Wednesday, April 19, 2017

“Pusher” Syndrome-- the neuroplastic model of recovery

Pusher syndrome (PS) is an altered sense of reality. 

Survivors with PS (sometimes known as "pushers") believe that they are sitting or standing “upright” when they are tilted approximately 18° towards the "bad” side. 

Therapists may be exacerbating pusher syndrome. When survivors with PS are forced to a “upright” they feel like they're leaning too far towards the "bad" side. “Pushers” react to this feeling by leaning towards the affected side. They see any attempt to get them truly straight as a serious threat that inspires fear. 

Another term for pusher syndrome is listing phenomenon. This may be a more accurate term because "pushers" only become "pushers" when they are pushed. Anyone who was shoved 18° out of balance would push back! There are other terms that have been used for PS including:
·       ipsilateral pushing
·       contraversive pushing
·       pusher behavior.

PS affects approximately 5% (although some estimates are as high as 50%) of all stroke survivors.

Survivors with PS have had damage to portion of the brain that controls the feeling of upright body posture. The area damaged is called the posterolateral thalamus. Loss of this area causes PS.

Balance is determined by 3 systems: vision, vestibular (inner ear) and proprioception. Patients with PS typically only have damage to one of the 3 systems: proprioception. Clinicians can help by directing patient focus to the balance systems that are still intact. Therapists can help pushers by helping them to attend to vertical visual cues. One technique involves having the therapist sit in front of the seated patient. Then use any visual cues available in the room, or the therapist’s own body (i.e. the forearm held vertically) to have the patient reorient themselves to true vertical. Carr and Shepard (reference below) suggest having the patient purposely, and within a safety-controlled environment, repeatedly reach for an object towards the hemiparetic side. The patient is then instructed to bring themselves back to visually confirmed true vertical. This simple technique hits on two basic concepts of the neuroplastic model; task specificity (reaching for an object creating a challenge to balance) and repetitive practice. The repetitive practice in this case is repeatedly reorienting to true vertical. Therapists can help pushers by teaching the necessary movements needed to realign to vertical. As is true with many of the recovery options that drive neuroplastic change, it is repeated self-correction that rewires the brain.

Pushers should be encouraged to hold a vertical position no matter what everyday task they’re doing. This incorporates another core concept in the neuroplastic model: massed practice. Therapists who encourage constant realignment to true vertical—in and out of the therapy gym—help the survivor mass their attempts at righting and equilibrium reactions.

Although certainly not proven, I would bet that the rewiring necessary to correct PS does not happen in the thalamic region—the region damaged in stroke survivors with PS. Using repetitive, task specific massed practice may instead force an enlargement and/or strengthening of the cortical representation of the intact vestibular and visual systems. 

Therapists can help PS patients by providing shepherding guidance on this necessary neuroplastic journey.

1. Karnath HO, Broetz D. Understanding and treating "pusher syndrome". Phys Ther.2003 Dec;83(12):1119-25. 
2. Shepherd RB, Carr JA. Response to Discussion Paper: New aspects for the physiotherapy of pushing behaviour, D. Broetz and H.-O. Karnath, Neurorehabilitation 20 (2005), 133-138. NeuroRehabilitation. 2005;20(4):343-5.  

Tuesday, April 18, 2017

Work the good side and the bad side gets...better?

I do a lot of talks. Tons of them. Constantly. To therapists. And I say to them usually early in the day, "Look, I'm staring down the barrel of hundreds of years (sometimes more than a thousand) years of clinical expertise. One of my goals today is to have you share your best ideas. That way, tomorrow, when I do another talk, I can present your idea, claim its my own, and give you no credit." They laugh. Its funny because its true. And they do give me their ideas and I do steal them and then present them in my book, articles, talks, or this lovely blog. 

And here's a stroke-recovery strategy I got the other day form the fine therapists at BONE Physical therapy and Rehabilitation (they appear not to have a website, but that link will at least get you a phone number.) They're in Columbus, GA.

Training the "good" side

In folks who have not had a stroke, we've known this for decades: If you strengthen only one side (say, your left side) the other side strengthens too.

It's true in survivors as well: If you strengthen (so says some preliminary research) the unaffected side, the effected side gets stronger. A researcher at the University of Victoria, Canada, Katie Dragert, appear to be the scientists who have explored this issue the most.

Here's an example: If you do resistance training for the dorsiflexion on the "good" side...
... the "bad side" gets stronger.

How did they do it? 
•Stroke survivors did performed 6 weeks of maximal dorsiflexion. 
•What did they gain on the "good side"?
~34% strength increase on the "good side."
•What did they gain on the "bad side"? 
~31% strength increase on the "bad side." 

We also know that bilateral training -- when you use both sides together, the "good" side helps the "bad" side become more coordinated. your challenge is to find a way to put these two concepts...
1. strengthen the good to strengthen the bad
2. use the good to train the bad
into recovery.

Thursday, April 6, 2017

"My dream for the future is to help as many people as I can possibly help"

I get a chance to communicate to a lot of survivors. I've treated them clinically and in experimental research protocols. I've also been in contact with a lot of survivors during my talks. And then of course, social media and email. 

Survivors, to varying degrees, are usually pretty good at explaining with appropriate passion what its like to have, survive and thrive after stroke.

One of best I've found so far has been Bill Torres. Find his story here. (Bring tissues.)

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