When your patient has pusher syndrome, it can be exhausting… to say the least! They have an overwhelming compulsion to push themselves over, and in the beginning of their rehab journey, it seems like nothing will stop them from this incessant pushing.
So why do they do it?
Pusher syndrome can be categorized as an impairment in body orientation perception. When a patient who has pusher syndrome is sitting upright, in midline – they feel as though they are leaning (approximately 18 degrees) toward their unaffected (strong) side. So, in order for them to feel like they are sitting straight, they push themselves toward their affected (weak) side to get themselves to what they think is midline. And, as we have all seen… they often overcompensate!
Also, if a patient has other impairments happening concurrently, such as visual, proprioceptive, and motor impairments, this makes knowing the correct body orientation even more difficult.
Let’s explore this a bit further and see how we might be able to help! Who does this affect and how can we stop the pushing, once and for all!
Want to upgrade those stroke skills? Check out Inpatient Stroke Rehab: 14 Strategies to Get Your Patient Home!
Who gets Pusher Syndrome and who doesn’t?
Any patient can experience pusher syndrome after a stroke, no matter where the stroke occurred in the brain. Depending on the source you look at, there is a wide variety when it comes to the exact number or percentage of patients that pusher’s occurs with. However, a consistent finding is that pusher syndrome is more prevalent when the stroke occurs in the right hemisphere vs. the left. This could be due to uprightness being controlled more by the right side of the brain. Pusher syndrome also requires more time for recovery when the stroke occurs in the right hemisphere. So, knowing that any of our patients could be experiencing this phenomenon… let’s make sure we are prepared to help them overcome it!
5 Strategies to Help our Patients Overcome Pushing
Strategy #1: Re-orientating them to true vertical
First thing’s first – since they have a skewed perception of vertical, we want these patients to relearn where they are in space. There are several different ways to achieve this. If their vision is mostly intact, we want to provide visual feedback in the beginning. Teach them to use their eyes, when their bodies and brains are sending them mixed signals. Place a mirror in front of them, use vertical lines on the mirror or in the environment for them to line up with, use yourself as a guide by sitting in front of them and having them match your posture. These are great forms of external attentional focus, which we know is going to produce better motor learning and retention!
Read this article to find out more about motor learning!
When reorienting someone with pusher syndrome back to vertical, make sure you start with their head and eyes. If they are not able to hold their head in midline due to spasticity or weakness, orienting their body to midline is going to be a difficult task. The same applies if your patient has a field cut (or other visual impairments). Addressing these things first is of utmost importance in order to have success in pusher syndrome rehab.
In the beginning of the rehab process, when pushing is strong, simply placing them in front of a mirror may not do the trick. You may need to give them physical support.
Our first instinct, with pusher syndrome, is to sit on their weak side (the side they are pushing toward)… and push back! But this is the opposite of what we should do! Remember, they feel as though they are leaning toward their strong side, so we want to provide a sense of security for them… so they don’t have the urge to push. We want to provide support from their strong side. This seems counterintuitive, but we need to retrain their brain that they will not fall, even though they feel like they are leaning. This could come in several forms. You could position their strong side next to a wall, so they see and feel that even if they are leaning in that direction, there is no way they will fall… because there is a wall there.
You could also place large bolsters or the tall end of a wedge next to their strong side. This would give them the feedback of support, but still allow you to position yourself in front of them or on their other side if needed. You could also have them weight bear through their elbow onto the object you’ve placed next to them, so they have to actively lean toward the side they want to push away from. Whether they are positioned next to a wall or bolster, you want to have your patient with pusher syndrome attempt to lean outside of their base of support toward their strong side, all while educating and verbally and visually orienting them to midline. This could look like rolling a large therapy ball toward their strong side or reaching for various objects.
As your patient with pusher syndrome progresses, and the pushing is less strong, you want to wean the amount of support you provide, so they can adjust the amount they are pushing (and eventually abolish it!). This may mean placing their “pushing hand” on something mobile like a rolling stool or rolling table during their transition from sit to stand – this almost eliminates the possibility of them pushing as the stool moves instead of them! And with practice, your patient will learn to modulate how much pressure they put through that hand.
You can also have your patient with pusher syndrome sit backward in a chair. The support they are relying on in this strategy is more medial and the chair back itself can serve as a vertical environmental reference. During this phase of pusher syndrome rehab, you can now have your patient attempt to actively reach outside of their base of support toward the strong and weak sides.
Strategy #2: Provide knowledge of results
So, how do we know if our patient with pusher syndrome is understanding our education and training? How do we know if they are going to carryover the skills we are teaching them? We need to allow our patients to *safely* fail. That’s right! We need to find out if they know what is happening. Even during that very first meeting, during our evaluation… we can push back against their push and ask, “What will happen if I let go right now?” If your patient says, “I will fall over!” – this is a good sign! They have more awareness that something is not right and will be more engaged in finding a solution with you. If they say, “Nothing,” try to gently show them that they will fall over if you let go. They may get it right away, they may slowly learn this with repetition, or they may never gain this awareness.
