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138 Physiotherapy Research International, 9(3) 138143, 2004 Whurr Publishers Ltd

CASE REPORT

Time course of pusher syndrome

under visual feedback treatment
DORIS BROETZ, LEIF JOHANNSEN and HANS-OTTO KARNATH Center of Neurology,
Hertie Institute of Clinical Brain Research, University of Tbingen, Germany

INTRODUCTION
Although most patients with hemiparesis
have good trunk balance soon after stroke,
some show the peculiar behaviour of using
the non-affected arm or leg to push away
actively from the non-paralysed side.
Without assistance, this active contraversive
pushing leads to loss of postural balance and
falling towards the paralysed side (Karnath
and Broetz, 2003). Patients resist any attempt
to passively correct their tilted body posture
towards earth-vertical upright orientation.
This disorder has been termed pusher
syndrome (Davies, 2000), and it is observed
in about 10% of acute stroke patients with
hemiparesis (Pedersen et al., 1996).
Recently, the mechanism leading to
contraversive pushing was investigated
(Karnath et al., 2000). These authors
observed that patients with pusher syndrome
perceive the body as oriented upright when it
was actually tilted ~20 to the ipsiversive
side. At the same time, the patients showed
normal processing of visualvestibular
information. For example, the patients had
no difficulty in correctly determining the
vertical orientation of visual objects.

Patients with pusher syndrome thus manifest

a selective disturbance of control of their
upright body posture. In contrast, orientation
perception of the visual world is unaffected.
When their attention is drawn to vertical
structures in their visual surroundings, the
patients thus can align their body along these
structures to a visually controlled upright
position (Karnath et al., 2000).
These new insights into the mechanisms
leading to pusher syndrome encouraged us to
suggest a new approach for the physiotherapy
of patients with pushing behaviour (Karnath
and Broetz, 2003). Since orientation perception of the visual surroundings is not
impaired in these patients they can see that
they are not in an erect position by looking at
their structural surroundings. However, they
cannot spontaneously make use of this
preserved ability; they have to be trained to
do so. The central feature of our treatment
approach is thus to use visual feedback to
demonstrate actual body orientation. Since
the patients feel erect when they see that they
are tilted and vice versa (Karnath et al.,
2000), they have to learn that visual information corresponds to reality.
Here, we aimed to evaluate our new

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treatment strategy in a series of eight
consecutively admitted cases showing
severe contraversive pushing. We followed
the time course of their recovery over 3.5
weeks post-stroke until the patients were
transferred to rehabilitation clinics.
METHOD
Contraversive pushing was assessed by the
use of the standardized Scale for Contraversive Pushing (Karnath and Broetz, 2003). The
Scale for Contraversive Pushing assesses:
Symmetry of spontaneous posture.
Use of the non-paretic arm and/or leg to
increase pushing force by abduction and
extension of extremities.
Resistance to passive correction of posture.

Patients
Eight consecutively admitted acute stroke
patients with severe contraversive pushing,
who stayed at least three weeks in our department, were investigated. Brain lesions were
identified by magnetic resonance imaging or
by computed tomography. Assessment of
contraversive pushing was carried out at
admission and subsequently at days 12, 18
and 24 post-stroke. The eight patients stayed
in our department for a median duration of 26
days (range 2235 days) before they were
transferred to a rehabilitation clinic. Clinical
and demographic information of the patients
are given in Table 1.
Treatment plan
Physiotherapy targeting pusher syndrome
took place for 30 minutes each working day

TABLE 1: Clinical and demographic data of the stroke patients with pusher syndrome (n = 8)
Sex

0 f, 8 m

Age (years), median (range)

63 (5179)

Aetiology

7 infarct, 1 haemorrhage

Lesioned hemisphere

6 right, 2 left

Time since lesion at first assessment with SCP (days), median (range)

4 (26)

Paresis of contralesional side, % present

Arm, median (range)
Leg, median (range)

100
0.5 (02)
2.3 (15)

Somatosensory deficit of contralesional side (touch)

Arm, % present
Leg, % present
% t.n.p.

