Immediate effectiveness of single-session therapeutic interventions in pusher behaviour

rTMS for Poststroke Pusher Syndrome: A Randomized, Patient-Blinded Controlled Clinical Trial

BACKGROUND

Patients with poststroke pusher syndrome (PS) require longer duration of rehabilitation and more supplemental care after discharge. Effective treatment of PS remains a challenge. The role of repetitive transcranial magnetic stimulation (rTMS) for PS has not been examined.

OBJECTIVE

Assess the efficacy of rTMS for patients with poststroke PS in reducing pushing behavior, enhancing motor recovery and improving mobility.

METHODS

A randomized, patient- and assessor-blinded sham-controlled trial with intention-to-treat analysis was conducted. Thirty-four eligible patients with poststroke PS were randomly allocated to receive either rTMS or sham rTMS for 2 weeks. Pushing behavior on the Burke lateropulsion scale and scale for contraversive pushing, motor function on Fugl-Meyer assessment scale-motor domain (FMA-m) and mobility on modified Rivermead mobility index were measured at baseline, 1 and 2 weeks after intervention. Repeated-measures analysis of covariance was used for data analysis.

RESULTS

There was no significant interaction between intervention and time on Burke lateropulsion scale (F = 2.747, P = .076), scale for contraversive pushing (F = 1.583, P = .214), or change of modified Rivermead mobility index (F = 1.183, P = .297). However, a significant interaction between intervention and time was observed for FMA-m (F = 5.464, P = .019). Post hoc comparisons of FMA-m show better improvement in rTMS group with mean differences of 12.7 (95% CI -7.3 to 32.7) and 15.7 (95% CI -4.6 to 36.0) at post-treatment week 1 and week 2 respectively.

CONCLUSIONS

rTMS did not demonstrate significant efficacy in improving pushing behavior and mobility in patients with PS. However, rTMS might have potential effect in enhancing motor function for patients with PS.

REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (registration No. ChiCTR2200058015 at http://www.chictr.org.cn/searchprojen.aspx) on March 26, 2022.

Feedback Interventions in Motor Recovery of Lateropulsion after Stroke: A Literature Review and Case Series

Lateropulsion is a post-stroke phenomenon marked by an active push of the body across the midline towards the more affected side and/or a resistance of the weight shift towards the less affected side. Within the mechanisms of treatment, feedback systems have been shown to be effective. The aim of the present study was to create a body of knowledge by performing a literature review on the use of feedback mechanisms in the treatment of lateropulsion and to report two cases of lateropulsion patients who had undergone feedback-based treatment.

METHODS

The review was performed across five different databases (Embase, Medline/PubMed, Scopus, Web of Science, and PEDro) up to February 2024, and haptic feedback intervention was incorporated into the case series (with lateropulsion and ambulation capacity as the main variables).

RESULTS

In total, 211 records were identified and 6 studies were included after the review of the literature. The most used feedback modality was visual feedback. In the case series, positive results were observed from the intervention, particularly in the recovery of lateropulsion and balance, as well as in the improvement of gait for one patient. Patients demonstrated good adherence to the intervention protocol without adverse effects.

CONCLUSIONS

Visual feedback is the most commonly used feedback modality in lateropulsion patients but other mechanisms such as haptic feedback also are feasible and should be taken into account. Larger sample sizes, extended follow-up periods, and the isolation of feedback mechanisms must be established to clarify evidence.

Effects of galvanic vestibular stimulation on postural righting reactions in hemiplegia

Patients with post-stroke hemiplegia often exhibit reduced ability to maintain sitting balance, a crucial factor for predicting prognosis. Galvanic vestibular stimulation (GVS) influences postural control by stimulating vestibular organ. Although several studies have focused on GVS in static postures, no studies have demonstrated the influence of GVS on righting reactions. Therefore, we aimed to investigate the effects of GVS on postural righting reactions in seated patients with stroke-induced hemiplegia. Using a vertical board (VB), righting reactions were induced by tilting the VB at 10° after patients sat for 1 min. Patients adjusted their bodies until feeling vertical upon prompt. Twenty-two left hemiplegic patients with cerebrovascular disease participated, divided into two groups undergoing right cathode GVS (RC-GVS) followed by left cathode GVS or vice versa, preceded by sham stimulation. Centre of pressure and the joint angle were measured. During the postural righting reactions towards the paralysed side, RC-GVS enhanced the righting reactions and moved the mean position on the x-axis (COPx) to the right and the mean position on the y-axis (COPy) to the front. During the postural righting reaction towards the right side, RC-GVS induced resistance against the righting reaction, COPx was deflected to the right, COPy was deflected backward, and the angle of the neck tilt increased. The findings revealed that GVS with anodal stimulation on the paralysed side could promote righting reactions in patients with post-stroke hemiplegia. SIGNIFICANCE STATEMENT: The study findings suggest that using the contralesional placement of the anode promotes righting reactions, and galvanic vestibular stimulation can induce joint movements in the neck and trunk by polarising it to act as resistance against righting reactions.

