Application of ‘the PUSH strategy’ to reduce contraversive pushing after stroke during inpatient rehabilitation

Abstract

OBJECTIVE:

Given the poor functional outcomes associated with contraversive pushing after stroke and lack of evidence guiding physical therapy interventions, the PUSH (Prioritizing Upright, Standing, and Higher-level stepping activities) Strategy was designed to address unmet needs. The aim of this paper is to describe the clinical application of the PUSH Strategy delivered during the physical therapy plan of care within inpatient rehabilitation.

METHODS:

The PUSH Strategy was applied during clinical practice in a large, urban inpatient rehabilitation hospital for patients demonstrating contraversive pushing after stroke with the goals to (1) reduce contraversive pushing, (2) contribute to facilitation of a community discharge, and (3) improve functional outcomes. Subsequently, outcomes [Burke Lateropulsion Scale (BLS), discharge disposition, and the Mobility and Walk portions of the Continuity Assessment and Record Evaluation (CARE) Tool] were collected at admission and discharge to assess patient progress.

RESULTS:

Between 2018 and 2020, 11 patients participated in the PUSH Strategy with 73% of patients achieving all three Strategy goals. On average, patients saw improvement in pushing [admit, 7.73 ± 3.3 (moderate pushing); discharge, 1.55 ± 2.4 (no pushing)] and function (admit mobility, 9.9 ± 4.4; discharge, 21.5 ± 5.3 and admit walking 8.1 ± 0.3, discharge 9.6 ± 2.7) during their inpatient rehabilitation stay. Nine were discharged to the community (82%).

CONCLUSIONS:

The PUSH Strategy was successfully applied for patients with post-stroke contraversive pushing during inpatient rehabilitation. Overall, patients demonstrated reduced pushing and improved functional outcomes during their rehabilitation and most were discharged to a community setting.

Keywords

Physical therapist stroke rehabilitation rehabilitation hospital stroke

1 Introduction and background

Contraversive pushing following stroke is an altered perception of the body’s orientation with respect to gravity and leads to a postural preference toward the more affected side of the body [1 –4]. Also known as pusher’s syndrome or lateropulsion, patients appear as though they are pushing themselves toward their weaker side and resist attempts to return to a midline position [5]. This altered perception and postural positioning [6] adversely impact mobility and transitional movements [2 , 7]. Incidence of contraversive pushing has been reported from 5% [8] to 63% [5] of people receiving rehabilitation post-stroke; variability is attributable to heterogeneous diagnosis criteria and prior lack of validated measures [9].

The clinical relevance of contraversive pushing to rehabilitation therapists corresponds to the functional implications. Specifically, patients with contraversive pushing demonstrate slower improvement of function during inpatient rehabilitation, require greater assistance from caregivers at discharge, and have an increased likelihood of discharge to a more dependent setting (e.g., skilled nursing facility) rather than returning home [2].

Resolution of contraversive pushing is recognized as a slow process [5] and time to recovery lengthens as severity of initial presentation worsens [7, 10]. Specifically, resolution of pushing by discharge from inpatient rehabilitation is found in 69.4% of those with mild pushing on admission, 49.3% with moderate, and 18.8% with severe [10]. Notably, patients who demonstrate contraversive pushing tend to eventually reach the same functional status as their counterparts who don’t, but require an additional three to four weeks of rehabilitation [8, 11]. Despite a strong indication for the necessity of increased time to meet functional goals [10, 11], patients admitted to inpatient rehabilitation with pushing may not be afforded longer lengths of stay compared to their counterparts without [2]. Consequently, when given equal time in inpatient rehabilitation, patients with contraversive pushing are discharged with greater lower extremity weakness, less functional independence, and are more likely to be discharge to institutional care settings [2, 10].

Despite the well-documented financial and functional implications of contraversive pushing, there remain no best practices or clinical guideline for minimizing the impact of pushing during the subacute phase of recovery [12]. Moreover, if left untreated, even small impairments in perception of verticality can result in prolonged deficits [13]. Contemporary management of this population typically focuses on improving seated static and dynamic balance prior to prioritizing standing activities using a variety of visual, facilitation, or sensory input strategies [1 , 14–17]. These methods often demonstrate equivocal outcomes to standard of care approaches and pushing often remains a barrier upon discharge from inpatient rehabilitation [17 –19]. However, recent randomized controlled trials that studied 66 total patients with contraversive pushing have reported reduced pushing when using Lokomat robotic gait training with body weight support on a treadmill compared to standard of care [14, 15]. Others suggest prioritizing standing interventions within the physical therapy plan of care for patients who push during inpatient rehabilitation may afford them more time spent upright and in midline and reduce the implications of contraversive pushing [20, 21]. Additionally, recent neurorehabilitation recommendations encourage a “leap-frog” approach to mobility interventions by forgoing postural stability activities in favor of higher-level upright activities, even in those with severe mobility impairments [22].

