Responsiveness of 2 Scales to Evaluate Lateropulsion or Pusher Syndrome Recovery After Stroke

doi:10.1016/j.apmr.2011.06.017

Archives of Physical Medicine and Rehabilitation

Volume 93, Issue 1, January 2012, Pages 149-155

Presented to the Australian Physiotherapy Association, Conference, October 4, 2009, Sydney, Australia.

https://doi.org/10.1016/j.apmr.2011.06.017 Get rights and content

Abstract

Clark E, Hill KD, Punt TD. Responsiveness of 2 scales to evaluate lateropulsion or pusher syndrome recovery after stroke.

Objectives

To analyze responsiveness to change of 2 outcome measures in the lateropulsion population after stroke. Lateropulsion describes an atypical balance problem after stroke where patients actively push themselves toward their paretic side. Secondary aims were to measure the incidence of lateropulsion and evaluate the site of the brain most commonly involved in lateropulsion.

Design

Stroke patients were screened for lateropulsion on admission to rehabilitation. Those demonstrating lateropulsion were assessed every 2 weeks using 2 scales to measure progress. Analysis of variance and the standardized response mean (SRM) were used to analyze change for each scale.

Setting

Rehabilitation and geriatric units.

Participants

Prospective purposive sample of stroke patients (N=43) demonstrating lateropulsion on admission from a consecutive admission sample of 160. To allow comparison, data from 43 stroke patients who did not display lateropulsion were collected retrospectively, matched on age (±5y) and sex.

Interventions

Not applicable.

Main Outcome Measures

Incidence of lateropulsion was calculated as a percentage of stroke patients admitted. Responsiveness to change was measured by using the Burke Lateropulsion Scale (BLS), to quantify severity of lateropulsion, and the Postural Assessment Scale for Stroke (PASS), which measures postural abilities.

Results

Of 160 stroke patients, 26.9% displayed lateropulsion (mean age, 72y; 51% men). The BLS and PASS had high levels of measurement responsiveness (BLS SRM =1.48 and 2.24; PASS SRM =1.76 and 1.87) at 4 and 8 weeks, respectively.

Conclusions

The BLS and PASS are responsive scales to monitor progress and recovery during rehabilitation. As more than 25% of stroke patients admitted to rehabilitation may exhibit lateropulsion, these 2 scales could be valuable in monitoring progress and designing future intervention studies.

Section snippets

Design

A prospective, purposive sample of stroke patients was investigated at Northern Health Rehabilitation Units and Geriatric Units across 2 sites in Melbourne, Australia. Over a 16-month period, all patients admitted to the rehabilitation or geriatric wards with a recent stroke (within the last 3mo) were screened for signs of lateropulsion. Screening for lateropulsion consisted of assessing the ability of patients to move toward their less affected side actively and passively in sitting and

Lateropulsion Incidence and Population

Over the 16 months of the study, 160 stroke patients were admitted to the 2 rehabilitation sites. All patients were screened for signs of lateropulsion within 5 working days of admission. Forty-three patients (26.9%) were clinically identified as having signs of lateropulsion. No participants were excluded because of the exclusion criteria (previous stroke with residual deficits) or an unwillingness to provide consent. All 43 patients screened as having lateropulsion scored greater than 2 on

Incidence

The incidence of lateropulsion in our rehabilitation units was 26.9% based on the criterion of a BLS score greater than 2. The incidence of lateropulsion has not previously been studied using the BLS as a diagnostic tool. Forty-three participants are also the largest sample of patients with lateropulsion studied thus far.

The incidence reported here is substantially higher than the 10.4% reported by Pedersen et al.² Our study was focused solely on patients referred to rehabilitation units,

Conclusions

More than a quarter of stroke patients undergoing rehabilitation demonstrated lateropulsion when assessed with the BLS. The BLS provides clear assessment criteria, and both the BLS and PASS scales are responsive to change in this population. Currently, lateropulsion rating scales are not used in routine clinical practice, suggesting lateropulsion, especially milder forms, may be underrecognized. The BLS and PASS scales appear to be appropriate tools for the evaluation of patients who display

Acknowledgments

We thank the Northern Health Physiotherapy Department for the use of staff time and resources. Special thanks to key members of the physiotherapy team—Bronwyn Hardman, Maivili Selvarajah, Robert Terkely, Michael Nguyen, and Frits Kadijk—for their data collection and support.