Lateropulsion in Right-Sided Stroke: Brain Anatomical Correlates of Severity and Duration

BACKGROUND AND PURPOSE

Lateropulsion (LP) is a profound disorder of postural control that has a significant impact on neurorehabilitation. Knowledge of relevant brain areas could guide decisions on appropriate intervention methods. Although LP severity and duration are highly variable in individuals with LP, imaging studies on LP have not sufficiently considered these aspects. The aim of this study was to investigate the lesion location in individuals after stroke and the correlation with LP duration and severity.

METHODS

A retrospective case-control study using voxel lesion symptom mapping (VLSM) in 74 individuals with right-sided brain lesion (49 with and 25 without LP) was performed to analyze the correlation between lesion location and LP severity. Duration was investigated in a subsample of 22 individuals with LP. LP was diagnosed by means of the Scale for Contraversive Pushing.

RESULTS

Individuals with LP showed significantly larger lesion sizes compared with the individuals with no LP. VLSM analysis of LP severity did not reveal statistically significant results. VLSM analysis showed a statistically significant association with longer LP duration for the inferior frontal gyrus, the hippocampus, the inferior parietal gyrus, the supramarginal gyrus, the angular gyrus, the temporal cortex, the sagittal stratum, and the superior longitudinal fasciculus.

DISCUSSION AND CONCLUSION

LP-relevant areas are located in the multisensory network. Areas of the frontoparietal network, which are related to spatial cognition, memory, and attention, were found to be relevant for duration and severity. The findings, especially those regarding duration involving the middle temporal cortex, could explain the better intervention outcomes for methods based more on implicit than on explicit knowledge of verticality.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A433 ).

Clinical practice recommendations for management of lateropulsion after stroke determined by a Delphi expert panel

OBJECTIVE

People exhibiting post-stroke lateropulsion actively push their body across the midline to the more affected side and/or resist weight shift toward the less affected side. Despite its prevalence and associated negative rehabilitation outcomes, no clinical practice guidelines exist for the rehabilitation of post-stroke lateropulsion. We aimed to develop consensus-based clinical practice recommendations for managing post-stroke lateropulsion using an international expert panel.

DESIGN

This Delphi panel process conformed with Guidance on Conducting and Reporting Delphi Studies recommendations.

PARTICIPANTS

Panel members had demonstrated clinical and/or scientific background in the rehabilitation of people with post-stroke lateropulsion.

MAIN MEASURES

The process consisted of four electronic survey rounds. Round One consisted of 13 open questions. Subsequent rounds ascertained levels of agreement with statements derived from Round One. Consensus was defined a priori as ≥75% agreement (agree or strongly agree), or ≥70% agreement after excluding 'unsure' responses.

RESULTS

Twenty participants completed all four rounds. Consensus was achieved regarding a total of 119 recommendations for rehabilitation approaches and considerations for rehabilitation delivery, positioning, managing fear of falling and fatigue, optimal therapy dose, and discharge planning. Statements for which 'some agreement' (50%-74% agreement) was achieved and those for which recommendations remain to be clarified were recorded.

CONCLUSIONS

These recommendations build on existing evidence to guide the selection of interventions for post-stroke lateropulsion. Future research is required to elaborate specific rehabilitation strategies, consider the impact of additional cognitive and perceptual impairments, describe positioning options, and detail optimal therapy dose for people with lateropulsion.

Treatment approaches for pusher behaviour: a scoping review

BACKGROUND

Some individuals with hemiplegia show a postural disorder called pusher behavior. Various underlying theoretical mechanisms have been proposed, thus leading to various treatment approaches.

OBJECTIVES

The aim of this scoping review is to identify and analyze the available evidence on the treatment approaches for pusher behavior.

METHODS

Two independent reviewers conducted a literature search for original studies reporting on treatments for pusher behavior. Studies were searched in PubMed, Scopus, Web of Science, CINAHL and PEDro from their inception to December 2020. Treatment approaches were grouped in homogeneous areas based on the supposed underlying mechanism. To assess the reporting of the interventions, the Template for Intervention Description and Replication (TIDieR) was used.

RESULTS

Thirty-one papers describing 45 interventions were included in the review. Most of the studies were case reports (i.e. including 1 person) (n = 16), followed by randomized controlled trials (n = 5), single subject design trials (n = 5), non-randomized controlled trials (n = 3), and case series (i.e. including more than 1 person) (n = 2). Treatment approaches were grouped into five categories: visual feedback, somatosensory cues, visual-somatosensory integration, brain stimulation, and other nonspecific treatments. The median number of TIDIeR items reported was 7 (range 4 to 10).