Given the delayed and often poorer health outcomes associated with patients with contraversive pushing as well as the lack of evidence supporting the current standard of care, an intervention approach was developed and subsequently applied for management of contraversive pushing in a large, urban inpatient rehabilitation hospital. This intervention approach was founded upon the co-principles of providing maximum time in upright midline posture [23] and incorporation of upright, complex tasks (compared to simple, seated tasks) to promote neuroplasticity [22, 24]. That is, this approach strategically aimed to Prioritize Upright, Standing, and Higher-level stepping activities (PUSH). The primary aim of this paper is to describe the application of the PUSH Strategy for reducing contraversive pushing and improving functional outcomes after stroke for patients during inpatient rehabilitation.

2 Methods

2.1 Description of the PUSH strategy

Integrating concepts described in rehabilitation literature [1 , 25] with principles of neuroplasticity [22 –24] (e.g., repetition, specificity, time, task complexity), the PUSH Strategy aims to provide maximum time in upright midline posture during physical therapy treatment of patients presenting with contraversive pushing after stroke during inpatient rehabilitation. In contrast to usual care which prioritizes sitting balance prior to progressing to standing activities [1 , 14–17], emphasis of the PUSH Strategy was placed on achieving midline posture in higher level activities (i.e., walking and standing) as early as medically possible during the patient’s rehabilitation admission, essentially leap-frogging sitting balance activities in the plan of care. Achieving large amounts of time walking and standing for patients with contraversive pushing often requires the assistance of support personnel and various devices (e.g. standing frame, support surfaces for standing balance, body weight support treadmill, or use of an overground robotic exoskeleton) in effort to reduce the physical burden on the therapists. Figure 1 depicts the prioritization schema of the PUSH Strategy within the context of the physical therapy plan of care during inpatient rehabilitation. These interventions were included within the standard of care for inpatient rehabilitation of three hours of daily therapy [26] and did not require additional therapy time. Patients received between 45 and 90 minutes of physical therapy and the remainder of daily therapy sessions were provided by occupational and speech therapy.

Fig.1

Figure of Prioritization; Illustrates prioritization of activities in the plan of care for a patient participating in the PUSH Strategy. Descriptively, therapists aim to focus on activities on the left of the diagram (e.g., gait and standing) in high doses as early as medically safe unless outside factors yield a need to perform the less prioritized tasks on the right (e.g., toileting needs or family training in preparation for discharge).

2.2 Goals of the PUSH strategy and outcome measures

The primary goal of the PUSH Strategy was to promote resolution of pushing as rapidly as possible to give patients with contraversive pushing the opportunity to recover functional mobility similar to peers without pushing. The outcome measure utilized to assess contraversive pushing was the Burke Lateropulsion Scale (BLS) [4]. The BLS was adopted into standard care in this inpatient facility and each patient admitted with a diagnosis of stroke was assessed for contraversive pushing. As one of few outcome measures designed to assess pushing in a patient post-stroke, the BLS has been found to be valid and reliable [4] and it is the only measure to assess pushing across multiple functional activities, including walking [27]. In addition, the BLS is able to detect mild contraversive pushing behavior and is sensitive to change with a minimal clinical difference of 2.18 [4 , 27]. The BLS has been recommended for use by clinicians to identify contraversive pushing, guide the plan of care, and objectively identify improvements [27].

A secondary goal of the PUSH Strategy was to improve the likelihood of a successful discharge to the community for the patient with contraversive pushing. Although many factors influence discharge disposition [28], pushing is associated with an increase in the chances of discharge to institutionalized care [2, 10]. As such, the PUSH Strategy aims to maximize opportunities for a community discharge by minimizing functional deficits associated with contraversive pushing. A community discharge was defined as any discharge from inpatient rehabilitation to a less dependent setting (e.g., home, transitional neuro rehabilitation, assisted living facility). Discharges to skilled nursing facilities (SNF) or acute care were not included as discharge to a community setting as they are considered to be lower levels of care. Discharge to a community setting is an important factor in resource allocation and overall healthcare cost [29] and therefore aligns with key healthcare system outcome metrics. However, and possibly of greater importance, discharge to home is a commonly cited goal for the patient admitted to inpatient rehabilitation after stroke [30].

