Families who care for a person with stroke sometimes meet a puzzling situation. The therapist has already helped the patient to sit or stand upright, yet the patient seems to be resisting, and uses the unaffected arm and leg to push actively, forcing the body to lean towards the affected side and even across the midline. The harder others try to straighten the patient, the stronger the resistance becomes. Families often think the patient is stubborn, unwilling to move or refusing to cooperate. In fact this is a sign after stroke with a clear medical definition: pusher syndrome (also called lateropulsion or contraversive pushing).
This article takes the view of postural control and vertical perception in physiotherapy. It explains the mechanism of pusher syndrome, why patients resist being straightened, how severity is assessed with the SCP scale, and the three main directions of treatment and the outlook. Spatial neglect, daily self-care (ADL) and cognitive training belong to occupational therapy and are only touched on briefly here; for details see occupational therapy after stroke. This article covers one specific cause under the topic of balance and fall prevention after stroke.
What is pusher syndrome
The most central point of pusher syndrome, and the one most often misunderstood, is that it is an active pushing force and is not simple weakness leading to a fall. The patient uses the arm and leg on the unaffected side to brace against the bed or the floor and actively pushes the trunk towards the affected side, and resists with force when others try to straighten the body. Once this is understood, carers can put aside the doubt about whether the patient is refusing to move or being deliberately difficult.
- The body falls passively towards the affected side because that side is weak
- When straightened up, the patient does not resist, and may even feel relieved
- The problem lies in strength and support, and the position can be kept once the centre of gravity is corrected
- The patient pushes actively with the unaffected arm and leg, so that the body crosses the midline and leans towards the affected side
- When straightened up passively, the patient resists with force, because they feel they are being pushed towards the unaffected side
- The problem lies in the internal sense of vertical being turned, which needs to be rebuilt, and adding strength alone does not solve it
Mechanism: a distorted sense of vertical and the second graviceptive system
To understand why the patient resists being straightened even when already leaning towards the affected side, the key is the finding of Karnath and colleagues (2000). The research team measured the subjective postural vertical (SPV, the direction the patient judges to be upright by feel alone with the eyes closed) of pusher patients and found that this sense is shifted by about 18° towards the unaffected side. In the same patients, however, the subjective visual vertical (SVV, the vertical line judged with the eyes) was completely normal.
This mismatch between the SPV and the SVV reflects damage to a "second graviceptive system", which is independent of the visual and vestibular systems and senses the direction of the body relative to gravity (involving the posterolateral thalamus). The patient believes that leaning towards the affected side is what upright feels like. When the therapist moves the patient to the objectively vertical position, the patient feels as if they are being pushed towards the unaffected side and instinctively pushes back. This resistance to being straightened is in fact the patient correcting an internal sense of vertical that is wrong (Karnath et al. 2000).
This gap in sensation is the entry point for rehabilitation training. The patient's body sense is skewed, but their visual sense of vertical (SVV) is still normal. The therapist can use this to guide the patient to look with their eyes and recognise the true vertical again, correcting the illusion in the body. This is the basic principle of visual feedback and midline re-education described below.
How common it is: more common with right hemisphere damage
Pusher syndrome is by no means rare in clinical practice. Abe and colleagues (2012) followed 1,660 patients with acute stroke and found that about 9.4% had pushing. The difference between left and right hemisphere damage was very marked. The prevalence after a right hemisphere stroke (17.4%) was clearly higher than after a left hemisphere stroke (9.5%), with a relative risk of about 1.83. These figures also support why pusher patients often have spatial cognition problems related to the right hemisphere at the same time, and why recovery generally takes longer in people with right hemisphere damage.
Spatial neglect often occurs together with right hemisphere damage, but the two are clearly different disorders. This page covers postural control and vertical perception only. For the recognition and treatment of neglect, see occupational therapy after stroke.
Clinical assessment: using the SCP scale to assess severity
In clinical practice, physiotherapists mainly use the Scale for Contraversive Pushing (SCP) to quantify the severity of pushing and to track the progress of rehabilitation. The reliability and validity study by Baccini and colleagues (2006) confirmed that the three items of the SCP have good to excellent inter-rater reliability and very high internal consistency, and that with the revised cut-off scores its results agree almost completely with the clinical diagnosis. The SCP covers the following three items (each assessed in sitting and in standing):
The three items are scored separately in sitting and standing, and the total score reflects the severity of the condition. Repeated tests at regular intervals record the progress of rehabilitation objectively. For a sign that fades over time but slowly, quantified assessment is especially important: with the scale scores the therapist and family can see the real progress each week clearly, without relying on guesses from impressions.
