Treatment interventions for pusher syndrome: A case series

The effect of using the hip exoskeleton assistive (HEXA) robot compared to conventional physiotherapy on clinical functional outcomes in stroke patients with hemiplegia: a pilot randomized controlled trial

TRIAL DESIGN

This study is a pilot randomized clinical trial aimed to investigate the effect of using Hip Exoskeleton Assistive (HEXA) robot compared to conventional physiotherapy on the quality of walking, disability, and quality of life of stroke patients with hemiplegia.

METHODS

In this study, 24 patients were randomly assigned to the intervention group (robotic physiotherapy with HEXA robot), or control group (conventional physiotherapy). In each session, both groups received 30 min of conventional physiotherapy including electrotherapy and conventional exercises, and then the intervention group did gait training for 30 min with the HEXA robot and the control group for 30 min without the HEXA robot. The treatment program was 12 sessions, 3 times a week. Before the 1st and after the 12th sessions, both groups were evaluated for walking quality, disability, and quality of life.

RESULTS

The results showed that the main effect of time was significant (P < 0.05) in all outcomes and patients in both groups achieved significant improvement in all outcomes after the intervention. The main effect of the group was also significant in the outcomes of 6MWT (P < 0.05) and TUG (P < 0.05), and the intervention group patients experienced more distance and speed in these two tests. This study was approved by the ethics committee of Mashhad University of Medical Sciences (IR.MUMS.FHMPM.REC.1400.079 dated 28th Jan 2022). The trial was registered with the clinical trials site of www.IRCT.ir (IRCT20210730052024N1) on January 28th 2022.

CONCLUSION

It seems that the HEXA robot can effectively improve walking capacity and speed.

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.

Case Report: Visual Deprivation in Pusher Syndrome Complicated by Hemispatial Neglect After Basal Ganglia Stroke

We aimed to explore whether motor function and activities of daily life (ADL) could be improved with the application of visual deprivation in two patients with Pusher syndrome complicated by hemispatial neglect after right basal ganglia stroke. We assessed two stroke patients suffering from severe motor disturbances, both tilting heavily to the left, with diagnoses of Pusher syndrome and left hemispatial neglect. Vision in the left eye was deprived using patches during clinical rehabilitation. Motor function promotion was confirmed using the Burke Lateropulsion Scale (BLS), Fugl–Meyer Balance Scale (FMBS), and Holden grade (HG), while the Barthel index (BI) assessed ADL immediately and 1 week after intervention. Both patients regained standing balance immediately using visual deprivation, as well as walking ability, although both scored 0 on the FMBS and HG. After 1 week of treatment, one patient increased to 11 and 3 on the FMBS and HG, respectively, while the BLS score decreased from 12 to 2, and the ADL increased from 23 to 70. The other patient demonstrated increases to 10 and 3 on the FMBS and HG, respectively, with the BLS decreasing from 13 to 3, and the ADL increasing from 25 to 60. Therefore, in the rehabilitation treatment of Pusher syndrome complicated by hemispatial neglect due to basal ganglia stroke, visual deprivation can significantly improve motor function and shorten the treatment course.

Post-stroke lateropulsion and rehabilitation outcomes: a retrospective analysis

PURPOSE

A person with post-stroke lateropulsion actively pushes themselves toward their hemiplegic side, or resists moving onto their non-hemiplegic side. This study aimed to determine the association of lateropulsion severity with: • Change in function (Functional Independence Measure - FIM) and lateropulsion severity (Four-Point Pusher Score - 4PPS) during inpatient rehabilitation; • Inpatient rehabilitation length of stay (LOS); • Discharge destination from inpatient rehabilitation.

METHODS

Retrospective data for 1,087 participants (aged ≥65 years) admitted to a stroke rehabilitation unit (2005-2018) were analysed using multivariable regression models.

RESULTS

Complete resolution of lateropulsion was seen in 69.4% of those with mild lateropulsion on admission (n = 160), 49.3% of those with moderate lateropulsion (n = 142), and 18.8% of those with severe lateropulsion (n = 181). Average FIM change was lower in those with severe lateropulsion on admission than those with no lateropulsion (p < 0.001). Higher admission 4PPS was associated with reduced FIM efficiency (p < 0.001), longer LOS (p < 0.001), (adjusted mean LOS: 35.6 days for those with severe lateropulsion versus 27.0 days for those without), and reduced likelihood of discharge home (p < 0.001).

CONCLUSION

Post-stroke lateropulsion is associated with reduced functional improvement and likelihood of discharge home. However, given a longer rehabilitation duration, most stroke survivors with moderate to severe lateropulsion can achieve important functional improvement.Implications for RehabilitationWhile people with post-stroke lateropulsion can be difficult to treat and require more resources than those without lateropulsion, the majority of those affected, even in severe cases, can make meaningful recovery with appropriate rehabilitation.Although those with moderate to severe post-stroke lateropulsion may have poorer outcomes (longer LOS and reduced likelihood of discharge home) it is still important to advocate for access to rehabilitation for this patient group to give them the opportunity for optimal functional recovery.