CONCLUSION

Pusher behavior is still little-known. Five main categories of treatment approaches based on the alleged etiological underlying mechanisms have been identified. Most of studies are case reports; controlled trials should be further conducted. Intervention reporting should be improved to allow treatment replication in larger trials.

Interventions for perceptual disorders following stroke

BACKGROUND

Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non-invasive brain stimulation, pharmacological and surgical approaches.

OBJECTIVES

To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living.  SEARCH METHODS: We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain.

DATA COLLECTION AND ANALYSIS

One review author assessed titles, with two review authors independently screening abstracts and full-text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB-1 tool, and quality of evidence using GRADE.  A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update.

MAIN RESULTS

We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch-somatosensory disorders. None addressed stroke-related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non-invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL):  Somatosensory disorders: one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure.  Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention.  Visual perception disorders: no trials measuring ADL compared an intervention with no treatment or control.  In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials).   AUTHORS' CONCLUSIONS: Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high-quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer-term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines.

rTMS for poststroke pusher syndrome: study protocol for a randomised, patient-blinded controlled clinical trial

INTRODUCTION

Poststroke pusher syndrome (PS) prevalence is high. Patients with PS require longer rehabilitation with prolonged length of stay. Effective treatment of PS remains a challenge for rehabilitation professionals. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation technique that is effective and recommended in the clinical guidelines of stroke rehabilitation. However, the role of rTMS for PS has not been examined. The study is to assess the efficacy of a specific rTMS programme for patients with PS in reducing pushing behaviour, enhancing motor recovery and improving mobility, as well as testing the safety of rTMS for patients with PS.

METHODS AND ANALYSIS

A randomised, patient and assessor blinded sham-controlled trial with two parallel groups will be conducted. Thirty-four eligible patients with PS will be randomly allocated to receive either rTMS or sham rTMS for 3 weeks. The primary assessment outcome is the pushing behaviour measured by the Burke Lateropulsion Scale and Scale for Contraversive Pushing. The secondary outcomes are the motor functions and mobility measured by the Fugl-Meyer Assessment Scale (motor domain) and Modified Rivermead Mobility Index, and any adverse events. Assessment will be performed at baseline and 1 week, 2 weeks and 3 weeks after intervention. Repeated-measures analysis of variance will be used for data analysis with the level of significance level set at 0.05.

ETHICS AND DISSEMINATION

The protocol has been approved by the Biomedical Ethics Committee of West China Hospital, Sichuan University on 23 March 2022 (2022-133). The trial findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2200058015).

Settings matter: a scoping review on parameters in robot-assisted gait therapy identifies the importance of reporting standards

Background

Lokomat therapy for gait rehabilitation has become increasingly popular. Most evidence suggests that Lokomat therapy is equally effective as but not superior to standard therapy approaches. One reason might be that the Lokomat parameters to personalize therapy, such as gait speed, body weight support and Guidance Force, are not optimally used. However, there is little evidence available about the influence of Lokomat parameters on the effectiveness of the therapy. Nevertheless, an appropriate reporting of the applied therapy parameters is key to the successful clinical transfer of study results. The aim of this scoping review was therefore to evaluate how the currently available clinical studies report Lokomat parameter settings and map the current literature on Lokomat therapy parameters.

Methods and results

A systematic literature search was performed in three databases: Pubmed, Scopus and Embase. All primary research articles performing therapy with the Lokomat in neurologic populations in English or German were included. The quality of reporting of all clinical studies was assessed with a framework developed for this particular purpose. We identified 208 studies investigating Lokomat therapy in patients with neurologic diseases. The reporting quality was generally poor. Less than a third of the studies indicate which parameter settings have been applied. The usability of the reporting for a clinical transfer of promising results is therefore limited.

Conclusion

Although the currently available evidence on Lokomat parameters suggests that therapy parameters might have an influence on the effectiveness, there is currently not enough evidence available to provide detailed recommendations. Nevertheless, clinicians should pay close attention to the reported therapy parameters when translating research findings to their own clinical practice. To this end, we propose that the quality of reporting should be improved and we provide a reporting framework for authors as a quality control before submitting a Lokomat-related article.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-022-01017-3.

Spanish translation and validation of the Scale for Contraversive Pushing to measure pusher behaviour

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Effects of dynamic supported standing training in a patient with pusher behavior: a case report

BACKGROUND

The effects of task-specific and voluntary exercise in upright positions for pusher behavior remain unclear. In this report, we aimed to describe the effects of dynamic supported standing training using a modified standing frame to correct the alignment in a patient with severe pusher behavior.

CASE DESCRIPTION

A 76-year-old man with cardioembolic ischemic stroke demonstrated pusher behavior. The patient underwent 3 days of dynamic supported standing training using a modified standing frame. The Scale for Contraversive Pushing, the Burke Lateropulsion Scale, and the Trunk Control Test were used to assess changes.