A tertiary goal of PUSH Strategy was to maximize functional independence for patients admitted with contraversive pushing. Functional outcomes were measured using the CARE (Continuity Assessment and Record Evaluation) Tool. This instrument is a mandated measure of functional dependency for use in inpatient rehabilitation facilities by the Center for Medicare and Medicaid Services [31]. CARE scores specific to physical therapy are described in Table 1. Scoring of each item is on a scale of 1 to 6 in which 1 defines the patient as fully dependent for an activity and 6 indicates full independence [31]. Admission and discharge scores were tracked to illustrate functional improvements made during inpatient rehabilitation.

Table 1
Items included from the CARE tool

Mobility Walking

Rolling left and right Walking 10 feet

Sitting to lying Walking 50 feet with two turns

Lying to sitting on side of the bed Walking 150 feet

Sitting to standing Walking 10 feet on uneven surfaces

Chair/bed to chair transferring Stepping up/down 1 step

Toilet transferring Stepping up/down 4 steps

Car transferring Stepping up/down 12 steps

Picking up an object

Mobility	Walking
Rolling left and right	Walking 10 feet
Sitting to lying	Walking 50 feet with two turns
Lying to sitting on side of the bed	Walking 150 feet
Sitting to standing	Walking 10 feet on uneven surfaces
Chair/bed to chair transferring	Stepping up/down 1 step
Toilet transferring	Stepping up/down 4 steps
Car transferring	Stepping up/down 12 steps
	Picking up an object

Note: Scoring of each item is on a scale of 1 (fully dependent) to 6 (fully independent). For each column above, items were totaled at admission and again at discharge, and a difference was computed to illustrate progress.

2.3 Participants

Patients were determined to be appropriate for the PUSH Strategy if they met the following eligibility criteria: admission to inpatient rehabilitation facility between February 2018 to February 2020 with a primary diagnosis of stroke within the past 6 months, between the ages of 18 and 100, a Burke Lateropulsion Scale (BLS) score of ≥ 3 (minimum of mild contraversive pushing behavior) [3], and a score of ≤ 2 (maximal or substantial assist required) on the “walking 150 feet” item of CARE Tool. Patients were excluded if they were medically unable to participate as deemed by therapist or physician (e.g., cardiovascular concerns limiting intensive standing and gait interventions), demonstrated behavioral or agitation issues to limit general participation in therapy, or had orthopedic issues or skin breakdown to prevent use of the standing frame or gait devices. Including the physician in decisions of eligibility aimed to avoid selection bias. Institutional review board approval from the affiliated hospital and written consent were obtained prior to initiating data collection procedures.

3 Results

Between February 2018 to February 2020, 15 patients with stroke were admitted to the inpatient rehabilitation facility with a BLS score ≥ 3. Of these, 11 met eligibility criteria for participation in the PUSH Strategy program. Of the four patients excluded, two were unable to participate due to behavioral and agitation concerns, one patient was determined medically unable to participate by the physician, and one patient experienced both medical issues and orthopedic limitations.

The 11 patients who completed the intervention presented with an average age of 64.3 years, were nearly evenly divided between genders (5 males, 6 females), and primarily included those with right brain damage, consistent with previous literature [32]. Outcomes, provided in detail with demographic information in Table 2, were generally favorable. Participants admitted with an average BLS of 7.73 ± 3.3 (mild pushing) and discharged with an average BLS of 1.55 ± 2.2 (no pushing) and 9 of 11 (82%) met the goal of resolution of pushing by discharge. Additionally, 9 of the 11 participants (82%) were successfully discharged to the community after an average inpatient rehabilitation length of stay of 34.9 ± 15.0 days. All patients demonstrated functional improvements in both categories of CARE scores (Mobility and Walk). On average, CARE score improvements were 10.5 ± 5.3 in Mobility and 1.4 ± 2.6 in Walking. Importantly, 73% of patients who met program eligibility criteria achieved all three program goals (resolution of pushing as evidenced by BLS scores ≤ 2, discharge to the community, and functional improvements during length of stay).