The three SCP observations (for families to use as day-to-day reference)
Formal scoring and clinical diagnosis are of course the job of the physiotherapist. But if family members understand the observation points behind the three SCP items, they can describe more specifically to healthcare staff what they see in daily care, for example at which angle the patient most often pushes back when being supported for a bed transfer, and so help the treatment team fine-tune the rehabilitation plan. The three items are put below in plain language. Families are advised to treat them as a vocabulary for daily observation and not to decide at home whether the patient is a pusher:
| ① Spontaneous posture (how the patient sits or stands without any support) | When still and unsupported, does the body lean towards the affected side by itself? In plain words: "When they sit relaxed, does the whole body sag towards the weak side?" The clearer the lean, the more severe this item. This is an observation point, not a conclusion. |
| ② Abduction and extension of the unaffected limbs (the unaffected arm and leg spread out to push) | Does the unaffected arm or leg spread out and straightento create a pushing force (as if pushing the body apart)? In plain words: "Are they using the good hand to brace against the bed or the armrest, as if pushing themselves away?" This is the sign of the active pushing movement. |
| ③ Resistance to passive correction (the patient is brought back to the middle and pushes back hard) | When someone gently brings the patient to the true vertical, does the patient push back hard and resist? In plain words: "The moment you help them sit upright, do they at once push hard back towards the weak side?" This is the most characteristic sign of pushing. But whether the patient is a pusher and how severe it is should be assessed by the therapist with the scale, and no conclusion should be drawn at home. |
Daily observation is not a clinical diagnosis.If family members notice all three of the following together, "the body falls towards the affected side", "the unaffected arm and leg brace and push" and "the patient pushes back hard when straightened", they can tell the physiotherapist. The actual scoring method of the SCP, the pass scores and the grading of severity need professional judgement, and are accurate only when tested by a physiotherapist in person. The family's role is to report what they see day to day and not to make a diagnosis themselves.
Three focuses of rehabilitation treatment
There is a clear order in managing pusher syndrome: pushing must be dealt with first and the correct sense of vertical rebuilt, and only then are the hemiplegic limbs and balance trained (Karnath & Broetz 2003; Nolan et al. 2023). The specific treatment rests on three pillars:
Focus 1: visual feedback and midline re-education
This is the core of the whole rehabilitation process. Since the patient's visual sense of vertical is intact, the therapist uses vision to override the body's biased sense of vertical (Karnath & Broetz 2003). In practice, clear vertical reference objects are provided in the environment, for example a full-length mirror, a straight line on the wall, a door frame, or the therapist's arm held vertically. These guide the patient to confirm with their own eyes that they are leaning and then to actively adjust the trunk back to the true vertical midline. The key is that the patient sees it and corrects it actively, and the therapist does not straighten the patient by force from outside (forced intervention from outside only triggers a stronger resistance).
Never straighten the patient by force. Pulling the patient upright by brute force only provokes stronger resistance and pushing, and also raises the risk of falls and of straining the shoulder joint. The correct approach is to provide visual references so that the patient adjusts the posture by themselves, with the therapist acting as a guide at the side and not as an opponent in a contest of strength.
Focus 2: graded weight shifting and trunk control
Once the patient has begun to build an awareness of vertical, training starts from a stable base of support (sitting) and gradually guides the patient to shift weight towards the unaffected side, getting used again to a symmetrical sense of weight bearing, and then moves on to standing and dynamic balance training. This part complements usual trunk control training, with adjustments for the pathology of pushing. The details of usual sitting balance and trunk training are not repeated on this page.
Focus 3: environment, positioning and day-to-day management
Nolan and colleagues (2023) used the Delphi expert consensus method to bring together an international panel of experts, who drew up 119 clinical management recommendations for lateropulsion, covering the direction of rehabilitation, positioning, overcoming fear of falling and fatigue management, training intensity and discharge planning. The core principle the experts conveyed is consistent: first rebuild the internal sense of vertical, reduce the degree of pushing and improve balance, and only afterwards give more advanced training for the hemiplegia.
What to deal with first (rebuilding the sense of vertical)
- Provide a clear visual vertical reference so that the patient adjusts their own posture to the true vertical
- Practise weight shifting in stages, moving slowly from sitting to standing and learning again to take weight evenly on both sides
- Arrange sitting and lying positions carefully, and deal with fear of falling and tiredness at the same time (Nolan et al. 2023)
What to leave until later or not to rush
- Strength training of the affected arm and leg too early, before the patient has regained the correct sense of vertical
- Straightening the patient by force, in a contest of strength with the patient's resistance
- Spatial neglect, daily self-care (ADL) and cognitive training, which are followed up by the occupational therapist
Guide for carers: use a mirror, vertical lines and visual cues instead of pushing
The sections above explained the medical principles of physiotherapy. This section is for the family members who do the daily care, and turns those principles into "no-push" guiding techniques that can be used when helping the patient with bed transfers, sitting up and standing. Please keep one core idea in mind: the patient's resistance to being straightened is not deliberate opposition. It happens because the sense of vertical in the brain is distorted, and the harder the carer pushes the patient back to the midline, the more the patient instinctively pushes towards the affected side. So do not contest strength with the patient. Instead, use the visual sense of vertical that is still intact to guide the patient to see it and correct it actively. The general principles for daily care are listed below. They do not replace on-the-spot guidance from a home-visit physiotherapist for the individual patient.
