Understanding the pusher behavior of some stroke patients with spatial deficits: a pilot study.

OBJECTIVE: To investigate whether pusher behavior (ie, a tendency among stroke patients with spatial deficits to actively push away from the nonparalyzed side and to resist any attempt to hold a more upright posture) affects only the trunk, for which gravitational feedback is given by somesthetic information, or the head as well, whose gravitational information is mainly given by the vestibular system (without vision).

DESIGN: Description and measurement of clinical features.

SETTING: Rehabilitation center research laboratory.

PARTICIPANTS: Eight healthy subjects age matched to 14 patients with left hemiplegia resulting from right-hemisphere stroke (3 pushers showing a severe spatial neglect, 11 without pusher behavior).

INTERVENTION: All participants were asked to actively maintain an erect posture while sitting for 8 seconds on a rocking, laterally unstable platform. The task was performed with (in light) and without (in darkness) vision.

MAIN OUTCOME MEASURES: The number of trials needed to succeed in the task was monitored. In successful trials, head, shoulders, thoracolumbar spine, and pelvis orientation in roll were measured by means of an automated, optical television image processor.

RESULTS: Compared with other patients and healthy subjects, the 3 pushers missed many more trials and displayed a contralesional tilt of the pelvis but kept a correct head orientation. This tilt was especially pronounced without vision. Spatial neglect was a key factor, explaining 56% of patients' misorientation behavior with vision and 61% without vision.

CONCLUSION: This pilot kinematic analysis shows that pusher behavior does not result from disrupted processing of vestibular information (eg, caused by a lesion involving the vestibular cortex); rather, it results from a high-order disruption in the processing of somesthetic information originating in the left hemibody, which could be graviceptive neglect (extinction). This disruption leads pushers to actively adjust their body posture to a subjective vertical biased to the side opposite the cerebral lesion.