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Cited by (46)

Improving orientation with respect to gravity enhances balance and gait recovery after stroke: DOBRAS cohort
2024, Annals of Physical and Rehabilitation Medicine
Lateropulsion is a deficit in body orientation with respect to gravity, frequent after stroke. Although it is a primary factor affecting mobility, the impact of its attenuation on balance and gait recovery has never been investigated. Moreover, most studies on the lateropulsion time-course focus on severe forms suspected to have a poor recovery, which is not proven.
To investigate lateropulsion attenuation and test 2 hypotheses: 1) lateropulsion attenuation greatly contributes to balance and gait recovery and 2) severe forms of lateropulsion recover slower than moderate forms.
This longitudinal study involved individuals included in the Determinants of Balance Recovery After Stroke (DOBRAS) cohort, after a first-ever hemispheric stroke, with data collected on day 30 (D30), D60 and D90 post-stroke. Body orientation with respect to gravity was assessed using the Scale for Contraversive Pushing (both scores and severity grouping), in parallel with balance (Postural Assessment Scale for Stroke) and gait (modified Fugl-Meyer Gait Assessment).
Among the 106 eligible individuals (mean age 66.5 [SD 9.7] years), on D30, 43 (41%) were considered upright and 63 (59%) showed lateropulsion: 30 (28%) moderate and 33 (31%) severe. Most individuals with lateropulsion (73%) improved their body orientation, progressing from severe to moderate lateropulsion, or becoming upright. However, half were still not upright on D90. The improvement in body orientation had a large impact on mobility, especially in individuals with severe lateropulsion, in whom it explained about 50% of balance and gait recovery between D30 and D60, then 20% (D60-D90). For moderate lateropulsion, its attenuation explained about 20% of balance and gait recovery until D90. Lateropulsion attenuation was not slower in individuals with severe forms.
Lateropulsion attenuation enhances balance and gait recovery in individuals after stroke suggesting that specific rehabilitation of body orientation with respect to gravity might help to recover mobility.
NCT03203109
The scale for retropulsion: Internal consistency, reliability and construct validity
2022, Annals of Physical and Rehabilitation Medicine
Citation Excerpt :
Only subtest C (resistance) showed moderate interrater reliability and fair agreement. Previous studies of patients with pusher behaviour also revealed difficulties in assessing resistance within a clinical scale [29,30]. This SRP subtest including assessment of resistance while sitting and while standing is based on expert opinion and received high expert agreement supporting its content validity.
Retropulsion is an impairment of body orientation against gravity in the sagittal plane. In a Delphi study, the Scale for Retropulsion (SRP) was developed with a high level of expert agreement.
To assess the clinimetric properties of the German SRP in patients with neurological disorders.
The SRP was applied to 70 hospitalized patients with neurological disorders (stroke, critical illness neuropathy and/or myopathy, Parkinson syndromes). Internal consistency was determined with the Cronbach ɑ. Test–retest and interrater reliabilities were evaluated with the weighted kappa, intraclass correlation coefficient (ICC), and Bland–Altman plots. The construct validity was evaluated with Spearman correlation.
The median (interquartile range) SRP score was 5 (3–8) and ranged from 0 to 22 (total scale range: 0 to 24). The SRP had excellent internal consistency (Cronbach ɑ = 0.875) and good to excellent test–retest reliability (weighted kappa = 0.957, ICC = 0.957) and interrater reliability (weighted kappa = 0.837, ICC = 0.837). Analysis of construct validity resulted in good correlations with other clinical balance scales (r_Sp > 0.80), and fair to moderate correlations with posturographic measures (r_Sp = 0.27–0.56) and the subjective postural vertical error in the sagittal plane (r_Sp = −0.325, P = 0.012) as well as the range in the frontal plane (r_Sp = 0.359, P = 0.007). The SRP discriminated between patients classified with and without retropulsion by an independent clinical expert (P < 0.001).
The SRP provides a valid and reliable bedside test to quantify retropulsion in individuals with neurological disorders.
Standing weight-bearing asymmetry in adults with lateropulsion following stroke
2021, Gait and Posture
Citation Excerpt :
These features are thought to be an attempt to align body position in space with an altered perception of postural verticality [6]. Up to a quarter of individuals following stroke undergoing rehabilitation may present with lateropulsion [12,13]. Individuals with lateropulsion have longer hospital stays [12,14] and poorer functional outcomes compared to individuals following stroke without lateropulsion [14,15].
Weight-bearing asymmetry biasing the non-paretic leg is common following stroke. However, little is known as to how lateropulsion impacts on the weight-bearing patterns adopted in standing by individuals following stroke.