Those patients with pusher syndrome that never learn that they are pushing… are going to be your trickier patients.
Strategy #3: Utilize different positions and functional activities
Daily routines and activities require us to get into all sorts of different positions throughout a normal day. So, we want to make sure that we are training our person with pusher syndrome to match what they would need to do in daily life. But utilizing different positions and functional activities, this will provide various versions of proprioceptive and visual input to help retrain the misperception of vertical.
One school of thought is to initially facilitate weight shifting or weight bearing toward the strong side in order to allow the person’s brain to habituate. Here are a few examples of how you can facilitate this.
When having your patient with pusher syndrome lie prone, make sure their strong arm is down by their side (to prevent pushing) and rotate their head toward weak side. Similarly, when propping them in prone on elbows position, do not allow their strong arm (elbow) to extend and instead facilitate weight bearing/leaning through the elbow. You can also hold their weak elbow straight and provide manual approximation to facilitate a weight shift toward their strong side.
When working in quadruped, you can have their weaker side resting on a slightly higher surface to facilitate more weight bearing on the strong side, then also complete active assisted weight shifts in all directions. When in tall kneeling, try to have their affected side resting on a slightly higher surface, similar to what you will do in quadruped.
Now, you might be thinking… we’re trying to orient them to true vertical! Why would I put them on an uneven surface on purpose? That’s a great question! You would think that we would want to use a level surface all the time for them to know what level is. But… we want them to learn that they are able to lean toward their strong side, lean on their strong side, and move to their strong side without falling. We want to habituate them to moving in that direction again. This will all contribute to them relearning where midline is.
Gait training can happen a few different ways. If you are using a body weight support system, you can adjust the straps of the harness to offset the pushing. So make the straps slightly looser on the strong side in order to facilitate more weight bearing toward that direction. If you are training over ground, it would be a great idea to utilize an assistive device that provides bilateral upper extremity support, such as a platform walker or EVA walker. This will not only provide more stability, but will allow you to integrate both sides of the body and avoid the pushing behavior.
You may also need two (or more) people to assist with over ground walking, depending on how strong your patient’s urge to push is! The first helper should stand on the strong side, in order to provide the patient with visual and tactile feedback that they are not going to fall in that direction, even though they feel as though they are leaning over. The second helper should stand on the weak side (the side they are pushing toward) as a safety precaution in case the first helper is not able to manage the pushing from the strong side.
Strategy #4: Complete bed mobility and transfers toward both sides!
If we want to make a right turn… we don’t make three lefts – we make a right! So why are we always wanting to train our patients in one direction? I know in the beginning of rehab, we normally start by transferring toward someone’s strong side (as it usually allows them to be more successful). In pusher syndrome, you may choose to transfer toward their weak side first (since they are already prone to moving in that direction).
However, you must eventually train them to move in all directions! Remember – we need to reorient them to true vertical… so they don’t continue to push. If they only ever move in one direction, they will not be aware of the “mistakes” they are making. Transferring/rolling/etc. toward the strong side will definitely take more time with a patient with pusher syndrome… but it’s worth it! Even though it’s tempting, don’t rush through the transfer… let them work it out! In the long run, they will be able to do more of these tasks independently and relearn midline faster!
Strategy #5: Use outcome measures
We all know that these patients usually take longer to meet their goals and therefore need more time in rehab! And sometimes it’s hard to get the time we need. Outcome measures can assist you in showing the small increments of progress that you might need to highlight for insurance companies to approve the time you need!
Here are a few to check out:
Scale for Contraversive Pushing
For more information about pusher syndrome and these outcome measures, visit – Pusher Syndrome – Physiopedia (physio-pedia.com)
What is my patient’s prognosis if they have Pusher Syndrome?
The good news is, that most patients who have pusher syndrome are able to achieve the same type of outcomes as those without pusher syndrome. However, this does not mean that we want to leave it unchecked. A patient with pusher syndrome will take significantly longer to achieve those outcomes. And with the limited amount of time we have in acute and subacute rehab settings, we must set our patients up for success in every way possible!
What else can I do?
Continue to educate yourself on pusher syndrome and other stroke interventions! The more skilled and intentional we become with our interventions, the faster our patients will reap the benefits!
If you’re interested in learning more, check out Inpatient Stroke Rehab: 14 Strategies to Get Your Patient Home.
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Ruth Polillo, MSPT, CBIS: Ruth graduated with a Master of Science in Physical therapy degree from Thomas Jefferson University in 2005, and has gained experience in every setting a therapist can work in. She is a co-founding member of ARC & an enthusiastic presenter! Ruth is passionate about continuing education and making hands-on clinical skills available to clinicians.