Contraversive pushing in non stroke pati

J Neurol (2004) 251 : 1324–1328
DOI 10.1007/s00415-004-0532-y

Taiza E. G. Santos-Pontelli
Octávio M. Pontes-Neto
José Fernando Colafêmina
Dráulio B. de Araujo
Antônio Carlos Santos
João P. Leite

Received: 12 February 2004
Received in revised form: 3 May 2004
Accepted: 6 May 2004

T. E. G. Santos-Pontelli · O. M. Pontes-Neto,
MD · Dr. João P. Leite (쾷)
Dept. of Neurology
University of São Paulo
School of Medicine at Ribeirão Preto
Ribeirão Preto
Campus Universitário

CEP 14049-900, Brazil
Tel.: +55-16/602-2556
Fax: +55-16/6330760
E-Mail: jpleite@fmrp.usp.br
J. F. Colafêmina, MD, PhD
Division of Otorhinolaringology
University of São Paulo
School of Medicine
Ribeirão Preto, Brazil
A. C. Santos, MD, PhD
Dept. of Internal Medicine
University of São Paulo
School of Medicine
Ribeirão Preto, Brazil
D. B. de Araujo, PhD
University of São Paulo
School of Physics
Ribeirão Preto, Brazil

ORIGINAL COMMUNICATION

Contraversive pushing in non-stroke
patients

■ Abstract Background Pusher
syndrome is a disorder of postural
control observed in patients with
right or left brain damage associated with hemiparesis. Those patients show a peculiar behavior of
actively pushing away from the
nonhemiparetic side and resisting
against passive correction, with a
tendency to fall toward the paralyzed side. Thus far this phenomenon has been exclusively associated
with stroke patients. Objective We
investigate the occurrence, imaging
features and clinical evolution of
pusher behavior in patients with
acute encephalic lesions at a tertiary emergency hospital. Methods
Pusher patients were identified
from 530 inpatients during a 1 year
period. Patients were evaluated using a standardized Scale for Contraversive Pushing (SCP), neurological examination, assessment of

neuropsychological symptoms, activities of daily living function and
neuroimaging studies. Results We
found eight patients (1.5 %) with

JON 1532

Introduction
Contraversive pushing behavior has been considered
one of the most intriguing disorders of postural control
in patients with brain lesions. The pusher syndrome was
first described by Davies who observed that some hemiplegic patients, rather than use the unaffected arm to
pull themselves up, extend this arm and actively push

severe contraversive pushing, three
female and five male. Age at symptoms onset ranged from 48 to 80
years (mean 65.4). All patients had
scores equal or above 1.5 in each
tested parameter of the SCP. Six patients (75 %) had right-hemisphere
brain damage. A stroke etiology
was found in four patients. The

other four patients had non-stroke
etiology (three traumatic, one
metastatic tumor). Stroke patients
showed complete recovery of
pusher behavior at a mean duration of 15.3 weeks. In patients with
brain trauma, pushing behavior
was completely resolved in a mean
time of 5 weeks. Conclusions The
results demonstrate that contraversive pushing may also occur in patients with non-stroke neurological
lesions and suggest that resolution
of symptoms may vary according
to the underlying etiology.
■ Key words pusher syndrome ·
postural control · trauma · tumor

away, toward the paretic side [2]. When sitting or standing, they lean toward the hemiparetic side and resist attempts at passive correction toward the earth-vertical
upright position [2, 5, 9].
It was at first assumed that the contraversive pushing
was part of a syndrome also encompassing spatial neglect and anosognosia, associated with right hemisphere strokes [2, 5]. However, systematic investigation
in larger series have revealed that the pushing behavior