(1) Are there differences in weight-bearing asymmetry patterns observed in standing in people with lateropulsion relative to healthy controls; (2) What is the relationship between weight-bearing asymmetry and clinical measures of lateropulsion and postural function; and (3) Are measures of weight-bearing asymmetry reliable between test occasions.
Thirty-three individuals with lateropulsion and 35 healthy controls participated in this study. For the participants with lateropulsion, weight-bearing asymmetry during standing tasks (measured using two Wii Balance Boards) and clinical measures of lateropulsion (Burke Lateropulsion Scale) and postural function (Postural Assessment Scale for Stroke) were assessed initially and fortnightly over eight weeks.
Individuals with lateropulsion displayed marked weight-bearing asymmetry in standing compared to healthy controls. This asymmetry was predominantly towards their non-paretic leg when standing unsupported, and mixed presentation of weight-bearing asymmetry directions when standing with arm support. No significant correlations were observed between directional weight-bearing asymmetry and the Burke Lateropulsion Scale. A moderate correlation was found between absolute weight-bearing asymmetry for the stand with arm support task and the Postural Assessment Scale for Stroke (r = −0.608). The weight-bearing asymmetry variables for the standing with arm support task were found to be highly reliable between test occasions (ICC 0.915−0.972) and the standard error of measurement was 8.2%–9.3% body weight.
Individuals with lateropulsion following stroke demonstrate marked and varied patterns of asymmetry in standing. Weight-bearing asymmetry when standing with arm support may be an appropriate outcome measure for use with patients with lower functional abilities, including those with lateropulsion.
Spanish translation and validation of the Scale for Contraversive Pushing to measure pusher behaviour
2021, Neurologia
El objetivo de este estudio es traducir y validar al español la Scale for Contraversive Pushing, usada para diagnosticar y medir el comportamiento empujador en pacientes que han sufrido un ictus.
Se realizó una traducción-retrotraducción de la Scale for Contraversive Pushing para la población española y, posteriormente, se evaluó la validez y fiabilidad de la misma a partir de una muestra de pacientes. Además, se analizó la sensibilidad al cambio en pacientes que resultaron ser empujadores y recibieron tratamiento de fisioterapia neurológica.
Las respuestas de los expertos indicaron que la escala era válida en cuanto a su contenido. La consistencia interna, medida a través del alfa de Cronbach, obtuvo un resultado de 0,94. La fiabilidad intraobservador e interobservador, calculada por medio del coeficiente de correlación intraclase, presentó un valor de 0,999 y 0,994 respectivamente. Cuando se analizó la fiabilidad de cada ítem, por medio del coeficiente de kappa o kappa ponderado, la mayoría de ellos obtuvo una puntuación superior a 0,9. Por último, las diferencias obtenidas entre la valoración inicial y final de los pacientes empujadores fueron significativas (t de Student pareada), objetivando que la escala era sensible a los cambios obtenidos tras un tratamiento de fisioterapia.
La Scale for Contraversive Pushing es válida y fiable para medir el comportamiento empujador en pacientes que han sufrido un ictus. Además, es capaz de evaluar los cambios ocurridos en los pacientes, tras recibir tratamiento de fisioterapia.
The aim of this study was to develop and validate a Spanish-language version of the Scale for Contraversive Pushing, used to diagnose and measure pusher behaviour in stroke patients.
Translation–back translation was used to create the Spanish-language Scale for Contraversive Pushing; we subsequently evaluated its validity and reliability by administering it to a sample of patients. We also analysed its sensitivity to change in patients identified as pushers who received neurological physiotherapy.
Experts indicated that the content of the scale was valid. Internal consistency was very good (Cronbach's alpha of 0.94). The intraclass correlation coefficient showed high intra- and interobserver reliability (0.999 and 0.994, respectively). The Kappa and weighted Kappa coefficients were used to measure the reliability of each item; the majority obtained values above 0.9. Lastly, the differences between baseline and final evaluations of pushers were significant (paired sample t test), showing that the scale is sensitive to changes obtained through physical therapy.
The Spanish-language version of the Scale for Contraversive Pushing is valid and reliable for measuring pusher behaviour in stroke patients. In addition, it is able to evaluate the ongoing changes in patients who have received physical therapy.
Effect of postural training using a whole-body tilt apparatus in subacute stroke patients with lateropulsion: A single-blinded randomized controlled trial
2021, Annals of Physical and Rehabilitation Medicine
Lateropulsion after stroke is defined as a postural bias toward the paretic side and push away from the non-paretic side. New rehabilitation techniques and programs should be designed to attenuate lateropulsion and improve functions of balance and gait.