Table 2
Characteristics and outcomes for PUSH strategy participants

Patient Gender Age (years) Stroke Location LOS (days) Discharge Disposition Burke Lateropulsion Scale CARE Mobility CARE Walk

Admit Discharge Admit Discharge Admit Discharge

1* M 58 R frontoparietal ICH 30 Community 11 0 7 25 8 11

2 M 95 R MCA infarct 21 SNF 14 8 7 13 8 8

3 M 85 L basal ganglia infarct 29 Community 6 1 10 20 8 8

4 F 64 R MCA infarct 63 Community 12 1 8 19 8 8

5 F 55 R ACA and MCA infarct 55 Community 5 0 7 26 8 11

6* F 34 R thalamic hemorrhage 46 Community 9 0 9 21 8 8

7 F 61 R MCA infarct 27 Community 4 2 12 19 8 9

8 M 76 R medulla infarct 15 Community 6 3 22 32 9 10

9* F 42 L MCA infarct 44 Community 8 0 12 24 8 17

10 M 62 L MCA infarct 29 Community 5 2 8 15 8 8

11 F 75 R MCA infarct 25 SNF 5 0 7 22 8 8

Mean ± SD 64.3 ± 17.8 34.9 ± 15.0 81.80% 7.73 ± 3.3 1.55 ± 2.4 9.9 ± 4.4 21.5 ± 5.3 8.1 ± 0.3 9.6 ± 2.7

Patient	Gender	Age (years)	Stroke Location	LOS (days)	Discharge Disposition	Burke Lateropulsion Scale	CARE Mobility	CARE Walk
1*	M	58	R frontoparietal ICH	30	Community	11	0	7	25	8	11
2	M	95	R MCA infarct	21	SNF	14	8	7	13	8	8
3	M	85	L basal ganglia infarct	29	Community	6	1	10	20	8	8
4	F	64	R MCA infarct	63	Community	12	1	8	19	8	8
5	F	55	R ACA and MCA infarct	55	Community	5	0	7	26	8	11
6*	F	34	R thalamic hemorrhage	46	Community	9	0	9	21	8	8
7	F	61	R MCA infarct	27	Community	4	2	12	19	8	9
8	M	76	R medulla infarct	15	Community	6	3	22	32	9	10
9*	F	42	L MCA infarct	44	Community	8	0	12	24	8	17
10	M	62	L MCA infarct	29	Community	5	2	8	15	8	8
11	F	75	R MCA infarct	25	SNF	5	0	7	22	8	8
Mean ± SD		64.3 ± 17.8		34.9 ± 15.0	81.80%	7.73 ± 3.3	1.55 ± 2.4	9.9 ± 4.4	21.5 ± 5.3	8.1 ± 0.3	9.6 ± 2.7

Note: Stroke location determined by physician history and physical; LOS = length of stay; R = right; L = left; MCA = middle cerebral artery; ACA = anterior cerebral artery; ICH = intracerebral hemorrhage; SNF = skilled nursing facility; M = male; F = female; SD = standard deviation. A lower score on the BLS represents improvement whereas a higher CARE scores represent improvement. Classification of BLS scores: 0-2 = no pushing; 3-8 = mild pushing; 9-12 = moderate pushing; 13-17 = severe pushing [3]. *individuals who utilized the overground robotic exoskeleton during PUSH Strategy intervention.

4 Discussion

The PUSH Strategy was developed to minimize the impact of contraversive pushing during inpatient rehabilitation by promoting a quicker resolution of pushing behavior and improving functional independence contributing to a successful discharge to the community. The program was successfully applied during clinical practice in a large urban inpatient rehabilitation setting, as most patients experienced resolution of pushing, discharged to a community setting, and demonstrated functional improvements.

With application of the PUSH Strategy, most (82%) patients demonstrated resolution of contraversive pushing during inpatient rehabilitation (indicated by a BLS score < 3). These findings differ from previous reports in which resolution of pushing occurred in less than 50% of those with moderate pushing and less than 70% of those with mild pushing [10] and a recent case series of five patients who underwent inpatient therapy focusing on sitting balance and transfers, in which pushing behavior resolved in only case [17]. Further, the presence of contraversive pushing is associated with reduced discharge to community [2, 10] with rates as low as 31% [2] (in contrast to 82% of this sample participating in the PUSH Strategy). Notably, many factors influence discharge disposition after inpatient rehabilitation [28], but it is vital to afford those who admit with contraversive pushing the same opportunity for a successful discharge to community as those who don’t by reducing the impact of these deficits. The early emphasis in upright gait and standing activities in the PUSH strategy may be a factor in these different outcomes.

