Scale for Contraversive Pushing
The SCP was developed by Karnath et al28 and is based on Davies'5 definition of pusher syndrome. The English translation of the SCP was published in 2000.29 The original German language version was later published in 2001.28 The SCP assesses patients in both seated and standing positions, assessing 3 components of contraversive lateropulsion: (1) symmetry of spontaneous body posture, (2) the use of nonparetic extremities (leg or arm) to push by abduction and extension thrust, and (3) the degree of resistance to passive correction of the tilted posture. The individual is considered to exhibit lateropulsion if each component has a minimum score of 1; however, a modified cutoff criterion of more than 0 has been frequently used to improve sensitivity and specificity (Table 2).7,15,25,30
Three articles that analyzed the SCP were included in the systematic review.14,15,27 A study by Baccini et al14 examined reliability, internal consistency, and criterion validity using clinical diagnosis by an expert as the reference standard (Table 3).14 Testers had moderate agreement using the original criterion for diagnosing contraversive lateropulsion (each component >1); however, a modified cutoff criterion (>0 on each SCP component) improved agreement between the expert's clinical diagnosis and the SCP score.14 Because of a sample size under 30 for the study, the COSMIN checklist shows poor-quality assessment for reliability, internal consistency, and criterion validity.18
Beyond their examination of psychometric properties of the SCP, Baccini et al15 also examined diagnostic agreement between SCP and clinical diagnosis with 3 cutoff criteria. The more conservative criterion (each component >1) yielded 6 false-negative results; however, the modified criteria (>0 on each SCP component) resulted in 2 misdiagnoses.18 Moderate construct validity was observed between the SCP component and total scores with the Barthel Index, the balance subscore of the Fugl-Meyer Assessment Scale, and the subscore of the mobility section of the motor assessment chart developed by Lindmark and Hamrin.31 The modified cutoff criteria (each component >0) yielded the highest sensitivity and positive predictive values.15
A 2014 study by Bergmann et al27 provides the first investigation in which multiple tools for contraversive lateropulsion evaluation were directly compared. When comparing the SCP to the BLS, 22.5% of cases resulted in inconsistent classification, with more false negatives observed with the SCP. These tools demonstrated moderate diagnostic agreement on the basis of the modified criterion (cutoff >0) and on detecting pre- and postintervention changes.27 The COSMIN checklist yielded a result of poor reliability secondary to small sample size (Table 4).
The cross-cultural validity of the SCP has not yet been considered in the translation from the original language of German into English. A formal description of the translation process including the number of translators, their expertise, and whether the process included forward and backward translation was not provided.4,32 Baccini et al14,15 did not describe which translation was used in their studies performed in Italy.
The original SCP did not provide a detailed guide for its administration or verbal instructions that should be provided. Karnath et al33 later clarified how to test the amount of extension and abduction of the nonparetic extremities. Findings from Baccini et al14,15 and Bergmann et al27 suggest an a posteriori change in the criterion for diagnosing contraversive lateropulsion (each component <0 instead of <1). Despite improvements in the sensitivity and consistency of classification with the SCP, the BLS appears to be more responsive. Future study requires larger sample sizes.
Swedish Scale for Contraversive Pushing
Hallin et al26 translated the SCP into Swedish, resulting in the S-SCP. The S-SCP is equivalent to the original scale, with the exception of modified verbal instruction for patients to when assessing resistance to passive correction of tilted posture.
Good interrater reliability was reported for the total S-SCP score and for each of the 6 postures assessed (Table 3).26 A sample size under 30 led to a poor-quality rating by the COSMIN checklist.26
Hallin et al26 note that the variables assessed in sitting posture had lower reliability than variables assessed in standing, postulating that contraversive lateropulsion manifests to a greater extent in stance. During standing, persons exhibiting lateropulsion have a reduced base of support, increased postural control demands, and increased opportunity to push with the nonparetic lower extremity. Although this is the only study to report the difference in reliability between these tasks, all of the outcome measures identified for lateropulsion include both sitting and standing components. Lateropulsion analysis across multiple tasks may contribute to a better understanding of the underlying mechanism, more accurately identifying the incidence of contraversive lateropulsion, and better classifying individuals based upon severity. Further study of the internal consistency, responsiveness, and validity is warranted to better recommend substitution of the S-SCP for the original SCP in Swedish-speaking settings.
Modified Scale for Contraversive Pushing
The M-SCP was developed from a modified version of the S-SCP. The modified scale further expanded the tasks examined to 4 sections: static sitting, static standing, sitting transfer, and standing transfer. All sections are scored between 0 and 2, with a score of 0 indicating no symptoms and 2 indicating that the condition fully meets the definition of contraversive lateropulsion.5,16
Lagerqvist and Skargren16 report the M-SCP to have moderate to excellent agreement for interrater reliability. The creators of the M-SCP were also involved in the data collection for the study, potentially introducing bias in the administration of the assessment.16 Low-to-moderate concurrent validity measurements observed comparing the M-SCP with the Berg Balance Scale and the Swedish Physiotherapy Clinical Outcome Measure (S-COVS). COSMIN review found the quality of the reliability and criterion validity assessment to be poor secondary to small sample size.
