Pusher Syndrome Following Stroke: Rehabilitation Challenges and Strategies

Abstract

CASE DIAGNOSIS: Pusher Syndrome

CASE DESCRIPTION: A 68-year-old woman developed left hemiparesis with mild weakness after a right thalamic infarct. During rehabilitation, she persistently tilted her trunk toward the paretic side and resisted correction to midline, using her stronger arm to push away from the intact side. Despite preserved vision and no major sensory loss, her postural control was severely impaired. Her Scale for Contraversive Pushing (SCP) score was 6 out of 6, consistent with severe Pusher Syndrome. These behaviors caused repeated imbalance and required maximal assistance for sitting and transfers, delaying gait training. Rehabilitation included mirror visual feedback with a vertical reference line, environmental alignment during postural tasks, task-specific training such as upright sitting and sit-to-stand with emphasis on even weight distribution, and consistent verbal cueing. Caregiver education reinforced safe mobility strategies. Over eight weeks, she improved from severe to minimal pADL dependency, with SCP score reduced to 0, restored balance, and supervised walking.

DISCUSSIONS: Pusher Syndrome occurs in approximately 5 to 10 percent of stroke survivors, most often with posterolateral thalamic lesions. It is characterized by an altered perception of vertical orientation, rather than primary motor or sensory deficits, leading patients to actively resist correction and push toward the paretic side. This behavior can significantly prolong rehabilitation and delay functional gains. In this case, structured rehabilitation interventions combined with caregiver support were associated with resolution of symptoms within eight weeks. The improvement in SCP score and recovery of daily function highlight the importance of rehabilitation-based management.

CONCLUSIONS: This case shows that Pusher Syndrome, though uncommon, can markedly hinder stroke recovery. Targeted rehabilitation strategies, including mirror visual feedback, task-specific balance training, and caregiver engagement, could contribute to improved postural alignment and functional recovery toward minimal dependency. Early recognition and structured rehabilitation could support better outcomes in this disabling condition.