OUTCOMES

Immediate improvements in sitting balance were observed after the intervention, and the effects persisted to 8 days later.

CONCLUSION

Dynamic supported standing training using a modified standing frame may improve pusher behavior with short-term training. The collapsed posture of the patient in the present case was corrected using the modified standing frame. This neutral standing position could have a positive effect on motor learning with respect to holding one's posture.

Scale for contraversive pushing in stroke patients: pusher behavior vs Thalamic astasia differential diagnosis and psychometric properties

BACKGROUND

: Few studies have investigated the psychometric properties of the Scale for Contraversive Pushing (SCP) in depth, and none have evaluated its ability to establish differential diagnosis between pusher behavior (PB) and thalamic astasia (TA).

OBJECTIVES

: To study the ability of the SCP to establish differential diagnosis, its reliability, content, construct, and internal validity in the assessment of subacute stroke patients.

METHODS

: 120 individuals were evaluated using the SCP over a four-week period of treatment. Intra- and inter-observer reliability, floor and ceiling effects, minimum detectable change (MDC), internal validity and sensitivity to change were explored. In addition, the Barthel Index and the Trunk Control Test were used to study their correlations with the SCP.

RESULTS

: Discriminant validity provides evidence that the correlation between SCP items was large or moderate. Convergent validity demonstrated that the correlation of each item with the total score of the scale was high (at around 0.8). Sensitivity to change was large (W = 0.274). Intra- and inter-observer reliability were excellent (Intraclass Correlation Coefficient > 0.9; k > 0.8), except for items B standing and C sitting (k > 0.7). The MDC was 1.39, and ceiling (8.333%) and floor (15.833%) effects were adequate. Cronbach's alpha (α) was equal to 0.901 (0.874-0.924) and McDonald's Omega (ω) was equal to 0.883 (0.856-0.973), showing excellent internal consistency.

CONCLUSIONS

: The SCP is a reliable and valid tool which can successfully establish differential diagnosis between PB and TA and evaluate the changes generated by physiotherapy treatment.

Effects of performing a lateral-reaching exercise while seated on a tilted surface for severe post-stroke pusher behavior: A case series

Background: For patients with severe post-stroke pusher behavior (PB), acquiring a vertical posture involves correcting paretic-sided body tilt to the non-paretic side. Active lateral sitting training may facilitate improvement in postural orientation for patients with PB. However, its effect on patients with severe PB remains unclear.Objective: To determine the effect of performing a lateral-reaching exercise in patients with severe PB seated on a tilted surfaceMethods: Three patients with severe PB due to right hemispheric stroke participated in our study. Using a single-case design, the intervention's effect was verified using the applied behavior analysis method. Conventional physical therapy was performed for 1 h at baseline and at follow-up. During the intervention, lateral sitting training on a tilted surface was performed 40 times per session (total, 2 sessions). PB was assessed using the Scale for Contraversive Pushing and the Burke Lateropulsion Scale, and patient-reported fear of falling. The Function in Sitting Test (FIST) and the Trunk Control Test (TCT) were administered.Results: PB improved in all patients post-intervention and persisted at follow-up. Fear of falling during the passive sitting task while moving toward the non-paretic side disappeared post-intervention and at follow-up. FIST and TCT scores improved in 2 patients.Conclusion: The lateral sitting exercise reduced severe PB in all patients; however, sitting balance and trunk performance did not improve in 1 patient. Future studies to examine the adaptability of this task and long-term effects are needed.

Transcranial direct current stimulation (tDCS) for improving activities of daily living, and physical and cognitive functioning, in people after stroke

BACKGROUND

Stroke is one of the leading causes of disability worldwide. Functional impairment, resulting in poor performance in activities of daily living (ADL) among stroke survivors is common. Current rehabilitation approaches have limited effectiveness in improving ADL performance, function, muscle strength, and cognitive abilities (including spatial neglect) after stroke, with improving cognition being the number one research priority in this field. A possible adjunct to stroke rehabilitation might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability, and hence to improve these outcomes in people after stroke.

OBJECTIVES

To assess the effects of tDCS on ADL, arm and leg function, muscle strength and cognitive abilities (including spatial neglect), dropouts and adverse events in people after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase and seven other databases in January 2019. In an effort to identify further published, unpublished, and ongoing trials, we also searched trials registers and reference lists, handsearched conference proceedings, and contacted authors and equipment manufacturers.

SELECTION CRITERIA

This is the update of an existing review. In the previous version of this review, we focused on the effects of tDCS on ADL and function. In this update, we broadened our inclusion criteria to compare any kind of active tDCS for improving ADL, function, muscle strength and cognitive abilities (including spatial neglect) versus any kind of placebo or control intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and risk of bias, extracted data, and applied GRADE criteria. If necessary, we contacted study authors to ask for additional information. We collected information on dropouts and adverse events from the trial reports.