1325

can be dissociated from both spatial neglect and
anosognosia and may also occur in left hemisphere
stroke patients [4–6, 9, 10].
Recently, a possible explanation for the pushing behavior has been suggested. Pusher patients experience
their body as oriented upright when it is actually tilted
18° to the ipsilesional side, in spite of having normal
function of vestibular and visual systems [4].
Imaging studies from pusher patients with either
right or left sided lesions have shown that the ventral
posterior and lateral posterior nuclei of the posterolateral thalamus are overlapping structures in all cases. A
central role of these nuclei on upright body posture has
been suggested, though additional substrates in the cortex may also be critical [5].
Thus far, the pusher behavior has only been described in stroke patients [2–7, 9, 10]. Moreover, the resolution of those symptoms has been reported as almost
complete within 6 months [7].
In the present study we investigated the occurrence,
imaging features and clinical evolution of pusher behavior in a group of patients with acute brain lesions in
a tertiary emergency hospital. Our investigations indicate that the behavior can be found in association with

non-stroke neurological conditions and that the time required for the resolution of symptoms may vary according to etiology.

Material and methods
Pusher patients were identified from 530 inpatients of a neurological
emergency unit at a tertiary hospital of University of São Paulo
School of Medicine at Ribeirão Preto, between 1 July 2002 and 30 June
2003. A physical therapist screened patients for any abnormal postural behavior by awaking and putting them in a seated position. If
any instability appeared, they were further assessed using a previously standardized Scale for Contraversive Pushing (SCP) based on
Davies’ criteria [4, 6]. This scale assesses three distinct aspects of postural control: 1) symmetry of spontaneous posture while sitting and
standing, 2) the use of the arm and/or the leg to extend the area of
physical contact to the ground while sitting and standing, and 3) resistance to passive correction of posture while sitting and standing [4,
6]. Patients were scored as having contraversive pushing if all three
criteria were met, reaching a total score of at least 1 in each criterion
(sitting plus standing in the 3 situations). The duration of pusher behavior was defined as the interval between injury onset and the complete resolution of symptoms. Evaluation included a full neurological
examination, assessment of neuropsychological symptoms of hemineglect and anosognosia, activities of daily living (ADL) function and
neuroimaging studies (CT and/or MRI). Patients were classified as
having spatial neglect when there was clear evidence of a typical clinical behavior such as [1] a spontaneous deviation of the head and eyes
toward the ipsilesional side, [2] orienting toward the ipsilesional side
when addressed from the front or the contralesional side, and [3]
ignoring of contralesional located people or objects [5]. Anosognosia

was rated by questioning the patient about limb weakness and confirmed only when no acknowledgement of motor weakness was obtained even after confrontation [1]. Activities of daily living (ADL)
function was assessed between 5 to 12 months after lesion onset by
the Barthel index (BI), which evaluates 10 different abilities and
ranges a total score from 0 to 100 points [8].

Neuroimaging was performed to establish the etiology and topography of brain lesions. The side and extension of the lesion was determined by combining clinical and neuroimage data. CT or MRI was
performed as early as possible according to the accessibility of the
scanner and the patient’s clinical condition. CT was performed on a
Somatom ARC equipment (Siemens, Erlangen, Germany), with
512 × 512 matrix, continuous 5 mm slice thickness on the posterior
fossa and 10 mm slice thickness in the supratentorial region. MRI was
performed on a 1.5-T superconductor system (Siemens, Vision Plus,
Erlangen Germany), with 25 mT gradients, using a circular polarized
head coil. The acquisition protocol included whole brain coverage
with a T2-weighted axial turbo spin-echo sequence (SE), T1weighted axial SE, T2 fluid attenuation inversion-recovered coronal
sequence, and a 3D time-of-flight MR angiography, at minimum. All
images were reported and reviewed by two neuroradiologists.
This study was approved by the ethics committee of our institution.

