This research highlight is for all my neuro nerds. I personally love working with the neuro population. They’re often some of my most motivated patients and it’s always fun to see their functional progress. No matter what your comfort or experience level, you’ve likely encountered a post-CVA patient with pushers syndrome. I think many of us would agree these patients can be some of the most difficult to treat. Well, Jaime Gillespie, Molly Trammell, and Chad Swank may have something to help you! If you work with CVAs you’re gonna wanna continue reading this week’s post and the authors’ publication on the “PUSH” strategy.
Application of “the PUSH strategy” to reduce contraversive pushing after stroke
Jaime Gillespie, Molly Trammell, and Chad Swank
The Rundown
The study took 11 patients who were determined to have pushers syndrome after acute CVA and treated them using the PUSH method. They determined the success of the treatment with three primary outcomes. The first was decreased pushing measured by the Burke Lateropulsion Scale (BLS). The second was functional outcomes using the mobility and walk sections of the Continuity Assessment and Record Evaluation or what many of us know as the CARE tool. Last was discharge destination to home, assisted living, or transitional neuro rehab. Their results showed an impressive 73% of the participants met ALL THREE of their goals.
Scales and Measures
Similar to the first research week highlight I want to go over the scales used. They’re important for understanding the study, but not always familiar to everyone. The Burke Lateropulsion Scale (BLS) was new to me. It measures the degree of pushers syndrome. The Scale uses a point system to quantify the amount of resistance, or pushing, a patient exhibits during functional mobility tasks.
The second outcome measure was the CARE tool, which is a little more familiar. The CARE Tool actually measures A LOT of things depending on setting. PTs usually just complete the functional mobility portions. The CARE tool asks for assistance levels (min, mod, max) the patient needs for functional mobility tasks including transfers and ambulation.
Overview of “the PUSH” Strategy
Our researchers’ primary intervention was the “PUSH” strategy. PUSH stands for Prioritizing Upright, Standing, and Higher-level stepping activities which outlines the principles of this approach. Basically, they tried to get patients to participate in standing and walking activities as quickly as possible. For neuro populations we usually make sure they have adequate static and dynamic sitting balance before prioritizing weight-bearing tasks. The PUSH strategy breaks this mold and tells us to get patients up and trying to find midline ASAP.
Given their treatment was pretty successful, it got me thinking. Maybe there’s other situations where we need to skip to the harder stuff and just let neuroplasticity do its thing to achieve better and faster results? Anyone else think of another circumstance or experienced it in your own practice where this might be true? Please share in the comments!
“PUSH” Barriers
The authors admit that although the PUSH strategy was effective, implementing it came with some challenges. This was primarily due to the level of assistance needed to get pushers to safely work in weight bearing positions. They report using a variety of equipment. This included standing frames, exoskeletons, body weight support treadmills, and other support surfaces for standing balance to help achieve this. They acknowledged you likely need this equipment and need the man power to decrease physical burden on therapists in order to best execute the PUSH strategy. Since the study’s results were so promising, I want to expand on possible ways to address these barriers and make it possible to implement the PUSH strategy.
Let’s talk about equipment first, maybe you have none. I can actually say I’ve been in this situation before. My first job was in long term care right in the middle of Covid. In order to still be able to provide quality treatments, but decrease risk of Covid exposure to patients, we treated them in a separate makeshift gym. We were at least lucky to have some parallel bars. Even if it took two therapists we were getting patients into those bars. We would at least attempt to stand because we knew that was going to be best for them.
A lot of the patients we put in there maybe started out needing max A. Many of them got better and eventually needed less. Some who were previously using a hoyer progressed to stand up lifts or even to transferring with just an AD. The point I’m trying to make is while you may wish you had more, use what you do have. Fancy and expensive equipment can definitely be nice, but not a necessity. The simple things can still yield big results.
Now let’s say you would reeaalllyyy like to get some of those fancy gadgets. It’s going to take some backing from your clinic directors, DORs, and/or clinic owners to invest in this kind of equipment. I would present them with hard facts about how it can improve patient care. If it fits for your setting it wouldn’t hurt to come at it from an angle of how this may drive more patients to seek care from your clinic versus others.
Get co-workers to support the idea with you as well. Your bosses are more likely to invest in something they know more than one clinician will use. Lastly, I would offer to become the “go-to” person for that equipment. Offer to take it on yourself to learn the ins and outs, train others, and even organize an in-service to make sure this investment will be taken care of and properly used.
Equipment or no equipment, manpower and physical burden can still become a problem in both scenarios. In LTC I was lucky to work with a really great team where we would often help each other out. We would assist with a stand, transfer, or wheelchair follow for each other while our patient was resting or waiting for our next one to come to the gym.
This was all great. However, it was difficult to get in a lot of reps like you would ideally have for an acute CVA. When you do have equipment such as exoskeletons, standing frames, and body weight support treadmills a lot of time it takes more than one clinician to get the patient set up! Sometimes you need more than one person to continue the rest of the treatment to provide manual cues or assistance, guarding, or to operate equipment.
There are a few possible solutions to this. The first is to co-treat with another discipline. This works if you’re in a setting with other rehab professionals and if you’re able to tie in their goals for the patient as well during the treatment. If you don’t work in this type of setting or can’t align goals, there’s an alternative. I honestly think we under utilize our techs for this kind of thing.
I feel like many techs don’t get trained in this type of equipment, so we never ask them to help us. It’s easier to pick someone who knows how. All techs who may help with patient care should get thoroughly trained in the devices a clinic has available. By trained I don’t mean walk them by it and say “this is our body weight support system” and move on. I mean actually set aside time to show them how to use it and try it themselves. This is probably the most economical solution because it doesn’t take another therapist away from their duties and the tech is still under the supervision of the PT throughout the session.
One last solution would be to try to find a fellow PT during a rare open time, but for many of us I would guess those are few and far between. It’s also likely that if your co-worker has an opening they would like to catch up on some documentation or just catch a break!
Anyone have this equipment and run into these issues? How does your clinic deal with it? Or better yet some tips and tricks to reduce the need for so much physical help? Drop below in the comments!
What It’s All About
I wanted my last point here to be a shoutout to the authors of the study about this carefully chosen topic. They definitely addressed a great need within this realm of neuro PT. In their article, they cite several sources that explain how patients with pusher’s syndrome usually progress slower, require more assistance with functional mobility, and end up discharging to a more dependent setting compared to non-pushers.
So pushers syndrome not only leads to worse outcomes, but also more utilization of the healthcare system. The development of the PUSH strategy aims to improve both these things. Which is really what research is all about right? Identify where we need to find more effective treatment or where it costs us a lot of money and see how we can make it better. Many will focus on the small sample size. Given this is something we clearly struggle with and they developed a whole new approach to try to improve it, I’d say this is a fairly ground-breaking study. So congrats to the authors!
There’s your research week highlight! What do you think of the PUSH strategy? If you have an APTA membership you can access the full article here
Give it a read and discuss in the comments section! Got a different article you want discussed on The PT Page? Send it my way through the contact page or Instagram @the_pt_page and subscribe to get the latest posts directly to your inbox!
Leave a Reply