Further study is needed to recommend M-SCP use in English-speaking countries including internal consistency, responsiveness, and cross-cultural validity assessment on a larger clinical population with a descriptive English translation process.
Burke Lateropulsion Scale
The construct of the BLS is based on Davies'5 definition of lateropulsion and measures the amount of resistance offered by the patient when sustaining or changing position.17,25,27 Performance is assessed during the execution of 5 tasks: rolling, sitting, standing, transferring, and walking. Each component score reflects the amount of resistance encountered by the examiner when correcting tilted posture and reflex equilibrium responses. Component scores range 0 to 3, with the exception of standing, which ranges from 0 to 4. Scores for rolling in supine, walking, and transferring are based on the severity of pushing sensed by the examiner. The sum score ranges from 0 to 17, with 0 indicating no lateropulsion. A total score of 2 or more has been recommended as the cutoff score to indicate the presence of lateropulsion; however, a cutoff score of more than 2 shows better agreement between the BLS and the SCP. 13,27,34
D'Aquila et al17 examined the concurrent validity and the inter- and intrarater reliability of the BLS (Table 3). Moderate correlations between the BLS and additional outcome measures suggest that lateropulsion is related to constructs of functional status and balance. Reliability and criterion validity each scored good on the COSMIN checklist secondary to a sample size of 85 (Table 4).
Clark et al25 reported the BLS to be highly responsive at 4 and 8 weeks poststroke, highlighting that the BLS may be a sensitive tool to measure reductions in contraversive lateropulsion over time. The sample size was moderate; however, responsiveness received a COSMIN score of poor because standardized response mean is considered an inappropriate assessment of responsiveness.18,24
As previously described, Bergmann et al27 used both the BLS and the SCP to evaluate contraversive lateropulsion. Criterion validity of the BLS was calculated using the SCP as the reference standard. Caution is advised in interpreting the reported results, as there is no established gold standard. Moderate diagnostic agreement was found between the 2 outcome measures as well as for postintervention changes (Table 3). Results suggest that the BLS is more responsive to small changes compared with the SCP. The BLS is the only measure to receive ratings greater than poor for reliability and responsiveness.
The BLS has a precise guide for administration and reportedly satisfactory clinimetric properties; however, some studies were rated with COSMIN as poor quality secondary to small sample sizes.25,27 Studies suggest that the BLS is more responsive than the SCP and has greater sensitivity for identifying contraversive lateropulsion.25,27 The wider score range of the BLS (0-17) compared with the SCP (0-6), including the assessment of the graduated angle where resistance to passive alignment correction begins, may better enable identification of small changes.30 Strong interrater and intrarater reliability is reported for the BLS in a wide range of individuals with and without contraversive lateropulsion.17 Internal consistency has yet to be assessed. The BLS includes the assessment of rolling, a movement that is easy to assess in early inpatient stays, as well as more functional tasks including transfers and walking.5 Examining a wider array of functional tasks may enable clinicians to better plan interventions when working with patients who have severe contraversive lateropulsion. Moderate negative correlations observed with the Postural Assessment Scale for Stroke Patients (PASS) suggest that clinicians should consider administration of the BLS in conjunction with other balance or postural control outcome measures that have well-established psychometric properties and are validated in the stroke population.
The aim of this study was to update and improve upon the systematic review by Babyar et al13 because of the lack of a well-established gold standard outcome measure. This was to be accomplished by (1) identifying additional scales for classifying contraversive lateropulsion, (2) providing newfound data regarding clinimetric properties for scales previously identified, and (3) creating an updated resource that can make recommendation for use of the most appropriate tool in clinical practice.
This revised search yielded 3 new articles and 1 additional outcome measure to add to the findings of the previous review.25–27 Limited results reveal a persistent lack of quality literature related to contraversive lateropulsion, perhaps because of failure to consistently identify the condition clinically, as well as the fact that it typically resolves within 1 year poststroke.10 This review raises questions about the cross-cultural validity of the SCP, which was not addressed by Babyar et al.13 The S-SCP has a thorough description of the translation process and modified verbal instruction, whereas the SCP lacks formal description of the translation from the original German text to English.4 The language of these outcome measures may significantly influence patient performance, as it influences the way in which clinicians encourage patients to alter postural alignment and the amount of resistance needed to move the patient into correct alignment. The SCP provides a single translated instruction to give to patients: “I will move your body sideways, please permit this movement.” 4 The extent to which the clinician may paraphrase outside of this instruction remains unclear. The BLS offers no specific verbal instruction to the client, but does more specifically describe testing positions to minimize variability. Individuals with native-level proficiency should perform all future translations, which should be fully disclosed.
