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.

Accuracy of the Australian National Sub-Acute and Non-Acute Patient Classification in predicting rehabilitation length of stay for stroke survivors who are ≥65 years of age and have lateropulsion

BACKGROUND

Lateropulsion is a common impairment after stroke. Regardless of stroke severity, functional recovery is slower in people with lateropulsion, resulting in requirement for longer rehabilitation duration. In Australia, inpatient rehabilitation funding is determined via the Australian National Sub-Acute and Non-Acute Patient Classification (AN-SNAP). AN-SNAP class is determined using age, diagnosis, weighted Functional Independence Measure (FIM) motor score, and FIM cognitive score.

OBJECTIVES

To explore accuracy of the AN-SNAP to predict length of stay (LOS) for people with poststroke lateropulsion.

METHODS

A retrospective database audit was undertaken. AN-SNAP predicted LOS for each participant was calculated based on 2019 calendar year national benchmarks. A multivariable linear regression model estimated mean differences in reported LOS and AN-SNAP predicted LOS after adjusting for lateropulsion severity (Four Point Pusher Score). A separate logistic regression model assessed whether FIM change during admission was associated with reported LOS exceeding AN-SNAP predicted LOS.

RESULTS

Data were available from 1126 admissions. Reported LOS exceeding AN-SNAP predicted LOS was associated with greater lateropulsion severity on admission. Where AN-SNAP predicted LOS was longer, those with no lateropulsion on admission showed shorter reported than predicted LOS. Greater improvement in FIM during rehabilitation was associated with increased odds of reported LOS exceeding AN-SNAP predicted LOS (OR 1.02, 95%CI 1.01-1.03, p < .001).

CONCLUSIONS

Inclusion of a measure of poststroke lateropulsion in the AN-SNAP classification model would result in more accurate LOS predictions to inform funding. Costs of longer rehabilitation LOS may be countered by optimized long-term physical function, reducing requirement for ongoing care.

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.

Is Lateropulsion Really Related with a Specific Lesion of the Brain?

Lateropulsion (pusher syndrome) is an important barrier to standing and gait after stroke. Although several studies have attempted to elucidate the relationship between brain lesions and lateropulsion, the effects of specific brain lesions on the development of lateropulsion remain unclear. Thus, the present study investigated the effects of stroke lesion location and size on lateropulsion in right hemisphere stroke patients. The present retrospective cross-sectional observational study assessed 50 right hemisphere stroke patients. Lateropulsion was diagnosed and evaluated using the Scale for Contraversive Pushing (SCP). Voxel-based lesion symptom mapping (VLSM) analysis with 3T-MRI was used to identify the culprit lesion for SCP. We also performed VLSM controlling for lesion volume as a nuisance covariate, in a multivariate model that also controlled for other factors contributing to pusher behavior. VLSM, combined with statistical non-parametric mapping (SnPM), identified the specific region with SCP. Lesion size was associated with lateropulsion. The precentral gyrus, postcentral gyrus, inferior frontal gyrus, insula and subgyral parietal lobe of the right hemisphere seemed to be associated with the lateropulsion; however, after adjusting for lesion volume as a nuisance covariate, no lesion areas were associated with the SCP scores. The size of the right hemisphere lesion was the only factor most strongly associated with lateropulsion in patients with stroke. These results may be useful for planning rehabilitation strategies of restoring vertical posture and understanding the pathophysiology of lateropulsion in stroke patients.

The importance of the insular cortex for vestibular and spatial syndromes

BACKGROUND AND PURPOSE

The aim of the study was to identify the neuroanatomical correlates and associations of neuropsychological syndromes after acute unilateral right-hemisphere brain lesions. The neuropsychological syndromes considered were orientation in three-dimensional space such as tilts of the subjective visual vertical or of the subjective haptic vertical, pusher syndrome, visual neglect and unawareness of paresis (anosognosia for hemiparesis). These neuropsychological phenomena have been found to occur separately or in different combinations after lesions to the right insular cortex.

METHOD

Magnetic resonance imaging scans were obtained from 82 patients with acute right-hemispheric stroke. A lesion-behavior mapping analysis was conducted to specify the neuroanatomical correlates of the above-mentioned neuropsychological syndromes.

RESULTS

In all analyses of the individual neuropsychological syndromes the insular cortex was affected.

CONCLUSIONS

Thus, the insular cortex is involved in (self-)perception and orientation within a three-dimensional space. Since isolated lesions of the insular cortex did not induce the above neuropsychological phenomena, there have to be other regions involved.

Role of diffusion tensor imaging in analyzing the neural connectivity of the parieto-insular vestibular cortex in pusher syndrome: As case report

RATIONALE

Pusher syndrome is a disorder of postural control. It is associated with unilateral lesions on central vestibular system. In the current study, we attempted to identify and investigate neural connectivity of the parieto-insular vestibular cortex in a patient with pusher syndrome, using diffusion tensor imaging.

PATIENT CONCERNS

A 60-year-old male patient had left hemiplegia due to an infarction on right premotor cortex, primary motor cortex, corona radiata and temporal and occipital lobe. The patient had severe motor weakness in left upper and lower limb, left side neglect and significant pusher syndrome.

DIAGNOSIS

Patient was diagnosed with left hemiplegia due to an infarction in the right middle cerebral artery territory at the neurology department of a university hospital.