This study aimed to determine the effects of whole-body tilting postural training (WTPT) using a Spine Balance 3D on lateropulsion and postural control as compared with general postural training (GPT). Postural training was performed and involved a whole-body tilt apparatus that enables postural training in the tilted position, in multiple directions.
This was a pragmatic, single-blind, randomized controlled trial conducted between June 2018 and May 2019. We randomly allocated 30 patients with subacute stroke and lateropulsion based on the Scale of Contraversive Pushing (SCP score > 0) to experimental (n = 15) and control (n = 15) groups. The experimental group received WTPT with a whole-body tilt apparatus, and the control group GPT. WTPT was performed with the Spine Balance 3D and GPT with postural training commonly applied in the clinic. All participants received treatment for 30 min/session, 2 times/day, 5 days/week for 3 weeks. The primary outcome measure was lateropulsion assessed with the Burke Lateropulsion Scale (BLS). Secondary outcome measures were postural control ability, activities of daily living, Postural Assessment Scale for Stroke (PASS) score, Berg Balance Scale (BBS) score, Korea-modified Barthel index (K-MBI), and Fugl-Meyer Motor Assessment-Lower Extremity (FMA-L) score.
For the primary outcome, after training, BLS scores were decreased more for the experimental than control group (Δ = –5.8 vs. Δ = –4.2, P = 0.002). For secondary outcomes, scores were improved more for the experimental than control group: PASS (Δ = 13.8 vs. Δ = 8.5, P < 0.001), BBS (Δ = 20.1 vs. Δ = 11.1, P = 0.001), K-MBI (Δ = 27.0 vs. Δ = 20.1, P = 0.005), and FMA-L (Δ = 10.2 vs. Δ = 6.3, P = 0.002).
WTPT is a potentially effective therapeutic intervention for lateropulsion recovery in patients with subacute stroke. It may be useful for improving postural control and activities of daily living.
Effectiveness of visual feedback and postural balance treatment of post-stroke pusher syndrome. A systematic review
2021, Revista Cientifica de la Sociedad Espanola de Enfermeria Neurologica
El síndrome del empujador se caracteriza por un empuje del paciente hacia el lado hemiparético con el lado contralateral, en sedestación, en bipedestación y durante el movimiento, sobrepasando la línea media frente a la acción gravitatoria, lo que produce un inadecuado ajuste y control postural.
Determinar la efectividad del tratamiento fisioterapéutico en el síndrome del empujador postictus y extraer pautas para su correcta identificación y abordaje interdisciplinar.
Se realizó una revisión sistemática (2000-2019), empleando para ello las bases de datos especializadas MEDLINE, Scopus, PEDro y Web of Science. Los descriptores utilizados en las estrategias de búsqueda fueron «pusher syndrome», «pushing behaviour», «controversive pushing», treatment, «physical therapy», physiotherapy.
Aunque aún la evidencia es limitada, la intervención intensiva de Fisioterapia en el paciente con síndrome del empujador tras sufrir un ictus parece mejorar los síntomas de este cuadro clínico en cuanto a la severidad y el control postural. De entre las diferentes formas de tratamiento, parece ser eficaz el entrenamiento a través de feedback visual, especialmente utilizando la plataforma de equilibrio de Nintendo Wii.
Es necesaria una intervención fisioterapéutica individualizada con cada paciente para facilitar y orientar las estrategias motoras más eficaces, siendo esencial las sinergias de trabajo entre los miembros del equipo interdisciplinar (con pautas concretas en transferencias y actividades funcionales entre sesiones) para llevar a cabo una continuidad de cuidados que garantice el mantenimiento de los logros obtenidos.
Pusher syndrome is characterized by the patient pushing towards the hemiparetic side with the contralateral side, in a sitting position, standing and during movement, surpassing the gravitational mean line, which produces inappropriate adjustment and postural control.
To determine the effectiveness of physiotherapy treatment in post-stroke pusher syndrome and to extract guidelines for its correct identification and interdisciplinary approach.
A systematic review was carried out (2000-2019), using the specialized databases MEDLINE, Scopus, PEDro and Web of Science. The descriptors used in the search strategies were “pusher syndrome”, “pushing behaviour”, “controversial pushing”, treatment, “physical therapy”, physiotherapy.
Although the evidence is still limited, the intensive intervention of Physiotherapy in the patient with pusher syndrome post-stroke seems to improve the clinical symptoms in terms of severity and postural control. Among the different forms of treatment, training through visual feedback seems to be effective, especially using the Nintendo Wii balance platform.
An individualized physiotherapeutic intervention with each patient is necessary to facilitate and guide the most effective motor strategies, work synergies between the members of the interdisciplinary team are essential (with specific guidelines on transfers and functional activities between sessions) to ensure continuity of care that guarantees achievements are maintained.

