Poststroke “Pushing”

Abstract

Background and Purpose-Patients with hemiparetic stroke have impaired balance control. Some patients ("pushers") are resistant to accepting weight on and actively "push" away from the nonparetic side. This research identified pushers from stroke patients with moderate to severe hemiparesis and examined longitudinal changes in symptoms, level of impairment, and functional independence. Methods-Prospective sample of hemiparetic stroke patients (nϭ65) located in Toronto, Canada. Detailed clinical assessments were performed within 10 days postonset, at 6 weeks, and at 3 months. Results-At 1 week after stroke, 63% of patients demonstrated features of pushing. In 62% of pushers, symptoms resolved by 6 weeks, whereas in 21%, pushing symptoms persisted at 3 months. Motor recovery and functional abilities at 3 months were significantly lower among the pushers compared with the nonpushers. Pushers also had a significantly longer hospital length of stay (89 days versus 57 days). It is noteworthy that motor and functional recovery improved significantly over the 3-month study period for both pushers and nonpushers. Conclusions-Identification of stroke patients with pushing symptoms has prognostic implications for recovery. In light of this potential recovery, rehabilitation specialists need to refine treatment approaches for the pushers to further improve functional outcome.

New Insights for a Better Understanding of the Pusher Behavior: From Clinical to Neuroimaging Features

“…Pedersen et al (Pedersen et al, 1996) found an incidence of 5.3 % of PB in all stroke patients who were admitted in study period and 10.4 % of patients without lower extremity paresis on admission, when early death or early recovery were excluded. Danells et al (Danells et al, 2004) found a PB incidence of 23% and 63% among 65 stroke patients with moderate to severe hemiparesis depending on the assessment cutoff. We found 1.5 % of pusher patients among all neurological inpatients of an emergency hospital (Santos- Pontelli et al, 2004), and Lafosse et al (Lafosse et al, 2005) found an incidence of 40 % of left-brain-damaged patients and 52% of right brain damaged patients at a rehabilitation center.…”

“…A possible gender influence on the incidence of PB was initially suggested (Lafosse et al, 2005). Nevertheless, analysis of several studies performed in large samples of neurologic injured patients found no persistent gender predominance (Danells et al, 2004;SantosPontelli et al, 2004;Lafosse et al, 2005). Paresis of the contralesional extremities seems to be more frequent and more severe in pusher patients than in control encephalic lesioned patients .…”

“…Among the studies that considered the PB according to Davies' description, the incidence of this disorder ranges from 1.5 % to 63 % of patients with acute encephalic lesions (Table 1) (Pedersen et al, 1996;Danells et al, 2004;Santos-Pontelli et al, 2004;Lafosse et al, 2005;Baccini et al, 2006). Pedersen et al (Pedersen et al, 1996) found an incidence of 5.3 % of PB in all stroke patients who were admitted in study period and 10.4 % of patients without lower extremity paresis on admission, when early death or early recovery were excluded.…”

“…There are few studies that address the resolution of PB (Karnath et al, 2002;Broetz et al, 2004;Danells et al, 2004;Santos-Pontelli et al, 2004;Lafosse et al, 2005). Until now, the PB is described as having good prognosis with a maximum recovery time of 6 months (Karnath et al, 2002).…”

“…Dannels and coworkers showed that the recovery of PB is neither strongly associated with age nor with the recovery of motor control evaluated by Fugl-Meyer motor scale (Danells et al, 2004). However, patients with neglect and those who presented higher initial SCP scores had longer PB recovery times (Danells et al, 2004;Lafosse et al, 2005).…”