INTERVENTIONS

One patient and 5 control subjects of similar age participated. Diffusion tensor imaging data were acquired at 4-month and 12-month after the initial injury.

OUTCOMES

Fractional anisotropy, mean diffusivity, and tract volume (TV) were measured. TV values in both affected and unaffected hemispheres of the patient were significantly decreased at 4-month compared to those of control subjects. In the unaffected hemisphere of the patient, TV value showed significant increase at 12-month compared to that at 4-month. Although the TV value at 12-month of the affected hemisphere was out of reference range, TV was considerably increased compared to that at 4-month. Mean values for fractional anisotropy or mean diffusivity in 2 hemispheres did not show significant difference compared to those of control subjects regardless of month.

LESSONS

Restoration of an injured projection pathway between the vestibular nuclei and parieto-insular vestibular cortex with recovery of pusher syndrome was found in a patient with stroke.

Perception of Verticality and Vestibular Disorders of Balance and Falls

Objective: To review current knowledge of the perception of verticality, its normal function and disorders. This is based on an integrative graviceptive input from the vertical semicircular canals and the otolith organs.

Methods: The special focus is on human psychophysics, neurophysiological and imaging data on the adjustments of subjective visual vertical (SVV) and the subjective postural vertical. Furthermore, examples of mathematical modeling of specific vestibular cell functions for orientation in space in rodents and in patients are briefly presented.

Results: Pathological tilts of the SVV in the roll plane are most sensitive and frequent clinical vestibular signs of unilateral lesions extending from the labyrinths via the brainstem and thalamus to the parieto-insular vestibular cortex. Due to crossings of ascending graviceptive fibers, peripheral vestibular and pontomedullary lesions cause ipsilateral tilts of the SVV; ponto-mesencephalic lesions cause contralateral tilts. In contrast, SVV tilts, which are measured in unilateral vestibular lesions at thalamic and cortical levels, have two different characteristic features: (i) they may be ipsi- or contralateral, and (ii) they are smaller than those found in lower brainstem or peripheral lesions. Motor signs such as head tilt and body lateropulsion, components of ocular tilt reaction, are typical for vestibular lesions of the peripheral vestibular organ and the pontomedullary brainstem (vestibular nucleus). They are less frequent in midbrain lesions (interstitial nucleus of Cajal) and rare in cortical lesions. Isolated body lateropulsion is chiefly found in caudal lateral medullary brainstem lesions. Vestibular function in the roll plane and its disorders can be mathematically modeled by an attractor model of angular head velocity cell and head direction cell function. Disorders manifesting with misperception of the body vertical are the pusher syndrome, the progressive supranuclear palsy, or the normal pressure hydrocephalus; they may affect roll and/or pitch plane.

Conclusion: Clinical determinations of the SVV are easy and reliable. They indicate acute unilateral vestibular dysfunctions, the causative lesion of which extends from labyrinth to cortex. They allow precise topographical diagnosis of side and level in unilateral brainstem or peripheral vestibular disorders. SVV tilts may coincide with or differ from the perception of body vertical, e.g., in isolated body lateropulsion.

Recovery of an injured medial lemniscus with concurrent recovery of pusher syndrome in a stroke patient: a case report

RATIONALE

A 67-year-old, right-handed male patient underwent craniotomy and drainage for hematoma removal related to an intracerebral hemorrhage (ICH) in the right thalamus and basal ganglia at the neurosurgery department of a university hospital.

PATIENT CONCERNS

He presented with severe motor weakness of left extremities, impairment of proprioception, and severe pusher syndrome at the start of rehabilitation.

DIAGNOSES

He was diagnosed as ICH in the right thalamus and basal ganglia.

INTERVENTIONS

The patient received comprehensive rehabilitative therapy, movement therapy, and somatosensory stimulation.

OUTCOMES

Four months after onset, left leg motor function (Motricity Index [MI] = 51) did not show significant recovery from that at two months after onset (MI = 41); however, in the same period, Nottingham Sensory Assessment and scale for contraversive pushing significantly improved. At four months, the patient was able to stand independently but required manual contact of one person during independent walking on an even floor. At seven months after onset, he was able to walk independently on an even floor.

LESSONS

Recovery of a severely injured medial lemniscus with concurrent recovery of impaired proprioception and pusher syndrome.

[Metavestibular disorders and disorders of higher vestibular function]

Vertigo, instability, oscillopsia and concomitant autonomic disorders are classical and well-known symptoms of vestibular disorders. At the same time, recent studies suggest that there are more complicated vestibular dysfunctions caused by the cortical projections of the vestibular system. The central vestibular system includes parietal temporal cortex and insular, anterior intraparietal sulcus, posterior parietal and medial parts of the superior temporal gyrus, singular gyrus retrosplenial cortex, hippocampus and parahippocampal area. The central part of the vestibular system closely interacts with other afferent systems forming a multisensory structure of higher brain functions. Dysfunctions of higher vestibular function play an important role in the development of clinical syndromes including pusher syndrome, room tilt illusion, unilateral spatial neglect syndrome, impairment of spatial memory and navigation. These syndromes can develop due to the direct damage of the cortical vestibular system or as a result of disconnection between the vestibular cortex and other parts of the sensory cortex.