MAIN RESULTS

We included 67 studies involving a total of 1729 patients after stroke. We also identified 116 ongoing studies. The risk of bias did not differ substantially for different comparisons and outcomes. The majority of participants had ischaemic stroke, with mean age between 43 and 75 years, in the acute, postacute, and chronic phase after stroke, and level of impairment ranged from severe to less severe. Included studies differed in terms of type, location and duration of stimulation, amount of current delivered, electrode size and positioning, as well as type and location of stroke. We found 23 studies with 781 participants examining the effects of tDCS versus sham tDCS (or any other passive intervention) on our primary outcome measure, ADL after stroke. Nineteen studies with 686 participants reported absolute values and showed evidence of effect regarding ADL performance at the end of the intervention period (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.13 to 0.44; random-effects model; moderate-quality evidence). Four studies with 95 participants reported change scores, and showed an effect (SMD 0.48, 95% CI 0.02 to 0.95; moderate-quality evidence). Six studies with 269 participants assessed the effects of tDCS on ADL at the end of follow-up and provided absolute values, and found improved ADL (SMD 0.31, 95% CI 0.01 to 0.62; moderate-quality evidence). One study with 16 participants provided change scores and found no effect (SMD -0.64, 95% CI -1.66 to 0.37; low-quality evidence). However, the results did not persist in a sensitivity analysis that included only trials with proper allocation concealment. Thirty-four trials with a total of 985 participants measured upper extremity function at the end of the intervention period. Twenty-four studies with 792 participants that presented absolute values found no effect in favour of tDCS (SMD 0.17, 95% CI -0.05 to 0.38; moderate-quality evidence). Ten studies with 193 participants that presented change values also found no effect (SMD 0.33, 95% CI -0.12 to 0.79; low-quality evidence). Regarding the effects of tDCS on upper extremity function at the end of follow-up, we identified five studies with a total of 211 participants (absolute values) without an effect (SMD -0.00, 95% CI -0.39 to 0.39; moderate-quality evidence). Three studies with 72 participants presenting change scores found an effect (SMD 1.07; 95% CI 0.04 to 2.11; low-quality evidence). Twelve studies with 258 participants reported outcome data for lower extremity function and 18 studies with 553 participants reported outcome data on muscle strength at the end of the intervention period, but there was no effect (high-quality evidence). Three studies with 156 participants reported outcome data on muscle strength at follow-up, but there was no evidence of an effect (moderate-quality evidence). Two studies with 56 participants found no evidence of effect of tDCS on cognitive abilities (low-quality evidence), but one study with 30 participants found evidence of effect of tDCS for improving spatial neglect (very low-quality evidence). In 47 studies with 1330 participants, the proportions of dropouts and adverse events were comparable between groups (risk ratio (RR) 1.25, 95% CI 0.74 to 2.13; random-effects model; moderate-quality evidence).  AUTHORS' CONCLUSIONS: There is evidence of very low to moderate quality on the effectiveness of tDCS versus control (sham intervention or any other intervention) for improving ADL outcomes after stroke. However, the results did not persist in a sensitivity analyses including only trials with proper allocation concealment. Evidence of low to high quality suggests that there is no effect of tDCS on arm function and leg function, muscle strength, and cognitive abilities in people after stroke. Evidence of very low quality suggests that there is an effect on hemispatial neglect. There was moderate-quality evidence that adverse events and numbers of people discontinuing the treatment are not increased. Future studies should particularly engage with patients who may benefit the most from tDCS after stroke, but also should investigate the effects in routine application. Therefore, further large-scale randomised controlled trials with a parallel-group design and sample size estimation for tDCS are needed.

Effect of postural training using a whole-body tilt apparatus in subacute stroke patients with lateropulsion: A single-blinded randomized controlled trial

BACKGROUND

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.

OBJECTIVE

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.

METHODS

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 30min/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.

RESULTS

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).

CONCLUSIONS

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.

Lesion Localization of Poststroke Lateropulsion

Background and Purpose- Hemispheric stroke studies associating lateropulsion (pusher syndrome) with the location of brain lesions have had mixed results from small, unmatched samples. This study was designed to determine whether lateropulsion localizes to specific brain regions across patients with stroke using a case-control design. Methods- Fifty patients with lateropulsion after stroke were matched with 50 stroke patients without lateropulsion using age, time since onset of stroke, admission motor Functional Independence Measure score, lesion side, and gender. The primary analysis included multivariate lesion symptom mapping using sparse canonical correlations to identify regions most associated with lateropulsion as assessed with the Burke Lateropulsion Scale. Secondary analyses included evaluating paired comparisons for lesion volume, degree of motor impairment, motor and cognitive Functional Independence Measure scores. Results- The lesion symptom mapping analysis of all lesions mapped onto a common hemisphere produced an overall significant model ( P<5×10^-5) with a regional peak at the inferior parietal lobe at the junction of the post-central gyrus (Brodmann Area 2) and Brodmann Area 40 as the lesion location most associated with lateropulsion. Lesion volume was larger for patients with lateropulsion. Despite adequate matching, motor performance and total Functional Independence Measure scores differed at a group level between patients with and without lateropulsion. Conclusions- This analysis implicated lesion involvement of the inferior parietal lobe as a key neuroanatomical determinant of developing lateropulsion. A better understanding of the anatomic underpinnings of lateropulsion may improve rehabilitation efforts, including the potential for informing noninvasive neuromodulation approaches.