Given these findings and contemporary recommendations to adopt a “leap-frog” approach to mobility interventions in those with moderate and severe mobility impairments [22], adoption of early upright gait and standing activities will likely encounter practical challenges in the clinical setting. The presence of contraversive pushing enhances the burden of care experienced by physical therapists attempting to mobilize these patients because they frequently have lower admission functional scores than their counterparts who do not demonstrate pushing [2, 10]). Additionally, therapists are challenged to manage not only the deficits noted in a typical hemiparetic patient, but also those caused by resistance to correction to midline [17]. As such, therapists managing patients with the PUSH Strategy used assistive devices to maximize the amount of time upright and in midline including walkers and other overground gait devices, parallel bars, passive standing devices [20, 21], body weight supported treadmill systems [33], and overground robotic exoskeleton devices. Despite the utilization of devices and technology to safely mobilize patients with contraversive pushing after stroke, interventions often required multiple staff members creating practical challenges associated with scheduling and staffing. Successful application of the PUSH Strategy may be dependent on the availability of both equipment and multiple staff members. Moreover, support from stakeholders (i.e., therapists and administration) [34] is likely to promote optimal delivery of the PUSH Strategy in patients with contraversive pushing.

Future clinical trials may consider examining practical questions (e.g., device options to achieve maximal time upright) and scientific questions (e.g., comparison to a control group). For example, several devices were used in this study to promote upright standing and walking. Interestingly, the three patients who used an overground robotic exoskeleton achieved the largest reduction in contraversive pushing. Others have demonstrated the use of treadmill-based robotic systems (e.g., Lokomat) to reduce contraversive pushing behavior more than traditional standard care interventions [14, 15]. Potentially, the advancing technology of robotic exoskeletons may be an important tool to promote the reduction of contraversive pushing.

Additionally, the lack of improvement in the functional domain of Walking on the CARE Tool despite the PUSH Strategy’s emphasis on high repetitions of stepping deserves examination. Recent studies suggest high cardiovascular intensities employed during gait interventions (beyond only repetition of stepping practice) may be necessary for the recovery of walking function after stroke [35 –37]. The cardiovascular intensity of interventions during the PUSH Strategy approach was not monitored. Future trials may consider combining the principles of the PUSH Strategy to reduce pushing and intensity principles to facilitate gait functional recovery for patients with contraversive pushing during the subacute phase of stroke.

4.1 Limitations

The focus of this study was to describe the application of the PUSH Strategy and not to examine the efficacy of the intervention for reducing contraversive pushing after stroke for patients during inpatient rehabilitation. In this single group study, a small sample size and lack of a control group limit the generalizability of the findings. Specifically, this small sample small was drawn from a single clinical center and lacks representativeness of the stroke population. Additionally, without a comparator group, the findings may be attributable to uncontrolled variables. A potential next step would be to conduct a controlled trial to address questions of efficacy. Further, the clinical facility for this study had access to advanced technology (e.g., robotic exoskeleton, body weight supported treadmill system) which may not be available to all facilities. Although the PUSH Strategy was not designed to depend on the use of specific equipment, these devices afford therapists the opportunity to mobilize patients with lower functional levels in comparison to traditional devices (e.g., walkers or canes). Additionally, as the goal of this study was to discuss application of a program for inpatient rehabilitation, patients were not followed after discharge from inpatient rehabilitation, leaving little understanding of the long-term outcomes for these individuals.

5 Conclusion

There is a strong need for evidence-based interventions to address contraversive pushing during the sub-acute phase of stroke. In response, the PUSH Strategy was applied during inpatient rehabilitation with emphasis of upright postures and gait activities to promote improved outcomes for patients with contraversive pushing after stroke. These preliminary findings suggest further exploration of the PUSH Strategy is warranted to determine its efficacy and pursuit of best practice in the management of this population.

Footnotes

Acknowledgments

The authors wish to acknowledge Lauren Gibson, Radha Morar, Amanda Ogletree, Kara Patterson, Christa Ochoa, and Charlie Ellis for their contributions to this project.

Conflict of interest

The authors have no conflicts of interest, funding or financial benefits to disclose. The following manuscript has not been presented or published elsewhere.

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