Results

Among 530 inpatients we found eight (1.5 %) with severe contraversive pushing, three female and five male.
Table 1 describes their demographic, clinical characteristics and outcome. The age at symptom onset ranged
from 48 to 80 years (mean 65.4). Investigation for pushing behavior was performed within a mean of 31.7 days,
with a range of 13 to 60 days after hospital admission.
Patients stayed at the hospital for an average of 36.7 days
(range = 8 to 57 days). Two of them (patients 5 and 6)
were transferred to a secondary hospital after discharge.
Hypesthesia was observed in four patients, while six
of them showed spatial neglect. All patients had scores
equal or above 1.5 in each tested parameter of the SCP.
Six patients (75 %) had right-hemisphere brain damage,
two (25 %) had left-sided lesions.
A stroke etiology was found in four patients (three ischemic, one with intraparenchymal hemorrhage). In the
other four patients severe contraversive pushing was associated with non-stroke etiologies (described below).
Patient 5, a 62 year-old institutionalized male with a
previous history of epilepsy, systemic hypertension and
chronic alcohol intake was admitted after he had been
found in a confused state and with aphasia. Cranial CT
showed a left fronto-temporal subdural hematoma with
midline shift and areas of hemorrhage in the left basal

ganglia and frontal cortex (Fig. 1A and 1B). He was
transferred to a secondary hospital after 32 days, still
with severe contraversive pushing to the right side.
Patient 6, an 80 year-old right-handed female was
found with left hemiparesis, dysarthria and altered
mental state. Cranial CT showed a right subdural
hematoma and periventricular hemorrhage. Emergency
decompressive surgery was performed. She required
orotracheal intubation, ventilatory and intensive care
support for 19 days. Afterward, she was transferred to
the neurological unit, when a severe contraversive pushing behavior to the left side was detected and completely
resolved within 7 weeks.

1326

Table 1 Demographic and clinical data, rehabilitation outcome and resolution of pushing behavior according to etiology
Patients

Age
(years)

Sex

Interval (in
days) between
lesion onset and
first evaluation

Pain Sensibility

Hemineglect

SCP*
(Post/Ext/
Resis)

Lesion
side

Side of

pushing
behavior

Clinical outcome
(Barthel Index)

Resolution
of pushing
behavior

Etiology

1
2
3
4
5
6
7
8

74
75
48
76
62
80
50
58

M
F
M
M
M
F
M
F

55
60
33
35
16
27
13
15

Hypesthesia
Hypesthesia
Normal
Normal
Normal
Hypesthesia
Normal
Hypesthesia

YES
YES
NO
NO
YES
YES
YES
YES

2/2/2
2/2/2
2/2/2
1.75/2/2
2/2/2
1.5/2/2
1.5/1.5/2
2/2/2

R
R
R
L
L
R
R
Ba

L
L
L
R
R
L
L
L

Death
(50)
(85)
(25)
(00)
(80)
(100)
Death

Not evaluated
24–28 weeks
12 weeks
8 weeks
Not evaluatedb
7 weeks
3 weeks
Not evaluated

Infarct
Infarct
Infarct
Hem
Traumatic
Traumatic
Traumatic
Tumor

* Scale for Contraversive Pushing (SCP) assesses 1) symmetry of spontaneous posture (Post) while sitting and standing (max, 2), 2) the use of the arm or the leg to extend
(Ext) the area of physical contact to the ground while sitting and standing (max, 2), and 3) resistance (Resis) to passive correction of posture while sitting and standing (max,
2) . Hem intraparenchymatous hemorrhage; R right; L left; B Bilateral
a Although patient 8 had a small lesion over the left parieto-occipital transition, the lesions in the right hemisphere were larger, had a mass effect and were related to the
clinical motor deficits; b Patient 5 was not evaluated owing to clinical deterioration and occurrence of seizures after transference to a secondary hospital