Electromyography-guided electrical stimulation therapy for patients with pusher behavior: A case series

BACKGROUND

Pusher behavior (PB) is a posture disorder due to a subjective bias in verticality perception. However, muscle activity characteristics in this disorder and the effective treatments are not known.

OBJECTIVE

To investigate electromyographic (EMG) activity and the effect of electrical stimulation (ES) in PB.

METHODS

Two PB patients were enrolled. The EMG activity was measured over the upper and lower limb muscles on the non-paretic side, and over the trunk muscles on both sides during sitting. We used a modified ABA single-case design consisting of consecutive baseline, intervention, and follow-up, each phase lasting 2 d. During the intervention, together with conventional treatment, the patient received ES for 5 min/d on the muscle antagonist to the muscle where excessive activity was observed. PB was assessed before and after each phase using the scale for contraversive pushing and the Burke lateropulsion scale. Truncal balance was evaluated using the trunk control test.

RESULTS

In both patients, electromyography of the non-paretic triceps brachii muscle revealed excessive activity. To inhibit the excessive activity, ES was applied to the non-paretic biceps muscle. All scores improved after the intervention and follow-up phases.

CONCLUSION

ES based on EMG activity is therapeutic for PB.

Usefulness of a standing frame to improve contraversive pushing in a patient post-stroke in inpatient rehabilitation

Despite the negative functional and financial implications of contraversive pushing (CoP) in the post-stroke population, little research has focused on improving this phenomenon more rapidly. A 58-year-old man was admitted to inpatient rehabilitation with a large frontoparietal intracerebral hemorrhage resulting in significant left hemiparesis and CoP. A standing frame protocol was implemented into standard care to improve CoP. The patient was assisted into a standing frame daily, and the Burke Lateropulsion Scale and Functional Independence Measure were tracked. Improvements in both outcome measures were greater than normative data.

Robot-assisted gait training effectively improved lateropulsion in subacute stroke patients: a single-blinded randomized controlled trial

BACKGROUND

Some stroke patients are known to use nonparetic extremities to push toward the paretic side, a movement known as lateropulsion. Lateropulsion impairs postural balance and interferes with rehabilitation.

AIM

The aim of the present study was to investigate the effect of robot-assisted gait training (RAGT) on recovery from lateropulsion compared with conventional physical therapy (CPT).

DESIGN

This was a single-blinded, randomized controlled trial.

SETTING

Participants were recruited from a rehabilitation department of a tertiary hospital.

POPULATION

Patients diagnosed with lateropulsion after a stroke.

METHODS

Thirty-six subacute stroke patients with lateropulsion were recruited. RAGT was performed in the experimental group (N.=18), and CPT was performed in the control group (N.=18). The participants received treatment for 3 weeks, 30 minutes per day, 5 days per week. Outcomes were assessed before the intervention (T0), immediately after the intervention (T1), and 4 weeks after the intervention (T2). The Burke Lateropulsion Scale (BLS) was evaluated as a primary outcome to assess the severity of lateropulsion. The secondary outcome measures were the Berg Balance Scale (BBS), the Postural Assessment Scale for Stroke (PASS), and Somatosensory Evoked Potentials (SSEP).

RESULTS

After intervention, the experimental group showed greater improvement in the BLS score at T1 (experimental group: Δ=-1.9, control group: Δ=-1.1, P=0.032) and T2 (experimental group: Δ=-2.8, control group: Δ=-6.5, P<0.001) than the control group. In addition, the BBS was significantly improved in the experimental group at T1 (experimental group: Δ=+7.1, control group: Δ=+1.9, P<0.001) and T2 (experimental group: Δ=+13.0, control group: Δ=+6.1, P<0.001). There were significant between-group differences in the PASS at T1 (experimental group: Δ=+3.2, control group: Δ=+1.6, P=0.014) and T2 (experimental group: Δ=+8.8, control group: Δ=+4.3, P<0.001).

CONCLUSIONS

RAGT ameliorated lateropulsion and balance function more effectively than CPT in subacute stroke patients.

CLINICAL REHABILITATION IMPACT

Early RAGT may be recommended for patients with lateropulsion after stroke.

