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"Pusher syndrome" is a clinical disorder following left or right brain damage in which patients actively push away from the nonhemiparetic side, leading to a loss of postural balance. The mechanism underlying this disorder and its related anatomy has only recently been identified. Investigation of patients with severe pushing behavior has shown that perception of body posture in relation to gravity is altered. The patients experience their body as oriented "upright" when the body actually is tilted to the side of the brain lesion (to the ipsilesional side). In contrast, patients with pusher syndrome show no disturbed processing of visual and vestibular inputs determining visual vertical. These new insights have allowed the authors to suggest a new physical therapy approach for patients with pusher syndrome where the visual control of vertical upright orientation, which is undisturbed in these patients, is the central element of intervention. [Karnath H-O, Broetz D. Understanding and treating "pusher syndrome." Phys Ther. 2003;83:1119-1125.]
Key Words: Hemiparesis, Pusher syndrome, Spatial neglect, Spatial orientation, Thalamus.
In 1985, Patricia Davies first described the surprising behavior of some patients with stroke who use their nonparetic extremities to push toward the paretic side.1 When sitting or standing, these patients use their nonparetic extremities to push away from the nonparetic side, leading to a loss of lateral postural balance (Fig. 1). If not prevented, they would push themselves laterally to the point where they would fall toward the hemiparetic side. There is forceful resistance against interventions aiming to correct their tilted posture. Davies1 termed this behavior the "pusher syndrome." An investigation of 327 patients with acute stroke and hemiparesis revealed that the disorder was present in 10.4% of the patients.2
The purpose of this article is to summarize the recent literature related to pusher syndrome, including its clinical diagnosis, related anatomy, and a description of the mechanism found to be responsible for the disorder. Further, a new physical therapy approach is suggested based on these new insights into the nature of pushing behavior.
Pusher Syndrome-Distinctive Disorder or Catch-all for Different Expressions of Postural Instability Following Stroke?
Pushing actively with nonparetic extremities to the side contralateral to the brain lesion (Fig. 1), which is termed "contraversive pushing," differentiates the clinical picture of pusher syndrome from the loss...