Why straightening the patient by force backfires
For a patient whose internal sense of vertical is off, when others move them to the objectively vertical position, they feel as if they are being pushed to fall towards the unaffected side, and instinctively push back to the original position with the unaffected arm and leg. The harder the others push, the harder the patient pushes back. Daily support then turns into a tug of war that can easily strain the patient's fragile affected shoulder joint and greatly raises the risk of both falling together. The correct response is therefore to replace opposing with guiding: let the patient look at a vertical reference and adjust their weight by themselves, while the carer only gives safe protection and verbal prompts at the side.
- 1First place a vertical reference directly in front of the patient's line of sightPut a mirror, a vertical line or door frameon the wall, or the carer's straight arm at eye level directly in front of the patient. This line is the patient's external correct answer. The patient's eyes judge the vertical accurately, and this can be used.
- 2Ask the patient to compare with their eyes: are they sitting or standing straight nowGuide in plain words: "Look at the mirror or the line. Are you sagging towards the weak side now?" Let the patient find the lean for themselves. The key is that the correction is led by the patient. Being convinced by themselves works far better than being straightened by others, and it does not trigger resistance.
- 3Give a visual cue on the unaffected side and ask the patient to move back to the middle by themselvesPlace a visible target on the unaffected side (the carer's hand, a marker, or the patient's own unaffected shoulder in the mirror) and ask the patient to move the body slowly towards the unaffected side until it lines up with the vertical line. Saying "move towards my hand" is more specific and easier to follow than "sit up straight".
- 4The carer only protects and gives light prompts, and does not straightenKeep the hands beside the patient to protect against a fall and do not push the patient back. If a direction cue is needed, use a light touchor say "a little more towards me", and avoid applying force that will be pushed back against. Go slowly throughout, and leave time for the patient to finish the correction alone.
- 5Work in short stretches and often, and praise self-correction at onceAsk for only a short stretch each time (for example lining up in sitting for three or four seconds), praise success at once, and lengthen the time step by step and move on to standing. Tiredness and fear of falling make pushing worse, so several short sessions are better than one session that ends in exhaustion.
There are three main things to avoid in daily care. First, never pull the patient upright by force, because this only makes the patient push back harder and easily injures the shoulder joint. Second, never pull on the affected arm for leverage when adjusting position, because the shoulder on the affected side is very easily injured after stroke. Third, never let each bed transfer turn into a contest of strength. If the patient pushes harder and harder, stop first, let the patient see the vertical reference clearly again, and guide the patient to adjust the posture by themselves.
- First place a mirror or a vertical line, or use a door frame, in front of the patient, so that the patient looks with their eyes and adjusts the posture by themselves
- Use questions (for example: "Do you feel your body is leaning towards the weak side?") to guide the patient to notice for themselves that the body is crooked
- Put a visual target on the unaffected side and ask the patient to move over by themselves, and do not push with the hands
- Use the carer's hands only to protect the patient from falling, and give direction cues by a light touch or by words
- Keep each practice short and split it into several sessions. Praise the patient at once whenever they sit upright by themselves, and watch their stamina at the same time
- Pulling the patient upright by force, meeting the patient's pushing head on, so that daily support becomes a contest of strength
- Pulling on the affected arm to adjust sitting or standing, which easily injures the affected shoulder joint
Outlook and time to recovery
What families care about most is: "Can this sign recover?" The clinical data give a generally positive answer. According to the systematic review by Nolan and colleagues (2022), patients who have lateropulsion need about 3–4 extra weeks of rehabilitation time, but with enough treatment time and support they can still end up with functional progress and a chance of going home from hospital similar to patients without lateropulsion. In most patients the symptoms fade within several weeks to 6 months, and for those with right hemisphere damage the time needed to recover is relatively longer (Abe et al. 2012). In summary: the hospital stay will be longer, but most patients do recover.
What this sign needs most is patience. When the family understands that the patient pushes to one side because the sense is wrong, and not because of stubbornness or sulking, and knows that it usually improves over time, they no longer need to contest strength with the patient in daily care. Working with the therapist and practising step by step with visual references usually works faster than hurried pushing.
Fall prevention for patients with pusher syndrome
The aim of recognising a pusher patient early is not only to promote recovery but also an important part of preventing falls. The study by Lewis and colleagues (2024) confirmed that during inpatient stroke rehabilitation, lateropulsion is an independent predictor of falls. Because the patient keeps pushing the weight towards the affected side and resists support from others, the risk of falling naturally rises greatly during bed transfers and standing. Recognising the pusher early, assessing objectively with the scale (SCP) and starting targeted intervention is therefore already a core part of the balance and fall prevention strategy of stroke rehabilitation.
- Understand that the patient's body sense of vertical is wrong (SPV shifted by about 18°), and that the patient is not stubborn or deliberately difficult
- Use vertical reference objects in the environment (such as a mirror or a straight line) to guide the patient to correct the posture by themselves
- Start from a stable sitting position, practise weight shifting in stages, and follow progress regularly with the SCP scale
- Treat the patient as being at high risk of falls, and give more protection at the side during bed transfers and standing
- Straightening the patient by force and meeting the pushing head on, so that support turns into a contest of strength
- Rushing into strength training of the affected arm and leg before the patient has regained the correct sense of vertical