Robot-assisted gait training to reduce pusher behavior: A randomized controlled trial

OBJECTIVE

To determine the effects of 2 weeks of intensive robot-assisted gait training (RAGT) on pusher behavior compared to nonrobotic physiotherapy (nR-PT).

METHODS

In a single-blind, randomized, controlled trial with 2 parallel arms, we compared 2 weeks of daily RAGT (intervention group) with the same amount of nR-PT (control group). Patients with subacute stroke who had pusher behavior according to the Scale for Contraversive Pushing (SCP) were included. The primary research questions were whether changes in pusher behavior would differ between groups post intervention, and at a follow-up 2 weeks afterward (SCP and Burke Lateropulsion Scale, Class II evidence). Secondary outcomes included the Performance-Oriented Mobility Assessment, the Functional Ambulation Classification, and the Subjective Visual Vertical.

RESULTS

Thirty-eight patients were randomized. Thereof, 30 patients received the allocated intervention and were included in the analyses. RAGT led to a larger reduction of pusher behavior than nR-PT at post test (SCP: U = 69.00, r = -0.33, p = 0.037; Burke Lateropulsion Scale: U = 47.500, r = -0.50, p = 0.003) and at follow-up (SCP: U = 54.00, r = -0.44, p = 0.008). Pusher behavior had ceased in 6 of 15 participants in the intervention group and 1 of 15 participants in the control group at post test. At follow-up, 9 of 15 and 5 of 15 participants, respectively, no longer exhibited the behavior.

CONCLUSIONS

Two weeks of RAGT seems to persistently reduce pusher behavior, possibly by recalibrating the disturbed inner reference of verticality. The potential benefits of RAGT on pusher behavior and verticality perception require further investigation.

TRIAL REGISTRATION

German Clinical Trials Register (registration number: DRKS00003444).

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that RAGT is beneficial to reduce pusher behavior in patients with stroke.

Spanish translation and validation of the Scale for Contraversive Pushing to measure pusher behaviour

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Prone positioning reduces severe pushing behavior: three case studies

[Purpose] Pushing behavior is classically described as a disorder of body orientation in the coronal plane. Most interventions for pushing behavior have focused on correcting the deviation in vertical perception. However, pushing behavior seems to involve erroneous movements associated with excessive motor output by the non-paretic limbs and trunk. The present study aimed to inhibit muscular hyper-activity by placing the non-paretic limbs and trunk in the prone position. [Subjects and Methods] The subjects of the present study were 3 acute stroke patients with severe pushing behavior. The study consisted of the following 3 phases: baseline, intervention, and follow-up. In addition to conventional therapy, patients received relaxation therapy in the prone position for 10 minutes a day over 2 days. The severity of pushing behavior was assessed using the scale for contraversive pushing, and truncal balance was evaluated using the trunk control test. These assessments were performed before and after the baseline phase, and after the intervention and follow-up phases. [Results] At the baseline phase, both scores were poor. Both scores improved after the intervention and follow-up phases, and all the patients could sit independently. [Conclusion] Relaxation therapy in the prone position might ameliorate pushing behavior and impaired truncal balance.

The Moving History of Vestibular Stimulation as a Therapeutic Intervention

Although the discovery and understanding of the function of the vestibular system date back only to the 19th century, strategies that involve vestibular stimulation were used long before to calm, soothe and even cure people. While such stimulation was classically achieved with various motion devices, like Cox's chair or Hallaran's swing, the development of caloric and galvanic vestibular stimulation has opened up new possibilities in the 20th century. With the increasing knowledge and recognition of vestibular contributions to various perceptual, motor, cognitive, and emotional processes, vestibular stimulation has been suggested as a powerful and non-invasive treatment for a range of psychiatric, neurological and neurodevelopmental conditions. Yet, the therapeutic interventions were, and still are, often not hypothesis-driven as broader theories remain scarce and underlying neurophysiological mechanisms are often vague. We aim to critically review the literature on vestibular stimulation as a form of therapy in various selected disorders and present its successes, expectations, and drawbacks from a historical perspective.

Effects of interactive visual feedback training on post-stroke pusher syndrome: a pilot randomized controlled study

Objective:

We investigated the effects of a computer-generated interactive visual feedback training program on the recovery from pusher syndrome in stroke patients.

Design:

Assessor-blinded, pilot randomized controlled study.

Participants:

A total of 12 stroke patients with pusher syndrome were randomly assigned to either the experimental group ( N = 7, computer-generated interactive visual feedback training) or control group ( N = 5, mirror visual feedback training).

Main outcome measures:

The scale for contraversive pushing for severity of pusher syndrome, the Berg Balance Scale for balance performance, and the Fugl-Meyer assessment scale for motor control were the outcome measures. Patients were assessed pre- and posttraining.