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: Supported by the Northern Health Small Research Grant, Melbourne, Victoria, Australia.

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

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Original articleResponsiveness of 2 Scales to Evaluate Lateropulsion or Pusher Syndrome Recovery After Stroke

Abstract

Objectives

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Design

Lateropulsion Incidence and Population

Incidence

Conclusions

Acknowledgments

Arch Phys Med Rehabil

J Clin Epidemiol

J Neurol Sci

Arch Phys Med Rehabil

Steps to follow: a guide to the treatment of adult hemiplegia

The listing phenomenon of hemiplegic patients

Neurol Rep

Atypical balance responses following stroke: a study of patients known as pushers

The neural representation of postural control in humans

Proc NatI Acad Sci U S A

Towards a theoretical understanding of pushing behaviour in stroke patients

Neuropsychol Rehabil

Correction of recalcitrant lateropulsion through motor relearning

Phys Ther Case Rep

Outcomes with stroke and lateropulsion: a case-matched controlled study

Neurorehabil Neural Repair

Poststroke “pushing”: natural history and relationship to motor and functional recovery

Stroke

Validation of a lateropulsion scale for patients recovering from stroke

Clin Rehabil

Evolution of subjective visual vertical perturbation after stroke

Neurorehabil Neural Repair

Influence of subjective visual vertical misperception on balance recovery after stroke

J Neurol Neurosurg Psychiatry

Lateropulsion, pushing and verticality perception in hemisphere stroke: a causal relationship?

Brain

Perception of lateropulsion after recent cerebral hemisphere stroke

Stroke

Prognosis of contraversive pushing

J Neurol

Original article
Responsiveness of 2 Scales to Evaluate Lateropulsion or Pusher Syndrome Recovery After Stroke