syndrome may have a slower recovery and a longer hospital stay, but usually make a full recovery within six months.

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