71
71
12.5

Aphasia
LBD % present
RBD % present

50
0

Spatial neglect
LBD % present
RBD % present

0
83

SCP = Scale for Contraversive Pushing (Karnath and Broetz, 2003); Paresis = paresis of the contralateral arm
and leg was scored with the usual clinical ordinal scale where 0 stands for no trace of movement and 5 for
normal movement; t.n.p. = testing not possible; RBD = right brain damage; LBD = left brain damage.

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140 Broetz et al.

after admission (six days per week). The
early treatment sessions post-stroke
comprised three aspects that were repeatedly addressed in each session (Broetz and
Karnath, in press):
Since the patients feel erect when they
see that their own body is tilted and vice
versa (Karnath et al., 2000), a first goal
was that the patients realized their
disturbed perception of erect body position. Sitting at the bedside, the patients
active increase of contraversive body tilt
was permitted. The physiotherapist
followed this controlled fall until the
patients lay on the bedside or expressed
the sensation of body tilt and the feeling
of falling. At this moment the patients
were asked to f ind ways of getting
upright again. In case they were not able
to reach a vertical position, the physiotherapist supported them to do this.
Patients were instructed to actively
explore their visual surroundings. They
were told to reach upright posture by
visually aligning their own body with the
vertical features seen in the environment.
Therefore, it is useful to work in a room
containing vertical structures, such as
door frames, windows, pillars or
pictures. It is also beneficial to use visual
aids that give feedback about patients
body orientation. For example, the therapists arm can indicate the cor rect
(vertical) orientation (Broetz and
Karnath, in press). The experience of not
falling after attaining the corrected position, combined with seeing that they are
upright, increases patients confidence,
and lowers the reaction to abduct and
extend non-paretic extremities. The
patients were motivated to control their
attempts to reach a vertical position.
Patients with contraversive pushing
respond to passive change in body orien-

tation with active resistance. However, if

they are shown an object at their nonparetic side (for example, a small ball)
and are asked to reach the object with the
hand by shifting their weight towards this
side, they are able to desist from pathological pushing temporally. The therapist
thus demonstrated the movements
requested and used acoustic signals, such
as knocking on the bed frame or the
therapy table, to show the patients the
object to be reached.
When the patients mastered the f irst
three goals, a fourth training aspect was
added. After having learnt how to reach a
vertical posture and how to stay in this
position, the patients typically still show
contraversive pushing once their concentration on own body posture and the
visual surroundings is distracted. The
next step of the treatment plan was to
automatize the trained orienting behaviour in order to enable vertical body
position while performing other activities. Thus, we distracted the patients by
involving them into a conversation or by
instructing to perform co-ordinated arm
or head movements without changing
posture. Finally, the treatment steps were
combined and practised until the patients
kept a stable upright posture and were
able to perform additional activities.
Further details of the treatment procedure
were outlined elsewhere (Broetz and
Karnath, in press).
RESULTS
Since 75% of the patients investigated were
not able to stand erect on admission, even
when being supported, to the present study
the patients pushing behaviour was scored
exclusively while sitting. Figure 1 shows the
time course of pusher syndrome as

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Visual feedback to treat contraversive pushing 141

3

2
Overall SCP score

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0
0

10

15

20

25

Days post-stroke

FIGURE 1: Mean overall Scale for Contraversive Pushing (SCP) score when sitting (maximum = 3) for eight
consecutively admitted cases with pusher syndrome. Illustrated is the combination of the three SCP variables
(contraversive tilt during spontaneous body posture; abduction and extension of the non-paretic extremities; and
resistance to passive correction of tilted posture). Standard deviations are given.

