Pushing to the paretic side — verticality misperceived

Pusher syndrome is one of the few balance presentations where the mechanism was measured rather than guessed: Karnath’s work showed these patients experience their body as upright when it is tilted toward the paretic side — a mis-set graviceptive vertical with an intact visual one — and Pedersen’s Copenhagen cohort put numbers to the incidence and the longer rehabilitation course. Neglect travels with it and is not the engine; an otolith lesion would tilt the visual vertical and does not. The treatment follows the dissociation: feed true vertical through the channel that works — mirrors, reference lines, real vertical tasks — grade weight-bearing through the non-paretic side, and score the response on Baccini’s Scale for Contraversive Pushing. What you do with it: stop arguing with her vertical, show it to her instead, position her inside a base she can control, and re-score the SCP so the whole team sees the same slope.

• Falls during transfers while the push is strong — supervision level and equipment reviewed before every session, not after the event
• Any new neglect deepening, drowsiness or new weakness — this is a fresh stroke problem, not a balance one; escalate

• Three falls in six months — the multi-factorial work-upTier 4
• Four hours of vertigo — triage before treatmentTier 3

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