Despite unevaluated clinimetric properties and mostly poor-quality assessment ratings (primarily due to small sample sizes), we recommend the BLS for early detection of contraversive lateropulsion in English-speaking countries.13 The BLS appears to be the most responsive of the lateropulsion scales and has the potential to be a more sensitive instrument to measure deviations in postural control in the context of multiple activities. The BLS assesses movements and postures, which may be more likely to be viewed early in hospital stays (ie, rolling), prior to assessing more advanced movements that may be impaired secondary to medical instability, decreased staff support, and decreased lower extremity strength.27 Unlike the SCP, the BLS includes a walking assessment, making it more functionally relevant later in an individual's recovery.
Although the original description Davies5 used to define contraversive lateropulsion remains relevant, clinicians should consider implementation of the BLS as soon as deviations in postural vertical are suspected following stroke. Identifying the presence of contraversive lateropulsion may help clinicians, particularly those in acute care environments, more accurately establish prognosis, set goals, and better formulate an appropriate plan of care, as contraversive lateropulsion has such a significant potential to alter rate of recovery and increase hospital length of stay.2,7,11,12 Early assessment will more objectively reveal presence of contraversive lateropulsion, quantify its severity, enabling clinicians to better plan interventions (ie, rehab tech assistance) and objectively quantify improvement in symptoms over time. The BLS includes more comprehensive list of functional tasks than the SCP, which are all likely to be included within a clinician's initial examination. The BLS administration would likely add only a few minutes to any clinical examination. Clinician-scientists should feel more confident designing and implementing interventional research on individuals with quantifiable contraversive lateropulsion using this tool alone.
Contraversive Lateropulsion can significantly limit a clinician's ability to treat patients with stroke without the assistance of another clinician because of safety concerns with transfers, standing, and ambulation.35 Delayed or absent functional training may thereby increase length of hospital stay and necessitate more intensive therapy.36,35 Identifying treatments that maximize functional recovery and minimize physical demand on therapists will help improve patient prognoses, promote safety, and minimize burden of care.
The etiology of contraversive lateropulsion remains poorly understood; however, it is clear that its manifestation relates to vision, somaesthetic input processing, and verticality perception, suggesting that consideration of constructs not evaluated in current lateropulsion outcome measures is warranted.30,36 With a range of affected regions of the brain, multiple subtypes of contraversive lateropulsion may exist, making identification of subtle changes and examination of various postures more valuable. The correlation between contraversive lateropulsion and subjective postural vertical should be further investigated along with function and balance to better validate all constructs comprising lateropulsion.6,34 We suggest that future studies concomitantly implement both the BLS and a well-established outcome measure for an associated construct (ie, balance) to improve clinical applicability.
Several limitations exist within the literature. Type of lesion (eg, ischemic and hemorrhagic) and stroke severity relating to lesion size and motor, sensory, and perceptual status were not provided in any included study. Reported duration from the stroke onset to time of assessment was wide: 19 ± 7.8 days to 1.6 ± 0.7 months (Table 3).14,27 Only 1 included study used a sample size greater than 100 and several lacked a heterogeneous population (Table 3).15 Moderate relationships were observed between measures of contraversive lateropulsion and several measures that assess balance and function; however, there is currently no clear gold standard with which to compare these scales. A few of the studies included in this review used assessors who also helped develop the scales, potentially biasing reliability measurements.16,17,26 Similar to Babyar et al,13 we question whether the presence or severity of contraversive lateropulsion can be assumed without a complete composite score, such as when a patient cannot be formally tested in a given subsection of a scale due to reasons unrelated to contraversive lateropulsion such as cardiovascular, physical, or cognitive impairments. In addition, not all statistical methods to assess clinimetric properties were considered appropriate according to the COSMIN checklist standards.25
There were limitations in the way this updated systematic review was conducted. Two individuals independently performed the title/abstract screen, and 2 other individuals performed full-text reviews. Potential for bias may have been reduced, and consistency may have been improved if the same individuals performed all portions of the search and screening process.
The BLS is recommended as the preferred tool to evaluate contraversive lateropulsion in English-speaking countries. The BLS is the strongest scale available, as it includes the widest array of functional testing positions and has less uncertainty with regard to cross-cultural validity in comparison to other existing scales. The BLS should be implemented in inpatient settings as soon as contraversive lateropulsion is suspected, to quantify severity, help clinicians plan interventions, and track change over time. Further studies are warranted with larger, more heterogeneous populations to improve the quality of examined measurement properties of these scales. Formal translations of contraversive lateropulsion scales should fully disclose the specific instructions to be given to the patient during the assessment.
We thank Jeannine Bergmann for her assistance in reviewing the article and Leila Ledbetter, MLIS, for her assistance in developing the search strategy.
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contraversive lateropulsion; contraversive pushing; COSMIN; pusher behavior; pusher syndrome
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