measured with the Scale for Contraversive

Pushing across the observation period of 3.5
weeks. We added the scores of the three subscales to obtain an overall score. The
maximum score was thus 3 (Karnath and
Broetz, 2003).
At day four post-stroke, none of the eight
patients were able to sit unsupported. All
eight patients showed severe contraversive
pushing on each of the Scale for Contraversive Pushing sub-scales. Within three
weeks, pushing behaviour improved significantly. When we compared the overall score
of the scale for Contraversive Pushing
between days four and 24 post-stroke, we
found significant improvement (Wilcoxons
Z = 2.23; p = 0.026).
Further, at day 24, six of the patients
(75%) had recovered sufficiently that they
could sit unsupported (McNemar test;
p = 0.031). These patients were able to keep a
stable upright body position even when

distracted; for example, when they did not

concentrate on their body orientation.
Moreover, 18 days post-stroke all eight
patients were able to stand erect while being
supported by a physiotherapist. The average
degree of pushing behaviour while standing
at day 18 was 0.79 on the posture subscale, 0.72 on the extension sub-scale and
1.0 on the resistance sub-scale.
DISCUSSION
The present study, carried out on eight
consecutively admitted patients with pusher
syndrome, showed that within 3.5 weeks
post-stroke, severe pusher syndrome is
successfully treated using our training
programme (Broetz and Karnath, in press)
on a daily basis. The central feature of this
treatment approach is the use of visual feedback about own body orientation to re-align
the body with true vertical orientation. The

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142 Broetz et al.

logic for this strategy derives from a
previous study investigating the mechanism
leading to pusher syndrome. Experiments
revealed that patients with contraversive
pushing felt that they were oriented upright
when they were actually tilted ~20 to the
ipsilesional side (Karnath et al., 2000). At
the same time, they showed normal
processing of visualvestibular information.
For example, the patients had no difficulties
in correctly determining the vertical orientation of visual objects. Patients with pusher
syndrome are thus able to utilize the
visualvestibular system to achieve a
vertical body orientation when explicitly
instructed to align their body with vertical
structures in their visual surroundings.
Consequently, the present treatment strategy
used this preserved ability as the central
feature of daily physiotherapy (Karnath and
Broetz, 2003; Broetz and Karnath, in press).
Several studies have investigated the
effect of auditory or visual feedback on
body balance to hemiparetic patients during
balance retraining sessions (Bjork and
Wetzel, 1983; Dursun et al., 1996; Walker et
al., 2000; Cheng et al., 2001; de Seze et al.,
2001). These studies found an improvement
in patients postural trunk control and thus
demonstrated that feedback mechanisms on
body posture are effective tools for treating
postural deficits after stroke. In the present
study we successfully applied similar principles of visual feedback on body posture in
our training programme to patients with
pusher syndrome. The patients were able to
use feedback about their body orientation in
relation to vertical structures in the visual
surroundings to successfully learn and
automatize strategies to compensate their
deficit.
Contraversive pushing is a disorder that
obviously has a good prognosis in general.
Only six months after a stroke, pathological
pushing was rarely still evident in an unse-

lected sample of patients with initially

severe pushing behaviour (Karnath et al.,
2002). But we also know that patients with
contraversive pushing take 3.6 weeks (63%)
longer than patients without that disorder to
reach the same functional outcome level
(Pedersen et al., 1996). Physiotherapy of
contraversive pushing thus aims to shorten
this period. Patients with contraversive
pushing should become independent of help
from others in less time and may be
discharged from inpatient care earlier.
The present study, of course, does not
allow us to draw general conclusions.
Although the patients investigated were
consecutively admitted to our department,
we cannot exclude that the time course of
contraversive pushing in the eight cases
simply represents the natural course of the
disorder. Further evaluation of the treatment
strategy using control groups is necessary.
However, in our day to day clinical treatment of patients with pusher syndrome the
training programme appears to accelerate
recovery and produces successful results. It
seems as if this new treatment approach has
the potential to shorten inpatient care and
accelerate independence in daily living.
ACKNOWLEDGEMENTS
This work was supported by a grant from the
Deutsche Forschungsgemeinschaft awarded to H-O K
(Ka 1258/2-3).

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Address correspondence to: Hans-Otto Karnath MD
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Hoppe-Seyler-Str. 3, D-72076 Tbingen, Germany
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(Submitted July 2003; accepted May 2004)