Patient 7, a 50 year-old right-handed male, admitted
with a Glasgow Coma Scale (GCS) score of 9 and left
hemiparesis after having been hit by a car. Cranial CT
showed a right temporo-parietal contusion, laminar
subdural hemorrhage and mild cerebral edema. He required orotracheal intubation, ventilatory support and
intensive care treatment for about 8 days. He was then
transferred to the neurological unit. He was found to
have severe pushing behavior to the left side that lasted
about 27 days. He was discharged after 37 days with a
GCS score of 15, mild left hemiparesis and complete resolution of pusher behavior.
Patient 8, a 58 year-old left-handed-female, with a
previous history of a right gluteus rabdomyosarcoma
treated with surgery and chemotherapy and a documented lung metastasis, presented to the emergency
room with left hemiparesis and decreased level of conscience. CT of the head showed multiple hemorrhagic
metastases with severe vasogenic edema around them,
which were distributed bilaterally within the deep white
matter (Figs. 1C and D). The lesions in the right hemisphere were larger and were related to clinical motor
deficits. The first evaluation for pushing behavior was
performed 15 days after admission. Severe pushing behavior to the left side was observed. Three weeks later
she was transferred to another hospital still with severe
contraversive pushing. Her last evaluation was 23 days
after discharge and, by that time, it was impossible to access pushing behavior because of her deteriorated condition and decreased level of conscience. The patient
died a few weeks after her last evaluation.

Discussion
This study was carried out in an emergency unit of a
university hospital, which is the regional reference for
both traumatic and acute neurological patients. Over a
one year period, patients were systematically evaluated
for abnormal postural behavior and submitted to rehabilitation according to their needs. Within this population, we found a relative frequency of 1.5 % for pushing
behavior, which is smaller than the 5.3 % found in a previous published series carried out in a specialized stroke
unit [9]. Our findings demonstrate, apparently for the
first time, that pushing behavior can occur in patients
with non-stroke neurological lesions, which represented
fifty percent of the present series.We believe that pusher
behavior may be underestimated in non-stroke conditions because all previous studies have focused on selected populations of stroke patients [2–5, 7, 9, 10].
We found right-sided lesions in six of our series of
eight. Although it was first assumed that pusher syndrome was associated with right hemisphere lesions,our
results are in agreement with more recent data which indicate that pusher behavior can occur with either right
or left-sided lesions [3, 5, 9].
Regarding the evolution of pusher symptoms, stroke
patients in the present study showed complete recovery
of pusher behavior in a mean duration of 15.3 weeks
(8–28 weeks), which is in agreement with previous studies [7]. In contrast, we found the pushing behavior to be
completely resolved in a mean time of 5 weeks (3–7
weeks) in patients with brain trauma. The apparent difference in recovery time may be related to etiology, extension, or inherent resolution mechanisms of the
causative lesion. The small number of non-stroke pa-

1327

Fig. 1 CT scans of patients showing different etiologies for pushing behavior. A and B are from patient 5,
with a traumatic brain injury. Note the left subdural
haematoma and mass effect with midline shift and
multiple areas of contusion over the left hemisphere.
C and D are from patient 8 with multiple hemorrhagic
metastasis from a pelvis rabdomiosarcoma. The
larger lesions were located in the right frontal and
parietal lobes causing a mild falx displacement

tients in the present study prevent statistical analysis. It
is well known that stroke patients presenting pushing
behavior have their rehabilitation time needed for recovery increased twofold over that of patients without
pushing [9]. The impact of pusher symptoms associated
with other etiologies is still unclear. Further studies may
help to clarify the prognosis of pushing symptoms in
other neurological conditions.
The demonstration of contraversive pushing in patients with different brain lesions indicates that the related alteration of vertical postural control may be a
consequence of any lesion that produces dysfunction in
the neural network which processes the input for vertical perception. The present data show that pusher be-

havior must be systematically evaluated in patients with
various encephalic disorders and this may help to reduce their stay in hospital, recovery time and improve
their quality of life. More efficient rehabilitation strategies have to be developed in stroke and non-stroke patients and further research on pusher behavior is
needed to explore the nature of the symptom.
■ Acknowledgements The authors thank the residents, physiotherapists, medical staff and patients of the Emergency Unit of the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto/USP.
J. P.Leite and O. M. Pontes-Neto, A. C. Santos and D. B. de Araujo are
supported by Fundação de Apoio a Pesquisa do Estado de São Paulo
(FAPESP) and Conselho Nacional de Desenvolvimento Científico e
Tecnológico (CNPq).

1328

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