Results:

A comparison of pre- and posttraining assessment results revealed that both training programs led to the following significant changes: decreased severity of pusher syndrome scores (decreases of 4.0 ±1.1 and 1.4 ±1.0 in the experimental and control groups, respectively); improved balance scores (increases of 14.7 ±4.3 and 7.2 ±1.6 in the experimental and control groups, respectively); and higher scores for lower extremity motor control (increases of 8.4 ±2.2 and 5.6 ±3.3 in the experimental and control groups, respectively). Furthermore, the computer-generated interactive visual feedback training program produced significantly better outcomes in the improvement of pusher syndrome ( p < 0.01) and balance ( p < 0.05) compared with the mirror visual feedback training program.

Conclusions:

Although both training programs were beneficial, the computer-generated interactive visual feedback training program more effectively aided recovery from pusher syndrome compared with mirror visual feedback training.

A Chinese Patient with Pusher Syndrome and Unilateral Spatial Neglect Syndrome

Objective:

To observe clinical manifestations, behavioral characteristics, and effects of rehabilitation on a patient with pusher syndrome and unilateral spatial neglect caused by right thalamic hemorrhage.

Methods:

Assessment of pusher syndrome was made by the Scale for Contraversive pushing (SCP), and unilateral spatial neglect syndrome was diagnosed using line cancellation, letter and star cancellation, line bisection tests and copy and continuation of graphic sequence test. Behavioral therapy, occupational therapy, reading training and traditional Chinese medicine methods were adopted for treatment of pusher syndrome and unilateral spatial neglect.

Results:

The patient showed typical pusher syndrome and unilateral spatial neglect symptoms. The pusher syndrome and unilateral spatial neglect symptoms were significantly improved following rehabilitation treatments.

Conclusions:

Pusher syndrome and unilateral spatial neglect syndrome occurred simultaneously after right thalamic hemorrhage. Early rehabilitation therapy can reduce the symptoms of pusher syndrome and unilateral spatial neglect syndrome and improve motor function.

Time to Recovery From Lateropulsion Dependent on Key Stroke Deficits

Background. Lateropulsion, a postural control disorder, delays recovery following hemispheric stroke. The number of stroke impairments may lead to differential recovery rates, depending on the intact systems available for recovery from lateropulsion. Objective. To study the impact of key postural control deficits on lateropulsion rate of recovery following stroke. Methods. Through retrospective analysis: 169 patients with hemispheric stroke in an in-patient rehabilitation facility were divided into 3 groups: (1) motor deficits only; (2) motor and hemianopic or visual–spatial deficits or motor and proprioceptive deficits; and (3) motor, proprioceptive, and hemianopic or visual–spatial deficits. Kaplan–Meier survival analysis determined if time to recovery from lateropulsion (achieving a score of 0 or 1 on the Burke Lateropulsion Scale) differed by group. Results. Log rank tests showed that time to recovery from lateropulsion differed based on the number of deficits (group, P = .012). Post hoc analyses by lesion side showed that group differences only occurred in right brain lesion ( P < .05) as compared with left brain lesions ( P = .34). Patients recovered from lateropulsion during in-patient rehabilitation if they had only motor deficits; those with all 3 postural control deficits showed the most protracted recovery. Conclusions. Rate of recovery from lateropulsion after stroke is dependent on the side of lesion, and number of key motor, proprioceptive, and/or hemianopic or visual–spatial deficits. The more postural control systems affected, the slower the recovery. Our data identify patients likely to need protracted rehabilitation targeting key postural control deficits.

Inconsistent classification of pusher behaviour in stroke patients: a direct comparison of the Scale for Contraversive Pushing and the Burke Lateropulsion Scale

Objective:

To compare the classification of two clinical scales for assessing pusher behaviour in a cohort of stroke patients.

Design:

Observational case-control study.

Setting:

Inpatient stroke rehabilitation unit.

Subjects:

A sample of 23 patients with hemiparesis due to a unilateral stroke (1.6 ± 0.7 months post stroke).

Methods:

Immediately before and after three different interventions, the Scale for Contraversive Pushing and the Burke Lateropulsion Scale were applied in a standardized procedure.

Results:

The diagnosis of pusher behaviour on the basis of the Scale for Contraversive Pushing and the Burke Lateropulsion Scale differed significantly ( χ2 = 54.260, p < 0.001) resulting in inconsistent classifications in 31 of 138 cases. Changes immediately after the interventions were more often detected by the Burke Lateropulsion Scales than by the Scale for Contraversive Pushing ( χ2 = 19.148, p < 0.001). All cases with inconsistent classifications showed no pusher behaviour on the Scale for Contraversive Pushing, but pusher behaviour on the Burke Lateropulsion Scale. 64.5% (20 of 31) of them scored on the Burke Lateropulsion Scale on the standing and walking items only.

Conclusions:

The Burke Lateropulsion Scale is an appropriate alternative to the widely used Scale for Contraversive Pushing to follow-up patients with pusher behaviour (PB); it might be more sensitive to detect mild pusher behaviour in standing and walking.